Health Promotion International, Vol. 18, No. 4, 397-405, December 2003
© Oxford University Press 2003 All rights reserved
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Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada*
School of Health Policy and Management, York University, Toronto, Canada
Address for correspondence: Dr Dennis Raphael, School of Health Policy and Management, Atkinson Faculty of Liberal and Professional Studies, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada, E-mail: draphael{at}yorku.ca
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SUMMARY |
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Despite Canada's reputation as a leader in health promotion and population health concepts, actual public health practice for the most part remains wedded to downstream strategies focussed on behaviour change. In Canada's largest province this has led to the implementation of a heart health promotion approach focussed on diet, activity and tobacco use. This is so despite increasing evidence that these approaches are generally ineffective, particularly for those at greatest risk. In addition, these strategies appear to divert public and governmental attention away from addressing the broader societal determinants of health. Examples of Ontario public health units that have begun to address societal determinants of health provide a counterbalance to the dominant paradigm that frames health as an individual responsibility. These new approaches focus attention upon the health-threatening effects of governments' regressive social and economic policies in a manner consistent with the best principles of health promotion.
Key words: critical perspectives; population health; public health
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INTRODUCTION |
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This paper considers the role that public health units in Ontario—Canada's largest province—play in addressing poverty and other societal determinants of health. These activities are considered in light of the history of Canadian policy statements on health promotion and population health, and an increasing conceptual and empirical literature on the relationship between poverty and health. The focus on heart health promotion in Ontario serves to illustrate four key arguments:
- despite Canada's reputation as a leader in health promotion and population health, public health practice emphasizes downstream, usually behavioural strategies rather than the broader societal determinants of health;
- these downstream approaches are dominant despite limited evidence of their effectiveness, particularly for those at greatest risk, and increasing evidence of the importance of the societal determinants of health;
- these downstream behavioural approaches have side effects that threaten population health rather than promoting it; and
- means are possible for health units to seriously address upstream societal determinants of health, including poverty, even in increasingly conservative political times.
Two important questions raised and considered by this analysis are ‘Why does public health in Ontario and elsewhere focus on downstream activities to the exclusion of more broadly based upstream concerns?’ and ‘What are the effects of this emphasis upon policy makers, the media, and the public's understandings of the causes of illness in Canada?’. The analysis and conclusions are relevant to public health practice across Canada and other nations. This would especially be the case in the US, where health promotion, with few exceptions, is usually defined as involving lifestyle approaches to health promotion.
Argument 1: despite Canada's reputation as a leader in health promotion and population health, public health practice emphasizes downstream—usually behavioural—strategies rather than addressing the broader societal determinants of health
Canada has been seen as a world leader in developing health promotion concepts (Restrepo, 1996). These concepts expanded the meaning of health and suggested new ways of thinking about public policy in support of health. Ideas about reducing health inequalities, empowering individuals and communities, and building healthy cities and communities were introduced by Canadians, and made their way into Canadian Federal and Provincial policy documents (Pinder, 1994; Health Canada, 2002
). Canada has also been a leader in conceptualizing the societal determinants of health. Poverty has been identified as a key determinant of health in many of these federal and provincial statements (Government of Ontario, 1994; Hamilton and Bhatti, 1996; Health Canada, 1998; Government of British Columbia, 2000).
Similarly, Canadian Public Health Association (CPHA) policy statements stress the importance of the societal determinants of health, including poverty (CPHA, 1993; CPHA, 1996a; CPHA, 1996b; CPHA, 1997). More recently, the CPHA passed an action plan to address the incidence of poverty and its impacts upon health (CPHA, 2000). Canadian concepts of health promotion and population health have influenced health policy thinking in Europe and, more recently, provided US health workers with ideas for improving the health of Americans (Auerbach et al., 2000; Auerbach and Krimgold, 2001; Minnesota Department of Health, 2001; Raphael, 2002a; Raphael and Bryant, 2002). A summary of Canadian government and association positions on poverty and health is available (Raphael, 2002b; Raphael, 2001c).
Yet, despite the best continuing efforts of Health Canada and CPHA staff to promote the importance of the societal determinants of health [see the new Population Health Template as an illustration of these efforts (Health Canada, 2002)], Canadian public health practice remains for the most part a downstream, and usually a behavioural change effort. One review of provincial practice found:
Many provinces had no evidence of mandated programs that were explicitly health focussed, that addressed broader determinants of health, or used multiple strategies [(Sutcliffe et al., 1997), p. 247]
A more recent and extensive survey of local public health units across Canada found that half of 98 responding health regions did not have any initiatives addressing poverty issues. Among those that did, virtually all were dealing with the consequences of poverty rather than addressing its causes (Williamson, 2001).
