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: ben@harrisroxashealth.com

Twitter: @ben_hr