Determinants of health: Divergence between two provinces

In this forum, I will be examining the Social Determinants of Health with classmate Iryna based on our home provinces of Ontario and Quebec.

Discussing the Social Determinants of Health at the community level: Barrie, Ontario

The socioeconomic factors that affect health are complex and intertwined throughout the life course of individuals. Known as the social determinants of health, they include (O’Hara, 2019): income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environment, personal health practices and coping skills, healthy child development and health services . To improve health and to narrow the health inequalities created by these socioeconomic factors, we must look beyond health care and focus on understanding and finding solutions to these root causes of poor health (O’Hara, 2019).

The Simcoe Muskoka District Health Unit (SMDHU) is committed to improving the health of our community and reducing health inequities amongst populated groups. Identifying populations at risk of health inequities will be an important aspect of the SMDHU work and will be reflected in their annual program planning (SMDHU, 2012). The SMDHU approach to addressing the determinants of health: A health equity framework provides the foundation for the SMDHU strategic plan 2012-2016 which cited a commitment to reducing health inequalities, this in turn, has informed the development of the SMDHU 2019-2022 strategic plan, which continues this direction through stated values including equity, and a priority area to enhance relationships with priority populations to address the social determinants of health (SMDHU, 2012 & Goldfinger, 2020).

This framework was develop to support public health staff at the SMDHU (2012) to support outcomes including:

• priority populations at risk of health inequities being prioritized for comprehensive agency response; and

• Implementing an action plan to address risk conditions to meet their public health needs.

Being short of money, good food and regular company — none of these facts are typically seen a “medical problems” but this groundbreaking report from the SMDHU makes it clear that in addressing non-medical issues by connecting people to better to their community, its resources and services, and to each other, they have been able to improve health outcomes and use healthcare resources more efficiently. Driven in part by an intake tool, modelled on the Canadian Index of Wellbeing, that helped identify that factors that residents in the Barrie and North Muskoka area recommended (SMDHU, 2012 & Daniel, 2019):

• Expansion of volunteer transportation programs to help combat social isolation and address issues related to food security and accessing a good diet;

• An increase to mental health services, including access to social workers for clients with recurring issues;

• Building and fostering programs that connect healthy members of the community with time to volunteer with SMDHU residents who require additional social supports that services cannot provide

• Raising the quality of the relationship between intake/care navigation workers and people with socially and medically complex factors in order to quickly identify intervention points (SMDHU, 2012 & Daniel, 2019).

Imagine on a continuous daily bases, having to make decisions on what is more important to have. Is it having enough money for groceries or to pay the rent or paying house hold bills or clothing or transportation. No one should have to make these decisions in order to met the basic needs of living. Yet, according to Simon (2018) the Statistics Canada revealed in 2016 that 12.2% of Barrie residents fell below the low income bracket. This is up from 2006 report of 8.4%. Addressing the social determinants of health is a grand task for any community. As healthcare professionals, we have the opportunity and indeed the obligation to apply the same best practice we routinely apply to other initiatives to our efforts to address social risk factors and unmet social needs. Addressing these needs requires a methodical approach, and to address the imperative determinants of health based on the community needs. It is impossible to accomplish all the needs and to do so efficiently and effectively, but rather narrowing down and developing concrete action plans is the way to go and to be successful in achieving those expectations and goals for the community.

Discussing the Social Determinants of Health at the provincial level: Ontario

Health inequities are systematic, avoidable and unjust differences in health between populations. These differences in the health of populations are often determined by social facts such as income, education level, ethnicity or gender, which are referred to as the Social Determinants of Health (SDOH). The purpose of raising awareness among the public about SDOH and health inequalities is to increase the salience of these issues in Ontario, which will in turn increase political will to act through effective public policy on SDOH and health inequity.

All Ontarian's should have the opportunity to be a healthy as possible, regardless of race, ethnicity, gender, socioeconomic status or other social circumstances. However, a great many will struggle with health inequalities; systematic and unfair disadvantages that threaten their health, such as lack of education, low income, lack of access to stable housing, healthy food, social isolation and lack of employment opportunities. The health and well-being of individuals is determined by a complex set of interactions among a range of social and economic factors, factors in the physical environment, individual behaviours, living conditions and genetic endowment. Ontario’s Public Health Units play a pivotal role in working on addressing the SDOH through program supports.

