Social Determinants of Health Midterm 1

The study of the social determinants of health deals with what 2 key problems?

1. What are the societal factors (ie. income, education, employment conditions) that shape health and and help explain health inequalities. 2. What are the societal forces (ie. economic, social, political) that shape the quality of these societal factors?

When was the Black Report published? Why?

1980, after the conservatives came into power under Margaret Thatcher.

Income is a prime determinant of Canadians' premature years of life lost and premature mortality from a range of diseases. __% of excess premature years of life lost can be attributed to income differences among Canadians.

23

The size of the middle class relative to other income groups, decreased by __% over the last 25 years. Surprisingly losses are experienced in both the _________ and _________ periods.

25 Recovery Recession

Despite economic growth, income gap is at a __ year high. Only the richest __-__% are getting richer. Since the year _____ growth in income inequality has accelerated.

30 10-20% 2000

In the textbook figure 3.1 shows you that only the top __% of the population (last _ quintiles) have experienced an increase in mean income (they're skewing the average) whereas the bottom __% earners have experienced a decline. What does this demonstrate?

40% 2 60% Those who have more have the ability to make more whereas the poor don't benefit from the average income pull-up (those who earn $100,000+ are benefiting greatly).

Wealth is much more unequally distributed than income. __% of wealth is realized by the top 10% of income earners. Meanwhile, the bottom half of households have _% of total wealth.

58% 3%

Average wealth measure is positive - __% increase for Canadian families. However this is really only true for the top 10% of the population.

79

What was the Lalonde report formally titled?

A new perspective on the health of Canadians

How is it inaccurate when incomes are said to be growing?

Data typically refers to a single measure of incomes, the mean (or average), for the entire population. ie. If 5 people make 20,000/year but one person makes 200,000 therefore the average income is 50,000/year which is misleading because the income values at the top skew the average.

Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of what?

Public policy decisions made by governing authorities.

According to the Ottawa Charter for HP what are the 5 strategies to improve health?

Re-orienting health services, develop personal skill, create supportive environment, strengthen community action, build health public policy.

Who was Marc Lalonde (The Lalonde Report - 1974)

Minister of Parliament, Cabinet Minister for National Health and Welfare (Canadian Lawyer and Politician)

What are the 12 SDH?

- Aboriginal status • early life experiences • education • Employment and working conditions • Food security • Gender • Health care services • Housing • Income and its distribution • Social safety net • Social exclusion • Unemployment and employment security

Describe the Whitehall Study II?

- All m/f non-industrial civil servants aged between 35-55, in 20 departments in Central London were invited to a cardiovascular screening examination at their workplace. - 10,308 participants in the baseline survey (2/3 men, 1/3 women) - Phase 1: medical examination + questionnaire (invited to the clinic every 5 years, questionnaire completed between clinic phases) - January 2012 - 11th wave

Canadian Health Measures Survey (CHMS)

- Collects health information through a household interview and direct physical measures at a mobile examination centre (MEC) - Interviews: info related to nutrition, smoking habits, alcohol use, medical history, health status, sexual behaviour, lifestyle and physical activity, the environment and housing characteristics, as well as demographic and socioeconomic variables. - Direct physical measurements: blood pressure, height, weight and physical fitness, blood and urine samples to test for chronic and infectious diseases, nutrition and environment markers.

What does upstream mean?

- Create environments that support health - Understanding what is causing the problem (root of the problem) - Focus on prevention by modifying the social determinants of health

What is the biomedical model of health? What is its defining feature?

- Freedom from disease, pain, or defect - Focuses on the physical processes (pathology, physiology, biology) of a disease - focuses on the individual Defining feature: mind-body dualism and machine metaphor

What did the Ottawa Charter for HP conclude?

- Health is a resource of everyday life, not the objective of living - Health is a positive concept emphasizing social and personal resources, as well as physical capacities.

What were the two key findings of Whitehall Study II?

- Over 15 years of data confirm the inverse relationship between socioeconomic position and CHD, diabetes, and metabolic syndrome. - job strain predicts CHD, common mental disorder, and sickness absence from work

What is the role of public policy and public environments?

- SODH does not exist in a vacuum - availability of resources (ie. food) is usually a result of public policy decisions - need to move UPSTREAM

What is the current approach to health?

- Sees individuals and biological processes in social context consider the whole person (holistic) - Focus on the factors and conditions that facilitate or promote health - Understandings of health tend to vary with social position (class, gender) and culture

What was the Black Report? What was its significance?

- Sir Douglas Black was commissioned by the federal government (1977, UK) to write report investigating why National Health Service (NHS) failed to reduce inequalities in health - Showed the extent of which ill-health and death are unequally distributed in Britain (inequalities have been rising rather than diminishing since implementing the NHS)

Health Canada definition of health?

