Social Determinants of Health

The World Health Organization (WHO) describes social determinants of health as  

 the circumstances, in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.

Social determinants of health include a range of factors that affect the health of individuals and populations. One factor is the environment people live in, which refers to their physical environment, local policies, work environment, food production, and health services. Other social determinants of health are education, income, race, social status, health behaviours, and working conditions.  

Income, education levels, employment, and social status have a particularly strong influence on a person’s health. They even have a greater impact than health care and lifestyle! For example, income, education, race, and health literacy all influence how well people can access health services. They also determine the type of housing they can afford and the food they buy, which are essential components of health.

Experiences of discrimination, racism, and historical trauma are important social determinants of health for certain groups such as Indigenous Peoples, sexual and gender minorities, Black Canadians, and refugees. 

Social determinants of health can contribute to health disparities or health inequalities, that is, differences in health for different population groups. A Canadian study from the Public Health Agency of Canada (2006) found that Indigenous peoples, sexual and racial/ethnic minorities, immigrants, and people living with disabilities are typically less healthy.  

You find more information here on the social determinants of health and the full report on health inequalities in Canada. The website also has a set of infographics that highlight the key inequalities. 

Living in the countryside has a special appeal. Among the benefits are the opportunity to reconnect with nature, a slower pace of living, strong community connections, and a safe place to raise a family. There is evidence that the sense of belonging that is often stronger in rural communities has far-reaching positive effects.

One should think that these life quality-enhancing features would also translate into better health. Not so! Research done around the globe shows that rural residents on average are not as healthy as their urban counterparts.  

Rural residents are more likely to experience some of the contributing factors that impact health that are highlighted in the diagram above. For example, increased levels of poverty can be compounded by limited public transportation or fewer choices for healthy food. Race and ethnicity can add another layer of complexity. For example, Indigenous peoples facing systemic racism and intergenerational trauma may be more likely to experience poverty.  

A Canadian report dove deep into the numbers. It found that people living in rural areas in Canada report poorer health and tend to die more often from a range of illnesses compared to urban residents. Health was poorest for those living furthest from urban centres.

Living in rural communities, however, does not automatically have a negative effect on health. As individuals, we can influence some of the social determinants of health; for others, we need the community to join forces to create conditions for a healthier life. Also, social cohesion and community engagement can have a greater impact on a person’s and community’s health than availability of health services.  

It is clear though that keeping rural communities healthy requires multi-level strategies that take local context into consideration and build on communities’ unique strength. 

The Government of Canada Health Inequalities Data Tool can illustrate the social determinants of health. The database contains information on different health variables that can be analyzed by province, age group, education, immigrant status, urban/rural geography, and many other variables. The tool creates graphs that compare the chosen health variables.

Below are a few examples of health related variables compared by geographic location across Alberta. 

The Health Inequalities Tool is an important source of information on social determinants of health and how they impact the health status of different populations.

Social capital is the networks of relationships among people who live and work in a community. The people in these networks share norms and values that help them cooperate for shared benefit. A sense of belonging, trust, safety, and mutual support are typical characteristics of social capital (see schematics below). 

A recent Canadian study found that rural Canadians have higher social capital than urban Canadians. Social capital was measured as a sense of community belonging, neighbourly relations, and numbers of close relatives and friends people have in their local communities. These findings are similar to international research studies about social capital.

Research has also shown that positive social connections can benefit mental health, support healthier lifestyles, and reduce the use of health services. In contrast, poor social connections can lead to physical and mental distress.  

We can grow our social capital by participating in community activities and events or joining social groups. Volunteering or spending time with family, friends, and neighbours can also build social capital. 

However, not all members of a rural community have the same opportunities to build and benefit from social capital. For example, not having a car or access to transportation can limit participation in community activities. This may lead to social isolation. This is a particular concern for low-income seniors.  There might be limited opportunities in rural communities for young adults to connect with peers, making it difficult for them to build social capital. The lack of privacy in small towns may prevent some residents from participating in social events because of worries of public scrutiny. Also, tight-knit social groups may not always be welcoming to newcomers which can lead to social exclusion.  

Think of social capital as a gradient, where people with lower income and education report lower social capital and those with higher income and education report higher social capital. This means that communities can create targeted strategies to increase social capital for all residents.

Health care crises or economic downturns can be particularly devastating for rural communities and can lead to elevated stress, anxiety, and depression in rural residents. One group particularly vulnerable is rural farmers. Farming is hard and relentless work with many factors out of human control, such as flooding, drought or hail that  influence productivity and yield.  

Research conducted in 2016 with over 1000 farmers in Canada found higher levels of anxiety and depression in farmers than in the average population. Nearly two-thirds of farmers who participated in the study had experienced psychological distress. Resiliency, which is the ability to recover quickly from difficulty, was lower amongst farmers than the average population. Female farmers scored more poorly than male farmers.

Females face some unique challenges in farming, including role conflict and high workloads.  On top of their farm work, many women take on off-farm jobs to supplement the farm income, while at the same time looking after children and domestic work.  This high demand can negatively impact their wellness.