In Ontario, I will explore the SDOH and how our province is developing solutions to assist in these ares of concerns.

Indigenous People

Health inequalities experienced by Indigenous people are rooted in colonialism and racism. Addressing theses inequalities require that Indigenous self-determination is recognized and affirmed by all areas of society, including the health sector. Indigenous people need culturally accepted and relevant health data to inform programs and services, monitor community strength and wellness and address health inequalities. For health data to become a source of empowerment, communities should be involved in conceptualizing, implementing, collecting, analyzing, reporting and disseminating their data. In addition to engaging with communities and preparing data governance agreements, health care organizations can implement practices to build trust and migrate the risk of harm; for instance, they can create an Indigenous advisory committee, build relationships with Indigenous Knowledge keepers and elders, hire Indigenous staff and health care providers, and design and develop a culturally safe environment. Through addressing these needs and implementing actions, will help make identifying SDOH easier for this community (Webber, 2019).

Race/Racism

Racial discrimination is a fundamental determinant of health, causing proximate health risk factors, health ailments and disease. According to Black Health Alliance (2018) black individuals in Ontario often face disproportionately poor outcomes when faces with the SDOH.

Black Health Alliance (2018) statistics reported:

• “Income: 24% of Black Ontarians qualify as “low income”, as compared to 14.4% of the general racialized Ontario population;”

• “Second-generation Black Canadians earn 10 to 15 per cent less than second-generation White Canadians, even when results are adjusted to reflect educational levels;”

• “Education: In the Toronto District School Board, 69% of Black students graduated in 2011, as compared to 87% of racialized students and 84% of White students,” and

• “Social Exclusion: Black Canadians make up 9.5% of the Canadian prison population while representing only 2.5% of the overall Canadian population”

Food Insecurity

Food insecurity affects families in many ways. Children are of primary concerns when families experience food shortage. Children who experience food shortage often experience a myriad of issues related to growth and development. They often have increase behaviours and learning problems and a lesser understanding of the importance of nutrition for good health. Children and youth make up 38% of those helped by the Canadian food bank. Ontario Public Health Units calculates the cost of basic healthy eating according to current nutrition recommendations and average food purchasing patterns. The calculation is completed by conducting a comprehensive survey of local grocery stores using the Nutritious Food Basket tool. The survey monitors affordability and accessibility of foods by relating the cost of the food basket to individual/family incomes (Hunger Report, 2018). On average a family of four would spend approximately $220-240 a week to buy the quantity of basic foods to meet minimum nutrition recommendations. Communities efforts across Ontario help to address the issue of food insecurity. These may include but is certainly not limited to: non-profit organization like The Garden Fresh Box program, Feed Ontario, Georgina Community Food Pantry, in-school for programs, and community support through donations/food drives (Hunger Report, 2018).

https://www.simcoemuskokahealth.org/docs/default-source/topic-healthyeating/nfbinfographic2019f.pdf?sfvrsn=2

Transportation

Individuals with low income cannot afford reliable transportation. This also has considerable impact on other important determinant of health. It becomes a barrier to daily functions including ability to access programs and services. One of the main transportation issues raised by communities was about the location of bus stops and the cost of riding the bus. For many low income individuals/families this makes securing employment more challenging, accessing a grocery store or food back difficult, and limits access to programs and services. Progress can be made through the provision of seamless services and systems-based approaches that build on existing strengths and capacities within communities. As such, implementation of an affordable bus pass pilot program (is different based on city). The program allows people living in low income households to purchase a transit pass at a reduction rate. Other solutions is to provide programs and services at community hubs that are centrally located in propriety neighbourhoods.

Employment

Unemployment, underemployment and stressful or unsafe work conditions are associated with poor health. Paid employment and benefits contribute to the health and well-being of individuals and their families, reduced likelihood of physical and mental illness, and increased life expectancy. Employment and job security have a great impact on one’s physical and mental health, providing both financial and non-financial benefits. Not only does paid work provide money, it also provides a sense of identity, purpose and social contacts. Unemployment can be very stressful and negative impact an individual’s self-esteem, increasing the likelihood of turning to unhealthy coping behaviours such as substance abuse, increase alcohol intake and tobacco usage. On average, those who immigrated to Canada have more formal education compared to those who where born in Canada, but the unemployment rate for the immigrant population is twice as high (Forchuk, Dickins & Corring, 2016). I have worked with a few Physician Assistance who are actually Medical Physician in their home countries, but was unable to practice in Canada for a variety of reason with the predominant being there schooling was not recognized in Canada and would take too long to go through the process here. Other barriers also concluded transport, childcare cost, filling out job applications, writing resumes and getting to and from job interviews. Ontario's unemployment rate was 6.5% in the first part of 2020. However given the COVID-19 pandemic, will contribute to the increase of unemployment. The impact of employment is a lack of opportunity to gain skills. Opportunities to gain skillful trades can achieve through community programs and employment volunteers to train (Forchuk, Dickins & Corring, 2016).

