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RES E A R C H A R T I C L E Open Access
Understanding action on the social determinants
of health: a critical realist analysis of in-depth
interviews with staff of nine Ontario public
health units
Dennis Raphael
*
and Julia Brassolotto
Abstract
Background: Addressing the social determinants of health (SDH) is identified as a role for local public health units
(PHUs) in the province of Ontario. Despite this authorization to do so there is wide variation in PHU practice. In this
article we consider the factors that shape local PHU action on the SDH through a critical realist analysis.
Methods: Interviews with Medical Officers of Health (MOHs) and lead staff from nine PHUs in Ontario identify the
structures and powers that allow PHUs to address the SDH as well as the many factors that either activate or inhibit
these structures and powers.
Results: We found that personal backgrounds and attitudes of MOHs and leading staff people as well as local
jurisdictional characteristics shape whether and how PHUs carry out SDH-related activities.
Conclusions: Action on the SDH is a result of a complex interplay of micro-, meso- and macro-level factors that
requires recognition of the contested nature of public health, presence of Ministry of Health mandates, local
jurisdictional characteristics, and politics. The most effective way to assure PHU action on the SDH is for the Ministry
of Health and Long-Term Care to mandate such activities and develop accountability mechanisms that assure
implementation.
Keywords: Social determinants of health, Public health practice, Critical realist analysis, Canada
Background
Acting on the social determinants of health (SDH) has be-
come a critical concern of the global public health commu-
nity [1]. This concern is evident in numerous statements
and documents provided by international, national and
local public health authorities. Despite this apparent con-
sensus, there is wide variation among national [2] and local
jurisdictions in the implementation of the SDH concept
[3,4]. This variation is not due to a lack of knowledge of
the importance of the SDH or the means of influencing
these SDH in the service of health. Instead, we argue that
this variation has much to do with differing interpretations
of the public health role in addressing the SDH [5]. At the
national level, these interpretations are shaped by the form
of the welfare state, the politics and ideology of governing
authorities, and the extent to which addressing the SDH is
consistent with prevailing societal values [2]. Even when
addressing the SDH is consistent with these societal values,
actual implementation of the SDH concept can vary at the
local level.
In jurisdictions where the SDH are on the national pub-
lic health agenda, key factors that lead to successful imple-
mentation by local authorities include governing through:
1) collaboration; 2) citizen engagement; 3) a mix of regula-
tion and persuasion; 4) independent agencies and expert
bodies and 5) adaptive policies, resilient structures and
foresight [6]. In jurisdictions where there is no national
directive to address the SDH, implementation of the SDH
concept may depend more on the initiative of local public
* Correspondence: draphael@yorku.ca
School of Health Policy and Management, York University, 4700 Keele Street
HNES Building, Toronto, ON M3J 1P3, Canada
© 2015 Raphael and Brassolotto; licensee BioMed Central. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Raphael and Brassolotto BMC Research Notes (2015) 8:105
DOI 10.1186/s13104-015-1064-5
health officials [5]. Only after a willingness to address
these issues is present , can these governance issues be
considered.
Canada is one of the nations where no national directive
exists to address the SDH [7]. In addition, public health is
a provincial responsibility and no province has explicitly
placed the SDH on its broad health policy agenda. As a re-
sult, local public health unit (PHU) action is very much
dependent on public health authorities’ willingness to ad-
dress the SDH. In Ontario – Canada ’smostpopulous
province – the Public Health Standards instruct local
PHUs to address the SDH, but there are no concrete in-
structions for how to do so, nor are there accountability
mechanisms to assure it happens [5,8].
Our analysis of nine local PHUs in Ontario revealed
three general approaches to addressing the SDH in pub-
lic health practic e [9] (Figure 1). Service delivery-oriented
PHUs limited themselves to service-related activities that
responded to SDH-related needs of client s while PHUs
identified as Intersectoral and Community-Focused car-
ried out both service-delivery and community-based
intersectoral activities desi gned to improve services and
stimulate health-promoting public policy. Public Policy/
Public Education PHUs also carried out service delivery
and engaged in policy-related community-based activ-
ities, but additionally assumed a leadership role in carry-
ing out public policy advocacy and public education
about the SDH.
We found that these differences in practice are associ-
ated with the ideological views towards addressing health
inequalities held by Medical Officers of Health (MOH) and
lead staff [5]. For us, an ideology constitutes a system of
ideas that leads to distinct ways of viewing and responding
to a problem, in this case addressing the SDH through
public health practice [5].
MOHs and lead staff of service-oriented units have a
functional and practical view of how SDH inform PHU
practice while those in intersectoral and community-
focused units have an opportunity-based analysis of the
role PHUs can play in addressing the SDH. Finally, those
in units carrying out public policy advocacy and public
education have a structural view of society and saw the
Figure 1 Public health units’ differing approaches to addressing the social determinants of health.
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 2 of 14
PHU role as helping to change societal structures that
marginalize and exclude people. Organizational struc-
tures of PHUs parallel these ideological differences with
greater centralization of SDH activities associated with
more advanced activity [9]. However, our previous work
did not identify how individuals’ personal backgrounds
and attitudes came to shape these ideological views nor
did it consider how local jurisdictional arrangements
and characteristics interacted with these ideological
views to shape PHUs’ SDH-related activities.
In this paper, we extend this work by considering these
issues within a critical realist framework. We do so with
the purpose of elucidating the existing societal structures
and powers that enable SDH-related activities and iden-
tifying factors that either facilitate or prevent the activa-
tion of these structures and powers. We also consider
how institutional factors interact with personal charac-
teristics of MOHs and features of local jurisdictions to
shape the form of SDH activities. This analysis provides
a framework for understanding the differences in SDH
activity among PHUs and contextualizing these practices
within micro-, meso-, and macro-level systems of influ-
ence. It also identifies future research questions and
means by which public health activity addressing the
SDH can be developed and implemented.
