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The Social Determinants of Health for First Nations Communities in Canada FNHMA Conference 2016 in Vancouver, BC Concurrent Workshop

PRESENTED BY:

CALVIN E. WOOD MYRLE BALLARD SANA NAFFA

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Introduction

The purpose of the presentation: Is to highlight the importance and impact of the Social Determinants of

Health on the health outcomes of a population

Have an overview of the SDH Globally and in Canada and especially for the Indigenous populations

Learn about the SDH strategies at global level and experiences from other countries

Explain how CAC is building culture sensitive approaches and taking into consideration the social determinants of health in health programming and accreditation processes.

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Presentation Outline

What are the Social Determinants of health globally: concept, framework, statistics

The Social Determinants of Health in Canada and SDH for First Nations communities

Global Strategies & International experiences How to address and tackle the SDH locally Your role as Health Managers Canadian Accreditation Council approach in addressing the SDH in

communities in the Accreditation process

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Equity and the Social Determinants of Health What good does it do to treat people's illnesses

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Then send them back to the conditions that made

them sick?

Health inequity: A multidimensional problem Geographical disparities in health: differences between different

geographical areas.

Gender inequity in health: systematic differences in health between men and women determined economically, socially or culturally (not biologically or physiologically).

Ethnic inequalities in health: between different ethnic groups.

Socioeconomic inequalities in health: based on social, economic, political, cultural, linguistic and others (marginalised groups).

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Social determinants of health

The circumstances in which people are born, grow, work and age and the systems put in place to deal with illness.

The conditions in which people live and die are, in turn, shaped by political, social and economic forces.

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What are the Social Determinants of Health?

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Source: Commission on Social Determinants of Health Final Report, 2008

What are the social determinants of health?

“The social determinants of health refer to both specific features and pathways by which societal conditions affect health and that potentially can be altered by informed action.” Source: Krieger N. A glossary for social epidemiology. J Epidemiology Community Health 2001; 55:693-700

Two categories of social determinants: structural – fundamental structures of social hierarchy intermediate - socially determined conditions in which people

are born, grow, live, work and age

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Themes underpinning SDH

Health equity The absence of systematic disparities in health (or its

social determinants) between more or less advantaged groups, or geographical areas.

The right to health

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” (WHO Constitution 1946).

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Life Expectancy http://gamapserver.who.int/gho/interactive_charts/mbd/life_expectancy/atlas.html

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12 Global Plan: TB not eliminated by 2050

1990 2000 2010 2020 2030 2040 2050 1

10

100

1000

10000

Inci

denc

e/m

illio

n/yr

Current trend (0.5%) extrapolated

Desired trend

Global Plan prediction: incidence falls 5-6% per year

Elimination target: 1 / million / year by 2050

SDH affecting TB Prevalence

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Dow

nstr

eam

U

pstr

eam

Exposure Infection Active disease Consequences

High level contact with infectious droplets

Impaired host defence

Weak and inequitable economic, social, and environmental policy

Globalisation, migration, urbanisation, demographic transition

Active TB cases in

community

HIV, malnutrition, lung diseases, diabetes,

alcoholism, etc

Crowding Poor

ventilation

Age, sex and genetic

factors

Tobacco smoke, air

pollution

Inappropriate health seeking

Unhealthy behaviour

Weak health system, poor access

Poverty, low SES, low education

The Nutrition Transition 14

WHO 2006

Nepal 2001

Socioeconomic position

58%

Socioeconomic-political context

5%Health systems factors

28%

Intermediary determinants

9%

Nepal 2001

Socioeconomic position

46%

Socioeconomic-political context

10%

Health systems factors

4%

Intermediary determinants

40%

Sri Lanka 2000Socioeconomic-

political context

21%

Health systems factors

10%

Intermediary determinants

20% Socioeconomic position

49%

Source: "Health inequities in the South-East Asia region", WHO 2007

Reducing inequities in maternal mortality Reducing inequities in child malnutrition

The relative impact of other sectors on health outcomes varies: •by condition/health issue • the health system's redistributive orientation • the nature of the intervention (e.g. with respect to duration)

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Key Determinants of Health in Canada By Public Health Agency Canada

Income and Social Status Social Support Networks Education and Literacy Employment/Working Conditions Social Environments Physical Environments Personal Health Practices and Coping Skills Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php#What

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Social Determinants of Aboriginal Health

Demonstrates health disparities with Aboriginal groups compared to non-Aboriginal

