Regional Determinants of Health

A comparison of focused determinants of health between southwestern Ontario and suburban Vancouver. With Guest co-author Gordon Tse.

The Government of Canada defines determinants of health as “are the broad range of personal, social, economic and environmental factors that determine individual and population health” (Government of Canada, 2018). The main determinants of health on which research and policy are formed around are listed by the Government of Canada as;

• Income and social status

• Employment and working conditions

• Education and literacy

• Childhood experiences

• Physical environments

• Social supports and coping skills

• Healthy behaviours

• Access to health services

• Biology and genetic endowment

• Gender

• Culture

In Kitchener Ontario the Waterloo Wellington Local Health Integration Network (WWLHIN) is responsible for local health care. The agency serves 775 000 people, 90% of the population lives in an urban setting.  However 90% of the geography of the region is rural (WWLHIN, 2014). This means that the region must meet the needs of many different types of rural communities, even though the majority of the population lives in an urban setting. The WWLHIN has a relatively young population (87% under the age of 65) and the low-income rates are marginally lower than the rest of the province (WWLHIN, 2014). Twenty percent of the population is identified as immigrants and only 11.7% are visible minorities, and the region has lower unemployment rates than the provincial average (WWLHIN, 2014). Only 2% of the region self identifies as Aboriginal (WWLHIN, 2014).

The Waterloo Wellington Local Health Integration Network, which directly manages healthcare in Kitchener, Ontario published a report in 2011 that identified key determinants of health and recommendations for future program funding (Seskar-Hencic, 2011). Neighbourhoods at risk were identified and common health issues tracked based on population groups and neighbourhood. The key populations identified in the report were, low income, young mothers, infants and new immigrants (Seskar-Hencic, 2011). The study published 7 key areas of focus for local health programs. These are;

• Ending persistent poverty

• Supporting employment and living wage

• Increasing food security

• Improving access to adequate housing

• Promoting healthy child development and learning, while enhancing access to affordable childcare

• Enhancing physical environments

• Improving access to recreation and sports

        (Adapted from Seskar-Hencic, 2011)

Moving from the Waterloo region to the western Canada, there is a health region that is among the largest in the country.  This health region is the Fraser Health Authority (FHA) which serves 16 communities in suburban Vancouver area.   To serve the many needs of this population of almost 2 million people, FHA has network of 12 hospital, almost 8,000 residential care beds, as well as services in mental health, home care, and community care (FHA, 2018).  Within this health region, 83% of the population resides in the urban areas while the remainder resides in the more rural eastern parts of the region (FHA, 2014).  A consolidated community of predominantly younger people, about 14% of the overall population is over the age of 65 (FHA, 2014).  The population is also diverse in its ethnic culture.  The region is home to 40% of all British Columbia immigrants and there are 32 Nation Bands (FHA, 2012).  The population is also rapidly expanding.  By 2036, the region’s population is expected to expand to about 3 million people (CFHI, 2012).

A strategic approach to delivering health care cited four determinants that would yield the greatest impact on improving health outcomes in the Fraser Health region (FHA 2012).  This strategy aligns with local and national mandates and these are:

• Chronic disease prevention

• Mental health/substance use and well-being

• Unintentional injury prevention

• Healthy aging

       (Adapted from FHA, 2012)

A reduction in chronic diseases adds quality of life to the individual yet it also reduces burden to the health care system such that resources could be redeployed.  Injury prevention reduces the risk for injury-related falls and can create a safer community.  Together, chronic diseases and injuries account for more than $22 billion per year in health care expenditure in British Columbia (FHA 2012).  Improvements in mental health and reduction is substance use can re-engaged people back to their work and reconnect them back with their families.   Healthy aging can increase the number of healthy older adults in the communities and help them live longer in their homes.

To realize the goals, the FHA uses an integrated approach that consists of partnerships, supportive environment, health equity, and model of care that spans the life continuum from childhood to older adult.  This strategic map has an evaluation phase which has currently not been made public.

In contrasting these two very different populations, both geographically and demographically speaking, it demonstrates the importance of focusing health strategies on meeting the specific needs of local regions. There is little similarity in terms of the determinants of health that these two respective health regions choose to focus on.   These two regions are also drastically different in terms of population demographics.  On the other hand, large similarities in the focus of health determinants would indicate that the regions were not addressing their population needs.  Despite these differences in health care focus, the goal of each local region is clear in assessing the needs of their populations, identifying the most prevalent unequal distribution amongst the population, and seeking to develop policy and programs aimed at targeting these populations. The ultimate goal not only being the wellbeing of local residents, but a more equal social distribution of resources, and ultimately lowering healthcare costs through prevention.

