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Social Determinants of Health: Planning to Action


I Introduction
II Social determinants of health and population health
III Addressing the social determinants of health
IV Health Equity Impact Assessment (HEIA) tool

-submitted by Nimira Lalani and Brian Hyndman, Public Health Ontario

I Introduction

Broadly speaking, the social determinants of health refer to the social and economic conditions that affect the health of individuals, communities and countries.  Unlike the determinants of health, the social determinants are modifiable through creating and investing in policies that “level up” the health of the most marginalized in society, and disinvesting or removing those policies identified as being harmful to health.(1)  Although often presented individualistically (as income and social status, education and literacy, employment/working conditions, etc.), the social determinants interact and intersect in complex ways, sometimes referred to as the “web of causation” leading to enhanced or constrained life opportunities. (2)

II Social determinants of health and population health

There has been growing recognition that population health is determined more by these social and economic factors than by the health care system, regardless of how much money is pumped into the latter.  In fact, 60% of the health of populations can be attributed to these social and economic conditions, compared to about 25% for the health care system. (3) This is not to deny the importance of addressing lifestyle factors.  A recent study showed that Ontarians could live an extra seven (health and disability-adjusted) years if they adopted healthy living behaviours – i.e., were physically active, ate a healthy diet, didn’t smoke, drank in moderation and managed their stress levels.This is encouraging because it shows that people can exert some degree of control over their lives. (4)  That said, it is important to situate these behavioural risk factors within a broader socio-environmental context to understand why some people may be better able to adopt these healthy behaviours than others. The impact of income alone cannot be underestimated: the World Health Organization has identified poverty as the single largest determinant of health. (5)  The 2011 Child and Family Poverty Report Card described how income inequality between the rich and poor in Canada has grown significantly over the last decade: the total share of pre-tax income now being held by the rich is the highest it’s been for 66 years.  To put this in perspective, in 2009 the richest 20% of Canadians earned on average $117,500 more than the poorest 20%. (6)  Yet, even small increases in income can make a big difference. In a study that looked at the relationship between income and health in Canada, researchers found that an annual increase of $1,000 for the poorest 20% of Canadians led to nearly 10,000 fewer chronic conditions and 6,600 fewer disability deaths every two weeks. (7)

The social determinants affects us all, not just people who may fall into the category called “priority populations” – people who experience limited and/or poor quality access to and experience of these social determinants.  The concept of a social gradient in health gets at this idea, demonstrating that a gradient in health and mortality exists and intersects across income, race and gender lines.  For example, men in the lowest income brackets live about seven fewer years compared to men in the richest income bracket, women outlive men but have greater years of ill-health, etc.  It is not just that people’s longevity is curtailed, but also that their quality of life is affected by their access, availability and quality of these determinants.  These differences are not natural, but rather unnecessary, avoidable and unjust (8) and thus amenable to policy and practice interventions.

III Addressing the social determinants of health

The solutions to addressing the social determinants need to reflect the complexity of its multifactorial origins.  First, we can broaden out the research questions to frame health “problems” from more of a socio-environmental perspective, rather than a more exclusively individualistic perspective. (9)  For example, instead of just asking why people smoke, we can ask about the social conditions and economic policies that predispose people to the stress that can encourage smoking. The language we use can enhance or cloud people’s understanding of these issues.  The Robert Wood Johnson Foundation, a US-based philanthropic organization focused on improving the health and health care of Americans, conducted extensive focus-testing with the American public, and found that simple, emotionally compelling and values-driven language (e.g., “health starts in our homes, schools and communities”) was much more effective than the use of the term “social determinants of health.” (10)  By adopting the principles of effective messaging, they were able to increase the proportion of Americans who identified social factors as influencing health by 31%.  In her report, Communicating the Social Determinants of Health: Scoping Paper, Diana Daghofer (11) identifies three roles public health practitioners can play to further an understanding of this field to different audiences: practitioners can act as educators to influence the political process, as motivators through using their experiences on the front-line to make the connections with people’s lived experience and the social determinants, and as activators,  by participating in the policy-making process.  [Note: originally cited in Raphael, D. (2006). The social determinants of health: what are the three key roles for health promotion? Health Promot J Austr., 17, 167-170. [cited March 11, 2011]. Available at: and Raphael, D. (2008). Getting serious about the social determinants of health: new directions for public health workers. Promot Educ, 15, 15-20.]

Furthering an understanding of the social determinants is arguably the first step in taking action in this area and to get everyone on board conceptually.  More technically, the Foundational Standard within the Ontario Public Health Standards (2008) (OPHS) acknowledges the importance of addressing health inequities while striving to advance population health.  Specifically, the Foundational Standard (2008, p. 13) directs Boards of Health to:

“….not only examine the accessibility of their programs and services to address barriers (e.g., physical, geographic, social and economic), but also assess, plan, deliver, manage and evaluate programs to reduce inequities in health while at the same time maximizing the health gain for the whole population.”

What this means in practice was clarified by a recent environmental scan conducted by the National Collaborating Centre for the Determinants of Health in 2010.  Specifically, they identified the following four roles for public health practitioners to use: assess and report on overall population health and the existence of health inequities; work in partnership with other partners/sectors; lead and/or support policy development and analysis; and modify existing public health interventions to ensure they take into account the needs of their local priority populations. (12)

IV Health Equity Impact Assessment (HEIA) tool

These roles can be supported by equity planning tools.  To this end, Public Health Ontario has been working with the Ministry of Health and Long-Term Care, Health System Strategy Division, to revise its Health Equity Impact Assessment (HEIA) tool. Originally launched in March 2011 after three years of development and piloting, HEIA is an evidence-based resource that facilitates improved planning and evaluation of programs and services by the Ministry, local health integration networks, public health units and other health service providers to improve health equity among populations.

HEIA was designed to meet four key objectives:

  • To help identify unintended potential health equity impacts of decision-making (positive and negative).
  • To support equity-based improvements in strategy/policy/planning/program/or service design.
  • To embed equity across an organization’s existing and prospective decision-making models.
  • To raise awareness about health equity throughout the organization.

The current version of the HEIA, which was launched on May 28th, 2012, encompasses five key steps. These can be completed with the help of a workbook and accompanying worksheet that can be used to document the information generated by the completion of each step. The workbook also provides helpful examples, definitions, references and data sources.

Step 1. Scoping

  • Consider and identify affected populations (this includes intersecting populations and relevant social determinants of health).

Step 2. Impact Assessment

  • Identify and record the potential unintended (negative/positive) impacts of the planned policy, program, decision.

Step 3. Mitigation

  • Identify and record the best ways to reduce the potential negative impacts and amplify the (unintended) positive impacts.

Step 4. Monitoring

  • Articulate how success could be measured for each mitigation strategy you have identified.

Step 5. Dissemination (added to new version)

  • Identify and record how results and recommendations for addressing equity will be shared.

To support the effective application of the HEIA by public health units, Public Health Ontario also worked with the Ministry to develop a special supplement guide. The Public Health Unit supplement, which was launched on May 28th in conjunction with the revised HEIA materials, illustrates the links between each step of the HEIA and relevant OPHS Foundational Standard requirements. It also provides additional mitigation and monitoring strategy considerations unique to the role of public health units. In June 2012, the supplement will be enhanced with the addition of three hypothetical HEIA case studies focused on public health programs and services.

It is hoped that the HEIA will enable public health units and other organizations with an interest in reducing health inequities to bridge the gap from planning to action. The HEIA and related resources are available for downloading at

V References and Resources