Law & Governance
Family as a Social Determinant of Health: Implications for Governments and Institutions to Promote the Health and Well-Being of Families
[This article was originally published in Healthcare Quarterly, 14(sp)]
A growing appreciation of the powerful impact of the social determinants of health, particularly the toxic effect of poverty on health, is driving the need for a re-evaluation of the role of governments and institutions such as hospitals in the lives of children and families. The well-being of families is the cornerstone on which society rests; yet evidence is growing that families are facing significant challenges beyond their control that adversely impact their ability to perform their essential role. With evidence of a growing divide in society – an expanding gap between the rich and the poor (Novak 2007) – contributing to a polarization of health and social outcomes along this continuum, there is an urgent need for revisioning priorities for health and social policies. Bold new ideas and leadership are needed to plan a future that encompasses social justice as a key value and operating assumption.
Families have a pivotal role to care for their loved ones, and, in the case of children, readying them for healthy, happy and productive lives as active contributors to society. The capacity of parents to provide the key functions associated with optimal care for their children is absolutely central. Loving care, a secure attachment, sufficient structure for healthy growth and development, non-coercive discipline and an overall safe family environment characterized by empathic relationships are among the important factors needed to raise healthy and well-adjusted children. In addition, the capacity of parents to provide sufficient material support in the form of good-quality housing, nutrition and opportunities to participate in social and recreational activities is among other essential dimensions associated with the social context in which children develop. In turn, society not only reflects the collective success of families and their capacity to prepare the next generation but, through the decisions of governments and institutions, powerfully shapes the social environment in which families live.
It is clear that the choices made today that affect the social world in which children are raised have both immediate and far-reaching consequences. For example, reflecting what is now understood about the "remarkable sensitivity of health to the social environment and to what have become known as the social determinants of health" (Wilkinson and Marmot 2003: 7), poverty is known to be one of the most toxic environments in which children can live. Research has shown that children living in poverty face higher rates of just about any adverse health or social outcome (Canadian Institute of Child Health 2000; Wilkinson and Pickett 2009), and rates of hospital admission, unplanned hospital readmissions, missed clinic appointments and death have been shown to be positively associated with higher rates of poverty (McNeill 2009). In addition to the tragic human burden associated with these findings, the healthcare system faces added financial costs providing this care.
As compelling as this evidence may be in the short run, it assumes even greater significance over the longer term. Hardship experienced in childhood is also associated with adverse adult outcomes. For example, recent research has found that childhood physical abuse is associated with 49% higher odds of cancer among adults (Fuller-Thomson and Brennenstuhl 2009). Further, sustained adverse experiences in early life that are not buffered by protective adult support are increasingly seen to be linked with problems in multiple organ systems that can lead to lifelong disease. This has significant implications not only regarding quality of life and capacity for productive contributions to society but also regarding the need for increased government expenditures for health and social services throughout the life cycle (Shonkoff et al. 2009). In this way, preventive planning regarding the social determinants of health – the "causes of the causes" of so many adverse health and social outcomes – has the potential to transform society.
Among the defined social determinants of health (York University Consensus Conference 2002), early child development is particularly important because it sets the stage for a child's entire life. In the way that adverse experiences in childhood have been shown above to have a profound effect on later health and well-being, the quality of child development experiences has its own trajectory with significant implications for later functioning. For example, research has clearly established a link between experiences in early childhood and developmental neurobiology. The developing human brain is intimately connected to the social environment (Shonkoff et al. 2009), which profoundly affects the development of neural pathways that are central to the structure and functioning of the brain. This hard-wiring of the developing brain is time sensitive, with children's brains reaching 90% the size of adult brains by four years of age. The sheer volume of neural connections that are established in early years is strongly associated with the quality of the social environment. This is crucially important because brain development affects a broad range of child functions such as emotion, temperament, social functioning, perceptual and cognitive ability, language development, literacy and numeracy capacity and so on (Mustard 2008). With the emphasis in today's knowledge-based world on the intellectual abilities of individuals and their capacity to contribute effectively to an ever-changing workplace, attention to the fundamental importance of brain development in children deserves scrutiny, not only for the well-being of children as individuals but also for the collective well-being of society.
Therefore, examining the social environment of children and the forces that shape their lives is of profound importance. This article explores the place of families in caring for their children within the context of the broader social environment in which they live, with particular attention given to the role of governments and institutions such as hospitals. When families struggle to fulfill their role, too often the analysis of the reasons stops at the critical point of identifying family characteristics and dynamics without an appreciation of the influence of the social context in which they are situated. Adding to this victimization, parents who are found wanting face the shame associated with being labelled "bad parents." Consequently, for the purpose of this analysis, families are cast as the dependent variable, and the roles of governments and institutions that shape the ability of parents to care for their children are explored as independent variables. The intent of this discussion is to highlight promising practices and simultaneously point to areas in need of development, with a particular focus on families in vulnerable circumstances.
