453847
2012
GHP19310.1177/1757975912453847D. RaphaelGlobal Health Promotion
Commentary Educating the Canadian public about the social determinants of health: the time for local public health action is now! Dennis Raphael1
Abstract: Despite Canada’s history of developing health promotion and population health concepts, Canada falls behind other wealthy nations in having these ideas implemented in the form of public policy that strengthens the social determinants of health (SDH). Much of this has to do with the lack of awareness by Canadians about the SDH that stems from the lack of media reporting on the determinants of health and the unwillingness of most local public health units across Canada to raise these issues in a consistent manner. Canada is not unique in this situation. If the public health community in Canada is to live up to its self-professed mission of improving the health of Canadians it must undertake to educate the public about the SDH as effectively as it took on the task of educating the public of the importance of not smoking, of exercising and adopting a healthy diet. (Global Health Promotion, 2012; 19(3): 54–59) Keywords: advocacy, determinants of health, health promotion
Introduction The evidence that social determinants of health (SDH) are the primary influences of health across the life span is now extensive (1). The SDH are especially important to the health of children. Adverse living conditions not only shape children’s health but threaten the foundations of health such that the onset of type II diabetes and cardiovascular diseases – among other diseases – during adulthood is firmly related to the experience of childhood adversity (2). Preventing these health problems benefits not only the afflicted but the society as a whole by increasing productivity and reducing health care need. Despite Canada’s history of developing health promotion and population health concepts, Canada falls well behind other wealthy developed nations in having these ideas implemented through public policy that strengthens the SDH (3). Canada’s incidence of poverty, degree of social and health inequalities between rich and poor and investments in public programs that support the health of the
general population and especially the health of the most vulnerable lags well behind other wealthy nations. A recent report by the influential Health Council of Canada identifies how Canada has failed to have its SDH rhetoric translated into health promoting public policies common elsewhere (4). This gap between rhetoric and implementation of public policy regarding the SDH is not specific to Canada, but common in other wealthy developed nations identified as liberal political economies (5,6). These nations include Australia, Ireland and the United Kingdom. While this paper focuses on the situation in Canada, its content applies to other nations facing a gap between rhetoric and action. It is also relevant for nations where public policy that addresses the SDH is evident but needs to be maintained or strengthened. To improve health we must strengthen the message of SDH. And, as the Canadian Public Health Association and the World Health Organization has noted, the most effective means of improving SDH is through advocacy for health promoting public
1. Correspondence to: Dennis Raphael, School of Health Policy and Management, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada. Email: [email protected]
Global Health Promotion 1757-9759; Vol 19(3): 54 –59; 453847 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975912453847 http://ghp.sagepub.com
D. Raphael
55
policy (1,7). Public policy action to strengthen the SDH has not been a priority for the Canadian federal and provincial governments focused on economic recovery and growth, reducing deficits and debts and maintaining the health care system. In this commentary, I examine the role local public health units – the agencies constituted at the municipal and/or regional level and charged with protecting and promoting the health of the population – can play in stimulating SDH-supporting public policy by raising public awareness of the SDH. Such an examination is important because without public understanding of the SDH, governments cannot be expected to undertake such public policy initiatives.
than Canada. And outside of Norway, all these states that surpass Canada on the Society indicators also surpass Canada on the Innovation indicator (see Table 1). The Economy indicator includes Gross Domestic Product (GDP) per capita, GDP growth, productivity growth, unit labour cost growth, inflation, deficitto-GDP ratio, employment growth, unemployment rate and long-term unemployment rate. Innovation consists of spending on research and development, technological cooperation, and patents, among others. The argument that provision of the SDH that improves health and quality of life comes at the cost of economic performance and innovation is clearly not supported.
