Revisiting our social justice roots in population health intervention research/Nouveau regard sur nos racines : la justice sociale dans la recherche sur les interventions en sante des populations.

Edwards, Nancy C.

Public health has its roots in social justice. Descriptions of public health work in the early 20th century reveal the appalling living conditions of the poor and the inequities that were predominant at the time. Class distinctions were apparent in life expectancy, and in differential rates of access to sanitation, clean water, education, food and adequate housing. Although there have been many improvements in the overall health of Canadians during the past century, substantial inequities remain. Canadian and international reports (1,2) have implored us to take action on these inequities. In this knowledge age, when we are working to build population health interventions on a solid foundation of theory and rigorous methods, it is important to revisit the social justice roots of population health interventions and consider why, as practitioners and scientists, we have sometimes deviated from these values.

Historical accounts indicate several important eras for population health interventions in Canada. The early part of the 20th century was a period when many basic public health regulations were being put into place to improve sanitation, safely preserve food, and reduce communicable disease transmission. (3) Community health workers, who were primarily nurses, were particularly active in school settings and in conducting home visits in poor and underserved communities. (3,4) Efforts to address deplorable social living and working conditions among vulnerable populations are prominent in descriptions of these early public health programs. Early descriptive epidemiological studies documented important socio-economic differences in health status, but did not consistently interrogate underlying issues of class and power.

Post World War II marked the beginning of an information era. Health education efforts were reinforced with the production of communication materials that could reach all Canadians. (5) Lt. Col. Gilchrist described how the Department of National Health and Welfare supported the production of resources relevant to child care, venereal diseases, water- and food-borne diseases, and mental health. (5) Posters, films, books and radio were identified as important delivery methods. Gilchrist noted that health educators working with government services and with voluntary agencies were "unanimous in their opinion regarding the teaching value of the motion picture". (5, p. 1416) The technology of the time was an important driver of these public health interventions, providing new modalities to make health information widely accessible and spurring research in the field of health education.

Over the next few decades, behavioural interventions began to gain favour. Behaviour change was viewed as being mainly under the control of the individual and changes in knowledge and attitudes were thought to be primary influences on lifestyle choices. Explanatory theories, particularly from psychology, gained a strong foothold in the field of designing and evaluating public health interventions. However, as Larry Green stated in a 1984 article, "the dominant contributions to the literature on interventions in health have been, perhaps regrettably, from psychology." (6, p. 215) Citing several large-scale community interventions including the Stanford heart health studies, which did not produce the expected health outcomes, Green observed that these interventions had focused on patient education rather than on the broader set of conditions that influence behaviour. Although these studies made many important contributions to our understanding of behaviour change processes, they left questions about other levers and supports for health changes largely unanswered. The prominence of reductionist science provided a set of methods that was a good match for research questions examining the effectiveness of behavioural interventions. Thus, these dominant paradigms in public health science and practice were mutually reinforcing and marked a period when social justice concerns were largely eclipsed by the promise of both quantitative science and individually-oriented interventions.

But there was growing concern that health education and behaviourally-oriented interventions were failing to reach those most in need. James Mason, for example, when he was Director of the Centers for Disease Control remarked, "It is my observation that, up until now, most of the behavior changes we have promoted have involved the better-educated, upper-, and middle-class segments of our society. If health promotion is a good thing, it should be good for the whole society, not just that portion which is favorably predisposed." (7) In response to these types of concerns, health promotion efforts began to shift attention towards environmental and policy conditions that shaped individual action, while also considering the mechanisms for collective change processes. The Ottawa Charter for Health Promotion (8) acknowledged the importance of working at all system levels and across sectors to improve health and to reach vulnerable populations. (9) It signaled the inherent complexity of public health issues and suggested that scientists needed to bridge quantitative and qualitative paradigms. Fusions of scientific fields, such as social epidemiology, and of research paradigms, such as mixed methods designs, were extending the nature of inquiry about determinants and interventions in public health. With increasing recognition that levers for population health improvements include those targeting macrosocial determinants of health; and that both top-down and bottom-up approaches are needed to reduce inequities through the "nutcracker" effect, (10) population health interventions began to shift, reconnecting us to the social justice roots of public health.

