4. Widening Our Lens: Social Determinants of Health

Question 1

L-4 Health Tips? (3)

Answer 1

1. Differences matter in matters of health.
2. You are affected by your situation (whether you like it or not).
3. We may at times find ourselves in the same storm (e.g., the pandemic), but we’re not all in the same boat…

Question 2

The Social Context of Health

Government of Canada (2023) Main determinants of health? + Demonstrating a pattern of?

Answer 2

1. Income and social status
2. Employment/working conditions
3. Education and literacy
4. Childhood experiences
5. Physical environments
6. Social supports and coping skills
7. Healthy behaviours
8. Access to health services
9. Biology and genetic endowment
10. Gender
11. Culture
12. Race / Racism / Discrimination

Most of these relate to the broader environmental factors. - Sociocultural context

Question 3

Health Disparities definition?

Answer 3

Inequalities or gaps in health or health care between groups (gender, ethnicity, culture, region, social status, etc.).

Question 4

Health Disparities can effect?

Answer 4

• how frequently a disease affects a group.
• how many people in a group get sick.
• how often the disease causes death for a group.

i.e., differences in morbidity and mortality rates between groups.

(Particularly large differences in suicide rates -> very concerning health disparities)

Question 5

Recent Report from the Public Health Agency of Canada:

“Health inequalities in Canada exist, are persistent, and in some cases, are growing. Many of these inequalities are the result of individuals’ and groups’ relative social, political, and economic disadvantages.”

Provide some examples?

Answer 5

• Shorter life expectancies among those living in lower-income areas.
• Higher suicide rates in First Nations, Métis, and Inuit communities.
• Lower self-reported mental health / higher mental illness among LGBTQ+ people, Indigenous people, and lower-income Canadians.
• Higher rates of asthma, diabetes, and obesity among First Nations people, Métis, and those living in Northern regions.

Question 6

Health of Indigenous Peoples

The Canadian Constitution defined 3 groups of Aboriginal peoples in Canada, now referred to as Indigenous: First Nations, Inuit, & Métis.

Mention some select disparities?

Answer 6

• Lower life expectancies; higher infant mortality rates.
• Lower self-reported health; higher rates of obesity, cancer, heart disease, hypertension, diabetes, asthma, etc.
• Higher rates of depression, substance abuse, and other mental illnesses.
• Those living on reserves, have worse health outcomes.
  (Living in less safe, unpredictable environments with less resources.)
• Certain age brakes, particularly young boys are much more likely to commit suicide.

Question 7

Life expectancy at birth by Indigenous identity, compared to all Canadians?

Answer 7

Enormous health disparities!
15 years difference for indigenous males and the rest of the population.

Question 8

Prevalence of select health conditions among First Nations on-reserve and general Canadian population?

Answer 8

In particular very large health disparities for diabetes.
One of the highest rates of diabetes in the world -> mostly affects First Nations living on reserve.

Question 9

Diabetes among First Nations
Environmental and lifestyle factors are largely to blame - why?

Answer 9

Less healthy diet, lower consumption of traditional foods, less physical activity due to historical changes to way of life.

Question 10

Diabetes among First Nations - Is poverty a factor?

Answer 10

Lower income and education are believed to play a role in the increased stress and poorer health of Indigenous peoples.

Poverty is a chronic stressor -> elevated cortisol.

Question 11

60% of First Nations children living on reserves live in poverty. Describe their situation?

Answer 11

Housing crisis, and clean drinking water crisis.
- Houses needs both repairing and building new houses.
- Many reserves lack sufficient amount of land to even build more homes.

Question 12

Spiralling suicide rates in the Ontario First Nation of Attawapiskat

• Population of 2000; Over 100 suicide attempts (ages 9-71) in 7 months (2016).
• 30 suicide attempts in month of March, 2016.
• 11 suicide attempts (ages 9-14 years old) on the night of April 9, 2016.

Contributing factors?

Answer 12

• Only accessible by helicopter by 8 moths of the year
• Because of how the remote the community is it faces challenges accessing any healthcare support.
• Extremely bad water quality, dangerous chemicals.
• Have a sense of hopelessness for the future, having family members that had been in residential school or forcefully placed in foster homes.
• Suicide contagion has a problem in these small communities, epcailly when people are in the same demograhpics.

Question 13

The Trauma of Colonization?

Answer 13

For Indigenous peoples, European colonisation involved a series of highly traumatic stressors, including new disease, loss of land, criminalisation/loss of culture, genocide, and forced assimilation.

• WHO recognises colonisation as the SINGLE MOST determinate factor of health for Indigenous peoples worldwide.

Question 14

The Trauma of Colonization - psychological outcomes?