Canada’s performance in addressing the SDH
Public policies that support the SDH
Canada’s disappointing performance in addressing the SDH is illustrated by a report card on Canada’s social and economic performance issued by the business-oriented Conference Board of Canada (8). The Board carries out extensive analyses of national performance on several broad indicators: health, education and skills, environment, society, economy and innovation on an ongoing basis. In these analyses, the Board provides ranks for these areas for 17 wealthy developed nations. Canadian performance is in the mid-range for most indicators. The important Society indicator – an excellent indicator of provision, and effects, of the SDH – consists of measures of jobless youth, confidence in parliament, disabled income, homicides, elderly poverty, burglaries, child poverty, assaults, working age poverty, life satisfaction, income inequality, acceptance of diversity, intergenerational income mobility, social isolation, gender income gap, suicides and voter turnout. It should be no surprise that the Scandinavian social democratic welfare states come in first, second, third and seventh on the set of indicators that cover this Society domain. And four Continental conservative nations also surpass Canada’s Society rank of ninth. What is of particular interest is the excellent economic performances of the social democratic welfare states of Denmark, Sweden and Norway and the Continental conservative states of the Netherlands, Austria and Switzerland. These nations have better Society and Economy indicators
Improving Canadians’ health involves instituting public policies that have been widely implemented in other wealthy nations. Canada is richer than most of these nations in per capita GDP and therefore has no excuse for not doing so. Public policies that strengthen the SDH are of two kinds. The first kind involves investing in the population through provision of benefits, supports and services that strengthen the SDH (6). Sometimes this involves spending on programs that benefit virtually all Canadians such as early child education and care, employment training and provision of communitybased health care and social services. Other times spending involves provision of adequate benefits to those unable to work because of illness, disability or unemployment. These commitments strengthen the SDH and recent scholarship indicates Canada is among the lowest-spending nations in supporting the SDH (3). Evidence from the Organization for Economic Co-operation and Development in addition to that provided in Table 1 demonstrates that such spending is not inconsistent with economic productivity and innovation but is consistent with improved health and quality of life (9). The second kind of public policy that strengthens the SDH provides rights and privileges to Canadians taken for granted in many wealthy developed nations. This involves the institution of collective employment bargaining, sometimes through the facilitation of workplace unionization, other times through employers voluntarily accepting workplace IUHPE – Global Health Promotion Vol. 19, No. 3 2012
Commentary
56
Table 1. National rankings on a range of indicators in 2008, nations ranked by scores on society area from best to worse
Denmark* Norway* Sweden* Netherlands** Austria** Switzerland** Finland* Belgium** Canada*** France** Ireland*** Germany** Italy** Australia*** United Kingdom*** Japan USA***
Society
Health
Education and skills
Environment
Economy
Innovation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
15 4 5 11 12 2 7 n/a 10 6 13 8 3 9 14 1 16
11 15 5 8 12 4 1 9 2 14 13 7 17 6 10 3 16
11 3 1 13 8 4 2 12 15 6 10 9 7 16 5 14 17
5 1 7 3 4 2 15 12 11 9 17 13 16 6 10 14 8
11 17 5 8 13 1 9 12 14 10 2 6 16 15 7 4 3
*Social Democratic political economies. **Conservative political economies. ***Liberal political economies. Source: Adapted from: Conference Board of Canada (8).
agreements that provide employment security and benefits (9) (see Figure 1[10-12]). Nations with larger proportions of their working population with collective agreements and/or members of unions manifest lower child poverty rates and better performance on indicators of citizen economic and social security (13). In essence, wealthy developed nations that strengthen the SDH have ensured that meeting citizen needs such as income, housing and employment does not fall by the wayside against the needs of those who manage the economy. Such balance is seen not only in Scandinavia but also in the Continental nations of Europe. Public policies that provide economic and social security are good for health.
The importance of public education Part of the reason Canadian governments have not instituted such health promoting policy is lack of Canadians’ awareness of the SDH. Despite the plethora of policy statements, documents and IUHPE – Global Health Promotion Vol. 19, No. 3 2012
reports from the Canadian Public Health Association, the Chief Health Officer of Canada, the Canadian Population Health Initiative and the Public Health Agency of Canada, there has been little penetration of these concepts into the public psyche (14). Without such awareness, SDH-strengthening public policy activities will be less positively received by voters, an important consideration for policymakers considering such policies. The reasons for lack of SDH awareness among Canadians includes lack of media reporting on the SDH and the unwillingness of federal and provincial health authorities and most public health units to consistently raise these issues. In a survey of the 36 public health units in Ontario, Canada’s largest province, only two of the 23 responding units had undertaken ‘community education and awareness campaigns’ about the SDH (15). The activities of these two health units and those of a few others across Canada demonstrate that such action is possible at the local level.
