CARRFS eNews spoke with Dr. Susan J. Bondy, Dalla Lana School of Public Health at the University of Toronto about integration of Social Determinants of Health with Surveillance.
This Article was published in January 2013.
What is public health and how has the understanding of public health changed over time?
In its earliest days public health focused largely on environmental determinants of health. It targeted infectious diseases as it needed to protect the population from infection and bad water sources. It was an infrastructure oriented approach toward prevention and protection. Certainly, that has changed over time. Infectious disease has been de-emphasized and moved towards chronic disease with a focus on health promotion, health behaviour and health care. Lately, however, we have seen a resurgence of infectious disease in its significance in public health.
Today, the health care system has to encompass both the prevention and the protection that can be achieved through the infrastructure; through monitoring and surveillance of the health care system; and how it actually works. Whether it is meeting all the goals for prevention or minimizing the burden of disease by maximizing health.
What is measured in public health and what methods are currently being used?
Most people measure some aspects of socio-economic status. Going back to the 1980’s, socio-economic status was education, income and prestige. In fact, one rarely measured all three of those axes. We tend to fall back on familiar indicators related to socio-economic decisions and easy to obtain data. And some measures like prestige are quite difficult to obtain in a questionnaire form.
We also tend to shy away from measures that might directly relate to how social standing affects health. We don’t have direct measures of individual wealth, connectivity, educational meaning and how this has changed over time.
“We need to keep measuring if people are aware of the health consequences of their actions.”
Furthermore, we are not measuring health in a social context - measures that evolve around where we work, how we work, whether we work or not. Occupation used as an indication of socio-economic status could be used, but it is difficult to handle all the categories, so it becomes under-utilized. I think we should look at a person’s economic circumstances and engagement in the economic world as it is a big predictor of how health services are used and how health information is acted upon.
We know that social determinants of health influence the health of a population - what influence does it currently have on surveillance?
We have in Canada a long tradition of public health researchers, social scientists, biologists and medical researchers who are cognizant of the importance of social determinants of health. Different disciplines demand that we capture information on social determinants - analyze data by socio-economic status, education, and region. This includes developing measures around equity, material deprivation in neighbourhoods and their relation to how health care is received. We have insisted that some reasonable measures have been incorporated into the surveillance systems - at least in terms of deliberately created data resources through e.g. surveys and existing administrative data. There are certainly gaps e.g. we don’t know much about the individuals in their social environment from health care data.
What are the difficulties of integrating the concept of social determinants of health into the traditional health surveillance?
Surveillance is to capture and relay information about the state of health, its determinants and its outcome to stakeholders - those who are in a position to take action based on the information. There are different challenges. You can capture and release the information through academic research, literature, public documents prepared by governments and by non-government research agencies. The pressures on these outlets are very different. There are different checks and balances on what can be published as research and what can be published as government papers. Sometimes you can’t publish academic research unless it has certain flair of innovation. What the governments can produce or the kind of questions the government’s bureaucrats are encouraged to ask and publish can shift with the political climate.
There is also a challenge in looking for socio-economic disparity in health care because one is, in fact, looking for bad news. Yet it is also an opportunity. If people who are wealthy and knowledgeable are able to improve their years of good quality life over time it shouldn’t be seen as bad news that there are groups that haven’t had the benefits yet. It should be proof of principle: That there is something we can do, through effective preventions, to raise the health care status for those who are not yet benefitting. There is a tension of producing bad news in doing research and publishing research on health inequity and on acting upon that information with the right attitude - to try to find opportunities and putting pressure on having these opportunities benefitting the people at the lower end of the socio-economic spectrum.
How could a comprehensive health equity surveillance system look like in Canada?
It needs to be free to innovate. It would have to keep challenging what we are measuring, what we are analyzing and what we are reporting - to keep looking for new mechanisms that could be actionable. We need to keep measuring if people are aware of the health consequences of their actions. We need to find out if they are motivated to change - whether they see personal benefits of the change. And we need to know if they can access the health services. All these mechanisms should be followed. It shouldn’t be static. It shouldn’t be obligated to do the same things all the time. One needs to be able to innovate to find new questions and new strategies. The system should be flexible enough to adapt to different sub-populations of interests and different places of interests. In fact, a comprehensive surveillance system will need to look very different in urban areas than in remote communities.
If we are too flexible aren’t we facing a dilemma as we need to measure the same things over a long period of time?
People who work with surveillance surveys and health indicators always experience tension between maintaining trend data and developing new measures. The two positions can’t be allowed to compete such as one trumps the other. They have to co-exist. The meaning of measures will change over time and our knowledge of what should be measured will change over time. E.g. the meaning of high-school education, computer literacy and university degree has changed over time. There are methods to incorporate new indicators into the mix along with existing indicators using sensitivity analysis to see trends and changes and to compare how the data look in the old system and how they will look like in a new system. This enables us to say: Why is it different? Are the measures changing or is it the people who are changing or is it the disease that is changing or is it all of the above? Persistence to maintain trend data - not loosing things that we have been monitoring in the past, and simultaneously being able to innovate and to get new information through new mechanisms and tools, have to go together.
In your opinion, what other difficulties are there to build a national surveillance system in Canada?
I think it is technologically difficult to bring current data systems together unless everybody in the system plays along. There are a lot of disincentives - not necessarily intentional - to data sharing. The way e.g. primary care physicians operate and the way the hospitals operate - not being asked to be accountable in ways that matter in form of creating meaningful data - is not optimizing the system. It might not be a lot of malice in the system, but I think there is a lack of incentives to go bring resources together and to build a comprehensive data system.
“CARRFS has the potential to elevate the profile of surveillance research as being important.”
What role could CARRFS play in building up such a national surveillance system in Canada?
I think CARRFS has tremendous potentials. I think that the disciplines that relates to surveillance and public health descriptive and analytic work are really important. CARRFS has enormous potential to create a number of things. One is a forum for communications so the people who are interested in this field have a social network to exchange ideas. It should have the capacity to elevate the profile of surveillance work. Surveillance and descriptive work can often be denigrated relatively to intervention research, clinical trials, hypothesis testing and academic research. It is crucial that public health gain attention of people who are really good scholars. And that good scholars are able to work in an applied and academic settings doing descriptive and analytic work that describes the state of the health of the population and how it has changed over time. CARRFS has the potential to elevate the profile of surveillance research as being important. CARRFS should provide evidence of the needs and utilities of good surveillance data and advocate for the expansion of resources that are dedicated to surveillance, better quality improvement, better sharing of data across provinces, across sectors within provinces and better interpretation of the data that do exist. <>
By Jostein Algroy