Determinants of health

Social Class and Health The Inverse Care Law

"The availability of good medical care tends to vary inversely with the need of the population served" (Tudor Hart 1971). - In areas with most sickness and death (greatest health needs), general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas; and hospital doctors shoulder heavier case loads with less staff and equipment more obsolete buildings and suffer recurrent crises ijn the availability of beds and replacement staff

Evidence for Gender Differences in Health

"Women get sick and men die" - women live on average 6-7 years longer than men and yet women record higher levels of morbidity in both chronic and acute illness over 60% of the GP consultations involve women over 60% of hospital beds are occupied by women - Admissions to psychiatric hospitals are 3 times higher for women than for men

Gender and Health Diseases with substantially different prevalence rates by gender

Coronary-heart diseases Mental diseases (depression; fear disturbances; emotional disorders); Metabolic disorders; Obesity; Cancer Sexually transmitted diseases; Autoimmune diseases - diabetes, multiple sclerosis Osteoporosis; Arthritis; Trauma, suicides Drug dependencies Eating disorders anorexia and bulimia; biorexia

Gender & Health: Gender - a biological or a social factor

Gender versus Biological sex Sex (male/female) is biologically given Gender (feminine/masculine) is socially acquired Cervical, breast or prostate cancer - related to Biological sex. Lung cancer; Esophagus cancer, Substance abuse (tobacco, alcohol, illegal drugs); Sexually-transmitted infections (STIs) e.g. HIV/AIDS; Injuries from risk- taking behaviour; Body image and eating disorders - related to Gender (social roles of men and women)

Four general groups of health determinants

Geneticandbiologicalfactors Lifestylefactors Environmental factors (incl. socio-economic) Healthcareservices

Smoking prevalence trends

In high income countries now declining; Increasing in developing countries Largest share of tobacco-related deaths in China (50- 60% male smokers). Smoking prevalence decrease (smoking cessation) during the last 2-3 decades in North America and Western and Northern European countries (especially in North European men) has lead to decreasing trends in lung cancer incidence and mortality rates.

Examples of Social Class Differences in Health

Life expectancy: A man in social class I is likely to live around 7 years longer than a man in social class V; Infant mortality: A child born into social class V is twice as likely to die before the age of 15 than a child into social class I; Long-standing illness: There are twice as many reports of long standing illness among men and women from social class V, compared to social class I. Low birth weight is the most important predictor of death in the first month of life and this is clearly class-related with two-thirds of all babies under 2500g are born by mothers in social class V.

Social Class & Health Social class differences in health (the "social class gradient in health";

People from lower social classes experience more sickness and ill health; Marmot's "Whitehall studies" of British civil servants document the existence of a health gradient by civil service rank: Those living in lower income areas were much more likely to develop coronary heart disease than those in well-off neighbourhoods. These effects remained strong even after controlling for tobacco use, level of physical activity, presence of hypertension or diabetes, level of cholesterol and BMI.

The lower the income, the greater the risk of premature illness and death Why?

Reduced access to other health promoting determinants (healthy food, adequate housing, clothing, transportation, green space/recreation, etc.) Greater exposure to health risks (auto injuries, water and air pollution, greater population density); Increased stress and loss of control; Greater marginalization, less sense of social cohesion.

Gender and Health Suicides and external causes for death

Suicidal attempts - more prevalent in women Suicidal deaths - higher incidence in men. Suicidal mortality rates much higher in men compared to women (3.5 times) with the exception to some rural areas in India and China. Mortality rates from trauma and external causes - almost 3 times higher in men.

Unhealthy diet There are convincing evidences that

The consumption of high levels of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity compared to low-energy foods such as fruits and vegetables. Saturated fat and trans-fat increase the risk of coronary heart disease and that replacement with monosaturated and polyunsaturated fat reduces the risk. The risk of type 2 diabetes is directly associated with consumption of saturated fat and trans-fat and inversely associated with polyunsaturated fat from vegetable sources. ↑ high energy density ↓ low nutritional value ↑ high accessibility of unhealthy food at lower price

Race, Culture and Health

The mortality rate of a given race or culture is dependent upon the country they live in. This suggests that social norms and attitudes about a race may be an important determinant of health. We can't change biological differences associated with race but we can change how people of certain races and cultures are valued and supported within our society. We can work toward creating greater cohesion across cultures.

