The Social Determinants of Health in Canada

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It has been known that the improvements in health in Canada and other countries have not been because of the advances in medicine or health care, but rather because of an improvement in the societies in which we live. Thus, the primary factors that shape the health of Canadians are not medical treatments or lifestyle choices, but rather by the living conditions they experience. These conditions are known as the social determinants of health.

Canada and Health

Being a wealthy developed country, many Canadians are largely unaware that their health is shaped by many factors that may seem unrelated to health. There is evidence that demonstrates the relationship between the social determinants of health Canadians experience and the wide health inequalities that exist. Canadian's lifespans and possibilities for developing disease can be determined by their living conditions. For example, a reduction of deaths from infectious diseases such as typhoid, influenza, and diphtheria were not because of immunizations or medicine, but rather from improvements in living conditions[1]. Ottawa Charter for Health Promotion states that the prerequisites for health include peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity[2]. Moreover, Health Canada identifies income, social status, social support networks, education, employment, working conditions, physical and social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, and health services as key determinants of health[3]. Therefore, some of the major determinants of health will be discussed below.

List of Social Determinants

  • Income
  • Education
  • Unemployment
  • Working Conditions
  • Early Childhood Development
  • Food Insecurity
  • Housing
  • Social Exclusion
  • Health services
  • Gender
  • Race
  • Aboriginal Status
  • Disability
  • (This Wiki will focus on the main determinants income, unemployment, education, gender, race, aboriginal status)

Social Determinants

Income

In Canada, income inequality and poverty has been a growing problem. The Organization for Economic Co-operation and Development (OECD) has found that Canada shows one of the greatest increases in income inequality and poverty from the 1990s to the mid-2000s.[4] The OECD also ranked Canada 22nd of 22 OECD nations in percentage of work being low waged with 21% of men identified as low-wage workers.[5] Moreover, data shows that the poverty rate in Canada had risen from 16.6% in 1986 to to 18% in 1996 [6]

Life Expectancy based on Income Quintile of Neighbourhood

Income levels affect ones ability to afford the basic necessities of health and play a large role in determining whether any of the other determinants (eg. food security, housing, education) of health can be attained. Compared to other wealthy developed countries, Canadians are provided with less benefits as a matter of right. For example, Canada funds public education and necessary medical procedures for children until they reach grade 12, but childcare, housing, food, clothing, post-secondary education and resources for retirement are not funded. Thus, low income predisposes people to deprivation of many determinants of health. The links between income and health outcomes are highlighted in many studies. Children living in family poverty are more likely to experience physical, mental, and social health problems. [7] [8][9] [10] Researchers have also found that men in the wealthiest neighbourhoods in Canada live on average four years longer than men in the poorest neighbourhoods and for women two years longer.[11] Another study also found out that those living in the poorest neighbourhoods had 28% higher death rates than those living in the richest neighbourhoods.[12] Additionally, many studies have demonstrated that diabetes and heart attacks are far more common among Canadians with low incomes [13] [14].

Unemployment

Job insecurity has been increasing in Canada for the past few years. Currently, excluding those who are unemployed, only half of the working aged Canadians have had a full-time job for six months or more.

Various Forms of Employment in the Canadian Workforce

The Canadian workforce contains 14% who are self-employed, 10% percent who have temporary work, 18% with part-time jobs, 6% who have been employed in their current job for less than 6 months and 5% who are working more than 1 job.[15] Moreover, on an OECD index that calculates the policies that protect employment and provides benefits to temporary workers, Canada performs very poorly by achieving a score that was ranked 26th out of 28 nations.[16]

Unemployment is related to poor health through various pathways. First off, employment provides the income needed to procure necessary material related to health. On the other hand, unemployment will mean material deprivation and poverty due to the reduced income and benefits. In this way, all the issues relating to health and income will be seen as well. Secondly, an insecure job often consists of intense work and hours, which can cause stress, body aches, injury, sleep deprivation, high blood pressure and heart disease. [17] Studies have also shown that unemployed people and their families suffer a much higher risk of premature death. [18]

Education

Education is an important social determinant of health. Compared to other countries, Canada's education state is good as Canadian test scores ranked in the top 4 of studied countries. [19]

Canadian test scores comparative

In Canada, high school education is publicly funded, thus Canadians citizens have the opportunity to gain some sort of education.[20] However, post-secondary education is not funded by the Canadian government, and as a result, only about half of the population has received some post-secondary education.[21]