Structures and powers with the potential to support
actions on the SDH
A critical realist perspective identifies the real, actual,
and empirical levels of a phenomenon [10]. The real is
the explication of the societal structures and powers that
have the capacity to allow a phenomenon to occur. In
this case, provincial guidelines , MOH responsibilities,
public health association statements and collaborative
working groups are the structures and powers that ap-
pear to allow PHUs to address the SDH. The actual re-
fers to whether these structures and powers are
activated such that a PHU carries out local SDH actions.
The actual therefore considers how the jurisdiction’s
organizational environments and characteristics, the
PHU’s working environment, and the training and prior-
ities of lead staff members either activate or inhibit these
powers. The empirical is what the PHU actually does to
address the SDH; that is, its specific programs, activities,
and initiatives.
The value of the critical realist approach is that it re-
veals that powers may exist unexercised, such that what
is happening does not preclude what can happen. This is
especially important in the Canadian case as existing
structures and powers may allow a range of SDH activ-
ities, yet translation into action is varied. This analysis
can identify the barriers to be surmounted in order to
enable PHU action on the SDH. Fig ure 2 outlines our
analysis of the structures and powers (the real) as well
as the influences that may enable these structures and
processes to become enabled (the actual)intoaction(the
empirical). As such it identifies the issues that that shape
how a PHU comes to be placed in the Figure 1 typology.
The Ontario Pub lic Health Standards mandate ad-
dressing the SDH and Ontario’s Medical Officer of
Health has reported on the need to address the SDH in
two Annual Repo rts [8,11,12]. In addition, the Ministry
of Health and Long-Term Care provides dedicated fund-
ing for two public health nurses for each of the 36 PHUs
to address the SDH. However, no guidance is provided
on how to do this and no accountability mechanisms
exist to assure implementation of SDH activities. Address-
ing the apparent PHU need for direction, the Ontario
Public Health Association participates with the Associ-
ation of Local Public Health Associations in the Joint
Working Group (JWG) on the SDH [3]. Its purpose is to
reduce social and health inequities by promoting local
PHU activities to address the SDH. Despite JWG efforts,
PHUs continue to struggle in this task [3,4].
It appears at the level of the real, PHUs in Ontario –
and the ir MOHs – have the authority to address the
SDH, but policies and practices for doing so are not
mandated [8]. More advanced action on the SDH that
moves beyond traditional service delivery is, however,
sporadic and related to MOHs’ commitments to doing
so. The following sections examine how MOHs and
their lead staff come to develop these commitments and
how these comm itments interact with a jurisdiction’s so-
cial, political, and organizational environments to shape
SDH-related activities. It is these interactions that acti-
vate or do not activate PHU powers into action.
Methods
Details of the study’s methods are provided in greater
depth elsewhere [5]. In brief, we selected a purposive
maximum variation sample of nine PHUs that differed
in the quantity and quality of their SDH-related activity.
Three sets of information were collected and analyzed
from this mix of nine regional and urban PHUs. The
first set of information consisted of SDH-related printed
materials and documents provided by each PHU: mis-
sion statements and reports, organizational charts and
strategic plans, training manuals, and examples of public
education and public advocacy. The second set of infor-
mation consisted of qualitative information collected
through nine structured open-ended interviews – one
for each PHU – with seven MOHs and in two cases, the
Associate MOH. The third set of information came from
nine interviews with the lead staff person(s) responsible
for directing and managing SDH issues for the PHU. The
lead staff persons came from varied educational and pro-
fessional backgrounds. Written informed consent for par-
ticipation in the study was obtained from participants.
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 3 of 14
There were no incentives offered for participation. Ethics
approval was obtained from York University’sEthics
Board, Certificate #2011 - 086.
We conducte d the interviews – the focus of this art-
icle – by telephone. E ach interview la sted 60–90 mi-
nutes. The participants were provided with the
questions in advance. Interviews were digitally recorded
and transcribed. We then analyzed the data in order to
understand how these differences in PHU SDH-related ac-
tivity came about. We applied the constant comparison
method whereby our reading of the transcripts identified
repeating ideas indicative of participants’ understandings
and experiences with the SDH [13,14]. These ideas were
then compared and synthesized to identify key themes. Of
particular interest is the relationship of findings to the typ-
ology of PHUs – service delivery oriented, intersectoral
and community-focused and public advocacy/public edu-
cation – identified in our earlier work.
Results
MOH and lead staff personal backgrounds and experiences
We inquired into the specific influences and experiences
that had come to shape ways of thinking about the SDH
and the public health role in addressing them. We iden-
tified three specific clusters of influences upon partici-
pants’ ways of thinking about the SDH and the public
health role in addressing them: personal upbringings
and backgrounds, educational backgrounds and training ,
and professional experiences.
Personal upbringings and backgrounds
In many ca ses , respondents spoke of how their up-
bringings and backgrounds had come to influence th eir
thinking about societal issues of inequality and in-
equity and, eventually, the SDH. These included being
members of particular classes or racial groups and be-
ing exposed to parent s’ attitudes and values. These
influences occurred prior to their post-secondary edu-
cation and training. In many cases these influences
shaped their choices of post-secondary education and
areas of training. The c oncepts learned during post-
secondary education further reinforced their thinking
about societal issues of inequality and inequity. These
influences were more likely to be spoken of by lead
staff than MOHs.
Figure 2 Potential structures and processes (the real) as well as influences (the actual) upon local public health units approaches
(the empirical) to addressing the social determinants of health.
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 4 of 14
I grew up in a low income household and as an adult
I am able to reflect upon some of the influences in my
life that led me to be a social worker and then to do
community development work. I think I have a
personal understanding of what poverty means
especially when you’re a child growing up with it so
certainly that would be a key influence. – Staff person
I guess the growing up and coming from a blue collar
family. So I’m from the North and my father worked
for a mining company so I would have been aware of
union issues, about mining incidents, about union
versus management kinds of things, and about the
health impacts of shift work, about a single industry
town and the impact when the company downsized
from 30,000 employees to 10,000. – Staff person
I grew up in [Caribbean nation] and my father was
very involved in the church. He was a minister so we
practiced and saw it every day. And when I cam e here
and I heard the term social determinants of health it
just kind of triggered that hey, this is something that
growing up you watched happen, you experienced
firsthand an d this is just a westernized way of framing
and naming an issue that has existed and has
persisted in society all along and really has never
really been addressed in a concerted way to support
people in achieving and getting to their full potential.