These findings are similar to a recent study from the US. Poor mental health in farmers has many personal ramifications, but it can also affect farm productivity and animal welfare in the long-run.  

Getting timely help for mental health concerns can be difficult in rural communities. In an RhPAP survey, rural residents listed insufficient resources, access to services and specialists, appointment wait times, lack of treatment options, and travelling for care as some of the barriers to getting help. Rural residents may also lack knowledge of what services are available and how to access them. 

One of the biggest hurdles to seeking help is stigma associated with mental health. In the Canadian study mentioned above, 40 per cent of surveyed farmers reported that they would feel uneasy seeking professional help for mental health because of “what some people may think”. There can be shame associated with personal or family issues and fear of lack of privacy. Read Stanford’s journey with mental health, a young farmer in southern Alberta. 

But things are starting to change in Alberta, not the least because men are stepping up to the challenge.

• Innisfail launched the Real Talk With Men 2021 Calendar as a way to encourage men to reach out and start conversations about mental health, suicide, addiction, and domestic abuse. The calendar features local men, individuals with lived experiences, offering messages of courage and hope. Research has shown that storytelling is an effective way to reduce stigma around mental health. These stories are particularly effective if they share the struggles but also the path to wellness. 

• AgSafe Alberta has been licensed to bring the “In the Know” program to Alberta. In the Know is a mental health literacy program that was specifically designed for the agriculture community in Ontario in 2016. AgSafe piloted the program in Alberta online in 2020 and are now in the process of recruiting facilitators and finding partners to deliver more sessions over the next two years. 

• The ARECA Farm Mental Health Project secured funding to coordinate the farm specific mental health response in Alberta. ARECA (Agriculture Research and Extension Council of Alberta) will work with partner organizations to identify and address gaps, and connect people, projects, and programs that are already supporting the mental health of farmers. The idea is to lay the groundwork for continued collaboration and ongoing activity, building on existing programs. 
• Led by the Canadian Mental Health Association, Alberta Division (CMHA AB), the Rural Mental Health Project aims to strengthen community capacity for better mental health in up to 150 rural and remote communities in Alberta. CMHA provides training and funding to local community Animators, which in turn bring the community together to figure out what healthy communities should look like. The communities create workable action plans building on their strengths and existing assets. Local animators are also connected through an Alberta wide resource network for learning and mutual support. 
• The Stigma-Free Society  has collected inspiring stories of individuals living in rural and agricultural communities that share their experiences with mental health and stigma. The Stigma-Free Society is committed to combating stigma of all kinds, with a focus on mental health. The story collection is part of their Rural Mental Wellness Toolkit . The toolkit has great resources on a range of topics for seniors, families and youth living in rural and agricultural communities. The society also hosts virtual life events and will be launching a peer support program later this year.  

All these programs aim to reduce stigma and increase resilience of rural residents including farmers, and create stronger local supports for mental wellbeing.  

Resilience is the ability to “thrive in the face of adversity” and bounce back from difficult life events. It helps guard against the negative impacts of stress and protects against negative mental health outcomes. Resiliency is not a personal characteristics, but a process that can be learned. This is good news for farmers that often can’t change the sources of their stress, such as weather.

A study in Australia found that farmers adopted several strategies that help them cope with adverse and potentially stressful situations. These included focusing on other skills and roles they have, such as being a parent or a community leader; taking a break from farming by engaging in hobbies and social activities with family and friends; and practicing self-care. Resilient people still experience stress and difficult emotions; however, they can better adapt to situations and seek help when needed.  

The initiatives described above will go a long way to support the mental health and wellbeing of farming communities. 

Rural Canada is an important driver of the Canadian economy. In 2016, 23% of Canadians worked in rural communities, which is over 4 million people. Rural communities also generate 27% of our national Gross Domestic Product (GDP). 

 Gross domestic product (GDP) is the standard measure of the value created through the production of goods and services in a country during a certain period. – OECD definition 

The rural economy in Alberta is diverse and creates jobs across different sectors. In 2019, about 27% of Albertans worked outside of Calgary and Edmonton. The rural economy continues to grow driven by the sectors listed below. In 2019, almost 42% of GDP in Alberta was generated in non-census metropolitan areas, that means outside of the two major cities of Calgary and Edmonton.

Economic stability is a key social determinant of health. At the community level, economic stability determines the resources available for essential services like health care, education, and community infrastructure. At the individual level, economic stability influences employment, food security, housing, and poverty.

Healthy People 2020 has compiled a webpage of research-based resources on economic stability as a social determinant of health. Although this resource is based in the American context, it has some great information for Canadians as well.

Younger people are leaving rural communities to pursue education and job opportunities. This means that many rural communities are aging. One way to address aging rural communities is to encourage new Canadians to immigrate to rural communities. This strategy brings young people and their families to rural areas and also skilled workers to contribute to the local economy.

Since 2010 immigration to western Canada has increased by 62%. Newcomers are increasingly less likely to move to large urban centres. Instead, many are moving to smaller rural communities in search of work. This has significantly influenced the economies of western Canada, including Alberta.  

Through the Government of Canada Rural and Northern Immigration Pilot, Claresholm, Alberta is one of 11 Canadian rural communities looking to attract immigrants to fill labor shortages. Labor shortages can occur in many fields. Depending on the needs of the community, they may look to attract workers with different skill sets.

