Chapter 11: CAGE(s) and Health

Question 1

How does the World Health Organization define health?

Answer 1

It defines healthy broadly as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”

Question 2

How does House describe the approach to health in the mid-twentieth century?

Answer 2

It was a purely biomedical approach to health and illness. Inequalities in health were analyzed and examined largely through the biology of the individual and the workings of the medical system. An individual’s behaviour in the form of “lifestyle” choices (ex. smoking, alcoholism, obesity, and physical exercise) was believed to have a significant effect on their health.
- individual biology does not explain health inequality accurately

Question 3

What is the biggest factor in determining our health?

Answer 3

Factors such as socio-economic status plays a significant role in health experiences
- smoking, immoderate eating, etc. account only moderately (10-20%) for socio-economic inequalities in health

Question 4

What psychosocial factor was studied in the 1960s that has a significant impact on health?

Answer 4

Stress.
Connection between SES and physical and mental health largely reflects:
(1) differential exposure to social stress over the life course based on social status
(2) status-based differences in the distribution of personal and social resources (ex. mastery and/or social support) to buffer the effects of these stressors
- aligns with the “exposure-resource” framework

Question 5

Define psychosocial risk factors.

Answer 5

A system of exposures, resources, and situational variables believed to have an impact on health; they include mastery or sense of control, self-esteem, ease or availability of social supports, negative life events, and daily exposure to stress or exposure to traumatic events.

Question 6

Define the fundamental cause theory.

Answer 6

Link and Phelan’s sociologically informed theory of the reasons for the strong associations between social factors and disease.
Link and Phelan recommend a focus on macro factors like “access to knowledge, money, power, prestige, and social connections” and the ways in which these factors can influence the exposure to health risks and preventive measures in order to explain long-time associations between inequality and health.
Despite medical advances, the underlying fact is that those from low SES communities lack resources to protect and/or improve their health status.
As new risk factors and new technologies are discovered, those people in society with better resources and connections are more able to benefit from new knowledge and avoid health risks.

Question 7

What does House believe we should focus on in regards to health?

Answer 7

Investigators should concentrate on factors such as socio-economic status and “race” or ethnicity because these characteristics “shape individual exposure to and experience of virtually all known psychosocial, as well as many environmental and biomedical risk factors, and these risk factors help to explain the size and persistence of social disparities in health”

Question 8

How is House’s framework (pg. 256) criticized?

Answer 8

Although House’s conceptual framework includes class, ethnicity, and gender, his inclusion is additive rather than interactive.
Gender and race or ethnicity are not considered to be related and that both race or ethnicity and gender are thought to be mediated by socio-economic status in their relation to health outcomes.
Age and the influence of social time are not explicitly accounted for, and the explanatory variables (ex. social supports and social roles) are only “minorly” affected by gender and ethnicity.

This conceptualization continues to treat gender, race, ethnicity, and socio-economic status as variables that can in some way be viewed as separate from one another, ignoring intersectionality.

Question 9

Who has the health advantage?

Answer 9

Those who possess more resources (ex. income, education, and social connections) often enjoy longer and healthier (both physical and mental) lives than people lower in the class structure. 
Health education and awareness, access to prevention, and the capacity to avoid risk factors (ex. toxic neighbourhoods)—all of which are resources held by members of the middle and upper classes—contribute to health advantage.

Question 10

How does life expectancy change depending on SES and depending on gender?

Answer 10

People living in the highest-income neighbourhoods had a higher life expectancy than people in the lowest-income neighbourhoods.

Women have a higher life-expectancy than men in all income groups, as income rises, the life expectancy gap between men and women diminishes: from 6.1 years in the lowest-income group to 3.7 years in the highest.

Question 11

How does life expectancy vary across regions in Canada?

Answer 11

Those born in the territories (Yukon, the Northwest Territories, and Nunavut) have a life expectancy far lower than those born in other provinces.

