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Health Equity: Programs, Projects and Practice

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I Introduction: Determinants of Health: What Makes Canadians Healthy or Unhealthy?

"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 junkyard next to his apartment building and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junkyard?
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 ...?" (1)

Many of you may have already seen this excerpt in other resources on the social determinants of health, but I have included it here because it illustrates the interconnectedness of the factors influencing the health of every Canadian. The notion of health equity raises complex issues, because it is difficult to pinpoint underlying and root causes of health. Often, what we know about equity is in reference to inequity (2).

As one moves up the social ladder, research shows a step-wise progression toward better health indicators. Even now, a five-year difference in life expectancy exists between the poorest and highest incomes in urban Canada (3). What is it about income groups that explain the difference?  Do low income groups exhibit poor health behaviours?  If so, why?  What role does personal empowerment play? According to Dr. Charles Gardner, Medical Officer of Health, Simcoe-Muskoka District Health Unit, stress, caused by a sense that one lacks control, impacts on our hormonal milieu and in turn on our immune response. This may explain why the differences we see in mortality rates are not explained by lifestyle. In Canada, the strongest predictors of disparities are socio-economic and Aboriginal status, gender and geographic location.

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II What Is Happening? A Global, National and Provincial Overview

There have always been groups advocating for people with low income, but now the public health community has decided to bring its perspective into the dialogue. Globally, the Collaborating Centre for Policy Research on the Social Determinants of Health of the World Health Organization brought together eminent leaders in the field. They have published several reports and interim statements designed to guide public policy (4). A new one is anticipated this spring.  

Nationally, Roy Romanow is spearheading the development of the Canadian Index of Wellbeing. The initiative adopts the premise that how well a country is doing cannot be captured by Gross Domestic Product (GDP), stock market or other economic indices, but rather by social and cultural indicators and other facets of wellbeing (5).

In Ontario, the provincial government struck an Equity Research Initiative to examine policy strategies across ministries.

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III Acting Locally on the Social Determinants of Health--Thoughts from Sudbury District Health Unit

Many practitioners may ask themselves what individual health units, health promotion professionals and community partnerships can do to make a difference in their communities. Below are many suggestions.  

In November 2007, the Heart Health Resource Centre (HHRC) hosted a symposium Health Equity: Are We There Yet? It examined the social determinants of health through a chronic disease prevention lens.

Sandra Laclé, Acting CEO of the Sudbury District Health Unit (SDHU) opened the recent HHRC symposium Health Equity: Are We there Yet? with a comprehensive look at reducing health inequities and improving heart health. She stressed the importance of choosing a model such as the one developed by Dahlgren and Whitehead (1993) to guide program development and direct strategy. Sandra suggested health units not get bogged down in discussions of the specific distinctions between the layers of the model, but rather understand that the key to reducing health disparities includes assessing health inequities through the lens the model provides. Universal health promotion strategies such as education tend to work better with higher economic groups. She advises, for instance, on focusing on peer led programs to increase the uptake among at risk groups in a positive way. She also advised program planners to be inclusive in programming. Identify the inequities so you can drill down to what matters in your intervention. For example, the number of smoke-free homes in Sudbury was significantly higher in higher income groups. Knowing this helped the health unit target its efforts appropriately.

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How Can Public Health Improve the Social and Economic Conditions That Put Individuals at Greater Risk of Poor Health?

SDHU uses a number of strategies to accomplish this. Examples of their related projects are noted below.

Inform public opinion--Act as a catalyst and enabler

  • Produced and publicized reports on local health status by the social determinants such as dental caries by income group; the cost of a nutritious food basket by general welfare rates.
  • Conducted a needs assessment of Sudbury's working poor population and produced a report on the high costs of low pay.

Assist or lead in the development of a health charter

  • Participated with partners in the creation of a children's health charter which asks for organizational commitment in addressing the social and economic conditions needed to improve to child health.

