Module 4

Question 1

Closing the Gap

Answer 1

In 2005, the Closing the Gap Commission was set up by the WHO as a call for action to address these social issues and achieve global health equity.

Question 2

gaps in global health

Answer 2

The gap in global health can be described as the health inequities that exist between wealthy and impoverished populations. Populations with the lowest income have high levels of illness and premature mortality

Question 3

life expectancy across the globe

Answer 3

an example of a gap in global health
life expectancy varies depending on the country you live in
people who live in high income countries tend to have greater life expectancies than low income countries

Question 4

social determinants of health

Answer 4

• Unemployment and job security
• Gender
• Indigenous status
• Disability
• Housing
• Early life
• Income and income distribution
• Education
• Race
• Employment and working conditions
• Social exclusion
• Food insecurity
• Social safety net
• Health services

Question 5

social gradient

Answer 5

the concept that, as wealth increases, so does health, in a stepwise fashion

Question 6

poverty impacts on health

Answer 6

Poverty can affect health both directly and indirectly. When living in poverty, it is challenging for individuals to buy healthy foods , or attain clean and safe living conditions, negatively impacting their underlying health. Other indirect consequences of poverty include the stressors that are placed on individuals, which can include the mental burden of financial stress, and the feeling of lacking support.

Question 7

the poverty trap

Answer 7

the mechanism that explains how individuals who are in poverty are trapped in poverty unless an external force intervenes by providing them with a significant amount of money and resources. The actions of those who are in poverty become self-reinforcing mechanisms that will keep them in poverty. For instance, if an individual working a low-paying job increases their working hours to make money for essential needs, they are more likely to get sick and have less time to improve their skills for a better job.

Question 8

GDP per capita across the globe

Answer 8

Every country has a Gross Domestic Product (GDP). The GDP is divided by a country’s population to get the GDP per capita. This measure is used as a comparative measure of economy and standard of living between countries. Values are normally presented in USD

Question 9

the WHO’s Closing the Gap in a Generation Report

Answer 9

In 2008, the commission called on the WHO and all governments to lead global action towards closing the health gap in a generation. The call to action was published in a report entitled Closing the Gap in a Generation: Health equity through action on the social determinants of health.
this report identified key social determinants of health that are crucial to creating this health gap

Question 10

ways to close the gap

Answer 10

3 key ways were proposed:
1. improving daily living conditions
2. addressing inequalities in power, money, and resources
3. measure and understand the problem and assess the impact of action

Question 11

improve daily living conditions

Answer 11

Improve the conditions in which people work and live, and implement a universal social protection policy to protect all individuals from insecure employment. Also, improve the circumstances in which children are born, and put an emphasis on equal childhood development and education between boys and girls to promote lifelong health.

Question 12

areas to address to improve living conditions

Answer 12

Equity from the start

Healthy places, healthy people

Fair employment and healthy work

Social protection throughout life

Universal health care

Question 13

addressing inequalities in power, money, and resources

Answer 13

Address the inequities that occur in the division of resources and power across the public and private sectors through effective health policy

Question 14

measure and understand the problem and assess the impact of action

Answer 14

Increase global health research through implementing effective measurement of health and the social determinants of health, as well as evaluate the impact that policies have on health.

Question 15

understanding of health

Answer 15

Traditionally, health is thought of in medical terms. In reality, health should also be viewed socially, so that changes can be made to social and economic conditions that will have positive impacts on health.

Question 16

housing and home environment

Answer 16

Housing is a key social determinant of health. It can be further understood by exploring its three main dimensions. These include the physical and structural elements, the social meanings attached to a house, and the spatial location of a house.

Question 17

housing and home environment: physical dimension

Answer 17

The physical condition of a house should meet all of an individual’s basic survival needs. This includes having clean water and sanitation, electricity, plumbing, heating, proper ventilation, and a safe infrastructure
Poor housing conditions are associated with high rates of communicable diseases, injuries, violence, poor nutrition, and mental health problems

Question 18

housing and home environment: social dimension

Answer 18

The social dimension of housing involves aspects such as affordability and home ownership; which contribute to a person’s sense of belonging and control over their home
Moreover, the domestic environment is also central to this dimension, where a personal sense of safety and stability and lack of overcrowding lead to the health and well-being of a household

Question 19

housing and home environment: spatial dimension

Answer 19

The spatial dimension of housing refers to the location of a house in relation to other things in its environment. This includes the distance to schools, healthcare services, recreation areas, and grocery stores
The proximity to industrial waste and other environmental contaminants is also important to consider.

