1. Addressing the Social Determinants of Health: Beyond documenting the Problem Kim Webster, Program Manager, VicHealth Presentation to the Social Justice Initiative Workshop Program: Justice, Equality and the Social Determinants of Health, June 14 2011

2. About VicHealth Independent statutory authority Bipartisan board of governance Focus on behavioural, social and environmental determinants of health Works across sectors (in the environments in which health is produced) Focus on building new evidence, knowledge and practice

3. Presentation overview Introduction to an approach to addressing the social determinants of health developed by VicHealth and its partners Illustrated with program examples – primarily from prevention of violence against women (but also prevention of race based discrimination) Identification of key lessons learned Explores extent to which approach might be transferrable to other settings and issues

4. The preventing violence against women example: definitions and concepts Any act of gender based violence that results or is likely to result in physical, sexual or psychological harm or suffering to women including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life (UN 1996). In the majority of cases the assailant is known to the victim, with a large proportion being a former or current intimate partner. Gender inequality a significant underlying cause.

5. What do we mean by prevention? Intervention (tertiary prevention) Strategies implemented after violence has occurred to deal with the violence, prevent its consequences and prevent reoccurrence/escalation Early intervention (secondary prevention) Targeted to individuals/groups with early signs of violent behaviour or being subject to violence to address those signs or increase skills Primary prevention Strategies to prevent violence before it occurs by making environments safer, building the knowledge and skills of individuals or changing behaviour

6. Why focus on primary prevention? Typically, the health sector’s engagement in social determinants of health (SDOH) has been in: Health service provision/behaviourist health promotion with sensitivity to the influences of SDOH on cause, access and treatment. Intervention responses to social problems so that their health impacts are minimised. Research and evaluation to establish health impacts and benefits. Advocacy to other sectors to act on health grounds.

7. Why focus on primary prevention? Primary prevention involves using health promotion strategies and approaches to address underlying causes (further up the stream, deeper into the iceberg). Indicated when a health problem is: Prevalent (population level problem) Associated with significant harm Preventable – causes of the problem are modifiable A health promotion approach is ‘’fit for purpose” (we return to this later …….) Additional criteria for VicHealth: Areas in which: Primary prevention is not being supported elsewhere There are significant gaps in practice and policy development

8. Health promotion’s contribution: the ecological approach Based on the notion that health/social outcomes are the product of multiple influences. These lie at different levels: individual, organisational, community, societal. Influences at these levels are related to and reinforce one another. Attempts to address the problem require a similarly complex response, i.e. multiple and reinforcing strategies at different levels of influence. Organisation Individual Community Society

9. Health promotion’s contribution: the ecological approach Initially developed by Broffenbrenner to shape responses to child development (1970s) Underpins the Ottawa Charter for Health Promotion and other heath promotion instruments Importance of strategies being based on the evidence Multi disciplinary Cross sector/cross setting ( need to engage with the settings in which health and illness are produced) Used successfully to reduce tobacco use and associated health problems. Can it apply in other areas? Note the ecological approach is NOT a theory Theory and evidence pertaining to specific social phenomena still needed to be assessed to ‘populate’ ecological models.

10. Key steps in establishing the approach: the PVAW example Establishing the case for a primary prevention approach. Development of evidence informed frameworks to guide practice. Formation of practice, research and strategic partnerships (including program governance). Workforce and resource development. Research and evaluation. Achieving sustainability/sustaining change.

11. The PVAW example: Making the case Prevalent – affects 1 in 5 women in the lifetime. Serious – responsible for 8% of the disease burden in Victorian women. Preventable – international consensus that VAW is associated with potentially modifiable risk factors.

12. Program logic What contributes to or causes the problem? IndividualOrganisationalCommunitySocietal What actions will be effective in addressing the problem? To which populations should we target our efforts? Through which settings should we deliver actions? IndividualOrganisationalCommunitySocietal What outcomes do we expect through these actions in the short term (12 months to three years?) IndividualOrganisationalCommunitySocietal What are the long-term benefits we hope to achieve? IndividualOrganisationalCommunitySocietal

13. Health promotion actions Public health strategyActions Direct participation Build individual skills to maintain equal and respectful gender relations Community strengthening Strengthen community capacity to understand the problem and to take action to shift social norms Organisational development Building capacity of organisations to create safe and welcoming environments for women, through policy, program and workforce development Communications and social marketing To raise awareness, create new social norms and shift attitudes Policy development/ legislative reform Policy development, resource allocation and legislative reform to support primary prevention Research and evaluation To increase understanding of violence and assess the effectiveness of prevention strategies.

14. Why a framework? Helps to make sense of complex social phenomena – provides a ‘road map’. Build consensus and understanding among key stakeholders and partners, especially in areas where there are competing paradigms. Helps to identify and define the roles of various partners (settings and populations). Provides a basis for unifying and coordinating effort. Boundary issues – both pushing and defining the boundaries. Provides a logic to follow given the long term nature of the effort required. Helps to ensure accountability and to secure and maintain support.

15. The PVAW example: Relationship between framework and program design Themes for action Promoting equal and respectful relationships between men and women Promoting non-violent social norms Improving access to resources and systems of support. Universal and targeted interventions Need for greater emphasis on men and boys Specific populations at risk/for targeting: Refugee, Indigenous, communities affected by economic disadvantage, young men in violence supportive cultures (some sporting cultures, military/quasi military organizations), children and young people Promising approaches: School based respectful relationships programs, community mobilization, communications and marketing

16. The PVAW example: Establishing the program Governance (expertise, strategy, protection). Workforce and resource development (short course, Everyone Wins). Partnerships for (a) implementation (b) strategic impact. Building research and evaluation capacity. Sustainability – policy partnership, resource and workforce legacy.

17. The PVAW example: Strategies Public health strategyActivity Direct participation programs Program targeted to young couples in the ante-natal period Community strengthening Partnership with two local governments to strengthen their capacity to address violence against women. Research & evaluation Community attitudes survey to raise awareness of the extent of the problem. Communications & marketing Development of a network of individuals to respond to media activity. Advertisement targeted to CALD communities Organisational development Development of the Everyone Wins, a resource to assist sporting clubs to strengthen welcoming and safe environments for women. Advocacy for policy and legislative reform Partnership with Victorian government to support the development of A Right to Respect, achieving an increased resource base to address the issue and a commitment to an evidence informed approach.

18. Key lessons learned Partnership activity – beyond the usual suspects. Challenges associated with this. Importance of establishing the business and economic case for intervention (ACCESS economics and BOD report). Primary prevention in the context of unmet need for tertiary responses. Importance of workforce and resource development. Getting the balance right on prescribing approaches versus community/organisational self determination.

19. Key lessons learned Values driven – dealing with discomfort with the approach (addressing structural causes disrupts the status quo). Acknowledging and dealing with risk. A matter of assessing environmental receptivity AND the evidence (e.g. schools). Top down/bottom up balance. Long term investment – not the quick fix. Duelling paradigms (drawing on the bits of each). Balance between honing the practice and securing strategic change.

20. Transferability Ecological environments within ecological environments. Strategic targets and approaches will differ depending on ecological environment. Transferability of framework capital – extensively used to guide practice. Extent of engagement depends on issue. The health sector clearly does not have the right tools to lead a comprehensive response (versus contribute) to change efforts for all SDOH; i.e. role is limited where solutions to problems lie primarily at the societal level or require high level sector specific expertise (e.g. unemployment where role may be confined to research/advocacy versus full suite).