Introduction

Health is not just confined to the medical realm; it is also fundamentally social, political, organizational, and commercial. Rural health inequities are often seen as outcomes of systemic differences in health that are caused by the unfair distribution of resources, wealth, and power in society (Commission of the Pan American Health Organization on Equity and Inequalities in the Americas, 2019). In Canada, the majority of healthcare practitioners and policy-makers consider the social determinants of health (SDOH) as a foundational framework to promote equity. SDOH include “the conditions in which people are born, grow, live, work and age” (WHO, 2021). However, SDOH alone do not adequately recognize the disparities and inequities that persist in rural and remote regions.

In the past decade, researchers have begun to explore the political, commercial, and corporate determinants of health (e.g. Dawes, 2020; Kickbusch, 2015; Millar, 2013). Policy-makers and corporate stakeholders in legal and regulatory systems often determine, if not dictate, the design and development of the market system and health service programs that impact the health and well-being of citizens. However, in Canada, many health-related strategic plans and policies are based on “urban-centric”, cost-effective, and efficiency-driven planning frameworks which often ignore the needs and unique challenges faced by rural and remote communities. Similarly, stakeholders with corporate and commercial interests have often viewed rural markets as unattractive and not profitable, further escalating the vulnerability and disadvantages of the population.

Although SDOH have received wide acknowledgement and discussion among policymakers and practitioners, less attention has been given to the political, commercial, and corporate determinants of health in the Canadian context (Kickbusch, 2015; Dawes, 2020; Millar, 2013). Health inequities in rural and remote areas matter for reasons of access, equity, and inclusion. Issues include lack of access, ranging from access to physicians to access to drinking water on many First Nations reservesFootnote 1. Additionally, legacies of exclusionary policy that have created and sustained health inequities can be traced back to political decisions that intersect with commercial and corporate determinants. We argue that an integrated determinants of health framework is inextricable from understandings of equity and inclusion, and such a framework will better serve rural and remote areas of the country.

The social, political, commercial, and corporate determinants of rural health equity

According to Statistics Canada, around 17.8% of the Canadian population live in rural areas (Statistics Canada, 2022). Compared to their counterparts in urban settings, rural and remote residents can face unique barriers such as lack of access to higher education, job opportunities, technologies and technology infrastructure (i.e. high-speed internet), comprehensive health services and goods, public funding and resources for sustainable community development. All these disparities are a sum of political, market, and socio-cultural influences over a long period of time.

In Canada, health authorities and practitioners have adopted SDOH in designing and reconfiguring health care services and programs. Previous studies have pointed out that the SDOH have a strong connection to governance and public policy (Manzano & Raphael, 2010). This highlights the central and important role that political structures play in social determinants of health.

In the past decades, new laws, policies, and government programs have been established to increase access to health care and treatments. Kickbusch (2015) notes the importance of analyzing “…how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance” (Kickbusch, 2015, p. 1). In his seminal work on the political determinants of health (PDOH), Dawes (2020) argues for the gravity of combining an understanding of political structures with a critical analysis of health equity actors involved in the creation of new laws in the United States such as the Affordable Care Act. Dawes (2020) examines political actors’ roles in ensuring health equity, and PDOH can refer to every power structure and political decision that creates social structures that impact peoples’ health. PDOH can also refer to access and equity, and even expand to government or partisan decisions that are made or not made regarding resource allocation (e.g. vaccination) as well as coalitions, political actors, and equity advocates.

