Vancouver HIV/AIDS
Care Co-ordinating Committee

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Documents: Stategies Report 1999-2002
This is a companion document to the Strategic Plan and a work in progress; this version March 31, 2000

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II. POPULATION HEALTH APPROACH

There is a compelling body of evidence which indicates that people with more resources—knowledge, power, money, prestige and social connections—continue to live longer and healthier lives than those with fewer resources. This is true regardless of where the cut-off is established and despite the expansion of more equitably distributed and effective medical intervention.

Population health analysis is the study of how individual characteristics and broader social and economic factors combine to determine the health of different population groups. It links research findings about various determinants of health into a unifying analytical framework.

A population health approach has two key attributes. First, it focuses on the health of populations, or groups of people, rather than the health of individuals Second, it is concerned with improving the health of the general population and the health of subgroups within the general population who experience much poorer health. The strategies used in a population health approach attempt to create environments that support health.

The main tenets of the population health approach (Evans, Barer and Marmor, 1994; Frank and Mustard, 1994; and Health Canada, 1996) are:

• The determinants of health in societies at an advanced stage of development are social, economic and cultural factors at both the individual and population level, not the availability and utilization of hospital-based medical services. Despite universal access to health services in Canada, the health system has not managed to eliminate or even reduce disparities in health and well-being for certain populations. For example, it is well known that the difference in life expectancy and life quality between income levels has not been narrowed by the availability of publicly funded health care.

 
• At the population level, societies with high levels and equitable distribution of wealth enjoy better health status as measured by morbidity and mortality. Those in lower socio-economic groups continue to have significantly lower life expectancy, fewer years free of disability and higher rates of illness and death for almost all causes than those in higher socio-economic groups. At the individual level, a person’s immediate social and economic environment, and the way in which this environment interacts with individual psychological resources and coping skills, has more to do with health status than was previously recognized in epidemiological studies of disease.

 
• It is increasingly understood that adequate nutrition and nurturing of children can prevent developmental health and social problems. What is less widely recognized is the link between early childhood development and the occurrence of major illnesses and death in adulthood. This has significant implications for interventions in the social environment, rather than the more traditional medical and public health measures that target individual risk factors and behaviours.

 
• Given that so many factors affect the health of populations, it is clear that the health care system alone cannot improve health status. As most determinants of health fall outside of the traditional health sector, those working in the health sector must forge relationships with groups whose activities may have an impact on health. It is critical to have a multi-sectoral perspective in taking action for health, rather than focusing predominantly on the provision of health services. This perspective requires broad-based community support and participation, as well as co-operation within and between levels and departments of government.

The term "determinants of health" is a collective label given to the social, economic and environmental factors and conditions, over which individuals have limited direct control, and which are thought to have an influence on health. The determinants of health go beyond lifestyle practice to influence individual and collective behaviour.

The most important determinants of health include income, social status, social support, education, employment, working conditions, social environments, gender, culture and physical environments. The effect of these determinants can be influenced by many individual factors such as personal health practices, coping skills, biology, genetic endowment and sexual orientation. It is the complex interactions among all these factors that have the most profound impact on health.

For the purposes of this strategic plan, the determinants of health have been grouped into four broad inter-related categories, each of which includes one or more specific determinants of health. The definition of each determinant has been taken from Towards a Common Understanding: Clarifying the Core Concepts of Population Health (Health Canada, 1996).

Health status improves at each step up the income and social hierarchy. Adequate income ensures basic living conditions are met, such as access to clean water, adequate food and safe housing, and is essential for the maintenance of health. There is a large body of empirical evidence which links poverty to a shorter life expectancy and higher socio-economic status to a slower progression of disease.

Social status is a vital component in an individual’s personal capacity to effectively negotiate societal systems. An individual who is treated with the dignity and respect generally accorded those with high social status is more likely to benefit from the services offered by representatives of those systems.

Support from families, friends and communities is associated with better health and seems to provide a buffer against health problems.

Health status improves as the level of formal education rises. Education increases opportunities for income and job security, and equips people with a sense of control over their life circumstances – key factors that influence health.

Unemployment, underemployment and stressful work are associated with poorer health. People who have more control over their work circumstances and less stress at work are healthier and often live longer than those engaged in more stressful or riskier activities.

Physical factors in the natural environment (e.g., clean air, clean water) are key influences on health. Factors in the human-built environment such as housing, workplace safety, and community and road design are also important influences.

An individual’s knowledge, intentions, health practices, behaviour, lifestyle choices and skills for dealing with life in healthy ways are key influences on health.

The effect of prenatal and early childhood experiences on subsequent health, well-being, coping skills and competence is very powerful. Children born in low-income families are more likely than those born to high-income families to have low birth weights, to eat less nutritious food, and to have more difficulty in school.

The basic biology and organic make-up of the human body are fundamental determinants of health. Genetic factors provide an inherited predisposition to a wide range of individual responses that affect health status. Although socio-economic and environmental factors are important determinants of overall health, in some circumstances genetic factors appear to predispose certain individuals to particular diseases or health problems.

The values and norms of a society influence the health and well-being of its individual members and populations. Social stability, recognition of diversity, safety, good working relationships and cohesive communities contribute to a society in which health risks are reduced. Studies have shown that low availability of emotional support and low social participation have a negative impact on health and well-being.

Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. "Gendered" norms influence the health system’s practices and priorities. As many health issues are a function of gender-based social status or roles, measures to address gender inequality within and beyond the health system can improve population health.

Some persons or groups may face additional health risks due to a socio-economic environment that is largely determined by dominant cultural values. These values may contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language and culture, homophobia, heterosexism, and lack of access to culturally appropriate health care and services.

Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function, contribute to population health.