– Staff person
I’m not an ethnic majority and certainly, you know,
having encountered, a lot of differen t people, certainly
issues of racism, and a general belief that people from
single parent families, non-white families would be
less successful in life. I think I’ve had more of a
sensitivity to some of these issues than perhaps some
of my peers. – MOH
Respondents make the connection between how their
ways of thinking about society – shaped by their back-
ground and upbringing – influence their thinking about
the SDH. This should not be surprising as writers have
commented on how personal worldviews come to shape
attitudes towa rds health in general and means of pro-
moting health in particular [15-17]. Nonetheless the se
issues are seldom mentioned in the SDH implementa-
tion literature. The next section examines how training
and education build upon these earlier experiences and
influence ways of thinking and acting on the SDH.
Educational background and training
MOHs are first trained as physicians and usually
complete a residency in Public Health and Preventive
Medicine. All of the nine MOHs in this study followed
this path and referred to this post-medical school training
as Community Medicine, the title used for this specialty
until five years ago. (Some MOHs in Ontario have not
completed a Public Health and Preventive residency but
instead one in Family Medicine, which may be supple-
mented by a one year Masters of Public Health. This alter-
native path usually occurs in rural public health units and,
as mentioned, did not apply to participants in this study).
It is not surprising that medical training was not seen
as a source of SDH concepts but it is rather striking that
none of the MOHs mentioned exposure to SDH con-
cepts during their community medicine training as it is
the one medical speciality where such concepts should
be found. This is not to say that these concepts were not
there, but that it did not resonate for them or influence
their thinking about the SDH.
In two cases, MOHs emphasized their learning about the
SDH through personal readin g spurred on by the increasing
profile of SDH in the public health sphere. These MOHs
were associated with service delivery-oriented PHUs.
I’ve read the SDH book edited by Sir Michael
Marmot. I have read the executive summary of the
WHO’s Commission on the Social Determinants of
Health. I have read all of the Senate Standing
Committee’s reports on population health. And I’ve
read other literature that has come my way to get my
head around the SDH. – MOH
I’m a Medical Officer of Health. If I don’t think about
it I’m not doing my job for one, right? Secondly I did
actually do a lot of reading on this fairly recently
because I wrote a chapter for a book that the group is
bringing out on social epidemiology so I took that
occasion to do a lot of reading. – MOH
As will be shown below, in many cases lead staff respon-
dents indicated their educational training shaped their
views on the SDH. For the MOHs however, such expo-
sures seemed to be sporadic and were a result of the indi-
viduals’ personal interest in moving beyond basic medical
studies by taking courses in sociology and philosophy.
I think certainly in my medical education I wa s
exposed t o some people who had a sociological
approach to medicine. I remember some of the
elective courses and the courses that most medical
students don’t care about much. History of medicine
and sociology of medicine were of particular interest to
me and I had some influential teachers at that stage. But
in medical school you’re being streamed into a clinical
discipline, fairly directly so those ways of thinking about
health really re-emerged later on after I’dbeeninclinical
training for a number of years. – MOH
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 5 of 14
SeveraloftheMOHswhoweremoreactiveinad-
dressing the SDH spoke of exposure to Aboriginal
health issues during medical training as shaping their
ways of thinking. These experiences combined with
their residency in Community Medicine (now called
Public Health and Preventive Medicine) to set their path
of concern with the SDH.
I worked on a reserve in Western Canada when I was a
medical student in a nursing station and saw 12 people
in a one room house. You know, the community I was
in had one of the highest TB rates in the world. So it’s
something I’ve lived with for a long time so I see it
everywhere. In local public health work here you can’t
name a public health issue that doesn’t have a social
determinants of health overlay. – MOH
As part of the residency I probably spent in total
almost six months working on Native reserves. So
what everybody talks about with Native reserves it
kind of slays me how so many people have no idea
what is going on up there or they’re totally shocked
when they see the stories. I guess because I would
have lived it and seen firsthand what basically is
happening. – MOH
It appears that many of those who hold the most power
in directing PHU activities are provided with a limited aca-
demic understanding of the SDH. While education can be
very influential, lived experience and/or direct exposure
may be more powerful motivators for change.
For lead staff, training in community nutrition, nursing,
social work, and international development studies shaped
their thinking about the SDH. Many of them were first ex-
posed to the SDH during their undergraduate degrees in
nursing, social work, and nutrition. All of the lead staff
had graduate degrees and these were in community nutri-
tion, social work and public policy, international develop-
ment, political science, health promotion, epidemiology,
and nursing. It is noteworthy that respondents suggested
that their ability to do community-based and policy-
related SDH work was a result of their graduate studies in
non-public health areas.
And from my perspective I think it’s really from the
educational preparation that I’ve had, which has been
primarily from a nursing background perspective and
obviously with a focus and experience and education
within the public health field. As well I would say it’s
my own experience from a personal perspective in
growing up and exposures to different environments,
family setting, community experiences that have
contributed to my perspective and how I think about
determinant s of health at this time. – Staff person
I think certainly a background in international
development introduced a lot of the concepts of the
importance of some of the bigger influences on
people’s lives, the political and economic influences
shaping lives. – Staff person
But I think when I went for a graduate degree in
social welfare and focused on community
development work I really started to understand. I did
placements at the housing health centre. I started to
understand how everything is connected so you can’t
really look at one service or one program in isolation of
how it interacts with everything else going on in
people’s lives. I came to understand how as government
we make things difficult for people by not connecting
the things that will help together. – Staff person
So my Masters is more broadly in organization and
leadership transformation and community
development, but my research project for my Masters
was around the social determinants of health and
public health. – Staff person
Interestingly, lead staff – espe cially those employed in
intersectoral and community-focused and public advo-
cacy/public education PHUs – came from areas out side
of public health. They saw their exposure to br oader
concepts common to social work, political science, social
welfare and internation al development as enabling them
to contribute to PHU’
s work on the SDH.
