Questions to AnswerQuestions to Answer

What are this person’s health concerns?What are this person’s health concerns? Which “social determinants of health” Which “social determinants of health”

have the most impact on this person’s have the most impact on this person’s situation?situation?

How would you prioritize these issues How would you prioritize these issues and determinants of health (on the same and determinants of health (on the same list)?list)?

Propose some approaches you can take Propose some approaches you can take to the top two issues on your list. to the top two issues on your list. Today? In the future?Today? In the future?

Bringing Health to Bringing Health to Poverty: A Call to Poverty: A Call to Action for Health Action for Health

ProvidersProvidersGary Bloch MD CCFPGary Bloch MD CCFP

St. Michael’s Hospital, Seaton St. Michael’s Hospital, Seaton House ShelterHouse Shelter

Health Providers Against PovertyHealth Providers Against Poverty((Masters Candidate, M.H.Sc.)Masters Candidate, M.H.Sc.)

April 25, 2007April 25, 2007

ObjectivesObjectives

To examine, in the context of the To examine, in the context of the available evidence, the impact of available evidence, the impact of poverty on healthpoverty on health

To identify and discuss specific To identify and discuss specific strategies health providers can use to strategies health providers can use to alleviate the impact of poverty on alleviate the impact of poverty on their clients’ health, at the individual, their clients’ health, at the individual, practice, and community levels.practice, and community levels.

OutlineOutline

Case Discussion (15 mins)Case Discussion (15 mins) Presentation: Background on Presentation: Background on

Poverty and Health (25 minutes)Poverty and Health (25 minutes) Discussion: What Can Health Discussion: What Can Health

Providers Do to Address Poverty? Providers Do to Address Poverty? (35 mins.)(35 mins.)

Poverty and Health Poverty and Health BackgroundBackground

Poverty in CanadaPoverty in Canada Population Health IndicatorsPopulation Health Indicators Chronic DiseaseChronic Disease Children’s HealthChildren’s Health The Social Policy ContextThe Social Policy Context

What is Poverty?What is Poverty? Absolute:Absolute: Income falls below an Income falls below an

objectively defined minimum level (e.g. objectively defined minimum level (e.g. Market Basket)Market Basket)

Relative:Relative: Income is a certain amount Income is a certain amount less than others in society (e.g. % of less than others in society (e.g. % of median income)median income)

Subjective:Subjective: Income is less than an Income is less than an individual feels she needsindividual feels she needs

Other considerations: depth of poverty, Other considerations: depth of poverty, longitudinal datalongitudinal data

Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Literature,” Literature,” CIHICIHI, June 2003., June 2003.

Figure 3.2: Percentage of Canadians Living in Figure 3.2: Percentage of Canadians Living in Poverty, 2004Poverty, 2004

15.5

17.7

15.114

0

2

4

6

8

10

12

14

16

18

Perc

enta

ge L

ivin

g in P

overt

y

All Persons Under 18 Years ofAge

18-64 years 65 years and over

Source: Statistics Canada (2006). Persons in Low Income Before Tax, 2004, CANSIM Tables.

Courtesy of: Dennis Raphael

Figure 3.7: Percentage of Canadians, Children, and Figure 3.7: Percentage of Canadians, Children, and Individuals in Female Lone-Parent Families Living Individuals in Female Lone-Parent Families Living

in Poverty by Province, 2004in Poverty by Province, 2004

18.4

23.1

62.7

13.916.5

57.7

14.4

18.1

50.2

11.710.8

32.9

15.815.6

39.9

14.717.4

54.6

15.8

19.2

47.6

16

20.1

57.3

13.214.5

54.2

19.2

23.5

62.8

0

10

20

30

40

50

60

70

Perc

enta

ge L

ivin

g in P

overt

y

NFL NB NS PEI PQ ON MB SK AL BC

All Children Female Lone-Parent Families

Source: Statistics Canada (2006). Persons in Low Income Before Tax, CANSIM Tables.