57
100
25
90 80
20
70 60
15
50 40
10
30 20
Child poverty rate
Union density and bargaining coverage
D. Raphael
5
10 0
0
Union Density
Collective Bargaining Coverage
Child Poverty Rate
Figure 1. Union density, collective agreement coverage and child poverty in 2008 (density and coverage rates) and mid-2000s (poverty rates) Data sources: Organization for Economic Co-operation and Development (10); Venn (14). Reproduced with permission from the Organisation for Economic Co-operation and Development, 2008 (12).
The public health unit role The role of local public health units in public education about SDH is therefore essential. Their effects could be substantial since public health units across Canada are relatively well-funded as compared with other local agencies, and they enjoy the respect and attention of the media and public. What these units could be doing about educating the public about the SDH seems rather simple: public health units could take on the task of educating the public about the SDH as effectively as they educated the public of the importance of not smoking, of exercising and adopting a healthy diet. But the apparent simplicity of this suggestion has not led to its implementation. Perhaps this suggestion raises the more difficult question of ‘For what purpose?’ In the case of social marketing campaigns related to ‘healthy lifestyle choices’, the specific actions recommended are clear: ‘Stop smoking, Get physically active, Eat healthier foods’. What is also clearly communicated is: ‘If you adopt healthier lifestyles you will be healthier and avoid illness’. What would be the desired outcomes of a social marketing campaign for the SDH? Hopefully, educated citizens would become engaged in the process by which public policy is made
at the municipal, provincial and federal levels. This could involve advocacy work that influences elected representatives and policymakers, having their professional, employee associations and unions raise the importance of strengthening the SDH, or joining and/or supporting an organisation concerned with one or more SDH such as anti-poverty, child care, food security, housing, health care or women’s issues, among others (16). It is not up to public health units to specify the activities that citizens could undertake to strengthen the SDH. Citizens themselves are quite capable of deciding this for themselves.
What would such public education activities look like? To my mind, it is unacceptable that the public health community tolerates the profound gap between their self-professed rhetoric of protecting and promoting Canadians’ health and their taking the most elementary steps to educate Canadians about the SDH. Public health units have not engaged in public education about the SDH because of their public health training, lack of broader understandings about the SDH, and reluctance to engage in activities that can be viewed as ‘political’. Another problem IUHPE – Global Health Promotion Vol. 19, No. 3 2012
58
Commentary
has been the lack of examples of what such activities would look like. Fortunately, examples now exist of public health units carrying out public education about the SDH. These have seen newspaper ads calling for starting a conversation about the SDH (17), public service messages appearing on television (18) and a public health unit’s video animation (19) – adapted for local use by another unit (20) – of how the SDH are the primary factors shaping health. Other units have developed similar materials (21-23). These activities assume that once public awareness of the SDH is raised, citizens will find ways to apply this new knowledge in a range of activities. This is the essence of health promotion: Health promotion is the process of enabling people to increase control over their health and its deter minants, and thereby improve their health (24). It is also the essence of democracy.
Conclusion These examples may provide a stimulus for public health units across Canada to begin the task of educating the public about the SDH. The document Social Determinants of Health: The Canadian Facts is also available as a public health primer for the public and to date has been downloaded 75,000 times (3). If the statement ‘Canadian Public Health Associa tion members believe in universal and equitable access to the basic conditions which are necessary to achieve health for all Canadians’ (25) is to be taken seriously, then public health units must communicate to the public what is known about the SDH and provide an arena for citizen action. What will it take for Canadian public health units to educate the public about the SDH? What will be the consequences for the health of Canadians if they do not? References 1. World Health Organization. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 2. Raphael D. Poverty in childhood and adverse health outcomes in adulthood. Maturitas. 2011; 69: 22-26. 3. Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto, Canada: IUHPE – Global Health Promotion Vol. 19, No. 3 2012