Education and professional training contribute to ways
of thinking about the SDH. For MOHs, the curriculum
content in medical school provided little concerning
these issues. It was the specific exposure to Aboriginal
health issues of some MOHs, either during medical
school or community placements and community medi-
cine residency, that shaped their views. Staff people cited
their undergraduate and graduate training and their per-
sonal experiences as having influenced their views on
the SDH, but it is of note that so many staff with man-
agerial responsibilities for addressing SDH come from
outside traditional public health training. They became
involved in PHU action on the SDH because the PHUs
saw their varied backgrounds as having the potential to
contribute to SDH activities.
Professional experiences
Once employed, some responden ts indicated their work-
place milieus shaped their thinking about the SDH. Lead
staff members entering PHUs where the SDH were treated
as a priority expanded their activities to working with coa-
litions to address broader issues of the health and well-
being of communities. In some of these cases respondents
moved from the social services and municipal government
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 6 of 14
sectors into public health. This was a result of increasing
PHU concern with SDH and a realization that those with
training and experience in disciplines with a broader per-
spective on community and policy would be able to con-
tribute to SDH-related activities.
Well, I’m actually a social worker so I came to the
social dete rminants of health long before I came to
public health. I used to work at the social planning
council and it was the Lalonde Report that first
stimulated talk about social determinants of health in
Ontario. The social planning council had tried to
incorporate social determinants of health into the
work it was doing and tried to connect what at that
time was our district health council was doing in the
health sphere with what we were doing in the social
sphere. – Staff person
When this opportunity came up and I applied for the
job it was for a nutrition and physical activity health
promoter position. At the end of the interview I was
simply asked ‘Is there anything else you would like to
add?’ and I went on my little rant about frustrations at
being unable to address social and economic
conditions. And little did I know that that was
actually very up and coming, front and foremost in
the mind of the MOH and that was where the unit
was moving. – Staff person
In one case, a staff member was required to narrow
their approaches as a result of the PHU approach to-
wards the SDH.
I think in public health we’re still very much looking
at the behaviour even though we understand other
factors influence determinants of health. When you
look at our outcomes, when you look at our
indicators, you look at what we’re accountable for, I
think we’re still what motivates us is the behaviour,
the behaviours. – Staff person
Professional experiences can combine with back-
grounds and previous experiences to either enhance or
limit the likelihood of acting on SDH issues. The follow-
ing se ction explores these findings.
Our findings reveal that the manner in which a public
health unit addresses the SDH is clearly associated with
the personal characteristics and backgrounds of MOHs
and the lead staff they hire to carry out the se activities.
MOHs associated with service delivery-oriented PHUs
had little to say about their personal experiences and back-
grounds. In contrast, MOHs whose units are identified as
intersectoral and community-focused and/or public pol-
icy/public advocacy spoke of how their thinking about the
SDHhavebeeninfluencedbytheirownvaluesandex-
periences, particularly working with Aboriginal commu-
nities in Canada . MOH’s associated with public policy/
public advocacy are distinguished by their structural
analysis of SDH issues and their be lief that PHUs need
to take a leadership role in shifting how society think s
about these issues.
Another finding is the extent to which lead staff
people responsible for addressing the SDH in the PHUs
carrying out intersectoral and community-focused and
public education/public policy advocacy came from dis-
ciplines outside the traditional public health arena. This
is particularly noteworthy in the case of the two PHUs
which have taken on a public education/public policy
advocacy stance. In these cases, the lead staff people
have graduate degrees in political science and social
work. In two of the three PHUs that, to date, have lim-
ited themselves to service delivery-oriented SDH, the
lead staff people have been trained in public health epi-
demiology and health promotion.
This does not necessarily imply their educational back-
grounds determine PHU approach, but it does suggest
that their employment is consistent with their training.
It is particularly interesting to note that lead staff mem-
bers in the intersectoral and community-focused PHUs
are all trained in community-related activity such as
community nutrition and social work and social policy.
For these PHUs, their experience in community action
has been applied in SDH-related activities. In terms of
our critical realist approach, personal exposure and lived
experience of structural inequities can be seen as activat-
ing features that enable the structures and processes as-
sociated with the real to become the actual. These
activating features result in more advanced SDH-related
activities, the empirical.
Jurisdictional characteristics and SDH activities
PHUs in Ontario differ on a range of charact eristics that
can potentially affect how they approach the SDH. As
shown in Figure 2, PHUs differ on whether they are re-
gional versus urban, the geography of their jurisdiction,
organization of the Board of Health that directs their ac-
tivities, populations they serve, local politics, and the pres-
ence of community organizations with concerns related to
the SDH. These categories emerged during inquiries into
barriers and supports for their SDH-related activities. We
found that many of these issues related to a jurisdiction’s
categorization as either “regional” or “urban”.
Regional vs. urban jurisdiction – with a relationship
to geography
Among the nine PHUs involved in the study, three are
urban units and six are regional. Regional PHUs are re-
sponsible for a wider geographical area that usually
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 7 of 14
contains one or two small cities and a number of smaller
towns and villages. Urban PHUs are responsible for a sin-
gle city. We found that regional PHUs are faced with chal-
lenges related to the nature of their Board of Health, wider
geography, and fewer community agencies concerned with
SDH-related issues. Local politics can also create chal-
lenges. We outline some of these challenges below.
Regional PHUs are faced with a challenge in that they
are required to address public health issues across a
range of communities. This usually involves significant
geographical areas and a number of more or less au-
tonomous communities. In contrast, urban PHUs have
the ability to focus on a single administrative district in
relation to their public health work.
Keeping in mind too that our catchment area is really
quite huge geographically so I think within our
catchment we have between 16 and 19 municipalities.