Implications for Governments
Recognition of the interdependence of factors associated with the social determinants of health that affect the ability of families to care for their children points to an essential role for governments. Putting in place policies and programs needed to support families in the crucial role that they have is essential. Of primary importance are government efforts to enhance equality by reducing the gap between the rich and the poor. The high levels of poverty that characterize Canadian society are not inevitable, and government policies are crucial components for achieving low levels of poverty. With estimates of national child poverty rates ranging from 14.9 to 19% (Innocenti Research Centre 2005; MacDonnell 2007) and as high as 28.8% in large urban centres such as Toronto, (MacDonnell 2007), the need is urgent.
Reducing the gap between the rich and the poor is crucial because international research has demonstrated a very strong association between the level of inequality in any society, measured by the size of the gap between the rich and the poor, and population outcomes such as infant mortality, readiness to learn at school, high-school completion, unplanned teenage pregnancy, prison incarceration rates, incidence of disease and longevity of life (Wilkinson and Pickett 2009). Furthermore, with the related knowledge that inadequate support today results in higher costs down the road associated with a greater use of health and social services, higher incarceration rates within the criminal justice system and the loss of productivity associated with school dropout and teenage pregnancy, the stark choice for governments to plan now or pay later has never been so clear. Given the knowledge that adults of all socio-economic levels live longer and healthier lives in more equal societies, there is strong evidence for personal self-interest beyond altruism to support efforts to create greater equality in society (Wilkinson and Pickett 2009). To underscore this assertion, earlier research also indicates that governments that provide services to correct for social inequalities improve the health of the entire population (Navarro et al. 2006). Social justice has never been such a compelling yet simultaneously self-serving goal for governments to achieve.
Unfortunately, Canada currently invests less than international comparators on programs and supports for families (Raphael 2010). This has created a social deficit that must change if we hope to reduce the widening income gap and provide adequate support for families. Programs such as the following support families and contribute to achieving greater equality:
- Employment-related strategies. Employment is the primary means by which parents provide for their families; thus, a goal of full employment is needed. Related strategies include setting a minimum wage rate that is high enough to ensure that a person working full time does not slip below the poverty line. The concept of a "living wage," the level of pay that is needed by two parents to pay for the essentials of food, rent, child care and transportation, has emerged as a benchmark for fairness. In addition, extending employment insurance to ensure that displaced workers have access to benefits and providing job training to prepare youth and others such as those on public assistance who may need additional support to enter the job market are necessary supports. Ensuring safe working conditions that protect workers from harm is essential to supporting the overall well-being of families. While often unpopular with employers, the presence of unions to support collective bargaining is nevertheless associated with fair wages that are sufficient to raise a family. Finally, finding ways to curtail exorbitant wages in both the public and private sectors that exacerbate the gap between the rich and poor is an essential part of an overall strategy.
- Child support programs. Children are our most precious resource, and working in partnership with parents to support child development and education is an essential investment. Services to support children and families include best start programs for young children, nationally regulated daycare that simultaneously ensures affordable high-quality care for children and supports working parents, generous child tax credits and cash transfers to support families raising children. Growing use of the Early Development Instrument (EDI) to monitor the progress of children, particularly those living in disadvantaged neighbourhoods and regions across Canada, is a very positive development, one that will provide essential information for planning. In addition, efforts to support latency-aged children and adolescents to stay in school are important to long-term success and the likelihood that they will grow up to be productive members of society.
- Social safety net. The presence of a safety net for those in vulnerable circumstances is central to supporting families. The National Council on Welfare, the government's own advisory body, has described the state of Canada's social safety net as an utter disaster. Current welfare rates result in too many children growing up in poverty. Expressions of fear about the fraudulent misuse of social supports or the promotion of dependency are often punitive, ill-informed and short sighted in terms of enhancing the likelihood that children will grow up to be productive members of society. Further, the focus on "un-deserving recipients" obscures the structural barriers associated with the social determinants of health that create obstacles for vulnerable families. Finally, the availability of good-quality, affordable and subsidized housing is an essential component of these strategies. Canada lags well behind other countries in ensuring the availability of this most fundamental resource.
