culture, diversity and health lecture
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Culture, Diversity and Health in Practice
Ben Harris-Roxas
@ben_hr on Twitter
Who am I?
I’ve worked as a social worker and public health researcher.
I consult and also teach at
UNSW, UWS and the University of Newcastle
I’m sorry I can’t be there.
A broader conceptualisation of the causes of health and illness require us to look at
culture, gender and socioeconomic status
• Historical understandings
Miasma model of disease
Environmental causes
The view that health ismerely the absence of
illness and disease
controlling the environmental causes of
disease=
dealing with most public health concerns
or does it?
many of the early gains in public health were linked to improving the environmental
factors that cause disease
the environmental determinants of health
You’ll learn more about these during the course
sanitation voted the most
important medical
advance since 1840.
air, water and soil quality and
toxicity
disease vector control
waste management
Image: ŧĒđĠūŸ®
housing quality and
overcrowding
But the global burden of disease has shifted
Source: WHO Global Burden of Disease 2002Source: WHO Global Burden of Disease 2002
Much of this disease stillhas environmental causes
Many of the new causes of disease seemed to be different in nature to
traditional environmental health concerns
Under-considered factors that powerfully influence health
and health related behaviours
NSW Health (2006) Report of the NSW Chief Health Office, NSW Health: Sydney.http://www.health.nsw.gov.au/public-health/chorep/dia/dia_typehos.htm
The causes of the causes?
Image: Supermietzi
Schroder S. (2007) We Can Do Better: Improving the health of the American people. New England Journal of Medicine, 357, 1221-1228.
What determines health?(A fuzzy pie chart)
Genetics10-25%
Risk Factors20-40%
Opportunities/ Socioeconomic
Status20-30%
Environment & Place5-15%
Health Services15-30%
Dahlgren G, Whitehead M. (1991) Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute of Futures Studies.
The Social Determinants of Health• Stress• Early life• Social exclusion• Work• Unemployment • Social support • Addiction• Food • Transport• The social gradient in health
Health Statistics NSWhealthstats.nsw.gov.au/Indicator/ses_lomidhiavodth
Murphy M et al. (2006) The Widening Gap in Mortality by Educational Level in the Russian Federation, 1980-2001. American Journal of Public Health, 96:1293–99.
cited in
Marmot M. (2007) Achieving Health Equity: From root causes to fair outcomes. Lancet, 370:1153-1163.
Health Impact Assessment and Culture
A combination of procedures, methods and tools by which a policy, program or project may be assessed for its potential and often unanticipated effects on the health of the population and the distribution of these impacts within the population.
Gothenburg Consensus Paper
European Centre for Health Policy (1999) Gothenburg Consensus Paper on Health Impact Assessment: main concepts and suggested approach, WHO Europe: Brussels (adapted by Mahoney & Morgan).
HIA is a developing approach that can help to identify and consider the potential - or actual - health impacts of a proposal on a population. Its primary output is a set of evidence-based recommendations geared to informing the decision making process.
Taylor & Quigley
Taylor L, Quigley R. (2002) Health Impact Assessment: A review of reviews. London: National Health Service, Health Development Agency.
Key Aspects of HIA
• A prospective activity
• Uses a combination of methods
• Looks at intended and unintended impacts
• Looks at the distribution of impacts
• Results in evidence-informed recommendations
When is an HIA done?
Explicit Focus on the Distribution of Impacts
1. Age
2.Gender
3.Socioeconomic status
4.Location
5.Ethnicity and culture
6.Existing levels of health and disability
If you implement the
proposal
These will be the impacts
If you make these changes
These will be the gains
Assessment Recommendations
Health Impact Assessment of the Northern Territory Emergency Response
• HIA conducted by the Australian Indigenous Doctors’ Association
• Partly funded by Fred Hollows Foundation
• Guided by communities in Central Australia and the Top End
• CHETRE was a supporting partner (HIA expertise and data collection)
Overview
• HIA of the Australian Northern Territory Emergency Response
• Detailed discussions with four affected communities (some very remote), a panel of experts and a series of stakeholder interviews
• Took almost 2 years and a large part of this involved building community trust and agreement to recommendations, ethics approval from three panels
• Rethinking dimensions of health
The Dance of LifeThe Dance of Lifeby Professor Helen Milroyby Professor Helen Milroy
Selected indicators of
PhysicalHealth
Psychological Health
SocialHealth
Social Wellbeing
Spirituality Cultural Integrity
• premature mortality
• morbidity• self-reported health
• behavioural risks to health ‑ alcohol and other substance misuse, poor nutrition, smoking, obesity,
• physical inactivity, interpersonal violence use of health care services ‑ preventive and curative services (e.g. immunisation, ear health, and health checks)
• anxiety and depression
• Suicide• Stress• trans-generational trauma, cumulative trauma
• freedom from stigma, shame, discrimination
• freedom from institutionalised racism
• number of new houses built
• number of new houses allocated to Aboriginal community members
• number of houses meeting national quality standards
• number of school places, teachers
• opportunities for employment
• number and location of health services
• number, qualifications, and location of health workforce
• number, location of police & other
• Autonomy – personal and collective
• Opportunities for social inclusion
• Participation in social decision making and social action
• Discrimination• Trust (in other people and in governments and their services, e.g. health, justice and housing)
• recognition and respect for Aboriginal people, world views, knowledge, values and aspirations
• Aboriginal world views incorporated into policy development and implementation
• alienation and despair
• Evidence of having taken back from government agencies certain rights of self-government
• Steps taken to secure Aboriginal title to traditional lands
• Degree of community control of services
• Official cultural facilities to help preserve and enrich cultural lives, including recognition and promotion of Aboriginal languages
The HIA predicts that “ the intended health outcomes.. are unlikely to be
fully achieved through the NTER measures. It predicts that it will leave a negative legacy on psychological and social wellbeing, on the spirituality and cultural integrity of the prescribed communities. However it may be possible to minimise or mitigate these negative impacts if the Australian and NT governments commit to and invest in taking the steps necessary to work in respectful partnerships with Aboriginal leaders and organisations.”
Successes: Did the HIA have an impact?
• No formal change to NTER• But better understanding of issues amongst
all involved• Kept issue of health impacts of NTER on
agenda• Expanded the discussion of impacts
beyond physical and social health to look at social wellbeing, spirituality and cultural integrity
Challenges: The New Plan for Compulsory Income
Management
e.g. Stronger Futures in Bankstown
NTER Intervention recognised SDOH but not the critical forces driving the distribution of SDOH and the values needed to drive the solution:•Democracy•Justice and Equity•Fairness•Transparency•Health•Sustainability
Opportunities: Thinking Differently?
The importance of gender
Mental Illness and GenderAdrianna Mendrek
CIHR Institute of Gender And Health
http://www.youtube.com/watch?v=hI-6Va_T7bw(6 mins)
• What factors determine the differences between men and women in terms of mental illness?– Biological and genetic– Behavioural– Social and cultural
My own clinical experience withdifferential diagnosis and culture
The End of Gender?Johanna Blakley
TED Talk
http://www.youtube.com/watch?v=ZR4LdnFGzPk’(8 mins)
• Is this credible?• What’s wrong with her argument?• What’s right?• What does it tell us about the social
construction of gender?
The Asian Super Highway
What are the potential health impacts?
What information could we use to assess these potential impacts?
These slides are available at
www.slideshare.net/benharrisroxas
Email: [email protected]
Twitter: @ben_hr