Courtesy of: Dennis Raphael

Figure 3.1: Canadian Poverty Rates Over Time, 1984-2004

15.718.7 17.620.8

14

30

37.6

44.6

11.615

51.4

66.5

0

10

20

30

40

50

60

70

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Pe

rce

nta

ge

Liv

ing

in P

ov

ert

y

All Canadians

Children

Seniors

Unattached Individuals

Two-Parent Families

Female Lone-Parent Families

Courtesy of Dennis RaphaelCourtesy of Dennis Raphael

Selected Major Canadian Selected Major Canadian Reports Mentioning Health Reports Mentioning Health

and Povertyand Poverty Health Council of Canada. Health Care Renewal Health Council of Canada. Health Care Renewal

in Canada Feb. 2006 & Feb. 2007in Canada Feb. 2006 & Feb. 2007 Ontario Health Quality Council. Yearly Reports Ontario Health Quality Council. Yearly Reports

2006 & 2007.2006 & 2007. Canadian Institute for Health Information and Canadian Institute for Health Information and

Statistics Canada. Health Care in Canada 2006Statistics Canada. Health Care in Canada 2006 Canadian Population Health Initiative: What Canadian Population Health Initiative: What

Have We Learned Studying Income Inequality Have We Learned Studying Income Inequality and Population Health. Dec. 2004and Population Health. Dec. 2004

Health Disparities task Group, Health Disparities task Group, Federal/Provincial/Territorial Advisory Federal/Provincial/Territorial Advisory Committee on Population Health and Health Committee on Population Health and Health Security. Dec. 2004Security. Dec. 2004

Toronto Public Health: Weekly Cost of the Toronto Public Health: Weekly Cost of the Nutritious Food basket in Toronto 2005, 2006, Nutritious Food basket in Toronto 2005, 2006, 2007.2007.

Isn’t it Just that Poor Isn’t it Just that Poor Health Causes Poverty?Health Causes Poverty?

Review by Phipps (CIHI, 2003): “all Review by Phipps (CIHI, 2003): “all [the studies reviewed] conclude that [the studies reviewed] conclude that reverse causation is not a serious problem and … the main direction of influence is from poverty to poor(er) health.”

Population Level Population Level IndicatorsIndicators

Life ExpectancyLife Expectancy

Poorest vs. richest areas:Poorest vs. richest areas:

5 years5 years shorter for men shorter for men

1.7 years1.7 years shorter for women shorter for women

R. Wilkins, et. al., “Trends in mortality by neighbourhood income in R. Wilkins, et. al., “Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996,” urban Canada from 1971 to 1996,” Health ReportsHealth Reports (Stats Can), 2002: (Stats Can), 2002: 13(Supplement).13(Supplement).

Adler, N. (2001). A Consideration of Multiple Pathways from Socioeconomic Status to Health. In J. Auerbach and B. Krimgold (eds.). Income, Socioeconomic Status, and Health. Washington DC: National Policy Association, Data from NCHS, 1998.Courtesy of Dennis Raphael

Infant Mortality and Infant Mortality and LBWLBW

Poorest vs. richest areas:Poorest vs. richest areas:

Infant Mortality: Infant Mortality: 61% higher61% higher

Low Birth Weight: Low Birth Weight: 43% higher43% higher

Wilkins, et. al., 2002.

Figure 8.1: Infant Mortality (per 1000) and Low Birthweight Rates (per 100) by Income Quintile of

Neighbourhood, Urban Canada, 1996

3.95

4.72

4.85

5

6.35

4.9

5.4

5.8

6.1

7

0 1 2 3 4 5 6 7 8

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

RatesInfant Mortality Low Birthweight

Odd of Reporting Fair or Poor Self-Rated Odd of Reporting Fair or Poor Self-Rated Health:Health:

Ontario, 1996Ontario, 1996

2.19

3.44

1.07

3.89

1.62

2.33

1.38

1.43

0 1 2 3 4 5

Age 40-64

Age 65+

Female

Individual low income

Individual medium income

No regular exercise

Smoker

Less than secondary education

Source: Xi et al. (2005). “Income inequality and health in Ontario”, CJPH, 96, 206-211Adapted from: Dennis Raphael

Person Years of Life LostPerson Years of Life Lost, , 19961996

Source:Source: Wilkins, et. al., 2002. Wilkins, et. al., 2002.