The Ontario Heart Health Initiative illustrates the downstream, behavioural change emphasis so prevalent in Canada. The initiative is a C$17 000 000 5-year programme of the Conservative government that recently received an additional C$29 000 000 for another 5 years. The specific focus is on lifestyle factors of diet, activity and tobacco use. No provision is allowed for addressing structural (societal or community) factors in heart health, despite increasing evidence of their importance. There also appears to be no recognition on the parts of its promoters and implementers that such an approach is inconsistent with 25 years of Health Canada and CPHA statements on health determinants. There is little acknowledgment that health promotion approaches have moved far beyond the targeting of individual risk behaviours (Labonte, 1992; Lyons and Lavalle, 2000).
This disconnection was recognized by one group of local implementers of the provincial initiative. The North York Heart Health (North Toronto) Network's members were frustrated by its limited mandate and the clear neglect by the initiative of broader community and societal issues implicated in heart health. The network commissioned a literature review of the relationship of income with heart health to raise awareness and help shift the direction of heart health activities in Ontario.
The release of the report Inequality is Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of Heart Disease in Canada (Raphael, 2001a) in November 2001 was received with little enthusiasm by other Ontario heart health networks, the Ontario chapter of the Heart and Stroke Foundation, and the provincial Ministry of Health and Long-Term Care. It contained six messages related to promoting heart health:
- The current emphasis on medical and lifestyle risk factors as a means of preventing cardiovascular disease in Canada is not enough.
- Low income is a major cause of cardiovascular disease in Canada.
- Social exclusion, involving processes of material deprivation, lack of participation in common societal activities, and exclusion from decision-making and civic participation, is the means by which low income causes cardiovascular disease.
- The directions in which Canadian society is heading are inconsistent with what is known about reducing the incidence of cardiovascular disease.
- These directions, including greater inequality of distribution of income, compromise the cardio-vascular health of Canadians at all income levels.
- Solutions are available to reduce the number of Canadians living on low incomes and to distribute income more fairly, thereby reducing social exclusion and helping to improve the cardiovascular health of Canadians.
The network was informed by the provincial government and the local health unit that additional funds were unavailable to reprint the report beyond its initial run of 300 copies and that posting of the report on the internet would not be sanctioned. These reactions were surprising, as the report simply brought together the literature on the role societal determinants play in the incidence of heart disease in Canada. It was also surprising since its content was consistent with federal and provincial statements on the societal determinants of health, and consistent with the principles of the Healthy Cities Movement that originated in Toronto (Raphael, 2001b). Clearly, a societal determinants of health approach to heart disease would not have government sanction in Ontario. The report did stimulate a small number of public health units in Ontario to address broader issues in health promotion and population health.
Argument 2: the downstream behavioural approach remains dominant in Canada, despite limited evidence of its effectiveness and increasing evidence of the importance of societal determinants of health
Three issues are raised by downstream, behaviourally oriented approaches to health promotion: victim blaming; the relative importance of individual risk factors in disease causation; and the effectiveness of behavioural change approaches.
The earliest critiques of downstream approaches to health promotion focussed on the issue of victim blaming. The following concerns were raised over 20 years ago (Labonte and Penfold, 1981; Labonte, 1994):
The argument was simple. The health of oppressed people (poor, women, persons from minority cultures, workers, and others) was determined at least as much, if not more, by structural conditions (poverty hazards, powerlessness, pollution, and so on) than by personal lifestyles. Moreover personal lifestyles were not freely determined by individual choice, but existed within social and cultural structures that conditioned and constrained behaviour. Behavioural health education, social marketing, or wellness approaches to health promotion fostered victim blaming by assuming that individuals were entirely responsible for their choices and behaviour. They also blamed the victim indirectly by ignoring the structural determinants of health, those causes that are embedded within economic, class- and gender-based patterns of social relationships. [(Labonte, 1994
The critique of risk factor approaches now recognizes that the individualization of risk is dependent upon prevailing political and economic ideologies rather than actual evidence (Tesh, 1990; Eakin et al., 1996; Lynch et al., 1997). We will return to the theme of victim blaming later.
The second critique of downstream, behavioural change approaches is based on findings that individual risk behaviours explain modest variance in the incidence of numerous diseases. This is especially the case for cardiovascular disease. The early Whitehall Studies (Marmot et al., 1978) first noted this, and these findings have been repeatedly replicated (Feldman et al., 1989; Lantz et al., 1998; Diez-Roux et al., 2000; Roux et al., 2001). A recent summary of this work in the area of heart disease is available (Raphael, 2002b).
