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The Health Gap: social determinants of health

One of the questions many people have asked in response to our Health Gap campaign is, how can there be a health gap when we have universal healthcare? Doesn’t everyone have equal access to healthcare in Canada?

It’s an excellent question, and one that brings up some vital issues affecting health.

Good health is dependent on much more than seeing a doctor. In fact, by the time someone gets to a doctor’s office, her health has already been affected by factors far beyond the healthcare system. These factors include income, socioeconomic status, education, environment and support network, among others.

These are called social determinants of health, and they can have a profound influence on an individual’s health and well-being. In terms of population health, it has been estimated that social and environmental factors determine more than half of a population's well-being – more than genes, medical care and health behaviours combined.   

Take income, for example. Even with a universal healthcare system that enables people to get medical care without having to worry about paying hospital or doctor’s bills, income still plays a major role in health and accessing healthcare services.

Being able to afford nutritious food and a clean, safe place to live makes people healthier. Someone who cannot afford to pay for her medication is less likely to have a good health outcome. That puts her at much greater risk for ongoing health issues and more severe health problems down the road. While screening programs for conditions such as breast and cervical cancer are available to all Canadian women, a woman needs to have the time, opportunity and transportation to get screened. Those who cannot take time off work or afford the childcare or the transportation costs necessary to attend the appointment are less likely to be screened, putting these women at increased risk for cervical cancer. Most cases of invasive cervical cancer are diagnosed in women who have never or rarely been screened.

One study found that the rate of premature deaths in Winnipeg’s poorest neighbourhoods was 2.5 times as high as the rate in the city’s wealthiest neighbourhoods. The POWER Study showed that in Ontario, people with low incomes were more likely to have unmet healthcare needs, and were more likely to report difficulties accessing care for urgent health issues.

A look at Statistics Canada’s chart showing rates of different health indicators in 2013-14 illustrates how vast the health gap can be between people with low and high incomes, and between those with low versus high education levels.

The effects of social determinants of health are highlighted in Women’s College research, such as Dr. Lorraine Lipscombe’s study on diabetes and income in Ontario. The 2013 study found that despite universal healthcare, people in low-income groups had significantly higher risk of developing diabetes than people in high-income groups. This increased risk was most pronounced in young people, and in women.

Social determinants of health may affect women in different ways than they affect men, and some of them affect more women than men. For example, Statistics Canada’s data show that women tend to have lower incomes than men, and the POWER Study showed that the vast majority (85 per cent) of single-parent households are headed by women. It also found that single-parent households headed by women were twice as likely to have lower incomes than those headed by men, and that one in four people with low incomes had concerns about food security, such as not having enough to eat.

Those are factors that can indicate health gaps. That’s why Women’s College Hospital, Women’s College Research Institute and the Women’s College Hospital Foundation are determined to close those gaps.


Bierman AS, Johns A, Hyndman B, Mitchell C, Degani N, Shack AR, Creatore MI, Lofters AK, Urquia ML, Ahmad F, Khanlou N, Parlette V. Social Determinants of Health and Populations at Risk In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 2: Toronto; 2012.

Bushnik, Tracey. Women in Canada: a gender-based statistical report (seventh edition 2016). Statistics Canada catalogue no. 89-503-X. (see Table 1)

Canadian Task Force on Preventive Healthcare. Recommendations on screening for cervical cancer. CMAJ January 8, 2013 vol. 185 no. 1 http://www.cmaj.ca/content/185/1/35.full

Canadian Task Force on Preventive Health Care Guidelines. Screening for cervical cancer. July 19, 2012. http://canadiantaskforce.ca/ctfphc-guidelines/2013-cervical-cancer/systematic-review/

Zoe Lysy, Gillian L. Booth, Baiju R. Shah, Peter C. Austin, Jin Luo, Lorraine L. Lipscombe. The impact of income on the incidence of diabetes: A population-based study. Diabetes Res Clin Pract. 2013 Mar;99(3):372-9. doi: 10.1016/j.diabres.2012.12.005.

Public Health Agency of Canada. Canadian Best Practices Portal Social Determinants of Health.

N. P. Roos et al., “Potential Savings From Reducing Inequalities in Health,” Canadian Journal of Public Health 95, 6 (2004): pp. 460–464. http://journal.cpha.ca/index.php/cjph/article/view/551/551

Statistics Canada. Tables by subject: Household, family and personal income. Average earnings by sex and work pattern. Last updated 2013.

Tarlov, A.R., Public Policy Frameworks for Improving Population Health. Annals of the New York Academy of Sciences, 1999. 896(SOCIOECONOMIC STATUS AND HEALTH IN INDUSTRIAL NATIONS: SOCIAL, PSYCHOLOGICAL, AND BIOLOGICAL PATHWAYS): p. 281-293.

U.S. Centers for Disease Control and Prevention. Social determinants of health: know what affects health. http://www.cdc.gov/socialdeterminants/

World Health Organization: Social Determinants of Health. http://www.who.int/social_determinants/en/


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