School of Health Policy and Management, York University. Available at http://thecanadianfacts.org (2010, accessed November 4, 2011). 4. Health Council of Canada. Stepping it Up: Moving the Focus from Health Care in Canada to a Healthier Canada. Toronto, Canada: Health Council of Canada. Available at http://www.healthcouncilcanada.ca/tree/ 2.40-HCCpromoDec2010.pdf (2010, accessed July 2, 2012). 5. Raphael D. The political economy of health promotion: Part 2, national provision of the prerequisites of health. Health Promot Int. 2011; DOI: 10.1093/heapro/dar058. 6. Raphael D. The political economy of health promotion: Part 1, national commitments to the provision of the prerequisites of health. Health Promot Int. 2011; DOI: 10.1093/heapro/dar084. 7. Canadian Public Health Association. Action Statement for Health Promotion in Canada. Ottawa, Canada: Canadian Public Health Association. Available at http://www.cpha.ca/en/programs/policy/action.aspx (1996, accessed November 4, 2011). 8. Conference Board of Canada. How Canada Performs: A Report Card on Canada. Ottawa, Canada: Conference Board of Canada; 2009. 9. Organization for Economic Co-operation and Development. OECD Employment Outlook 2004. Paris, France: Organization for Economic Co-operation and Development; 2004. 10. Organization for Economic Co-operation and Development. Trade Union Density. Available at http://stats.oecd.org/Index.aspx?DataSetCode=UN_ DEN (2010, accessed July 2, 2012). 11. Venn D. Legislation, Collective Bargaining and Enfor cement: Updating the OECD Employment Protection Indicators, OECD Social Employment and Migration Working Papers, No. 89, Paris, France: OECD; 2009. 12. Organization for Economic Co-operation and Develop ment. Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris, France: OECD; 2008. 13. Swank D. Globalization, domestic politics, and welfare state retrenchment in capitalist democracies. Social Policy Soc. 2005; 4: 183-195. 14. Canadian Population Health Initiative. Select Highlights on Public Views of the Determinants of Health. Ottawa, Canada: CPHI. Available at https:// secure.cihi.ca/estore/productSeries.htm?pc=PCC267 (2004, accessed November 4, 2011). 15. Joint OPHA/ALPHA Working Group on the Social Determinants of Health. Activities to Address the Social Determinants of Health in Ontario Local Public Health Units. Toronto, Canada: Joint OPHA/ALPHA Working Group on the Social Determinants of Health. Available at http://www.alphaweb.org/docs/lib_013531606.pdf (2010, accessed November 4, 2011). 16. Raphael D. About Canada: Health and Illness. Winnipeg, Canada: Fernwood Publishing; 2010. 17. Sudbury and District Health Unit. The most important things you can do for your health may not be as
D. Raphael
obvious as you think. Sudbury, ON, Canada: Sudbury and District Health Unit. Available at http://www. sdhu.com/content/healthy_living/doc.asp?folder=322 5&parent=3225&doc=7846&lang=0 (2011, accessed November 4, 2011). 18. Peterborough County-City Health Unit. Poverty and Health: Take Action for a Healthier Community. Available at http://pcchu.peterborough.on.ca/PH/ PH-home.html (2008, accessed November 4, 2011). 19. Sudbury and District Health Unit. Let’s Start a Conversation about Health ... and Not Talk about Health Care at all. Sudbury, ON, Canada: Sudbury and District Health Unit. Available at http://www. sdhu.com/content/healthy_living/doc.asp?folder=222 03&parent=3225&lang=0&doc=11749#video (2011, accessed on November 4, 2011). 20. Chatham-Kent Health Unit. Let’s Start a Conversation about Health . . . and Not Talk about Health Care at all. Chatham, ON, Canada: Chatham-Kent Health Unit.
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Available at http://www.youtube.com/watch?v=NyTnivn93Y&feature=related (2011, accessed November 4, 2011). 21. Interior Health Region. Beyond Health Services and Lifestyle: A Social Determinants Approach to Health. Kelowna, BC, Canada: Interior Health Region. 22. Regina Qu’Appelle Health Region. From Concept to Action: Social Determinants of Health Work Plan. Regina, Canada: Regina Qu’Appelle Health Region; 2008. 23. Vancouver Coastal Health. Population Health: What makes our communities healthy? Vancouver, Canada: Vancouver Coastal Health; 2011. 24. World Health Organization. The Bangkok Charter for Health Promotion in a Globalized World. Geneva, Switzerland: World Health Organization; 2005. 25. Canadian Public Health Association. Welcome to CPHA. Ottawa, Canada: Canadian Public Health Association;. Available at http://www.cpha.ca/en/ default.aspx (2011, accessed November 4, 2011).