Answer 14

• Despite little research, there is evidence of higher prevalence of PTSD among Indigenous people in Canada.
• Among 127 survivors of residential schools in BC, 64% met the criteria for PTSD.
• Indigenous peoples around the world report higher psychological distress.

Question 15

Intergenerational Trauma? Defintion + what direct and indirect mechanisms may be involved?

Answer 15

Such historical traumas have had lasting effects on Indigenous peoples that are still felt today, including increased distress and compromised health -> Intergenerational trauma refers to trauma passed down to subsequent generations.

• Vicarious trauma (via stories etc.)
• Lack of culture and cultural identity.
• Marginalisation and discrimination.
• Compromised parental functioning.
• Modelling of poor coping.
• Genetic/biological vulnerabilities.

Question 16

What are Epigenetic Effects?

Answer 16

Epigenetics: The study of changes in organisms caused by changes in gene expression due to environmental influences.
Heavily informed by animal research…

Question 17

Intergenerational Epigenetic Effects? + Research to support this?

Answer 17

Epigenetic changes can be heritable via various processes; can affect multiple generations.

PTSD-like symptoms of isolation and jumpiness observed in male mice exposed to early stress/trauma; also alterations in genes associated with stress-related hormones and behaviours.

Pups showed same symptoms of trauma: anxious behaviour, same signature gene changes.

Question 18

Intergenerational Epigenetic Effects in humans?

Answer 18

• At this time, it is not possible to attribute intergenerational effects in humans to a single set of biological determinants, epigenetic or otherwise.

But studies have suggested a role of epigenetics…
- E.g., One study found that children of Holocaust survivors had epigenetic changes to a gene linked to cortisol
- Prospective, multi‐generational studies are needed.

Question 19

In a study of 90 adult children of residential school survivors they found increased childhood adversity in and allostatic load.

BUT?

Answer 19

But childhood adversity did NOT mediate the relationship, suggesting maternal trauma may have become biologically embedded and passed on to children.

Possibly through epigenetic mechanisms (but unknown).

Question 20

The Role of Cultural Identity?

Answer 20

• Cultural identity is a key factor in health.
• Historical and ongoing attacks on Indigenous culture have compromised
  cultural identity clarity.
• Cultivating a stronger cultural identity may be an important way to reduce the impact of stress and trauma on the
  health of Indigenous communities.

Independence and autonomy, -> those communities that have more control over their governance land etc do much better.

Question 21

Indigenous communities have demonstrated resilience in the face of profound trauma, and despite ongoing threats to cultural identity, e.g., discrimination.

What are the results?

Answer 21

Indigenous communities that engage in more efforts to reclaim their culture tend to experience:
- decreases in youth suicide
- improved education
- fewer children being placed in foster care

Question 22

Factors in Resilience for Indigenous youth (urban and rural)?

Answer 22

A sense of connection to the land and nature and engagement with nature have been associated with better health and resilience.

Question 23

What is income quintiles?

Answer 23

Income quintiles reflect efforts to divide Canadians according to 5 evenly distributed groups based on personal income, family income, or average neighbourhood income.

In Canada, the lowest quintile (Q1) had an average personal income (after tax) of $16,000 in 2010. The highest quintile (Q5) had an average personal income of $85,500 in 2010.

Question 24

Life expectancy at birth, Canadian females and males, by neighbourhood income quintile?

Answer 24

Life expectancy increases with each income quintile, a linear relationship.

Question 25

Mortality rates per 100,000 for select causes of death, by income quintile, males & females 25+, Canada?

Answer 25

Each higher income quintile there is lower mortality rates.

Question 26

Five-year net survival by patient income quintile for four cancers, age-standardized?

Answer 26

A study increase in survival rate for more affluent groups. Smaller differences though then the other stats.

Question 27

Mortality rates per 100,000 for HIV/AIDS, by income quintile, males and females 25+, Canada?

Answer 27

Very large difference in the lowest quintile compared to the other.

Question 28

Percent of Canadians reporting diabetes (Type 1, Type 2, & gestational) by income quintile?

Answer 28

Higher in the lowest quintile.

Question 29

The Socioeconomic Gradient in Health?

Answer 29

At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health.

• Much more reliable for physical outcomes than psychological outcomes.
• After $85k a year psychological outcomes tend to be better BUT life satisfaction continues to increase an income increases.
• Income matters more when you have less, the impact is larger. But diminishing returns for higher incomes - smaller impact.

Question 30

“Thousands of studies across a variety of disciplines have documented that people with larger incomes and better education tend to have better health and live longer. This pattern holds across all ages and in all countries that have been studied, and for virtually all measures of health..”