Adapted from: Dennis RaphaelAdapted from: Dennis Raphael

30.9

19.2

17.6

5.3

4.9

4.8

3.8

13.5

24

0 5 10 15 20 25 30 35

Neoplasms

Income-Related

Injuries

Circulatory

Infectious

Perinatal

Ill-defined

Congenital

All other

%

Chronic DiseaseChronic Disease

Cause of Death Increase in Mortality in lowest vs. highest income

quintile neighbourhoods

All causes Both sexes 32%

Ischemic Heart Disease Males 31%

Females 25%

Cirrhosis Males 150%

Females -5%

Uterine Cancer Females 50%

Lung Cancer Males 56%

Infectious Diseases Both sexes 241%

Mental Disorders Both sexes 30%

Diabetes Males 56%

Females 47%

[i] Adapted from Wilkins, et. al., 2002, 14-15.

Adler, N. (2001). A Consideration of Multiple Pathways from Socioeconomic Status to Health. In J. Auerbach and B. Krimgold (eds.). Income, Socioeconomic Status, and Health. Washington DC: National Policy Association, Data from NCHS, 1998.Courtesy of Dennis Raphael

DiabetesDiabetes

Increase in prevalence among low Increase in prevalence among low income vs. high income: income vs. high income: Men 40%Men 40% Women 280%Women 280%

For low vs. high physical activity:For low vs. high physical activity: Men 40%Men 40% Women 50%Women 50%

Douglas G. Manuel & Susan Schulz, “Chapter 4 Diabetes Health Status and Risk Factors,” in J. Douglas G. Manuel & Susan Schulz, “Chapter 4 Diabetes Health Status and Risk Factors,” in J. Hux, G. Booth & A. Laupacis, eds., Hux, G. Booth & A. Laupacis, eds., The ICES Practice Atlas: Diabetes in Ontario,The ICES Practice Atlas: Diabetes in Ontario, 2002, 2002, Institute for Clinical and Evaluative Sciences.Institute for Clinical and Evaluative Sciences.

Increased Risk of Diabetes in Increased Risk of Diabetes in Ontario Among Low Income Ontario Among Low Income

Residents, 1997/97Residents, 1997/97

1.51.2 1

3.8

2.32

11.4

0

1

2

3

4

5

Low Low-Middle Upper-Middle High

Income Level

Dia

bete

s Pr

eval

ence

Rat

io

Males Females

Courtesy of Dennis RaphaelCourtesy of Dennis Raphael

Cardiovascular DiseaseCardiovascular Disease

Low income responsible for 25-30% Low income responsible for 25-30% of CVD mortalityof CVD mortality On par with smoking and hypertensionOn par with smoking and hypertension

$10 000 increase in neighbourhood $10 000 increase in neighbourhood median income = 10% decrease in median income = 10% decrease in CVD mortalityCVD mortality

Peter Tanuseputro, et. al., “Risk Factors for Cardiovascular Disease in Canada,” Can J Cardiol 2003; Peter Tanuseputro, et. al., “Risk Factors for Cardiovascular Disease in Canada,” Can J Cardiol 2003; 19(11):1249-1259. 19(11):1249-1259.

