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Shifting the Dialogue on Chronic Disease

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I Introduction

Over the past few decades, there has been a shift in the way in which we perceive health, and the factors that make for good health. Here are three perspectives on a major chronic disease:

Cardiologist:
"Heart disease is caused by hypertension, family history, and a build-up of arterial plaque."

Public health nurse, nutritionist or fitness instructor:
"Heart disease is caused by smoking, physical inactivity, excess alcohol consumption and a high fat diet."

Social worker, social epidemiologist or anti-poverty activist:
"Heart disease is caused by stress, poverty, unemployment and social isolation."

(From HP 101, http://www.ohprs.on.ca)

These are three different paradigms or frameworks for looking at health. The first is an example of a bio-medical model, the second a behavioural model, and the last, a social determinants of health model. Depending on the model that we adopt, we take different routes to address the issue. The doctor will prescribe cholesterol-reducing pills, the fitness instructor will tell us to be more physically active, eat healthy foods, and quit smoking. The social worker or activist will direct our attention "upstream," to influence those factors that cause us to experience lack of health "downstream."

These three paradigms are not mutually exclusive and each has a role to play. BUT, for large-scale improvements in population health, action at the level of the social determinants is needed.

The Ontario Chronic Disease Prevention Alliance in its March 2006 report states, "Chronic disease can no longer be explained only as an outcome based on engaging in the ‘wrong' health behaviours. There is a need to look beyond individual responsibility to understand the ways in which the social environment shapes the decisions we make and the behaviours we engage in."

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II Moving from Knowledge to Action

The growing incidence and prevalence of chronic disease, and the growing body of research that links this to the conditions in which people live, work, play and love, makes acting on the social determinants of health more urgent and necessary than ever before. However, despite increased understanding of the need to act on the determinants, few are able to take action on these determinants. Many of those working directly to prevent chronic disease remain focused on healthy lifestyles and pay little attention to the social determinants of health. At the same time, many who work in social services sectors do not recognize the work they do as being linked to chronic disease or health more broadly.

Primer to Action: Social Determinants of Health is an electronic resource that helps us understand how the social determinants of health affect chronic disease, and what we can do about it. Set in an electronic, easy-to-read format, with hundreds of links and resources, it is a practical resource for busy health and community workers and activists. Primer to Action helps us move toward upstream actions to impact health.

Primer to Action provides a point of entry to understand and take action on six health
determinants: Income, Employment, Housing, Food Security, Education and
Inclusion. It offers concrete suggestions for change in the community, the workplace and the broader society.

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III Multi-stage Participatory Process

Primer to Action was produced in March 2007, by three partners: Health Nexus (then Ontario Prevention Clearinghouse), the Ontario Chronic Disease Prevention Alliance (OCDPA), and the Canadian Cancer Society, Ontario Region. After the launch of the Primer, the partners received overwhelmingly positive feedback. They also recognized that there was further work to be done to help its potential audiences move from knowledge to action.

Primer to Action Phase II was completed in April 2008, and is a partnership between OCDPA and Health Nexus. The Public Health Agency of Canada, Ontario and Nunavut funded Phase II and part of Phase I.

Phase II had two key components: to test, apply and revise the Primer, and secondly, to educate Ontario health intermediaries about the intersection between the SDOH and CDP, through workshops based on the Primer.

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IV Revised Primer to Action Features Over 400 Links
                
The revised and improved Primer to Action (http://www.healthnexus.ca/projects/PrimertoAction_May30.pdf) is now available. This edition contains expanded content on the determinants, plus a section on how each of the determinants is linked to chronic disease. There is a greater focus on issues of health equity. Many new links have been added, bringing a total of over 400 links embedded throughout the resource.

Early sections of the Primer introduce the concept of social determinants of health, and how individuals can fit in, either as health and community workers, or in their role as community members. This is followed by sections on the six determinants. Each section describes the links to chronic disease, promising practices, a planning tool and further resources. The Primer is designed to help users approach their work in ways that may be new and different.

The revised edition incorporates feedback from workshop participants (see below); key informants; five content reviewers from different sectors (English and French); advisory committee members; an electronic survey; comments from readers; and an evaluation.

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V Workshops Help Inform the Revised Primer

As part of the project, five workshops were held in different parts of the province, three in English and two in French. One of the workshops was for member organizations of the OCDPA. Each workshop was organized in partnership with a local co-host. Co-hosts included a CHC, a public health unit, a multi-sector coalition, and a settlement organization. Workshops included local content, plus a role for the local co-host. In all, 139 participants attended the workshops, 38 of whom were francophone. One French workshop was held by videoconference, with participants in three Northern Ontario locations.

The workshops were designed to get participants thinking about the social determinants of health and its relation to chronic disease, in general and with respect to their own individual location. The workshops included small group discussions about local issues, using the Primer as a framework.

Many of the comments from participants have been incorporated into the revised edition of Primer to Action. One of the most positive features of the workshops noted by participants was the networking opportunity. Sectors that were represented included Community Health Centres, public health, housing, income supports, settlement, other community services, people working in chronic diseases such as diabetes, cancer and pulmonary disease, students and researchers, the LHINs and government.  

The Primer has been widely promoted and well received. Presentations on the Primer have been made at the OPHA conference, 2007, the Heart Health Symposium, 2007, the FOCUS/ODAP conference, 2008, CPHA conference, 2008 and AOHC conference 2008. Further presentations are planned.

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VI How to use the Primer to Action

We have received many ideas from the field on how to use the primer. Here are some of the suggestions:

  • Those working in mental health will find this shows the links between mental health and the determinants. This can also be useful to someone new to the field, or to people working in policy.
  • Those working in the settlement sector can use the Primer to understand how links between the different sectors impact health. It can also be used for training.
  • Those working to promote healthy lifestyles tend to focus on individual behaviour change messages. The Primer will help them understand how the social determinants of health impact people's behaviour.
  • The Primer is a great starting point to engage people in discussion on broader social forces and how they impact us. We plan to use the Primer to engage members of our community.
  • People working in government can benefit from the Primer, to help them see the bigger picture.  
  • The Primer is a great starting point for writing a proposal for funding.
  • There are great examples of lessons learned from other communities
  • It's a good place to start when planning a community initiative.
  • A great planning tool. Helps you think systematically about how to address issues in your work.

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VII Shifting the Dialogue at the Global Level

The revised Primer to Action has arrived at an opportune time. The WHO Commission on the Social Determinants of Health (CSDH) is due to release its final report in the next few months. Established in 2005, the CSDH has had a profound impact worldwide, helping to  focus our attention on the "causes of the causes."

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VIII Feedback and Acknowledgements

We know that a document such as Primer to Action is never "complete" - it is always a work in progress. We would like to hear from you. Tell us if you found the Primer useful, how you have used it, how it can be improved, resources you would like to see mentioned, and any other comments and suggestions. We can be reached at [email protected].

I would like to thank my colleagues who worked with me on this project for their comments and suggestions on this article - Suzanne Schwenger and Robyn Kalda of Health Nexus.