The Social Determinants of Health
Presented by Lori Kleinsmith, Health Promoter at
Bridges Community Health Centre, Port Colborne, Ontario
Follow me on Twitter - @LoriKleinsmith
The primary factors that shape the health of Canadians are not medical treatments or
lifestyle choices, such as smoking, diet and exercise, but rather the living conditions they
experience. These conditions have come to be known as the social determinants of health.
Unfortunately, this information – based on decades of research and hundreds of studies in
Canada and elsewhere – is unfamiliar to most Canadians. As well, many Canadians assume
that we have full personal control over these factors, yet in most cases these living
conditions are – for better or worse – imposed upon us by the quality of the communities,
housing situations, work settings, health and social service agencies, and educational
institutions in place.
This deceptively simple story speaks to the complex set of factors or conditions that determine
the level of health of every Canadian. It’s called Jason’s Story:
"Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was some
sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to
supervise them.
But why does he live in that neighbourhood?
Because his parents can't afford a nicer place to live.
But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?"
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What Are the Social Determinants of Health?
Health Canada and WHO have produced lists with a few variations – the one I’ve provided is
produced by Dr Dennis Raphael, a professor at York University - Social Determinants of
Health: The Canadian Facts considers 14 social determinants of health:
1. Income and Income Distribution (perhaps the most important)
2. Education
3. Unemployment and Job Security
4. Employment and Working Conditions
5. Early Childhood Development
6. Food Insecurity
7. Housing
8. Social Exclusion
9. Social Safety Network
10. Health Services
11. Aboriginal Status
12. Gender
13. Race
14. Disability
Income is perhaps the most important social determinant of health. In Canada, income
often determines the quality of other social determinants of health such as food security,
housing, and education. It is important to look at income both at the individual or family
level as well as how it is distributed across the population. Thus, we need to look at both
poverty or low socio-economic status as well as income inequality issues. Canada’s income
inequality gap, while not as wide as the US, continues to widen compared to other OECD
countries.
How Do the Social Determinants Impact on Health?
People who suffer from social and material deprivation and adverse living conditions also
experience high, chronic levels of physiological and psychological stress. Stressful conditions
arise from coping with on-going conditions of low income, poor quality housing, food
insecurity, inadequate working conditions, insecure employment, and various forms of
discrimination based on race, disability and/or gender. A lack of supportive relationships,
social isolation and exclusion further increase stress.
At the physiological level, chronic stress can lead to prolonged biological reactions (fight or
flight) that put strain on the body. Our bodies were designed to handle intermittent
stressors not chronic, prolonged stressors. Our bodies need time to recover in non-stressful
environments to prevent toxicity. Over time, chronic stress weakens our resistance to
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disease and people become more vulnerable to cardiovascular and immune system
diseases and adult-onset diabetes. The wealthiest 20% of Canadians live 2-4 years longer
than the poorest 20%. At the neighbourhood level, this gap is even wider, as shown in the
Hamilton Code Red series – up to a 20 year difference in life span.
At the psychological level, stressful and poor living conditions can cause continuing feelings
of shame, insecurity and worthlessness. When living conditions are chronically adverse,
everyday life often appears unpredictable, uncontrollable, and meaningless. This raises
anxiety, hopelessness and exhaustion and makes every day coping even more challenging.
Suicide rates in our lowest income neighbourhoods are almost twice as high as those seen
in the weathiest neighbourhoods. In an attempt to relieve some of these pressures, the
adoption of unhealthy coping behaviours such as smoking, alcohol, and other drugs and
overeating of sugars and carbohydrates can happen, despite people knowing these are
generally unhealthy. The momentary sense of relief over-rides any concerns about long
term health risks. Too often, the medical community is ill-equipped to deal with the
impacts of the social determinants of health – doctors can prescribe a pill for someone
experiencing anxiety or depression, but don’t necessarily dig deeper to find out what might
be causing it – housing, income, employment challenges, etc. are often the root causes.
Factors or Barrier Preventing Canada from Advancing Work on the Social Determinants of
Health
Compare these two lists – Top Ten “Healthy Lifestyle” Tips:
1. Don't smoke. If you can, stop. If you can't, 1. Don't be poor. If you can, stop. If you
cut down.
can't, try not to be poor for long.
2. Follow a balanced diet with plenty of fruit 2. Don't have poor parents.
and vegetables.
3. Own a car.
3. Keep physically active.
4. Don't work in a stressful, low paid manual
4. Manage stress by, for example, talking
job.
things through and making time to relax. 5. Don't live in damp, low quality housing.
5. If you drink alcohol, do so in moderation. 6. Be able to afford to go on a holiday and
6. Cover up in the sun, and protect children
sunbathe.
from sunburn.
7. Practice not losing your job and don't
7. Practice safer sex
become unemployed.
8. Take up cancer screening opportunities.
8. Take up all benefits you are entitled to, if
9. Be safe on the roads: follow the Highway
you are unemployed, retired or sick or
Code.
disabled.
10. Learn the First Aid ABC: airways,
9. Don't live next to a busy major road or
breathing, circulation
near a polluting factory.
10. Learn how to fill in the complex housing
benefit/shelter application forms before
you become homeless and destitute
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List one is heard or used most predominantly in media, school curriculum, etc. We don’t hear
much mainstream discussion of the second list.
Research is also finding that the quality of these health-shaping living conditions is strongly
determined by decisions that governments make in a range of different public policy domains.
Governments at the municipal, provincial/territorial, and federal levels create policies, laws and
regulations that influence how much income Canadians receive through employment, family
benefits, social assistance, public pensions, the quality and availability of affordable housing,
the kinds of health and social services and recreational opportunities we can access, and even
what happens when Canadians lose their jobs during economic downturns.
Canada has produced a wealth of research on the social determinants of health and is
considered a world subject matter expert. Yet, Canada is a laggard in the implementation
of robust public policies to improve the social determinants of health through public policy
action. For example, despite having a variety of income support programs, many of these
programs lack the proper design to ensure all recipients in need can access the program
and not live in poverty – old Age Security, Employment Insurance are two examples.
Access to affordable quality childcare across Canada remains a significant issue and the cost
of post-secondary education continues to rise, while other countries offer tuition-free
college and university. Canada is the only G-8 country without a National Housing strategy
and is the only country with a national medicare program that does not also provide a
national pharmacare program.
Improving the health of Canadians requires we think about health and its determinants in a
more sophisticated manner than has been the case to date. What are some ways to do
this?
Useful Links/Resources
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Social Determinants of Health: The Canadian Facts - http://www.thecanadianfacts.org/
Communicating the Social Determinants of Health: Guidelines for Common Messaging http://nccdh.ca/resources/entry/communicating-the-social-determinants-of-healthcommon-messaging-guidelines
What Makes Canadians Healthy or Unhealthy? http://www.phac-aspc.gc.ca/phsp/determinants/determinants-eng.php#unhealthy
Code Red Series: An in-depth look at health risks across Hamilton’s different
neighbourhoods - http://www.thespec.com/hamilton-topics/3236468-code-red-hamilton
Why Are Canadians Not Being Told the Truth about Disease?
http://www.thespec.com/opinion-story/4405922-why-are-canadians-not-being-told-thetruth-about-disease-/
The Spirit Level: Why Greater Equality Makes Societies Stronger http://www.equalitytrust.org.uk/resources/spirit-level-why-equality-better-everyone
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