Lecture 4 Flashcards
health disparities, explanations, relationship with SES, intergenerational trauma, and minority stress model
Social Context of Health
What are Health disparities?
Inequalities (differences or gaps) in health (morbidity and mortality) or health care between groups (Groups of race, ethnicity, gender, culture, region, access to healthcare, etc.)
Health disparities matter because:
We need to identify which groups are facing health disparities and discuss ways to treat it
We acknowledge those disparities but we don’t take into account race or ethnicity
To improve the overall quality of life in a group—maximizing the resources of our popular to make it better, diversifying ideas and opportunities to be creative
There are serious limitations on human potential when facing health disparities
To see such severe health disparities is an interesting point of consideration, especially in Canada where there is free healthcare
Social Context of Health
Discuss Health Disparities in Canada
Disparities do exist in Canada and in some cases are growing
Examples include (but are not limited to):
Shorter life expectancies among those living in lower-income areas.
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
The pandemic has exasperated existing health disparities, especially in terms of socio-economic status
Social Context of Health
Discuss the health disparities faced by Indigenous populations
Half of indigenous peoples live on reserves, and half live off of reserves
First Nations,Inuit and Metis
Population of about 1.8 people total in Canada
Higher infant mortality, lower self-reported health (heart disease, obesity, diabetes, asthma) higher mental illness, 4x more lilely to experience stress and trauma, and youth are 5x more likley to due by suicide (11x more likleuy among Inuit youth)
Different age brackets and genders can affect this result
Male youth can be up to 40x the national average
Life expectancy—Inuit males and females are significantly lower (Inuit males can be 15 years less than national average)
Self-reported health by Indigenous people aged 12+ — those who are non-indigenous were more likely to rate health higher
Self-report is effective in predicting later health outcomes, because the individual has a better grasp on other life factors that affect them
Chronic conditions: generally speaking, health on reserves is worse than other indigenous communities
Greatest health disparity is diabetes
Worst rate of diabetes in the world—of all types of diabetes
Those who are affected the most are First Nation peoples living on reserves
Social context to health
Discuss Diabetes among First Nations
Environmental and lifestyle factors are largely to blame.
Less healthy diet, lower consumption of traditional foods, and less physical activity due to historical changes to way of life (PHAC, 2011).
Environmental, diet lifestyle factors at play (not chosen)
**Is poverty a factor? Yes. **
Lower-income and education are believed to play a role in the increased stress and poorer health of Indigenous peoples (Bombay et al., 2009; Mikkonen & Raphael, 2010).
Discussion: How might these factors lead to diabetes?
Diet: fewer healthy dietary options, type 2 diabetes and processed food
Stress: elevated cortisol levels
Both high blood glucose and overtime, insulin resistance
Support for environmental and lifestyle factors playing a role
Thrifty gene effect—First nation women were mor likely to conserve calories, not proven and is pretty much misinformation
Keeps being brought up as a matter of just genetic differences
First Nation people were not able to access traditional food sources
Damming of rivers, relocation of entire communities
Generally more unhealthy diet for communities in reserves and those of compromised lifestyles
Cost of food in some communities is extraordinarily high
$70 for a watermelon sometimes
Less physical activity since traditional lifestyle is compromised
Social Context to Health
Discuss Poverty in Indigenous Communities leading to health disparities
On-reserve Living
Between 47 and 53% of First Nations children living on reserves live in poverty
In the media: Spiralling suicide rates in the Ontario First Nation of Attawapiskat
2016: Attawapiskat declares states of emergency over spate of suicide attempts
Population of 2000; Over 100 suicide attempts (ages 9-71) in 7 months (2016).
30 suicide attempts in March 2016.
