Connecting the Dots: Public Policy, the Social Determinants of Health, and

Mental Health

Dennis Raphael, PhDProfessor of Health Policy and Management

York University

Presentation at the Research Day Symposium Ontario Shores Centre for Mental Health Sciences

Whitby, Ontario, March 22, 2013

Today’s Presentation• To provide definitions of mental health, social

determinants of health, and public policy • To identify the role that the social determinants

of health – that is, living conditions – play in shaping mental health

• To show how public policy – and the ideology behind it – shapes the quality of these social determinants to which people are exposed

• To identify means by which the mental health sector can contribute to public policy discussions that shape mental health

To provide definitions of mental health, social determinants of

health, and public policy.

Defining Mental Health I• “Mental health is a state of well-being in which

an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.”

• “In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community.”

• Source: World Health Organisation (2010). Mental Health: Strengthening Our Response, Fact sheet #220. Geneva: WHO.

Determinants of Mental Health • “Multiple social, psychological, and biological

factors determine the level of mental health of a person at any point of time.”

• “For example, persistent socio-economic pressures are recognized risks to mental health for individuals and communities. The clearest evidence is associated with indicators of poverty, including low levels of education.”

• Source: World Health Organisation (2010). Mental Health: Strengthening Our Response, Fact Sheet #220. Geneva: WHO.

Strategies and Interventions • “Mental health promotion involves actions to create

living conditions and environments that support mental health and allow people to adopt and maintain healthy lifestyles. These include a range of actions to increase the chances of more people experiencing better mental health.”

• “A climate that respects and protects basic civil, political, socio-economic and cultural rights is fundamental to mental health promotion. Without the security and freedom provided by these rights, it is very difficult to maintain a high level of mental health.”

• Source: World Health Organisation (2010). Mental Health: Strengthening Our Response, Fact Sheet #220. Geneva: WHO.

Defining Mental Health II• In practice however, mental health is usually defined

as not having a mental illness. • Funding emphasis is on treatment of mental illness

and perhaps prevention of mental illness (e.g., suicide) but not upon promoting mental health.

• Media coverage parallels this emphasis on mental illness.

• Recent emphasis is upon removing stigma of mental illness with virtually nothing being said about means by which mental health – as defined by the WHO --can be promoted.

What are Social Determinants of Health?

• Social determinants of health are the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.

• Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

The Canadian Perspective • Aboriginal status• disability• early life• education• employment and

working conditions• food security• health services

• gender• housing• income and income

distribution• race• social exclusion• social safety net• unemployment

Source: Mikkonen, J. and Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. On-line at http://thecanadianfacts.org

What is Public Policy?• Public policy is a course of action or inaction

chosen by public authorities to address a given problem or interrelated set of problems.

• Policy is a course of action that is anchored in a set of values regarding appropriate public goals and a set of beliefs about the best way of achieving those goals.

• The idea of public policy assumes that an issue is no longer a private affair.

• Source: Wolf, R. (2005). What is public policy? Available at http://www.ginsler.com/html/toolbox.htp

Public Policy Antecedents I• early life – adequate income either inside or outside of the

working force, availability of quality childcare and early education, support services

• education – support for literacy initiatives, public spending, tuition policy

• employment and working conditions – training and retraining programs (active labour policy), support for collective bargaining, increasing worker input into workplaces

• food security – developing adequate income and poverty-reduction policies, promoting health food policy, providing affordable housing

• health services – managing resources effectively, providing comprehensive accessible, responsive and timely care

Public Policy Antecedents II• housing – providing adequate income and affordable

housing, reasonable rental controls and housing supplements, providing social housing for those in need

• income and income distribution – fair taxation policy, adequate minimum wages, social assistance and social assistance levels that support health

• social exclusion – developing and enforcing anti-discrimination laws, providing ESL and job training, approving foreign credentials, supporting a variety of other health determinants

• social safety net – providing supports comparable to those provided in other developed nations

• unemployment – active labour policy, providing adequate replacement benefits, enforcing labour legislation and workplace regulations

To identify the role that the social determinants of health –

that is, living conditions – play in shaping mental health

Prevalence of Major Depression in Canada by Income Group (in %), 2002

8.5

5.34.2 3.7

0

2

4

6

8

10

Prev

alen

ce (%

)

Income Group

LowestLower MiddleUpper MiddleHighest

Source: Patten et al.; (2006). Descriptive epidemiology of major depression in Canada. Canadian Journal of Psychiatry, 51 (2), 84-86.

Probability of Depression (based on CIDI to SF Score) in Atlantic Canada, 2000-2001

13

7.46.4

5

0

2

4

6

8

10

12

14

Prob

abili

ty (%

)

Income Group

LowestLower MiddleUpper MiddleUpper

Source: Starkes et al. (2005). Unmet need for the treatment of depression in Atlantic Canada. Canadian Journal of Psychiatry, 50 (10), 580-590.

Prevalence of Depression in 25 Census Metropolitan Areas, Canada, 2000-2001

10.79

6.53

17.07

10.95

02468

1012141618

Prev

alen

ce (%

)

Men Women

LowMiddle/High Income

Source: Smith et al. (2007). Gender, income, and immigration differences in depression in Canadian urban centres. Canadian Journal of Public Health, 98 (2), 149-153.