The often-cited example of tobacco control illustrates radical changes in thinking about the design and evaluation of population health interventions that have occurred over the last fifty years. There has been a steady progression in the scientific agenda from one that focuses on tobacco as a lifestyle choice requiring knowledge and behaviour change interventions, to one that acknowledges tobacco control approaches as examples of complex interventions operating within complex adaptive systems. (11) This progression has required an amalgam of the best know-how of many disciplines; and recognition of the longevity, coherence and multi-level nature of efforts that are required to produce and track significant improvements in health at the population level. Consequently, researchers have been led into new domains of inquiry, including the examination of naturally occurring interventions such as policy change processes; comparative studies of social norms and their influence on smokers and policy-makers; and research on interventions that cross jurisdictions and operate at various systems levels. The social justice underpinnings of tobacco control efforts have also been brought into focus. We have seen, for example, how slumping profits in higher-income countries have driven tobacco companies to increase sales of tobacco products in lower- and middle-income countries. (12) The WHO Framework Convention on Tobacco Control illustrates the types of alliances that are needed to address such health threats on a global scale, again pushing scientists to re-examine the methods, theories and measurement tools that are required to learn from these endeavours.

As we look to the future, we have a unique opportunity in Canada to further develop the science of population health interventions. The conditions for this work have been created through the outstanding efforts of public health workers who have advocated for vulnerable populations and the socially disadvantaged, (13-16) and by scientists who have deepened our understanding of social determinants and undertaken foundational work relevant to the emerging science of population health interventions. (17-20)

System supports are required for changes in the delivery of public health services and advances in population health science. The National Health and Research Development Program was the primary supporter of public health research in Canada for 30 years. This laid the groundwork for population health research to be firmly placed alongside biomedical, clinical and health services research when the Canadian Institutes of Health Research was established in 2000. The Institute of Population and Public Health was set up with Dr. John Frank as its inaugural Scientific Director. The first strategic plan for the Institute had a strong focus on understanding and to some extent addressing social and environmental determinants across the life course. With a view to catalyzing scientific inquiry and strengthening the research capacity required for the field of population health science, important initiatives such as the Centres for Research Development and the Applied Public Health Chairs Programs were supported.

The second strategic plan for the Institute, which has recently been launched, has four strategic objectives: a) to further our understanding of pathways to health equity, b) to examine the impact of complex population health interventions on health and health equity, c) to examine how implementation systems for population health interventions may strengthen or weaken the impact of population health interventions on health and health equity, and d) to stimulate theoretical and methodological innovations in knowledge generation, knowledge synthesis and knowledge integration for population and public health. The Institute aims to support population health intervention science that addresses health inequities.

The new science of population health interventions requires that we return to the social justice roots of public health. Funding mechanisms that encourage transdisciplinary efforts and bridge paradigms, methods and measures are essential. We need the best and brightest ideas of practitioners, managers, scientists, policy-makers and community partners to tackle the equity gap through interventions in public health and other sectors. Being responsive to the population and public health problems that lie before us requires that we avoid narrowing our approaches to those that are familiar and comfortable. (21) Our strengths include our understanding of social, environmental and macrodeterminants of health; our roots in social justice; and our concern about improving the overall health of populations while narrowing the equity gap. Our ongoing challenge is how to address these through leading-edge science, and how to approach these in ways that will ultimately benefit those who are experiencing the dark side of material and social disadvantage. We will have succeeded if the history books of this century describe how we inserted social justice into the practice and science of population health interventions in Canada and globally.

REFERENCES/REFERENCES

(1.) Report on the state of public health in Canada: Addressing health inequalities. Public Health Agency of Canada, 2008. Available at: http://www.phac-aspc.gc.ca/publicat/2008/cphorsphc-respcacsp/ cphorsphc-respcacsp11-eng.php (Accessed October 4, 2009).

(2.) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008.

(3.) Public Health Notes: Public health in England and Wales in 1910. Am J Public Health 1912;2:47-66.

(4.) Edwards N, Smith D. Community health nursing research: A retrospective. Can Nurse 2008;104:32-35.

(5.) Gilchrist CW. Canada sees new horizons for health education. Am J Public Health 1947;37:1415-20.

(6.) Green LW. Modifying and developing health behavior. Annu Rev Public Health 1984;5:215-36.

(7.) Mason JO. Health promotion and disease prevention: The federal and state roles. Focal Points 1984;1:1-2.

(8.) Ottawa Charter. Ottawa Charter for Health Promotion: First International Conference on Health Promotion. Can J Public Health 1986;77:425-30.

(9.) Green LW, Kreuter MW. Health promotion as a public health strategy for the 1990s. Annu Rev Public Health 1990;11:319-34.

(10.) Baum F. Cracking the nut of health equity: Top down and bottom up pressure for action on the social determinants of health. Intl J Health Promot Educ 2007;14(2):90-11.