Question 20

impacts of poor living conditions on health

Answer 20

Poor sanitation, crowded living quarters, and poor ventilation contribute to the spread of communicable diseases. Refugees also struggle with mental health issues due to difficulties integrating with the community, which builds up into frustration.

Question 21

living conditions on Indigenous reserves

Answer 21

Indigenous Peoples living on reserve have many health outcomes that fair worse than the general Canadian population. Many of these outcomes are the result of poor living conditions. One example of these below standard conditions are long term drinking water advisories.
- As of December 2020, there were a total of 59 long term drinking water advisories in 41 communities, many of which were Indigenous reservations.
- One community, the Neskantaga First Nation, has been under a long term drinking water advisory for over 25 years.

Question 22

early childhood development and health

Answer 22

Adequate living conditions are particularly important to ensure healthy early childhood development. In the first six years of life, a number of instrumental developmental changes occur that allow children to reach their full potential. In particular, the healthy development of the brain allows for progression of linguistic, cognitive, and psychosocial development.
At least 200 million children globally are not achieving their full development potential due to poor living conditions in early life.

Question 23

equity from the start

Answer 23

• Equity from the start means that every child is given the same opportunities and access to services such as education, food, and nutrition, health care, and that they grow up in safe and healthy environments

Question 24

the Jamaican Study

Answer 24

The Jamaican Study was a longitudinal study that looked into the relationship between ensuring the healthy development of children, both physical and psychosocial, and a child’s later development in life
This study in Jamaica was done over a 24-month period. They took children who were stunted and they had four different groups: one control, one group supplemented with high nutrition, one group stimulated psychosocially, and the last group was both stimulated psychosocially and also had nutrition. Group four had the best development. This study highlighted what people already knew: early childhood development is a really key time to be able to make a huge impact on the social determinants of health and on the health of an individual in the future.

Question 25

effect of employment and working conditions on health

Answer 25

The employment and working conditions of individuals can have profound effects on health and health equity. When individuals work in healthy conditions, they gain financial security, social status, personal development, social relations, self-esteem, and protection from physical and psychosocial illness

Question 26

adverse working conditions

Answer 26

tend to be clustered in lower-status occupations. They are associated with poor physical and psychosocial health and stress, which has been shown to increase risk of coronary heart disease by 50%
Some examples of adverse working conditions include a physically or psychologically demanding job, low job autonomy, inflexible working hours, and an effort-reward imbalance

Question 27

job security

Answer 27

Unemployment can have profound negative impacts on physical and mental health through financial insecurity, material deprivation, a lack of opportunities for personal development, and increased stress

Question 28

COVID 19 and employment

Answer 28

There are many professions, such as manual labourers and those in retail, that do not have the luxury of working from home. Individuals in these positions barely make enough money to survive on a daily basis, and so they’ve had to choose between not earning enough money to meet their basic needs or returning to work and putting themselves (and their families) at risk of becoming infected with the virus.
In addition, with children being out of school, the cost of childcare can be far too high to make it worth going to a low-paying job, and so some people had to stop working
For individuals that do have the ability to work from home, the home environment can be a source of domestic violence and abuse.

Question 29

migrant work and early childhood development

Answer 29

Early childhood health and development is crucial in preventing future illnesses and diseases.
- The construction industry is the second largest employer in India, employing almost 30 million workers. Migrant construction workers in India cannot afford to pay for childcare for their children. As a result, 3 million children can be found unsupervised on construction sites across India

Question 30

Mobile Creches Program

Answer 30

The problem of unsupervised children on construction sites across India was identified by Meera Mahadevan in 1969. To address this issue, Meera founded the Mobile Creches program, which runs daycare centres at construction sites in India, providing a safe and enriching environment of children of migrant workers. This type of environment promotes healthy development allowing the children to reach full potential and is associated with positive health outcomes throughout life.

