Unit 1 Flashcards
What are the social determinants of health?
- Neighborhood and built environment
- Health and Health care
- Social and community context
- Education
- Economic stability
What are the variables that lead to disease? (Conventional model of health and disease)
Internal factors x External factors = disease
What are internal factors?
innate characteristics of an individual, typically unmodifiable such as age, sex, genetics
What are external factors?
Environmental factors and non-innate individuals characteristics and often modifiable.
What are some environmental factors that are usually not controlled by individuals
- lead in drinking water
- air pollution
- seatbelt law
What are some lifestyle factors that are determined by individual choice?
- physical activity
- sleep
- cancer screening behavior
What are medical care and personal care influenced by?
upstream determinants - they do not occur in a vacuum
Upstream
What has a direct effect on behaviors, morbidity and mortality
- macro level and include global forces and government policies
Social gradients in health provide clues to understanding what?
SDOH
What are some examples of neighborhood conditions
- access to healthy foods
- quality housing
- crime and violence
- environmental conditions
What are some examples of employment conditions
- heavy lifting
- unsafe conditions
- sedentary positions
- high stress/high demand/low control
- lack of workplace opportunities, resources and benefits
What are some examples of how education influences health
- high school graduation, enrollment in higher graduation and language/literacy –> higher health
- more education > more personal control
- more education > better employment
- more education > increased social support
what are some examples of economic stability
- poverty
- employment
- food security
- housing stability
What are some examples of social and community context
- social cohesion
- civic participation
- discrimination
- incarceration
Social factors are more likely to predict disease rather than what?
medical care
Midstream
v
Downstream
g
Health inequality
Differences in the health of individuals or groups without concern about moral judgement on whether observed differences are fair or just
Health inequity (health disparity)
A health inequality that denotes an unjust difference in health
- systematic differences in health that could be avoided by reasonable means
- unfair distribution of health risks and resources
What are 4 motives for studying health inequalities
- Striking differences in health still exists among (and within) countries today
- The persistence of health differences based on nationality, race/ethnicity, or other social factors raises moral concerns
- “Health as a Human Right” 1948
- UN’s Millennium Development Goals
What is the Utilitarian standpoint on health disparities
Between 2003-2006 alone, the direct economic cost of health inequalities based on race or ethnicity in the US was estimated at 230$ billion
- when direct costs (worker productivity) were factors into the calculations, the economic burden increase to 1.24 trillion
Where does health tend to be poorer?
in less equal societies, especially when inequality is measured at large geographic scales
How is social class measured?
as a gradient
What are the measures of social class?
- education attainment
- inequalities in the distribution of power or wealth
- ownership of assets
- social capital
Describe the framework for understanding health inequalities
- Cause pathways and conditional health effects
- Selection
- people have a tendency to sort themselves into groups - Context vs. composition
- contextual effect
- compositional effect - Life course perspective
Contextual effect
the influence a neighborhood or other type of unit has on people (schools, classrooms, hospitals)
Compositional effect
reflective of the characteristics of individuals that comprise the neighborhood
Why is the relationship between income and health hard to measure?
Is the observed effect a relationship between income and health OR a relationship between the things that income represents? (education, political stability, better diet, improved living conditions, etc.)
The relationship is between these variables is the problem collinearity
- which variable is actually creating the most impact?
- very difficult to measure
- is there plenty of money - or just not distributed equitably?
What is the Preston’s curve?
An empirical cross-sectional relationship that shows individuals born in richer countries can expect to live longer than those born in poor countries
At what point does the Preston curve flatten out?
The relationship flattens out at approximately 10,000 GDP per capita - at high levels of income, increased income has little associated change in life expectancy
What is Wilkinson’s theoretical synthesis
Income distribution is a marker of how unequal a society is
- income inequality measures the differences in social standing or social status
According to Wilkinson’s theoretical synthesis, those in lower income bracket will suffer from what?
stress, envy, inferiority, lack of self-esteem, etc.