IUHPE – Global Health Promotion Vol. 19, No. 3 2012
2012
GHP19310.1177/1757975912453847D. RaphaelGlobal Health Promotion
Commentary Educating the Canadian public about the social determinants of health: the time for local public health action is now! Dennis Raphael1
Abstract: Despite Canada’s history of developing health promotion and population health concepts, Canada falls behind other wealthy nations in having these ideas implemented in the form of public policy that strengthens the social determinants of health (SDH). Much of this has to do with the lack of awareness by Canadians about the SDH that stems from the lack of media reporting on the determinants of health and the unwillingness of most local public health units across Canada to raise these issues in a consistent manner. Canada is not unique in this situation. If the public health community in Canada is to live up to its self-professed mission of improving the health of Canadians it must undertake to educate the public about the SDH as effectively as it took on the task of educating the public of the importance of not smoking, of exercising and adopting a healthy diet. (Global Health Promotion, 2012; 19(3): 54–59) Keywords: advocacy, determinants of health, health promotion
Introduction The evidence that social determinants of health (SDH) are the primary influences of health across the life span is now extensive (1). The SDH are especially important to the health of children. Adverse living conditions not only shape children’s health but threaten the foundations of health such that the onset of type II diabetes and cardiovascular diseases – among other diseases – during adulthood is firmly related to the experience of childhood adversity (2). Preventing these health problems benefits not only the afflicted but the society as a whole by increasing productivity and reducing health care need. Despite Canada’s history of developing health promotion and population health concepts, Canada falls well behind other wealthy developed nations in having these ideas implemented through public policy that strengthens the SDH (3). Canada’s incidence of poverty, degree of social and health inequalities between rich and poor and investments in public programs that support the health of the
general population and especially the health of the most vulnerable lags well behind other wealthy nations. A recent report by the influential Health Council of Canada identifies how Canada has failed to have its SDH rhetoric translated into health promoting public policies common elsewhere (4). This gap between rhetoric and implementation of public policy regarding the SDH is not specific to Canada, but common in other wealthy developed nations identified as liberal political economies (5,6). These nations include Australia, Ireland and the United Kingdom. While this paper focuses on the situation in Canada, its content applies to other nations facing a gap between rhetoric and action. It is also relevant for nations where public policy that addresses the SDH is evident but needs to be maintained or strengthened. To improve health we must strengthen the message of SDH. And, as the Canadian Public Health Association and the World Health Organization has noted, the most effective means of improving SDH is through advocacy for health promoting public
1. Correspondence to: Dennis Raphael, School of Health Policy and Management, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada. Email: [email protected]
Global Health Promotion 1757-9759; Vol 19(3): 54 –59; 453847 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975912453847 http://ghp.sagepub.com
D. Raphael
55
policy (1,7). Public policy action to strengthen the SDH has not been a priority for the Canadian federal and provincial governments focused on economic recovery and growth, reducing deficits and debts and maintaining the health care system. In this commentary, I examine the role local public health units – the agencies constituted at the municipal and/or regional level and charged with protecting and promoting the health of the population – can play in stimulating SDH-supporting public policy by raising public awareness of the SDH. Such an examination is important because without public understanding of the SDH, governments cannot be expected to undertake such public policy initiatives.
than Canada. And outside of Norway, all these states that surpass Canada on the Society indicators also surpass Canada on the Innovation indicator (see Table 1). The Economy indicator includes Gross Domestic Product (GDP) per capita, GDP growth, productivity growth, unit labour cost growth, inflation, deficitto-GDP ratio, employment growth, unemployment rate and long-term unemployment rate. Innovation consists of spending on research and development, technological cooperation, and patents, among others. The argument that provision of the SDH that improves health and quality of life comes at the cost of economic performance and innovation is clearly not supported.
