Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation

Investigating the impact of poverty on mental illness in the UK Biobank using Mendelian randomization

It is unclear whether poverty and mental illness are causally related. Using UK Biobank and Psychiatric Genomic Consortium data, we examined evidence of causal links between poverty and nine mental illnesses (attention deficit and hyperactivity disorder (ADHD), anorexia nervosa, anxiety disorder, autism spectrum disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, post-traumatic stress disorder and schizophrenia). We applied genomic structural equation modelling to derive a poverty common factor from household income, occupational income and social deprivation. Then, using Mendelian randomization, we found evidence that schizophrenia and ADHD causally contribute to poverty, while poverty contributes to major depressive disorder and schizophrenia but decreases the risk of anorexia nervosa. Poverty may also contribute to ADHD, albeit with uncertainty due to unbalanced pleiotropy. The effects of poverty were reduced by approximately 30% when we adjusted for cognitive ability. Further investigations of the bidirectional relationships between poverty and mental illness are warranted, as they may inform efforts to improve mental health for all.

A Scoping Review and Narrative Synthesis Comparing the Constructs of Social Determinants of Health and Social Determinants of Mental Health: Matryoshka or Two Independent Constructs?

Background

Many health research policies invoke the construct of Social Determinants of Health, and more recently the construct of Social Determinants of Mental Health. While frequently referred to in the literature, it is unclear how these constructs relate to each other. Some commentators conceptualise the Determinants of Mental Health as a subgroup of the Determinants of general Health and others describe the Determinants of Mental Health as an autonomous construct. The current review investigates the relationship between both constructs.

Methods

Comprehensive literature searches were conducted for both constructs separately within seven electronic databases. A template analysis was conducted to compare the conceptualisations of the Social Determinants of Health and the Social Determinants of Mental Health.

Results

Of 4250 search results, 50 papers (25 for each construct) fulfilled our inclusion criteria and were incorporated into a narrative synthesis. Discussions of the Social Determinants of both general and Mental Health listed the same determinants. Both constructs were conceptualised on multiple levels and factors. Stress and health behaviour were also described as mediators for both constructs. The constructs differed, however, with respect to two components of their aetiologies and epistemologies. First, the causal mechanisms invoked for the Determinants of general Health followed predominantly direct pathways, in contrast to indirect pathways for the Social Determinants of Mental Health. Second, the Social Determinants of Mental Health were reported to influence mental health mediated through individuals' perceptions and appraisal processes. Appraisal processes were considered of far less relevance in the construct of Social Determinants of Health.

Conclusion

The constructs of Social Determinants of Health and Social Determinants of Mental Health align in many respects but differ on important aetiological and epistemological grounds. Similar social factors are considered important, but whereas physical health conditions are primarily conceptualised to be driven by objective realities, mental health is explained mainly in terms of perception of these realities. This differentiation between physical and mental health is in line with a modern understanding of mind-body-dualism, the naturalistic dualism after Chalmers. Differentiating the Social Determinants of Mental Health from the Social Determinants of Health might bear relevance for policy making and research.

Routinely asking patients about income in primary care: a mixed-methods study

Background

Income is a key social determinant of health, yet it is rare for data on income to be routinely collected and integrated with electronic health records.

Aim

To examine response bias and evaluate patient perspectives of being asked about income in primary care.

Design & setting

Mixed-methods study in a large, multi-site primary care organisation in Toronto, Canada, where patients are asked about income in a routinely administered sociodemographic survey.

Method

Data were examined from the electronic health records of patients who answered at least one question on the survey between December 2013 and March 2016 (n = 14 247). The study compared those who responded to the income question with non-responders. Structured interviews with 27 patients were also conducted.

Results

A total of 10 441 (73%) patients responded to both parts of the income question: ‘What was your total family income before taxes last year?’ and ‘How many people does your income support?’. Female patients, ethnic minorities, caregivers of young children, and older people were less likely to respond. From interviews, many patients were comfortable answering the income question, particularly if they understood the connection between income and health, and believed the data would be used to improve care. Several patients found it difficult to estimate their income or felt the options did not reflect fluctuating financial circumstances.