References

Canadian Foundation for Healthcare Improvement.  (2012).  Fraser Health: Population Health Analysis [PDF file].  Retrieved from http://ihsts.ca/wp-content/uploads/2014/03/FraserHealth-Population-Health-Analysis.pdf

Fraser Health Authority.  (2018).  About Fraser Health.  Retrieved from https://www.fraserhealth.ca/footer-menu/footer-bottom/about-us/

Fraser Health Authority.  (2014).  2014/15 - 2016/17 Service Plan [PDF file].  Retrieved from https://www.fraserhealth.ca/media/201415FHServicePlan.pdf

Fraser Health Authority.  (2012).   Championing Better Health for Fraser Region: A Strategic Map for 2013-2017 [PDF file].  Retrieve from https://www.fraserhealth.ca/media/Population%20Strategic%20Map.pdf

Government of Canada. (2018). Social determinants of health and health inequalities. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html?option

Seskar-Hencic, D. (2011). Addressing Social Determinants of Health in the Waterloo Wellington Social Health Integration Network Area: Public Health Perspective on Local Health Policy and Programming Needs.  Retrieved June 5, 2018 from http://www.waterloowellingtonlhin.on.ca/~/media/sites/ww/files/aboutus/RPT_EQUITY_20111018_PublicHealth_SocialDeterminants.pdf?la=en

Waterloo Wellington Local Health Integration Network. (2014). About US.  Retrieved June 6, 2016 from http://www.waterloowellingtonlhin.on.ca/aboutus.aspx

Waterloo Wellington Local Health Integration Network. (2014). What Makes Us Sick? Retrieved June 5, 2018 from http://www.waterloowellingtonlhin.on.ca/forhsps/equity/socialdeterminants.aspx

The History of Canada’s Study of Determinants of Health: A literature review

Canadian physicians and nurses agree that attention to social determinants of health is a crucial component of development of national policy and is essential to the wellness of Canadians and the longevity of our healthcare system (Canadian Nurses Association, n.d.). Here is a brief synopsis of two peer reviewed journal articles that help us to understand how Canadian healthcare providers came to use the terms "determinants of health" and its importance in public policy formation today.

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Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. (2010). Canada: A land of missed opportunity for addressing the social determinants of health. Health Policy, doi:10.1016/j.healthpol.2010.08.022

This article by Bryant et al (2010) displays the initial achievements that Canada made in addressing determinants of health in the late 1970’s with the introduction of the universal public health insurance program in 1971 and the release of the LaLonde report in 1974. Canada became a world leader in population health and saw a drastic decline in health inequities, specifically those related to treatable medical conditions. The authors demonstrate that Canada as a nation has failed to develop the application of social determinants of health into public policy change since that time. Since 1980 Canada has fallen in ratings of the Organization for Economic Cooperation (OECD) from tenth (out of thirty) to twenty-fourth. The article demonstrates that lack of knowledge around determinants of health is not the problem, as multiple public health agencies publish numerous reports about the topic, but that a shift of Canada’s political and economic system has failed to turn these identified concepts into national public policy. The article highlights how income inequity, housing affordability, reduction of family and childhood poverty and early childhood development are negatively affected by ineffective federal policy related to determinants of health. The article concludes that in order to effect positive change in determinants of health, nations policy shifts that are in line with research social movements will require strong federal leadership and national policy development.

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Globerman, S., & Millar, J. (2003). Evolution of the Determinants of Health, Health Policy, and Health Information Systems in Canada. American Journal of Public Health. 93(3). https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.93.3.388

Globerman & Millar (2003) give a history of how determinants of health are defined in Canadian healthcare and health policy and how these determinants shape our view of population health in Canada today. The article describes how the Lalonde report in 1974 and the Canadian Institute for Advanced Research outlined determinants of health and identified how statistical data should be gathered in Canada. The initial determinants of health outline in 1974 were human biology, health care systems, environment and lifestyle. The main focus of health promotion at that time was to use media to direct people to live healthier lifestyles (ie activity, smoking cessation, healthy eating). In 1996 in order to lesson “victim blaming” the concept was expanded to include a variety of social factors and emphasize the need for multilevel health collaboration involving research, education, community development and healthy public policy. The authors demonstrate the need for regional health management that focuses on local determinants, Ontario at the time of publication was the only province that did not have regionally managed healthcare services. [Note: Since publication Ontario has introduced Local Health Integration Networks in or to address this need.] The article outlines some public policies that have been developed in order to ensure a national strategy on addressing determinants of health and social inequities and highlights information systems that are used to gather data nationally on population health. The article concludes that although several Canadian health commissions publish reports on the importance of addressing social determinants of health, there remains a lack of national evidence-based policy to address the issues.