Links with Distal, Intermediate, and Proximal levels to health inequities Distal: historic, political, social and economic Intermediate: community infrastructure, resources, systems and

capacities Proximal: health behaviors, physical and social environments

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Source: Reading & Wien, 2013

Consensus on SDH of Aboriginal People While there is no definitive list of social determinants for Aboriginal peoples, there is consensus in the research community that the following promote the health and wellbeing of Aboriginal peoples and communities: food security, connection to the land, housing and community infrastructure, access to potable water, income distribution and employment, mental and physical wellness, early childhood development and education, prevention of family violence, and access to language and culture. Sources: Aboriginal Children in Care Working Group.(2015). Aboriginal Children in Care: Report to Canada’s Premiers (Page14); Reading and Wien 2013

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Colonization is a Fundamental Health Determinant (WHO)

Along with social determinants that affect socio-economic status and physical and mental wellbeing, several seminal reports have argued that the ongoing impact of colonization is a key factor in the poorer health and wellbeing outcomes for Aboriginal peoples. In its extensive work on this topic, the World Health Organization (WHO) concluded that the “colonization of Indigenous peoples was seen as a fundamental underlying broader health determinant.” Aboriginal partners and organizations have consistently advocated for policies that target social determinants, including measures to combat the legacy of colonialism. Meaningful gains in Aboriginal child and youth outcomes will only be achieved by supporting the self-determination of First Nations, Métis and Inuit peoples which will enable them to realize their own social and economic goals.

Source: World Health Organization. Social Determinants and Indigenous Health: The International Experience and its Policy Implications. 2007. Page 2.

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DeColonization becomes paramount

- Racism and social inclusion (not exclusion)

- Self determination – education, housing, safety and health

Source: World Health Organization. Social Determinants and Indigenous Health: The International Experience and its Policy Implications. 2007. Page 2.

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Median Employment Income Gap

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2001 2006 1996

$12,003

$21,431

Total Aboriginal identity Non-Aboriginal identity

$16,036

$25,081 $27,097

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$18,962

3 Median Employment Income for Aboriginal and Non-Aboriginal Populations by Census Year

• Daniel Wilson and David Macdonald (2010). The Income Gap Between Aboriginal Peoples And The Rest Of Canada.

Median Employment Income Rural/Urban 22

Rural Urban

$20,994

$28,077

$23,242

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$18,750

Total Aboriginal identity Non-Aboriginal identity

5 Median Employment Income Rural/Urban (2006) 9

• Daniel Wilson and David Macdonald (2010). The Income Gap Between Aboriginal Peoples And The Rest Of Canada.

Education Gap: Indigenous and Northern Affairs Canada (www.aadnc-aandg.gc.ca)

48%

10%

65%

29%

65%

26%

54%

12%

SOME FORM OF SECONDARY EDUCATION

UNIVERSITY LEVEL FEMALES % OUT OF UNIVERSITY LEVEL

LESS THAN HIGH SCHOOL

Education Gap

Aboriginal Canadians Non-Aboriginals Canadians

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Health Gap:

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1.5

74 70

3 3 5 17%

82.2

8% TIMES OF

TUBERCULOSIS RATES ON RESERVE

TIMES INFANT MORTALITY RATE

LIFE EXPECTANCY IN YEARS

RATE OF SUICIDE IN INUIT PER

100,000

TIMES WOMEN SUICIDE RATES

TIMES WOMEN LIKELY TO

CONTRACT HIV

TIMES INCIDNCE TYPE II DIABETES

MENTAL HEALTH SEEKING HELP

Health Gap

Aboriginal Canadians Non-Aboriginals Canadians

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Source: http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#culture http://www.heretohelp.bc.ca/visions/aboriginal-people-vol5/aboriginal-mental-health-the-statistical-reality The Standing Senate Committee on Social Affairs, Science and Technology, “Proceedings from the Standing Senate Committee on Social Affairs, Science and Technology,” Issue 7, Evidence, 17 November, 2011, 1st Session of the 41st Parliament, http://www.parl.gc.ca/Content/SEN/Committee/411/soci/07mn-49183e.htm?Language=E&Parl=41&Ses=1&comm_id=47