11 suicide attempts (ages 9-14 years old) on the night of April 9, 2016
Remote location does not make mental health support easy
Water quality is one of many factors
Sense of hopelessness, lack of opportunities and help provided
Probably still ongoing
Lack of adequate housing, and no land to build the housing with homes in serious disrepair
Lower income and lower rates of education
Specifically in its effect on stress
Chronic stress—poverty and living in poverty
Link of poverty on higher blood sugar (glucose) levels
Poor diet based on financial needs (more sugars)
Food choices are often high-calorie, low nutrition food
Also being higher in cortisol
Two factors: diet and stress —> higher blood sugar levels
The territory of Nunavut had the highest rate of suicide in the world
Young, Inuit, adult men have a high rate of suicide—almost 400 out of 100,000 people
Inuit people, compared to other groups, expeience the highest rate of suicide
Lack of access to resources and access to healthcare in northern regions
Trying to better manage intergenerational trauma—and community identity
And trying to get more counselors and therapists in these communities—not a solution for the underlying issues
Social Context to Health
Discuss the Trauma of colonization
leading to health disparities
Trauma of colonization
European colonization—new disase, loss of land, criminalization/loss of culture, genocide, and forced assimilation
Has been recognized as the single most social determinant of stress on Indigenous populations by WHO
Increased psychological distress and PTSD
Up to 64% of residential school survivors met the criteria for PTSD
Conclusions:
Direct experiences of trauma—the ongoing effects of colonization, and built into social institutions that continue to lead trauma
Vicarious trauma
Lack of cultural identity
Ongoing discrimination and marginalization
Compromised parental functioning
Modeling of poor coping
Communities with no mental health support would have poor coping
Genetic/biological vulnerabilities
Social Context to Health
What is intergenerational Trauma?
Thinking of the lasting impacts→ Intergenerational trauma
Trauma is passed down to subsequent generations, and even trauma symptoms in the absence of traumatic events (with on-going things at play)
Modelling of coping beahviour
Cope less well with stress
Impact on parenting (people with PTSD)
Greater impact parenting, behavioural mechanism like coping, trauma can be passes on that way, maybe they’re not as attentive or nurturing as parents
Discussion: direct and indirect mechanisms involved in intergenerational trauma
* Direct experiences of trauma
(How they were treated, ongoing effects)
* Vicarious trauma via stories, especially from those they love and are close to
* Lack of culture and cultural identity; attacked and compromised
* On-going marginalization and discrimination
* Compromises parental functioning
* Modelling of poor coping
* genetic/biological vulnerabilities
Social Context to Health
What is the Epigenetic effects?
Epigenetics: The study of changes in organisms caused by changes in egen expression (that are due to environmental influences)
EX Rat study in UBC
Grooming behavior of mother —> Offspring health
Some rats lick their pups more than others
Lower frequency of licking and grooming —> higher stress reactivity—especially in the 1st week of life
Concrete evidence of at least 2 generations of transmission in animal research
Psychological functioning, to an extent, are results of the experiences of your grandparents and the resources they had at the time
EX Early stress in male rats
Stimulates PTSD by stressing the rats earlier
Isolation, jumpiness and exaggerated struggle response
Observed epigenetic changes—specifically changes in cortisol regulation
Pups had no interaction with their father (to remove any foreign environmental influences)
Otherwise given a very enriching environment, with lots of attention from the mother
Potential to reverse epigenetic changes—not impossible to reverse, but very difficult
Easier when the remedy is introduced earlier in life for the child
Idea that father could have interventions that could reverse the effects—is very implausible
Epigenetic effects can also happen in adulthood
If you provide offspring that has inherited epigenetic effects with an enriching environment, it’s possible to reverse some of those effects
The issue:
Cannot look at these effects directly
Often have to rely on correlational studies
To uncover epigenetic effects that are inherent in nature
Some epigenetic effects are not intergenerational—the prenatal effects can be had from things that the mother is going through (like higher cortisol levels affecting the fetus)
We want to observe people before they see epigenetic effects, follow them, witness their life events, and then witness their children
Intergenerational Epigenetic Effects: Epigenetic changes can be heritable via various processes; can affect multiple generations
One study found that women who were pregnant and in the twin towers in 9/11 had symptoms of PTSD and anxiety—and their children also had those effects
Social Context to Health
Discuss the Intergenerational effects of residential school
Possibly of intergenerational epigenetic effects
Is correlational in nature—so is limited in that aspect
EX Study of 20 adults who had parents that were residential school survivors
Adults who had either their mother, father, both or grandparents in the residential school system
Both maternal and paternal residential school survivors —> heightened childhood adversity in their childhood
Study asked individuals to self-report childhood adversity
Common for researchers to ask adults about their early childhood environment (how safe you felt at home? what are your relationship like with your parents? did you have resources growing up? did you eat 3 meals per day?)