Conclusion

Many patients will provide data on income in the context of a survey in primary care, but accurately estimating income can be challenging. Future research should compare self-reported income to perceived financial strain. Data on income linked to health records can help identify health inequities and help target anti-poverty interventions.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Women's Participation in Pap Smear Screening in a Developing Country: Evidence for Improving Health Systems

Introduction

Every year about 83,000 women are diagnosed with cervical cancer in the Americas. Latin America and the Caribbean (LAC) has one of the highest incidence and mortality rates from cervical cancer in the world. Although incidence has decreased by half in the last 30 years, cervical cancer remains a public health concern. The detection of precursor lesions through Papanicolaou (Pap) smear remains a critical tool in the context of prevention in Costa Rica and many other LAC countries.

Objective

To determine predictors of participation in Pap smear screening among Costa Rican women, with a special focus on women who have never had a Pap smear or have had a smear 5 or more years ago.

Methods

The data source for this study is the Costa Rican Households National Survey conducted in 2014. This survey is representative at the national, urban/rural zone, and administrative region level. A subsample of women aged 20 to 69 years who responded to the survey's Papanicolaou Module were included in this study (n = 11,709). Statistical analyses were conducted in R-Studio. Statistical significance level was set at 5%. Two multinomial regression models were estimated. The first model aimed to explain the five different categories of cytology use, which were defined according to the last time women had a Pap smear. The second model aimed to explain the five different categories of reasons why women had never had a Pap smear. Both models controlled for age, educational attainment, and marital status.

Results

Young women with high educational attainment were more likely to have never had a cytology. Women with a lower educational attainment, married, or in domestic relationship and of older age had greater odds of having had a cytology 5 or more years ago. Each year increment in age was significantly associated with an increase in the odds of never having a Pap smear because of health care access issues or because of cultural reasons as compared to not having an active sexual life.

Conclusions

Findings can inform public policy targeted to higher risk female populations where access to health services can be improved.

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines—epidemiology, sociology, political economy, and the human rights perspective—to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.

Considering methodological options for reviews of theory: illustrated by a review of theories linking income and health

BACKGROUND

Review of theory is an area of growing methodological advancement. Theoretical reviews are particularly useful where the literature is complex, multi-discipline, or contested. It has been suggested that adopting methods from systematic reviews may help address these challenges. However, the methodological approaches to reviews of theory, including the degree to which systematic review methods can be incorporated, have received little discussion in the literature. We recently employed systematic review methods in a review of theories about the causal relationship between income and health.

METHODS

This article discusses some of the methodological issues we considered in developing the review and offers lessons learnt from our experiences. It examines the stages of a systematic review in relation to how they could be adapted for a review of theory. The issues arising and the approaches taken in the review of theories in income and health are considered, drawing on the approaches of other reviews of theory.

RESULTS

Different approaches to searching were required, including electronic and manual searches, and electronic citation tracking to follow the development of theories. Determining inclusion criteria was an iterative process to ensure that inclusion criteria were specific enough to make the review practical and focused, but not so narrow that key literature was excluded. Involving subject specialists was valuable in the literature searches to ensure principal papers were identified and during the inductive approaches used in synthesis of theories to provide detailed understanding of how theories related to another. Reviews of theory are likely to involve iterations and inductive processes throughout, and some of the concepts and techniques that have been developed for qualitative evidence synthesis can be usefully translated to theoretical reviews of this kind.

CONCLUSIONS

It may be useful at the outset of a review of theory to consider whether the key aim of the review is to scope out theories relating to a particular issue; to conduct in-depth analysis of key theoretical works with the aim of developing new, overarching theories and interpretations; or to combine both these processes in the review. This can help decide the most appropriate methodological approach to take at particular stages of the review.

Considering methodological options for reviews of theory: illustrated by a review of theories linking income and health

BACKGROUND

Review of theory is an area of growing methodological advancement. Theoretical reviews are particularly useful where the literature is complex, multi-discipline, or contested. It has been suggested that adopting methods from systematic reviews may help address these challenges. However, the methodological approaches to reviews of theory, including the degree to which systematic review methods can be incorporated, have received little discussion in the literature. We recently employed systematic review methods in a review of theories about the causal relationship between income and health.

METHODS

This article discusses some of the methodological issues we considered in developing the review and offers lessons learnt from our experiences. It examines the stages of a systematic review in relation to how they could be adapted for a review of theory. The issues arising and the approaches taken in the review of theories in income and health are considered, drawing on the approaches of other reviews of theory.