Question 31

neighbourhood and natural environment

Answer 31

In the Closing the Gap in a Generation report, the second goal for “improving living conditions” was Healthy Places Healthy People. In addition to the home environment, discussed before, this also involves improving the larger built-in environment where people live, which has a large impact on physical and mental health.
Related to this is the WHO’s Healthy Cities program, which is a long term international development initiative that aims to create an environment that supports health and a good quality of life

Question 32

Healthy cities, healthy communities movement

Answer 32

With a growth of urbanization, people living in cities usually have better access to opportunities and healthcare. However, city life leads to sedentary lifestyles, pollution, and crowded living conditions, which can negatively impact population health

Question 33

urbanization and health problems: crowding

Answer 33

○ With an increase in urbanization comes an increase in population density. If the volume of stores and access to service does not keep up with this increases population demand, then the increased population must compete for the limited daily resources

○ In order to keep up with demand, urban centres get more investment, while rural communities, including many Indigenous communities, end up suffering from underinvestment and lack of access to essential services

○ Urbanization also leads to city level crowding, because a greater population must live in the same geographical location. With limited space, the cost of housing increases, which can then lead to crowding at the family level

Question 34

urbanization problems: violence

Answer 34

○ With increased urbanization and crowding, there tends to be an increase in disparities in the standards of living amongst citizens, which may lead to conflicts over resources
○ As well, urban cities tend to have areas with higher crime rates, which create insecurity for much of the population. Often women, migrants, and refugees bear the brunt of this lack of security, which significantly impacts on their livelihoods, health, and access to basic services

Question 35

urbanization problems: diseases

Answer 35

○ In urban centres that experience crowding and urbanization, there is an increased risk of the spread of communicable diseases due to a large population living in a close proximity

○ Research has shown that urbanization accounts for significant changes in dietary patterns and physical activity levels, which increase the risk of obesity in children, and increase both injuries and non-communicable diseases in the urban-poor

Question 36

urbanization problems: physical inactivity

Answer 36

here is increasing evidence that the design of a city strongly impacts the walkability and access to services
○ For instance, if there are sidewalks and safe neighbourhoods, individuals are more likely to take active forms of transportation
Conversely, if there are more fast food restaurants than grocery stores, it is easier for individuals to pick up less healthy fast food

Question 37

urbanization problems: climate change and pollution

Answer 37

Urbanization has also led to increases in greenhouse gas emissions, which is the main cause of climate change.

Question 38

urbanization problems: gentrification

Answer 38

Gentrification is the process through which low-value neighbourhoods experience an influx of affluent residents and business, transforming the neighbourhoods to high value areas
Gentrification tends to occur once the other impacts of urbanization have happened
Although this may sound like a good way to ‘clean up’ a city, there are some major consequences. Gentrification drive up rent and property values, leading to the forced displacement of low income individuals, and changes in the racial and ethnic composition of a neighbourhood
If individuals are not displaced, then often they can no longer afford daily basics, such as healthy food
These social and economic changes are associated with a loss of community identity and social bonds

Question 39

government and social policies

Answer 39

The Closing the Gap in a Generation report identified two areas of improvement that lie within the policy level of global and population health:
1. Social protection across the Life course
2. Universal healthcare

These two areas focus on the broader structural forces that play a significant role in determining the health of the population

Question 40

social protection across the lifecourse

Answer 40

Only 19% of the world’s population have a form of social security to protect them against emergencies such as illness, disability, or loss of income and work
The WHO has identified that a universal comprehensive social protection policy is needed, because greater social security has been associated with better population health.

Question 41

feasibility of social security

Answer 41

Limited institutional infrastructure and financial capacity in low income countries are barriers to implementing a universal comprehensive social security plan

Question 42

universal healthcare policy

Answer 42

A key global aspiration is universal healthcare coverage for all individuals, regardless of their ability to pay. There are a number of innovative, needs-based, primary healthcare models aiming to achieve this goal

Question 43

racial inequality in healthcare

Answer 43

visible minorities in Canada experience healthcare inequities, which can be attributed to a lack of minority healthcare workers, meaning the current Canadian healthcare system lacks the ability to deliver culturally sensitive care. The language, cultural, and spiritual differences between physicians and patients is a huge barrier to healthcare for many racialized minorities in Canada, including immigrants and Indigenous Peoples

Question 44

optimal healthcare system

Answer 44

Given that optimal healthcare systems are characterized by an equitable system that does not rely on an individual’s ability to pay for health care, there is a need for equitable health policies.