Advocate--Participate in equity-based local planning

  • SDHU maintains membership on the local social planning council and has supported the local poverty plan.
  • Joined other health units to present a framework to integrate social and economic determinants of health into public health to the MOHLTC.
  • Continue to speak at conferences and participate in working groups to address the social and economic inequities that are the root causes of health inequities.

Improve environments where people live, work and play so that priority populations have greater access to opportunities for health

  • Held focus groups with youth to uncover barriers to participation.
  • Actively creating recreational opportunities for broad range of residents.
  • Offer programs such as community gardens and community food advisor training.
  • Provided volunteer child minding and transportation to increase access.
  • Facilitated youth in developing a tobacco cessation program. This peer led program was developed with and by the youth - with health unit staff providing existing cessation resources.
  • Participate in the Aboriginal Community Food Advisor Program.
  • Provide clinical services at locations accessible to those with the greatest needs.

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How Can Public Health Foster Greater Social Support and Community Participation Among Priority Populations?

Social inclusion principles suggest that all participants are valued members of society. They also help to create a shared sense of belonging. One of SDHU's strategic directions aims to increase community voices for public health. As such, it is moving in the direction of encouraging communities to participate in the planning, delivery and evaluation of programs and services. The SDHU participates with local community action networks, has conducted a "Count me In" campaign and is beginning to use the Best Start hub locations to provide programs that are easily accessible for higher risk families.

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How Can Public Health Support Healthy Lifestyles Among Priority Populations?

According to the SDHU, the bottom line--public health must act on the social determinants of health or real gains in the population's health will be limited.

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IV Programs, Projects and Practices of Community Partnerships

Accounts of how individual programs, projects and practices within health units and community partnerships have addressed social inequities in health follow. Many of these were presented at the Heart Health Resource Centre (HHRC) symposium, held in November 2007. However, some have since been "discovered."

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A Media Campaign to Raise Awareness of Health Inequities
Anne Adair, Former Coordinator, Health for Life, Peterborough

In November 2006 a Statistics Canada survey conducted in Peterborough, Ontario, revealed that as household income increased, residents' recognition of the importance of the determinants of health decreased. While virtually all survey respondents, regardless of income, rated "availability of doctors" as "very important to health," the same consistency in responses was not seen when ranking select determinants of health. For example, 88.4% of low-income residents ranked "adequate income" as "very important to health," yet only 73.8% of high-income residents recognized that "adequate income" was "very important to health." Similarly divergent response rates were seen between income levels when residents were asked to rank the importance of "access to nutritious food" and "social support networks."

Recognizing that decision-makers are more likely to be higher-income earners, it was felt that increasing awareness of the determinants of health among this segment of the population was prudent. To that end, Health for Life Peterborough and the Peterborough County-City Health Unit worked with local CBC affiliate, CHEX Television, to create a series of ads which would highlight health inequalities. The intent of the ads was to shift the dominant thinking from how the medical system and individual behaviours affect health, to how social programs and policy decisions affect health.

Three ads, targeting middle- and upper-income residents of Peterborough, were produced. They presented adequate income, access to food, and affordable housing, as essential to good health. The ads directed viewers to the health unit website for further information on the determinants of health, links to related websites, and suggestions on how citizens could take action to support a healthier community.

Total cost for production and placement of the ads was $5,500. They aired 114 times during the fall of 2007. Feedback on the ads has been positive. The Statistics Canada survey question related to the determinants of health will be repeated in late 2008.

To view the television ads, visit the "Poverty and Health" section of the health unit's website at http://www.pcchu.ca. For more information please contact Health Promoter, Christine Post, at the Peterborough County-City Health Unit, (613) 743-1000 x293 or cpost@pcchu.ca.

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The "Fitness for Moms on Limited Income" Project--Timiskaming Heart Health Project
Martha McSherry, Coordinator, Timiskaming Heart Health Project

Project Goals

  1. To decrease the incidence of heart disease in women.
  2. To increase the capacity of women to care for their own heart health.
  3. To collaborate with key partners and participant Moms to promote heart health lifestyle choices that are accessible, available and affordable for Mothers in low socio-economic situations.