• in Nunavut, women live on average 73.9 years, while men live about 68.8 years
• in Ontario, women have an average life expectancy of 83.9 and men 79.8

Although the average life-expectancy rate increased for Canadians on the whole between 1991 and 2001, an analysis of life expectancy for the majority of the Inuit population in Canada showed no increase for that period of time, and life expectancy of Inuit at birth averaged 68 years.

Question 12

How does life expectancy vary across cities in Canada?

Answer 12

In Vancouver life expectancy at birth is 81.1 years, while in Greater Sudbury it is only 76.7 years.

Mortality differences between rural and urban regions
- generally higher mortality rates due to injuries and various occupational hazards, particularly for men in rural areas

Health patterns across regional Census Metropolitan Areas show that CMAs in Atlantic Canada each have life expectancies below the Canadian national average.
Within Ontario, CMAs show variation between the north and the south, with northern Ontario CMAs showing lower life-expectancy rates.

Question 13

How does income level affect life expectancy?

Answer 13

Research on mortality shows that health status is correlated with income level

• health status in some contexts deteriorates with incremental declines in income.
• in places where incomes are more variable, death rates are higher

Compared with findings in the US, national socio-economic gradients in health are less evident in Canada; yet significant relationships between health and income exist both across and within Canadian cities and neighbourhoods.

Question 14

What is the question related to the correlation between SES and health? What research has been done surrounding it?

Answer 14

Does low income, education, and bad jobs result in poor health and increased risk of death or do those with poor and declining health consequently experience lower income and education levels.

Phelan and Link argue that higher socio-economic status enables individuals to marshal greater flexible resources in protecting their health (ex. by moving to healthier neighbourhoods)
- they found significantly stronger relationships between preventable causes of mortality and SES compared with less preventable forms of mortality

Individuals with higher SES are able to better avoid health risks from know causes of disease.
- this relationship is less for diseases that are less preventable and/or less curable.

This means that rather than ill health primarily influencing SES level, the relationship between SES and health is one where SES enables individuals to better avoid and predict health risks.

Question 15

What are the two streams in the current stress research?

Answer 15

1. Examines the extent to which different societal groups (ex. varying by income, race/ethnicity, age or gender) are exposed to chronic strains and stressful events and, in doing so, documents the effect of inequality on population mental health;
2. Focuses on individual perceptions of stress and the resources or buffers at hand for maintaining mental health

The conclusion is that the two approaches are “complementary”

Question 16

Define class-linked stress.

Answer 16

Class linked stress is stress exposures that are largely dependent on social status.
Example: working-class and lower-income individuals are more frequently employed in physically stressful jobs (ex. where there are extreme temperatures, high noise levels, shift work, or noxious fumes, or where the worker has to work at an assembly-line pace).

People with less power in society are more exposed to ongoing life stresses and strains and often have fewer resources and social supports to help them cope.

The development of psychosocial resources, such as mastery, self-esteem, and the perception of control over one’s environment, is hindered for those who encounter ongoing structural barriers and disadvantages.
- schizophrenia may be related to class-linked stress

Question 17

What are some research findings in relation to low-income and life expectancy?

Answer 17

Low-income populations were 16 times more likely to attempt suicide than high-income populations
Infant mortality rates are much high in Canadian territories
The length of time individuals spend in either economic advantage or disadvantage may influence health trajectories over the life course

Question 18

How is mental health affected by SES?

Answer 18

It’s been found that living in poverty can be a stronger predictor of poor mental health than being enlisted for the war.
The poor, the young, ethnic minorities, and blacks have higher rates of mental illness than the well-to-do, older persons, ethnic majorities, and whites.
- the lower the person’s income, the worst their mental health

Question 19

How does being Aboriginal affect health?

Answer 19

Aboriginal peoples in Canada face many health challenges, their rating on a variety of health status measures is worse than those of non-Aboriginals.

• aboriginals are twice as likely to be hospitalized due to kidney disease and heart attacks, than non-Aboriginals.
• 22% of First Nations men have high blood pressure compared with 8% of non-Aboriginal men in Canada

The rate of tuberculosis among Inuit is 92.0 per 100,000/year compared with a rate of 30 among First Nations groups and 1.3 among non-Aboriginals in Canada.