Education

Level of education is a strong predictor of health. The higher and the more successful the education experience is for children, youth and adults, the better their health will be. Youth with post-secondary education are more likely to be employed than those without and employment contributes to better health. When compared with post-secondary graduates, Ontarian’s who did hot complete high school are almost twice as likely to report fair to poor health. The highest mortality rates are found among people who did not complete secondary schooling, those who are unemployed or who are not seeking jobs ad those who have unlike jobs and are consequently living on low income. The Ministry of Children and Youth Services has identified the mandate that every young individual graduates from post-secondary school as one of its five strategic goals. Quality early learning and child development services provide children with the skills, capabilities and knowledge required for success in school. Interventions providing focus on specific priority populations and local issues have proven to have a strong and positive impact in closing equity gap. Pathways to Education program aims to address the issues of youth school attendance, academic achievements and credit accumulation by partnering with parents, community agencies, volunteers,local school boards and secondary schools to develop intense, multi-faceted and long-term support for post-secondary students. This program is a proven social and health investment that reduces high school drop out rates by addressing the four pillars of academic, social, advocacy and financial supports. Staying in school and educational achievements leads to improvement in socioeconomic conditions and as a result minimizes or removes barriers to health (Kenny & Moore, 2013).

Social and Community Support

Individuals who are supported by their family, friends, and communities experience better health. Barriers to health may include the experience of discrimination, stigmatization, marginalization and a lack of culturally appropriate resources and services. Lack of social connectedness affects Ontario’s rural communities. The more remote the community, the more likely it is that the residents experience a variety of barriers such as lack of transportation, suitable housing and social connectedness are less healthy overall. Building strong connections to ensure neighbourhood residents experience a sense of belonging is important. Social connectedness ensures people have the support they need during various life changes that can affect their health, changes such as having and raising children, attaining education or employment training, looking for housing or entering the job market. The Community Development Worker often acts as a link between communities, local governments and other statutory bodies. They are frequently involved in addressing inequality and projects often target communities perceived to be culturally, economically or geographically disadvantage.

Housing

Homelessness is both a product and contributor of poor health which often leads to increase risk of chronic conditions when compared to the general population. Affordable and acceptable housing is a crucial social determinant of health. Affordability of suitable housing is directly related to income. In order to be able to obtain employment and provide a supportive home for raising healthy children, stable affordable housing is widely considered to be essential (Cote & Tam, 2013). In Ontario, it is the only Canadian province where social housing is a municipal responsibility, whereas the federal and provincial governments “play funding, regulatory and oversights roles, cities and communities deliver housing (Cote & Tam, 2013). ” A great majority of housing in the province of Ontario is either privately owned or rented. With 4.5 million Ontario’s households, 70% are owners, with a growing number living in condominiums; whereas renter will generally live in rental apartments. Social housing supported by private and municipal non-profit and co-operative providers acts as the safety net for low income families/individuals with 5% of all housing and 20% from rental supply (Cote & Tam, 2013). Ontario is trying to bridge the gap for low income individuals and families to cover their rent and other house hold expenses though services like social assistance allowance, the Ontario housing benefit. In addition too, The Ontario Ministry of Municipal Affairs and Housing released Ontario’s Long-term Affordable Housing strategy to help simply the rent-geared-to-come proceed to reduce the administrative burned of the process on tenants and housing providers. Other solution incorporates the reduction of house hold bills based on income. For example reducing home energy bill cost though local providers (Forchuk, Dickins & Corring, 2016).