Closely connected to governance but distinctly different are commercial determinants of health (ComDOH), corporate determinants of health (CorpDOH), and their interconnection with social and political determinants of health that have been a growing focus for scholars (Millar, 2013). The term “commercial determinants of health” initially referred to the recognition of market and non-market activities of harmful commodities (e.g. tobacco, alcohol) as drivers of non-communicable diseases (Kickbusch et al., 2016; Moodie et al., 2013). Some would consider these “lifestyle diseases” (Freudenberg, 2012), “industrial epidemics”, or “profit- or corporate-driven diseases” (Gilmore et al., 2011; Jahiel, 2008) given the prominent involvement of market agents and commercialized goods. However, determinants of health are not limited to the production and consumption of harmful or healthful commodities in the market. Millar (2013) introduced the concept of “corporate determinants of health”, highlighting corporate and organizations’ roles in the health economy. He further connected the new concept with corporate social responsibility and moved beyond the transaction-based discussion (i.e. seller–buyer relationship). For Millar, CorpDOH included employee well-being and the triple bottom line (profit, people, and the planet).

Multiple determinants of health frameworks have been proposed in the past decade, and we observe that these existing frameworks have not addressed the specific health needs and service gaps in rural and remote communities. We therefore conceptualize an integrated determinants of health framework that includes and combines the political, commercial, and corporate determinants with the World Health Organization’s (2021) list of SDOH. This is essential for understanding rural health challenges in rural and remote Canada as outlined in Table 1.

Table 1 Definitions of social, political, corporate, and commercial determinants of health and their relevance and application to rural communities
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Determinants of rural health equity

Rural populations in Canada currently experience a unique set of challenges, with many communities historically disadvantaged due to age, geography, experiences with political systems, and challenges faced by rural and remote Indigenous communities in particular (Wilson et al., 2020). Rural settings can create conditions that exacerbate disparities for ethnic and racial minorities. The proposed integrated determinants of health framework (Fig. 1) allows for inter- and intradisciplinary work that systematically combines aspects of social, political, corporate, and commercial determinants. Centering health equity actors as well as corporate actors who are involved in policymaking processes in Canada, particularly in rural Canada, can help address issues in rural and remote areas. Figure 1 illustrates the ways in which the four sets of determinants of health are connected and overlap. The “personal” and “community” attributes illustrate how rural health equity, or the conditions under which individuals have access to resources that create opportunities for health, is impacted by these factors, as well as the four determinants.

Fig. 1
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Integrated determinants of health framework for rural health equity

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Based on the integrated determinants of health framework, we propose four sets of strategic recommendations to inform policy-makers, practitioners, corporate stakeholders, and community leaders to continue working towards health equity in rural Canada (Table 2). For instance, it is important to diligently develop a rural-oriented health care and market system to ensure rural populations’ equitable access to health services and healthy goods. Creating inclusive and respectful intra- and inter-community networks with key stakeholders and organizations is critical to address health and health care–related challenges. Collaboration and creativity are crucial to build capacity. We recommend that community stakeholders and policy-makers develop an ecosystem to embrace collaboration and innovation. It is important to create a sustainable platform to empower and engage community stakeholders to create adaptive solutions to address opportunities and challenges unique to rural and remote communities.

Table 2 Strategic recommendations for implementing the integrated determinants of health framework
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These recommendations provide an early attempt to strategically adopt the integrated framework to develop a more equitable, inclusive, and adaptive determinants of health framework to address rural health inequity and disparity. Rural health inequities are avoidable, preventable, and unjust. We believe that the integrated determinants of health offer a new blueprint for key stakeholders to make important inroads in managing sustainable systems for health equity in rural and remote Canada.

Conclusion

Inequities and systemic disparities among rural and remote-living residents persist in Canada. Challenges faced by rural and remote communities have been amplified due to new public health protocols and many other socio-political issues. An urgent focus on rural health equity is imperative, with growing recognition that urban-centric policy is not translatable to many areas of Canada, and that comprehensive frameworks are essential in combating health inequity.

The proposed integrated framework illustrates how these complementary sets of determinants encompass health equity principles at their core, and provides a tool to understand the social, political, commercial, and corporate structures that have created our health systems and impact health in rural areas of Canada. The integrated determinants of health framework can be used by public health scholars, political scientists, and interdisciplinary researchers to centre health equity and to highlight the actors and processes involved in rural health.