RESULTS

Different approaches to searching were required, including electronic and manual searches, and electronic citation tracking to follow the development of theories. Determining inclusion criteria was an iterative process to ensure that inclusion criteria were specific enough to make the review practical and focused, but not so narrow that key literature was excluded. Involving subject specialists was valuable in the literature searches to ensure principal papers were identified and during the inductive approaches used in synthesis of theories to provide detailed understanding of how theories related to another. Reviews of theory are likely to involve iterations and inductive processes throughout, and some of the concepts and techniques that have been developed for qualitative evidence synthesis can be usefully translated to theoretical reviews of this kind.

CONCLUSIONS

It may be useful at the outset of a review of theory to consider whether the key aim of the review is to scope out theories relating to a particular issue; to conduct in-depth analysis of key theoretical works with the aim of developing new, overarching theories and interpretations; or to combine both these processes in the review. This can help decide the most appropriate methodological approach to take at particular stages of the review.

Putting the world as classroom: an application of the inequalities imagination model in nursing and health education

This article focuses on the description of an educational initiative, the Interdisciplinary Population Health Project (IPHP) conducted in the academic year of 2006-2007 with a group of nursing and health care students. Inspired by population health, community development, critical pedagogy, and the inequalities imagination model, students participated in diverse educational activities to become immersed in the everyday life of an underserved urban neighborhood. A sample of convenience composed of 158 students was recruited from 4 health disciplines in a Western Canadian university. Data were collected using a modified version of the Parsell and Bligh's Readiness of Health Care Students for Interprofessional Learning Scale. A one group pretest-posttest design was used to assess the outcomes of the IPHP. Paired t tests and one-way analyses of variance were used to compare the responses of students from different academic programs to determine if there were differences across disciplines. Findings suggest that students' readiness to work in interprofessional teams did not significantly change over the course of their participation in the IPHP. However, the inequalities imagination model may be useful to enhance the quality and the effectiveness of fieldwork learning activities as a means of educating culturally and socially conscious nurses and other health care professionals of the future.

Social contextual factors contributing to child and adolescent labor: an ecological analysis

OBJECTIVE: To examine the relationship between social contextual factors and child and adolescent labor. METHODS: Population-based cohort study carried out with 2,512 families living in 23 subareas of a large urban city in Brazil from 2000 to 2002. A random one-stage cluster sampling was used to select families. Data were obtained through individual household interviews using questionnaires. The annual cumulative incidence of child and adolescent labor was estimated for each district. New child and adolescent labor cases were those who had their first job over the two-year follow-up. The annual cumulative incidence of child and adolescent labor was the response variable and predictors were contextual factors such as lack of social support, social deprivation, unstructured family, perceived violence, poor school quality, poor environment conditions, and poor public services. Pearson's correlation and multiple linear regression were used to assess the associations. RESULTS: There were selected 943 families corresponding to 1,326 non-working children and adolescents aged 8 to 17 years. Lack of social support, social deprivation, perceived violence were all positively and individually associated with the annual cumulative incidence of child and adolescent labor. In the multiple linear regression model, however, only lack of social support and perceived violence in the neighborhood were positively associated to child and adolescent labor. No effect was found for poor school quality, poor environment conditions, poor public services or unstructured family. CONCLUSIONS: Poverty reduction programs can reduce the contextual factors associated with child and adolescent labor. Violence reduction programs and strengthening social support at the community level may contribute to reduce CAL.

Inequalities in health and health service utilisation among reproductive age women in St. Petersburg, Russia: a cross-sectional study

BACKGROUND

Russian society has faced dramatic changes in terms of social stratification since the collapse of the Soviet Union. During this time, extensive reforms have taken place in the organisation of health services, including the development of the private sector. Previous studies in Russia have shown a wide gap in mortality between socioeconomic groups. There are just a few studies on health service utilisation in post-Soviet Russia and data on inequality of health service use are limited. The aim of the present study was to analyse health (self-rated health and self-reported chronic diseases) and health care utilisation patterns by socioeconomic status (SES) among reproductive age women in St. Petersburg.

METHODS

The questionnaire survey was conducted in 2004 (n = 1147), with a response rate of 67%. Education and income were used as dimensions of SES. The association between SES and health and use of health services was assessed by logistic regression, adjusting for age.

RESULTS

As expected low SES was associated with poor self-rated health (education: OR = 1.48; personal income: OR = 1.42: family income: OR = 2.31). University education was associated with use of a wider range of outpatient medical services and increased use of the following examinations: Pap smear (age-adjusted OR = 2.06), gynaecological examinations (age-adjusted OR = 1.62) and mammography among older (more than 40 years) women (age-adjusted OR = 1.98). Personal income had similar correlations, but family income was related only to the use of mammography among older women.