This evidence has accumulated in conjunction with model building in the area of population health and social epidemiology. Davey Smith and his colleagues provide compelling evidence in support of a life-course approach to heart disease (Davey Smith et al., 2001; Davey Smith et al., 2002). Further evidence is available on how adverse conditions during the very early years predict heart disease in later life (Barker et al., 1989; Eriksson et al., 1999; Forsen et al., 1999; Eriksson et al., 2001). Nevertheless, heart health initiatives in Ontario and elsewhere reify the ‘holy trinity’ of risks: diet, smoking and exercise (Nettleton, 1997). Nettleton argues:
As with any area of medical or scientific research, the selection of factors to be studied cannot be immune from prevailing social values and ideologies....It is also evident that so called lifestyle or behavioural factors (such as the holy trinity of risks—diet, smoking and exercise) receive a disproportionate amount of attention [(Nettleton, 1997
The ‘holy trinity’ has been deified by Ontario's public health units and local heart health networks. The issue is not whether eating poorly, using tobacco and remaining sedentary are bad for health. Their impact, however, is limited as compared with other societal determinants, and an emphasis upon individual risk factors to the exclusion of all other considerations is problematic (Shaw, 2002).
The third issue is increasing recognition of the limited effectiveness of such approaches, especially among disadvantaged groups. Ebrahim and Davey Smith (2001), commenting on the most well-known heart health community-based programmes, concluded: ‘Intriguingly, these uniformly disappointing developed country programmes have been reported as successes’ [(Ebrahim and Davey Smith, 2001), p. 202]. In Canada, two consultants for Health Canada reached a similar conclusion in their review of lifestyle approaches to heart health promotion:
This 4-year, community-based cardiovascular disease prevention programme was aimed at adults aged 18 to 65 years living in St-Henri, a low-income, inner-city neighborhood. Over 40 interventions were implemented (i.e. smoking cessation workshops, contests, heart health cooking classes and recipe contests, nutrition education workshops, direct mail and ad campaigns...)... Although they carefully adapted each intervention to local needs, the results were dismal. [(Lyons and Lavalle, 2000
Fitzpatrick offers a critical assessment of the limited effectiveness of behavioural change-oriented health promotion programmes (Fitzpatrick, 2001). In Inequality is Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of Heart Disease in Canada, the following was noted. First, behavioural factors account for a small proportion of disease incidence as compared to societal factors such as poverty. Secondly, it adopts a ‘blaming the victim’ approach, whereby those who are disadvantaged are blamed for their own illness when the factors responsible are beyond their control. Thirdly, emphasis on risk behaviours fails to address underlying issues of why disadvantaged people adopt these behaviours. Fourthly ‘It [individual choice approach] has also been signally unsuccessful in leading to the development of effective interventions to achieve behaviour change in disadvantaged groups.’ [(Jarvis and Wardle, 1999), p. 241]
In contrast, evidence is accumulating of how upstream policy-oriented approaches influence population health. The Widening Gap report in the UK details how as income inequality increases, health differentials between areas increase, and as income inequality decreases, health differentials decline (Shaw et al., 1999). Analyses of the policy environment and its impacts on the health and well-being of women within five nations are available (Raphael and Bryant, 2002), and Navarro examines how population health is related to overall political and social policy in numerous developed nations (Navarro, 2002; Navarro and Shi, 2002).
Argument 3: these downstream behavioural approaches have side-effects that may serve to threaten population health rather than promoting it
Downstream approaches warp policy makers, the media, and the public's understandings about the causes of disease in general and heart disease in particular. A recent study asked 601 residents of Hamilton, Ontario, to identify ‘the major cause of heart disease’ (Paisley et al., 2001). Respondents were provided with an additional six opportunities to identify ‘any other cause of heart disease’. In response to these open-ended questions, only one respondent of 601 identified poverty as a cause of heart disease, out of 4200 potential responses.
Why does the public have this blind spot? It is well known that the media focus on lifestyle issues to the exclusion of societal determinants of health. It is also apparent that the disease-oriented organizations limit their consideration of factors to medical and lifestyle issues, as do Ontario public health units. The outcome is a virtual wiping of any public awareness of the role societal determinants of health play in promoting health in general, and heart health in particular.