“Low income is an important risk factor for becoming psychologically distressed, and stressors account for part of this increased risk.”

Social Determinants of Mental HealthSDOH can affect health in a number of ways:• Social determinants define the prerequisites for

health, such as shelter, food, warmth, and the ability to participate in society;

• Social determinants can cause stress and anxiety which can damage people’s health;

• Social determinants limit peoples’ choices and militates against desirable changes in behaviour.

Source: Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Brunner, E. and Marmot, M. G. (2006), Social organization, stress, and health in Marmot, M. G. and Wilkinson, R. G. (Eds.), Social Determinants of Health, Oxford University Press, Oxford..

Source: Netter, F. (1968). The Ciba Collection of Medical Illustrations, Vol. 1-Nervous System With a Supplement on the Hypothalamus. New York: Ciba Pharmaceuticals

24

Pathways (Clyde Hertzman)• Latent: Specific biologic or developmental

factors at sensitive periods that have a lifelong effect regardless of later circumstances.

• Pathway: Experiences that set individuals unto life trajectories that affect health, well-being and competence over time

• Cumulative: Accumulation of advantage or disadvantage over time involving addition of latent and pathways effects

To identify the role that the social determinants of health –

that is, living conditions – play in recovery from mental illness

To show how public policy – and the ideology behind it –

shapes the quality of these social determinants to which people are

exposed

Materialist Approach

• “Health inequalities result from the differential accumulation of exposures and experiences that have their sources in the material world.”

• Lynch JW, et al. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

Neo-Materialist Approach

• “The effect of income inequality on health reflects a combination of negative exposuresand lack of resources held by individuals, along with systematic underinvestmentacross a wide range of human, physical, health, and social infrastructure.”

• Lynch JW, et al Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

Figure 3. Total Public Expenditures as Percentage of GDP, Selected OECD Nations, 2007

28.4

27.3

26.4

26.3

26.1

25.2

24.9

24.8

23.1

21.6

21.3

20.8

20.6

20.5

20.1

18.5

18.4

16.9

16.3

16.2

16

0 6 12 18 24 30

FranceSwedenAustria

BelgiumDenmarkGermany

ItalyFinland

PortugalSpain

GreeceNorway

LuxembourgUK

NetherlandsSwitzerland

New ZealandCanada

IrelandUSA

Australia

Nat

ion

Source: OECD Social Expenditure Database, http://stats.oecd.org/Index.aspx?datasetcode=SOCX_AGG

Figure 6. Public Spending on Active Labour Policy as Percentage of GDP, Selected OECD Nations, By Welfare State Type, 2007

1.3

1.3

1.2

1.1

0.9

0.9

0.7

0.7

0.7

0.6

0.6

0.6

0.5

0.5

0.5

0.4

0.3

0.3

0.3

0.2

0.1

0.00 0.25 0.50 0.75 1.00 1.25 1.50

DenmarkSw edenBelgium

NetherlandsFranceFinland

GermanySpain

AustriaNorw ay

IrelandSw itzerland

PortugalItaly

LuxembourgNZUK

AustraliaCanadaGreece

USA

Nat

ions

Percentage of GDP Spent on Active Labour Policy

Source: From Social Expenditure Database, OECD 2008. Paris: OECD.

Figure 7. Public Expenditure on Childcare and Early Education Services as Percentage of GDP, Selected OECD Nations, by Welfare State, 2005

0.1

0.20.2

0.3

0.3

0.4

0.40.4

0.4

0.4

0.40.5

0.60.7

0.8

0.8

0.91.0

1.0

1.2

0.6

0.0 0.2 0.4 0.6 0.8 1.0 1.2

GreeceCanada

Sw itzerlandAustriaIreland

USAGermanyAustraliaPortugal

LuxembourgSpain

NetherlandsUK

ItalyNew Zealand

Norw ayBelgiumFinland

Sw edenFrance

Denmark

Nat

ions

Percentage of GDP

Source: OECD Family Database (2010). Available at www.oecd.org/dataoecd/45/27/37864512.pdf

Source: Nanos Research (Oct. 18, 2012). Financial Security. Available at www.nanosresearch.com/library/polls/POLNAT-W12-T558E.pdf.

42

43

Toronto

Source: Glazier R.H. et al. (2007). Neighbourhood Environments and Resources for Healthy Living—A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences.

Source: Charron, M. (2009). Neighbourhood Characteristics and the Distribution of Police-reported Crime in the City of Toronto. Ottawa: Statistics Canada.

Source: United Way of Greater Toronto. (2004). Poverty by Postal Code: The Geography of Neighbourhood Poverty, 1981-2001. Toronto: United Way of Greater Toronto.