– Staff person
You’re trying to do things that are right for [name of
the region] but we have over ten local municipalities
and all these municipalities see themselves as separate
and distinct. So I’d say there ’s a sense of
disconne ction and the geography does not serve as
well. We have three separate United Ways. So we
have a United Way for what’s called […] and area, one
that’s[…] and district, and I believe there’s one in […]
But to me that speaks to this disconnect. We really
should have one United Way that really focuses on
the entire community. But politically we also have,
you know, more than ten separate mayors who have
their own agenda, trying to meet their own
community needs. – Staff person
Regional PHUs see themselves as facing larger geo-
graphical challenges such as coordinating and partnering
with multiple and siloed services, serving communi ties
with different demographics, and working with a large
number of politicians – who may not necessarily work
easily with one another. Urban PHUs did not mention
these types of challenges. These challenges can act as
barriers to SDH activity because interse ctoral collabor-
ation is more difficult to coordinate. Action on the SDH
requires support and buy-in from a greater number of
decision-makers, and the number of jurisdiction s served
by the PHU and their variation in social needs can make
it challenging to establish SDH-related priorities.
Board of health organization
The Ontario public health system consists of 36 local
public health unit s of which 22 are autonomous bodies
with the remainder having municipal – usually regional
– councils acting as the Board of Health. Autonomous
Boards of Health usually consist of both elected repre-
sentatives and members of the public. Regional PHUs
usually do not have a distinct Board of Health associated
with the PHU and this is the case for the six regional
PHUs in this study. Members of these Boards may be
elected politicians or municipal officials and these re-
gional PHUs report more challenges to addressing the
SDH than do the urban units with autonomous Boards.
In some of the urban PHUs, the Board has stimulated
SDH activity. In most other cases, efforts have been
undertaken to build support among Board members for
SDH-related activities. These efforts have faced mixed
results. The first two quotations below are related to
having a regional Board, the next three to having an au-
tonomous one.
We have a regional system so our 31 councillors form
our Board of Health and most of them were elected
on a man date of fiscal responsibility and restraint. So
when we raise these issues, we’ve changed the way
that we’ve presented social determinants of health
issues. We don’t use the term social determinants of
health really anymore. We’ve moved on to using
language like making […] a healthy place to live,
work , grow and play regardless of your income or
your education lev el, trying t o come about it that
way. Because addressing the social determinants is
seen as sometimes superfluous as compared to some
of the other things we do such as restaurant
inspections. – MOH
And the other thing I would add and this is one of the
advantages of being part of a regional government,
and that is the strong links with our social community
service department and the other departments that
are around the table such as planning for example.
And, and not to mention finance department, public
works. By being the head of the health department I
get to sit on the senior, what’s called the management
committee team for […]. We meet. Meetings can be
scheduled weekly. We don’t meet all the time weekly
but because of that, you know, your line about what
do we see as our role, so for example affordable
housing and childcare spaces, that is one of the
primary mandates of one of my sister departments if I
can use that word, social and community services. So
yes, we’ve got an interest in it but I don’t have to start
trying to beat my head against the wall to get
somebody thinking about it because I have another
department whose primary mandate, one could argue
is a significant or more so than even public health in
dealing with truly some of the upstream issues if
you’re looking at basic housing and childcare a s well
as income support. – MOH
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 8 of 14
So ours is an independent Boar d of Health. If you
look at public health structures some are part of
regional government and others are not and so ours is
not. It’s an independent corporation but the
membership is made up overwhelmingly by municipal
politicians appointed by our local municipalities in
keeping with a regulation of the Health Protection
and Promotion Act. I think it’s actually a superb
Board. I’ve worked for a number of Boards in the past.
I think this is probably the best Board I’ve ever
worked with. I think they’re very supportive of our
mandate, very interested in our mission, and our
strategic planning has participated readily in strategic
planning and are very supportive of social
determinant s as being a priority within strate gic
planning and has supported advocacy positions we’ve
brought to them before for their support. – MOH
Having a Board that is strongly committed is a big help.
They are pushing me as much as I’m supporting them
and, you know, we have been pushed for example on
the issue of racialization. A member of the Board has
been very outspoken on this and has asked for a
number of reports and that’s helped me to move that
agenda forward inside the organization. – MOH
Our Board of Health has been supportive. When we
presented our position statement and did a
presentation to them on what the social determinants
of health were, there was unanimous acceptance of
that position statement and an agreement that’s the
work we should be doing. – MOH
Yet even in this respect, there is not a perfect relation-
ship between having a regional Board of Health and dif-
ficulty in gaining support for a SDH agenda. One MOH
from a regional PHU with an autonomous Board states:
Well the Board has been supportive, you know. The
chair of our Board is the executive director of the […]
and she’s definitely supportive of this work and is an
eloquent speaker and certainly able to share these
messages with the rest of the Board. The Board hasn’t
been in the way or they’ve been supportive all the way
along. - MOH
Generally then, PHUs dealing with regional boards
face greater challenges associated with having to deal
with the entire regional government rather than an au-
tonomous Board of Health.
Local politics
Local politics play a role in influencing SDH-related PHU
activity. Canada has been experiencing a drift towards
conservative market-oriented public policies for some
time now. Some PHUs are located in areas that tradition-
ally vote for the social democratic New Democratic Party
at the provincial and federal levels and have like-minded
elected officials at the local level (municipal elections are
non-partisan). Other PHUs are located in areas that elect
more conservative candidates at all levels. Generally, re-
gional PHUs are seen by interviewees as having more con-
servative local politics thereby, experiencing more
challenges to addressing the SDH. Politically left-leaning
jurisdictions are seen as more supportive of a PHU ad-
dressing the SDH as it is consistent with their more col-
lective approach to addressing social issues. One staff
member from an SDH-active PHU stated:
And we certainly don’t feel [the conservative drift]
locally. As you know, we’ve always been a NDP
stronghold in many cases. – Staff person
In PHUs where SDH activity is occurring, local politics
requires sensitivity to the framing of issues. MOHs and
staff need to frame SDH arguments in a form acceptable
to elected representatives and the public.
