Community Health Nursing Week 2 PDF

Community Health Nursing Week 2 TORONTO METROPOLITAN UNIVERSITY, Daphne Cockwell School of Nursing Social Determinants of Health, Health equity, Health Promotion Revised by: Dr. Rupi Khaira, RN 1...

Community Health Nursing Week 2 TORONTO METROPOLITAN UNIVERSITY, Daphne Cockwell School of Nursing Social Determinants of Health, Health equity, Health Promotion Revised by: Dr. Rupi Khaira, RN 1  Module 2 Concepts Setting the Context Health Inequities & Disparities Critical questions Social Determinants of Health 2  Determinants of Health ecological perspective is a valuable framework for promoting health within communities, emphasizing the interaction between individuals and their physical and social environments. approach is based on the understanding that public health and well-being are influenced not only by individual behaviours but also by broader social, economic, and environmental contexts. 3  What determines health? There are four concepts of difference when we examine “what determines health?” 1. Disparity 2. Inequity 3. Inequality 4. Burden Each concept addresses different questions and is applied to policy and program planning from a different perspective. 4  1. Concept of Disparity Disparity is the quantity that separates a group from a reference point on a particular measure of health that is expressed in terms of a rate, proportion, mean, or some other quantitative measure (HP, 2010). 5  2. Concept of Health Equity Health equity is the fair distribution of health determinants, outcomes, and resources within and between segments of the population, regardless of social standing. 6  Concept of Inequity Inequity then is: – A difference in the distribution or allocation of a resource between groups (usually expressed as group specific rates) – Examples of resources: Health insurance Education Flu vaccine Fresh food Clean air 7  3. Concept of Inequality A measure of the degree of association between differences in rates between groups and the distribution of the population among groups. The degree of variation in rates among unordered groups, weighted by group size (race and ethnicity). 8  Educational inequality in infant mortality for white non-Hispanic mothers, U.S. 2005 12 10 Infant deaths per 1,000 live births 8 6 9-11 years 4 12 years 13-15 years 16 years 16 years and and over over 2 9.1% 27.9% 24.0% 0-8 years 1.6% 37.4% 35.5% 0 0 20 40 60 80 100 Cumulative percent of the population ◼The slope index of inequality = -7.3. The infant mortality rate declines by an average of 7.3 infant deaths per 1,000 live births over this population, ordered by years of education. Source: National Vital Statistics System (NVSS), CDC, NCHS.  Educational inequality in infant mortality for Hispanic mothers, U.S. 2005 12 10 Infant deaths per 1,000 live births 8 6 13-15 years 4 16 years + 0-8 years 9-11 years 12 years 2 20.8% 26.5 30.6% 13.7% 8.4% 0 0 20 40 60 80 100 Cumulative percent of the population ◼The slope index of inequality = -1.1. The infant mortality rate declines by an average of 1.1 infant deaths per 1,000 live births over this population, ordered by years of education. Source: National Vital Statistics System (NVSS), CDC, NCHS.  4. Concept of Burden Burden – The difference in the number of persons affected between groups. – Generally, the larger the group – the larger the burden. 11 Number of Infant Deaths by Mother’s Education, US 2005 EDUCATION NUMBER 0-8 years 1,145 There are more mothers in this 9-11 years 3,836 group, and more 12 years 6,747 deaths in this group 13-15 years 3,666 16 years or more 3,231 Not stated 994 Source: National Vital Statistics System (NVSS), CDC, NCHS. A difference in burden… ◼ For example—The burden of infant deaths is greatest for mothers with 12 years of education.  Distinctions Among the Concepts Application to policy or Concept Research question program planning Disparity Is there a difference in health status Is the difference too large? rates between population groups? Inequity Is the disparity in rates due to Is the distribution of resources fair? differences in social, economic, environmental or healthcare resources? Inequality* How do rates vary with the amount of Can the distribution of the population the resource, and how is the among resource groups and/or the rates population distributed among within resource groups be influenced? resource groups? Burden How many people are affected in How many people would benefit specific groups and in the total from interventions? population? *Questions and applications refer to ordered groups  The Full Picture “Health disparities are, first and foremost, those indicators of a relative disproportionate burden of disease on a particular population. Health inequities point to the underlying causes of the disparities, many if not most of which sit largely outside of the typically constituted domain of “health”…[H]ealth disparities are directly and indirectly associated with social, economic, cultural and political inequities; the end result of which is a disproportionate burden of ill health and social suffering…” (Adelson, 2005) 14  Setting the Context Research indicates: in all countries, poorer people have more illness & shorter life expectancies than the rich (CNA, 2005, p. 1). “The issues of inequalities in health is not confined to the problem of the poorest of the poor…it’s socially graded…across the whole of society…solutions have to be social across the whole of society” (Marmot, 2009, p. 24; V; CRC for Aboriginal Health, 2008 – Prof. Sir Michael Marmot). 