1. Public Awareness and Understanding of Health Inequalities in Ontario Ketan Shankardass, PhD Department of Psychology, Wilfrid Laurier University Centre for Research on Inner City Health in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital November 30, 2012

2. Outline 1.The link between public awareness and political will for health equity 2.Ontario public awareness of health inequalities 3.Implications for broadening awareness of SDoH in Ontario

3. Health

4. Social Determinants of Health Health Sector Health Services (Adapted from World Bank, 2011) How broad is your health system? Health System

5. Need to strengthen chronic disease prevention, e.g., Diabetes in Ontario (Canadian Diabetes Association, 2010)

6. Diabetic Ontarians tend to have lower income or education (Manuel and Schultz, 2003)

7. Food insecurity is more common in lower income households in Ontario (POWER Study, 2010)

8. …particularly among those with mid/low income Neighbourhood ‘activity-friendliness’ predicts diabetes in Toronto... (Booth et al, 2007)

9. Why not broaden action on the social determinants of health? Why not tackle the growing health and economic burden of diabetes and obesity – and reduce inequities in these outcomes – by supporting measures to ensure that all Ontarians have adequate: ▫Family income ▫Food security ▫Neighbourhood activity friendliness

10. Political will as a key driver of action on the social determinants of health Problem stream Policy stream Political stream Window of Opportunity to Act on SDoH Public Awareness and Understanding as a Driver of Political Will (Kingdon, 1984)

11. Public Opinion on Health Inequalities in Ontario Telephone survey using random digit dialling 2006 Ontarians aged 18 years and over Survey conducted in 2010 fall/winter The survey included questions pertaining to three broad themes: 1.awareness of health inequalities 2.attributions of the causes of health inequalities 3.opinions about solutions to health inequalities

12. Public Awareness of Health Inequalities in Ontario Respondents asked to agree/disagree with four statements about health inequalities in general and by income in Ontario: 1.In Ontario, all people are equally healthy and can expect to live for more or less the same amount of time 2.In Ontario, people who are rich are much healthier than those who are poor 3.In Ontario, people who are poor are less likely to live into their 80s than people who are rich 4.Over the last few years, people who are rich have become healthier while people who are poor have become less healthy

13. Public Awareness of Health Inequalities in Ontario 1.In Ontario, all people are equally healthy and can expect to live for more or less the same amount of time 2.In Ontario, people who are rich are much healthier than those who are poor 3.In Ontario, people who are poor are less likely to live into their 80s than people who are rich 4.Over the last few years, people who are rich have become healthier while people who are poor have become less healthy 73% disagreed 53% agreed 64% agreed 57% agreed (Shankardass et al 2012) 11%

14. The rich are less likely to suffer from... ~20% (Shankardass et al 2012)

15. So what? A small majority of Ontarians are aware of income-related health inequalities ▫30% in a 2005 national study (CIHI 2005) ▫82% in a 2004 study in Saskatoon (Lemstra et al 2007)

16. So what? Much lower awareness of income-related inequalities in specific health conditions ▫Even Ontarians who are generally aware have an incomplete understanding of the breadth of the issue

17. So what? There is a need for more “knowledge translation” of evidence outlining inequalities Aim to: a.Reduce the size of the core minority who remain unaware b.Improve awareness about the variety of outcomes impacted Which Ontarians to target? How to frame the issue to those groups?

18. Younger Ontarians are less aware of income-related inequalities Age Group Relative Odds Compared to Youngest Age Group “The rich are much healthier than the poor” (Shankardass et al 2012)

19. Females are less aware of income- related inequalities than males Relative Odds for Males (Shankardass et al 2012)

20. Rural Ontarians are less aware of income-related inequalities Relative Odds for Urban Areas (Shankardass et al 2012)

21. Ontarians with low educational attainment are less aware of income- related inequalities Relative Odds for High School Attainment (Shankardass et al 2012)

22. Ontarians who don’t vote NDP or Liberal are less aware of income- related health inequalities Relative Odds for NDP Voters Relative Odds for Liberal Party Voters (Shankardass et al 2012)

23. (Gollust et al 2009)

24. “Right Choices” model for why there are health inequalities

25. -Unequal health opportunities versus unequal outcomes -Explaining the role of external factors in clear and compelling ways -A clear and practical vision of how to solve the problems -Health as an exceptional case -Explaining the health gradient (“a grand challenge”) To move the public away from the “right choices” model:

27. Attributions for income-related health inequalities among Ontarians (Lofters et al, unpublished)

28. (Reutter et al 1999, as cited in Raphael 2012)

29. Attributions for income-related health inequalities among Ontarians, by political affiliation (Lofters et al, unpublished)

30. Moving the SDoH agenda forward In Ontario, we need to strengthen public awareness about income-related inequalities… -Generally and about specific outcomes -Particularly among Ontarians who are: -Younger -Female -Rural -With low educational attainment -Who vote Progressive Conservative -Focus on translating explanations related to: -Neighbourhoods and health -Accessibility of the health care system -Disempowering effect of low income

31. THANK YOU Questions? Comments?

32. Structural determinants of health (Solar and Irwin, 2007)

33. (The Ontario Educational Communications Authority, 2011)

34. Health in All Policies as health promotion Advocate for political/economic/social/ cultural/environmental/biological/behavioural conditions favourable for health and equity Continue to work on clearly and concisely articulating links amongst health determinants and health/equity outcomes Build the case for a multisectoral approach, one sector at a time Build public awareness and understanding of health determinants and “population health”

35. Health in All Policies as health promotion Mediate the specific interests of actors in the pursuit of health and equity E.g., Health Impact Assessment using “win-win approach” Health diplomacy “to make the healthier choice the easier choice for policy makers” (Krech, 2011) May involve trade-offs initially to foster durable relations with increasingly health-aware partners Good cop-bad cop? The need for legislation to compel action, as needed

36. Social marketing? Considering a “social marketing” perspective can help think about messaging that will resonate with specific under-aware subpopulations Consumer-oriented marketing techniques have been used in the design, implementation and evaluation of health promotion aiming to influence behaviours Incorporates the four “Ps” of marketing ▫Place – who are you trying to target? ▫Product – what are you trying to sell? ▫Price – how “costly” is buy-in? ▫Promotion – what approach will promote buy-in?

37. Key concepts of social marketing Consumer orientation ▫E.g, Research to understand knowledge, attitudes and beliefs of the target audience and their social context to improve design and implementation Existing behaviour and behavioural goals ▫E.g., What is the starting point and what specific changes would we like to see? What’s the best process for achieving these goals?

38. Key concepts of social marketing Intervention/marketing mix ▫A range of efforts may be used to achieve goals Audience segmentation ▫There may be a need to target different messages/approaches to different audiences (think: differences in social-cultural context)

39. Key concepts of social marketing Exchange ▫Acknowledgment of the “costs” (interpreted broadly) of people changing behaviour ▫The maximization of perceived benefits and minimization of perceived costs Competition ▫Taking into consideration all other factors that compete for people’s attention and willingness to adopt the behaviour being promoted