What factor could explain this?

Answer 30

Even if people who are rich are really stressed out, they have CONTROL!

Question 31

nequalities in COVID-19 Deaths
Between January and August, 2020, there were significant inequalities in COVID-19 death rates for Canadians living in?

Answer 31

• lower income neighbourhoods
  and neighbourhoods with more people who:
• are a visible minority
• recently immigrated to Canada
• were born outside of Canada, or
• speak neither English nor French

Men also had higher rates of COVID-19 deaths than women, especially in these neighbourhoods.

Death rates have also been higher (1) in poor countries compared to rich; and (2) in countries with more inequality compared to those with less inequality.

Question 32

The Whitehall Studies (1967-1988)
Series of longitudinal studies investigating the social determinants of health in thousands of British civil servants (government employees), all of whom are ranked yet have equal access to health care.

Results + proposed explanation?

Answer 32

• Higher employment grade (ranking) was associated with higher life expectancy and lower incidence of many diseases and risk factors (in a gradient-like relationship)
• Stress and cortisol were proposed as primary mechanisms to explain these gradients
  →Lower control, reduced predictability, and fewer resources due to smaller paycheque

Question 33

Baboons & Stress?

Answer 33

• Lower-ranking males experience ongoing, uncontrollable social stress which affects health.
• Among baboons, displacement aggression is common: top baboon kicks the one below him, and so on.
• This leads to chronically elevated stress hormones in low-ranking members of the troop.

Question 34

The Status-Health Relationship
It has been found that…?

Answer 34

Low Status is associated with:
Increased Morbidity
& Mortality, Lower
Quality of Life, etc.

But stress appears to be one key mechanism!
Because Low Status leads to stress which causes all the negative outcomes.

Question 35

Low SES, Appraisal, and Coping?

Answer 35

• Low-SES individuals report more frequent stressful life events and more chronic stressors.
• Low-SES individuals have a tendency to interpret stressors as more threatening.
• Disadvantaged people (including those with lower income/status) also cope less effectively with stress.

Question 36

Low SES and Allostatic Load?

Answer 36

The burden of coping with limited resources and negative life events results in increased allostatic load on individuals at lower ends of the socioeconomic gradient.

Social ordering and dominance hierarchies are among the most potent stressors.

Question 37

Biological Embedding Model?

Answer 37

• Childhood adversity gets programmed into the immune system through multiple mechanisms, including epigenetics.
• E.g., Immune cells develop pro-inflammatory tendencies that manifest throughout life and contribute to increased chronic disease.
  -> Inflammation is a precursor for all types of chronic disease.

Question 38

Factors in Resilience - ‘Shift-and-Persist’

Some individuals are able to overcome low-SES adversities…
Over a lifetime, some low-SES children develop an approach to life that prioritizes?

Answer 38

1. Shifting Oneself → Accepting stress for what it is and adapting through reappraisals.
2. Persisting→ Enduring life with strength by maintaining meaning and optimism.

Question 39

What’s the impact on the group?

Answer 39

• Among rich countries, higher income inequality (i.e., larger gap between rich and poor) is associated with lower life expectancy, higher rates of mental illness, higher crime, poorer childhood outcomes, lower well-being, etc. (on average for a given society).
• Even the rich in more unequal countries are worse off (on average) than the rich in more equal countries.

Question 40

How exactly is social inequality having a negative impact?

Answer 40

We’re not entirely sure, but Wilkinson suggests these factors…
- heightened levels of competition in a society.
- social evaluation anxiety – increased stress due to greater threats to self-esteem, social status, and fear of judgment.

This makes sense because social ordering and dominance hierarchies are among the most potent stressors.

Question 41

Inequality is a detriment at all levels…
Example: Status Anxiety?

Answer 41

A measure of social evaluation: “Some people look down on me because of my job situation or income.”

Status anxiety is higher across high-inequality countries for everyone, compared to low inequality. (even the rich are affected)

Question 42

Moving Forward
“The evidence that large income differences have damaging health and social consequences is strong and in most countries inequality is increasing. Narrowing the gap will improve the health and wellbeing of populations.”

In real terms, what can we do to narrow the gap?

Answer 42

• Free healthcare and education (including higher education)
• Lower sense of competition skip the fucking grades!

Question 43

Stigma definition?

Answer 43

Stigma = negative attitudes & behaviours based on group membership or affiliation.

Question 44

Marginalization definition?

Answer 44

Marginalization = treatment of person or group as less important.

Question 45

Minority Stress Model?

Answer 45

Stigma, prejudice, and discrimination create a hostile social environment → leads to increased stress for minorities and increased incidence of disease & illness.