Aboriginal people were found to be much more likely to have cardiovascular disease than those of European ancestry (18.5% compared to 7.6%)

Question 20

What is the leading cause of death for Aboriginals?

Answer 20

For Aboriginal people, the leading cause of death is from injury, while injuries sit as the 4th leading cause of death in Canada for others.

Although the Aboriginal population is substantially younger than non-Aboriginals in Canada (median age 27 compared to 40), even when controlling for age, there are significantly more injuries among Aboriginal people.

Question 21

How do mortality rates compare for Aboriginals and non-Aboriginals?

Answer 21

Aboriginal people have higher mortality rates than the non-Aboriginal population, though it is important to note that compared to Aboriginal peoples in the US and New Zealand, those living in Canada are particularly disadvantaged in terms of mortality rates.

For Canadian Aboriginals, life expectancy is approximately five to seven years shorter than for the general population in Canada and infant mortality rates are generally twice as high, and are triple among Inuit.
- influenced by isolation, poverty, racism, and post-colonial legacies

Question 22

Describe suicide rates among Aboriginals.

Answer 22

The high mortality and morbidity rates of Aboriginal populations in Canada are accompanied by high rates of poorer mental health.
- suicide and self-injury are the leading causes of death among First Nations youth and adults between ages 10 and 44.

Compared with the national average, First nations youth (15-24 years) are nearly 7 times more likely to commit suicide than non-Aboriginals.

Suicide rates for Canada’s Inuit populations are even more severe at 11 times higher than the national average.

Depression is highly prevalent in Aboriginal populations; as many as 30% of First nations people report feeling depressed for 2 weeks or more, an indicator of clinical levels of depression.

Question 23

How does being an immigrant affect health?

Answer 23

Immigrant populations, particularly those from non-European countries, exhibit better health and live longer than Canadian-born populations.

This is partly because immigration to Canada is dependent upon an applicant’s good health.

However, the healthy-immigrant effect starts to dissipate after 10 years in Canada.

• related to lifestyle factors such as diet and physical activity, social isolation and lack of access to health care
• racial discrimination is negatively correlated with mental health, those who experience racism were 60% more likely to report having fair or poor health

Question 24

How does gender affect mortality rates?

Answer 24

In Canada, the leading causes of death for men and women continue to be cardiovascular disease and cancer; more men continue to die from both, but this disadvantage is closing, particularly with regard to cardiovascular disease.

Throughout the life course, men are more likely to die than women, although the difference peaks in early and middle adulthood, owing to the strong influence of external causes on men’s death rate.

Cancer accounts for more potential years of life lost for women, while accidents typically account for a greater number of potential years of life lost for men.

Although most of the causes of death are similar for men and women, suicide is a notable exception.

• men’s suicide rates are higher in every age group than women’s and the overall suicide rate for men is 16.3 compared to 5.4 for women in 2004
• men aged 55-64 have the highest overall suicide rate

Question 25

How does gender affect morbidity?

Answer 25

Historically, women have experienced a higher degree of morbidity than men.

Although Canadian women’s life expectancy at birth (83.6 years) is longer than men’s (79.3 years), women have more disability during their lifetime.

In Canada, women generally have higher disability rates than men, and these differences increase over the life course, with women over the age of 75 having a disability rate of 57.8% and their male counterparts 54%.

Women are also more likely to experience pain and limitations of mobility and agility.

For almost all chronic health conditions (except diabetes), women are more often afflicted than men; that is particularly the case for arthritis and rheumatism.

Question 26

How does heart disease affect women?

Answer 26

Too many women are unnecessarily suffering and dying from heart disease. They have been left behind because they are under-researched, under-diagnosed and under-treated, and under-supported during recovery. It is shocking we are only beginning to understand women’s hearts, and gains in knowledge are so slow to reach the bedside.

Heart disease is the leading cause of premature death for women in Canada (dying before reaching their expected lifespan).