First of all, level of education is highly correlated with other social determinants of health. A lack of education can further perpetuate the effects of low income, employment insecurity and working conditions. Studies have shown that people with limited literacy will likely have a low income.[22] Also, one's health may be at risk when safety is dependent on the ability to read and comprehend rules, signs and manuals while at work or performing dangerous tasks.[23] Similarly, a lack of education can be directly linked to health as one may have difficulty reading medical prescriptions and understanding other important written material.[24] Furthermore, those with a higher education level can function better in the world as they will have a better understanding of the different societal factors that affect their health and can make better lifestyle choices. For example, a study found that low literacy was associated with tobacco and alcohol use.[25] Other studies also found that people with lower literacy have less knowledge about medical conditions and treatments, make less use of preventative services and are less likely to seek care, even though their hospitalization rates are higher.[26] In general, a higher education level provides one with a greater ability and more resources to attain a healthier lifestyle.

Gender

Statistics of Different Groups of Women and Poverty

Women in Canada tend to experience more adverse social determinants of health than men. For occupation, women are less likely to be employed than men and are more likely to be working part-time. [27] Secondly, women also tend to earn less than men. For example, among women working in management, women on average ear $956 per week compared to the $1261 earned by men.[28] Moreover, the gap in earnings seems to have increased from 2004 to 2005 [29]. Among other nations, Canada is is one of the nations with the greatest gap between gender earnings with a ranking of 19th of 22 of nations in terms of wage gap reductions. [30]. Thus, women will experience to a greater extent the affects of low income and health.

Gender can also affect health as a result of the different roles and responsibilities associated with gender. Women tend to carry more responsibility for raising children and do housework. This forces women to stay home, making them less likely to be working full-time and to be eligible for unemployment benefits. [31]. For example, many women aged forty who had interrupted their careers for maternity leave were earning about 30% less than women with no children.[32] Single mothers are especially at high risk of being in poverty because they often need to stay home to look after their child due to the lack of affordable childcare services. As a result, they are unable to work full-time hours and will have lower wages.[33] As for males, masculinity is often associated with strength, which means that some males may choose to tough it out rather than seek care. Males tend to take more safety-related risks and are more often injured [34] [35] [36]. Men are also more likely to experience social exclusion that can lead to homelessness and substance abuse, the suicide rate of men is 4 times higher than that of women and lastly men are more likely to be victims of physical assault [37] [38].

Race

Canada prides itself on being multicultural. However, racialized Canadians face many more difficulties that may threaten their health. Canadian of colour have higher unemployment rates and lower incomes and those of European descent. [39] Non- european immigrants were also 2 times as likely to report health problems as findings show that they were 50% more likely to frequently visit doctors than the Canadian born population. [40] Racialized groups in Canada tend to have lower status occupations and are more likely to experience low income, poverty, housing insecurity and food insecurity [41] Thus, the Canadian society's discrimination towards different races can determine one's health.

Aboriginal Status

Canada and Canadian Aboriginal Human Development Index Comparison

There are about 1.2 million Aboriginal peoples in Canada, which is about 3.8% of the Canadian population[42] The health of Aboriginal people have generally been worse than the average Canadian. The life expectancies of Aboriginal peoples are 5 to 14 years less than the Canadian population[43] Infant mortality rates are 1.5 to 4 times greater among Aboriginal Canadians than Canadians [44] Rates of infectious diseases are also much higher in the Aboriginal than non-Aboriginal Canadian population.[45] Suicide rates among Aboriginal Canadians are five to six times higher than the average Canadian, along with higher rates of depression, alcoholism, and experiencing sexual abuse during childhood. [46] When looking at the United Nations Human Development Index, a huge difference is clearly seen as Canada itself ranked 8th but the Canadian Aboriginal population ranked 33rd. [47]

The health issues among the Aboriginals is resulting from the poor status of many different social determinants of health, reflecting their history of exclusion in Canada [48] The average income of Aboriginal men and women in 2001 was $21,958 and $16,529 respectively, which is 58% of the average income of non-Aboriginal men and 72% of the average income of non-Aboriginal women.[49] For education, among First Nation people living on reserve, 40% of men and 43% of women attain a high school education and for people living off-reserve the statistics were 56% for men and 57% for women.[50] For food security, a study showed that 14% of Aboriginal households experienced food insecurity while only 2.7% of non-Aboriginal households experienced it. [51] For example, a study in the Aboriginals communities in Repulse Bay and Pond Inlet found that about 50% of each community’s families reported not having enough to eat [52] Evidently, the Aboriginal peoples in Canada have a lower status when it comes to their social determinants of health.