Unemployment and Health

The unemployed report higher rates of mental ill health including depression, anxiety, sleep disturbance; Suicide rates are twice as higher among the unemployed; The death rates among the unemployed are at least 20% higher than expected after adjustment for social class and age; The unemployed have higher rates of bronchitis, ischemic heart disease, and TB than the employed; Over 60% of the unemployed people smoke compared to 30% of the employed.

Tobacco use stats

There are currently about 1 billion smokers in the world. Risks to health from tobacco use result not only from direct consumption of tobacco but also from exposure to second-hand smoke. Almost 6 million people die from tobacco use each year, accounting for 6% of all female and 12% of all male deaths in the world. Of these deaths, just over 600 000 are attributable to second-hand smoke exposure among non-smokers and more than 5 million to direct tobacco use. By 2030, annual tobacco-related deaths are projected to increase to 10 million, accounting for 10% of all deaths in that year.

Socio-economic status and Health

There is a very strong correlation between socio-economic status and health. There is a continual gradient, from the top to the bottom of the socioeconomic ladder, relating status to health - the "SES Gradient". Lower socioeconomic status - linked to: chronic stress, heart disease, ulcers, type 2 diabetes, rheumatoid arthritis, certain types of cancer, and premature aging, etc

The Health Iceberg

Visible above the waterline - the state of health we are concerned with; Just below the surface are the known risk factors for this health issue; What sets up these risk factors? Lifestyles. But the real question is what creates these life styles - the psycho-socio-cultural environment.

Employment and Health

Work It determines income levels; It affects self esteem; The type of employment may itself directly affect health (occupational health risks); Poverty associated with unemployment contributes to poor health. - Example: high demands and low control over job decisions - contributing to job stress and cardiovascular risk

Environment percentage

(17-20%)

Genetic and biological factors percentage

(18-22%)

Life style percentage

(49-53%)

Healthcare services percentage

(8-10%)

Muscle dysmorphia or bigorexia

- A body dismorphic disorder in which a person becomes obsessed with the idea that he is not muscular enough - those who suffer from muscle dysmorphia (mostly men): - tend to hold delusions that they are skinny or too small but are often above average in musculature - are preoccupied with thoughts concerning appearance especially musculature - selectively focus their attention on perceived defect (too skinny body, underweight, etc.) - ignore information that their body image is not consistent with reality - Muscle dysmorphia influences persons mood often causing depression or feelings of disgust. this is often connected with constant comparing of a persons body to unattainable ideal

Gender and Health: Cancer

- Cancer of the stomach: 2 times higher incidence in men Cancer of the colon: higher incidence in men (1.5 times) - Cancer of the esophagus (2 to 10 higher rates in men) Cancer of the liver - 2 - 3 times higher in men

Education & Health

- Less educated people tend to have poorer health than better educated people - female education and literacy is strongly associated with lower infant mortality rate People with higher education have better access to healthy physical and social environments, smoke less, eat better, and are more physically active. Education is also related to income and social status Education equips people with knowledge and problem solving skills, increases sense of control and mastery;

Tobacco use consequences

- Proven relationship between 20 different diseases - Enormous toll of deaths from lung cancer, other cancers, chronic pulmonary disease, coronary heart disease, stroke. - smoking is estimated to cause about 71% of all lung cancer deaths, 42% of chronic respiratory disease and nearly 10% of cardiovascular disease. Smoking is also an important risk factor for communicable diseases such as tuberculosis and lower respiratory infections. Smoking during pregnancy increases the risk for low birth weight babies; Smoking and sudden infant death syndrome Smoking and male impotency. - Smoking affects all organs in the human organism

Unhealthy diet

- The amount of dietary salt consumed is an important determinant of blood pressure levels and overall cardiovascular risk and stroke. A population salt intake of less than 5 grams per person per day is recommended by WHO for the prevention of cardiovascular disease. However, data from various countries indicate that most populations are consuming much more salt than this. It is estimated that decreasing dietary salt intake from the current global levels of 9-12 grams per day - to the recommended level of 5 grams per day - would have a major impact on reducing blood pressure and cardiovascular disease.