Canada’s performance in addressing the SDH
Public policies that support the SDH
Canada’s disappointing performance in addressing the SDH is illustrated by a report card on Canada’s social and economic performance issued by the business-oriented Conference Board of Canada (8). The Board carries out extensive analyses of national performance on several broad indicators: health, education and skills, environment, society, economy and innovation on an ongoing basis. In these analyses, the Board provides ranks for these areas for 17 wealthy developed nations. Canadian performance is in the mid-range for most indicators. The important Society indicator – an excellent indicator of provision, and effects, of the SDH – consists of measures of jobless youth, confidence in parliament, disabled income, homicides, elderly poverty, burglaries, child poverty, assaults, working age poverty, life satisfaction, income inequality, acceptance of diversity, intergenerational income mobility, social isolation, gender income gap, suicides and voter turnout. It should be no surprise that the Scandinavian social democratic welfare states come in first, second, third and seventh on the set of indicators that cover this Society domain. And four Continental conservative nations also surpass Canada’s Society rank of ninth. What is of particular interest is the excellent economic performances of the social democratic welfare states of Denmark, Sweden and Norway and the Continental conservative states of the Netherlands, Austria and Switzerland. These nations have better Society and Economy indicators
Improving Canadians’ health involves instituting public policies that have been widely implemented in other wealthy nations. Canada is richer than most of these nations in per capita GDP and therefore has no excuse for not doing so. Public policies that strengthen the SDH are of two kinds. The first kind involves investing in the population through provision of benefits, supports and services that strengthen the SDH (6). Sometimes this involves spending on programs that benefit virtually all Canadians such as early child education and care, employment training and provision of communitybased health care and social services. Other times spending involves provision of adequate benefits to those unable to work because of illness, disability or unemployment. These commitments strengthen the SDH and recent scholarship indicates Canada is among the lowest-spending nations in supporting the SDH (3). Evidence from the Organization for Economic Co-operation and Development in addition to that provided in Table 1 demonstrates that such spending is not inconsistent with economic productivity and innovation but is consistent with improved health and quality of life (9). The second kind of public policy that strengthens the SDH provides rights and privileges to Canadians taken for granted in many wealthy developed nations. This involves the institution of collective employment bargaining, sometimes through the facilitation of workplace unionization, other times through employers voluntarily accepting workplace IUHPE – Global Health Promotion Vol. 19, No. 3 2012
Commentary
56
Table 1. National rankings on a range of indicators in 2008, nations ranked by scores on society area from best to worse
Denmark* Norway* Sweden* Netherlands** Austria** Switzerland** Finland* Belgium** Canada*** France** Ireland*** Germany** Italy** Australia*** United Kingdom*** Japan USA***
Society
Health
Education and skills
Environment
Economy
Innovation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
15 4 5 11 12 2 7 n/a 10 6 13 8 3 9 14 1 16
11 15 5 8 12 4 1 9 2 14 13 7 17 6 10 3 16
11 3 1 13 8 4 2 12 15 6 10 9 7 16 5 14 17
5 1 7 3 4 2 15 12 11 9 17 13 16 6 10 14 8
11 17 5 8 13 1 9 12 14 10 2 6 16 15 7 4 3
*Social Democratic political economies. **Conservative political economies. ***Liberal political economies. Source: Adapted from: Conference Board of Canada (8).
agreements that provide employment security and benefits (9) (see Figure 1[10-12]). Nations with larger proportions of their working population with collective agreements and/or members of unions manifest lower child poverty rates and better performance on indicators of citizen economic and social security (13). In essence, wealthy developed nations that strengthen the SDH have ensured that meeting citizen needs such as income, housing and employment does not fall by the wayside against the needs of those who manage the economy. Such balance is seen not only in Scandinavia but also in the Continental nations of Europe. Public policies that provide economic and social security are good for health.
The importance of public education Part of the reason Canadian governments have not instituted such health promoting policy is lack of Canadians’ awareness of the SDH. Despite the plethora of policy statements, documents and IUHPE – Global Health Promotion Vol. 19, No. 3 2012
reports from the Canadian Public Health Association, the Chief Health Officer of Canada, the Canadian Population Health Initiative and the Public Health Agency of Canada, there has been little penetration of these concepts into the public psyche (14). Without such awareness, SDH-strengthening public policy activities will be less positively received by voters, an important consideration for policymakers considering such policies. The reasons for lack of SDH awareness among Canadians includes lack of media reporting on the SDH and the unwillingness of federal and provincial health authorities and most public health units to consistently raise these issues. In a survey of the 36 public health units in Ontario, Canada’s largest province, only two of the 23 responding units had undertaken ‘community education and awareness campaigns’ about the SDH (15). The activities of these two health units and those of a few others across Canada demonstrate that such action is possible at the local level.