Source: Toronto Star

Murders in Toronto

51

Figure 3.5: Total Average Income by Income Quintile, All Family Units, Canada, 1995-2008

15,00013,100

55,10047,500

169,000

128,400

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2205

2006

2007

2008

Lowest Quintile Second Quintile Middle QuintileFourth Quintile Highest Quintile

52

Source: Curry-Stevens, A. (2009). When Economic Growth Doesn’t Trickle Down: The Wage Dimensions of Income Polarization, In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives (2nd ed., pp. 41-60).

54

Public Policy and Ideology

Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A hierarchial cluster analysis of the welfare regimes in advanced countries. Current Sociology, 51(5), 499-527.

60

The Story Behind the StoryFigure 1. Union Density, Collective Agreement Coverage and Child

Poverty, 2008 (density and coverage rates) and Mid 2000s (poverty rates)

0102030405060708090

100

Denmark

Finlan

dSwed

enNorw

ayAus

triaSwitz

erlan

dFranc

eBelg

ium

Luxe

mbourg

Netherlan

dsGerm

any

Greece

Italy

Spain

Portug

al

United King

domAus

tralia

Canada

New Zealan

dUSA

Uni

on D

ensi

tyan

d B

arga

inin

g C

over

age

0

5

10

15

20

25

Chi

ld P

over

ty R

ate

Union Density Collective Bargaining Coverage Child Poverty Rate

To identify means by which the mental health sector can contribute to public policy

discussions that shape mental health

Moving Forward

If you are in a hole and you want to get out, the first thing you have to do is stop digging.

-- Alexander Raphael,Age 8.

Structural Health Promotion• Identifying how societal structures and public

policy shape the health of populations in general and the most vulnerable in particular

• Increasing activities that individuals and communities can take to increase their control over the determinants of health

• Creating healthy public policy that is responsive to the needs of the citizenry.

Source: Raphael, D. (2008). Grasping at straws: A recent history of health promotion in Canada. Critical Public Health, 18, 483-495.

Structural Mental Health Promotion• Providing all citizens with basic human rights

and citizenship• Strengthening communities• Increasing consumer and professional

participation in mental health activities and services

• Promoting knowledge development on the determinants of mental health

• Coordinating public policy development in areas that influence mental health

Source: Adapted from Health and Welfare Canada (1988). Mental health for Canadians: Striking a balance. Ottawa: Health and Welfare Canada.

What is the Political System?• Political System: comprises numerous forces

that affect the state and government, including the private sector (interest groups such as health insurance/social security corporations, professional organizations) hospitals, pharmaceutical industry, political parties, and civil society (social movements, individual citizens, etc.

- Walt, 1994, Health Policy: An introduction to process and power. London: Zed Books, p.15

0 10 20 30 40 50 60 70 80

Percentage of Food Banks Recommending Action

Increase Social Assistance BenefitsRaise the Minimum Wage

Facilitate Affordable Rental Housing

Improve Rates and Access to EI

Increase Disability Supports

Improve Income Supports for SeniorsExpand Job Training Opportunities

Provide Affordable Childcare

Increase National Child Benefit

Lower Tuition, Increase Student Grants

Other PoliciesExpand Settlement Services

Figure 13.3: Policy Priorities of Canadian Food Banks

Source: From Hunger Count 2005: Time for Action (p. 27), by the Canadian Association of Food Banks (CAFB), 2005. Toronto: CAFB.

Working to Influence Public Policy

Source: Campaign 2000 (2008). www.campaign2000.ca/FullPartyGridElection008.pdf

Canada

Ontario

Is this the right time?

Partners in a Proposed Canadian SDOH Alliance• York University• University of Ontario Institute of Technology• University of British Columbia• University of Manitoba• McGill University• St. Francis Xavier University• Memorial University of Newfoundland Division

of Community Health and Humanities• University of Toronto• University of Alberta• Sudbury and District Public Health Unit• Canadian Association of Family Resource

Programs• YMCA, National Office• YWCA, National Office• Canada Without Poverty• Canadian Association of Social Workers• House of Friendship, Kitchener• KFL&A Public Health Unit• Canadian Mental Health Association• Canadian Public Health Association• Association of Ontario Health Centres• Association of Local Public Health Associations• SPC of Cambridge and North Dumfries• Hamilton Spectator• Canadian Medical Association

• Medical Reform Group• Health Providers Against Poverty• Alberta Health Services• Public Health Association of B.C• Child and Youth Health Network for Eastern

Ontario• National Collaborating Centre for

Determinants of Health• Canadian Association for School Health• Canadian Association of Community Health

Centres • Canadian Centre for Policy Alternatives• Canadian Council on Social Development• Wellesley Institute• Ontario Healthy Communities Coalition• Centre for Effective Practice• ERDCO (Ethno-racial People with

Disabilities Coalition of Ontario)• Community-Campus Partnerships for Health• Mamow-ki-ken-da-ma-win - North-South

Partnership for Children• People's Health Movement Canada• Population Health Research Network

Initiative, Government of Ontario• Interfaith Social Assistance Reform Coalition• Saskatoon Health Region• Ontario Women's Health Network

80

thecanadianfacts.org

83

84

85

Dennis Raphael

draphael@yorku.ca

This presentation and other presentations and related papers are available at:

http://jasper.yorku.ca/draphael

[go to the library there]