The barriers to physical activity for the targeted audience were identified in focus groups. The Mothers reported that they walk, push strollers, climb stairs to apartments, but prefer access to fitness facilities. User fees, childcare costs, transportation costs, and the cost of fitness gear prevented them from participating. Many women also had difficulty finding time for exercise related to multiple roles such as wage earner, spouse and mother.

The planning process involved the following steps:

  1. Identified partner organizations such as municipal recreation, organizations providing services for women on limited income, public health unit, heart health committee, etc.
  2. Assessed the needs of the target audience using focus group discussions.
  3. Involved members of the participating and/or target audience in the planning.
  4. Established responsibilities of the partnering organizations—addressed barriers noted above.
  5. Found the right facilitator(s) and established the best times for the Mothers to access facilities, at little or no cost.
  6. Recruited participants, promoted and marketed the program.

The 12-week Fitness for Moms on Limited Income program was offered for one hour, twice a week, two times per year between 2003 and 2006. The variety of fitness activities offered depended on the facilities available, facilitators, equipment, and the interests of participants. Partner agencies and participants shared the user fee costs. An agency serving women on limited income and transportation provided childcare and equipment (swimsuits, runners) were provided by partner agencies for participants when needed.

Lessons Learned

  • Include the participants in the planning and evaluation of the fitness opportunities.
  • Work with partners who demonstrate adequate interest by contributing a portion of funds to ensure the program takes place.
  • Partnerships helped with the barriers: childcare, transportation, membership fees, fitness gear.
  • Provide basic fitness information in small chunks e.g., fitness myths, Canada's physical activity guide, setting goals, tracking activity.
  • Best way to recruit low-income women is through low-income women.
  • Ensure sessions don't conflict with school buses, and mealtimes (In some sessions, attendance was sporadic due to childhood illnesses or Mothers' busy schedules.)
  • Affordable, quality childcare is required.
  • Let the target audience determine the cost of the program.
  • Provide a variety of fitness activities.

For further information contact Martha McSherry at mcsherrym@timiskamingu.com.

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African Caribbean Diabetes Prevention and Heart Health Education Program
Julie Charlebois, Toronto Heart Health Partnership, and Dr. Miriam Rossi, University of Toronto

Partners: The Black Secretariat, Anglican Church of the Nativity, Revivaltime Tabernacle, and Church of the Pentecost (two locations)

This project implements comprehensive public education strategies that are culturally appropriate and reflect an integrated approach to addressing the modifiable risk factors. The activities occur in four faith-based communities. All projects are volunteer- delivered, with a heavy emphasis on train-the-trainer supports. Activities have included:  Cook, Glow and Grow, Food and Health Fairs, Ebony Yoga, Cooking at the Heart of Diabetes, Nutrition and Stress, Meditation, Move to the Beat, Reggaesize and the On the Move Walking Program.

Successes/Impacts

Four churches have acted as hosts for activities targeting the surrounding communities as well as their own parish. Successes have been numerous, as these programs have been very responsive to the cultural practices of the audience. Some examples follow:

  • This programming, while targeting youth, has had great intergenerational effect.
  • People who don't attend the churches came out because they trusted the church (taxi drivers).
  • An aboriginal residence opened beside one of the churches; inter-cultural outreach took place; first nations leaders and leaders of the black community have created joint programming that is attended by both cultural communities.
  • Two week March Break camp was implemented since many youth are left on their own because of working parents. Two retired principals were enlisted to run the program; address lifestyles, tutoring, job skills, financing.
  • Children in the programs have had healthy eating modeled for them and are requesting veggie and fruit-based snacks. Some parents report that their children now want these types of  "healthy" foods and whole grain bread, not white bread, at home.
  • Two engineering professors volunteered to tutor young males without fathers, working to increase self-esteem, skills and ultimately health.
  • The positive impact on young people is visible.
  • Programming in one site is offered in both English and Twee (Ghana).