According to Wilkinson’s theoretical synthesis, those with higher income have access to what?
Education, better housing, health care, employment, etc.
How does available income shape someones life?
Available income shapes a person’s opportunities, sense of their capabilities, diet, living conditions, etc.
What does the amount of disposable income a person has depend on?
Taxes and transfers
- tax credits, allowances, pensions, etc. (many of them based on household size)
- income taxes may be proportional (flat tax) or based on income (progressive tax)
How do government programs benefit the less well-off
Government programs that target the poor or disadvantaged disproportionately benefit the less well-off, narrowing the (income?) gap
Where are the distribution of benefits of public programs more progressive? Least progressive?
Most: Australia
Least: US
Public spending paid to people in the lowest income quintile, the bottom ___ of the income distribution
20% (Australia = 41.5%; US = 24.8%)
What is the life expectancy in Australia and US
Australia: 82.9
US: 78.5
Gini Coefficient
Most commonly used measure on income inequality
What does the scoring of the Gini Coefficient mean if the score is 0? 1?
A score of 0 would mean income is perfectly, evenly distributed
A score of 1 means that a single person has all the income in that society
Differences in health status have mostly to do with what?
Differences in health status have mostly to do with differences in the resources available to, and the related capacities of individuals
What is the single most powerful measure of resources and capabilities
income
Describe the gap between the rich and the poor
is continues to broaden
What is the connection between income inequality and health
Casual connection between income inequality and health
How society organizes its taxation system, programs, and services has a dramatic effect on what?
the income, inequality, and the number of children and adults in poverty
Which of the 5 domains of the SDOH does food insecurity fit into?
Economic stability
What are other topics that fall into the economic stability domain of SDOH
employment, food insecurity, housing stability, and poverty
High food security
no reported indications of food-access problems or limitations
Marginal food security
one or two reported indications (anxiety over food sufficiency and/or shortage of food in the house). Little or no indication of changes in diets or food intake
Low food security
reports of reduces quality, variety, or desirability of diet. Little or no indication of reduced food intake
Very low food security
Reports of multiple indication of disrupted eating patterns and reduced food intake
How does the USDAs food and nutrition assistance program increase food security?
By providing low-income households access to food for a healthful diet and nutrition education
The USDA monitors efforts through a national, representative survey, what does it monitor through these surveys?
Household food insecurity, food expenditures, use of federal food and nutrition assistance programs (SNAP, National School Lunch Programs, and WIC)
What was the percentage of those who reported to be food insecure and food secure in 2017 through HOUSEHOLD reports
- 2% food secure
11. 8% food insecure
What is the percent of children who face food insecurity?
7.7% (in 2016 is was 8%)
Episodes of food insecurity are recurrent, not ___
Chronic
Explain the occurrence of food insecurity for about one-fourth of US households with very low food security
About one-fourth of US households with very low food security at any time during the year experienced the associated conditions rarely or occasionally - in only 1 or 2 months of the year
Explain the occurrence of food insecurity for about three-fourths of US households with very low food security
The conditions were recurrent, experienced in 3 or more months of the year
What were some rates in which food insecurity tended to be higher for?
a. households with incomes are or below the federal poverty line
b. all households with children particularly households with children headed by a single parent
c. women and men living alone
d. black and hispanic headed households
e. households in principal cities and nonmetropolitan areas
What is the prevalence of food insecurity among the lowest and highest state?
lowest - Hawaii (7.4%)
highest - New Mexico (17.9%)
Approximately 58% of food-insecure households reported that, in the previous month, they has participated in one or more of the three largest federal assistance programs; what were some of these programs?
- SNAP (Supplemental Nutrition Assistance Programs)
- WIC (Nutrition program for Women, Infants and Children
- National School and Lunch Program
How much did the typical average food secure household spend for food compared to the typical food insecure household of the same size and composition
23% more for food
What are some examples of Food Assistance Programs?