• early heart attack signs were missed in 78% of women
• every 20 minutes a woman in Canada dies from heart disease
• five times as many women die from heart disease as breast cancer
• two-thirds of heart disease clinical research focuses on men
• women who have a heart attack are more likely to die or suffer a second heart attack compared to men.

Question 27

What is the differential exposure hypothesis versus the differential vulnerability hypothesis?

Answer 27

1. The differential exposure hypothesis argues that women are subject to more stressors than men on account of their heavier domestic and caring responsibilities.
2. The differential vulnerability hypothesis argues that women are more affected by stressors than men on account of a “generalized female disadvantage in social roles and coping resources.”

Question 28

How has life expectancy of Canadians changed over time?

Answer 28

The life expectancy and the overall health of Canadians increased over the 20th century.

Whereas an infant born in the 1920s could expect to live only 59 years, an infant born in 2014 could expect to live about 81 years.

The improvement is largely attributable to public health programs, sanitation, and immunization.

Sadly, the distribution of these amenities remains inequitable. Infants born in the territories have a life expectancy of 75 years compared with just over 81.1 years for Canada.

Question 29

How does mental health differ based on gender?

Answer 29

Women were thought to suffer worse mental health than men, specifically depression. However, research has shown that men and women experience similar levels of mental illness but it manifests itself in different ways.
- men are more likely to suffer from substance abuse, women more likely to suffer mood disorders

Question 30

What has research found in regards to multi-tasking?

Answer 30

Mothers spend 10 more hours each week multi-tasking, compared with fathers. Multi-tasking was associated with an increase in negative emotions, stress, psychological distress, and work-family conflict.

Question 31

How does age affect health?

Answer 31

The length of time one can expect to live and the diseases one is likely to die from have varied considerably over time, partly because of historical variation in the social factors that influence health.

The influence of the persistence of poverty, fluctuations in socio-economic status, marital status, and changing conceptualizations of race, ethnicity, and gendered meanings over the life course all contribute to health status, and all have changed historically.

The majority of seniors (81%) report at least one chronic health condition. but over 1/3 of seniors rank their heath high, with 37% rating their health as “excellent” or “very good”.

Women aged 65 and older drunk less alcohol, smoke less and use illicit drugs less than any other age or gender group.

Question 32

How has mortality rates based on age changed?

Answer 32

in 1926 Canadians aged 5-64 accounted for 54% of deaths. In 2002 Canadians aged 5-64 accounted for only 21% of deaths.

Question 33

How does education affect health through time?

Answer 33

The majority of seniors (58%) aged 65-74 who are university graduates rated their health as “excellent” or “very good” compared to 48% of 25-64 year old’s who did not graduate from high school.

Question 34

How is mental health affected as we age?

Answer 34

Mental health varies considerably over the life course.

• 70% of young adults with mental health issues report their symptoms began in childhood
• young adults aged 15-24 have the high prevalence of mood, anxiety, or substance-use disorder

Socio-economic and environmental factors in the mental health of children and youth are significant.

Mental health and well-being are increasingly being conceptualized as cumulative effects, with experiences across the life course, particularly early experiences, shaping and determining later health outcomes.

Aktar-Danesh and Landeen found that low levels of education and other SES characteristics predicted higher levels of depression and that this relationship intensified with age.
- neighbourhood factors were more strongly associated with symptoms of mental health than family SES

Gender and the meaning of gender as it changes over the life course has an impact on mental health status.

• women express far more distress than men over the life course
• as people get older, women’s self-esteem becomes increasingly lower than mens

Question 35

How does agency and lifestyle interact?

Answer 35

Lower socio-economic status has been associated with less healthy behaviours, such as tobacco use, physical activity, and poor nutrition.
Low SES individual living in poor communities have less access to grocery stores and affordable fruit and vegetables. They have less access to gyms.
Children in the poorest communities gained the greatest amount of weight over an eight-year period. It is the negative effect of poverty (rather than the protective effect of higher income) that accounts for weight increases over time.