(11.) Hawe P, Shiell A, Riley T. Theorising interventions as events in systems. Am J Community Psychol 2009;43:267-76.

(12.) Gilmore AB, McKee M. Moving East: How the transnational tobacco industry gained entry to the emerging markets of the Former Soviet Union-part I: Establishing cigarette imports. Tob Control 2004;13:143-50.

(13.) Mezei R, Stanwick R. Hot water scalds prevention: A case for the power of public health partnerships in affecting regulatory change. Pediatr Child Health 2004;9(3):153-55.

(14.) Cushman RA. Hockey injuries of the spine in Canada, 1966-96. CMAJ 2000;162(6):787-88.

(15.) Crowe C. Dying for a home: Homeless activists speak out. Toronto: Between the Lines, 2007.

(16.) Collishaw N. The conquest for non-smoking zones confronted with industry tactics: Scientific misinformation and front groups. The Canadian Experience. Promot Educ 2005;Suppl 4:28-29.

(17.) Hawe P, Potvin L. What is population health intervention research? Can J Public Health 2009;100(1)(Insert):18-114.

(18.) Raphael D. Social Determinants of Health: Canadian Perspectives, 2nd ed. Toronto: Canadian Scholar's Press, 2009.

(19.) Labonte R, Schrecker T, Sen Gupta A. Health for some: Death, disease and disparity in a globalizing era. Toronto: Centre for Social Justice, 2005.

(20.) Heymann J, Hertzman C, Barer ML, Evans RG (Eds). Healthier Societies: From Analysis to Action. Oxford University Press, 2005.

(21.) Hawe P. The social determinants of health: How can a radical agenda be mainstreamed? Can J Public Health 2009;100(4):291-93.

Author Affiliations

Professor, School of Nursing and Department of Epidemiology and Community Medicine, University of Ottawa; Scientific Director, Institute of Population and Public Health, Canadian Institutes of Health Research, Ottawa, ON

Nancy C. Edwards, RN, PhD, FCAHS

La sante publique a ses racines dans la justice sociale. Les descriptions du travail de sante publique au debut du xxe siecle revelent les conditions de vie epouvantables des pauvres et les inegalites qui primaient a l'epoque. Des differences de classes etaient visibles dans l'esperance de vie et dans l'acces inegal a l'hygiene, a l'eau pure, a l'instruction, aux aliments et aux logements convenables. Et bien que la sante globale des Canadiens se soit beaucoup amelioree depuis un siecle, d'importantes inegalites demeurent. Des rapports canadiens et internationaux (1,2) nous implorent de les reduire. En cette ere du savoir, ou nous nous efforcons de construire les interventions en sante des populations sur une base theorique solide et selon des methodes rigoureuses, il est important de jeter un nouveau regard sur le souci de justice sociale qui est a la racine de ces interventions et de nous demander pourquoi, nous les praticiens et les scientifiques, nous sommes parfois ecartes de ces valeurs.

L'histoire definit plusieurs grandes periodes dans les interventions en sante des populations au Canada. Le debut du xxe siecle est l'ere ou l'on instaure de nombreux reglements de sante publique de base pour ameliorer l'hygiene, conserver les aliments sans danger et reduire la propagation des maladies transmissibles (3). Les travailleuses et les travailleurs en sante communautaire, qui sont principalement des infirmieres, interviennent surtout dans les ecoles et en faisant des visites a domicile dans les collectivites pauvres et mal desservies (3,4). Les efforts deployes pour remedier aux conditions sociales, de vie et de travail deplorables dans les populations vulnerables figurent en bonne place dans les descriptions de ces programmes de sante publique naissants. Les premieres etudes epidemiologiques descriptives confirment d'importants ecarts socioeconomiques dans l'etat de sante des gens, mais ne se penchent pas systematiquement sur les enjeux sous-jacents de la division des classes et du pouvoir.

Au lendemain de la Deuxieme Guerre mondiale, on entre dans une ere d'information. Les efforts d'education sanitaire sont renforces par la production d'outils de communication qui peuvent joindre toute la population canadienne (5). Comme l'explique le lieutenant-colonel Gilchrist, le ministere de la Sante nationale et du Bien-etre social appuie la creation de ressources sur le soin des enfants, les maladies veneriennes, les maladies d'origine hydrique et alimentaire et la sante mentale (5). Les affiches, le cinema, les livres et la radio sont consideres comme d'importants vehicules. Gilchrist note que les educatrices et educateurs sanitaires qui travaillent pour les services gouvernementaux et les organismes benevoles << sont unanimes a croire en la valeur pedagogique du cinema (5, p. 1416) >>. La technologie de l'epoque est un important vecteur de ces interventions de sante publique, car elle offre de nouvelles modalites qui generalisent l'acces a l'information sanitaire et encouragent la recherche dans le domaine de l'education sanitaire.