Early Childhood Development

Children need a safe, supportive environment, as well as a warm nurturing relationship with their primary caregivers, to be able to meet their full potential; growing up in a neglectful unsafe or abusive environment can negatively affect brain development. Environmental conditions can subsequently impact social, emotional, physical, cognitive and/or behavioural development. Research has proven that parenting and family relationship have the greatest impact on children’s heathy development and well-being; however, high quality early learning programs and child care can also play a pivotal role in a child’s overall development. The associations between socio-economical status and health outcome begins before birth and continues throughout life (Ontario Public Health Association, 2003).

The National Longitudinal Survey of Children and Youth (1999) idetified:

• Children in low-income families are twice as likely to be living in poorly functioning families as are children in high-income families;

• Under 50 % of children in low-income families live in substandard housing, compared to 15 % of children in high-income families;

• More than one-quarter of children in low-income families live in problem neighbourhoods, compared to one-tenth of children in high-income families;

• Approximately 40 % of children living in low-income families demonstrate high levels of indirect aggression (such as starting fights with their peers or family members);

• Children in low-income families are over two and a half times more likely than children in high-income families to have a problem with one or more basic abilities such as vision,hearing, speech or mobility;

• Great than 35 per cent of children in low-income families exhibit delayed vocabulary development, compared to around 10 per cent of children in higher-income families;

• Almost three-quarters of children in low-income families rarely participate in organized sports, compared to one-quarter of children in high-income families

Discussing the Social Determinants of Health at the provincial level: Quebec

(This section has been accredited and completed by classmate Iyran as part of out collaboration with another classmate)

Various social factors, such as education, income, work, living environment, housing and access to services, determine an individual’s state of health. These interact in varying combinations throughout the life course. Inequitable distribution of these factors, or health determinants, among groups generates considerable health differences among people within a community or a country, or between countries. The gaps or unequal distribution of health status, linked to these determinants within a population are referred to as social inequalities in health (SIH). Data on the scope of SIH in Québec speak for themselves. The differences between socioeconomic groups, in terms of life expectancy and premature mortality, are marked. For example, in 2006, the gap in life expectancy between the most disadvantaged and most advantaged segments of the population was 8.1 years for men and 3.9 years for women. Similarly, in the most disadvantaged segment of the population, 93% more individuals did not consider their health to be good, 88% more were daily smokers, 54% more were dissatisfied with their social life and 28% more were obese, as compared with the most advantaged segment. Some population groups, such as Aboriginal peoples, were shown, in certain cases, to be affected to an alarming degree by social inequalities in health.

The Québec government has mainly implemented a series of policies that, although not introduced specifically to combat SIH, may have a real effect on these by targeting one or more determinants of health. Government policies focused on specific health determinants in Québec:

1. Early childhood and education. To provide assistance to families, Québec has adopted the Québec Parental Insurance Plan for workers who take maternity leave, paternity leave, parental leave or adoption leave. The QPP launched the Child Assistance Measure,  which has replaced family allowances and benefits, and the Supplement for Handicapped Children. With regard to childcare services, parents have access to a limited number of places in daycare centres at a cost of $7 a day under the government’s Reduced-Contribution Program. Public daycare centres must apply Québec's educational program for childcare services. Moreover, which was adopted in June 2013, grants access to early childhood educational services to all 5-year-olds (4 years of age for children from disadvantaged backgrounds). Pregnant women and mothers living in vulnerable situations (poverty, young age, or parents with low levels of education) are eligible to receive Services intégrés en périnatalité et petite enfance (SIPPE) [integrated perinatal and early childhood services], from the beginning of a pregnancy until the child reaches age five. An assistance is offered to families with the aim of supporting parents and creating an environment that is conducive to optimal child development. With regard to work-family balance, the ministère de la Famille [department for families] implemented the Programme de soutien financier aux milieux de travail en matière de conciliation travail-famille [financial support program for workplaces - balancing work and family] from which stems the norme Conciliation travail-famille [workfamily balance standard] from the Bureau de normalisation du Québec [Québec standards bureau] to encourage workplaces to establish and implement management practices and measures to reconcile work and family.