- health as a capacity or resource, not a state; being able to pursue one's goals, to acquire skills and education to grow - the capacity of people to adapt to, respond to, or control life's challenges and changes

What two myths did the Whitehall Study dispel?

- people in high status jobs have higher risk of heart disease - the gradient of health in industrialized societies is simply a matter of poor health for the disadvantaged and good health for everyone else

The health of Canadians has improved since 1900. What factors do Canadians believe are responsible for this? What factor do most analysts conclude is largely accountable?

1. - Improved health care (only 10-15% of increased longevity since 1900 is due to improved health care) - Development of vaccines and medical treatments (but by the time these were developed dramatic declines in mortality had already occurred) - Improvements in behaviour (ie. smoking, diet) 2. Improving material conditions of everyday life experienced by Canadians since 1900 (ie. education, housing, health and social services, and other social determinants of health).

What were 3 outcomes of the Social Determinants of Health Across the Lifespan conference at York University?

1. 1st edition of Social Determinants of Health: Canadian Perspectives (the textbook) 2. Drafting and ratification of the Toronto Charter on the Social Determinants of Health 3. Establishment of a "Social Determinants of Health" listserv

What 4 criteria were used to identify the 23 key social determinants of health especially relevant to Canadians (developed at the York University Social Determinants of Health across the Lifespan conference)?

1. All these social determinants of health (SDH) are important to the health of Canadians. 2. All these SDH are understandable to Canadians. 3. All these SDH have clear policy relevance to Canadians decision makers and citizens. 4. All these SDH are especially timely and relevant. (pg. 7)

What 2 UK reports sparked interest in how social conditions shape health? What is the significance of these studies? What did they describe?

1. Black Report (1980); Health Divide (1992) 2. Stimulated the study of health inequalities, the factors that determine them, and how public policy can increase or reduce them. 3. Lowest employment-level groups showed a greater likelihood of suffering from a wide range of diseases and dying prematurely from illness or injury at every stage of the life cycle. Professionals have the best health, followed by skilled workers, and manual labourers the worst.

The Black and the Health Divide Reports consider what 2 primary mechanisms for understanding health inequalities?

1. Cultural/behavioural 2. Materialist/structural

Health field can be broken up into what four broad elements?

1. Human biology 2. Lifestyle 3. Environment 4. Health Care Organization

In 1974 the federal government's A New Perspective on the Health of Canadians identified what 4 factors as determinants of health? What was the significance of this document?

1. Human biology, environment, lifestyle, and health care organization. 2. It outlined determinants of health outside of the health care system.

Analysis is now focused upon what three frameworks by which social determinants of health come to influence health? Evidence strongly supports which 2 explanations for understanding how the SDH come to influence health status.

1. Materialist - how living conditions (and the SDH that constitute them) shape health 2. Neo-materialist - Extends the materialist analysis by asking how these living conditions come about 3. Psychosocial comparison - Considers whether we compare ourselves to others and how these comparisons affect our health and well-being Materialist and neo-materialist.

What were the two key findings of Whitehall Study I?

1. Men in the lowest employment grades were more likely to die prematurely than men in the highest grades. 2. Inequalities in health were not limited to the health consequences of poverty.

What are the three distinct clusters of welfare regimes among wealthy developed nations?

1. Social democrat (Norway, Sweden, Denmark, Finland) - very well developed welfare states that provide a range of universal and generous benefits 2. Conservative (France, Germany, Netherlands, Belgium, etc.) - Between the other two in terms of services and supports 3. Liberal (Canada, US, UK, Ireland) - spend less on supports/services - modest universal transfers and social insurance plans - benefits are provided via means test to the least well-off

How is income measured using mean?

Average income after tax by economic family types.

What are the 12 social determinants of health identified by the organizers of the York University conference?

Aboriginal status, early life, education, employment and working conditions, food security, gender, health care services, housing, income and its distribution, social safety net, social exclusion, unemployment and employment security.

Most surveys of population health focus on what rather than what?

Absence of sickness rather than presence of health.

In its Action Statement for Health Promotion in Canada, the Canadian Public Health Association (CPHA) identified what as the single best strategy to affect the determinants of health?

Advocating for healthy public policies.

According to Canadian political economist Gary Teeple, when was Canada's performance in implementing social determinants-relevant policy strongest and why has it weakened since the 1970s?

After WW2 Canada became a welfare state. Increasing globalization is partially to blame for the weakening of the welfare state.

Health has its roots in the Greek word _____ which means _____.

Holos Whole

Explain how the redistributive effect (through taxes and transfers) dramatically reduces inequality. What did the Yalnizyan study demonstrate in relation to this that was not as good news?

