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Using Neighbourhood Data to Address the Social Determinants of Health

Contents

I Introduction
II Detailed Information about Your Neighbourhoods
III A Closer Look at Possible Solutions
IV Using the Data to Make a Difference
V Outcomes to Date
VI The Role of Public Health Practitioners
VII References

--submitted by Diana Daghofer, Wellspring Strategies and Hope Beanlands, Scientific Director, National Collaborating Centre for Determinants of Health

I Introduction

To have an impact on the health of their communities, public health professionals need to start with relevant data. Evidence on what works to address the issues, and a process to follow for effective implementation help map the course to success. Some recent reports, and work by the National Collaborating Centre for Determinants of Health (NCCDH), will provide that information to support public health professionals in addressing health inequities.

II Detailed Information about Your Neighbourhoods

Urban settings, where a growing number of Canadians live, provide focal points for studying the health effects of unequal socio-economic status (SES). The Canadian Population Health Initiative (CPHI) of the Canadian Institute for Health Information (CIHI) studied health disparities in 15 Canadian cities, including Toronto, Hamilton, London and Ottawa, in Reducing Gaps in Health – A Focus on Socio-Economic status in Urban Canada.[1]

The report compared hospitalization rates and health survey data on health behaviours and conditions between residents of the most deprived neighbourhoods in Canada to those of the least deprived. Using CIHI’s Discharge Abstract Database and National Trauma Registry, it provides hospitalization rates around 21 indicators, including diabetes, chronic obstructive pulmonary disease, asthma in children, injuries of various kinds, mental health issues, and low birth weight. Self-reported health indicators (collected by the Canadian Community Health Survey [2]) were used to gauge perceived health and well-being, including self-rated health, physical inactivity, smoking, alcohol intake, overweight or obesity, and influenza immunization.

Rather than focusing on a single element of material or social disadvantage, the CPHI report uses both income and a deprivation index developed by l’Institut national de santé publique du Québec, that takes into account education, employment status, income and family structure (percent of single-parent families, persons living alone and persons separated, divorced or widowed). [3] As such, it assesses both material and social factors.

The deprivation index was used to assign small geographical areas or neighbourhoods, typically containing 400 to 7000 people, into high, average or low socio-economic status areas. This approach allowed for a pan Canadian analysis, as well as individual city analyses for each of the 15 participating census metropolitan areas (CMAs).

The results showed a consistent pattern: people who lived in areas of increasing deprivation had poorer health and used hospitals more, for most conditions. Further, this pattern followed a gradient – the more deprived a neighbourhood was, the poorer the health outcomes of its inhabitants, with health improving at each level of income. The data were released nationally and locally. Many cities used the information to report on local health disparities, and proposed interventions and solutions.

III A Closer Look at Possible Solutions

Health Disparity in Saskatoon: Analysis to Action [4] presents neighbourhood-level health data for that city, and reviews policies successfully used in Canada and internationally to address the underlying social determinants of health. The report provides 46 evidence-based policy options to reduce health and social disparities, based on data from Canada, the US, Europe, Australia and New Zealand.

Social determinants of health are clearly linked. Without adequate income, it is difficult to secure housing, appropriate food and other resources required for health. [5] The evidence is clear that income and education are strongly associated with health [6, 7] and that there are consistent gradients of improved health with higher income and education levels. [8] Poverty is a common thread among low SES groups in all cities. In Saskatoon, use of health services had limited, if any, association with disease, and behaviours had limited independent association, as risk behaviours are often associated with income status. [9]

Working with the authors of these two reports, the NCCDH is in the process of preparing a series of Evidence Reviews, examining health issues and their links to social determinants of health in selected cities across Canada. The Evidence Reviews can be used by public health practitioners to focus on areas where the disparities are particularly striking for a given city, and will highlight available evidence to guide action.

IV Using the Data to Make a Difference

Saskatoon Health Region (SHR), through its Public Health Observatory, started an extensive process to document and began to address health inequities in that city. Regular health surveillance data made it appear that the health of residents was fairly good and improving. However, data averaging was hiding what public health people knew to be true – there were pockets within the city where residents did not experience these health outcomes.

In 2005, health data pointed to serious discrepancies between low-income neighbourhoods and the rest of the city. Information on infant mortality, teen pregnancy and other health measures prompted a comprehensive research study to compare the health status of residents in Saskatoon’s six lowest income neighbourhoods to the rest of the city. Some of the results were particularly concerning. For example, the infant mortality rate in Saskatoon’s low income neighbourhoods was over four times higher than in the rest of the city – a larger gap than in developing nations.

With the preliminary research results in, staff at SHR recognized that the disparity was so disturbing that they could not simply publish the data in a journal. They felt it was important to involve the community and health care partners in a process of communication, consultation and ongoing data gathering.

Saskatoon’s Regional Intersectoral Committee (RIC) was the perfect place to start. This provincially-mandated intersectoral group has 30 members, including senior leaders from four municipal departments, seven provincial ministries, two federal agencies, researchers, Aboriginal organizations and a dozen community-based organizations.

Many community groups had been working for years to address poverty and other social determinants of health in Saskatoon. Since many of the solutions would be found within the community, the knowledge and collaboration of residents and community-based organizations would prove invaluable to bringing about change. The United Way took a leadership role, taking a very public stance on the issue and opening dialogue with smaller community organizations. These groups, in turn, provided the much-needed link directly to the people most affected by the social determinants of health – the families living in poverty.

