Equity, Social Determinants and Health Policies

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Equity, Social Determinants and Health Policies

• Louise Potvin, PhD
• CHSRF Chair Community Approaches and Health
  Inequality,
• Léa-Roback Research Center on Health Inequalities
  of Montreal
• Université de Montréal
• Municipal Forum about Health Policy and Health in
  Cali
• Cali, Columbia
• July, 10th, 2007

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Work developed in collaboration with Pr.
Katherine L. Frohlich Université de Montréal
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Objectives

• Propose that social inequalities in health are
  the by-products of institutional, population
  approach to health promotion and prevention
  program
• Examine how the concept of vulnerable population
  stems from those health inequalities

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Plan

• Roses population approach
• Population approach and health inequalities
• Mechanisms of vulnerabilities

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Roses Population Approach Beyond the Notion of
Population at Risk
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www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/p
ubs/1974-lalonde/lalonde_e.pdf
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The Lalonde Report Two Innovations

• The four elements of the health field
• Human biology
• Social and physical environment external to
  human body and over which individuals have little
  or no control
• Lifestyle aggregation of decisions by
  individuals
• Health care organization
• A policy for prevention Focusing on
   populations at risk  rather than on sickness
  episodes

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Lalondes Population at Risk

• That part of the population that is making the
  greatest contribution to the average risk
• Resulting from three kinds of information
• Causes of mortality and kind of morbidity
• Underlying reasons for their occurrence
• Susceptible segment of the population those
  who exhibit the risk factors

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Targeting Population at Risk
Known risk factor
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Three Critics of  Population at Risk  Approach

• Blaming the victim emphasis on the life choice
  part of lifestyle (health promotion)
• Not preventing the rest of the population of
  becoming at risk (Syme)
• Not addressing the conditions that influence the
  incidence and give the distribution its shape
  (Rose)

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Symes Critique
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A Population Approach to Prevention
1. The distribution of risk in a population is
shaped by contextual conditions
2. The majority of cases occur in individuals at
average risk
3. The aim is to improve the condition of the
overall population by modifying the conditions
that shape the distribution of risks
4. Changing the conditions that affect the
overall distribution in the population also
improves the risk of those at greater risk.
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1. Context and Distribution of Risks
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2. Risk and Prevalence
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3. Improving Health in Overall Population
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4. Affecting also Population at Risk
Serdula, Mk et al. Trends in alcohol use and
binge drinking, 1985-1999. Am J Prev Med 2004
26(4)294-298.
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Population Approach and Health Inequalities
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Results of a Population Approach

• Improvement of the overall health of the
  population by most population health indicators
• Inability to reduce inequalities between various
  subgroups of the population and in some instances
  increase of inequalities between subgroups

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Increase of Life Expectancy at Birth, Canadian
Population, 1960-1990
Statistics Canada www.statcan.ca/english/Pgdb/hea
lth26.htm
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Life Expectancy at Birth per Income Quintile, Men
and Women, Montréal, 1994-1998
Income Quintile
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Life Expectancy of Aboriginal People in Canada,
1998
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Infant Mortality per 1000 Live Births by Income
Quintile 1971-1996, Canada
Difference Q5 Q1 (71 96) 9.8 8.1 1.6
2.4 1.5 3.3 Ratio Q5 / Q1 (71 96) 1.97
1.73 2.23 1.61 1.34 1.93
Wilkins, Berthelot, Ng. Trends in Mortality
by Neighbourhood Income in Urban Canada from 1971
to 1996. Heath Reports 2002 13 (suppl 1).
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Desired Effect of Population Interventions
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Unintended Effect of Population Approach
Concentration of Vulnerabilities
Concentration of vulnerabilities
Concentration of benefits
Mean effect
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Population Approach Unintended Consequences
Less vulnerable
Most vulnerable
Corrective approach
Health Outcome
TIME
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Limits of a Population Approach

• AETIOLOGY Roses theory reflects
  cross-sectional thinking it does not take into
  consideration the mechanisms that led to the
  distribution of risk.

2. INTERVENTION Roses theory does not take
into account that individuals have differential
capacity to transform resources provided by
health interventions into health, and that those
differences may be related to the mechanisms that
produced the risk distribution.
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Mechanisms Contributing to the Concentration of
Vulnerabilities
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Mechanisms that Concentrate Vulnerabilities
1. Life course At any point in time an
individuals health is the result of all previous
exposures
2. Concentration of risk Risks do not come
alone, co-morbidity and multiple exposure are
more frequent in some populations
3. Fundamental cause Risk factors and their
accumulation are the expression of more
fundamental causes that are linked to ones
position in social structure and that shape ones
response to intervention
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Life Course Accumulation of Risks from Birth to
5 Months by Family Income
Premature
Premature
Term
Term
Perceived health less than excellent
Chronic health problem
Québec birth cohort, 1999-2000.
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Vulnerable Population Concentration of Risks,
Montréal-Centre, 1998
Risk factors
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Fundamental Causes
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Vulnerable Populations

• Distinct from populations at risk they are at
  risk of risks
• Associated with position in social hierarchy and
  not to disease aetiology
• Concentrate all sorts of risks associated to
  their position in the social stratification
• Those risks cumulate throughout life course
• Associated with a lower capability to take
  advantage of health systems interventions,
  including public health

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Three Approaches to Improving Population Health
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Conclusions

• Population approach represents a progress from
  populations at risk approach allows maximum
  absolute benefits (Lynch)
• Population approachs main limitations
• Potential to increase health inequalities
  differential distribution of benefits
  exacerbating vulnerabilities
• One risk factor at a time
• Corrective interventions and vulnerable
  populations
• Target fundamental causes
• Integrated interventions multiple risks
• Focus on the whole population of people made
  vulnerable by their sharing of the fundamental
  cause
• No single approach can do it all