Question 45

pillars of an optimal healthcare system

Answer 45

1. Local Action:
   Appropriate local action across the range of social determinants
2. Primary Level of Care:
   Emphasis on the primary level of care with adequate referral to higher levels.
3. Equitable System:
   An equitable system not relying on ability to pay
4. Prevention, Health Promotion, and Intervention:
   Prevention and health promotions valued just as highly as curative interventions

Question 46

health inequality in Indigenous Canadian populations

Answer 46

not every individual in Canada has equal access to health services, nor do they experience an equal quality of services. Specifically, individuals living in remote, Indigenous communities in Canada have less access to quality healthcare.

Question 47

health inequalities that Indigenous Canadians face

Answer 47

lack of access to quality nursing stations

lack of access to medical transportation

lack of support allocation and comparable access

Question 48

actions to enhance healthy equity in Indigenous populations

Answer 48

• Recognizing the Indigenous health care rights enshrined in international and national law
  
  • Establishing a dialogue with Indigenous peoples to identify and eliminate healthcare inequities
  • Acknowledging, respecting, and addressing the distinct health needs of Metis, Inuit, and off-reserve First Nations Peoples
  • Providing sustainable funding for existing and new Aboriginal healing centres to address the harms caused by Residential Schools
  • In collaboration with Indigenous healers and elders, recognizing as medically legitimate the value of traditional healing practices
  • Hiring and retaining Indigenous health care professionals, as well as ensuring that all staff have cultural competency training

Question 49

equitable health policies

Answer 49

Given that optimal healthcare systems are characterized by an equitable system that does not rely on individual’s abilities to pay for health care, there is a need to equitable health policies. Equitable health can be determined by a number of government and economic factors including finance, education, housing, employment, transportation, and health itself. To address this issue from a government perspective, it is essential that policies across departments align in their goal to produce health equity

Question 50

intersectoral action of health (ISA)

Answer 50

Aligning health policies across a number of government departments to promote health equity is called intersectoral action for health (ISA). It implies the inclusion of several sectors, in addition to the health sector, when attempting to design public policies meant to address health outcomes. ISA is crucial because most of the decisions that impact the health of a population lie beyond the health sector. The health sector must work with other sectors of government and society to address the SDHs. Canada has played an important role in intersectoral approaches. The Public Health Agency of Canada (PHAC) and WHO have been working collaboratively since 2006 to establish effective intersectoral approaches.

Question 51

market responsibility

Answer 51

Industry, or the market, can have a large impact on health. The market can bring health benefits through new technologies, and goods and services. However, it can also adversely affect the social determinants of health through economic inequalities, resource depletion, environmental pollution, unhealthy working conditions, and the circulation of dangerous goods. There are 3 main aspects of market responsibility that can be optimized for health:
- Social goods should be governed by the public sector
- Legislation should promote gender equality
- Promote political empowerment

Question 52

social goods governed by the public sector

Answer 52

Commercialization of education, healthcare, and other basic human and societal needs produces health inequity. Thus, it is advisable for these social goods to be governed by the public sector.
As an example, the transition of water services in some regions of the world to public governance. For this to be effective, public sector leadership is required for national and international regulation of products, activities, and conditions that damage health. Additionally, the assessment of impact of market regulation and all novel policies should be conducted on both a national and international scale.

Question 53

gender equity

Answer 53

Gender inequities appear to pervade in all societies, with women tending to have less power, resources, entitlements, and social value than men. As seen in the figure, women across the globe earn significantly less income than men. Further, girls and women often do not have the same opportunities for education and employment as boys and men.
Empowerment of women and reducing gender inequities is essential to reducing health inequity

Question 54

empowering women

Answer 54

Empowering women can occur through many changes made to policy that affect societal structures. Examples include:
- Legislation that enforces equity and equality
- Making discrimination on the basis of gender illegal
- Investing in formal and vocational education for girls
- Guaranteeing pay equity
- Increasing investment in female sexual and reproductive health

Question 55

gender inequality in healthcare: south Asia

Answer 55

○ South Asia is a region where gender bias towards males is socially acceptable and commonly seen. Sadly, girls in most areas in South Asia are falling behind nutritionally as a result.
○ This negative health impact continues to magnify when these girls grow up to be mothers. For example, over half of the women in Bangladesh are undernourished at reproductive age.
○ Maternal conditions directly impact the health of the offspring, meaning a female offspring may begin life in a malnourished state, and continue to live in a vicious cycle of poor health and malnourishment