D. Raphael, “From increasing poverty to societal disintegration: how economic inequality affects the D. Raphael, “From increasing poverty to societal disintegration: how economic inequality affects the health of individuals and communities,” in Armstrong, et. al., (eds), health of individuals and communities,” in Armstrong, et. al., (eds), Unhealthy Times: The Political Unhealthy Times: The Political Economy of Health and Care in Canada. 2Economy of Health and Care in Canada. 2001, Toronto, Canada, Oxford Press001, Toronto, Canada, Oxford Press

25%27%

36%

28%

40%

49%

56%

50%

Males Females

0%

10%

20%

30%

40%

50%

60%

Heart Attack Congestive Heart Failure

Angina Chest Pain

Figure 19: Excess Hospitalization Rates Related to Income, Ontario, 1992-97

Courtesy of Dennis Raphael

Mental HealthMental Health

Depression: Overall prevalence 9.17%; Depression: Overall prevalence 9.17%; among low income 14.52% (10.79% men, among low income 14.52% (10.79% men, 17.09% women)17.09% women)¹¹

Food insecure individuals 3X more likely to Food insecure individuals 3X more likely to have MDE or significant distress (NPHS have MDE or significant distress (NPHS 1999)1999)

Lowest third income 2.6 times more likely to Lowest third income 2.6 times more likely to have lower sense of control over their liveshave lower sense of control over their lives

¹¹Katherine L W Smith, et. al., “ “Gender, Income and Immigration Differences in Depression in Canadian Urban Centres,” CJPH, Mar/Apr 2007; 98(2): 149.

Children’s HealthChildren’s Health

Annual Family Income and Annual Family Income and Percentage of Children with Percentage of Children with “Lower Functional Health”“Lower Functional Health”13.4

8.6 8.1 8.3

5.1

0

2

4

6

8

10

12

14

<20,000 20,000-39,999 40,000-59,999 60,000-79,999 >80,000

Functional Health includes testing for vision, hearing, speech, mobility, dexterity, cognition, emotion, pain and discomfort

Prepared by the Canadian Council on Social Development using the National Longitudinal Survey of Children and Youth, 1994-1995

Adapted from Dennis Raphael

Income and Children’s Income and Children’s ProblemsProblems

29

11

7

39

25

7

3.5

31

21

8

4

28

19

53

24

0

5

10

15

20

25

30

35

40

Perc

enta

ge o

f C

hild

ren

Very Poor Poor Not Poor Well-Off

Emotional or behavioural Repeated a grade Social One or more

Source:Source: National Longitudinal Survey of Children and YouthCourtesy of Dennis Raphael

Cumulative EffectsCumulative Effects

Children living in poverty suffer cumulative Children living in poverty suffer cumulative health effects throughout their lifespans, health effects throughout their lifespans, regardless of later socioeconomic statusregardless of later socioeconomic status

Specifically increased risk for CVDSpecifically increased risk for CVD

G. Davey-Smith & D. Gordon, “Poverty across the life course and health,” in Pantazis, C. G. Davey-Smith & D. Gordon, “Poverty across the life course and health,” in Pantazis, C. and Gordon, D. (Eds), and Gordon, D. (Eds), Tackling Inequalities: Where Are We Now and What Can Be Tackling Inequalities: Where Are We Now and What Can Be Done?Done?, 2000, Bristol, U.K., Policy Press., 2000, Bristol, U.K., Policy Press.

How Does Poverty Cause How Does Poverty Cause Poor HealthPoor Health

Absolute income: unable to attend to basic Absolute income: unable to attend to basic needs (e.g. nutrition, health care, needs (e.g. nutrition, health care, environmental hazards) below a certain environmental hazards) below a certain income levelincome level

Relative position: Ongoing stress of being Relative position: Ongoing stress of being lower on the income scale results in poor lower on the income scale results in poor healthhealth

Neo-materialist: income inequality part of Neo-materialist: income inequality part of larger process including other inequalities larger process including other inequalities (e.g. medical, transportation, housing, (e.g. medical, transportation, housing, education)education)

Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Literature,” Literature,” CIHICIHI, June 2003., June 2003.