I don’t think for us [the conservative drift] has had
much of an influence, we continue to be involved to
the same degree at the grassroots level. We continue
to do the same activities. We might look for different
opportunities or do things in a slightly different way
but we continue to just work away at the local level.
– Staff person.
If the government changes in the next provincial
election we’ll have conservative governments at all
three levels which probably will not help. We’ve had
discussions about that internally. You know, how does
that affect what we try to do in terms of advocacy? I
think there are still some opportunities for progress,
but it certainly isn’t as optimistic as if we were facing
different leadership. – MOH
In other PHUs, local politics are seen a s a barrier to
carrying out SDH-related activities.
The other big thing is, so, we live in a very
conservative, a politically conservative environment,
and we are considered from a profile we are
considered a very valued and credible resource in our
community. And we need to maintain that
relationship forever as a credible and reliable
resource. So then when we start looking at public
campaigns and speaking out in a more unified voice
we have to do it in a way that doesn’t jeopardize those
strategic alliances. – Staff person
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 9 of 14
Ijustthinkgiventhatweareamoreconservative
society t hat leads to greater em pha sis being placed on
the individual as opposed to collectives. So when
you’re taking an a dvocacy position you need to be
realistic. A significant vocal minority of Canadians –
and given our electoral system – amajorityofour
elected officials – are fairly c ool towards providing
approaches concerned with colle ctives a s opposed to
individuals. Does it make public health officials more
skittish with respect to approaching councils, Boards,
MPPs and so forth? I think that all depends. Nobody
wants to take forward proposals that you know are dead
on arrival and the more conservative a particular setting
is the more likely it is that these sorts of approaches are
dead on arrival and, you know, you may be reluctant to
take things forward. – MOH
These quotations suggest that local politics indeed play
a role in PHUs addressing the SDH. It suggests a need
in many cases to create messages that frame these issues
as being concerned with promoting the health and well-
being of the community, rather than explicitly express-
ing SDH issues in political terms. Politics is therefore a
potentially activating or inhibiting factor allowing the
real to become the actual in regards to SDH-related
PHU activity.
Community organizations
PHUs differ in the extent to which they are able to inter-
act with a range of community organizations. Urban
public health units are more likely to have strong net-
works of civil society organizations that are concerned
with a range of SDH. Regional PHUs are generally in ju-
risdictions with fewer community organizations.
I think we have great partners out in the community.
We’ve taking on an issue like food security. We’ve
worked closely with [name of agency] and [name of
agency] and had collaborative efficacy and
collaborative program development. So that’s a great
support to have partne rs in the community. – MOH
The community partners have been key. We do have a
community that elects people that are generally open to
these ideas so political support has been pretty key. I
don’t think we would have been able to move or
convince our Board to do some things we have if they
weren’t open to the ideas to begin with. – MOH
[Name of person] came to [name of city] and did a
presentation to some of our healthy lifestyle staff in
2003. And when he was a keynote speaker at the
Social Planning Council Annual General Meeting, the
chair of our Board of Health was in attendance. So
then the Board requested some follow up and a few
months later there was a presentation made to the
Board of Health on the social determinants. That
introduced the process and we did another
presentation to the Board of Health a few months
later and then they unanimously passed
recomme ndations endorsing the Toronto Charter for
a Healthy Canada. That was the underpinnings of the
organizational support and it built from there with
our social determinants of health comm ittee and then
a staff position. But it was an important catalyst to get
the discussion going. – Staff Person
Well we had a mayor who was elected in 2006 who
formed an action committee on poverty reduction. So
the mayor and a couple of the councillors were very
interested and active in this area and took a
leadership role so that certainly helped to bring the
community together. It gave the health unit and our
staff lots of opportunities to participate in the
municipal process. So also there are really active
social justice groups in [name of city] and very active
community agencies and because [name of city] is
fairly small the agencies really develop quite close and
personal trusting relationships among themselves.
It’s quite ea sy and accepted for multi-agencies just
to call each other and get together and discuss an
idea or a gap and try and brainstorm around how
they can do something about it and then put it into
place. It’s not really a big bureaucratic issue to get
some of these initiatives started and that’s been
really helpful. – Staff person
So I bet you we share the same barriers with [name of
other regions] and all those places, right? These are
rapidly growing communities and civil society is
grossly under-develope d, right? I bet [name of city]
has 50 times as many NGOs as we do. It’s just not
that kind of place. There’s very, very little out there.
And if you do get an NGO it’ll either be serving a
tiny, tiny sector or it’ll be, you know, completely
inadequate to serve a large population. And particularly
in the ethno-cultural community it’s just dozens and
dozens of little tiny organizations, not necessarily
cooperating with each other. And you’ll find that
education and social services are as under-funded as
health services. So it’s very difficult. You think of [name
of city] and everything is the opposite. – MOH
In short, local environments and the presence of sup-
portive agencies have an influence upon PHUs’ SDH ac-
tivities. The increasingly popular concept of intersectoral
action has come to prominence as a means of promoting
SDH-related activity but has tended to focus narrowly
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 10 of 14
on health-related interventions by various governmental
departments rather than the kinds of broader relation-
ships with various civil society organizations identified
here [18]. The findings here suggest attention be di-
rected toward how these collaborations may represent,
in part, a building of social movement s whose aims ex-
tend beyond SDH concepts to a broader concern with
societal social justice and equity [19].
These relationships do not come naturally. Whether the
local environment is seen as supportive or not, the PHU
has to work actively to build trust with local agencies.