57
100
25
90 80
20
70 60
15
50 40
10
30 20
Child poverty rate
Union density and bargaining coverage
D. Raphael
5
10 0
0
Union Density
Collective Bargaining Coverage
Child Poverty Rate
Figure 1. Union density, collective agreement coverage and child poverty in 2008 (density and coverage rates) and mid-2000s (poverty rates) Data sources: Organization for Economic Co-operation and Development (10); Venn (14). Reproduced with permission from the Organisation for Economic Co-operation and Development, 2008 (12).
The public health unit role The role of local public health units in public education about SDH is therefore essential. Their effects could be substantial since public health units across Canada are relatively well-funded as compared with other local agencies, and they enjoy the respect and attention of the media and public. What these units could be doing about educating the public about the SDH seems rather simple: public health units could take on the task of educating the public about the SDH as effectively as they educated the public of the importance of not smoking, of exercising and adopting a healthy diet. But the apparent simplicity of this suggestion has not led to its implementation. Perhaps this suggestion raises the more difficult question of ‘For what purpose?’ In the case of social marketing campaigns related to ‘healthy lifestyle choices’, the specific actions recommended are clear: ‘Stop smoking, Get physically active, Eat healthier foods’. What is also clearly communicated is: ‘If you adopt healthier lifestyles you will be healthier and avoid illness’. What would be the desired outcomes of a social marketing campaign for the SDH? Hopefully, educated citizens would become engaged in the process by which public policy is made
at the municipal, provincial and federal levels. This could involve advocacy work that influences elected representatives and policymakers, having their professional, employee associations and unions raise the importance of strengthening the SDH, or joining and/or supporting an organisation concerned with one or more SDH such as anti-poverty, child care, food security, housing, health care or women’s issues, among others (16). It is not up to public health units to specify the activities that citizens could undertake to strengthen the SDH. Citizens themselves are quite capable of deciding this for themselves.
What would such public education activities look like? To my mind, it is unacceptable that the public health community tolerates the profound gap between their self-professed rhetoric of protecting and promoting Canadians’ health and their taking the most elementary steps to educate Canadians about the SDH. Public health units have not engaged in public education about the SDH because of their public health training, lack of broader understandings about the SDH, and reluctance to engage in activities that can be viewed as ‘political’. Another problem IUHPE – Global Health Promotion Vol. 19, No. 3 2012
58
Commentary
has been the lack of examples of what such activities would look like. Fortunately, examples now exist of public health units carrying out public education about the SDH. These have seen newspaper ads calling for starting a conversation about the SDH (17), public service messages appearing on television (18) and a public health unit’s video animation (19) – adapted for local use by another unit (20) – of how the SDH are the primary factors shaping health. Other units have developed similar materials (21-23). These activities assume that once public awareness of the SDH is raised, citizens will find ways to apply this new knowledge in a range of activities. This is the essence of health promotion: Health promotion is the process of enabling people to increase control over their health and its deter minants, and thereby improve their health (24). It is also the essence of democracy.
Conclusion These examples may provide a stimulus for public health units across Canada to begin the task of educating the public about the SDH. The document Social Determinants of Health: The Canadian Facts is also available as a public health primer for the public and to date has been downloaded 75,000 times (3). If the statement ‘Canadian Public Health Associa tion members believe in universal and equitable access to the basic conditions which are necessary to achieve health for all Canadians’ (25) is to be taken seriously, then public health units must communicate to the public what is known about the SDH and provide an arena for citizen action. What will it take for Canadian public health units to educate the public about the SDH? What will be the consequences for the health of Canadians if they do not? References 1. World Health Organization. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 2. Raphael D. Poverty in childhood and adverse health outcomes in adulthood. Maturitas. 2011; 69: 22-26. 3. Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto, Canada: IUHPE – Global Health Promotion Vol. 19, No. 3 2012