The Policy EnvironmentThe Policy Environment

Where does Canada rank Where does Canada rank internationally on health and social internationally on health and social spending???spending???

8.07.5

7.47.2

7.16.8

6.76.7

6.46.46.3

6.36.3

6.26.2

6.16.1

5.75.4

5.35.25.2

5.15.0

4.94.8

4.43.9

3.2

0 2 4 6 8

GermanyIceland

SwedenFrance

DenmarkNorwayCanada

CzechBelgium

SwitzerlandPortugal

ItalyJapan

AustraliaUSA

UKNew ZealandNetherlands

SpainFinlandAustriaGreece

HungarySlovakIreland

LuxembourgPolandTurkeyKorea

Figure 12.3: Public Expenditure on Health as % of GDP, 2001

Courtesy of Dennis Raphael

29.2

28.928.5

27.4

27.226.4

26.0

24.824.4

24.3

23.923.0

21.8

21.821.1

20.8

20.1

20.119.8

19.6

18.518.0

17.9

17.816.9

14.8

13.813.2

11.8

6.1

0 5 10 15 20 25 30

DenmarkSwedenFrance

GermanyBelgium

SwitzerlandAustriaFinland

ItalyGreeceNorwayPoland

UKNetherlands

PortugalLuxembourg

Czech RepublicHungaryIcelandSpain

New ZealandAustralia

Slovak RepublicCanada

JapanUSA

IrelandTurkeyMexicoKorea

Figure 12.12: Total Public Expenditure as a % of GDP, 2001

Source: OECD (2004). Social Expenditure Database www.oecd.org/els/social/expenditureCourtesy of Dennis Raphael

5.55.2

4.84.1

3.93.9

3.83.6

3.33.0

2.8

2.82.7

2.52.5

2.52.4

2.32.3

2.32.12.1

1.81.4

1.10.8

0.70.5

0.4

0 1 2 3 4 5 6

PolandSwedenNorway

NetherlandsDenmark

FinlandSwitzerland

LuxembourgBelgium

CzechNew Zealand

IcelandHungaryAustria

UKPortugal

SpainSlovak

GermanyAustralia

FranceItaly

GreeceIreland

USACanada

JapanKoreaTurkey

Figure 12.5: Public Expenditure on Incapacity-Related Benefits as % of GDP, 2001

Courtesy of Dennis Raphael

Figure 12.3: Average Net Incomes of Social Assistance Recipients as Percent of Median Equivalent Household Income,

Married Couple with Two Children, 2001

22

010203040506070

Austra

lia

Germ

any

Poland

Czech

Rep

ublic

Denmar

k

New Zea

land

Finlan

d

Austri

aUK

Irelan

dCHE

Sweden

Franc

e

Nether

lands

Belgium

Norway

Canada

PRTSpa

inUSA

Hungar

y

Greec

eIta

ly

Per

cen

tag

e

No Housing Related Benefits With Housing-Related Benefits

Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.1, p.45.

Courtesy of Dennis Raphael

Source: Daily Bread Food Bank (2006). 2005 profile of hunger in the GTA. Toronto: DBFB.

What Can We Do About What Can We Do About It?It?

An Example: The Special Diet An Example: The Special Diet Campaign and Health Providers Campaign and Health Providers

Against PovertyAgainst Poverty

Background to the Background to the CampaignCampaign

Social assistance in Ontario:Social assistance in Ontario: Recipients’ income 34-58% of poverty lineRecipients’ income 34-58% of poverty line 22% rate cut 1995, 40% total decrease in real $ 22% rate cut 1995, 40% total decrease in real $

nownow Single person on welfare in Toronto earns Single person on welfare in Toronto earns

$569/month, needs an extra $390/month to $569/month, needs an extra $390/month to meet basic needsmeet basic needs

Single parent earns $1653, needs an extra Single parent earns $1653, needs an extra $223/month$223/month