Canadian Government and Health

The World Health Organization states that health deterioration is caused by both poor social policies and programmes, unfair economic arrangements, and bad politics. [53] Canada has had a reputation of being a "health-promotion powerhouse" due to its high quality concepts and ideas.[54] In 1986, the Action Statement for Health Promotion in Canada stated that healthy public policies will positively affect the determinants of health. [55] However, there is evidence showing that Canada has not applied many of their public health concepts in practice. [56] From the 1970's, the Canadian Government has since weakened the welfare structure and their policies have increased income and wealth inequalities, created crises in housing and food security, and increased employment instability. [57] Moreover, Canadian spending in support of families, persons with disabilities, older Canadians, and employment training is also among the lowest of these same wealthy developed nations. [58].

Policy Implications

Canada's Growing Gap [59] and Britain's Acheson Independent Inquiry into Inequalities in Health [60] recommended many ways to the government can reduce health inequities via different public policies :

Income and Poverty:

  • Increasing the minimum wage to a living wage
  • boost assistance levels for those unable to work
  • improve income support
  • Reduce income inequalities in income via progressive taxation

Education:

  • adequately fund and improve the Canadian education system
  • funding mechanisms should be more strongly weighted to reflect need and socioeconomic disadvantage
  • improve access to higher education by better controlling the tuition fees for university and college education

Employment:

  • provided access to adequate income, training, and employment opportunities
  • further investment in high quality training for young and long-term unemployed people
  • greater degrees of unionized workplaces

Race:

  • needs of minority ethnic groups be specifically considered in the development and implementation of policies aimed at reducing socioeconomic inequalities

Aboriginal status: The 1996 Royal Commission on Aboriginal Peoples made a number of recommendations, virtually all of which have not been implemented. [61]

  • Replace the federal Department of Indian Affairs with two departments, one to implement a new relationship with Aboriginal nations and one to provide services for non-self-governing communities.
  • Creation of an Aboriginal Parliament.
  • Initiatives to address social, education, health, and housing needs, including the training of 10,000 health professionals over a 10-year period, the establishment of an Aboriginal peoples’ university, and recognition of Aboriginal nations’ authority over child welfare.

Gender:

  • Improving and enforcing pay equity legislation
  • Provide accessible and affordable high quality childcare program
  • create and improve policies which reduce excess accidental mortality and suicide in young men