- Supplemental Nutrition Assistance Program (SNAP)
- National School Lunch Program
- Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
- Office of Head Start
- Food Banks, Food Pantries
- Meal from the Heartland, Feeding America food network
What are three policies that ensure young children have reliable access to food
- increasing SNAP benefits by using alternative calculation method
- Increasing WIC age-eligibility from age 5 years to 6 years
- Expanding participation in school meal program by increasing the Community Eligibility Program (CEP) criteria
SNAP
Maximum allotments are currently based on the cost of the USDAs Thrifty Food Plan - the calculation model that is the lowest cost of four food plans developed by the USDA
–> using the low-cost food plan would lead to a 28-30% increase in food purchasing power even through their actual earned incomes would remain unchanged
–> Increased benefits - approximately $1,547/year for families composed of one adult and two children
WIC proposal
- Raise the maximum age cutoff for WIC receipt from 5 to 6 “WIC to Six”
- Current policy grants benefits up to the day before the child’s fifth birthday so new policy would extend those benefits up to the day before the child’s 6th birthday
What was the average WIC eligibility rate for children 1-4 in 2013?
55.9%
Based on population estimates, an estimated _____ 5-year children would be eligible for WIC benefits using the “WIC to Six” model
583,999
What was the proposal for school meals?
Proposal to increase benefits by moving to the next higher income-to-poverty ratio category
- free school breakfast and lunch
- reduced-price school breakfast and lunch
describe the positives and negatives of how employment and working conditions are determinants of an individual’s life chances
positive: earning income, material benefits, source of social integration, prestige
negative - physical and psychosocial stressors
Employment status provides a critical link between what?
educational attainment and earned income
Health status of those who do not work for pay or are unemployed
less health than those who do work
What are the major sources of financial resources necessary for workers and their families
earnings from employment
Essential material resources are tied to employers to include what?
pensions, health insurance, and unemployment insurance, workmans comp., etc
Negative exposures into the workplace that can harm health
- exposure to chemicals, noise, heat, and vibration
- strain-related injuries associated with repetitive work
- lack of physical activity due to sedentary position
- shirt duration and schedule (night shift)
- stress and job strain
What are the jobs that are most hazardous?
the jobs that do not require lots of education
Karasek’s demand and control model
Job stress/strain arises from the interaction of psychological demands with decision latitude (control, autonomy)
Mitigation strategies:
- social support at workplace
- organizational justice
- more on powerpoint after this slide
if you have low control and autonomy, it will lead to unhealthy health impacts at work
What are some work-based health protection and promotion strategies for preventing work-related illness and injury?
a. Workplace safety measures
b. control of workplace hazards
c. improved ergonomics
d. health and safety training
What are some work-based health protection and promotion strategies for reducing work-related stress
a. decreasing job strain
b. fostering social support among workers
c. stress management
d. supporting work-family balance (e.g. through flexible schedules)
What are some work-based health protection and promotion strategies for supporting healthier behaviors through workplace environments and services offered at work
a. Health screening and services
b. Promoting health behaviors
c. creating a health-promoting environment
What are some work-based health protection and promotion strategies for expanding work-related resources and opportunities
a. medical care benefits
b. paid sick and personal leave
c. child and elder care services
d. job training and education
e. adequate wages and salaries
How do we prevent work-related illness/injury?
Modify the workplace environment to decrease workers’ exposures to risky and unsafe physical conditions
- educate workers about safe workplace practices
ex. smoke-free workplace environment; financial and information assistance to employers to incorporate evidence-based practices for ergonomic design
What are some ways that we can support healthy behaviors in the workplace?
a. create work environments that are more conducive to healthy behaviors
b. fitness programs, health risk assessments, health education
What are some examples of supporting healthy behaviors in the workplace?
- incentives for employees to participate in comprehensive physical and mental health programs
- On-site fitness centers, healthier food choices in cafeterias, lifestyle coaching
- worksite clinics
- tax incentives to employers who implement programs
How can we improve resources and opportunities in the workplace?
a. expand work-related compensation and benefits
b. worker education training increase access to higher-status and higher wage jobs
What are some examples on how we can improve resources and opportunities in the workplace?