Before taxes and transfers, the inequality between the rich and poor is in the triple digits with the richest 10% earning 109 times the income of the poorest 10%. When taxes and transfers are added, the ratio drops to 9.9 times. The redistributive effect is becoming less significant over the last generation (the ratio has grown -> 9.9 in 2007 was an all time high).

Describe the class structure prior to the 19th/20th century (expansion of waged labour and the industrial revolution) and after it? What is it like now?

Before: the distribution of the population was pyramid shaped, with the vast majority living in poverty. After: apple shaped; massive expansion of the middle class with prognosis for upward mobility. Now: Rotten apple, more divided and polarized; hollowing out of the middle class -> middle income earners dropped from 60 to 44% while the ranks of the very poor and the very rich rose significantly.

What is the leading cause of death in the 20th century?

CV disease

How are quintiles used to measure income?

Changes in income by quintiles (20% segments).

The well-off group of people earning between $60,000 to $99,999/year has shrunk by 6.1% over the last generation. Why is this concerning to the middle class?

Creates a structural barrier to a more affluent Canada, whereby decreasing odds of moving up thwarts the middle class (the rich are getting richer but are not being replaced by mobility upwards from the middle class).

What are the 3 main sources of consumer debt?

Credit cards, cars, line of credit.

What are the two pathways by which the SDOH influence health. Where is the problem in each and how do you solve it?

Cultural/Behavioural - Individual Level - lifestyle explanations rooted in ideology of individualism - problem is in individuals; must treat individuals and modify individual behaviours Material/structuralist - societal level - problem is in social conditions and systems; change social conditions to promote health for entire groups and populations

What are deciles and ratios in relation to income measurement?

Deciles -> top 10% and bottom 10% (how income varies over time) Ratios -> how much more the richest 10% are making compared to the poorest 10% (ie. 100x more)

Have infant mortality rates in Canada experienced a drastic increase or decrease since the 1930s?

Decrease (but big regional differences ie. among First Nations)

What is discourse?

Discussion/debate

Not only poverty but ________ of poverty are associated with childhood health.

Duration

Since a social determinants of health approach sees the mainsprings of health as being how a society organizes and distributes economic and social resources, it directs attention to ________ and ______ policies as a means of improving it.

Economic Social

What are social determinants of health?

Economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole.

_____________ is the study (or the science of the study) of the patterns, causes, and effects of health and disease conditions in defined populations.

Epidemiology

What kind of effect do transfers and taxes have? How?

Equalizing effect Raise the incomes of those at the bottom (through transfers) and lower the incomes at the top (through income taxes).

What does evidence indicate that health inequalities among Canadians result primarily from?

Experiences of qualitatively different environments associated with the social determinants of health (ie. income is a SDH in itself but also a determinant of quality of life, education, food security etc.)

True/false. Surveys show that Canadians have good awareness of the important role that living conditions play in determining health.

False. They have little awareness of this.

What did Rudolf Virchow identify in relation to health?

How health-threatening living conditions were rooted in public policy-making and emphasized the role that politics played in promoting health and preventing disease.

In what publishing did the term "social determinants of health" make its debut? What is the name of the man who fleshed out the environmental determinants of health in this report?

Health and Social Organization: Towards a Health Policy for the 21st Century Tarlov

How do we know that social factors are better predictors of health than individual behaviours or lifestyle?

Health and ill health are not distributed randomly, but vary according to economic and other social factors.

What is the key point of the Ottawa Charter for HP?

Health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

What definition of Health Promotion did the Ottawa Charter for HP present?

Health promotion is the process of enabling people to increase control over and to improve their health.

The diseases most related to income differences in mortality among Canadians are _____ ______ and ______.

Heart disease and stroke.

Who described Health as "a condition in which the functions of the body and soul are in harmony with the outside world"?

Hippocrates

Describe the difference between the health indicators incidence and prevalence.

Incidence -> rate of new (or newly diagnosed) cases of the disease. Generally reported as the number of new cases occurring within a period of time (ie. per month, per year) Prevalence -> actual number of cases alive, with the disease either during a period of time (period prevalence) or at a particular date in time (point prevalence).

What are 7 indicators of health?

Incidence, prevalence, mortality, morbidity, life expectancy, infant mortality, subjective measures (ie. telephone interview, CHMS)

Has life expectancy increased or decreased markedly in the 20th century?

Increased

What was the conclusion of the Black Report?

Inequalities were not mainly attributable to failings in the NHS but to many other social inequalities influencing health (income, education, housing, diet, unemployment, work conditions).

What is the problem with current governmental and public health activities focused on promoting health?