Reference

Canadian Nurses Association. (n.d.) Health in All Policies National Action Plan. Retrieved from https://www.cna-aiic.ca/-/media/nurseone/page-content/pdf-en/hiap-national_action_plan_e.pdf?la=en&hash=FB495B27139AAB8767E5A94E84033DFEE5C4F04C

What should "health" mean?

Discussions on the World Health Organizations definition of the word "health" and how it can be adapted to meet the needs of today's healthcare systems.

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The World Health Organization (WHO) defined health in 1948 as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and although amended, the definition has not changed since that time. Since then the complexities of health care in the Canada have expanded and our societal knowledge of global health has become increasingly prevalent. For these reasons it has become essential for those involved in providing healthcare to reconsider what we consider the definition of health to be. By incorporating the concepts of potential and systemic support proposed by Bircher (2005) and Badash et al (2017) respectively, a more comprehensive definition of health can be considered.

The Government of Canada uses the WHO definition of health as a platform but expands their definition to include the notion that “an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment” (Government of Canada, 2008). This expansion of ideas to include a focus on social well being and aspirations of health is in line with a theory proposed by Bircher (2005). His theory defines health as

“a dynamic state of wellbeing characterized by a physical,

mental and social potential which satisfies the demands of

a life commensurate with age, culture and personal responsibility.

If the potential is insufficient to satisfy these demands the

state is disease” (Bircher, 2005)

Bircher uses the term potential to define the opportunities for health in the future, in the same way that the Government of Canada includes the concept of an individual’s aspirations in its definition of health. Potential is further defined as having 2 separate components; the biological competent that is comprised of a person’s genetic makeup which is unchangeable and acquired potential that is developed physically, socially and spiritually as we age (Bircher, 2005). The third element that Bircher proposes effects health are the demands of life (2005). As stated in his theory, when the demands (physically, socially, spiritually, socially or financially) exceed a person’s potential (biologically or acquired) to cope, the state which a person is in is disease (Bircher, 2005). By including this concept of potential into the definition of health, it highlights the importance of social and preventative medicine and could ultimately save healthcare dollars by limiting care to those who truly need it (Bircher, 2005). The WHO definition of health considers “complete physical, mental and social well-being” (WHO, 1948) in everyone, which seems unrealistic in terms of fiscal and material resources.

As outlined in the Canada Health Act the role of the Canadian Government in healthcare is “to protect, promote and restore the physical and mental well-being of residents of Canada” (Government of Canada, 2017). By adopting a broader definition of the term health that includes the requirement of an effective healthcare delivery system governments could further assess and manage the needs of their communities. Badash et al (2017) proposes a theory of health that can directly assist governments in meeting societal needs. The definition of health proposed by Badash et al is

“holistic state of physical, mental, emotional, and social wellness

supported by an integrated and technologically sophisticated

healthcare delivery system tailored to meet the entirety of a patient’s

medical needs, including disease prevention and management

of undesirable conditions, comorbidities, complications, and unique

patient circumstances” (2017)

This theory directly addresses the need for healthcare systems to address disease prevention and to use technology to meet needs identified by the patient (Badash et al, 2017). This theory is similar to the WHO theory that it incorporates physical, mental and social wellbeing, however it expands to include the ideas that health care be centered around the needs of the patients and prevention of illness in the future through the use of efficient and sophisticated healthcare systems (Badash et al, 2017).

Badash, I., Kleinman, N. P., Barr, S., Jang, J., Rahman, S., & Wu, B. W. (2017). Redefining Health: The Evolution of Health Ideas from Antiquity to the Era of Value-Based Care. Cureus, 9(2), e1018. http://doi.org/10.7759/cureus.1018

In the definition of health outlined by the World Health Organization in 1948 there is no regard given to the concepts of an individual’s potential for wellbeing and growth and does not address the complex needs of modern healthcare systems. By including the concept of investment in developing acquired potential and preventing illness (Bircher, 2005) and including the concepts of technology and tailored healthcare delivery systems (Badash et al, 2017) the WHO could develop a more comprehensive definition of the word health that would be better suited for complex needs of those involved in planning healthcare in todays world.

References

Badash, I., Kleinman, N. P., Barr, S., Jang, J., Rahman, S., & Wu, B. W. (2017). Redefining Health: The Evolution of Health Ideas from Antiquity to the Era of Value-Based Care. Cureus, 9(2), e1018. http://doi.org/10.7759/cureus.1018

Bircher, J. (2005). Towards a dynamic definition of health and disease. Medicine, Health Care and Philosophy, 8(335). https://doi.org/10.1007/s11019-005-0538-y

Government of Canada. (2008). What is Health? Retrieved May 29, 2018 from https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-approach/what-is-health.html

Government of Canada. (2017). Canada Health Act. Retrieved May 29, 2018 from https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html

World Health Organization. (1948). Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948