For further information contact Dr. Rossi at miriam.rossi@utoronto.ca.

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Camps United
Tracy Cato, Executive Director, It's In Me Education and Training Program

Major Partners:  City of Toronto Parks, Recreation and Forestry, Elmbank Community Centre, Humber College, Humber Student Federation, Chartwell Services, Toronto District School Board, Toronto Community Housing Corporation, It's In Me Education and Training Program, West Indian Volunteer Support Services, Albion Neighbourhood Services, North York Harvest Food Bank, and Second Harvest

Camps United has provided innovative programs to children and youth in the Jamestown corridor of Etobicoke. A large proportion of residents have low incomes. The extensive list of partners above enables organizers to offer free swimming, sailing, African dance and drumming, arts and crafts and flight simulation classes. Yes--flight simulation!  Groups of 10 participants have two leaders who teach them and escort them to and from the site of the classes. Students are given breakfast and lunch. Some children receive food to take home after the classes.

Future pilots?

Camps United offers a very popular flight simulation program to kids from 9 to 15 years. The youth attend classes at the Rexdale Pro Tech Media Centre. The Urban Pilots Network, an organization of black pilots, participates in the program. The students tour Buttonville Airport and see areas not always open to the public. They learn about mechanics and finally, they each fly in the cockpit of a four-seater Cessna. Some of the "graduates" have enrolled in the Air Cadets to further their training and learn navigation.

Successes

Over the last five years, 500 children and youth ages 3 to 15 years participated in the after school programs. Children and youth who participate are exposed to opportunities they might otherwise not have. Their expectations about what is possible are enhanced beyond those of their peer groups who don't participate in the programs. They believe the possibilities are endless. Dane, aged 12 years, doesn't talk about finishing high school--he talks about college and university.  The Camps United programs are aimed at increasing the expectations of children and youth in Jamestown by engaging them in innovative ways.

Important learning

Initially, most of the available camp spots in Jamestown were booked online by parents living outside the area. Parents in Jamestown who don't have easy access to computers were unable to register the children. They solved the problem by having many of the programs targeted to low income children taken out of the City's online catalogue. This way, parents had to register in person. This better suited the local parents and resulted in high registrations of local children and youth.

For further information contact Tracy Cato at itsinmeprograms@yahoo.com.

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V Summary

All of the programs, projects and practices above demonstrate innovative ways to address at least one aspect of health inequity. They do this in innovative ways unique to the communities they serve.

It may seem like we are a million miles away from achieving health equity in Ontario, but we must continue moving forward. The health sector has some capacity to reduce disparities by making programs more effective and responsive. We have a role to play in awareness-raising, reporting, advocacy and fostering inclusion through diverse partnerships. Although we can learn from European reports and experiences, we can learn from each other too.

To see a full set of the slides of the presentations of the HHRC November 2007 symposium, Health Equity: Are We There Yet?, go to http://www.hhrc.net/workshops/2007_archive.cfm.

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VI References

1. Toward a Healthy Future: Second Report on the Health of Canadians, retrieved from http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html, accessed December19, 2007.
2. Richard Prial, Equity: A Priority for Ontario's Health System, Presented at the HHRC symposium, Health Equity: Are We There Yet?, November 29, 2007.
3. Charles Gardner, A Comprehensive Approach to Reducing Health Inequities and Improving Heart Health, presented at the HHRC symposium, Health Equity: Are We There Yet?, November 29, 2007.
4. M. Whitehead and C. Dahlgren, Achieving Health Equity: from root causes to fair outcomes, retrieved from http://whqlibdoc.who.int/publications/2007/interim_statement_eng.pdf on December 19, 2007.
5. For information on the Canadian Index of Wellbeing go to http://www.atkinsonfoundation.ca/ciw.