Also examined allostatic load
7 bio markers
Included: cardiovascular reactivity, blood pressure, cortisol reactivity, cortisol levels, waking cortisol levels, BMI, inflammation
Maternal survivors only showed increase in allostatic load
Perhaps there were prenatal effects
Childhood adversity —> one possibility is that maestral survivors lead to higher childhood adversity, and then led to higher allostatic load
Childhood adversity is a psychosocial variable
In this sample, childhood adversity did not mediate allostatic load—so maternal trauma might have been embedded in children
Biological mechanism: perhaps epigenetic in nature, but not confirmed
Social Context to Health
Discuss the role of cultural identity on health
Cultural identity is a key factor in health.
Historical and ongoing attacks on Indigenous culture have compromised cultural identity clarity
Connection to own culture
Individualist vs collectivistic culture mismatch was an explanation
Today it is a compromised cultural identity clarity in suicide rates
On-going attacks on culture, think about health outcomes on gender and race, its the same idea
Cultivating a stronger cultural identity may be an important way to reduce the impact of stress and trauma on the health of Indigenous communities
More resilience
People with less cultural idnetity clairty has higher isk of suicidal ideation
Friction and tension between the fact that Indigenous cultures are collectivist—but they are in a individualistic environment
Nowadays, we believe that it’s the attacks on cultural identity that reduces cultural identity clarity
Regulating, prohibiting and attacking has lead to less cultural clarity
Also other marginalized groups—when their sense of inditeity is compromsied, tehya re mor elikely to attempt suicide
Furthermore, in these other groups, there’s also evidence that the primary factor is ongoing discrimination, stigmatization and marginalization
The discussion is to cultivating a stronger cultural identity may be important on reducing stress and trauma
Being surrounded, maintaining connections, with your culture could be good
Social Context to Health
Discuss
Factors in Resilience in Indigenous communities
Indigenous communities have demonstrated resilience in the face of profound trauma, and despite ongoing threats to cultural identity, e.g., discrimination
decreases in youth suicide, improved education, and fewer children being placed in foster care
Looks like reclaiming ownership of land, self-governess, control over community and having a cultural centre
Autonomy and independence
In Indigenous youth (urban and rural), a sense of connection to the land and nature and engagement with nature have been associated with better health and resilience (Hatala et al., 2020; Lines et al., 2019).
“Aboriginal law and life originates in and is governed by the land. The connection to land gives Aboriginal people their identity and a sense of belonging.” (Jens Korff, 2021)
Reclaiming: regaining title over ancestral lands, regaining of control of the local gov’t, regaining control over education in their communities, enhancing cultural resources (like cultural centers and cultural events)
Regaining control—an effect of perceived control on a larger socio-cultural scale—a sense of autonomy
The common theme of control
Social Context to Health
Discuss Socioeconomic Status (SES)
Role of SES in health—organized population in income quintiles
Lowest income to highest income, distribution people into 5 different groups
Lowest income quintile: average mean personal income of 16,000 per year
Includes people who have no income at all
Highest income quintile: average mean personal income of 85-90,000 per year
Includes millionaires
Gradient relationship: greater income —> greater life expectancy
In reality, you can divide people any way you want (groups of 10 or 20) and there’s still a gradient relationship
Better average health overall in richer people
This is seen in risk of disease and duration of cancer
Also mortality rates in HIV/AIDS
Social Context to Health
What is the Socioeconomic gradient in health
Each rung in the income ladder —> less sickness san better life expectancy and improve health
This increasing effect also plateaued eventually—when you already have a lot of income, having more income will affect your health outcomes less
Especially compared to when you have less income—in this case, when you have less income and then make more income, it will affect your health outcomes much more
Happiness and level of overall stress plateaus—but life satisfaction continues to increase the more income you make
This gradient is supported of 10,000+ studies
Just difficult to determine a casual source
There’s a directional relationship—but multiple papers assert that there’s a lot of evidence about a causal effect of more income —> healthier lives
Social Context to Health
Discuss the Status-Health relationship
Chronic stress should be the first thing you’re thinking of
It’s a key mechanism for those of lower status, and decreased health outcomes
Low SES report more stressful life events and more chronic stressors
They also interpret stressors as more threatening
Higher SES will interpret the same stressors as less demanding
So appraisal is also affected
Disadvantaged people also cope less effectively with stress