The approach leads to a neglect of alternative visions of health determinants and health promotion; a point recently made in an editorial on social epidemiology (Shaw, 2002). In models of how research leads to action, awareness of a health issue is a necessary precursor to any policy change (Whitehead et al., 2000). The complete lack of awareness of the role societal determinants play in heart disease precludes any policy action on the societal determinants of health in general, and heart disease in particular in Ontario. This is one way the emphasis on behavioural approaches to health promotion threaten efforts to improve population health.
Some reasons why public health and disease-oriented associations ignore these issues can be entertained. The denial of the importance of societal determinants of health is consistent with the ascendance of governmental commitments to neo-liberalism and neo-conservative ideologies that position societal issues, including health and health promotion, as individual issues beyond the concern of governments and their institu-tions (Nettleton, 1997). While even centre-left governments are prone to lifestyle approaches (see Fitzpatrick's critique of the Blair UK government, 001), more conservative governments can promote these approaches at the same time as they weaken the societal structures that affect population health far more profoundly.
The point is particularly relevant to the present Ontario provincial government. By any objective population health yardstick, the economic and social policies carried out by the Ontario Conservative Government have weakened population health. Numerous reports and studies have reported the explosive growth in numbers of children and families living in poverty, living as homeless or home-insecure, and using food banks or other emergency food supplies (Golden, 1999; Ontario Non-Profit Housing Association and Co-operative Housing Federation of Canada, 2000; Raphael et al., 2000; Daily Bread Food Bank and North York Harvest, 2001; Federation of Canadian Municipalities, 2001; Raphael, 2002a; Raphael et al., 2001c; Raphael, 2001d; Ontario Campaign, 2002). These events resulted in large part from the province drastically reducing social assistance benefits, eliminating 18 000 new social housing units at the same time as it eliminated tenant rent control, and transferring wealth from the poor to the wealthy through an income tax reduction for the well-off.
Argument 4: means are possible for health units to seriously address upstream societal determinants of health, including poverty, even in these increasingly conservative political times
Many Ontario public health departments avoid an activist, societal-oriented approach such as the one that led to the development of the Healthy Cities Movement in Toronto during the early 1980s (Raphael, 2001b). Indeed, it is rare to find public health units in Ontario or Canada taking on roles of addressing broader societal determinants of health. In Quebec, however, the Health Unit for the Region of Montreal specifically addresses societal determinants of health inequalities (Lessard, 1997). There are now two such examples in Ontario. These units lead the way for public health units to consider broader health determinants, including poverty. Such activities help move public health to a position where they promote public awareness of the importance of societal determinants of health and work towards the development of healthy public policy.
Waterloo Regional Health Unit
The Waterloo Region Public Health Unit established a unit for the social determinants of health that is committed to promoting evidence-based and participatory approaches to programme and policy development (Waterloo Region Public Health Unit, 2002a). Three broad areas of support services were created: Program Planning and Evaluation Support, Healthy Communities and Policy Support, and Epidemiology and Data Support. The acceptance of the importance of the broad societal determinants of health poses a direct challenge to traditional approaches to public health programming:
For many years, traditional public health approaches have focussed on disease risk factors and behaviour change as a means to attain health. Research accumulating over the last 10 years illustrates that broader social, economic and environmental ‘risk conditions’ determine the choices that individuals can make, and have more influence on health than lifestyle factors per se. Programs which overlook the broader social, economic and environmental context, are unlikely to be effective at improving health outcomes for the entire population [(Waterloo Region Public Health Unit, 2002), p. 1].
The report Our Journey (Waterloo Region Public Health Unit, 2002b) identifies a number of elements that supported this move towards a focus on broader health determinants. There were numerous supportive elements within the corporate culture. The unit moved to a more horizontal management of health issues to ensure better integration of activities—both within the department, with other corporate departments, and with the community at large. It established an Urban Poverty Consortium that produces newsletters addressing poverty as a health issue and provides updated information on poverty as a determinant of health, relevant research and policy studies, and suggestions for policy responses.
There was a strong leadership team that had significant leadership experience in public health of over a decade. These leaders enjoyed strong support by the central administration, which supported budget and planning that freed up more time for the coordination of planning and policy development. A solid research centre with a skilled librarian and advanced information systems support located nearby supported these activities. The staff team had a long history of working on a collegial basis with local organizations using both community development and community-based models. There was also a willingness to hire staff with diverse backgrounds, such as in economics and community psychology.
The department had public credibility because of its success with other initiatives such as an immunization campaign, and the institution of a smoking by-law. This allowed for the building of trust among decision makers who would provide support for this new strategy. Finally, a strong Regional Council recognized and supported a focus upon social, economic and environmental issues.