Au cours des decennies suivantes, les interventions visant a modifier les comportements gagnent en popularite. On considere que le changement comportemental est principalement l'affaire de l'individu, et que les habitudes de vie sont surtout influencees par les changements dans les connaissances et dans les attitudes. Les theories explicatives, surtout celles de la psychologie, s'imposent dans la conception et l'evaluation des mesures d'intervention en sante publique. Cependant, comme l'ecrit Larry Green dans un article paru en 1984, << les travaux publies sur les interventions en sante s'inspirent principalement de la psychologie, ce qui est peut-etre malheureux (6, p. 215) >>. Citant plusieurs interventions communautaires a grande echelle, dont les etudes de Stanford sur la sante cardiovasculaire, qui ne donnent pas les resultats cliniques escomptes, Green observe que ces interventions mettent l'accent sur l'education du patient plutot que sur les conditions generales pouvant influencer le comportement. Les etudes en question eclairent beaucoup nos connaissances des processus du changement comportemental, mais elles laissent dans l'ombre des questions sur les autres leviers et soutiens des changements dans l'etat de sante. La place importante de la science reductionniste favorise l'emergence d'un ensemble de methodes qui correspondent bien aux questions de recherche sur l'efficacite des interventions comportementales. Ainsi, les paradigmes dominants de la science et de la pratique de la sante publique se renforcent mutuellement et caracterisent une periode ou les preoccupations pour la justice sociale sont en grande mesure eclipsees par les promesses de la science quantitative et des interventions sur l'individu.

Certains commencent pourtant a s'apercevoir que l'education sanitaire et les interventions comportementales n'atteignent pas les plus necessiteux. James Mason, par exemple, note alors qu'il est directeur des Centers for Disease Control : << D'apres mes observations, jusqu'a maintenant la plupart des changements comportementaux que nous avons promus ont implique les gens instruits des classes moyennes et superieures. Si la promotion de la sante est une bonne chose, elle devrait l'etre pour toute la societe et non pas seulement pour le segment qui lui est favorable a priori (7). >> En reponse a ce genre de preoccupations, on se met a diriger les efforts de promotion de la sante vers les conditions environnementales et politiques qui faconnent l'action individuelle, tout en tenant compte des mecanismes du changement collectif. La Charte d'Ottawa pour la promotion de la sante (8) reconnait l'importance de travailler a tous les niveaux des systemes et dans tous les secteurs pour ameliorer la sante et atteindre les populations vulnerables (9). On y souligne la complexite inherente des questions de sante publique, en laissant entendre que les scientifiques doivent allier les paradigmes quantitatif et qualitatif. Les fusions de domaines scientifiques comme l'epidemiologie sociale et de paradigmes de recherche comme la mixite des methodes etendent la nature du questionnement sur les determinants et les interventions en sante publique. Lorsqu'on commence a s'apercevoir que les leviers pour ameliorer la sante des populations englobent aussi ceux qui ciblent les determinants macrosociaux de la sante, et qu'il faut a la fois des approches ascendantes et descendantes pour reduire les inegalites (pour produire l'effet << casse-noisettes (10) >>), les interventions en sante des populations changent de cap et renouent avec le souci de justice sociale qui est a la racine de la sante publique.

L'exemple souvent cite de la lutte contre le tabagisme illustre bien la transformation radicale de nos idees sur la conception et l'evaluation des interventions en sante des populations depuis 50 ans. On observe une evolution constante du programme de travail scientifique; apres avoir considere le tabagisme comme une habitude de vie qu'il faut contrer en intervenant sur les connaissances et sur le changement comportemental, on commence a percevoir les approches antitabac comme des interventions complexes qui fonctionnent dans des systemes evolutifs complexes eux aussi (11). Cette evolution necessite une mise en commun des connaissances de pointe de nombreuses disciplines; on reconnait aussi la longue duree, la coherence et la nature << multiniveau >> des efforts necessaires pour produire des ameliorations significatives dans la sante d'une population et pour en suivre l'evolution. Par consequent, les chercheurs decouvrent de nouvelles pistes, dont l'examen des interventions qui surviennent naturellement (comme les changements dans les politiques), l'etude comparative des normes sociales et de leur influence sur les fumeurs et les decideurs, ou la recherche sur les interventions intergouvernementales et interoperationnelles. Le souci de justice sociale qui sous-tend la lutte contre le tabagisme entre aussi en ligne de compte. On voit, par exemple, que le recul des benefices dans les pays a revenus eleves pousse les cigarettiers a augmenter les ventes de produits du tabac dans les pays a faible revenu et a revenu intermediaire (12). La Convention-cadre pour la lutte antitabac de l'OMS indique les types d'alliances dont on a besoin pour contrer de telles menaces pour la sante a l'echelle planetaire, ce qui pousse aussi les scientifiques a revoir les methodes, les theories et les outils de mesure qui serviront a tirer des enseignements de ces alliances.