- laws that require employers to provide paid sick leave and parental leave
- tax credits for low-income workers with children
- job training and education programs for disadvantages youth
- government funded careers centers
Education attainment (def)
The years or level of overall schooling a person has, rather than instruction on specific health topics
- quality of education is hard to measure and not typically available - but equally important
Describe the health gradient when it comes to education
Having less than a high school degree > poorest health outcomes (relationship is also on a gradient)
Describe the health of people who do have an education
people with more education are likely to life longer, to experience better health outcomes, and to practice health-promoting behaviors
Describe how education impacts infant mortality rate
Babies born to mothers who have not finished high school are nearly twice as likely to die before their first birthdays as babys born to college graduates
is education an upstream or downstream determinant
one of the major upstream determinants of health
Health benefits of education –> individuals level
enhancing cognitive skills, navigating the healthcare system, personal health behaviors, attainment of the economic social resources
How does education contribute to human capital?
- cognitive skills
- problem solving ability
- learned effectiveness
- personal control
- reading, math, science
Non-cognitive skills:
conscientiousness, openness to experience, extraversion, agreeableness, and emotional stability
How does education benefit someone when it comes to navigating the healthcare system
- understand health needs
- follow or read instructions (health literacy)
- advocate for themselves or their families
- communicate effectively with their healthcare providers (symptoms, health history)
Explain how education benefits someone when it comes to personal health behaviors
- Adults with higher levels of education are less likely to engage in risky behaviors
- Education offers more opportunities to learn about health and health risks
Adults with higher levels of education also tend to have lower exposure to stress related to economic deprivation, as well as more resources
Describe the education gradient in health behaviors
higher the education, less likely that you are going to engage in risky behaviors
Explain how education can benefit individuals in terms of economic and social resources
Adults with more education have greater access to important material, financial, and social resources
a. Economic
- gaining employment
- health insurance
- worksite and health promotion
b. social resources
- greater social support
- social networks, civic groups and organizations
What are some things at the community level that we can do from and educational standpoint?
- Individuals with more education benefit from health-related characteristics of the environments in which they live, work, and study
- Access to the resources that are important to health is contingent on community-level resources and institutions
- social capital and collective efficacy
Describe the earning potential between different genders and races based on eduction
Wages at the lower or middle of the income distribution stagnating or falling while those at the top continue to rise
What are the 3 major pathways to explain the link between educational attainment and health
- health knowledge and behavior
- Employment and income
- Social and psychological factors
What does poor health lead to?
Poor educational attainment
Whole School, Whole Community, Whole Child Model
A unified, collaborative approach to designed to improve learning and heath in out nation’s schools
How can we improve health through education?
Through education policies and programs; close gaps in educational attainment
What types of benefits would investments to promote and increase educational attainment have?
both human and economic benefits
Every Student Succeeds Act (2015)
- Health education as an academic subject (separate from physical education)
- longstanding commitment to equal opportunity for ALL students
Literacy
A person’s ability to read, write, speak, and compute and solve problems at levels necessary to function on the job and in society, achieve’s one’s goals and develop one’s knowledge
Health literacy
the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
National Assessment of Adult Literacy (NAAL)
Conducted in 2003 to assess the English literacy of adults in the US
- -> administered to more then 19,000 adults (ages 16 and older) in households or prisons
- -> measured literacy directly through tasks completed by adults rather than subjective evaluations such as self-report
National Assessment of Adult Literacy (NAAL): results
Proficient health literacy = 12%
Intermediate health literacy = 53%
Basic health literacy = 22%
Below Basic health literacy = 12%
Who is most at risk for low health literacy?
- older adults, racial and ethnic minorities, people with less than a high school degree or GED, people in low-income levels, non-native speakers of English, people with compromised health status
What the the best practices to improve health literacy?