2. Academic success and learning support services.In order to improve student retention and academic success, the Ministère de l’Éducation, des Loisirs et des Sports (MELS) [department of education, recreation and sports] adopted the I care about school! strategy. This strategy comprises several interventions such as reducing the number of students per class in elementary school, offering homework assistance, providing individualized support for students who have repeated a year, promoting vocational training in high school, and reinforcing the New Approaches, New Solutions,  intervention strategy, whose evaluation report asserts that, although it achieved no measurable changes in academic achievement levels among disadvantaged students, in an improved form, this program could become a promising tool. The Healthy Schools program, under the joint responsibility of the Ministère de la Santé et des Services sociaux (MSSS) [department of health and social services] and the MELS, aims to implement effective prevention and promotion practices in schools, in a comprehensive and concerted way, so as to promote the educational success, health and well-being of young people. Moreover, the Québec government offers financial aid to students in the form of loans and bursaries, administered by the MELS, in an effort to promote access to education. This program comprises various measures such as the Work/Study Program to help reconcile work with studies.

3. Employment, income and social solidarity. The Québec population has access to a Social Assistance Program and a Social Solidarity Program both under the responsibility of the Ministère de l’Emploi et de la Solidarité sociale (MESS) [department of employment and social solidarity] and intended to provide last resort financial assistance to designed to help ensure a minimum level of income and to grant financial assistance to persons who may or may not have a severely limited capacity for employment. The Youth Alternative Program specifically targets young people under age 25 and comprises an intervention plan for entering the job market. As for the Québec Pension Plan,  this is a compulsory public insurance plan designed to provide persons who work in Québec (or have worked in Québec) and their families with basic financial protection in the event of retirement, death or disability.

4. Employment assistance and support. The government has introduced a number of measures to facilitate access to the labour market and to support workers. Emploi-Québec is responsible for implementing many of the employment assistance measures such as the Emploi-Québec is responsible for implementing many of the employment assistance measures, such as the Stratégie de mobilisation tous pour l’emploi [mobilization strategy for employment for all], Employment Pact, employment assistance allowances, wage subsidies and skills training. Revenu-Québec is responsible for the Work Premium,  a refundable tax credit intended for low- or middle-income workers. To help promote the innovative business projects of young people from underprivileged backgrounds, the Ministère des Finances et de l’Économie (MFE) [department of finance and the economy] launched the Stratégie québécoise de l’entreprenariat [Québec entrepreneurship strategy]. The MESS is responsible for overseeing the Income Support Program for Older Workers which provides monthly financial assistance to older workers who were dismissed or laid off because of the economic situation. Finally, the Employment Integration Program for Immigrants and Visible Minorities (PRIIME) is the result of a partnership between EmploiQuébec, the Ministère de l’Immigration et des Communautés culturelles (MICC) [department of immigration and cultural communities] and Investissement Québec.

5. Social inclusion and the fight against discrimination. In order to promote social inclusion, the government has taken a number of steps, including adopting the 2010- 2015 Government Action Plan for Solidarity and Social Inclusion, which aims to coordinate action to help disadvantaged individuals and to combat poverty. In the same vein, the MSSS is responsible for the new Politique nationale de lutte à l’itinérance [national policy for combating homelessness] and the Plan d’action interministériel en itinérance [interdepartmental homelessness action plan] and the ministère de l’Emploi et de la Solidarité sociale is responsible for the Governmental Policy on Community Action. People with low incomes can access legal services through the Legal Aid program of the Ministère de la Justice [justice department]. Other measures target specific populations, including the Secrétariat à la jeunesse's [youth secretariat’s] 2009-2014 Youth Action Strategy and the MFA's Action Strategy for the Elderly. As regards discrimination, the National Assembly has adopted the Pay Equity Act, the Politique gouvernementale pour l’égalité entre les femmes et les hommes,  [government policy on gender equality], and the Government policy to promote participation of all in Québec’s development. Finally, the Act to secure handicapped persons in the exercise of their rights with a view to achieving social, school and workplace integration and the resulting policy statement Equals in Every Respect: Because Rights Are Meant to be Exercised is championed by Québec's handicapped persons' protection office.

6. Working conditions, health and safety. The Act Respecting Labour Standards applies to most Québec employees, but excludes self-employed workers and certain categories of employees. It covers various aspects of employment, such as minimum wage, work hours and holidays. Collective agreements between a group of employees and an employer are governed primarily by the Labour Code. In Québec, the Occupational Health and Safety Plan comprises two main laws: the Act Respecting Industrial Accidents and Occupational Diseases, which provides compensation for employment injuries and the consequences they entail for beneficiaries, and the Act Respecting Occupational Health and Safety, which focuses on the prevention of work accidents or occupational disease. In 2012, only 25% of Québec employees worked for companies that have a prevention program in place.

