At the ninth annual Health Promotion Summer School held in June 2002, Toronto Public Health Social Epidemiologist Dianne Patychuk presented a workshop entitled "Analysing your community for planning community health action." This toolbox offered frameworks and tools that linked social epidemiology with community knowledge to plan community actions to reduce unjust and avoidable health and social inequalities.
II Social Epidemiology and the Social Determinants of Health
Social epidemiological studies focus on the socio-economic determinants of health such as education, income and social status, physical and social environments and employment/working conditions. The social epidemiologist uses analytical methods to compare disease rates and risk conditions in different populations to understand how health determinants and health outcomes are interrelated in specific situations and locales. For example, a study of mortality and morbidity in Simcoe County to determine which socioeconomic indicators were the best predictors of population health incorporated 45 census variables into the analysis (Kendal 2002).
That socio-economic factors have a drastic effect on the health of individuals and communities needs no introduction for health promotion. Income difference alone accounts for 20-30% of health differences, far greater than the influence of lifestyle factors. Indeed, strategies to reduce risky behaviour are incomplete if they do not also address the economic and social stresses that limit choices and opportunities (Patychuk 2001). Barriers to health care (e.g., dental services, cancer screening, even OHIP) are also intricately linked to the impact of economic and social policies. Furthermore, programs that are geared towards the general population that do not take into account income differential can actually widen the gap in the health between the higher and lower income groups. For example, uptake from health promotion programs is quicker and easier for those with greater access to information and resources. Giving greater attention to the health problems of the well-off than the health problems more common among the disadvantaged can further widen existing disparities. Many studies show higher illness and death rates in lowest income communities with people each step up the income ladder healthier than on the step below. Community level studies are needed to move from evidence of heath inequities to designing strategies to reduce them that will be effective and relevant to diverse local needs and situations.
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III Inclusive Partnerships -- "Don't Plan For Us Without Us"
A partnership between epidemiologists/researchers and community organizations creates excellent data-sharing opportunities, provided inclusive practices are followed. The epidemiologist gains access to community understanding, and community partners access data otherwise inaccessible due to scarce resources or lack of bureaucratic power. Both parties benefit from increased availability and quality of information, allowing evidence-based decision-making that in turn increases the capacity of the partnership to lobby for change and set upon courses of action.
Community level information not only belongs to the community, it should be generated by the community as well as have community input in all stages of local data collecting, analyzing and reporting. Local participation increases the credibility and relevance of the research to community priorities. Finally, inclusive partnerships require certain practices. Non-essential jargon should be replaced with plain language, and the partnership should be based on the principles of anti-oppression and anti-racism with a respect for the diversity of community and professional ways and networks. Community input must be acknowledged and relevant information shared and used to guide advocacy and action.
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IV Analyzing the Community for Action
Before a community analysis occurs, the research partners must decide how their gathered information will be applied to make a difference to the health and social inequities in a population. This influences the choice of health indicators and data collection methods.
A vast range of indicators can be used. The Provincial Health Indicators Work Group has identified over 120 core indicators. They define health indicators as "standardized measures that summarize factors influencing the health of individuals and their communities" (APHEO 2002). Most of these are based on available census or health status indicators that health units and Health Canada typically track. See http:/www.statcan.ca/english/freepub/82-221-XIE/01002/toc.htm for health indicators at the health unit and district health council level.
With equity the goal, indicators need to reflect diversity within and between communities. The Urban Poverty Project of the Canadian Council on Social Development supplements standard census data by making more detailed cross-tabulations available at the census tract level to the cities in the partnership. These data can be used to describe age, sex and income differences within and between neighbourhoods and communities on standard indicators for immigration, education, employment and housing. Analysis of health differentials at the small area or small group level is limited by the availability of data. However, some analysis is possible using health data linked to address. For example, if studying youth sexual health, one might look at the age specific distribution of STDs in different geographic areas, the location of youth-friendly sexual health clinics and access to condoms, local surveys of youth sexual practices as well as incidence of low income, education and school attendance, youth employment, immigration history, cultural background, language. This allows for identification of specific interventions that may range from expanding peer programs in specific geographic or cultural communities where there are service gaps or access barriers to waiving fees on after-school recreation programs.
Other data collection methods include surveying ESL classes, summarizing data from legal aid clinics, community quality of life studies, voter participation and school profiles. The needs and issues of people who do not have safe and secure housing are missed by data sources that depend on population addresses so alternative ways of addressing this gap are needed. "Our Health. Our Say," a Street Health project that identified necessary funding and service changes to Ontario's Health Care system, collected data through community-based consultation with 243 diverse, underhoused and homeless people surviving in downtown Toronto. The format for sharing the information affects its use. Neighbourhood Profiles that include census, municipal and health indicators and a description of community issues and initiatives have been useful to community health planning partnerships in Toronto.
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V Taking Action on Priorities
The first step to taking action is to determine priorities. These may be identified through high incidence rates, severity of health consequences, the widening of inequities, the identification of greatest need, increase in risk conditions, the capacity to act, the ability to build effective strategies that both strengthen community resilience and target risk reduction, and public/political support.
One of the most important community actions is the ability to witness and state. Study results should be publicized to highlight the health consequences of social inequalities, followed by advocating for rights and entitlements whether for adequate income and wages, funding for new or existing programs or waiving user fees for services or participation. Programs can be examined to determine how to increase the community's capacity, and then workshops can be organized for staff and community members to exchange their skills.
Acting on information gathered through community analysis can lead to beneficial changes for the community. Regardless of the type of study conducted, or the breadth of the resulting action, this type of inclusive partnership between epidemiology and community organizations brings enormous benefits, from information sharing to the ability to advocate for positive change. A copy of the workshop presentation is available from firstname.lastname@example.org.
*Association of Public Health Epidemiologists in Ontario (APHEO) 2002. Provincial Health Indicators Work Group: Terms of Reference. http://www.cehip.org/apheo/indicators/
*Canadian Council on Social Development Urban Poverty Project : Custom Tabulations of the 1996 Census. See city level summary report at www.ccsd.ca/pubs/2000up
* Garfield, E. 1988 "Mapping the World of Epidemiology. Part 1. The Disease Detectives". Essays of an Information Scientist 11(35): 281-289.
*Kendal, D. 2002. The Geodemographics of Population Health in Simcoe County. Unpublished research, Ryerson University.
*Patychuk, D. "Addressing the Determinants of Health in York Communities." Presentation, October 9, 2001