Food Bank Use and Food Insecurity

14%

26%

28%

8%

14%

12%

2%

0% 5% 10% 15% 20% 25% 30%

RECEIVING FOOD FROM A FOOD BANK

RURAL FOOD BANK USERS

FOOD INSECURE

HOUSEHOLD SEVERLY FOOD INSECURE

Food Bank use & Food Insecurity

non-aboroginals aboriginals

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Sources: Tarasuk, V, Mitchell, A Dachner, N. Household food insecurity in Canada 2011. Research to identify policy options to reduce food insecurity (PROOF). http://nutritionalsciences.lamp.utoronto.ca/resources/proof-annual-reports/annual-report-2012/ Food Banks Canada, Hunger Count 2014. http://www.foodbankscanada.ca/FoodBanks/MediaLibrary/HungerCount/HungerCount2013.pdf

Housing Gap

19%

40% 35%

21%

12%

25% 26%

6%

OFF RESERVE CORE HOUSING NEEDS

LONE PARENT HOUSEHOLD NEEDS

OFF RESERVE RENTER WITH CORE HOUSING NEEDS

ON RESERVE BELOW ADEQUACY STANDARD

Housing Gap

aboriginal household non-aboriginals households

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Information on shelter costs for on-reserve housing is not collected by the National Household Survey; however, adequacy and suitability of housing on-reserve can be examined. Using household incomes (collected on-reserve); the percentage of households living in housing below standard(s) and unable to meet the cost of acceptable housing can also be derived.

Water & Waste Water Systems Sources (%) As of January 31, 2015 136 Drinking Water advisory in 93 First Nations Communities

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8

36

2

waste water

piped trucks individual systems no service

72

13.5

13

1.2

water

piped truck delivery

serviced by individual wells no service

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Violence Against Women

3.5

5

70%

13

0

0

0

0 2 4 6 8 10 12 14

RATES OF VIOLENCE

DIE OF VIOLENCE

DO NOT HAVE SHELTERS

VIOLENT CRIME AGAINST WOMEN IN NUNAVUT

Violence Against Women

non-aboriginal women aboriginal women

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Source: United Nations. Committee on the Elimination of Discrimination against Women Report of the inquiry concerning Canada of the Committee of the Elimination of Discrimination against Women under article 8 of the Optional Protocol to the Convention on the Elimination of All Forms of Discrimination against Women. CEDAW/C/OP. 8/CAN/1. March 6, 2015. (Advance Unedited Version) http://tbinternet.ohchr.org/Treaties/CEDAW/Shared%20Documents/CAN/CEDAW_C_OP-8_CAN_1_7643_E.pdf

Early Child Development and Child Care

Less than a third of children living in First Nations communities receive child care (30%)

Only 39% of the 30 % receive child care in a formal setting

78% do not have access to licensed, regulated child care services

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Early Childhood Development: FNCIS 2008 Report Source: First Nations Canadian Incidence Study, 2008.

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30.6

13.6

3.7 1.1

SUBSTANTITED INVESTIGATION OF MALTREATMENT

PER 1000 CHILD INVESTIGATED FOR NEGLECT

PER 1000 CHILD OUT OF HOME CHILDREN WELFARE PLACEMENT

Child Development and Care

aboriginal children non-aboriginals

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Global and Local Strategies 31

Global Commission on Social Determinants of Health

The global Commission on Social Determinants of Health (CSDH) was launched by WHO in March 2005.

The Commission’s mandate is to turn “existing knowledge on social determinants [of health] into actionable global, regional and national policy agendas” based on the relevant evidence and existing interventions to address them.

Suggested options ranged from correcting “health disparities” by recommending specific health care strategies, to taking a stronger stand for health equity that requires far reaching social change.

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Social Determinants of Health Conceptual Framework

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Distribution of health & well-being

•Material circumstances

•Social Cohesion

•Psychological factors

•Behaviors

•Biological factors

Social Position

Education

Occupation

Income

Gender

Ethnicity/Race Health care system

Socioeconomic and Political context

Governance

Policy (Macroeconomic, social, health)

Cultural and societal norms and values

Social Determinants of Health and Health inequalities

Source: Commission on Social Determinants of Health Final Report, 2008

The Final Report of CSDH Focuses on inequalities in health

that are avoidable, and therefore inequitable;

Accepts that addressing such inequities is a matter of fairness and social justice;

Is prompted to act by evidence that a social gradient in health exists in all countries;

Recommends three areas for action to close this gap:

1. the conditions in which people are born, live, grow, work and age;

2. the structural drivers of those conditions at the global, national and local level;

3. monitoring, training and research

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The Commission’s Overarching Recommendations 1. Improve Daily Living Conditions Improve the well-being of girls and women and the circumstances in which their children

Put major emphasis on early child development and education for girls and boys,

Improve living and working conditions and

Create social protection policy supportive of all, and create conditions for a flourishing older life.

