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Department
Health Studies
Course
HLTB15H3
Professor
Suzanne Sicchia
Semester
Fall

Description
Week 1! Article 1 Social Determinants of health: The Canadian Facts • Is about Canadian society, and what we need to put faces and voices to the inequities – and the health inequities in particular – that exist in our midst • “social injustice is killing people on a grand scale” o Demonstrates how the conditions in which people live and work directly affect the quality of their health • Health inequities are not just about the poor but also about public policies and political choices and our commitments Introduction • The primary factors that shape the health is living conditions people experience which is known as the social determinants of health • Canadians are largely unaware that our health is shaped by how income and health is distributed, whether or not we are employed, and if so, the working conditions we experience • Our income inequality and poverty rates are growing and are among the highest of wealthy developed nations Stress, bodies, and illness Why is it important? • People who suffer from adverse social and material living conditions also experience high levels of physiological and psychological stress • The lack of supportive relationships, social isolation, and mistrust of others further increases stress • Chronic stress can lead to prolonged biological reactions that strain the physical body • Physiological tensions proved by stress make people more vulnerable to many serious illnesses such as cardiovascular and immune system diseases, and adult-onset diabetes • People who experience high levels of stress often attempt to relieve these pressures by adopting unhealthy coping behaviours, such as the excessive use of alcohol, smoking, and overeating carbohydrates. These things are unhealthy but they are effective in bringing momentary relief • Stressful living conditions takes up most of one’s energy that is directed towards coping with day-to-day life Policy implications • The focus must be on the source of problems rather than dealing with symptoms. Therefore, an effective way to reduce stress and improve health is by improving the living conditions people experience • Elected representatives and decision-makers must commit themselves to implementing policy that ensures good quality social determinants of health for every Canadian Income and income distribution Why is it important? • Income is the most important social determinant of health • The relationship between income and health 2 different levels 1. We can observe how health is related to the actual income that an individual or family receives 2. We can study how income is distributed across the population and how this distribution is related to the health of the population • Income is especially important in societies which provide fewer important services and benefits as a matter of right • Childcare, housing, post-secondary education, recreational opportunities and resources for retirement must be bought and paid for by individuals • Low income predisposes people to material and social deprivation • In the long run, social exclusion affects one’s health and lessens the abilities to live a fulfilling day-to-day life • Researchers have also found that men in the wealthiest 20% of neighbourhoods in Canada live on average more than four years longer than men in the poorest 20% of neighbourhoods • Those living in the most deprived neighbourhoods had death rates that were 28% higher than the least deprived neighbourhoods • Canada is now one of the higher income inequality nations • Increasing income inequality has also led to a hollowing out of the middle class in Canada with significant increases from 1980-2005 in the % of Canadian families who are now poor or very rich • Wealth is probably a better indicator of long-term health outcomes as it is a better measure of financial security than income Policy implications • There is an emerging consensus that income inequality is a key health policy issue that needs to be addressed by governments and policymakers • Increasing the minimum wage and boosting assistance levels for those unable to work would provide immediate health benefits for the most disadvantaged Canadians • Reducing inequalities in income and wealth through progressive taxation is a highly recommended policy option shown to improve health • A greater degree of unionized work places would most likely reduce income and wealth inequalities in Canada. Unionization helps to set limits on the extent of profit-making that comes at the expense of employees health and wellbeing Education Why is it important • People with higher education tend to be healthier than those with lower educational attainment 1) Level of education is highly correlated with other social determinants of health such as the level of income, employment security, and working conditions 2) Higher education makes it easier to enact larger changes in the Canadian employment market 3) Education increases overall literacy and understanding of how one can promote ones own health through individual action • The manner by which education influences the pop.’s health is shaped by public polices • Education in Canada is good but the troubling aspects are that children whose parents do not have post-secondary education perform notably worse than children of more educated parents Policy implications • Elected representatives must commit themselves to adequately funding the Canadian education system so that schools are able to provide well-developed curricula for students • Tuition fees for university and college education must be better controlled by Canadian governments to that fees do not exclude children of low-income families from higher education Unemployment and job security Why is it important? • Frequently leads to material and social deprivation, psychological stress, and the adoption of health-threatening coping behaviours • Job insecurity has been increasing in Canada during the past decades currently only half of working aged Canadians have had a single full-time job for over six months or more • # of people having part-time work expanded during the past 2 decades this trend is associated with more intense work life, decreased job security and income polarization b/w the rich and the poor • Unemployment is related to poor health 1) Unemployment often leads to material deprivation and poverty by reducing income and removing benefits that were previously provided by ones employer 2) Losing a job is a stressful event that lowers ones self-esteem, disrupts daily routines, and increases anxiety 3) Unemployment increases the likelihood of turning to unhealthy coping behaviours such as tobacco use and problem drinking • Insecure employment consists of intense work with non-standard working hours associated with higher rates of stress, bodily pains and a high risk of