Nous avons maintenant une occasion unique, au Canada, de developper la science des interventions en sante des populations. Les conditions prealables d'un tel travail sont reunies grace aux efforts exceptionnels des intervenants en sante publique qui prennent la defense des populations vulnerables et socialement defavorisees (13-16) et des scientifiques qui approfondissent nos connaissances des determinants sociaux et qui jettent les bases de la science toute jeune des interventions en sante des populations (17-20).

Il faut des systemes pour soutenir les changements dans la prestation des services de sante publique et les avancees scientifiques en sante des populations. Le Programme national de recherche et de developpement en matiere de sante a ete le principal soutien de la recherche en sante publique au Canada pendant 30 ans. Il a permis d'asseoir solidement la recherche en sante des populations a cote de la recherche biomedicale, clinique et sur les services de sante lors de la creation des Instituts de recherche en sante du Canada en 2000. L'Institut de la sante publique et des populations a vu le jour sous la direction scientifique du Dr John Frank. Le premier plan strategique de l'Institut visait principalement a etudier, et dans une certaine mesure a influencer, les determinants sociaux et environnementaux au cours de la vie. En vue de provoquer un questionnement scientifique et de renforcer les capacites de recherche en science de la sante des populations, on a appuye d'importantes initiatives comme les Centres de developpement de la recherche et les Programmes des chaires en sante publique appliquee.

Le deuxieme plan strategique de l'Institut, lance recemment, comporte quatre objectifs strategiques : a) mieux comprendre les voies de l'equite en sante, b) etudier l'impact d'interventions complexes en sante des populations sur la sante et l'equite en sante, c) examiner comment les systemes de mise en oeuvre des interventions en sante des populations peuvent accentuer ou attenuer les effets de ces interventions sur la sante ou l'equite en sante, et d) stimuler les innovations theoriques et methodologiques dans la production, la synthese et l'integration des connaissances en sante publique et des populations. L'Institut entend soutenir la science des interventions en sante des populations qui s'attaque aux inegalites en sante.

La nouvelle science des interventions en sante des populations nous oblige a revenir au souci de justice sociale d'ou la sante publique tire ses racines. Des mecanismes de financement qui encouragent les efforts transdisciplinaires et qui rapprochent les paradigmes, les methodes et les mesures sont essentiels. Nous avons besoin des idees les meilleures et les plus brillantes des praticiens, des gestionnaires, des scientifiques, des decideurs et de partenaires communautaires pour combler les inegalites par des interventions en sante publique et dans d'autres secteurs. Pour etre receptifs aux problemes de sante publique et des populations a resoudre, evitons de nous en tenir aux approches familieres avec lesquelles nous sommes a l'aise (21). Nous avons des forces : nous connaissons les determinants sociaux et environnementaux et les macrodeterminants de la sante; nous plongeons nos racines dans la justice sociale; et nous voulons ameliorer la sante globale des populations tout en reduisant les inegalites. Notre defi constant est d'aborder ces questions par une recherche scientifique de pointe et d'une maniere qui profitera en bout de ligne a ceux et celles qui vivent le cote sombre de la defavorisation materielle et sociale. Si les livres d'histoire sur notre siecle expliquent que nous avons integre la justice sociale dans les pratiques et dans la science des interventions en sante des populations au Canada et dans le monde, nous aurons reussi.

REFERENCES

La liste des references se trouve a la page 406.

Affiliations de l'auteur

Professeure, Ecole des sciences infirmieres et Departement d'epidemiologie et de medecine sociale, Universite d'Ottawa, directrice scientifique, Institut de la sante publique et des populations, Instituts de recherche en sante du Canada

Nancy C. Edwards, inf. aut., Ph.D., MACSS