Some people come to expect that bad things will keep happening in poverty — and they give up, learning that they don’t have an effect
Less perceived control
“There’s no small stuff”
Richer neighborhoods can surpass life expectancy over 20 years compared to some poorer neighborhoods
The lack of choices and lack of perceived control
Brings up the point that there’s a difference with stress—disadvantaged people worry about everything though
When you have money, some things that seem devastating might not even affect them
Social Context to Health
Low SES and its associations
Low-SES individuals report more frequent stressful life events and more chronic stressors
Low-SES individuals tend to interpret stressors as more threatening
Disadvantaged people (including those with lower income/status) also cope less effectively with stress
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
Problematic for everyone but especially those on the bottom
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
Chen et al. (2007) have found increased asthma symptoms among youth living in poorer neighbourhoods
Social Context to Health
What is the “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:
Shifting oneself: accepting stress for what it is and adapting through reappraisals
Persisting: enduring life with strength by maintaining meaning and optimism
Nothing new here, maintain a sense of purpose, challenge vs. threat, optimism
How exactly is social inequality having a negative impact?
What’s the impact on the group?
There is a strong suggestion of a causal link or effect between inequality and health in a society
Suggested by Wilkinson:
Higher levels of competition
People compete more over access to resources —for people can access resources
Widened gap = more people spread out over the SES ladder
Greater distance between people = more speed on the ladder
Social evaluation anxiety: increased stress due to greater stress to self-esteem, social status or fear of judgement
More concern about your place in society
More concern about how other people will view you, your status can vary so much
Social ordering and dominance hierarchies are also a very potent stressor
Doesn’t matter how you get inequality — pay gaps, or higher taxes
Everyone is affected — not just those who are lower income, even higher income people are worse off
Brings in status anxiety, involving the sentiment of “people are looking down on me because of my status or income.”
Status anxiety is lowest for everyone in more equal countries
Reason for everyone to care about this
The implication that rises from this work isn’t that we need a socialist society — just a recommendation that we need to narrow the gap or stop the gap from growing
The fallout is the people who work in public health
In some ways, the gap is a large, but necessary problem to solve
In more diverse work teams, they produce better outcomes
When everyone goes in with the same ideas, then there’s less creativity
Minority Stress and Stigma
Define Stigma and Marginalization
Stigma: the experience of negative attitudes or behaviors based on group membership or affiliation
Shame is often associated
Marginalization: treatment of person or group as less important
Minority Stress and Stigma
What is the Minority Stress Model?
stigma, prejudice, and discrimination create a hostile social environment → leads to increased stress for minorities and increased incidence of disease and illness
Simply living in a social environment with that aggression has an effect on health, they don’t even need to personally experience discrimination
the knowledge that you are apart of a stigmatized group creates an ongoing marker of chronic stress
Creates a lot of fear and anxiety over time
Supported in 100s of studies
Racial and sexual minorities
Bulk of studies on African-americans, supporting the minority groups
Some with LGBTQ+ individuals
Depression and substance use and suicide (particualrly in LGBTQ+ groups) are increases
Some suggestion in research that JUST being a minority isn’t a source of stress
It’s also because of stigma and marginalization that’s ongoing as a function of their social status
Could be their condition in poverty
Specific sources of stress in minorities:
Direct experiences of stigma and discrimination
Less direct experiences of social stigma and internal bias towards themselves
Can lead to a lot of self-loathing over time
We also recognize increased likelihood of rejection and the expectation of rejection/exclusion
EX Racism and sexism in hiring culture
Hiding or concealing identity (especially in LGBTQ+ community)
Minorities are also far more likely to live in poverty —not just by ethnicity alone, LGBTQ+ members also are affected
Discrimination and stigma prevent these minorities from escaping poverty
Minority Stress and Stigma
Discuss racism and health
Mental burden on the targeted people or groups
Cortisol explaining health disparities also explain the health outcomes we associate with racism
Everything from substance abuse to cardio-vascular disease are heightened
Institutionalized racism: biases in social systems, policies or institutions that lead to differential treatment
Limited resources and opportunities over time —> more stress
Personal experiences of racism: more directly cause heighed stress
Factors in Resilience
In racialized groups (e.g., African Americans), 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 (Brown & Tylka, 2010).