Canadians in the highest income groups are more likely to be physically active, to take vitamins, and to eat fruits and vegetables than are those with lower family incomes.
However, high SES get 35% of their dietary intake from fat, compared to 15% from low SES.

Question 36

What has been found in research of smoking on health in Canadians?

Answer 36

Smoking is on the decline in Canada, with 16.1% of Canadians smoking in 2014 compared to almost 30% in the early 1990s.
Immigrants tend to smoke significantly less than Canadian-born citizens.

Smoking accounts for much preventable illness and death

• in 2014 about 26,000 Canadians were diagnosed with lung cancer and about 20,000 (27% of all cancer deaths) people died from lung cancer.
• men are still somewhat more likely to develop lung cancer than women, but the gap is narrowing.

When the number of cigarettes smoked is controlled for, the ill effects of smoking are greater among those from lower SES groups than among those of higher SES groups.

Question 37

What are some health risks for men compared to women?

Answer 37

Although men are more likely to be physically active than women, the fact that women are less likely than men to engage in binge drinking, to smoke, or to be overweight contributes to the higher risk of premature death from heart diseases among men.

Men engage in riskier activities than women and are more likely to die as a result of suicide and motor vehicle accidents.

Men are also less likely than women to visit a physician and more likely to have emergency-room visits, while women tend to survive longer than men with the same chronic conditions (e.g., heart disease, lung cancer).

Question 38

How is access to health care in Canada?

Answer 38

Access to health care, even within the “equal access” Canadian system, varies on the basis of class, gender, ethnicity, race, and age.

Poverty, for example, can impede access to health care in concrete ways.

• mothers of many children in low SES attend many less appointment than mothers in high SES
• people in low income households are 10 times more likely to report unmet health care needs than people in middle- to high-income households.
• higher rates of morbidity in low-income neighbourhoods are thought to explain the higher levels of hospital utilization

Immigrant status does not appear to lead to differences in physician visits.
- for both Canadian-born and immigrant populations with low incomes, the number of physician contacts is higher than for similar high-income Canadians

Question 39

How does SES affect access to surgery?

Answer 39

Even though people from lower-income and poorer neighbourhoods use hospitals more often than people from higher income neighbourhoods, they undergo less surgery.

Roos and Mustard argue that this is due to the underuse of specialist services by lower-income individuals, possibly owing to better access and a stronger communicative relationship on the part of individuals from higher SES.

Specialists and surgeons offer more treatment to people with higher SES, perhaps as a result of referral decisions from a treating physician.

Specialists visits are significantly less for those living in low-income households, visible minorities, Aboriginal people, and those over the age of 75.

Question 40

What is accounted for as “lifestyle behaviour”

Answer 40

The decisions people make about whether to smoke, how much to drink, how much physical activity to get, whether to engage in risky activities, whether to participate in preventative health actions, etc. are all “lifestyle behaviours”.

Question 41

How does being Aboriginal affect lifestyle behaviours?

Answer 41

Aboriginals face higher levels of smoking, obesity, and alcohol consumption. Likely due to the poverty and discrimination faced.

Question 42

How does alcohol consumption change by CAGE?

Answer 42

Whites drink more alcohol over their lives than blacks or hispanics, however blacks and hispanics drink more in later life per occasion than whites.

Men drink more than women, and people who had many children or were regular churchgoers were found to drink less.

Using alcohol and illicit drugs is much more common for male young adults.

Question 43

How does being Aboriginal affect access to health care?

Answer 43

Aboriginals living on reserves have very little access to physicians and hospitals; in the territories, only 31% of off-reserve Aboriginals reported having a regular doctor compared with 67% of non-Aboriginals in the region.
52 communities across Inuit Nunaat did not have year-round access to doctors and that only a few communities had hospitals.

Question 44

How are health care professionals influenced by CAGE?

Answer 44

The actions and decisions of health care providers have been shown to be influenced by racial or ethnic backgrounds of their patients.