Consideration of the best way to provide programs inevitably leads to a discussion of universal versus targeted services. The value of investments in universal programs that provide a baseline of support for all children and families should not be underestimated. Universal programs eliminate the aura of stigma that is often associated with targeted programs and ensure a broad commitment to maintaining high quality. Although universal programs are often touted as unaffordable, they need to be considered – it is frequently a question of priority rather than affordability. The examples of providing affordable daycare in Quebec and all-day kindergarten recently initiated in Ontario are innovative developments that promise significant benefits for children, families and society.
It is often asserted that it is not possible to have generous social programs and a competitive economy; however, a natural experiment involving governments in Northern Europe has demonstrated this to be erroneous. Sweden, Norway, Finland and Denmark have achieved some of the best population health and social outcomes worldwide by offering comprehensive government programs while simultaneously maintaining highly competitive economies. In the global economy in which countries compete for businesses to locate within their boundaries, the evidence of this success is significant. The example of Northern Europe challenges the mantra of low taxes and minimalist approaches to government that too often results in inadequate programs and services for families, growing inequality and, consequently, poor population outcomes. There is a vibrant role for government to address the limitations of our economic systems that leave many individuals and groups behind. Business and economic leaders are key advisors about the operation of the market and have been dominant voices in shaping public policy in Canada, but governments must re-balance their consultations to provide a greater role for health and social scientists who can provide essential insights needed to inform public policy.
A lack of scientific evidence in the past regarding the potent influence of the social environment may have contributed to the role of political ideology in the formation of government policy; however, with the quality of evidence available today, governments have an obligation to ensure that health and social policies are shaped by the best evidence available. In the way that evidence-based practice is a hallmark of best practices for healthcare practitioners of all disciplines, government policy must also reflect best evidence. "Evidence, not ideology" should be the rallying cry of citizens, planners and governments. Collectively, governments must do a better job of partnering with colleges, universities and other knowledge-based organizations to mobilize knowledge to inform public planning. Of equal importance, they must engage the public in understanding the relationship between the social circumstances in which people live and the collective well-being of both individuals and society. Understanding the mechanisms of how the social determinants of health "get under the skin" to cause illness and the way that the social environment impacts the hard-wiring of children's brains are central to this important task. An informed public is at the heart of a strong and vibrant democracy.
It is worth noting that the extent of the perceived role for governments related to these issues differs across the political spectrum. Right-of-centre parties that advocate tax cuts and small government as a policy panacea appear least able to provide leadership regarding these issues. Research suggests that this approach is also out of step with the Canadian public, who perceive an important role for governments to advocate for the common good and to actively shape Canadian society (Harris/Decima 2010, March 13). Canada differs in its desire for active governments from other countries, notably the United States where the recent rise of the Tea Party movement reflects a fundamental mistrust of government that exists among many there. In the name of liberty and low taxes, government involvement in the lives of citizens beyond an absolute minimum is disparaged. The consequences of this approach have been shown to have a devastating effect on society in general and vulnerable populations in particular. The tide may be shifting in Canada regarding an openness for higher taxes as one strategy to support the kind of society that Canadians want, rather than another round of program and service cuts that erode the foundations on which society rests. Reallocation of resources is another strategy. For example, the "tough on crime" agenda promoted by some governments where tax revenues are used to build prisons and incarcerate individuals for long sentences has been shown to be an expensive and ineffective way to rehabilitate those who break the law. With crime rates falling in Canada, greater attention to the conditions in which people live and efforts to address the growing levels of inequality in Canadian society that undermine individuals and families would be far better targets for government intervention. There is a long-standing tradition that Canadians embrace a different set of values that diverge in significant ways from those in the United States (Adams 2003), and we would do well to model ourselves after other jurisdictions in the world, such as those in Northern Europe, that have demonstrated significantly higher levels of success supporting families and achieving a healthier population than both Canada and the United States. As Canadians, we need to nourish our collective inclination to support the common good and look to our governments to reflect these values.