As a result of the health disparities data, municipal representatives were able to see their important role in improving the social environment. For example, using the report, the manager of community services was able to map how the department’s work in housing has a direct impact on health. It provided the foundation to bring the social determinants of health into the strategic planning process at City Hall.

Researchers at the university and affiliated institutions helped lend credibility to the health disparities process. A farther-reaching result was changes to the curriculum in the Community Health Epidemiology and Medicine programs at the University of Saskatchewan that will shape future health professionals by including issues of health equity.

V Outcomes to Date

With a clear understanding of the situation, the Saskatoon Health Region has made reducing health disparity one of its organizational priorities. It is actively working on program and policy changes to do what it can from a health system perspective.

The RIC has also made reducing health disparity a priority, and has created a leadership group, comprised of some RIC members, business leaders, faith leaders, people living in poverty and additional representatives from NGOs and First Nations communities. They are working on a local Action Plan to Reduce Poverty (or "increase prosperity" as some prefer), to be released next year. It will capture progress made since the release of the report, and document partners’ plans and a timeline to implement the recommended policy and program changes.

The RIC has also convened working groups in the areas of Aboriginal employment and affordable housing. Health partners and the United Way are co-chairing this process, supporting the efforts of the various working groups and committees. Provincial government leaders are involved at various levels in the working groups and committees.

The involvement of a broad-based coalition was key to refining the knowledge of health disparity in Saskatoon. It helped identify and focus investment on those initiatives most likely to reduce the extensive health disparity. The collaborative work has already resulted in policy and program changes in the city’s low-income neighbourhoods, including:

  • The personal income tax threshold for low-income people has changed:
    • the personal tax credit amounts (exemption) has been increased by $4000 (personal and spousal)
    • the child tax credit has been increased by $2000
    • a low-income tax credit has been created, including increasing the threshold where tax credits begin to be reduced (to $28,335 from $13,935).
  • Minimum wage was increased from $8.60 an hour to $9.25, in May 2009.
  • Funding for affordable housing and investment in several inner city schools has increased.
  • Health services have been increased in inner city schools, including public health, primary care and a paediatric clinic.
  • Efforts to improve immunization coverage in the inner city have increased.
  • There is increased programming for mental health promotion and physical activity promotion in school in the inner city.

Efforts continue in Saskatoon, with consultations going on now on regarding improved social services programs and funding. Presentations have been made to provincial policy makers in areas such as health, education, and social services, and to various senate committees federally.

VI The Role of Public Health Practitioners

A case story being prepared by NCCDH documents the process followed by Saskatoon Health Region. It provides an excellent example, including successes and lessons learned, for public health practitioners.

The case story notes that local data is a powerful motivator. It emphasizes the importance of broad-based community involvement and support for progress to be made. Finding common ground among the diverse opinions of such a varied group can be challenging, but is a required starting point, according to Dr. Cory Neudorf, who led the process. He further notes: “Focus on the early wins and agreement that we need to work together to start turning the situation around. You need to work at local, provincial and federal levels at the same time, but do not let delays in one area prevent movement forward in another.”

Aside from the critical health issues that can be alleviated, the Saskatoon case story reveals the significant savings in healthcare costs possible when the socio economic position of a city’s poorest residents is improved. People from low income neighbourhoods in Saskatoon were 27–33% more likely to be hospitalized and 36–45% more likely to receive a medication, bearing out previous research into healthcare utilization.

As the voice for population health concerns, public health practitioners can play an important role in addressing health inequities. The upcoming series of Evidence Reviews on health disparities will assist practitioners in the use of evidence and local data to influence change in health outcomes in communities across Canada.

VII References

1. Canadian Institute for Health Information, Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada (Ottawa, Ont: CIHI, 2008)

2. Statistics Canada, Canadian Community Health Survey, CCHS Cycle 2.1 (2008), [online], from http://www.statcan.gc.ca/rdc-cdr/cchs-escc2_1-eng.htm, and CCHS Cycle 3.1 (2005) [online], from http://www.statcan.gc.ca/concepts/health-sante/cycle3_1/index-eng.htm, viewed on January 19, 2009

3. Pampalon R. and Raymond G., “A Deprivation Index for Health and Welfare Planning in Quebec,” Chronic Diseases in Canada 21, 3 (2000): pp. 675-690

4. Lemstra M, Neudorf C. Health Disparity in Saskatoon: analysis to intervention, Saskatoon: Saskatoon Health Region; 2008

5. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2008, Public Health Agency of Canada, available at http://www.phac-aspc.gc.ca/publicat/2008/cpho-aspc/index-eng.php (accessed December 31, 2008)

6. R. Wilkins, “Mortality by Neighbourhood Income in Urban Canada From 1971 to 2001,” presented at the Health Analyst and Measurement Group (HAMG) Seminar, Ottawa, Ont., on January 16, 2007 (For the data sources and methods, see R. Wilkins, J. M. Berthelot and E. Ng [2002]. “Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996.” Health Reports 13 [Supplement]: pp. 45–71.)

7. A. Zajacova, “Education, Gender, and Mortality: Does Schooling Have the Same Effect on Mortality for Men and Women in the US?,” Social Science & Medicine 63, 8 (2006): pp. 2176–2190

8. N. A. Ross et al., Unpacking the Socioeconomic Health Gradient: A Canadian Intra-Metropolitan Research Program (Ottawa, Ont.: Health Canada, 2006)

9. Lemstra M, Neudorf C. Health Disparity in Saskatoon: analysis to intervention, Saskatoon: Saskatoon Health Region; 2008