A strong suggestion of clarity and confidence is key
Similar to the conversation surrounding Indigenous peoples
Findings suggest that racial identity clarity also matters
Learning about one’s raccial history and developing a strong sense of identity and history —> better health and wellbeing, lower risk of suicide
Cultural Identity Clarity
Minority Stress and Stigma
Discuss the topic of Trans Stigma and Stress
One of the worst stigmatizations and marginalization
Survey found that 2/3s faced stigma and discrimination, 1/3 are physical threatened or injured, others reported poverty, limited access to healthcare
Suicide rates are alarmingly high
41% in a study attempted suicide
77% seiously considered suicide, 43% attempted suicide
20x the national average
Reasons are:
Direct experiences of exclusion and discrimination
Including experiences of discrimination from family and loved ones
Some gender dysphoria, it is a potent stressor — but it’s not the leading cause of suicide
Resilience
Social support
Personal control
More positive coping responses (positive reappraisal)
Importantly, like other communities, stronger gender idenitity clarity —> less risk of suicide
This is underscored by a lack of direct attacks on identity
Recent study found that gender-affirming care in early childhood resulted in a 52% drop in suicidality (compared to 5% in the control group)
Important to grasp how every medical institutions will do gender-affirming care is to save lives — not just to make people happier
Back to the idea of control and having control of the body and care experience better outcomes due to gaining autonomy
Resilience on the greater sociocultural level for control, not just personal control
What are the effects of disease threats?
Some countries might have access to more resources and better healthcare (EX more vaccines)
Regarding inequality it can exspeerate the SES disparities in disease threat
Higher rates of illness in lower SES people — will continue to widen the gap in poverty
Harder to catch up, harder to take time off of work
The divide is widened further
Being closer to the bottom will fall harder
But being at the top will continue profiting
Pandemics can either worsen poverty (defending the status quo when we are faced with disease threat) or can reduce inequality (if only happen if the pandemic is so bad, and the status quo is upheaved)
Throughout history, infectious diseases have been associated with “othering” (racism, xenophobia, bigotry)
“Outbreaks create fear, and fear is a key ingredient for racism and xenophobia to thrive.” (Devakumar et al., 2020, The Lancet)
Increased nationalism due to fear
Historical pathogen prevalence around the world has been associated with closed-mindedness and authoritarianism (Murray et al., 2013)
Become more narrow-minded
In the media…
COVID-19 fueling Anti-Asian racism and xenophobia worldwide
What can we do to mitigate such effects?
Reflecting on Factors on Resilience
Communities regaining control fare better — more perceived control is better
Strong support networks and social ties
For minorities, being able to foster connections within your community and group
Identity clarity
Strong sense of one’s identity
Important observation that discrimination and marginalized limit one’s sense of identity
Engaging in positive appraisal
Shift in response — people living in poerty and maintaining optimism
Being able to maintain a positive outlook tend to fare better
Low SES —> increased morbidity
Expanded that to include more factors —like subordination, or low social rank
This is mediated by chronic stress
Link between lower status and chronic stress
But why?
Social evaluation, more likely to be stigmatized and discriminated against
Lower perceived control
These are very prominent sources of chronic stress
Lower SES —> Chronic Stress —> Lower Health