Geiger notes that “disparaging racial stereotyping, not clinical data, was predictive of refusal to recommend bypass surgery for many African-American patients in one large series of cases.”

These findings suggest that once a person is in the medical system, the services that are made available to them vary on the basis of race.

• African-American patients and patients from lower-income groups are perceived in a variety of more negative ways than white patients and patients from higher-income groups; believing they are less compliant and less intelligent
• patients are less likely to ask questions and be active health care consumers when they are aware of hostility or negativity on the part of their physician

Question 45

How does gender affect access to health care?

Answer 45

Men are much less likely to visit physicians or consult a specialist than women.
- in 2010, 20% of men reported not having a regular medical doctor

According to the constructs of masculinity, health-conscious behaviour fails to connote a “strong” persona and is considered to be “feminine.”

This is an instance where gender structures work against both men and women.
Physicians provide less information to men than women and spend less time with men, and this may jeopardize men’s health.
The fact that physicians spend more time with women may also be the reason for the overmedicalization and pathologization of women’s bodies.

Hence, although women’s use of the medical system is thought to be due to their greater tendency to be ill and their overuse of health services, men’s utilization of health care is considered a sign that they are healthier than women.

Question 46

Define medicalization. What is it’s consequences?

Answer 46

The defining of a natural biological event or progression as a form of illness requiring medical intervention and treatment (ex. menopause has been treated with hormone replacement therapy.)

When women voice dissatisfaction or anger about their life circumstances, physicians have tended to see the problem as an internal one requiring a medical solution (e.g., psychotropic drugs) rather than as a symptom of societal inequality requiring a societal solution.

Question 47

What has been found in research in Hormone Replacement Therapy (HRT) in women? What is the author questioning?

Answer 47

That HRT causes breast cancer. After this finding came to light, 14 000 cases of breast cancer were avoided. The author is questioning why more women aren’t outraged by this finding.

Question 48

What are the four structural factors that Vertinsky says contribute to the limited physical activity of women?

Answer 48

1. The authoritative role played by medical discourse in discouraging strenuous exercise for both younger and older women;
2. The impact of media and beauty standards that see physical fitness only as a means to reach unattainable standards, along with the perception that women are naturally weaker and less physically able;
3. Ageist assumptions about physical abilities of older women, along with the reliance on drug therapies; and
4. Racial and ethnic bias in accounts of physical activity, with young, white women idealized in sport.

Women’s positioning within the processes of production, reproduction, and distribution means that women of various ages and racial and ethnic backgrounds tend not to have as much money or time to spend on physical activity as men do.

This suggests that ideological structures combine with material structures to influence lifestyle “choices.”

Question 49

How doe the reproductive processes of women create an unequal health disadvantage? What seems to be the equivalent for men?

Answer 49

There seems to be a “cost of caring”. Engaging in unpaid work can lead to higher stress and lower levels of health. Walter and colleagues studied registered nurses and found that unpaid work substantially affected health for women. Women were much more affected by caregiver burdens and time constraints and had to contend with “having to divide themselves up in pieces and juggle things”. They have the burden of “double days”.
Men suffer from greater occupational concerns which affect their health more negatively than for women.

Question 50

Why do Aboriginals suffer from significantly lower levels of health?

Answer 50

Poverty, geographic isolation, lack of housing

- as many as 47% of Aboriginal lone parents are in need of core housing

Question 51

Define hypersegregation.

Answer 51

The situation in which disproportionate numbers of minority-group members are located in impoverished, dangerous, and environmentally polluted neighbourhoods.
Poor African-Americans more often live in extremely disadvantaged neighbourhoods than do poor non-Hispanics whites.
The hypersegregation or ‘housing discrimination that blacks face at every level of socio-economic status but especially at the low end . . . May partially explain the disparity in health outcomes between poor blacks and poor whites.”

Question 52

Where does Ramanow recommend the federal government dire more money to health services?

Answer 52

1. Home care
2. Primary patient care
3. “Catastrophic” drug care, ex. HIV/AIDS