Preventative strategies focusing on healthy eating and physical activity, collectively known as healthy living, have become an important strategy in Canada for combating chronic diseases. Chronic diseases are rising to epidemic proportions in the Canadian population and costs associated with treating them pose a serious threat to the sustainability of the health care system . Addressing the underlying causes of chronic diseases and their inequitable distribution through a preventative health promotion strategy has been acknowledged as an effective way to reverse these trends in both Ontario (ON) and British Columbia (BC). These provinces have recently reformulated their chronic disease prevention strategies as part of Canada's renewal of public health systems, initiated in 2003 as a response to Severe Acute Respiratory Syndrome (SARS). A common strategy that both provinces pursue is to address chronic disease prevention through healthy living initiatives - initiatives that work to promote healthy eating and physical activity as well as address other risk factors such as unhealthy alcohol consumption and tobacco use.
While healthy eating and physical activity were traditionally considered individual lifestyle choices, public health has shifted its perspective in the past several decades to encompass the broader context in which these choices are made. This includes daily living and working conditions that are not conducive to healthy lifestyles as well as broader structural determinants that create inequities between population groups, which together form the social determinants of health. The World Health Organization (WHO) has defined the social determinants of health in the following way:
"The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries" , p.1].
Within a Canadian context, some examples of social determinants of health that have been identified are: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, aboriginal status, gender, race and disability . The social determinants of health have been consistently linked in the literature to chronic diseases such as cardiovascular disease, respiratory diseases, diabetes and cancer in Canada and worldwide; for example, it has been found that low socioeconomic status (SES), often measured by income and education levels, is associated with higher rates of cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus and asthma [4–9]. Research on Canadian cities has shown that people living in low income neighbourhoods experience significantly higher rates of chronic diseases such as diabetes and die several years earlier than their wealthier counterparts . Job insecurity, characterized by unemployment, part-time employment and temporary employment, has been found to result in elevated blood pressure and higher risk of death from cardiovascular disease [11, 12]. Even in a financially secure job, poor working conditions that place high demands on the worker, combined with low support and low job control have been correlated with elevated stress and increased rates of coronary heart diseases as well as higher risk of cardiovascular-specific mortality [13–15]. Nor are these trends colour-blind; racialized groups such as Aboriginal people, new immigrants and minorities of colour consistently earn lower incomes and experience higher rates of chronic disease than North Americans of European descent [16–19].
Canadian policy documents outlining priorities for public health have stressed the importance of an approach that addresses the social determinants of health [20–22]. In a recent high-level United Nations meeting on chronic diseases, the role that the social determinants of health play in chronic disease was recognized, as was the importance of addressing them in disease prevention strategies . A delegation from Canada participated in this meeting, and Canada endorsed the resulting declaration . An approach that effectively engages with the determinants has been suggested in Mikkonen and Raphael's The Social Determinants of Health: The Canadian Facts, and includes policies that offer a higher minimum wage, higher assistance levels for those unable to work, a more progressive taxation structure that redistributes income more fairly, increased unionization, better funding of public education, government regulation of post-secondary institution tuition, stronger legislation on anti-discrimination policies and equal opportunity hiring, a national childcare strategy, strategies to increase the affordability of nutritious food, increased spending on a housing strategy, policies that reduce barriers for refugees and immigrants to practice their professions, and recognizing Aboriginal government authority over a wider range of Aboriginal affairs .
Provincial health policy on chronic disease prevention for BC and ON corresponds to federal priorities. ON has stated in policy documents that the causes of chronic diseases are complex and rooted in broad determinants of health, which encompass lifestyle, socioeconomic, cultural and environmental factors [25, 26]. In order to tackle these upstream causes, the province has decided on a comprehensive, integrated population health approach that is evidence-based [27, 28]. For example, in a policy document on combating obesity, ON committed to a population health approach, which explores health disparities and interactions among the social determinants of health in order to improve the well-being of populations . This approach can also be seen in the Ontario Action Plan for Healthy Eating and Active Living . ON has made efforts to integrate a social determinants of health perspective into the province's public health practice through data and information use guidelines for boards of health of public health units. In the Healthy Eating, Physical Activity and Healthy Weights guidance document, the board of health is instructed to use information on health inequities and the social determinants in order to assess population needs and identify groups at highest risk .
BC shares fundamental similarities with ON in its agreement on the importance of the social determinants of health and the need for an evidence-based, population health approach to chronic disease prevention. In the Model Core Program Paper on chronic disease prevention in BC, the paper's working group identified key principles for successful disease prevention, which includes a focus on social, environmental and economic determinants of health, a "whole of society" approach to population health, and an equity lens to examine health disparities between different groups , p. iv]. The determinants of health are understood to interact with each other in a variety of ways, to compound vulnerabilities for certain sections of the population, and to be modifiable through health public policy and changing social norms. Like ON, BC also takes health disparities between different parts of the population into account, such as between men and women, different ethnic groups, those who identify as Aboriginal, or between people of varying socioeconomic status .
In order to effectively address the social determinants of health, ON and BC have committed to multi-sectoral action that targets the population on a variety of levels. Both BC and ON have stressed the importance of partnerships in the public health model to achieve prevention goals with other levels and sectors of government, NGOs, private industry, service providers, researchers, and communities to name a few [25, 28, 30–32]. These partnerships are considered crucial for real change, given the upstream, wide-ranging impact of the social determinants of health. Both provinces advocate for comprehensive strategies that target the population in diverse environments and at multiple levels [25, 31].
These strategies suggest a socio-ecological approach to healthy eating and active living, a model of health that recognizes the interaction between individuals and their greater environment and its impact on health. In a socio-ecological model, the health behaviours that individuals engage in are impacted by individual factors (such as knowledge, lifestyle choices, and attitudes towards health behaviours), as well as interpersonal, community, organizational and society-level factors [33, 34]. Interventions that follow this model aim to target the population at all these levels and address downstream as well as upstream barriers to healthy living . It is important to note that although the socio-ecological model is different from the social determinants of health approach, it does not preclude attention to the social determinants of health. The social determinants of health can in theory be addressed at multiple levels within the socio-ecological framework, especially those that are more upstream such as at the societal level.
Based on the priorities that are listed above for healthy eating and active living in ON and BC, it would be expected that initiatives in both provinces target the population in diverse settings and at multiple levels, with a majority of initiatives focusing on improving population health through a social determinants of health framework. However, what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.
This study seeks to evaluate healthy living initiatives in BC and ON that focus on healthy eating and physical activity based on their approach to the social determinants of health and health inequities. The authors draw on a political economy of health perspective in order to evaluate the initiatives within their broader social, political and economic context . This implies that the findings related to the data are discussed in relation to the larger discourse around the socioeconomic environment and acknowledge the effect of structures and processes external to the health sector. Recommendations that emerge from the discussion are approached in a similar way.