15  Setting the Context: Health Inequities & Disparities (Beiser & Stewart, 2005; Gardner, 2008) Canada (with underlying assumptions re: these): Generally high standard of living Promise of universal access to high quality health care Commitment to equity & access to health & opportunity 16  The reality… In Canada: Specific sub-populations suffer a burden of illness & distress greater than others “Socially Excluded, Marginalized, &/or at Risk Populations” Aboriginal peoples The poor LGBTTIQQ * Immigrants The homeless The elderly Refugees Some children & youth The Disabled People-Low literacy Some women People-stigmatized conditions * LGBTTIQQ: Lesbian, Gay, Bisexuals, Transgendered, Inter-sexed, Two-Spirited, Queer, & Questioning 17  Some Research Statistics ◼ 3 times as many people with low income report poor or only fair health than those with high income ◼ Burden of chronic illnesses follows a social-economic gradient, e.g., diabetes x 2 as high for low income ◼ Areas where disadvantaged populations have greater need, access to the use of health services is inequitable (Gardner, 2008, p. 2). ◼ Aboriginal peoples are twice as likely to report fair or poor health status than non-Aboriginal with the same income levels. ◼ People living in Canada’s northern remote communities have the lowest disability-free life expectancy & the lowest life expectancy. ◼ Spousal violence rates for Aboriginal women “remain more than 3 times higher than for non-Aboriginal women or men” (Statistics Canada, 2006, p. 65). ◼ 18% of Canadians live in deep poverty, & income inequality is increasing (Beiser & Stewart, 2005, p. S4) ◼ Homeless people are at risk for premature death, infectious diseases, mental illness & substance abuse (Beiser…2005, p. S4) ◼ Immigrants who arrive in Canada are on the whole healthier than native born Canadians, yet within the first decade their health deteriorates (Beiser…2005, p. S4). 18  What causes health inequalities? Health inequalities refer to differences in health status of individuals and groups. Are linked to a range of personal, social economic and environmental factors According to the WHO, there are 5 main causes of health inequalities: 1. Difference levels of power and resources 2. Different levels of exposure to health hazards 3. Different impacts of exposure of health hazards 4. Different impacts of being sick 5. Different experiences in early childhood Now, let’s define the terms in our class… 19 What are health disparities & inequities? (HD Task Group…, 2004) Health disparities Differences in health status occur among population groups defined by specific characteristics. Most often result from inequalities in the distribution of the underlying determinants of health across populations. Associated factors: Socio-economic status (SES), Aboriginal identity, gender, geographic location Note: These factors are interdependent. 20  What are health inequities & disparities? Cont’d (Gardner, 2008) Health inequities & disparities: Differences in health outcomes Avoidable, unfair, & systematically related to social inequalities & disadvantage. Vary by income, race, gender, abilities, sexualities, age… Socially unjust Roots lie in the wider social, economic, political, environmental, & cultural contexts. Yet these are all modifiable! Therefore, we must reduce & eliminate socially & institutionalized structured inequalities & differential outcomes to produce health equity. 21  Health Inequities & Disparities Affect Everyone The health of communities is affected by disparities All of society feels the impact of health disparities – directly & indirectly “In addition to the excess burden of illness on those who are already disadvantaged, - health disparities threaten the cohesiveness of community & society, - challenge the sustainability of the health system, & - have an impact on the economy. These consequences are avoidable and can be successfully addressed” (HD Task Group…2004, p. 3). 22  How can disparities be addressed? ◼ Compare our health system & health disparities to countries, e.g., Sweden & the United Kingdom (UK) where health disparities are less prevalent. ◼ Analyze how it is possible to address health disparities more appropriately in some countries versus other countries. ◼ Examine how health disparities are measured, by whom, & for what purposes. ◼ Investigate promising initiatives that have an evaluative component in their work. ◼ Develop health promoting research initiatives with the purpose of improving the health conditions & health services for people who are socially excluded, marginalized, &/or at risk for health disparities. 23 How can disparities be addressed? ◼ Analyze current health policies. ◼ Work with others to advocate for and/or develop ‘healthy’ policy options. ◼ Work with those who are most often burdened with health disparities to learn about their lives, their needs & their perspectives & continue to work with them throughout the whole process of working towards ‘healthy’ social change (as per Marmot in CRC Video 2008). 