School of Health Policy and Management, York University. Available at http://thecanadianfacts.org (2010, accessed November 4, 2011). 4. Health Council of Canada. Stepping it Up: Moving the Focus from Health Care in Canada to a Healthier Canada. Toronto, Canada: Health Council of Canada. Available at http://www.healthcouncilcanada.ca/tree/ 2.40-HCCpromoDec2010.pdf (2010, accessed July 2, 2012). 5. Raphael D. The political economy of health promotion: Part 2, national provision of the prerequisites of health. Health Promot Int. 2011; DOI: 10.1093/heapro/dar058. 6. Raphael D. The political economy of health promotion: Part 1, national commitments to the provision of the prerequisites of health. Health Promot Int. 2011; DOI: 10.1093/heapro/dar084. 7. Canadian Public Health Association. Action Statement for Health Promotion in Canada. Ottawa, Canada: Canadian Public Health Association. Available at http://www.cpha.ca/en/programs/policy/action.aspx (1996, accessed November 4, 2011). 8. Conference Board of Canada. How Canada Performs: A Report Card on Canada. Ottawa, Canada: Conference Board of Canada; 2009. 9. Organization for Economic Co-operation and Development. OECD Employment Outlook 2004. Paris, France: Organization for Economic Co-operation and Development; 2004. 10. Organization for Economic Co-operation and Development. Trade Union Density. Available at http://stats.oecd.org/Index.aspx?DataSetCode=UN_ DEN (2010, accessed July 2, 2012). 11. Venn D. Legislation, Collective Bargaining and Enfor cement: Updating the OECD Employment Protection Indicators, OECD Social Employment and Migration Working Papers, No. 89, Paris, France: OECD; 2009. 12. Organization for Economic Co-operation and Develop ment. Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris, France: OECD; 2008. 13. Swank D. Globalization, domestic politics, and welfare state retrenchment in capitalist democracies. Social Policy Soc. 2005; 4: 183-195. 14. Canadian Population Health Initiative. Select Highlights on Public Views of the Determinants of Health. Ottawa, Canada: CPHI. Available at https:// secure.cihi.ca/estore/productSeries.htm?pc=PCC267 (2004, accessed November 4, 2011). 15. Joint OPHA/ALPHA Working Group on the Social Determinants of Health. Activities to Address the Social Determinants of Health in Ontario Local Public Health Units. Toronto, Canada: Joint OPHA/ALPHA Working Group on the Social Determinants of Health. Available at http://www.alphaweb.org/docs/lib_013531606.pdf (2010, accessed November 4, 2011). 16. Raphael D. About Canada: Health and Illness. Winnipeg, Canada: Fernwood Publishing; 2010. 17. Sudbury and District Health Unit. The most important things you can do for your health may not be as
D. Raphael
obvious as you think. Sudbury, ON, Canada: Sudbury and District Health Unit. Available at http://www. sdhu.com/content/healthy_living/doc.asp?folder=322 5&parent=3225&doc=7846&lang=0 (2011, accessed November 4, 2011). 18. Peterborough County-City Health Unit. Poverty and Health: Take Action for a Healthier Community. Available at http://pcchu.peterborough.on.ca/PH/ PH-home.html (2008, accessed November 4, 2011). 19. Sudbury and District Health Unit. Let’s Start a Conversation about Health ... and Not Talk about Health Care at all. Sudbury, ON, Canada: Sudbury and District Health Unit. Available at http://www. sdhu.com/content/healthy_living/doc.asp?folder=222 03&parent=3225&lang=0&doc=11749#video (2011, accessed on November 4, 2011). 20. Chatham-Kent Health Unit. Let’s Start a Conversation about Health . . . and Not Talk about Health Care at all. Chatham, ON, Canada: Chatham-Kent Health Unit.
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Available at http://www.youtube.com/watch?v=NyTnivn93Y&feature=related (2011, accessed November 4, 2011). 21. Interior Health Region. Beyond Health Services and Lifestyle: A Social Determinants Approach to Health. Kelowna, BC, Canada: Interior Health Region. 22. Regina Qu’Appelle Health Region. From Concept to Action: Social Determinants of Health Work Plan. Regina, Canada: Regina Qu’Appelle Health Region; 2008. 23. Vancouver Coastal Health. Population Health: What makes our communities healthy? Vancouver, Canada: Vancouver Coastal Health; 2011. 24. World Health Organization. The Bangkok Charter for Health Promotion in a Globalized World. Geneva, Switzerland: World Health Organization; 2005. 25. Canadian Public Health Association. Welcome to CPHA. Ottawa, Canada: Canadian Public Health Association;. Available at http://www.cpha.ca/en/ default.aspx (2011, accessed November 4, 2011).
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