Lanark, Leeds and Grenville (LL&G) Public Health Unit
The LL&G Public Health Unit has entered into a partnership with >70 local health and health-related organizations to establish the LL&G Health Forum (Lanark Leeds and Lennox Health Unit, 2002). This action was a response to the local health unit's Health Status Report, which indicated that mortality in the area had increased during the 1990s due to chronic disease, primarily heart disease and cancer.
The Forum heightens awareness of the societal determinants of health through action in three areas: integration of services, promoting healthy lifestyles and behaviours, and strengthening environments. There is an emphasis in the last theme upon education, income, employment, social supports and housing as important societal determinants of health. The Forum intends to develop a report card on the status of each societal determinant. The report card will be an educational tool to raise public awareness of the importance of the societal determinants of health.
The Forum's first task is to draft a Health Improvement Plan Proposal. This proposal consists of a process for: (i) assessment of baseline status; (ii) a needs clarification and priority setting; (iii) identification of strategies to meet priority needs; (iv) a definition of outcomes measures; and (v) a design of the Community Report Card. A health planner has been hired to begin the process and carry through on its implementation. The planner has skills in literature searching and critical research appraisal, as well as in qualitative research methods. The latter are important since community consultation is an important part of the Forum's activities.
To help reduce poverty and its health effects, the Forum has entered into a relationship with the Leeds and Grenville Community Action Coalition, as with the local Chambers of Commerce, Municipal Councils, Early Years Steering Committees, and Healthy Children Coalition. Activities will improve access to higher education and training, and regional economic development, improving supports and services for lower income populations.
These examples illustrate the means by which Ontario public health units can address any number of societal determinants of health. Another avenue would be the systematic reporting to citizens of the importance of various societal determinants of health and the current state of these in each municipality. This process is already well underway through the Quality of Life Indicators project of the Federation of Canadian Municipalities (Federation of Canadian Municipalities, 1999). The profile of public health in these activities is relatively low and presents an area where public health expertise could make a contribution if the willingness to do so was present.
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DISCUSSION: WHY THE PUBLIC HEALTH BLIND SPOT? |
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Despite the literature detailing the importance of societal determinants of health such as poverty and the ineffectiveness of lifestyle approaches, public health communities in Ontario persist in limiting their discussion of the causes of, and means of, preventing disease to medical and lifestyle risk factors.
One explanation for this may be that busy public health units are unable to keep up with the new theoretical developments in social epidemiological theory that treats societal factors such as poverty seriously [(Raphael, 2002a); (Krieger, 2001), p. 668]. Another, perhaps more likely explanation for public health units' neglect of broader upstream issues is their submission—most likely reluctantly—to the dominant ideology towards health and health promotion of present-day governments. The Ontario Conservative Provincial Government is perceived as being especially sensitive to any criticism of its economic and social policies, and suggestions that they may be damaging health.
Government championing of a behavioural change-oriented heart health, as well as other health promotion programmes, consistent with an individualized approach to illness and health promotion, gives the impression that the government is supporting the health of citizens while relieving the same government of any responsibility for its health-damaging policies. This is a clear assertion of ideological power that is shaping public health practice and public understanding of the nature of disease and health in Ontario (Eakin et al., 1996).
Essentially, individuals and communities encountering health difficulties as a result of governmental policies are doubly damaged. First, they experience health-threatening life situations, and secondly they fall under the accusatory and blaming gazes of public health and other governmental authorities. Public health units can become complicit in this process of ‘poor bashing’, a process of ‘Ignoring facts and repeating stereotypes about people who are poor’ (Swanson, 2001).
Whither public health: some modest proposals
A starting role for public health units could involve their being responsible for carrying out and making public ‘health impact analyses’ of various government policies (Raphael, 1998). At the municipal level, health impact analyses could assess the effects of user fees for libraries, recreation and park services, and increases in public transportation fares. At the provincial level, analyses of the impact upon health of reducing social assistance rates, eliminating new social housing and rent control, and providing transfers of money from the poor to the wealthy through income tax reductions could be undertaken. Certainly, recent federal changes in transfer grants, unemployment insurance and pensions could also be the focus of health impact analyses.