Marital Status & Health

- The marriage (or stable continuous partnership) is good for health (for most people) - People living along (single people, the widowed, elderly living by themselves) tend to have poorer health

Health Inequalities Within Countries

- There is a 33 years gap in male life expectancy between asians in westchester co and american indians in south dakota

Abdominal (Apple-shaped) obesity

- Typical for men; - Related to higher risk for CHD and diabetes

What disease risks are (causally) attribu- table to higher than optimal salt intakes

- Unmediated Stomach cancer - Mediated by effect on blood pressure; - increased ischemic heart disease increased stroke increased other vascular disease

Breast Cancer Screening and Mortality Rates

- in many countries in northern and western europe and north america - clear trends of decreasing mortality of breast cancer - due to effective screening programmes and early diagnosis and treatment. - for the period of 1989-2006 the mortality rates for breast cancer in the UK have decreased by 34% - in other european countries (e.g. Bulgaria) - the mortality rates for breast cancer are high and still increasing

Social Class and Health Social class classification

- indicates the way of life and living standards experienced by groups of different social class - it correlates with other aspects of social position such as income, housing, education, working and living environments

Income and Health Income is a major determinant

- of standard of living - variations in ill health and premature mortality reflect differences in levels of income and material deprivation

Religion and Health

- religion - affects some health related behaviours such as eating habits, smoking, alcohol consumption, sexual behaviour, contraceptive use, healthcare utilization, etc examples: - jehovah witnesses and transplantation or blood transfusion - lower incidence of cervical cancer in muslim women

Gender and Health Gender differences in relation to:

- risk factors exposure - access to health information and health services - health services utilization - illness and its social significance - perceived differently by men and women - attitudes for protecting and promoting personal health and the health of the rest of the family members - different consequences of impaired health

Place of Residence and Health

- rural versus urban - urban slums versus desirable urban areas - poor country versus rich country - infant mortality rates and maternal mortality rates much higher in the developing and least developed countries - life expectancy - much higher in the developed world - north south divide - mortality rates increase steadily moving from the southeast to the northwest and north south divide is present for many chronic diseases

How low income can affect health?

-Inadequate or unfit housing; -lack of food, lack of education; Stress and lack of social support - health damaging behaviours such as smoking or drinking or giving children sweets are a way of helping people to cope with the demands of disadvantage poverty reduces peoples choices of a healthier life style

Example: Breast Cancer Screening and Mortality Rates Effective screening programmes

-early diagnosis and treatment - lower mortality and higher survival rates.

Insufficient physical activity Globally

31% of adults aged 15 years or older were insufficiently active (men 28% and women 34%) in 2008. In all WHO regions, men were more active than women. The prevalence of insufficient physical activity rose according to the level of country income.

Health Iceberg State of health

Heart disease

Socio-economic Inequalities in health

It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent

Men's health behaviours

Men appear to leave intervention until later Fewer men go to visit their GP Those men that do, go less often Many men don't see the need for help, or have more difficulty asking for it

Healthcare Services as Determinants of Health

Quality, accessibility and timeliness of health care

Gender - Men

Role of provider Occupational accidents Risky behaviour to 'prove' masculinity Less contact with health services/too embarrassed to seek help May equate illness with weakness

Lifestyle Factors examples

Smoking, alcohol and drug abuse; low physical activity; poor unhealthy diet; psychosocial stress; etc.

Hip and thigh (Peer-shaped) obesity

Typical for women; - Lower risk for CHD and diabetes

Environmental Factors Unfavourable factors of the environment

air, drinking water and soil pollution; other physical and chemical factors of the environment; risk factors from the working environment;

Lifestyle Factors related to

all socially significant chronic non- communicable diseases: coronary heart disease (CHD), stroke; most neoplasms; diabetes; chronic respiratory disease; injuries, obesity, chronic liver diseases and cirrhosis, etc. 70-80% of all deaths in the developed and 40% of all deaths in the developing countries are related to lifestyle factors that are potentially manageable and avoidable.

Harmful use of alcohol There is a direct relationship between higher levels of alcohol consumption

and rising risk of some cancers, liver diseases and cardiovascular diseases. The relationship between alcohol consumption and ischaemic heart and cerebrovascular diseases is complex. It depends on both the amount and the pattern of alcohol consumption.