Policies to achieve these goals will involve civil society, governments, and global institutions.

2. Tackle the Inequitable Distribution of Power, Money, and Resources Address inequities – such as those between men and women

Strong public sector that is committed, capable, and adequately financed.

Strengthened governance

3. Measure and Understand the Problem and Assess the Impact of Action Acknowledging that there is a problem, and ensuring that health inequity is measured – within countries

and globally Establish ongoing surveillance system

Source: Closing the Gap Into a Generation, Commission on Social Determinants of Health FINAL REPORT, 2010 P 43.

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Early child development and education

Healthy Places Fair Employment Social Protection

Universal Health Care

Health Equity in all Policies

Fair Financing Good Global Governance

Market Responsibility

Gender Equity

Political empowerment – inclusion and voice

CSDH – Areas for Action 36

Key ways of addressing the social determinants of health

Life course approach The life course perspective looks at people’s lives and the structural context

in which they live over the course of their life. The life-course perspective should be used to understand the context of

patients’ lives and is an effective way to plan partnerships and action on social determinants of health appropriately, at every stage of life.

with a focus on the early years as a key time to intervene

Social Gradient Completely eliminating the social gradient in health and wellbeing is

unlikely. But it is possible to have a shallower social gradient than is currently the case.

Everybody is affected by health inequality, including health professionals. Actions to improve the social determinants of health will benefit everybody.

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Intersectoral Action on Health (IAH) Working together across sectors to improve health and influence its determinants

1. Self Assessment

2. Engagement of concerned sectors

3. Area of concern

4. Select engagement

approach

5. Develop a strategy

6. Use a framework

7. Strengthen governance

Structures

8. Enhance Community

Participation

9. Choose other good practices

10. Monitor & Evaluate

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WHO. (2011) Intersectoral Action on Health

Experiences from other countries Viet Nam’s national mandatory helmet law – success of a multisectoral approach: the

NTSC reported that 1557 lives had been saved and 2495 serious injuries prevented since the helmet law took effect, compared to the same time the previous year.

Liverpool Active City – an intersectoral approach to improve health and well-being by boosting levels of physical activity The strategy and actions have focused on:

Increasing the profile of active living in Liverpool. Improving the coordination of existing services. Ensuring access to appropriate activities for all. Ensuring structural support for physical activity and integrating with wider urban agendas. Findings from the Sport England Active People Survey and the national survey PE and Sports

Strategy for Young People provide some evidence that physical activity levels in Liverpool have increased since the onset of the Liverpool Active City programme – particularly amongst children and within areas with the worst health outcomes. Programme output data also paints a compelling picture to suggest that the programme has resulted in more people being more active more often.

Jordan: Women Overweight and Obesity in Jordan- an Intersectoral collaboration to reduce incidence and prevalence of Non-communicable diseases as diabetes

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SDH National Workshop in July 2009 40

Jordan experience – how to apply

Identify inequities: communities health profiles Identify the social determinants of health for the health outcomes :

geographic /gender/poverty/access to information and services Prioritization: high volume/high risk/ problem prone/ cost of

inaction/preventable and under control and authority Form steering level committee / Task force committee Intersectoral approach: government sectors, health, education,

JFDA, RMS, municipalities, Universities, civil societies and community representatives (healthy villages programs)

A strategy and a framework for action prepared

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Overweight and Obesity among Jordanian Women and its Social Determinants

1. Place of residence was significantly related to BMI status . More than 60% resided in the central region and around 9% in the south

2. Women married at age 10-15 were more likely to be obese compared to women married at age 20 or above.

3. Women who didn’t smoke were 1.5 times more likely to be obese compared to women who smoked

4. Women gave birth to six children or more were 2.5 times more likely to be obese compared to women who gave 1-2 births

5. Women classified at low (30%, 40%) and middle (33%, 40%)wealth index were slightly more likely to be obese compared to women classified as having high wealth index (36%, 37%)

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Nov Dec Jan Feb. March April May June

July Aug. Sept. Oct. Nov. Dec 2008 2009

Equity in Access Analysis

Phase 1

Phase 2

Identification of Barriers and Social Determinants

Phase 3

Definition of types of interventions

Pha

se 4

Jun

e

Proposal for the RE-DESIGN of programs

selected from a SDH and

Health Equity Approach.