CONCLUSIONS

Our study suggests a considerable inequality in health and utilisation of preventive health service among reproductive age women. Therefore, further studies are needed to identify barriers to health promotion resources.

A social ecological conceptual framework for understanding adolescent health literacy in the health education classroom

With the rising concern over chronic health conditions and their prevention and management, health literacy is emerging as an important public health issue. As with the development of other forms of literacy, the ability for students to be able to access, understand, evaluate and communicate health information is a skill best developed during their years of public schooling. Health education curricula offer one approach to develop health literacy, yet little is known about its influence on neither students nor their experiences within an educational context. In this article, we describe our experience applying a social ecological model to investigating the implementation of a health education curriculum in four high schools in British Columbia, Canada. We used the model to guide a conceptual understanding of health literacy, develop research questions, select data collection strategies, and interpret the findings. Reflections and recommendations for using the model are offered.

Organizational capacity for chronic disease prevention: a survey of Canadian public health organizations

BACKGROUND

There are no national data on levels of organizational capacity within the Canadian public health system to reduce the burden of chronic disease.

METHODS

Cross-sectional data were collected in a national survey (October 2004 to April 2005) of all 216 national, provincial and regional-level organizations engaged in chronic disease prevention through primary prevention or healthy lifestyle promotion. Levels of organizational capacity (defined as skills and resources to implement chronic disease prevention programmes), potential determinants of organizational capacity and involvement in chronic disease prevention programming were compared in western, central and eastern Canada and across three types of organizations (formal public health organizations, non-governmental organizations and grouped organizations).

RESULTS

Forty percent of organizations were located in Central Canada. Approximately 50% were formal public health organizations. Levels of skill and involvement were highest for activities that addressed tobacco control and healthy eating; lowest for stress management, social determinants of health and programme evaluation. The few notable differences in skill levels by provincial grouping favoured Central Canada. Resource adequacy was rated low across the country; but was lowest in eastern Canada and among formal public health organizations. Determinants of organizational capacity (organizational supports and partnerships) were highest in central Canada and among grouped organizations.

CONCLUSION

These data provide an evidence base to identify strengths and gaps in organizational capacity and involvement in chronic disease prevention programming in the organizations that comprise the Canadian public health system.

Getting serious about the social determinants of health: new directions for public health workers

International interest in the social determinants of health and their public policy antecedents is increasing. Despite evidence that as compared to other wealthy nations Canada presents a mediocre population health profile and public policy environments increasingly less supportive of health, the Canadian public health gaze is firmly - and narrowly - focused on lifestyle issues of diet, physical activity and tobacco use. Much of this has to do with Canada being identified as being driven by a liberal political economy, a situation shared with a cluster of other developed nations. Reasons for Canada's neglect of structural and public policy issues are explored and ways by which public health workers in Canada and elsewhere can help to shift policymakers and the general public's understandings of the determinants of health are outlined.

Successful Aging: The Role of Physical Activity

Although no amount of physical activity can stop the aging process, a moderate amount of regular exercise can minimize the physiological effects of an otherwise sedentary lifestyle and increase active life expectancy by limiting the development and progression of chronic disease and disabling conditions. Ideally, exercise prescription for older adults should include aerobic, muscle strengthening, and flexibility exercises. In addition, individuals at risk for falling or mobility impairment should also perform specific exercises to improve balance. The intensity and duration of physical activity should be low at the outset for those who are highly deconditioned, are functionally limited, or have chronic conditions affecting their ability to perform physical tasks. Furthermore, the progression of activities should be individualized and tailored to tolerance and preference. Incorporating principles of behavioral change into the design and application of exercise and physical activity programs will increase the likelihood of an individual initiating and maintaining a regular program of exercise and/ or physical activity. Strategies for maintaining physical function and improving overall health of older adults with chronic conditions and disability are discussed. All older adults with and without disabilities should be encouraged to develop a personalized physical activity plan that meets their needs and personal preferences.

Long-term employment and health inequalities in Canadian communities

OBJECTIVES

This study examines the long-term unemployment rate and various health outcomes across Canadian communities to estimate employment-related health inequalities in these communities.