7. Environment and land use planning. Prompted by the Sustainable Development Act, the Ministère du Développement durable, de l’Environnement, de la Faune et des Parcs (MDDEFP) [department of sustainable development, the environment, wildlife and parks] developed the Government Sustainable Development Strategy 2008-2013 which aims to influence and encourage sustainable development. Preventing and reducing social and economic inequality are at the heart of this strategy.

8. Strategic planning and revitalization. The Act Respecting Land use Planning and Development represents the legislative framework within which all urban planning and development plans in Québec must be designed, under the responsibility of the municipalities. The Stratégie pour assurer l’occupation et la vitalité des territoires 2011-2016 [2011-2016 strategy to ensure the occupation and vitality of territories] is under the jurisdiction of the Ministère des Affaires municipales, des Régions et de l’Occupation du territoire (MAMROT) [department of municipal and regional affairs and territorial occupancy]. The Act to ensure the occupancy and vitality of territories helps to achieve long-term sustainability. This national strategy offers large cities support in implementing their strategies for revitalisation urbaine intégrée (RUI), [integrated urban revitalization], which are aimed at revitalizing neighbourhoods through the mobilization of citizens and partners, the implementation of poverty reduction measures, and the enhancement and improvement of built environments.

9. Housing. As regards social housing, the Société d’habitation du Québec (SHQ) [Québec housing corporation] is responsible for coordinating the government actions outlined in its Plan stratégique SHQ 2011-2016 [2011- 2016 strategic plan]. Low-income households have access to a wide variety of social housing programs managed by the SHQ, the best known being the Low-rental Housing Program, which helps offset rental costs on 63,000 dwellings. The SHQ also adopted the Cadre de référence sur le soutien communautaire en logement social - Une action intersectorielle des réseaux de la santé et des services sociaux et de l'habitation [framework for community support for social housing – intersectoral action by the health and social services and housing networks] in collaboration with the MSSS.

10. Transportation and mobility. The Ministère des Transports du Québec (MTQ) [Québec department of transportation] is mandated to ensure the mobility of persons by way of effective and safe transportation systems and, as such, to establish paratransit services to meet the needs of persons with a disability, such as for example, the Programme d’aide gouvernementale au transport adapté aux personnes handicapées [paratransit government assistance program]. The new National Strategy for Sustainable Mobility is intended to ensure the inclusion of public transit in all significant proposals for land development. The Québec Public Transit Policy, much like the Bicycle Policy, is directly in keeping with the government's efforts toward achieving sustainable development.

11. Promotion of healthy lifestyles and prevention of obesity. Since June 2006, the Act to Establish the Sports and Physical Activity Development Fund has offered financial support to municipalities, educational organizations and non-profit organizations for the construction, renovation, equipping and bringing up to standards of sports and recreational facilities. The Programme Kino-Québec [Kino-Québec program] aims to promote a physically active lifestyle and is managed jointly by the MELS, the MSSS and the health and social services agencies. In 1997, the Programme éducatif en services de garde [an educational child care program] was implemented to promote child development. It focuses on prevention and promotion in order to create an environment that is conducive to the adoption of healthy eating habits, lifestyle and behaviours.

12. Food safety. The MSSS's Cadre de référence en matière de sécurité alimentaire [reference framework for food security] is aimed at promoting concerted collective action on the key environmental and individual determinants of food security. The primary purpose is to improve physical and economic access to healthy food for people living in poverty.

13. Tobacco, alcohol, drugs, other substances and gambling. Under the Tobacco Act passed in 2006, it is forbidden to smoke in public spaces and to sell or supply tobacco to a minor on the grounds or within the premises of buildings placed at the disposal of a school. This Act also outlines legislative measures regarding the advertising of tobacco products and restrictions on points of sale. The objectives of the MSSS's Plan québécois de prévention du tabagisme chez les jeunes 2010-2015 [Québec plan for the prevention of teen smoking] are to prevent people from starting to smoke, to help smokers to quit and to protect people from exposure to environmental tobacco smoke (ETS). To prevent, reduce and treat the individual and collective problems that arise from substance abuse, the MSSS and nine other departments are working on implementing the Plan d’action interministériel en toxicomanie 2006-2011 [ inter-departmental action plan on substance addiction]. This plan focuses on prevention, early intervention, treatment and social reintegration.

