9.3 Learnings About The Key Determinants Of Health

Many of the initiatives covered in these case studies have touched on a core group of determinants: income and social status, social support networks, social environments, education, and employment and working conditions. Others have aimed to cover the entire range of determinants, while others have focussed more specifically on one or two. Regardless of their scope in terms of the determinants addressed, the initiatives have been grounded on an evidence base to support decision making, usually gained from a combination of accumulated research findings, community needs assessments, environmental scans, and experiential learnings.

Some determinants have been easier than others to address in an intersectoral mode. Any issues related to income and social status have seemed more difficult to deal with, perhaps because they lob responsibility for action into others' laps, notably provincial, and to some extent federal, income security and social welfare programs. In one case, the Atlantic social and economic inclusion and exclusion initiative, this difficult issue has been deftly and definitively handled by reframing the problem in ways that have allowed stakeholders to shun their old roles and think in new ways - as social and economic inclusion and exclusion. Similarly, in the case of the Vancouver Agreement, reframing the drug/disease problem as one of housing and urban development has also seemed to open new doorways to action.

Addressing interactions among the determinants is even more complex than addressing the determinants themselves, particularly when the initiatives lead to direct actions in terms of service delivery as re-structured by population health-influenced policy. In the situation addressed by the Vancouver Agreement, for example, effective population health mobilization has required negotiating solutions among the organizations responsible for various aspects of the physical and social environments of the DTES, for the income and social status of residents, and for the provision of health and social services - all of this in a lively, multi-level political environment, with the desired end result being a new unified service delivery model based on a new set of shared attitudes and values. In the Quebec case, population health mobilization in support of food security required addressing the interplay among income and social status, social support networks, education, employment and working conditions, and social environments, with emphasis on the quality of the physical environment, and this among players who did not necessarily come to the table with a strong awareness of their interdependence. One of the benefits of the population health approach may indeed be that it confronts sectoral players involved - including the health sector - with the reality that their sectoral actions always occur in a context, of which it pays to be mindful. The studies also suggest that interactions among the determinants are among the most ambitious targets that mobilization champions can set out for themselves; although the rewards are potentially great, the risk of failure is high.

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