Such activities would be in the best tradition of public health and could begin to redress the skewed perception that policy makers, the media and the public have about the determinants of health and well-being. Raising the profile of the societal determinants of health and the important role that economic and social policy-making plays in the health of populations, can help improve the health of the citizenry. The Waterloo Region Community Health Department and others are helping to lead the way:
It is now well established that factors outside of the health care system have a major influence on the population's health. Less clear, is what Public Health can do about underlying conditions that exists in the social, economic and environmental spheres that also impact on health. This report begins to describe the ways in which our health department is trying to shift a portion of our resources to these underlying conditions. The paradigm shift we are undertaking is only beginning, but over time, we hope to answer the key question before us: ‘How do we shape public health programs to embrace new evidence and address the fundamental conditions that affect health’ [(Waterloo Region Public Health Unit, 2002b
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FOOTNOTES |
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* Material in this paper was presented at the All-Members Meeting of the Association of Local Health Authorities, February 1, 2002, Toronto, Ontario.
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REFERENCES |
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TOPSUMMARYINTRODUCTIONDISCUSSION: WHY THE PUBLIC...REFERENCES |
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Auerbach, J. A. and Krimgold, B. (eds) (2001) Income, Socioeconomic Status, and Health: Exploring the Relationships. National Policy Association, Washington, DC.
Auerbach, J. A., Krimgold, B. and Lefkowitz, B. (2000) Improving Health: It Doesn't Take a Revolution. National Policy Association, Washington, DC.
Barker, D. J., Osmond, C. and Simmonds, M. (1989) Weight in infancy and death from ischemic heart disease. Lancet, 2, 577–580.[Web of Science][Medline]
British Columbia Ministry of Health (2000) A Report on the Health of British Columbians. Victoria.
Bunton, R., Nettleton, N. and Burrows, R. (1995) The Sociology of Health Promotion: Critical Analyses of Consumption, Lifestyle and Risk. Routledge, London, UK.
CPHA (1993) Inequities in Health. CPHA, Ottawa.
CPHA (1996a) Action Statement on Health Promotion. CPHA, Ottawa. Available online at http://www.cpha/cpha.docs/ActionStatement.eng.html
CPHA (1996b) The Health Impacts of Unemployment. CPHA, Ottawa.
CPHA (1997) Health Impacts of Social and Economic Conditions: Implications for Public Policy. CPHA, Ottawa.
CPHA (2000) Reducing Poverty and Its Negative Effects on Health: Resolution Passed at the 2000 CPHA Annual Meeting. CPHA, Ottawa. Available online at http://www.cpha.ca/english/policy/resolu/2000s/2000/page2.htm
Daily Bread Food Bank and North York Harvest (2001) Who's Hungry Now? Food Recipient Profiles, 1995, 2000, 2001. Daily Bread Food Bank and North York Harvest, Toronto.
Davey Smith, G., Grunnell, D. and Ben-Shlomo, Y. (2001) Life-course approaches to socio-economic differentials in cause-specific adult mortality. In Walt, G. (ed.) Poverty, Inequality and Health: an International Perspective. Oxford Universtiy Press, New York.
Davey Smith, G., Ben-Shlomo, Y. and Lynch, J. (2002) Life course approaches to inequalities in coronary heart disease risk. In Marmot, M. (ed.) Stress and the Heart: Psychosocial Pathways to Coronary Heart Disease. BMJ Books, London, UK.
Diez-Roux, A. V., Link, B. G. and Northridge, M. E. (2000) A multi-level analysis of income inequality and cardiovascular disease risk factors. Social Science and Medicine, 50, 673–687.
Eakin, J., Robertson, A., Poland, B., Coburn, D. and Edwards, R. (1996). Towards a critical social science perspective on health promotion research. Health Promotion International, 11, 157–165.
Ebrahim, S. and Davey Smith, G. (2001) Exporting failure? Coronary heart disease and stroke in developing nations. International Journal of Health Services, 30, 201–205.
Eriksson, J. G., Forsen, T., Tuomoilehto, J., Winter, P. D., Osmond, C. and Barker, D. J. (1999) Catch-up growth in childhood and death from coronary heart disease: longitudinal study. British Medical Journal, 318, 427–431.
Eriksson, J. G., Forsen, T., Tuomilehto, J., Osmond, C. and Barker, D. J. (2001) Early growth and coronary heart disease in later life: longitudinal study. British Medical Journal, 322, 949–953.
Federation of Canadian Municipalities (1999) Quality of Life Reporting System: Quality of Life in Canadian Communities. Federation of Canadian Municipalities, Ottawa.
Federation of Canadian Municipalities (2001) Second Report: Quality of Life in Canadian Communities. Federation of Canadian Municipalities, Ottawa.
Feldman, J. J., Makuc, D. M., Kleinman, J. C. and Cornoni-Huntley, J. (1989) National trends in educational differentials in mortality. American Journal of Epidemiology, 129, 919–933.
Fitzpatrick, M. (2001) The Tyranny of Health: Doctors and the Regulation of Lifestyle. Routledge, London.