- Identify the intended users of the health information and services
- -> audience segmentation - Evaluate users’ understanding before, during and after the introduction of information and services
- -> invite members of the intended users group to determine what information they will need and how to use it - Acknowledge cultural differences and practice respect
- -> accepted roles of men and women, favorite and forbidden foods, body language - Limit the number of messages, use plain language, and focus on action
What affects health at every stage of life?
family income education neighborhood resources social capital sleep stress
early childhood experiences are tied to what in regards to health?
tied to health throughout life, particularly in adulthood
Effects of early childhood interventions are greatest for who?
children who are at the greatest social and economic disadvantages, but children in ALL families benefit from early childhood programs
is it possible to turn vicious cycles into paths to health > early childhood interventions?
yes
At every stage of our lives, social advantage (or disadvantage) is linked to what?
health –> it accumulates over time
What is one of the most effective ways for society to achieve its health potential?
improving early childhood social circumstances
How are children born to mothers with low income and educational level more likely to be born? what are these birth outcomes strong predictors of?
prematurely or of low birthweight; these outcomes are strong predictors of infant survival and also of health across the entire life course
What factors are strongly linked to a child’s health?
nutrition, housing quality, and household and community safety
What are children exposed to lead-based paint at risk for?
they are at higher risk of most likely to suffer from lead-poisoning that can lead to irreversible neurological damage
What do children exposed to lead pain typically live?
commonly found in lower income neighborhoods
background about lead-based produced –> esp. pain
Lead was banned in the use of paint and use in gasoline in 1978; the children that frequent any homes build before 1978 should be tested for lead levels in their blood because some of those symptoms mimic ADHD –> may not be a behavioral issue at all, it could be an indication that the child has been exposed to lead, mostly in the form of lead-based paint
Highest rates of infant mortality by race/ethnicity (of mother) in 2014:
Black or AA: 11%
American Indian or Alaska Native: 7.5%
Asian or Pacific Islander - 4%
Total (average) - 6%
What has a great affect on brain, cognitive, and behavioral development?
Early childhood experiences
What do social experience in the first few years of life shape?
the development of infants and toddler - can be adverse or favorable
What can parent’s social and economic resources affect
the quality and stability of the relationships with their infants which in turn affects the child’s emotional development
- maternal depression
- language development
What was the purpose of the Adverse Childhood Experiences (ACE) Study?
To explore the relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction
What were the methods used in the Adverse Childhood Experiences (ACE) Study?
A questionnaire mailed to 13, 494 adults who completed a standardized medical evaluation at a large HMO (1995-1997)
What was the conclusion of the Adverse Childhood Experiences (ACE) Study?
Strong, graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death
Definitions of Adverse Childhood Experiences (ACE): Intimate partner violence
violent treatment of mother or step-mother
Definitions of Adverse Childhood Experiences (ACE): household substance abuse
a household member was a problem drinker or alcoholic or used street drugs or abused prescription medications
Definitions of Adverse Childhood Experiences (ACE): mental illness
a household member was depressed or mentally ill or a household member attempted suicide
Definitions of Adverse Childhood Experiences (ACE): criminal behavior in the household
a household member went to prison
What were some of the risk factors and disease conditions assessed in the ACE study?
Smoking severe obesity physical inactivity depressed mood suicide attempts alcoholism any drug use parenteral (intravenous) drug abuse high lifetime number of sexual partners history of having a STD
WHAT THE PARTICIPANTS SAID THEY CURRENTLY HAD
what was the most and least prevalent childhood exposure in the ACE Study?
Most = substance abuse in the household (25.6%) Least = evidence of criminal behavior in household (3.4%)
More than half of the respondents experienced one or more category of adverse childhood exposure
–> 6.2% reported 4 or more exposures
How does ACEs affect our health?
people with 6 or more ACEs died nearly 20 years earlier on average than those without ACEs
What are some recommendation to better childhood experiences to better health outcomes later in life?