Phase 5

Implementation

Pilot program or study

Validation Indicators Monitoring Evaluation

Budget Planning

Phases for the Integration of a SDH and HE in Public Health Programs

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Jordan experience – how to apply

A list of policies were suggested and enforced by legal authorities Raising awareness and advocacy about the problem Building capacities for staff and communities Empowering communities to participate: Development Councils /

Income generating projects/Employment opportunities /environmental factors/gender representation/Elders involvement

Health in All Policies: Education sector, schools canteens, poverty strategy, civil societies, municipalities,

Initiate programs to tackle the issue: health promotion and education at community level

Monitor indicators: health outcomes, Obesity? Incidence of Diabetes? heart diseases?

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Social determinants of health model - social position CSDH Conceptual Framework

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Challenges

Program ownership between entities Mindsets and Long history of working alone and culture of Anti

partnership Inadequate awareness of decision makers on the importance

of approaching various aspects of social determinants of health from the perspective of health in all policies.

Poor coordination of different health and non health sectors in addressing SDH issues and endorsing health policies in all sectors.

Lack of concerted efforts among donors to fund different interventions tackling SDH ( pooling of resources).

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Local actions

Policy-makers engagement in health sector strategies Health profiling and SDH at local level Programs based on local needs and priority health indicators Research: quantitative and qualitative Community participation and empowerment : community leaders,

elders, chiefs, patients groups Intersectoral collaboration examples:

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48 Tackling social determinants and health equity through community-based initiatives

Poor, rural, disempowered

community

Skills development

Income generation

Public health interventions

Organized and

empowered community

Improved quality of

life

Community-based initiatives

Sustainability

Improved health

Address SDH and health

equity

c

Social development

Community organization & engagement of public

sectors

Women’s development

Reduced poverty

First Nations Mental Wellness Continuum Framework January 2015, by Health Canada

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Indigenous wellness framework (2015)Health Canada: culture as an intervention model

• Belonging • Meaning

• Hope • Purpose

Physical Behaviour expressed through

wholeness way of being

Spiritual Behavior

expressed through belief

identity

Emotional Behavior

expressed through attitude and relationship

Mental Behavior expressed

through intuition understanding

Rational

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Health System Roles Health system roles: as employers, managers and commissioners

As employers: Employing a diverse workforce As managers: Creating equitable workplace environments As commissioner: addressing health equity in procurement and practices

Working in partnership: within the health sector and beyond Advocating for change: for the patient, community and health system

For patients and their families: This includes advocacy on behalf of patients to ensure they get appropriate care and support from health services and wider services and support in the community

For communities: Advocacy should extend to advocating for improvements in the community which will positively impact on patients health such as promoting good quality green spaces and healthy housing.

At the policy and strategy level: Health professionals should contribute to policy and strategy setting a the local, national and international level.

Source: Institute for Health Equity © IHE

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Canadian Accreditation Council approach

Literature review and evidence based approach in developing standards

Multi disciplinary approach Engaging elders, chiefs and First Nations Treaties personnel in the

process of planning, development and implementing accreditation programs

Rely on peer volunteer reviewers from same culture, language, background familiar with the community challenges and the social determinants

Standards address community engagement in the health programs implementation

Standards address that programs are developed based on local health needs and epidemiological profiles

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Canadian Accreditation Council approach

Standards address that health outcomes are monitored regularly, measures include collection of outcome data, outcome data analysis, outcome tools and process assessment and outcome data dissemination

Support organizations to develop research-based practices Focus on Patient – centered care and persons served outcomes:

inclusiveness, uniqueness, achieving goals, safety and health Develop tools to measure dimensions of quality of services that looks

behind the health sector Provides training on culture and diversity inclusion Recruit diverse technical and administrative staff Have Aboriginal Advisory Board

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Framework for the Treaty 8 First Nations of Alberta Standards for Schools

Philosophy Customs

Social Values Language

Physical

Emotional

Mental

Spiritual

Wisdom Love

Respect Bravery Honesty Humility

Truth

Motion Spirit Alive

Related Renewal

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Canadian Accreditation Council Roles in the process of Accreditation Convening role

Convening sectors nationally and regionally Convening expert advice on methods and tools for measurement of health equity to issue guidelines Engaging with existing processes of health and social reform Working with specific key sectors affected by the SDH as poverty, gender inequities, priority public

health conditions, child health

Synthesizing Policy lessons Reviewing evidence Recognising problems of current approaches Learning for successful models Assisting in providing solutions rather than making diagnosis Sharing experience with implementation

Engaging organizations in research Sharing successes and best practices Discussing barriers and challenges Collecting and disseminating tools

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www.who.int/social_determinants/en

Closing the gap in a generation