Forsen, T., Eriksson, J. G., Tuomilehto, J., Osmond, C. and Barker, D. J. (1999) Growth in utero and during childhood among women who develop coronary heart disease: longitudinal study. British Medical Journal, 319, 1403–1407.
Golden, A. (1999) Taking Responsibility for Homelessness: an Action Plan for Toronto. City of Toronto.
Government of British Columbia (2000) A Report on the Health of British Columbians. Government of British Columbia, Victoria.
Government of Ontario (1994) Wealth and Health, Health and Wealth. Queen's Printer for Ontario, Toronto.
Hamilton, N. and Bhatti, T. (1996) Population Health Promotion: An Integrated Model of Population Health and Health Promotion. Health Promotion Development Division, Health Canada, Ottawa. Available online at http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm
Health Canada (1998) Taking Action on Population Health: a Position Paper for Health Promotion and Programs Branch Staff. Health Canada, Ottawa. Available online at http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm
Health Canada (2002) The Population Health Template. Health Canada, Ottawa.
Jarvis, M. J. and Wardle, J. (1999) Social patterning of individual health behaviours: the case of cigarette smoking. In Wilkinson, R. G. (ed.) Social Determinants of Health. Oxford University Press, Oxford.
Keating, D. P. and Hertzman, C. (1999) Developmental Health and the Wealth of Nation: Social, Biological, and Educational Dynamics. Gilford, New York.
Krieger, N. A. (2001) Theories for social epidemiology in the 21st century: an ecosocial perspective. International Journal of Epidemiology, 30, 668–677.
Labonte, R. (1992) Heart health inequalities in Canada: models, theory and planning. Health Promotion International, 7, 119–128.
Labonte, R. (1994) Death of a program: birth of a metaphor. In Rootman, I. (ed.) Health Promotion in Canada: Provincial, National and International Perspectives. Saunders, Toronto.
Labonte, R. and Penfold, S. (1981) Canadian perspectives in health promotion: a critique. Health Education, 19, 4–9.
Lanark Leeds and Lennox Health Unit (2002) A Strategy for Health Improvement for The Lanark, Leeds and Grenville. Lanark, Leeds and Grenville Health Forum, Brockville.
Lantz, P. M., House, J. S., Lepkowski, J. M., Williams, D. R., Mero, R. P. and Chen, J. J. (1998) Socioeconomic factors, health behaviors, and mortality. Journal of the American Medical Association, 279, 1703–1708.
Lessard, R. (1997) Social Inequalities in Health: Annual Report of the Health of the Population. Direction De La Sante Publique, Montreal, Canada. Available online at http://www.santepub-mtl.qc.ca
Lynch, J. W., Kaplan, G. A. and Salonen, J. T. (1997) Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic life course. Social Science and Medicine, 44, 809–819.
Lyons, R. and Lavalle,. (2000) Healthy Lifestyle: Strengthening the Effectiveness of Lifestyle Approaches to Improve Health. Health Canada, Ottawa. Summary available online at http://www.hc-sc.gc.ca/hppb/phdd/docs/healthy/chap3.html
Marmot, M. G., Rose, G., Shipley, M. and Hamilton, P. J. S. (1978) Employment grade and coronary heart disease in british civil servants. Journal of Epidemiology and Community Health, 32, 244–249.
Minnesota Department of Health (2001) A Call to Action: Advancing Health for All Through Social and Economic Change. Minnesota Department of Health, St Paul, MN. Available online at http://www.health.state.mn.us/divs/chs/hsd/action.pdf
Navarro, V. (ed.) (2002) The Political Economy of Social Inequalities: Consequences for Health and Quality of Life. Baywood, Amityville, NY.
Navarro, V. and Shi, L. (2002) The political context of social inequalities and health. In Navarro, V. (ed.) The Political Economy of Social Inequalities: Consequences for Health and Quality of Life. Baywood, Amityville, NY.
Nettleton, S. (1997) Surveillance, health promotion and the formation of a risk identity. In Peberdy, A. (ed.) Debates and Dilemmas in Promoting Health. Open University Press, London.
Nettleton, S. and Bunton, R. (1995) Sociological critiques of health promotion. In Burrows, R. (ed.) The Sociology of Health Promotion: Critical Analyses of Consumption, Lifestyle and Risk. Routledge, New York.
O'Loughlin, J. L., Paradis, G., Gray-Donald, K. and Renaud, L. (1999) The impact of a community-based heart disease prevention program in a low income, inner city neighbourhood. American Journal of Public Health, 89, 1819–1826.