METHODS

The study uses cross-sectional community-level health data along with data on the long-term employment rate for various communities across Canada to quantify health inequalities among these communities. The health outcomes that are considered in this study include total and disease specific mortality rates; health conditions such as high blood pressure, diabetes, injuries, and self rated health; and life expectancies at birth and at age 65. Health inequalities are estimated using the concentration index, which is used to measure health inequalities along socioeconomic dimensions. The concentration index is estimated by a regression of weighted relative health (ill health) over weighted cumulative relative rank of the populations. All the estimates are provided separately for males and females.

RESULTS

The findings of the study support the existence of inequalities in community health outcomes as related to the long-term employment rates in those communities. Communities with lower long term employment rates (higher unemployment rates) have poorer health outcomes in terms of higher mortality rates, worse health conditions, and shorter life expectancies.

CONCLUSION

Health inequalities related to long-term employment have important policy implications. They call for policies that would increase and maintain long term employment rates as part of a broader socioeconomic approach to health. Long term employment ensures income security and prevents the psychosocial experiences leading to mental and physical ill health.

Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's

Compared to other industrialized countries, the U.S. spends most of all on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been already known for decades. For example, the turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada (OECD 2005a, Health data 2005, fourteenth OECD electronic database on health systems, date of release June 2005, last update 04/26/2005). The present study integrates the dispersed literature on spending and health care rankings and adds some statistical analysis to these studies. The evaluation of different factors influencing health care expenditure in the U.S. relative to other countries is restricted to a comparison with Canada. The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 reveals that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol's cost disease and pharmaceutical prices. It is not primarily inefficiency in health care production but the dominant prevalence for free choice and own responsibility that explains the paradox of high expenditure on health care and low ranking on health care indicators.

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.

Path analysis of income, coping and health at the local level in a Canadian context

This article explores the relationships between social, physical, and sociodemographic characteristics and the health status of individuals within four contrasting neighbourhoods in Hamilton, Ontario, using a cross-sectional design. Using data from a telephone survey conducted in 2001 and 2002 of a random sample of adults (1504 respondents, response rate = 60%), path analysis was used to estimate direct and indirect effects of neighbourhood location and satisfaction on health; specifically, the effect of income, coping skills, and neighbourhood satisfaction on self-rated health. Coping was found to be an important mediator between several lifestyle and neighbourhood characteristics and health outcomes. Income and other measures of wealth such as housing tenure, employment, money worries, and lack of money/food bank use were found significant in all health outcomes as well as daily coping ability. Since coping ability was found to be more important for health status than income, policy implications include a greater emphasis on social programmes to assist individuals to manage stress, as well as income support.

Health disparity by neighbourhood income

BACKGROUND

Canadian cities are becoming more segregated by income. As such, investigation is required into the magnitude of health disparity between low-, average- and high-income neighbourhoods in order to quantify the level of health disparity at the scale of an urban city.

METHODS

A cross-sectional ecological study design was used to review all hospital discharges, physician visits, medication utilization, public health information and vital statistics for an entire city by neighbourhood income status. Postal code information was used to identify six existing contiguous residential neighbourhoods in the city of Saskatoon that were defined as low-income cut-off neighbourhoods (N=1 8,228). There were two comparison groups: all other Saskatoon residents (N=184,284) and the five most affluent neighbourhoods in Saskatoon (N=1 6,683).

FINDINGS

Statistically significant differences in health care utilization by neighbourhood income status were observed for suicide attempts, mental disorders, injuries and poisonings, diabetes, chronic obstructive pulmonary disease, coronary heart disease, chlamydia, gonorrhea, hepatitis C, teen birth, low birthweight, infant mortality and all-cause mortality. The rate ratios increased in size when comparing low-income neighbourhoods to high-income neighbourhoods. No clear trend was observed for stroke or cancer.

The state's role in promoting population health: Public health concerns in Canada, USA, UK, and Sweden

Despite the expanding literature on the importance role public policy plays in influencing the broader determinants of the public's health, profound differences exist among jurisdictions in the attention placed by the State - as represented by public health authorities and agencies - upon such activities. In this paper we examine the dominant public health models of Canada, USA, UK, and Sweden. The Canadian and USA public health communities are focused upon individualized approaches to risk management. In contrast, the UK and Swedish public health scenes are more oriented toward broader approaches to health determinants. We argue that the extent to which governments, public health agencies and public health workers concern themselves with public policy approaches to address broader determinants of health depends upon the particular model of health adhered to within each jurisdiction. And whether a health model is adopted depends upon the ideological and political context within which a nation is situated. Canada represents a situation where concerted effort to influence governmental policy directions by the public health community could reap significant benefits.