injury which increases changes of physiological and psychological problems and negative effects on personal relationships Policy implications • National and international institutions need to be legally mandated to make agreements that provide the basic standards of employment and work for everyone • Power inequalities between employers and employees need to be reduced through stronger legislation governing equal opportunity in hiring, pay, training and career advancement • Unemployed Canadians must be provided access to adequate income, training, and employment opportunities through enhanced government support • Workers, employers, government officials, and researcher need to develop a new vision of what constitutes healthy and productive work Employment and working conditions • People who are already most vulnerable to poor health outcomes are also the ones most likely to experience adverse working conditions • Work dimensions which shape health outcomes 1) Employment security 2) Physical conditions at work 3) Work pace and stress 4) Working hours 5) Opportunities for self-expression and individual development at work • Imbalances between demands and rewards often lead to significant health problems • Workers perceive and develop a range of physical and mental afflictions • Health problems are seen among workers who experience high demands but have little control over how to meet these demands • low-income women working in the sales and service sector Policy implications • government policies must support Canadians working life so that demands upon workers and their rewards are balanced • special focus should be on improving conditions of employees in high –strain low-income jobs • collective and organized action through unionization of workplaces is an important means of balancing power between employers and employees • working conditions can be made better when employees are provided with opportunities to influence their work environment • more quantitative and qualitative research on working conditions in Canada is urgently needed Early childhood development Why is it important • latency effects: how early childhood experiences predispose children to either good or poor health regardless of later life circumstances • Pathway effects: a situation when children’s exposures to risk factors at one point do not have immediate health effects but later lead to situations that do have health consequences • One way to weaken the relationship between parents socioeconomic status and children’s developmental is to have high quality early child education regardless of parents wealth • Adverse childhood experiences can create a sense of inefficacy- or learned helplessness- which is a strong determinant of poor health Policy implications • Governments must guarantee that affordable and quality child care is available for all families regardless of wealth or income level • Providing support and benefits to families though public policies forms a base for healthy childhood development. Providing higher wages and social assistance benefits would reduce child poverty and be one of the best means to improve early childhood development • All Canadians would benefit from improved early childhood development in terms of improved community quality of life, reduced social problems , and improved Canadian economic performance Food insecurity Why is it important • People who experience food insecurity are unable to have an adequate diet in terms of its quality or quantity • The risk of food insecurity is especially great in lone-parent families and families receiving social assistance • Dietary deficiencies-more common among food insecure households-are associated with increased likelihood of chronic disease and difficulties in managing these diseases • Malnutrition during childhood has long-term effects on a child physiological psychological development • Food banks provide last resort support to food insecure households and exist as a consequence of filed public policies Policy implications • Governments must reduce food insecurity by increasing minimum wages and social assistance rates to the level where an adequate diet is affordable • Governments must assure that healthy foods are affordable • Providing affordable housing and childcare would reduce other family expenses and leave more money for acquiring and adequate diet • Facilitating mothers employment through job supports, making available affordable child care and providing employment training would serve to reduce food insecurity among the most vulnerable Canadian families • Better monitoring systems must be designed and implemented to produce up-to- date accounts of food insecurity in Canada Housing Why is it important? • Housing a public policy issue because governments have a responsibility to provide citizens with the prerequisites of health • Canada is experiencing a housing crisis. Over the past 20 years, rents have risen well beyond the cost of living and this is especially so in cities • Most low-income Canadians are among the one third of Canadians who are renters and rents are increasing faster than renter household incomes • Homeless people experience a much greater rate of was wide range of physical and mental health problems than the general population • Growing number of Canadians are under-housed, living in motels, dependent on the shelter system, or living on the street Policy implications • Housing policy needs to be more explicitly linked to comprehensive income, public health, and health services policy • Housing policy must make affordable and quality housing available for all Canadians. Provinces should provide their matching share for housing provision as defined in the affordable housing framework agreement of 2001 • The federal government must increase funding for social housing programs targeted fro low-income Canadians. Housing policies should support mixed housing as an antidote for urban segregation Social exclusion Why is it important • Social exclusion refers to specific groups being denied the opportunity to participate in Canadian life • Canadian society marginalize people and limit their access to social, cultural and economic resources • They lack power • Four aspects to social exclusion 1) Denial of participation in civil affairs - Laws and regulations prevent non-status residents or immigrants from participation 2) Denial of social goods 3) Exclusion from social production is a lack of opportunity to participate and contribute to social and cultural activities 4) Economic exclusion • Social exclusion creates the living conditions and personal experiences that endanger health • Social exclusion creates a sense of powerlessness, hopelessness and depression Policy implications • Governments at all levels must revise laws and regulations and develop programs that will allow new Canadians to practice their professions in Canada • Governments must enforce laws that protect the rights