Ontario Campaign 2000 (2002) Child Poverty in Ontario: Report Card 2000. Ontario Campaign 2000, Toronto. Available online at http://www.campaign2000.ca
Ontario Non-Profit Housing Association and Co-operative Housing Federation of Canada (2000) Where's Home? 2000 Update. Daily Bread Food Bank and North York Harvest, Toronto.
Paisley, J., Midgett, C., Brunetti, G. and Tomasik, H. (2001) Heart Health Hamilton-Wentworth Survey: programming implications. Canadian Journal of Public Health, 92, 443–447.[Web of Science][Medline]
Raphael, D. (1998) Public health responses to health inequalities. Canadian Journal of Public Health, 89, 380–381.[Web of Science][Medline]
Raphael, D. (2001a) Inequality is Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of Heart Disease in Canada. North York Heart Health Network, Toronto.
Raphael, D. (2001b) Letter from Canada. Paradigms, politics, and principles: an end-of-the-millennium update from the birthplace of the Healthy Cities Movement. Health Promotion International, 16, 99–101.
Raphael, D. (2001c) Canadian policy statements on income and health: sound and fury—signifying nothing. Canadian Review of Social Policy, 48, 121–125.
Raphael, D. (2001d) How economic inequality affects the health of individuals and communties. In Coburn, D. (ed.) The Political Economy of Health and Care in Canada. Oxford University Press, Toronto.
Raphael, D. (2002a) Beyond medicine and lifestyle: addressing the societal determinants of cardiovascular disease in North America. Leadership in Health Services, 15, 1–5.
Raphael, D. (2002b) Social Justice is Good for Our Hearts: Why Societal Factors—Not Lifestyles—Are Major Causes of Heart Disease in Canada and Elsewhere. CSJ Foundation for Research and Education, Toronto.
Raphael, D. and Bryant, T. (2002a) The limitations of population health as a model for a new public health. Health Promotion International, 17, 189–199.
Raphael, D. and Bryant, T. (2002b) The Quality of Women's Life in Canada. York Centre for Health Studies, Toronto.
Raphael, D., Brown, I. and Wheeler, J. (eds) (2000) A City for All Ages: Fact or Fiction? Effects of Government Policy Decisions on Toronto Seniors' Quality of Life. Centre for Health Promotion, University of Toronto.
Raphael, D., Brown, I., Bryant, T. et al. (2001) How government policy decisions affect seniors' quality of life: findings from a participatory policy study carried out in Toronto, Canada. Canadian Journal of Public Health, 92, 190–195.[Web of Science][Medline]
Roux, A., Merkin, S., Arnett, D. et al. (2001) Neighbourhood of residence and incidence of coronary heart disease. New England Journal of Medicine, 345, 99–106.
Shaw, M. (2002) The accidential epidemiologist. International Journal of Health Services, 31, 523–526.
Shaw, M., Dorling, D., Gordon, D. and Smith, G. D. (1999) The Widening Gap: Health Inequalities and Policy in Britain. The Policy Press, Bristol.
Swanson, J. (2001) Poor-Bashing: The Politics of Exclusion. Between the Lines Press, Toronto.
Tesh, S. (1990) Hidden Arguments: Political Ideology and Disease Prevention Policy. Rutgers University Press, New Brunswick, NJ.
Waterloo Region Public Health Unit (2002a) Health Determinants—Planning and Evaluation. Available online at http://chd.region.waterloo.on.ca/web/health.nsf/form?OpenForm
Waterloo Region Public Health Unit (2002b) Our Journey, Waterloo Region Public Health Unit, Kitchener. Available online at http://chd.region.waterloo.on.ca/web/health.nsf/DocID/B8980155CB5DC83C85256B140059160D/$file/Community%20Health%20Dept%20Report%20HDP&ED.pdf?openelement
Whitehead, M., Diderichsen, F. and Burströom, B. (2000) Researching the impact of public policy on inequalities in health. In Graham, H. (ed.) Understanding Health Inequalities. Open University Press, Buckingham.
Williamson, D. L. (2001) The role of the heath sector in addressing poverty. Canadian Journal of Public Health, 92, 178–183.[Web of Science][Medline]
Williamson, D. L. and Green, L. W. (1999) The Role of the Health Sector in Addressing Poverty as a Determinant of Health. Paper presented at the Annual Meeting of the CPHA, Winnipeg, Canada.
World Health Organization (WHO) (1986) Ottawa Charter for Health Promotion. WHO Europe, Geneva. Available online at: http://www.who.dk/policy/ottawa.htm
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