Addressing the Social Determinants of Health: Beyond documenting the Problem

Kim Webster, Program Manager, VicHealth

Presentation to the Social Justice Initiative Workshop Program: Justice, Equality and the Social Determinants of Health, June 14 2011

About VicHealth• Independent statutory authority• Bipartisan board of governance• Focus on behavioural, social and environmental

determinants of health• Works across sectors (in the environments in which

health is produced)• Focus on building new evidence, knowledge and

practice

Presentation overview• Introduction to an approach to addressing the

social determinants of health developed by VicHealth and its partners

• Illustrated with program examples – primarily from prevention of violence against women (but also prevention of race based discrimination)

• Identification of key lessons learned• Explores extent to which approach might be

transferrable to other settings and issues

The preventing violence against women example: definitions and concepts

• Any act of gender based violence that results or is likely to result in physical, sexual or psychological harm or suffering to women including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life (UN 1996).

• In the majority of cases the assailant is known to the victim, with a large proportion being a former or current intimate partner.

• Gender inequality a significant underlying cause.

What do we mean by prevention?

Intervention (tertiary prevention)

Strategies implemented after violence has occurred to deal with the violence, prevent its consequences and prevent reoccurrence/escalation

Early intervention (secondary prevention)

Targeted to individuals/groups with early signs of violent behaviour or being subject to violence to address those signs or increase skills

Primary preventionStrategies to prevent violence before it occurs by making environments safer, building the knowledge and skills of individuals or changing behaviour

Why focus on primary prevention?Typically, the health sector’s engagement in social determinants of health (SDOH) has been in:• Health service provision/behaviourist health

promotion with sensitivity to the influences of SDOH on cause, access and treatment.

• Intervention responses to social problems so that their health impacts are minimised.

• Research and evaluation to establish health impacts and benefits.

• Advocacy to other sectors to act on health grounds.

Why focus on primary prevention?Primary prevention involves using health promotion strategies and approaches to address underlying causes (further up the stream, deeper into the iceberg).

Indicated when a health problem is:• Prevalent (population level problem)• Associated with significant harm• Preventable – causes of the problem are modifiable • A health promotion approach is ‘’fit for purpose”

(we return to this later …….)

Additional criteria for VicHealth: Areas in which:• Primary prevention is not being supported elsewhere• There are significant gaps in practice and policy development

Health promotion’s contribution: the ecological approach• Based on the notion that health/social

outcomes are the product of multiple influences.

• These lie at different levels: individual, organisational, community, societal.

• Influences at these levels are relatedto and reinforce one another.

• Attempts to address the problem require a similarly complex response, i.e. multiple and reinforcing strategies at different levels of influence.

Organisation

Individual

Community

Society

Health promotion’s contribution: the ecological approach• Initially developed by Broffenbrenner to shape responses to

child development (1970s)• Underpins the Ottawa Charter for Health Promotion and other

heath promotion instruments• Importance of strategies being based on the evidence• Multi disciplinary• Cross sector/cross setting ( need to engage with the settings in

which health and illness are produced)• Used successfully to reduce tobacco use and associated health

problems. Can it apply in other areas?

Note the ecological approach is NOT a theory• Theory and evidence pertaining to specific social phenomena still

needed to be assessed to ‘populate’ ecological models.

Key steps in establishing the approach: the PVAW example• Establishing the case for a primary prevention

approach.• Development of evidence informed frameworks to

guide practice.• Formation of practice, research and strategic

partnerships (including program governance).• Workforce and resource development.• Research and evaluation.• Achieving sustainability/sustaining change.

The PVAW example: Making the case• Prevalent – affects 1 in 5 women in the lifetime.• Serious – responsible for 8% of the disease burden in

Victorian women.• Preventable – international consensus that VAW is associated

with potentially modifiable risk factors.

Program logicWhat contributes to or causes the problem?

Individual Organisational Community Societal

What actions will be effective in addressing the problem?

