"Public Health Units and Poverty in Ontario: Part of the Solution or
Part of the Problem?"
paper available at ...
http://www.alphaweb.org/public/index.asp?action=show&publication_id=130

Thank you for disseminating this referenced document and promoting
discussion. I still have some uncertainty on this and am therefore
rephrasing and reposting for further discussion.

This is a timely paper on poverty, health and health unit programs. It
is relevant to current health promotion planning, particularly  within
the newly formed macro Health Regions of British Columbia. It is also
relevant to planning models such as the 'conceptual model for prevention
in BC' currently being drafted by the province and health regions. Since
I cannot send an attachment, you need to visualize a schematic of the
model. Healthy British Columbians is the central component of the model.
Immediately adjacent are 5 programs/issues dealing with 'lifestyle'
risks such as tobacco, nutrition, physical activity etc. Medium term
(5-10 years) impacts proposed to flow from the model are all directed at
changing behaviour. Such behaviour is commonly articulated as being
grouped into a lifestyle construct. Peripheral boxes of the model are to
promote healthy environments (e.g. policies), preventive services,
education and infrastructure supports (e.g. information). This is a
common layout of models to represent general health promotion/prevention
activities (i.e. the health of a central target population surrounded by
proximal risk factors and then distal policies/environment). This layout
tends to align with our thinking regarding the 'causal chain of
disease'.

The point raised by Dennis is that we should rethink the area of the
model (or chain) that we target.  ... and perhaps rewrite
the model? We are to pay greater attention to social epidemiology rather
than medical epidemiology. Presumably, public
health epidemiology is more closely linked with a medical model. Can we
all agree that the traditional definition of
epidemiology is the 'study of the distribution and determinants of
disease in human populations?' Personally, I use a slightly
modified definition but the definition and science of epidemiology
focuses our attention on humans.

The paper by Dennis criticizes a 'lifestyle' approach for prevention
activities. This was the main criticism of the 1974 Lalonde
report. However, later models further developed the Lalonde model, i.e.
a model by the Ontario Premiers Council on Health
and a model promoted through the Canadian Institute of Advanced
Research. These later models show that behaviours and
lifestyle are 'downstream' from genetics and the physical and social
environments. The medical-care system is further
downstream. Several subsequent papers have highlighted the predominance
of the social environment as an upstream
determinant of health. Therefore, when Dennis questions that we in
public health  may not have appropriate theory to address
the broader determinants, it should be pointed out that a number of
theories and frameworks are in place - also for example,
the widely used PRECEDE-PROCEED framework for health promotion planning
begins with an analysis of the broad social
setting but the broader social circumstances lead into
knowledge/attitude/behavioural patterns and the morbidity/mortality
outcomes. The PRECEDE model further emphasizes the predisposing,
enabling and reinforcing factors that continue to be
connected to social interactions. Most practitioners of public health
are aware of these person-environment connections in a
general sense. And most would agree that lifestyle 'choices' really are
not entirely self-determined choices - consider the
associations between risk behaviour and the social environment of
children and early adolescents. Part of the socialization
process is to learn responsible citizenship but can we really say that
children are responsible for behavioural choices?
Choices by children are made in relation to the physio-social context
that we collectively influence, including items such as
socioeconomic status, culture, parental smoking etc.

Dennis argues that for the most part Public Health personnel are focused
on risk behaviour but should be more focused
upstream on the social determinants of health, e.g. poverty. In addition
to a dearth of theory, he notes that perhaps one
impediment is that government doesn't want criticism of social/economic
policies and wants to shift responsibility (&
programs) onto individuals via their choices and behaviour.
Subsequently, public health workers 'submit' to this ideology and
fear advocacy due to dependency on government funding. We are in a
conundrum if we are afraid to discuss and advocate
on the real problem. Although the fear of genuine advocacy holds merit,
in my opinion at this point it is still more fruitful to
discuss what we should be focused on rather than why we are focused in
any particular area.

A number of questions arise ...
1. Do public health personnel emphasize lifestyle factors?
2. Should public health emphasize policy factors such as poverty?
3. Should we depict our models to make the social environment more
central ... and therefore, I suppose more central in our
subsequent thinking and planning?

As long as our models depict the health status of people at the core and
lifestyle risk/protective factors immediately adjacent then our
attention will tend to focus on these aspects as our main conceptual
paradigm for planning, programming and evaluation. An issue such as
poverty may be the focus of a specific project/program but will remain
peripheral in the broader panorama of public health... and therefore
subject to the criticism that overall our emphasis is misplaced.

Recognizing that we have limited resources and being spread too thin
creates problems, how should we divide (or emphasize) our efforts among
these factors? Should we reduce our specific work on tobacco for example
and deploy the resources to poverty?

I look forward to comments of others. Thank you.


--
Dr. Ronald A Dovell
Health Planning Researcher
Interior Health
Email:  [log in to unmask]

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