Instead of efforts to improve Canadian's living conditions, individualized approaches focus on biomedical and behavioural risk factors. When living conditions are considered it is usually to identify those Canadians whose living conditions are said to put them at risk for making "unhealthy lifestyle choices" (health behaviours that are less important determinants of health) rather that urging governmental authorities to improve their living circumstances (a primary determinant of health).

What is the significance of the life-course approach?

It directs attention to how social determinants of health operate at every level of development (early childhood, childhood, adolescence, and adulthood) to both immediately influence health and to provide the basis for health or illness during later stages of life. *SODH can have a cumulative effect

What is the main cause between differences in overall health status between developed and developing nations?

Lack of basic necessities of life (food, water, sanitation, primary health care etc.) in developing nations.

It has been known since the mid-19th century that __________ __________ are the primary determinants of health.

Living conditions

There is lots of evidence linking individual income and health status in Canadian children. What are some of the negative implications in children linked to low-income/poverty?

Low-birth weight, injury-related mortality, developmental problems, obesity, and asthma.

What three factors did English political economist Friedrich Engels discover were the primary contributors to social class differences in health?

Material living conditions, day to day stress, and the adoption of health threatening behaviours.

How is income measured using median? What is the problem with the median?

Median -> actual income of the middle-income earner. Median total income, by family type, by province and territory. Tells you very little about incomes outside the middle range.

The average wealth measure suggests that there's a 79% increase in mean wealth recorded for Canadian families over the last generation. Is this accurate?

No, once again it's an average so there is an uneven distribution (the rich families are bringing the average up, the poor families have gotten poorer).

What is the government's role in income inequality?

Our governments have become increasingly tolerant of income inequality and are reducing the levers that promote income equality (ie. drops in income transfers such as employment insurance or social assistance).

The Ottawa Charter for HP emphasized what 8 fundamental conditions and resources required for health?

Peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice/equity.

The Canadian government document Achieving Health for All: A Framework for Health Promotion outlined what?

Reducing inequities between income groups as an important goal of government policy.

The difference between the median and the mean has been ______ dramatically over the last 25 years from $4000 to the high of $12,600 in 2005. Why is this?

Rising Due to the dramatic rise in mean incomes as they are swayed by the prevalence of very high incomes.

What does Raphael mean by the quote "income is a determinant of health, and that it is a marker of many other SDHs"

SDH are not isolated, they interact with and influence one another. (ie. if you don't have a good income you might not have adequate housing)

What is the WHO definition of health?

State of complete physical, mental, and social well-being and not merely the absence of disease.

What was Whitehall Study I? Who was studied?

Study of health inequalities among British civil servants in 1967. 18,000 male civil servants aged 35-55.

What is another name for income inequality?

The Growing Gap

What does the life-course approach emphasize?

The accumulated effects of experience across the lifespan in understanding the maintenance of health and the onset of disease. (ie. poor growth and development, adverse early environmental conditions, and adverse economic and social conditions are associated with an increased risk of adult chronic disease).

What does the median income indicate?

The actual income of the middle-income earner in the population.

The Ottawa Charter for Health Promotion (1986) was an outcome of what conference?

The first International Conference on Health Promotion

Who are the 3 hardest-hit groups when it comes to income inequality?

The poorest Canadians, people of colour, women.

What is the measure of wealth? What does it allow us to review?

The total sum of the value of all assets minus all debts owed. The cumulative impact of years of differential incomes on the net assets of various groups within the population.

What is the problem with both the average and the median income measures?

They tell us very little about the incomes of those outside of the middle range - and the average actually tells us nothing about income earners at all.

What was the purpose of the Whitehall Study II (1985)?

To examine the association between socioeconomic status and all-cause mortality in British civil servants (examine reasons for the social gradient in health and disease).

True/false. Material and social circumstances to which people in developed nations such as Canada are exposed to in their homes, workplaces, and communities are far more important to their health than so-called "lifestyle choices" ie. using tobacco or alcohol, partaking in physical activity.

True

Among developed nations such as Canada, USA, and Sweden, less profound but still highly significant differences in health status indicators exist. Using these countries as an example, explain why this might be?

USA takes a laissez-faire approach to providing various forms of security, health, and social services whereas Sweden's welfare state makes extraordinary efforts to provide security and services. Different political ideologies = different policies Nations such as sweden focus on security provisions which shape the quality of numerous social determinants of health.

What is the primary culprit for burgeoning inequality?

Wages paid by employers.

Wealth

Who owns and controls what OR total sum value of all assets minus debts

Income inequality

extent to which income is distributed unevenly in a country

Table 3.1 in the textbook shows that the ratios are consistently getting _______ (apart from some sporadic _______)

higher declines

Dramatic improvements in health status have occurred in Canada since 1900 but.....

inequalities still exist within Canada, especially with Aboriginals.

Income

wages, salaries, and bonuses made in a year