Lifestyle factors Most NCDs

are strongly associated and causally linked with four particular behaviours (lifestyle factors): tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol. In terms of attributable deaths, the leading NCD risk factor globally is raised blood pressure (to which 13% of global deaths are attributed), followed by tobacco use (9%), raised blood glucose (6%), physical inactivity (6%), and overweight and obesity (5%)

Harmful use of alcohol There is a high level of variation in alcohol consumption

around the world. On average, global adult per capita consumption was estimated at 6.0 litres of pure alcohol in 2008. Adult per capita consumption was highest in the European Region (12.2 litres) and lowest in the Eastern Mediterranean Region (0.6 litres). In general, abstention rates are lower and per capita consumption is higher in the countries with higher income. The adult per capita consumption in upper-middle- and high-income countries (around 10 litres) was more than double the level of low- and lower-middle- income countries (around 3 to 4 litres).

Genetic and Biological Factors Related to

chromosome diseases; mental retardation; diabetes; atherosclerosis; blood hypertension; ischemic heart disease; some neoplasms (breast cancer, colorectal cancer); mental disorders, etc.

Lifestyle factors related to

coronary heart disease (CHD), stroke; most neoplasms; diabetes; chronic respiratory disease; injuries; obesity; chronic liver diseases, cirrhosis, etc.

The harmful use of alcohol is a major risk

factor for premature deaths and disabilities in the world (3rd leading risk factor as a cause of DALYs). Hazardous and harmful drinking was responsible for 2.3 million deaths worldwide in 2004 ( 3.8% of all deaths in the world). An estimated 4.5% of the global burden of disease - as measured in DALYs - is caused by harmful use of alcohol.

Health Iceberg Contributing factors

genetics, high BP, high cholest., obesity

Insufficient physical activity high income countries...

had more than double the prevalence compared to low-income countries for both men and women, with 41% of men and 48% of women being insufficiently physically active in high-income countries as compared to 18% of men and 21% of women in low-income countries. These data may be explained by increased work and transport-related physical activity for both men and women in the low -and lower-middle-income countries. The increased automation of work and other aspects of life in higher-income countries is a likely determinant of insufficient physical activity.

Insufficient physical activity People who are insufficiently physically active

have a 20-30% increased risk of all-cause mortality compared to those who engage in at least 30 minutes of moderate intensity physical activity on most days of the week. Participation in 150 minutes of moderate physical activity each week (or equivalent) is estimated to reduce the risk of ischaemic heart disease by approximately 30%, the risk of diabetes by 27%, and the risk of breast and colon cancer by 21-25%. Additionally, physical activity lowers the risk of stroke, hypertension, depression, obesity, osteoporosis. It is a key determinant of energy expenditure and thus fundamental to energy balance and weight control.

Gender and Health Women

higher recorded morbidity lower mortality compared to men In more developed countries women have higher morbidity rates men - have higher mortality rates; Women have higher Life expectancy at birth, but spend greater part of their life with illness and disability. - Women - primary responsibility for household an domestic labour - look after family - responsible for familys health are more like to be carers - familiar with health issues - more likely to report own ill health

Insufficient physical activity is the fourth leading risk factor for mortality

in the world (after high blood pressure, tobacco use and high blood glucose). Approximately 3.2 million deaths and 32.1 million DALYs (representing about 5.5% of all deaths and 2.1% of global DALYs) each year are attributable to insufficient physical activity).

Environmental factors Socio-economic factors

income, social status; unemployment; education; expenditure; housing and living conditions; social support or exclusion (homeless, unemployed, refugees, immigrants in general have poor health, etc.);

Lifestyle factors 70-80%...

of all deaths in the developed and 40% of all deaths in the developing countries are related to lifestyle factors that are potentially manageable and avoidable.

Healthcare Services as Determinants of Health effectiveness

of preventive interventions; coverage with immunization programmes; coverage with family planning programmes, contraceptive use; effectiveness of the screening programmes; organisation and efficiency of health services for pregnant, women and children, for chronically ill patients, for elderly, etc.

Health iceberg. Psycho social cultural and environmental determinants

poor access to services/ information; no support network/resources; poor self image; poor local facilities

Health iceberg lifestyle behaviours

smoking, alcohol, stress inactivity, poor diet

Unhealthy diet The World Cancer Research Fund has estimated

that 27-39% of the main cancers can be prevented by improving diet, physical activity and body composition. Approximately 16 million (1.0%) DALYs and 1.7 million (2.8%) of deaths worldwide are attributable to low fruit and vegetable consumption. Adequate consumption of fruit and vegetables reduces the risk for cardiovascular diseases, stomach cancer and colorectal cancer.

Genetic and Biological Factors determine

the individual predisposition to hereditary and degenerative diseases