The public health unit has spent a lot of time
nurturing relationships with all of those groups and so
most of the relationships we have with organizations
are based in a history that is not specifically the social
determinant s of health. For example with the YMCA,
the background would be around things like physical
activity and having shared space with them with
childcare centres and early learning centres. Other
groups such as the United Way have relationships
with the unit by way of one of the associate medical
officers of health and our medical officer chairing
United Way campaigns. And I think that that has
been really positive because of the long time
trajectory around addressing the social determinants
of health with its ups and downs allow you to weather
those downs together and it doesn’t mean an end to
the relationship. I also think that in the past we’ve had
some very strong political leaders who have been
extremely supportive of social determinants of health
issues. – MOH
Jurisdictional characteristics therefore also play a role
in whether and how PHUs address the SDH. In urban
PHUs the geography and type of Board facilitates move-
ment from the real to the actual while the opposite is
the case for regional PHUs. MOHs and staff are sensitive
to local politics and ascribe an influence to this as well.
Discussion
The characteristics associated with how PHUs approach
the SDH interact in complex ways. It is difficult to iso-
late the specific characteristics of jurisdictions that shape
the PHUs activities, but after reviewing our findings we
identify five distinctive groupings that illustrate how jur-
isdictional characteristics that have been discussed in the
previous section are associated with PHU SDH ap-
proach. Table 1 provides a summary of these findings.
Public policy and public education
The two PHUs carrying out public policy advocacy and
public education differ in that one is an urban unit while
the other is regional. They are similar in that they report
numerous supports to their SDH-related activities and
these supports are primarily located in an urban centre
(the regional unit has a significant city in its jurisdic-
tion). Their supports include a responsive political envir-
onment and a network of supportive community
agencies working on SDH-related activities. Agency sup-
ports are a result of the PHU reaching out to these agen-
cies and providing both leadership and support for a
SDH agenda.
In both cases, the stand-alone Board of Health consists
of both elected officials and citizen members and has been
supportive of the PHUs’ SDH thrust. Again, this is the re-
sult of the PHU expending significant efforts to educate
Board members. The primary driver of SDH activity is the
MOH and lead staff’s belief in the value of this agenda.
They then identify the means to facilitate this thrust. The
PHUs exercise central control over their SDH efforts with
evaluation and accountability across the unit being the re-
sponsibility of specific assigned lead staff.
For those who see public health as having a central
role in changing how a society thinks about promoting
health through action on societal structures and pro-
cesses, these PHUs provide a working model of how to
go about it.
Intersectoral and community-focused PHUs
Two of the intersectoral and community-focused PHUs
are urban units and two are regional. In the urban units,
the two cities have a well-established network of social
service and support agencies. The PHUs reach out to
these agencies and provides support, but have made an
explicit decision not to provide leadership in public pol-
icy advocacy and public education for these networks.
This appears primarily to be a reflection of the ideo-
logical belie fs of the MOH and lead staff who take an
opportunity-based approach where SDH are seen as lim-
iting people’s opportunities that can best be addressed
though community-based work and not public health.
Both of the urban, intersectoral and community-
focused PHUs report to a stand-alone Board of Health
that is supportive of the SDH-approach. At the City
Council level, one unit reports a positive supportive en-
vironment while the other repor ts a more mixed picture.
However, it appears these PHUs have not taken full advan-
tage of this support to move towards a leadership role in
public policy advocacy and public education regarding the
SDH, as is the case for the two public policy and public
education PHUs described above. These PHUs do not ex-
ercise centralized control over SDH-related initiatives but
devolve responsibility for implementation and account-
ability to PHU departments or units.
The two regional PHU s are spread over a larger area that
includes smaller cities, towns, and villages. The network of
social service and support agencies is less developed than
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 11 of 14
those of the urban PHUs. Intersectoral work is facilitated
at the regional government level where the Board of Health
consists solely of elected representatives. There is some
participation with regional networks concerned with pro-
moting the region’s well-being. The political environment
appears to be more conservative than in the urban centres.
Nevertheless, the PHUs are pushing forward with their
agenda and seeking to build support. These two PHUs also
do not exercise centralized control and devolve responsi-
bility and accountability to PHU departments or units.
These PHUs provide a model by which public health
can collaborate with existing sectors to promote health
through reform of existing institutions and agency ef-
forts. The approach has the potential to influence public
policy change, but it does not place public health at the
vanguard of such efforts.
Service delivery-oriented PHUs
These three PHUs are all regionally organized with re-
sponsibilities for numerous smaller cities, towns, and vil-
lages. The network of social service and support
agencies is generally less developed and the PHUs have
not reached out to social service and support agencies to
develop a SDH agenda. These PHUs operate within a
generally conservative political environment. The Board
of Health is generally absen t from discussions about
SDH work. The MOHs have a functional view of the
role that PHUs should play in addressing the SDH,
which is very much a reflection of their personal back-
grounds, experiences, and ideologies, as well as the juris-
dictional environments in which they operate.
These PHUs provide a model of the traditional ap-
proach to providing health-relate d services and pro-
grams to disadvantaged populations. It recognizes the
important role that the SDH play in shaping health and
the importance of providing these disadvantaged sectors
with responsive and appropriate supports and services.
Conclusions
These findings suggest that translating the potential for
SDH-related activities into action is very much a result
of the complex interaction of ideological beliefs held by
the MOH influenced by local jurisdictional features. In
terms of our critical realist approach, at the level of the
real there would appear to be sanction for PHUs in
Ontario to address the SDH in a variety of ways.
Table 1 Groupings related to local structures and environments and PHUs’ SDH activity
Public Education and Public Advocacy
Regional (1 PHU) Urban (1 PHU)
Urban centre within larger geographical area. Urban jurisdiction.
Well developed network of social service and support agencies
within the urban centre.
Well developed network of social service and support agencies.
PHU reaches out to these agencies and provides both leadership
and support.
PHU reaches out to these agencies and provides both leadership and support.
Progressive political environment. Progressive political environment.
Board of Health provides both impetus and support for
SDH-related action.
Board of Health provides both impetus and support for SDH-related action.
Intersectoral and Community Focused
Urban (2 PHUs) Regional (2 PHUs)
Urban jurisdiction. Regional jurisdiction spread over larger area.
Well-developed network of social service and support agencies. Undeveloped network of social service and support agencies.