References

  1. ↑ McKinlay, J. M. & McKinlay, S. M. (1987). Medical measures and the decline of mortality. In H. Schwartz (ed.). Dominant issues in medical sociology. New York: Random House
  2. ↑ World Health Organization (1986). Ottawa charter on health promotion. Geneva: Author. On-line at: http://www.who.dk/policy/ottawa.htm
  3. ↑ Health Canada (1998). Taking action on population health: A position paper for Health Promotion and Programs Branch Staff. Ottawa: Health Canada, 1998. On-line at: http://www.hcsc.gc.ca/main/hppb/phdd/resource.htm
  4. ↑ Organisation for Economic Co-operation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Paris: Organisation for Economic Co-operation and Development
  5. ↑ http://www.oecd.org/edu/eag2013%20(eng)--FINAL%2020%20June%202013.pdf
  6. ↑ Centre for International Statistics, Canadian Centre on Social Development (1998). Incidence of child poverty by province, Canada, 1990-1996. Ottawa. On-line at: http://www.ccsd.ca/factsheets/fscphis2.htm
  7. ↑ Lightman, E., Mitchell, A., & Wilson, B. (2008). Poverty is making us sick: A comprehensive survey of income and health in Canada. Toronto: Wellesley Institute.
  8. ↑ Raphael, D. (2010). The health of Canada's children. Part I. Canadian children's health in comparative perspective. Paediatrics and Child Health, 15(1), 23–29.
  9. ↑ Raphael, D. (2011). Poverty in Canada: Implications for health and quality of life (2nd ed.). Toronto: Canadian Scholars' Press.
  10. ↑ Wallis, M., & Kwok, S. (Eds.). (2008). Daily struggles: The deepening racialization and feminization of poverty in Canada. Toronto: Canadian Scholars' Press
  11. ↑ Wilkins, R. (2007). Mortality by Neighbourhood Income in Urban Canada from 1971 to 2001. Ottawa: Statistics Canada, Health Analysis and Measurement Group
  12. ↑ Auger, N., & Alix, C. (2009). ‘Income, Income Distribution, and Health in Canada’. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (pp. 61-74). 2nd edition. Toronto: Canadian Scholars’ Press
  13. ↑ Auger, N., & Alix, C. (2009). ‘Income, Income Distribution, and Health in Canada’. In D. Raphael (Ed.)
  14. ↑ Social Determinants of Health: Canadian Perspectives (pp. 61-74). 2nd edition. Toronto: Canadian Scholars’ Press
  15. ↑ Statistics Canada. (2005). Enquete sur la population active. Special calculations of the Statistical Institute of Quebec.
  16. ↑ Tremblay, D. G. (2009). ‘Precarious Work and the Labour Market.’ In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (2nd ed., pp. 75-87). Toronto: Canadian Scholars’ Press
  17. ↑ Ferris Je et al. Employment status and health after privatisation in white collar civil servants: prospective cohort study. British Medical Journal, 2001, 322:647-651.
  18. ↑ Beale N, Nethercott S. Job-loss and family morbidity: a study of a factory closure. Journal of the Royal College of General Practioners, 1985, 35:510-514
  19. ↑ Progress in International Reading Literacy Study (PIRLS, 2006) and Trends in International Mathematics and Science Study (TIMSS, 2007).
  20. ↑ Lucy Scholey. "2015 federal budget ‘disappointing’ for post-secondary students: CFS".
  21. ↑ http://well-being.esdc.gc.ca/misme-iowb/.3ndic.1t.4r@-eng.jsp?iid=29
  22. ↑ Weiss, B.D., Blanchard, J.S., McGee, D.L., Hart, G., Burgoon, W.B., & Smith, K.J (1994). Illiteracy among Medicaid recipients and its relationship to health car costs. Journal of Health Care for the Poor and Undeserved, 5(2), 99-111.
  23. ↑ Health Canada. How does literacy affect the health of Canadians? 2003
  24. ↑ Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviriaral therapies in HIV patients of low literacy. J Gen Intern Med 1999
  25. ↑ Hawthorne G. Pre-teenage drug use in Australia: Key predictors and school-based drug education. J Adolesc Health 1997;20(5):384-95.
  26. ↑ Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40(5)
  27. ↑ http://people.stfx.ca/accamero/gender%20and%20health/gender%20as%20a%20determinant%20of%20health/gender%20as%20a%20determinant%20of%20health.pdf
  28. ↑ Jackson, A. (2010). Work and labour in Canada: Critical issues (2nd ed.). Toronto: Canadian Scholars' Press Inc..
  29. ↑ Canadian Labour Congress (2008). Women in the Workforce: Still a Long Way from Equality. Available at http://equalpaycoalition.org/cms/upload/CLC%20womensequalityreportEn.pdf. Data Source: Statistics Canada (2008). Income Trends in Canada. Ottawa: Statistics Canada. Income Data are in constant 2005$.
  30. ↑ Organisation for Economic Co-operation and Development. (2009). Gender Gap in Median Earnings of Full-time Employees. Available at www.oecd.org/dataoecd/1/35/43199347.xls.
  31. ↑ Armstrong, P. (2009). ‘Public Policy, Gender, and Health.’ In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (pp. 350-361). 2nd edition. Toronto: Canadian Scholars’ Press, Inc.
  32. ↑ When Working Is Not Enough To Escape Poverty: An Analysis Of Canada’s Working Poor, Dominique Fleury and Myriam Fortin, Policy Research Group, Human Resources and Social Development Canada, August 2006