Increase the attention to primary, secondary, and tertiary prevention strategies needed
What is a primary prevention strategy that could be used to better childhood experiences?
prevention of the occurrence of adverse childhood experiences from happening in the first place
What is a secondary prevention strategy that could be used to better childhood experiences?
preventing the adoption of health risk behaviors as responses to adverse childhood experiences during childhood and adolescents
- u have been exposed to one or more ACE and you are stressed, this is how you can prevent the risky behaviors from starting
What is a tertiary prevention strategy that could be used to better childhood experiences?
helping change the health risk behaviors and improve the disease burden among adults whose health problems may represent a long-term consequence of adverse childhood experiences
- when u have been exposed, and already adopted the behavior
What is stress?
Refers primarily to the experiences people have when they face challenging events or conditions that they feel exceed their resources for coping
- generally threatening, unpredictable, incontrollable
During childhood and adolescents, stress appears to increase the risk of what
poor mental and physical health
Among adults, exposure to work-related stress and other stressors has been linked with what
CVD as wellas CVD risk factors
Consistent findings and less consistent findings of behaviors when someone it stressed
CONSISTANT FINDINGS
- smoking
- disordered drinking
- substance abuse
- unhealthy eating habits
LESS CONSISTENT FINDINGS
- PA
- poor sleep
When subjects anticipated a stressful situation (performing speech that would be video recorded) they tended to do what? and what was the effect observed
eat more sweet and fatty foods; the effect was only observed among emotional eatings
Emotional eaters
people who eat as a way to cope with stress
Higher stress levels are associated with what
lower exercise
People with higher stress levels spend more time doing what
watching TV and using computers, which increases sedentary time
The body’s response to stress involved complex interactions between two main physiologic systems: what are they?
The neuroendocrine system (brain and hormonal systems activated by the brain)
The immune system (primary role is to defend the body against infection through several mechanisms, including inflammation)
Stress pathways
First, our body judges a situation and decides whether or not is it stressful, based on sensory input and processing and on stored memories
- if situation is judged as being stressful, the hypothalamus (at base of brain), is activated that results in the production of glucocorticoids
The hypothalamus-pituitary-adrenal (HPA) axis
The hypothalamus activates the pituitary gland which activated the outer portion of the adrenal gland, or cortex
The adrenal cortex releases what hormone? and what does that hormone do?
cortisol (the “stress hormone”)
- higher blood volume, BO and blood sugar levels
- processing the proteins and fat to glucose
- lowers production of sexual hormones
- suppression of immune system
The HPA axis is a _______ that shuts itself off
negative feedback loop
The SNS: The hypothalamus activates the inner portion of the adrenal gland, which releases what
catecholamines including epinephrine (adrenaline) and norepinepherine (noradrenaline)
- increase HR and BP
- slower digestion and kidney function due to increased blood flow to the heart, brain, and skeletal system
Ones the stressful “threat” is over, what happens
the PNS branch of ANS takes control and brings the body back into balanced state
Chronic sympathetic stimulation of the cardiovascular system due to stress leads to what
sustained increase in BP which can lead to damaged arteries and plaque formation
Chronic elevation of stress hormones can do what
suppress immunity and promote inflammation by directly affecting cytokine profiles
What can high cortisol levels increase
insulin resistance and fat accumulation
People with social disadvantages such as low socioeconomic status experience a lot of stress. and they have ____ and ____/
High demand: more stressors
- material and financial difficulties; subordinate social status
low control
- less resources to cope
Implications to improve health and reduce disparities: interventions in health sector
- supportive couseling in combination with psychoactive medication
- policies disigned to remove financial, cultural, and geographic barriers to couseling and medication
- increasing peoples capacity to manage stress more constructively and avoid health-damaging behaviors
- integrating social and medical services in medical care settings
Implications to improve health and reduce disparities: interventions outside the health sector
- early childhood development programs
- career development training
- improving access to affordable medical care
- numerous benefits to low-income working families can buffer some of the stress from economic challenges
- family friendly workplace and flexible working hours