Finally, recognizing the fundamental interconnectedness of government departments and ministries such as health, social services and education points to the need for better integration and planning. As boundaries between health and social well-being disintegrate, the need for a bold integrated vision is greater than ever before. Combining health and social policy may be a fruitful way of achieving greater sectoral integration, re-balancing government support across these portfolios and simultaneously moving in a proactive way to address the "causes of the causes" of so many adverse health and social outcomes associated with the social determinants of health. One international approach regarding health policy that is worth watching is in Sweden where a national health strategy based on the social determinants of health rather than disease categories has been adopted. This has been accompanied by rigorous research to evaluate the effectiveness of the strategy. To support such a move in Canada, a national dialogue is needed about the kind of Canada we want for children and families. Adopting a "child-centred" philosophy, one in which the needs of children are primary and inform government planning at all levels, would be a powerful step in creating a just society. Indeed, promoting a children's rights approach, informed by the United Nations Convention on the Rights of the Child that Canada endorsed 20 years ago, may hold particular promise for harnessing the political determination necessary to achieve this vision (Hertzman 2010, March). Increasingly, a children's rights approach (e.g., the right to health as a resource for life) is seen as necessary to provide motivation for governments to take the needs of children seriously and to invest in human capital development. A recent policy statement from the American Academy of Pediatrics advocates that the integration of children's rights, social justice, human capital investment and health equity is necessary to achieve child well-being (American Academy of Pediatrics 2010). The creation of a national think tank, supported by foundations and other granting bodies, that is dedicated to identifying the best targets for investment, together with an international search for evidence-based programs that represent best practices, would contribute to building consensus regarding key priorities for supporting children and families that could be used to inform public policy and program development. Governments of all stripes would benefit from the recommendations of such a group.
Implications for Institutions
As stewards of large budgets, hospitals and other institutions are key players in the delivery of health services; but what is their role in supporting families, in particular those families that face challenges? In a context of finite resources and seemingly infinite need, hospitals need clear priorities to shape their investments and expenditures. Of central importance is a question of whether health is defined in narrow medical terms or more inclusively and in a manner consistent with the definition used by the World Health Organization (WHO), which asserts that health is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO 1948: 100). Such a definition of health sets the stage for a responsive approach to delivering health services, one that is informed by knowledge regarding the powerful influence of the social determinants of health and the need to treat patients within the social context in which they live. Evidence is accumulating that medical interventions alone may have limited effectiveness for vulnerable populations in particular if they are not complemented by efforts to ensure families' legal and social stability.
With this in mind, five key responsibilities for hospitals stand out. They relate to making a commitment to health equity a central value, promoting a philosophy of family-centred care, adopting an inter-professional approach to care, training all healthcare providers in a core curriculum about the powerful impact of the social environment on health and taking an advocacy role to achieving social justice.
A commitment to achieving health equity ensures efforts to work with all families. In Ontario, a recent move by a regional health planning body (i.e., the Toronto Central Local Health Integration Network) has required all hospitals within its area to develop and submit health equity plans. This is a welcome development and defines hospitals as key stakeholders in promoting social justice. As hospitals begin to get used to this new responsibility, they are recognizing a variety of related issues that need to be addressed, such as providing staff education to promote cultural competency among their workforce, setting appropriate indicators for achieving health equity within a Balanced Scorecard and planning for the appropriate staffing mix of professionals on programs. Finding a new balance between expenditures to support traditional priorities and ensuring appropriate care to their most vulnerable patients is central to this challenge. Ethical issues related to the allocation of resources are inherent in this challenge, but the need to target some resources to achieve health equity is paramount. With limited capacity for accessing new public funding, achieving health equity will mean having to confront challenges associated with reallocating resources.
Family-centred care is an approach that defines the family as the unit of care. This philosophy serves to unite all healthcare providers in a common approach to working with families as partners in care. Such a commitment helps to ensure that the diversity of families related to race, culture, religion, ability, sexual orientation, socio-economic status etc. is respected and recognizes that equal care is often not enough to achieve health equity – that some family circumstances require additional services and understanding. A related commitment to involving families in defining the important institutional parameters of family-centred care and promoting such care within the hospital is of central importance. Moving beyond a rhetorical commitment to family-centred care and relinquishing sufficient control to give families a real voice in defining the services they need are indicators of the commitment to family-centred care. Strategies to provide opportunities for "patient engagement," whether targeted for personal care or hospital planning, hold promise for mutual benefit, including increased responsiveness of hospitals to patient needs and preferences.
Recognizing the complexity of healthcare, hospitals have moved to embrace inter-professional practice (IPP). This approach recognizes that healthcare needs are often complex, requiring the skill sets of many disciplines. For example, social workers have an important role to assist vulnerable families to address the adverse impact of poverty and other social determinants of health by (1) connecting families to community-based services, (2) accessing financial resources, (3) advocating for entitlements when needed, (4) addressing social obstacles that may limit access to care or compromise the effectiveness of medical interventions, (5) providing clinical interventions to assist families with high levels of stress that are associated with living in difficult social circumstances, (6) coaching to maximize personal agency to deal with structural obstacles, (7) identifying systemic gaps in service and advocating for changes and so on. Similarly, the need for interpreters is fundamental to serving diverse populations that may not understand English or French. An institutional commitment to provide adequate staffing levels consistent with benchmarks and/or available standards to address these dimensions of care is an indication of the level of commitment to serving at-risk families and achieving health equity.