  33. ↑ Pederson, A., Raphael, D., & Johnson, E. (2010). ‘Gender, Race, and Health Inequalities’.
  34. ↑ Public Health Agency of Canada. (2011-05). Sex and Gender-Based Analysis Training Manual. Unpublished.
  35. ↑ Johnson, J. L., Greaves, L., & Repta, R. (2009). Better science with sex and gender: Facilitating the use of a sex and gender-based analysis in health research. International Journal for Equity in Health, 8(14).
  36. ↑ Health Canada. (2010-03-12). Health Portfolio Sex and Gender-Based Analysis Policy. Retrieved on December 8, 2011, from http://www.hc-sc.gc.ca/hl-vs/pubs/women-femmes/sgba-policy-politique-ags-eng.php
  37. ↑ Scott-Samuel, A., Stanistreet, D., & Cranshaw, P. (2009) ‘Hegemonic Masculinity, Structural Violence and Health Inequalities.’ Critical Public Health, 19, 287-292.
  38. ↑ Pederson, A., Raphael, D., & Johnson, E. (2010). ‘Gender, Race, and Health Inequalities’. In T. Bryant, D. Raphael & M. Rioux (Eds.), Staying Alive: Critical Perspectives on Health, Illness, and Health Care (pp. 205-238). 2nd edition. Toronto: Canadian Scholars’ Press.
  39. ↑ Statistics Canada. (2003). 2001 Census of Canada. 2001 Census Analysis Series. The Changing Profile of Canada’s Labour Force. Catalogue no. 96F0030XIE2001009, February 2003. Ottawa: Statistics Canada.
  40. ↑ Ng, E. et al. (2005). Healthy Today, Healthy Tomorrow? Findings from the National Population Health Survey. Ottawa: Statistics Canada.
  41. ↑ Galabuzi, G. E. (2005). Canada’s Economic Apartheid: The Social Exclusion of Racialized Groups in the New Century. Toronto: Canadian Scholars’ Press
  42. ↑ Statistics Canada. (2011). Population Projections by Aboriginal Identity in Canada, 2006 to 2031. (Ottawa: Statistics Canada).
  43. ↑ http://www12.statcan.ca/census-recensement/2006/as-sa/97-558/pdf/97-558-XIE2006001.pdf
  44. ↑ Luo, Z. (2004). Infant mortality among First Nations versus non-First Nations in British Columbia: Temporal trends in rural versus urban areas, 1981-2000. International Journal of Epidemiology, 1252-1259.
  45. ↑ http://www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/index-eng.php
  46. ↑ Peters, P.A., Oliver, L., & Kohen, D. E. 2013. Next link will take you to another Web site Mortality among children and youth in high percentage First Nations identity areas, 2000-2002 and 2005-2007. Statistics Canada.
  47. ↑ Cooke, M. et al (2007). Indigenous Well-being in Four Countries: An Application of the UNDP’S Human Development Index to Indigenous Peoples in Australia, Canada, New Zealand, and the United States. BMC International Health and Human Rights, 7:9.
  48. ↑ Smiley, J. (2009). ‘The Health of Aboriginal People.’ In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (pp. 280-301). 2nd edition. Toronto: Canadian Scholars’ Press.
  49. ↑ Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Retrieved from: http://www.thecanadianfacts.org/
  50. ↑ Smiley, J. (2009). ‘The Health of Aboriginal People.’ In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (pp. 280-301). 2nd edition. Toronto: Canadian Scholars’ Press.
  51. ↑ Smiley, J. (2009). ‘The Health of Aboriginal People.’ In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (pp. 280-301). 2nd edition. Toronto: Canadian Scholars’ Press.
  52. ↑ http://www.ruor.uottawa.ca/bitstream/10393/30217/1/2004_Inuit_Food_Security.pdf
  53. ↑ World Health Organization. (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization
  54. ↑ Dupéré, S., Ridde, V., Carroll, S., O'Neill, M., Rootman, I., & Pederson, A. (2007). Conclusion: the rhizome and the tree. In M. O'Neill, A. Pederson, I. Rootman & D. S. (Eds.), Health Promotion in Canada: Critical perspectives (2nd ed.). Toronto: Canadian Scholars Press Inc., in press.
  55. ↑ http://www.cpha.ca/en/programs/policy/action.aspx
  56. ↑ Raphael D. Addressing health inequalities in Canada: little attention, inadequate action, limited success. In: O'Neill M., Pederson A., Dupéré S., Rootman I., editors. Health Promotion in Canada: Critical Perspectives. a. Toronto: Canadian Scholars' Press; 2007.
  57. ↑ Raphael D. From increasing poverty to societal disintegration: How economic inequality affects the health of individuals and communities. In: Armstrong H, Armstrong P, Coburn D (Eds.), Unhealthy Times: The Political Economy of Health and Care in Canada. Toronto: Oxford University Press, 2001.
  58. ↑ World Health Organization. (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization.
  59. ↑ in Britain, the Acheson Independent Inquiry into Inequalities in Health
  60. ↑ Acheson, D. (1998). Independent inquiry into inequalities in health. Stationary Office: London: UK . On-line at: http:// www.official-documents.co.uk/document/doh/ih/contents.htm
  61. ↑ Royal Commission on Aboriginal Peoples. (1996). Report of the Royal Commission on Aboriginal Peoples. Ottawa: Indian and Northern Affairs
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