The Special Diet Supplement: Up to The Special Diet Supplement: Up to $250/month extra per individual recipient$250/month extra per individual recipient

The CampaignThe Campaign

Mass assessment clinicsMass assessment clinics

Advocacy: government, health Advocacy: government, health organizations, mediaorganizations, media

Alliances with antipoverty, health orgs, Alliances with antipoverty, health orgs, communitiescommunities

Education and outreach to health providersEducation and outreach to health providers

The ResultsThe Results

6000+ forms signed … millions of 6000+ forms signed … millions of dollars to people living in povertydollars to people living in poverty

Awareness raised: government, health Awareness raised: government, health providers, health organizations, providers, health organizations, media/publicmedia/public

Mobilization of health providers and Mobilization of health providers and new voice in the antipoverty movementnew voice in the antipoverty movement

Mobilization of low income peopleMobilization of low income people Government Action, ?policy changesGovernment Action, ?policy changes

What can health providers What can health providers do about poverty and do about poverty and

health???health???

BrainstormBrainstorm

What Can We Do About What Can We Do About It???It???

Individual Patient-Provider Individual Patient-Provider InterventionsInterventions

Practice InterventionsPractice Interventions

Community InterventionsCommunity Interventions

Individual Patient-Individual Patient-ProviderProvider

See situation from client’s See situation from client’s perspective … alter prioritiesperspective … alter priorities

Limitations poverty places on Limitations poverty places on patient’s ability to adhere to care: patient’s ability to adhere to care: time, priorities, hopelessness, time, priorities, hopelessness, demands of social servicesdemands of social services

Assess eligibility for income Assess eligibility for income supplements, ODSP, exclusion from supplements, ODSP, exclusion from forced work/education programsforced work/education programs

Practice Level Practice Level InterventionsInterventions

information on income support programs information on income support programs and supplementsand supplements

contact information for welfare and contact information for welfare and housing offices, social workers, legal aid housing offices, social workers, legal aid clinics, and antipoverty/advocacy clinics, and antipoverty/advocacy organizations organizations

form letters, e.g. to support access to form letters, e.g. to support access to affordable housing, and to appeal affordable housing, and to appeal rejected income supplement applications rejected income supplement applications

Information on the health effects of Information on the health effects of poverty poverty

Changes to Initial Changes to Initial AssessmentsAssessments

Social Determinant of Health

Intake Questions

Income What is your current income level? What are your current sources of income? Who does this income support? If you are working, do you feel your job is secure and do you have room for advancement?

Social Assistance If you are on social assistance, have you applied for additional income through supplemental allowances or disability support programs?

Housing What is your current living situation? Have you ever been homeless? Do you feel your housing is stable and permanent?

Social Supports What supports do you currently have, from family, friends, or your community, in this city and elsewhere?

Education What is the highest level of education you have achieved? If you are from another country, is your education recognized here?

Additional Interventions for Additional Interventions for Periodic Health ExamPeriodic Health Exam

Assessment of eligibility for social assistance supplements

Support of application for disability supports

Referral to social worker, employment counselor, antipoverty advocates

Consider poverty a risk factor for chronic and acute disease, and assess consider earlier screening for high prevalence conditions: e.g. cardiovascular, respiratory, liver disease; cancer; mental illness; addictions; (etc.)

Community Level Community Level InterventionsInterventions

Direct Health Services for underserved groupsDirect Health Services for underserved groups Use privileged voice to speak publicly about Use privileged voice to speak publicly about

poverty and healthpoverty and health Educate people living in poverty about health Educate people living in poverty about health

risks to improve their ability to advocate for selvesrisks to improve their ability to advocate for selves Participate in public events around decreasing Participate in public events around decreasing

povertypoverty Meet with elected representativesMeet with elected representatives Tell your clients’ storiesTell your clients’ stories Conduct and support research into health and Conduct and support research into health and

povertypoverty