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Ask Canadians what determines their health and you would get many different answers. Some would say luck, or other "big picture" concepts. Some would say their family history or gene pool. Most would point to their lifestyle - whether they smoke, how they eat and drink, how much they exercise, and perhaps how they manage their stress levels. Few would mention their education, income, or housing.
Yet research shows that it is our deep, enduring social, economic and environmental
position that is the most powerful influence on how long and how healthily we
live.
The concept of Broad Determinants of Health is very simple yet very powerful. In practise, it seems difficult to explain and even more difficult for institutions and communities to embrace. So, rather than an academic and linear explanation, here is a story:
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Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a bad cut on his leg and it got infected.
But why does he have a bad cut on his leg?
Because he was playing in the junk yard next to his apartment building
and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there
and there is no-one to supervise them.
But why does he live in that neighbourhood?
Because his parents can¹t afford a nicer place to live.
But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?
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(This story appears in "Towards a Healthy Future: Second Report on the Health of Canadians. It is adapted from D. Werner and B. Bower (1982) In Helping Health Workers Learn.
Palo Alto: The Hesperian Foundation. http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#income)
This simple story raises some important questions about what really determines health, and how we can collectively improve the health of the nation.
 This fictional story is no more important or dramatic than the millions of stories of ordinary Canadians whose health is determined by their personal circumstances and where they live and work:
- People living in neighbourhoods which are polluted by nearby industries.
- Low income families for whom healthy fruits and vegetables are expensive and not so easy to access in corner stores.
- Single mothers for whom smoking is a simple and single pleasure.
There are many reasons why Jason's story, among the other ordinary stories, is never-ending. Here are four:
- As the form of the story indicates, if we are searching for causes of Jason's hospitalization, we will continue for some time finding more and more root causes, causes that are more systemic, longer term, entrenched and thus more challenging to address in the name of prevention.
- Just as the beginning of the story is elusive, so too is the end. Would the story end when our health care system and modern pharmaceuticals heal Jason's infection? Or does the story end when the playground is fixed up, or when Jason or his father find education and meaningful employment? The story may actually be about social justice and reducing inequities.
- Sadly, based on current circumstances and trends, poverty and its consequences may be always with us, never-ending. As advocates routinely point out, we have the resolve, the resources, and the institutions to fix Jason's infections, but not to fix the playground or assist his father in finding meaningful employment.
- The story will end if we become complacent. I think the real point of Jason's story is that we must continue to feel shock, shame, and/or outrage and continue to believe we can do better in creating caring communities that offer the most opportunities to all.
Intrigued? Feel like taking action?
As a first step, visit the Health
Promotion page of the Canadian Health Network. It includes links to great
resources and frequently asked questions (FAQs) about health promotion - use
the Guided Search features to narrow your search and find the document or organization
you need.
This centre takes you to many places including Public
Health Agency of Canada's Population Health Site which lists twelve determinants
of health:
- Income and Social Status
- Social Support Networks
- Education
- Employment/Working Conditions
- Social Environments
- Physical Environments
- Personal Health Practices and Coping Skills
- Healthy Child Development
- Biology and Genetic Endowment
- Health Services
- Gender
- Culture
Beginning with income, the web site presents Premises and Underlying Evidence for each of the Determinants.
The Population Health site is a good jumping off point to many organizations and resources addressing the broad determinants of health. One of them, The Making Connections project, a collaboration of 6 Ontario organizations, produced a booklet and resource guide of that name. The booklet is organized around some of the broad determinants - each includes a fictional vignette that dramatizes the human side and impact of these determinants and is accompanied by statistics and suggested action steps.
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This article was prepared for CHN by Larry Hershfield, Centre for Health Promotion at University of Toronto.