While the value of IPP for front-line care is frequently articulated, an expanded knowledge base is also needed for overall hospital planning and decision-making. If hospitals are to be successful achieving health equity and supporting families, they will need a mix of leaders and disciplines to contribute the knowledge and expertise required for this essential planning. In Ontario, the government has recently announced an intention to revise the Public Hospitals Act to open up medical advisory committees in hospitals to include a broader mix of disciplines, which is a welcome move. The same may be needed in many hospitals regarding the executive team that has overall responsibility for budgets and operational decisions. A concentration of decision-making within one or two dominant healthcare disciplines is likely to lead to approaches to care associated with these scopes of practice, and there is a risk of bias in the form of attention to the priorities and aspirations of these disciplines. In the move to program management, there has been a significant deterioration in many hospitals of the capacity for disciplines beyond medicine and nursing to have a real voice in planning. Hospitals must do more to level the playing field to enhance the contributions of all healthcare professions to ensure the needed range of knowledge and expertise is available to inform planning. Similarly, the composition of hospital boards may need to expand to ensure adequate expertise to inform decision-making regarding strategic directions related to these emerging priorities. Consistent with a children's-rights approach, in institutions serving children, there is a need for a vibrant children's council or a similar mechanism to ensure that the voices of children are heard and included in planning. For academic health science centres, programs of research that cross disciplines and examine the interface between health and the social circumstances of children and their families are needed to generate knowledge to inform care.
A related role for healthcare institutions is to partner with colleges and universities to provide training to all healthcare providers to ensure a necessary degree of literacy in key dimensions of practice. A core curriculum is emerging that includes training about the social determinants of health, the toxic effect of poverty on children's health and development, cultural competency, family-centred care, IPP and the expertise that each healthcare discipline brings to providing care. Conceptual frameworks such as the social ecological model (Bronfenbrenner 1979) are useful theoretical approaches for appreciating the range of issues that may need to be addressed in individual circumstances to provide effective care. This integrative framework includes considerations at the micro-level (e.g., individual biology and functioning), mezzo-level (e.g., social context of the family, school etc.) and macro-level (e.g., structural configuration of society including the social determinants of health). Attention to these domains helps to equip inter-professional healthcare teams to provide integrated care, maximizing the likelihood of achieving health equity for all patients.
Finally, an emerging role for hospitals is related to taking an active role as an advocate to promote systemic changes and policy reform. Identifying gaps in service and structural barriers adversely impacting families is central to this emerging role. Hospitals are in an ideal location to identify potential reforms that would better serve families. The notion of advocacy may be uncomfortable for some healthcare leaders and board members due to concerns about the risk of creating antagonistic relationships with stakeholders such as government funders and donors, but the need to reform systems of care is essential. The language of "knowledge mobilization" may be a more comfortable approach that could lead to partnering with stakeholders such as government, patients and families and other service providers to promote needed changes.
What are the implications of these ideas and developments for healthcare leaders? We must all reflect on these challenging issues and consider the next evolution of the healthcare field. Our personal values as healthcare leaders are at play in the context of hospital decision-making and require personal reflection and transparent planning processes. The recognition that we cannot provide healthcare to children in a vacuum is essential knowledge for healthcare leaders. The social environment in which children live must be taken into account if we hope to achieve health equity for vulnerable populations in particular. Beyond hospital roles, during elections we must ask ourselves about which political parties are advancing policies that will support families to care effectively for their children and thereby prepare them to be productive contributors to society in the future.
With the emergence of scientific evidence concerning the social determinants of health and their powerful impact, governments and hospitals must re-evaluate their role supporting families. It is no coincidence that the frequent observation within hospitals that medical acuity is increasing has been paralleled by a simultaneous deterioration of the social safety net in Canada, leaving many families in vulnerable circumstances. Governments have a key role to promote policy reforms to create a more egalitarian society by reducing the growing gap between the rich and the poor and by providing programs that support families. With the quality of evidence available worldwide about the types of policies, programs and services that are associated with positive population health and social outcomes for children and families, the way forward is emerging with greater clarity. Hospitals must also do their part to address the social injustice of health inequalities and re-cast themselves as advocates of change within an expanded vision of health to legitimate their role as healthcare leaders.
About the Author(s)
Ted McNeill, PhD, RSW, is the director of social work and child life at The Hospital for Sick Children and associate professor in the Factor-Inwentash Faculty of Social Work, University of Toronto, in Toronto, Ontario.
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