PHU reaches out to these agencies and provides support for
intersectoral action.
Works primarily within regional government structures and participates
with networks.
Progressive political environment. Conservative political environment.
Board of Health is supportive but does not provide impetus for action. Board of Health consists of entire regional council and has been
brought along on issues.
Regional/Service Delivery-Oriented (3 PHUs)
Regional jurisdiction spread over larger area.
Undeveloped network of social service and support agencies.
PHU has not yet reached out to social service and support agencies.
Conservative political environment.
Board of Health consists of entire regional council and has not been concerned with these issues.
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 12 of 14
However, this sanction is ambiguous at best as there is no
requirement or exposition of how PHUs are supposed to
do so. Additionally, since MOHs are hired by local juris-
dictional authorities, it is understandable that many would
not want to go out on a limb in carrying out activities that
will not be understood or well received by such author-
ities. As noted earlier, no senior level of government in
Canada – Federal, provincial, or territorial – has made ad-
dressing the SDH an explicit goal of their ruling agenda.
Mandating the addressing of the SDH by local authorities
in a variety of ways in the Public Health Standards might
go a long way in strengthening the structures and pro-
cesses available for addressing the SDH by local PHUs.
At the level of the actual, facilitators of action include:
an autonomous Board, being an urban jurisdiction, a so-
cially progressive political environment, and presence of
supportive community agencies. However, carrying out
SDH-related public health activities requires a firm belief
that such efforts are useful and a commitment to carry
out the work necessary to see this work brought to fru-
ition. This process will involve educating members of the
Board of Health and local elected representatives, reaching
out to agencies whose mandate is related to various SDH,
and a willingness to help shift the status quo.
We have suggested elsewhere that the ideological be-
liefs held by MOH are the primary drivers of SDH-
related action and findings from this analysis do not dis-
pute this [5]. This article adds to our earlier work by re-
vealing that the features that can activate existing
structures and processes to address SDH issues require
aligning a range of factors that include personal charac-
teristics and jurisdictional features. These efforts may be
more difficult in PHUs that are responsible for a region
as opposed to a city and in more politically conservative
than progressive areas. Attempts to meaningfully address
the SDH will only take place when the PHU indicates a
commitment to carry out these SDH activities – or such
activities are institutionalized within the organization.
The current situation, whereby initiative on the part of
local PHUs is the primary driver of SDH-related activities,
is a reflection of the lack of guidelines by the Ministry of
Health and Long-Term Care on how to carry out these ac-
tivities. As one MOH states:
The Public Health Standards themselves have been a
bit of a barrier because they weren’t specific in
requiring specific actions and accountability. A sort of
check for what every health unit should do in terms
of social determinants. As a result, the other items are
much more specific in the Public Health Stan dards,
and this forces units to attend to those and they’re so
busy meeting some of those standards and objectives
that it’s hard for them to really make progress
upstream on those issues. – MOH
As a result , it is not surpri sing that PHU action is a
function of the micro- and meso-le vel characteristics
we have identified. It appears that the easiest way to fa-
cilitate the activation of structures and processes ( the
real) into action (the actual) that produces the kinds of
SDH activities we have described (the empir ical)isfor
the Ministry of Health and Long- Term Care to mandate
such action at the macro-level. This view would not be
inconsistent with the principle that local public health
efforts should be context-driven and tailored to meet
local needs , but it would ser ve to shift these local ef-
forts to a higher plane of action. If such a mandate
came about , the issues we have identified would be the
factors that PHUs need to take into account a s they
carry out t heir required mandate of addressing the
SDH.
From a research perspective, there is a need to extend
inquiry into exploration of the micro-level (individual at-
titudes and perspectives), meso- (jurisdictional and
organizational) and macro-le vel (Ministry and provincial
government man dates and dire ctives) influences that
shape SDH action at the provincial level. How do civil
servants at Ministries of Health and related ministries
understand these issues? How do they feel bound by
elected officials and public understandings of these is-
sues? What do they see as means of moving the SDH
agenda forward?
The generality of our findings is limited by our focus
on the Ontario scene. PHUs in Ontario operate on a
governance model that is very different from the rest of
Canada, where public health is integrated into regional-
ized health authorities. As such there is no official dis-
tinction between ‘regional’ and ‘urban’ jurisdictions in
those places and PHU activity is more likely to be linked
to broader health policy considerations than may be the
case in Ontario. Whether these features make it more
likely that SDH-related issues will be addressed by local
PHUs is unclear and deserves inquiry.
Our findings indicate that action on the SDH by local
PHUs is not a simple result of knowledge creation and
dissemination. It is a result of a complex interplay of
micro-, meso- and m acro-level factors that involves
recognition of the contested nature of public health,
Ministry of Health mandates , and politics. A critical
realist perspective recognizes these complexities and
should be a useful approach for understanding these
issues.
Abbreviations
JWG: Joint Working Group on the Social Determinants of Health;
MOH: Medical Officers of Health; PHU: Public Health Unit; SDH: Social
Determinants of Health.
Competing interests
The authors declare that they have no competing interests.
Raphael and Brassolotto BMC Research Notes (2015) 8:105 Page 13 of 14
Authors’ contributions
DR conceived of the study and wrote the first draft of this paper. JB rewrote
the first draft, providing the final text. JB and DR jointly carried out the
interviews, analyzed the data, and identified themes. DR is a professor of
public policy and management at York University in Toronto. He studies
how the distribution of the social determinants of health in a jurisdiction is
shaped by the political economy of a nation and the balance of power and
influence among differing societal sectors. JB is a postdoctoral fellow in the
School of Health Policy and Management at York University. She conducts
research in the areas of feminist political economy, care work, and the social
determinants of health. Her current work focuses on the intersections of
formal and informal care provision for seniors with chronic health conditions.
Both authors read and approved the final manuscript.
Acknowledgments
Funding for this project was provided by a York University Faculty of Health
small research grant.
Received: 8 October 2014 Accepted: 17 March 2015
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