To which populations should we target our efforts?

Through which settings should we deliver actions?

Individual Organisational Community Societal

What outcomes do we expect through these actions in the short term (12 months to three years?)Individual Organisational Community Societal

What are the long-term benefits we hope to achieve?

Individual Organisational Community Societal

Health promotion actions Public health strategy Actions

Direct participation Build individual skills to maintain equal and respectful gender relations

Community strengthening

Strengthen community capacity to understand the problem and to take action to shift social norms

Organisational development

Building capacity of organisations to create safe and welcoming environments for women, through policy, program and workforce development

Communications and social marketing

To raise awareness, create new social norms and shift attitudes

Policy development/legislative reform

Policy development, resource allocation and legislative reform to support primary prevention

Research and evaluation

To increase understanding of violence and assess the effectiveness of prevention strategies.

Why a framework?• Helps to make sense of complex social phenomena –

provides a ‘road map’.• Build consensus and understanding among key

stakeholders and partners, especially in areas where there are competing paradigms.

• Helps to identify and define the roles of various partners (settings and populations).

• Provides a basis for unifying and coordinating effort.• Boundary issues – both pushing and defining the

boundaries.• Provides a logic to follow given the long term nature of

the effort required. Helps to ensure accountability and to secure and maintain support.

The PVAW example: Relationship between framework and program designThemes for action• Promoting equal and respectful relationships between men and women• Promoting non-violent social norms• Improving access to resources and systems of support.

Universal and targeted interventionsNeed for greater emphasis on men and boys

Specific populations at risk/for targeting: Refugee, Indigenous, communities affected by economic disadvantage, young men in violence supportive cultures (some sporting cultures, military/quasi military organizations), children and young people

Promising approaches: School based respectful relationships programs,

community mobilization, communications and marketing

The PVAW example: Establishing the program• Governance (expertise, strategy, protection).• Workforce and resource development (short

course, Everyone Wins).• Partnerships for (a) implementation (b) strategic

impact.• Building research and evaluation capacity.• Sustainability – policy partnership, resource and

workforce legacy.

The PVAW example: StrategiesPublic health strategy Activity

Direct participation programs

Program targeted to young couples in the ante-natal period

Community strengthening

Partnership with two local governments to strengthen their capacity to address violence against women.

Research & evaluation Community attitudes survey to raise awareness of the extent of the problem.

Communications & marketing

Development of a network of individuals to respond to media activity. Advertisement targeted to CALD communities

Organisational development

Development of the Everyone Wins, a resource to assist sporting clubs to strengthen welcoming and safe environments for women.

Advocacy for policy and legislative reform

Partnership with Victorian government to support the development of A Right to Respect, achieving an increased resource base to address the issue and a commitment to an evidence informed approach.

Key lessons learned• Partnership activity – beyond the usual suspects.

Challenges associated with this.• Importance of establishing the business and economic

case for intervention (ACCESS economics and BOD report).

• Primary prevention in the context of unmet need for tertiary responses.

• Importance of workforce and resource development.• Getting the balance right on prescribing approaches

versus community/organisational self determination.

Key lessons learned• Values driven – dealing with discomfort with the

approach (addressing structural causes disrupts the status quo).

• Acknowledging and dealing with risk.• A matter of assessing environmental receptivity AND the

evidence (e.g. schools).• Top down/bottom up balance. • Long term investment – not the quick fix.• Duelling paradigms (drawing on the bits of each).• Balance between honing the practice and securing

strategic change.

Transferability• Ecological environments within ecological environments.• Strategic targets and approaches will differ depending on

ecological environment.• Transferability of framework capital – extensively used to

guide practice.• Extent of engagement depends on issue. The health sector

clearly does not have the right tools to lead a comprehensive response (versus contribute) to change efforts for all SDOH; i.e. role is limited where solutions to problems lie primarily at the societal level or require high level sector specific expertise (e.g. unemployment where role may be confined to research/advocacy versus full suite).