“Health promotion supports personal and social development through providing information, education for health, and enhancing life skills… Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves”
When I began work for a master's in Health Promotion at Queen's University I was bright-eyed and bushy-tailed, eager to start my research and change the world. Little did I know, I was about to begin what would be the two most grueling years of my life. It was all in the name of this seemingly simple question question: what is health?
After studying the subject for more than six years, I have come to realize you can't fully understand health if you don't understand the social determinants of health (SDOH). The World Health Organization defines the SDOH as "the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life." The SDOH set the stage for either good or poor health. These outcomes are intricately linked to our social system, and the relative advantage and disadvantage experienced across the social and economic hierarchy.
Now to the average teenager, the sources of our health may look something like one of these.
If asked what health was all about when I was 17, I probably would've drawn a similar illustration. It may be amusing at first glance, but when you think about it these simple sketches signify a much bigger problem. What are we teaching these kids? Or more importantly, what aren't we teaching them?
After a thorough review of the then-current Ontario Health Curriculum for grades 9-12, it was obvious why I knew nothing of the SDOH as a teen. There are essentially no health courses in high school that clearly educate students about their influence. This teaching gap was the fuel for my thesis project. After blood, sweat and tears, through countless e-mails, written letters and phone calls to principals and teaching staff, I was finally given access to the local public school board to evaluate grade 11 and 12 students on their perspectives about the social determinants of health.
My suspicions were unsurprisingly confirmed. The health knowledge of my participants reflected the unbalanced curriculum. When asked to make a world map of the determinants they perceived to influence their health, shown in the diagrams above, diet and exercise stole the show. Many students spoke of nutrition and physical activity in relation to body image and weight control. I was relieved to see a few students list "school" or "parents" as health determinants, but when I asked the class to explain why or how education and family environments influence health, you could hear the crickets chirp. They didn't have the first idea. Similar research in the field has come to the same obstacle — youth in general have difficulty explaining the causal pathways between social determinants and health outcomes.
"For some strange reason I was expecting that over 30 years of evidence supporting the SDOH might earn them a spot in the new curriculum."
Since publishing my thesis, an eight year-long review of the Ontario Health Curriculum was finalized. According to the Ontario Ministry of Education's news release, it was "the most extensive curriculum consultation process ever undertaken by the ministry, and involved parents, students, teachers, faculties of education, universities, colleges and numerous stakeholder groups." For the most part, the only value added to the health curriculum was expanding the units on sexual health.
I wonder if they'll teach students that sexual assaults, teen pregnancies and low contraceptive rates are much more likely to occur across communities lower on the income scale. Or that they're also more likely to occur in single-parent families, with unstable living conditions and job insecurity. I assume the answer is 'no'. And I assume they'll not discuss how those same social and environmental circumstances also increase an individual's odds of smoking habits, obesity, chronic disease and substance abuse, among other outcomes.
"We're still supportive of a conventional model of health which attributes outcomes to individual lifestyle choices."
A new health curriculum document released this year discusses the importance for teachers to understand how the social determinants will influence their students' achievement and learning outcomes, but doesn't give any direction to educate the students about why these disparities matter. For some strange reason I was expecting that over 30 years of evidence supporting the SDOH might earn them a spot in the new curriculum. The social determinants have been a significant focus of health research across the globe since the 1980s. Consistent, compelling evidence about the impacts of the SDOH already exists, and we have seen in other countries the incredible impacts of social investment on both health and economic outcomes.
We just aren't there yet. As forward-thinking as many Canadians are, as a nation we're still supportive of a conventional model of health which attributes outcomes to individual lifestyle choices and behavioural factors like exercise, diet, substance abuse and sexual health. Why is there such a huge gap between what we know, and what we do about it? Like many of our elders who still struggle to overcome the social, cultural and religious prejudices of their generation, Canadian society has become stuck in its ways.
Conventionality is one of the most powerful influences on curriculum development. Established social values regarding what is important or true guide educational priorities. It's logical — what we're taught, we place value in, and what we value, we teach. The problem comes when this becomes a cycle that perpetuates a particular worldview. To think critically is just so... well, critical. We need to be open to the possibility that new ideas can be equally true, or even more true than old ones. Remember when we all thought the world was flat?
"The public education system is the biggest 'bang for our buck' as a channel for knowledge translation."
When we accept and teach health as an outcome of individual behaviour or choice we are inherently teaching youth to put all the blame on individuals for their own circumstances. We fault the victims instead of questioning a socioeconomic system which favours a privileged few. It's a system that's cut public funding for education and community development, while funneling money into our healthcare system. Instead of investing in social programs that can reduce the detrimental health effects of inequality, we constrain choice and opportunity for those in need of financial and social support.
If we want to change our perspectives, and the way we make decisions about our own health and the health of our communities, a good start is to reevaluate what we teach, and maximize the positive impacts of education we are providing youth. The public education system is the biggest 'bang for our buck' as a channel for knowledge translation. It targets an age group primed to start developing their own thoughts and ideas, and who will have the potential to effect future change.
They're our future policy and decision makers — today's youth will decide tomorrow's priorities. We need to instill social responsibility in our youth today, if we hope for change tomorrow.
To look at the homeless man on the corner and collectively say, "we haven't taken care of him" instead of "he hasn't taken care of himself" can be a huge shift in the way we see the world. Some societies are there already, but Canada just hasn't made it there yet. And it's largely because we just aren't teaching our young people to think more widely about health.
Born and raised in Kingston, Ontario, Kelly Kenney completed her master's in Health Promotion at Queen's University in 2012, and is currently working for the Ontario Provincial Government as a Senior Housing Advisor. She believes in the power public education, and views curriculum development as the optimal channel for SDH knowledge exchange from the professional and academic worlds to the public.