Example, being aware of your membership in a group that is more likely to be kliied on a daily basis/

Question 46

Minority Stress - Examined primarily in regards to racial and sexual minorities.. Provide some examples?

Answer 46

• African Americans have higher rates of stroke, diabetes, perinatal
  disease, some cancers, depression, & substance abuse.
• LGBTQ+ individuals have higher rates of immune dysfunction, some cancers, substance abuse, depression, anxiety, & attempted suicide.

Found or suggested to explain health disparities in many other groups, including Indigenous peoples

Question 47

Minority Stress
Specific sources of stress vary, but include?

Answer 47

• Direct experiences of discrimination, prejudice, harassment.
• Social stigma; internalized bias and stigma
• Rejection and expectations of rejection
• Hiding or concealing identity (esp. LGBTQ+ people).

Question 48

Minorities are also more likely to live in poverty. Why?

Answer 48

Discrimination and marginalization are common barriers for minorities seeking to escape poverty.

Question 49

Racism and Health?

Answer 49

• Racism places a substantial strain on the mental and physical health of targeted individuals.
• Research suggests a consistent relationship between racism and a variety of mental health outcomes in addition to physical health outcomes.

Question 50

Mechanisms reinforcing Racism and its Health consequences?

Answer 50

Institutional racism can limit resources and opportunities (which then impacts health, leads to stress), while personal experiences of racism increase stress over time.

Question 51

Factors in Resilience in racialized groups (e.g., African Americans)?

Answer 51

• Subjective social status and perceived social support are correlated with greater resilience to poor health outcomes.
• Racial socialization (i.e., learning about race and racism; the place of one’s race in society) and racial identity are also correlated with heightened resilience in Black youth.
  (Connection to earlier material with clear cultural identity for Indeigoues peoples)

Question 52

According to the Canadian Trans Youth
Health Survey?

Answer 52

• 2/3 of participants reported discrimination because of their gender identity.
• 1/3 of younger participants had been physically threatened or injured.
• Poverty, hunger, mental health, and accessing health care were issues for many.

Transgender (trans) people are one of the most stigmatized and marginalized groups in Canada (and around the world).

Question 53

Trans Stigma and Mental Health?

Answer 53

Suicidality is highly prevalent among trans people (similar to or greater than other members of the LGBTQ+ community).

• 2010 US study of 7000 trans people: 41% had attempted suicide.
• 2011 Ontario study of 433 trans people: 77% had seriously
  considered suicide; 43% had attempted suicide.
  …compared to 1.5% of the general population who have ever attempted suicide.

Leading causes include direct experiences with exclusion and discrimination.

Question 54

Factors in Resilience -
Among trans youth and adults, psychological well-being (including lower risk of suicidality) is associated with?

Answer 54

• personal mastery
• support-seeking and social support
• emotional coping (esp. positive reappraisal)

Lower suicidal ideation has also been associated with greater gender identity clarity
- A recent randomized clinical trial found that early gender-affirming care resulted in a significant reduction in suicidality (52% drop compared to 5% in controls)

Question 55

Considering the populations discussed (Indigenous, racialized,
and transgender/gender-diverse people) are there any common themes that emerge (pertaining to factors in resilience)?

Answer 55

• Social support networks, especially people who belong to your community.
• Identity clarity
• More positive reappraisal and emotional coping strategies

Question 56

The Status-Health Relationship Expanded?

Answer 56

Low S.E.S., Low Social Rank, Subordination, Minority Status
->
Social Evaluation, Stigma, Discrimination, Marginalization, Lower Control
->
Chronic Stress
->
Increased Morbidity & Mortality, Lower Quality of Life, etc.

Question 57

How might disease threat (as in a pandemic) affect inequality, stigma, discrimination, and/or racism?

Answer 57

• Regarding inequality, it may be exacerbated by socioeconomic disparities in disease threat.
• Example, people loosing their jobs due to illness.
• Meanwhile, the rich are getting richer during the pandemic!
• Pandemics can either worsen inequality (by leading people to defend and protect the status quo) or reduce it (by upending the status quo).
• The second effect will only happen if the pandemic is bad enough, that everyone is feed up and protest the system.

Question 58

Throughout history, infectious diseases have been associated with?

Answer 58

“othering” (racism, xenophobia, bigotry).

“Outbreaks create fear, and fear is a key ingredient for racism and xenophobia to thrive.”
-> Fear makes people more likely to defend their preexisting believes (status-quo) and more hostile towards outgroups.

• Greater conformity to traditional gender roles / support for gender stereotypes after COVID-19. (True for liberals and conservatives)
• Historical pathogen prevalence around the world has been associated with authoritarianism, conservatism and nationalism.