Social determinants of health are the social, economic, and environmental factors that influence health and well-being. Social determinants influence health as they define the extent of resources and opportunities that can be made available to individuals, given their social location (Marmot & Wilkinson, 2005; Raphael, 2009). They explain the health disparities observed among individuals and represent an important and continuing public health concern within the health promotion and health services spheres of research.
Although it is often suggested that the responsibility of addressing social determinants of health should be relegated to federal and provincial governments who represent primary funders of healthcare in Canada, as well as to the individual as the bearer of the consequences of health behaviours, it may be unrealistic to look for solutions solely at macro and micro levels. Thinking at a more intermediate or meso-level, as a space where mechanisms of influence account for the macro societal factors and impact proximate individual behaviours, may be a more appropriate approach to tackle social determinants of health, namely through city and municipal initiatives in urban and community spaces.
The cities and municipalities in which we live affect our lives on a daily basis. Cities oversee infrastructure (roads, sidewalks, bike lanes, parks), waste maintenance (composting, recycling, garbage), safety (school crosswalks, police services), employment possibilities, transportation (school buses, city transit), community services (after-school services, boys and girls’ clubs), and social cohesion (festivals, heritage celebrations). Cities and municipalities therefore hold an important intermediate position to influence many social determinants of health in our everyday lives (Schulz, Krieger & Galea, 2002; Schulz & Northridge, 2004). Research led by Amy Schulz emphasizes this logic, as “communities may intervene to ‘push up’ against the fundamental (macro) factors that contribute to health disparities through multiple pathways and at the same time directly influence proximate (micro) factors that lead to both individual and population health and well-being” (Schulz & Northridge, 2004, p. 458).
To illustrate this point, communities with adequate resources may be able to maintain safe sidewalks (an intermediate factor), contributing to increased physical activity (a proximate factor), and decreased rates of obesity and unintentional injuries (health outcomes). Other examples of city initiatives include the implementation of bike lanes, which have been identified as an effective way to increase citizen accessibility to environmentally-friendly mobility and health through physical activity (Parker, Gustat & Rice, 2011). From an ecological perspective, cities and municipalities thus retain strong potential to develop healthy strategies to influence population health and well-being.
International initiatives have recognized the potential influence that cities can have on population health. In 1986, the WHO launched the Healthy Cities Programs, a long-term international development initiative that aims to place population health on the agendas of municipal decision-makers and promote comprehensive local strategies for health protection and sustainable development (World Health Organization, 1998). Initially, the program gathered cities across Europe and North America and today groups more than 1000 cities worldwide. These initiatives are important for comparative purposes across cities and to ensure accountability of municipal activities towards population health.
Cities and municipalities however face a number of limitations when trying to address social determinants of health. For example, not all communities have the same degree of resources, which is particularly the case in developing countries. Furthermore, there may be a weak desire to sustain municipal healthy initiatives by decision-makers and budget holders, as noted by the WHO Healthy City Programs. Additionally, within cities, resources may not be spread and guaranteed in an equitable manner across neighbourhoods. Some initiatives such as bike lanes (Tucker & Manuagh, 2016) as well as supermarkets, may be concentrated in more affluent areas, leading for instance to food deserts in poor neighbourhoods (Institut national de santé publique du Québec, 2013).
City and municipal initiatives have the potential to impact population health through their proximity to a number of social determinants of health. It is easy to reflect on the many ways municipal factors influence many aspects of our daily lives: walking on sidewalks or using bike lanes to get to work, spending an afternoon in the park, finding employment, or buying healthy groceries near your residence. Taking these reflections on the conjecture between cities and social determinants of health towards action will require more interdisciplinary work from pure and social sciences, as well as exploiting ecological perspectives of health and urbanization.
Institut national de santé publique du Québec (2013). Accessibilité géographique aux commerces alimentaires au Québec : analyse de situation et perspectives d’interventions. Direction du développement des individus et des communautés.
Marmot, M. & Wilkinson, R. (2005). Social Determinants of Health. Oxford University Press.
Parker, K. M., Gustat, J., & Rice, J. C. (2011). Installation of bicycle lanes and increased ridership in an urban, mixed-income setting in New Orleans, Louisiana. Journal of physical activity and health, 8(s1), S98-S102.
Raphael, D. (2009). Social Determinants of Health: Canadian Perspectives. Canadian Scholars’ Press.
Schulz, A., Krieger & Galea, 2002. Addressing Social Determinants of Health: Community-Based Participatory Approaches to Research and Practice. Health Education & Behavior. 29 (3): 287-295
Schulz, A. & Northridge, 2004. Social Determinants of Health: Implications for Environmental Health Promotion. Health Education & Behavior. 31 (4): 455-471.
Tucker, B., & Manaugh, K. (2016). Whose Bike Lanes? Access to Safe Cycling Routes
Across Neighborhoods in Rio de Janeiro and Curitiba. In Transportation Research Board 95th Annual Meeting (No. 16-4013).
World Health Organization (1998). Health Promotion Glossary. Division of Health Promotion, Education and Communications (HPR), Health Education and Health Promotion Unit (HEP). Geneva, Switzerland.
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