The Alberta Immigrant Nominee Program (AINP) has several streams for individuals who are working or intend to work in Alberta, as well as for entrepreneurs interested in establishing a business in the province. In a move to expand the federal Rural and Northern Immigration Pilot, the provincial government is planning a Rural Renewal Program Stream to prioritize permanent resident applications from immigrants committed to living and working in smaller communities throughout Alberta. A similar program was introduced in Manitoba to great success. Modeled on a successful program in British Columbia, a second stream – Alberta’s Rural Entrepreneur Immigration Stream (REIS) – would support regional communities to attract entrepreneurs with a desire to start businesses, create jobs, settle in smaller communities, and contribute to their local economy. 

However, newcomers need a broad range of supports to help them settle into rural communities. If they fail to integrate into the web of the community, rural immigrants may be at risk for poorer health. 

The video below was created through a Patient & Family Storytelling project at Alberta Health Services. Suni’s Story shares the challenges of being an immigrant to rural Alberta with English as a second language accessing our healthcare system. It explores how health providers and patient advocates can play a role in supporting new immigrants by speaking their language and understanding their culture. 

The pandemic has shown us that existing social inequities increase the risk of exposure and infection to COVID-19. Health disparities also increase the risk of severe COVID-19 because of underlying medical conditions and reduced access to health care.

These risks are increased when the ability to physically distance is limited. Physical distancing is difficult in certain work environments, like retail and meat packing plants; in group living situations, such as crowded housing, congregate care like long-term care and group homes, and incarceration settings. There are also increasing concerns about the effects of COVID-19 related to sex/gender, homelessness, and refugee status. Racialized people, including Indigenous, Black, Latino and other ethnic minorities, and low-income populations are disproportionately affected by COVID-19.  

This disproportionate effect of COVID-19 on racialized people is not only an issue in Canada’s large urban centres. Immigrants arriving in Canada are increasingly less likely to move to large cities; instead, many are moving to smaller rural communities in western Canada in search of work. According to Statistics Canada, the top places of birth among recent immigrants (2011-2016) to Alberta are the Philippines, India, China, and Pakistan, representing 51% of the recent immigrant population.

Advocates are calling for the collection of race-based data in health care settings. By collecting race-based data, researchers can link various public health issues, including COVID-19, along with health policies, health service delivery, and health outcomes to specific racialized groups. This helps us to gain a deeper understanding of the public health impacts facing different groups based on common cultural (and other) characteristics. It also helps us to understand how to create effective health messages, programs, and services to address the unique health needs of different groups. 

To understand more about the push to collect and analyze race-based health data to tackle the effects of the COVID-19 pandemic, watch the video below.  

It can be difficult to find primary caregivers for pregnant Albertans in remote, rural, and Indigenous communities.  According to the Public Health Agency of Canada in 2009, 25.6% of Canadian women travelled to another city, town or community to give birth, and overall, 2.5% of women travelled more than 100 kms to give birth.

Travel is inconvenient and can create hardship during pregnancy and labour. Traveling away from your community can mean the loss of important family and social support at a very vulnerable time. It is also a cost that is shouldered by women and families, which has the greatest impact on families with the least resources. Research shows that women who must travel far distances for maternity services face increased rates of negative prenatal outcomes, including more unplanned out-of-hospital deliveries and more inductions. Inductions are medically stimulated uterine contractions to begin labour before it begins on its own. Inductions require medications, which can alter the process of labour and comes with particular additional risks.

In 2017, the Maternal Newborn Child & Youth Strategic Clinical Network conducted a review of existing research to look at the availability and access to prenatal care services for marginalized women in Alberta.

Several strengths were highlighted in existing services, including:  

• a strong provincial network of non-profit agencies and Canadian Perinatal Nutrition Programs 
• specialized maternity services offering tailored prenatal care 
• several regional prenatal service networks 

Also identified were significant gaps and needs, including: 

• poor access to health services in remote and rural areas 
• lack of services and isolation issues in the North Zone 
• need for more primary care providers and supportive housing for pregnant women in the South Zone 

The scan resulted in proposed policy recommendations to address these gaps and enhance rural maternity care. The recommendations include:

1. Regional prenatal networks to connect all the various services – once connected, they can engage in joint strategic planning, communication, and coordination, which would reduce service overlap and make the services easier for expectant mothers to navigate. 
2. Expand specialized maternity care services for vulnerable women – this includes prenatal care and supportive housing.  
3. Implement standardized trauma-informed care training curriculum for all maternity services to ensure all services are equipped to support vulnerable families. 
4. Increased funding to support existing services to meet the needs of more families with less financial stability and support. 

Explore some great resources and learn more about social determinants of health by clicking on the links below:

• Government of Canada report: Social determinants of health and health inequalities, also includes links to a database
• Rural Health Information Hub: Social determinants of health in rural areas information, including FAQs and a comprehensive rural communities toolkit with 7 modules 
• Academic article: Social capital and health in rural and urban communities
• Academic article: Social capital experiences in two rural Ontario communities