Question 56

inequality in gender healthcare in North America

Answer 56

○ Gender inequality in healthcare is most observable in the LGTBIQ youth population
○ Compared to heterosexual peers, queer youth face greater risks to their health and well-being
○ Exclusion, isolation, and fear of homophobia from healthcare workers, peers, and family are barriers to accessing healthcare for this vulnerable population
○ Queer youth are at a higher risk of mental health issues. Gay, bisexual, or others that have male-to-male sexual contact are at the highest risk of contracting HIV, with almost 70% of the new HIV cases in 2018 reported in the US amongst gay and bisexual men

Question 57

political empowerment

Answer 57

Political empowerment represents the ability of individuals to contribute to and be included in political processes. Having the freedom to participate in political decision making is important for citizens because it gives them autonomy, provides an opportunity to voice their needs and interests, and allows them to challenge unfair, graded distribution of social resources.
Currently, there is inequity in who participate in political decision making, with those who are most disadvantages having the least amount of political power. This leads to an unfair distribution of societal power and resources, which contributes to health inequity. In order to reduce health inequity, ways to increase the political empowerment of disadvantaged people must be identified and implemented.

Question 58

top down and bottom up approaches

Answer 58

Two main methods for political empowerment

Top Down:
When the state works to guarantee a complete set of rights for all citizens, and a fair distribution of resources across society

Bottom Up:
Bottom up, or grassroots approaches, are founded by self organization of disadvantaged groups

Question 59

FGM

Answer 59

Female Genital Mutilation (FGM) has been a strongly entrenched practice in many of the tribes in Tanzania. Traditionally, it has been seen as a rite of passage prior to marriage, and in many cultural groups, was carried out in a ritualistic way when the girl was in her early teens. Although there is no physical benefit to the girls, in fact causing significant emotional and physical trauma, the practice has continued, with the perpetrators often believing that they were doing what was best for the girls. The WHO and the UN have clearly stated that this practice is a violation of human rights of women and girls.
In response to pressure, Tanzania passed a law criminalizing the act in 1998. although this has allowed prosecution of the parents and cutters, the cultural beliefs that it is essential for the health and well being of the girl have remained strong. In many cases, the fear of prosecution has caused tribes to perform the act at a much younger age, often in babies, so that the girls are not old enough to have learned that it is an unhealthy and unfair practice and therefore cannot resist.

Question 60

top down promotes a bottom up approach: FGM

Answer 60

The top down approach of criminalization of FGM has allowed the empowerment of grassroots organizations founded by women and girls, many of whom have escaped their family and village to avoid the cutting.
One such organization, NAFGM, carries out a set of complementary actions to combat the practice at the grassroots and community level. Some work that they do includes:
- Running rescue homes with education and vocational school for girls that have escaped
- Educating both boys and girls about the trauma caused by FGM
- Educating midwives and the cutters in the community
One of the many tactics that has been used by NAFGM is recognizing the status and large financial reward that cutters have in the community. Thus, NAFGM finds other high-status roles for cutters when they finally reject the job

Question 61

addressing inequities through policy

Answer 61

Health policies are aimed at reducing health inequities:
1. Social goods being governed by the public sector
2. Legislation that promotes gender equality
3. Promoting political empowerment, especially for disadvantaged populations

Question 62

measuring and monitoring health

Answer 62

The third and final recommendation of the Closing the Gap in a Generation report identified the need to continuously measure health problems and solutions to design effective, targeted interventions. Continuous measurement may involve using resources like the GBD study, which provides information on the magnitude of health problems. Reports such as the MDG Task Force Report done in 2015 at the conclusion of the Millennium Development Goals, provide critical information about the successes and short coming of interventions as a way to improve future interventions

Question 63

barriers in interventions

Answer 63

Barriers are understood as obstacles that could harm the feasibility of a policy or intervention
○ Examples: civil unrest, government policies or agendas, physical barriers (ex: lack of infrastructure)

Question 64

enablers to interventions

Answer 64

Enablers relate to factors or resources that can be leveraged to increase the feasibility or effectiveness of a policy or intervention
○ Examples: the willingness of a community to accept a policy or participate in an intervention,