24  What are health determinants? Simply: “Health determinants are those factors that influence health” (Naidoo & Wills, 2010, p. 157) Health inequalities/disparities are linked to these factors. The term ‘social determinants of health’ grew out of researchers’ search for the specific mechanisms by which members of different socio-economic groups come to experience varying degrees of health and illness (Wilkinson & Marmot, 2003, in Raphael et al., 2006, p. 116) Let’s examine these determinants as defined by others… 25  Social Determinants of Health Naidoo & Wills (2010, p. 157) [UK: United Kingdom] Socio-economic & environmental health determinants - in their chapter Income & poverty Employment & unemployment Crime & violence, including ‘domestic’ violence Housing Sustainability, regeneration & renewal Transport 26  Social determinants (cont’d) Social determinants of health: “…those structural factors that impact on health & are beyond any individual’s ability to change” (Naidoo & Wills, 2010, p. 157). Social determinants of health: a broad term encompassing both socio-economic , cultural, environmental factors, e.g., income, housing, gender, race, violence, & much more. Both are fundamentally shaped & determined by collective societal choices in social policies & regulatory & legislative frameworks. Such policies exist at different levels-global, national, regional, & local. Action has begun to identify & address the social determinants. Much more research, critical analysis, & action still needs to be done. 27 Mikkonen & Raphael - Canada (2010) Stress, bodies, & illness Income & income distribution Education Unemployment & job security Early childhood development Food security Housing Social exclusion Social safety net Health services Aboriginal status Gender Race Disability 28  Public Health Agency of Canada (2005) “Population Health Approach” 1. Income and social status 2. Social support networks* 3. Education & literacy 4. Employment /working conditions 5. Social environments 6. Physical environments 7. Personal health practices & coping skills* 8. Healthy child development 9. Biology & genetic endowment 10. Health services 11. Gender 12. Culture  Adapted at the policy level in  Federal, several provincial, & some regional governments. [Recommended reading: module 4] 29  * Community Health Nurses of Canada (2011, p. 27) Recognized Determinants of Health 1. Income and Income Distribution 2. Education / Literacy 3. Unemployment and Job Security 4. Employment and Working Conditions 5. Early Childhood Development (early life) 6. Food Insecurity 7. Housing 8. Environment (including social, physical; natural and built environments) 9. Biology and Genetic Endowment 30  Community Health Nurses of Canada (2011, p. 27) cont’d 10. Healthy Child Development 11. Social Exclusion 12. Social Status 13. Social Safety (Support) Networks 14. Health Services 15. Personal Health Practices and Coping Skills 16. Aboriginal Status * See next slide 17. Gender 18. Culture 19. Race 20. Disability 31  Aboriginal specific determinants of health (CHNC, 2011) * In addition the CHNC (2011) notably include what the National Aboriginal Health Organization has identified: Aboriginal specific determinants of health 1. Colonization 2. Globalization 3. Migration 4. Cultural continuity 5. Territory 6. Access 7. Poverty 8. Self determination 32  Commission on the Social Determinants of Heath (WHO, 2008) The social determinants of health are the conditions in which people are born, grow, live, work, & age, including the health system. These circumstances are shaped by the distribution of money, power, & resources - at global, national, & local levels, - which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities the unfair & avoidable differences in health status seen within & between countries (WHO, 2008). 33  Three Overarching Recommendations (WHO, 2008) Commission on the Social Determinants of Health final report: 3 overarching recommendations - to taking action on health inequity, - a matter of social justice 1. Improve daily living conditions 2. Tackle the inequitable distribution of power, money, & resources 3. Measure & understand the problem & assess the impact 34  How to: Reducing Health Inequities & Disparities (Beiser & Stewart, 2005, p. S5) “Canada’s commitments to social justice, universal health care & equity are sources of national pride” (p. S5). These principles challenge us to * Take our place among countries willing - to contribute knowledge about & - to confront & redress inequalities in health that are avoidable, unnecessary, & unfair - inequitable. * Living up to our national these ideals requires that we address this challenge collectively 35  How to: Reduce health inequities in health: Action plan (Gardner, 2008) 12 point action plan under 3 major themes: 1. Build equity into service provision 2. Strategically target investments & interventions for greatest equity impact 3. Build equity into system transformation. Begin by: Creating a powerful equity vision Start from strengths Take a long view, but get going 36  How to: Reduce Health Inequities in Health: Summary of Approaches (Ridde, 2007) ◼ Public Health ◼ Health Promotion Process: Technocratic Process: Empowerment End goal: Improve population Basis: Ottawa Charter health - Provides populations with -------------------------------- means to ensure greater control over & improve their ◼ Community Health own health Process: Participatory End goal: Reduce health End goal: Improve population inequalities in health health Values: Advocacy, equity, & social justice 37  Implications of How To: for Nursing (CHNs) (CNA, 2005) Individual nursing practice ◼ Understand the impact of social determinants of health on our clients ◼ Include questions in our assessments on social determinants, e.g. income, housing, food security, social support etc. ◼ Work with disadvantaged communities to understand the link to social determinants & organize to take collective action Reorienting the health care system ◼ Ensure health promotion programs go beyond lifestyle & behaviour to take social determinants into account ◼ Encourage health departments to take a social determinants approach, re the impact of poverty, violence, hunger, etc. “Healthy” public policies ◼ Speak from experience, e.g., use stories to advocate for policies that address social determinants of health ◼ Analyze critically how structural issues of class, gender, race, abilities, sexualities, & cultural affect the ways populations experience health problems & develop initiatives that address these issues. ACT collaboratively with communities to dismantle health inequities & disparities in the work towards social justice in health for all 38  Thinking “upstream” Means making smarter decisions based on long- term thinking What better goal than creating the conditions for all people to enjoy true health — complete physical, mental, and social well-being? And what better measure of its success than the health of those people? Upstream thinking seeks to generate a new frame of thinking. Focuses on decisions that will make the most impact on the quality of our lives. So, how do we create this?...Critical question! 39  Upstream thinking proactive approach to healthcare that aims to address the root causes of health issues before they escalate into significant problems. This concept prioritizes prevention and health promotion by identifying and addressing the social, environmental, and economic determinants of health. You tube video UPSTREAM THINKING 40  Thinking “upstream” Connect individuals and partner organizations – Common goals – Common language Aid in creating a public demand for policies and actions consistent with the new frame. 41  Upstream vs Downstream (1 of 2) Upstream approaches are often prevention and promotion strategies focused on policy interventions that benefit the whole population PHC interventions that focus on people’s well-being by addressing and taking action on the root causes of preventable diseases and injuries. Acute care services are usually tertiary prevention measures, are focused on individual treatment and cure, and are considered downstream interventions.  Upstream vs Downstream (2 of 2) Upstream approaches extend beyond addressing individual behaviours and identify programs, policies, and environmental changes  Theory and Upstream Thinking (Butterfield, 2001- Also see Cohen, 2012, M-4) Thinking upstream - society as a locus of change (vs. the individual), i.e., with critical social theory, social determinants of health Downstream approaches (micro - narrow scope) short-term, individual-based interventions Upstream approaches (macro - broad scope) looking beyond the individual to where the real problems lie (McKinlay, 1979) viewing a problem emphasizing variables that precede or play a role in the development of a problem 44  Public Health and Community Services aim to work upstream… (build skills, confidence, and increase prevention through support and social change) …Illness services work downstream (diagnosis, treatment and support after a crisis) 45  Downstream thinking Examples: – Providing treatments for existing health problems – Changing “individual” views of health for individual benefit. 46  Application Now, in your groups, let’s examine your chosen at-risk population for these concepts and factors. 47  Next: Theory What theoretical frameworks best guide CHN practice for population groups more at risk to health inequities and disparities? 48  References plus course readings Canadian Nurses Association. (2005, October). Social determinants of health and nursing: A summary of the issues. CNA Backgrounder. Retrieved from http://www.cna- nurses.ca/CNA/documents/pdf/publications/BG8_Social_Determinants_e.pdf (Opens PDF document) Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security. (2004, December). Reducing health disparities – roles of the health sector: Recommended policy directions and activities (pp. 1-5). Ottawa: Her Majesty the Queen in Right of Canada, represented by the Minister of Health. Cat. No. HP5-3/2005. Retrieved from http://www.phac-aspc.gc.ca/ph- sp/disparities/pdf06/disparities_recommended_policy.pdf (Opens PDF document) Marmot, M. (2009). Closing the health gap in a generation: The work of the Commission on Social Determinants of Health and its recommendations. Global Promotion, Supplement 1, 23-27. http://ped.sagepub.com/content/16/1_suppl/23 (Opens new window) 49