14. Health care and services. The Québec Health Insurance Plan (RAMQ) entitles all residents of Québec to obtain medical services free of charge. The medical services covered by the Health Insurance Plan are those that are medically necessary and rendered by a general practitioner or a medical specialist. The Plan also covers dental and optometry services for certain clients, including children, the elderly and people who have been on social assistance or welfare for at least one year. Another universal public plan that provides free access to hospital services is the Hospital Insurance Plan. Finally, the Public Prescription Drug Insurance Plan is intended for persons who do not have private insurance to cover medication costs.

15. Strengthening health competencies within communities. A health-based study program (100 hours) is part of the MELS's Government Policy on Adult Education and Continuing Education and Training. Its aim is to lay the groundwork for responsible and preventive health-related actions through the acquisition of competencies applicable in real-life situations, where behaviour management is addressed from the perspective of nutrition, physical exercise, recreation, or recovery.(R. Lambert; J. St-Pierre; L. Lemieux; M. Chapados; G. Lapoint; P. Bergeron; R. Choiniere; M-F. Leblanc; G. Trudel;, 2014)

References (Iryna)

R. Lambert; J. St-Pierre; L. Lemieux; M. Chapados; G. Lapoint; P. Bergeron; R. Choiniere; M-F. Leblanc; G. Trudel;. (2014). Policy Avenues: Interventions to reduce social inequalities in health. Quebec: Insituit national de sante poublique du Quebec.

Reference (Nina)

Black Health Alliance (2018). Social Determinants of Health. Retrieved October 18, 2020 from, https://blackhealthalliance.ca/home/social-determinants-health/

Cote, A. & Tam, H. (2013). Affordable Housing in Ontario: Mobiizing Private Capital in an Era of Public Constraint. Retrieved October 19 2020, from https://munkschool.utoronto.ca/imfg/uploads/238/imfg_perspectives___affordable_housing_(april_2013).pdf

Daniel, D. (2019). Care providers are using new tools to address social determinants of health. Retrieved October 18, 2020 from https://www.canhealth.com/2019/08/28/care-providers-are-using-new-tools-to-address-social-determinants-of-health/

Forchuk, C., Dickins, K., & Corring, D.J. (2016). Social Determinants of Health: Housing and Income. Retrieved October 19, 2020 from, https://pdfs.semanticscholar.org/9f0e/77e10be87ff7a338db022cef7de4c6992fd0.pdf

Golderfinger, D. (2020). Proposed Barrie Health According to address ‘root causes of emergency calls, transport, treatment. Retrieved October 18, 2020 from https://globalnews.ca/news/7263852/proposed-barrie-health-accord/

Hunger Report (2018). A Looming Crisis: Senior Hunger in Ontario. Retrieved October 19, 2020 from, https://feedontario.ca/wp-content/uploads/2018/11/Hunger-Report-2018-Digital.pdf

Kenny, K.E. & Moore, S. (2013), Canadian adolescent perceptions and knowledge about the social determinants of health: an observational study of Kingston, Ontario youth. BMC Public Health 781. Retrieved October 19, 2020 from, https://link.springer.com/article/10.1186/1471-2458-13-781

National Longituindal Survey of Children & Youth (1999). Retrieved October 19, 2020 from, https://www150.statcan.gc.ca/n1/en/pub/89f0078x/4198664-eng.pdf?st=xO46Gg95

O’Hara, P. (2019). Social Inclusion Health Indicators: A framework for Addressing the Social Determinants of Health. Retrieved October 18, 2020 from, https://www.homelesshub.ca/resource/social-inclusion-health-indicators-framework-addressing-social-determinants-health

Ontario Public Health Assocation (2003). Public Health Responds to the Challenge to Reduce Poverty and Enhance Resiliency in Children and Youth. Retrieved October 19, 2020 from, https://opha.on.ca/OPHA/media/Resources/Resource%20Documents/2004-05_pp.pdf?ext=.pdf

Simcoe Muskoka District Health Unit (2012). Simcoe Muskoka District Health Unit Approach To Addressing The Determinants of Health. Retrieved October 18, 2020 from https://www.simcoemuskokahealth.org/docs/default-source/jfy-communities/sdohfoundationaldocument_-_final_2

Webber, J. (2019). Failure to acknowledge inequities in the social determinants of health. Canadian of Family Physician 65(9), 603-607.