of minority groups, particularly concerning employment rights and anti-discrimination • Attention must be directed to the health needs of immigrants and to the unfavourable socio-economic position of many groups, including the particular difficulties many new Canadians face in accessing health and other care services Social safety net Why is it important? • The social safety net refers to a range of benefits, programs, and supports that protect citizens during various life changes that can affect their health and their normal life transitions • Unexpected life events increase economic insecurity and provoke psychological stress • Canada becoming unable to work through unemployment or illness and experiencing family break-ups are good predictors of coming to experience poverty • A weak social safety net turns citizens against communal action and decreases social cohesion Policy implications • The social safety net provided by Canadian federal, provincial/ territorial, and municipal governments needs to be strengthened. Canada’s spending in support of citizens lags far behind many there developed economics. Current benefits do not provide adequate income for life transitions • Strong political and social movements are needed to pressure governments into creating public policy that will strengthen Canada’s social safety net Health services Why is it important • The main purpose of a universal health care system is to protect the health of citizens and spread health costs across the whole society • The Canada health act sets out requirements provincial governments must meet through their public health-care insurance plans • Act does not provide a detailed list of insured services • Canadian health act states every Canadian has to be provided uniform access to health services in a way that is free of financial barriers (accessibility) • Canada is amongst the lowest in its coverage of total health care costs • Medicare covers only 70% of total health care costs-the rest is covered by private insurance plans and out of pocket spending • Canadians with below average incomes are three times less likely to fill a prescription due to cost and 60% less able to get a needed test or treatment due to cost than above average income earners Policy implications • District health authorities and health policy makers must direct attention to existing inequities in access to health care and identify and remove barriers to health care • Governments must implement a pharmacare program and increase public coverage of home care and nursing home costs • The Medicare system must be strengthened and governments should resist the increasing involvement of for profit companies in the organization and delivery of health care • Health authorities must find means of controlling the use of costly but ineffective new treatments that are being marketed aggressively by private corporations • As the commission on the future of health care in Canada concluded Canadians need to accept the notion that the medicare system is as sustainable as we want it to be • Consideration should be given to providing dental care to families living on low incomes Aboriginal status Why is it important • Aboriginal peoples in Canada- First nations, Dene, Metis, and Inuit – number 1.2 million and constitute 3.8% of the Canadian population and is tied up with their history of colonization • Aboriginal Canadians living off reserve are four times more likely to experience food insecurity than non-aboriginal Canadians. 33% of off reserve aboriginal households experienced moderate or severe food insecurity • Life expectancies of aboriginal people are five to 14 years less than the Canadian population • Infection and chronic diseases are much higher in the aboriginal population • Suicide rates are five to six times higher and aboriginal peoples have high rates of major depression (18%), problems with alcohol (27%), and experience of sexual abuse during childhood (34%) Policy implications • Recognition of an aboriginal order of government with authority over matters related to the good government and welfare of aboriginal peoples and their territories • Replacement of the federal department of Indian affairs with two departments one to implement a new relationship with aboriginal nations and one to provide services for non-self-governing communities • Creation of an aboriginal parliament Gender Why is it important? • Women in Canada experience more adverse social determinants of health than men • Women are less likely to be working fulltime and are less likely to be eligible for unemployment benefits • Almost every public policy decision that weakens the social safety net has a greater impact on women than on men • Women tend to earn less than men regardless of occupation • Major concern in terms of gender inequality is the lack of affordable and high quality daycare • Women have a life expectancy of 79 years as compared to men’s 76.3 years • Women have more episodes of long term disability and chronic disease than men • Men experience more extreme forms of social exclusion that manifests in homelessness and severe substance abuse and suicide is 4 times higher than of women • About 95% of Canada’s prison population are men • Moreover men’s health is sometimes influenced for the worse • Health of both genders is shaped by the distribution of social and economic resources Policy implications • Improving and enforcing pay equity legislation would improve the employment and economic situation of Canadian women • Providing a national affordable high quality childcare program would provide opportunities for women to engage in the workplace and improve their financial situations • Improving access to employment insurance for part time workers would assist women who combine work and caregiving responsibilities • Creating policies that make it easier for work places to achieve collective agreements through unionization would be especially beneficial for Canadian women Race Why is it important? • Canada prides itself on being a multicultural society • One third of racialized Canadians are Canadian born and other two thirds are immigrants • Racism can take three forms 1) Institutionalized racism is concerned with the structures of society 2) Personally mediated racism is defined as prejudice and discrimination and can manifest itself 3) Internalized racism is when those who are stigmatized accept these messages about their own abilities and intrinsic lack of worth • Canadians of colour in every province experience higher unemployment and underemployment rates, and lower incomes than Canadians of European descent Policy implications • Canadians institutions must recognize the existence of racism in Canada and develop awareness and education programs that outline and adverse effects of racism • Governments must enact laws and regulations that allow foreign trained immigrants to practice their occupations in Canada • Authorities must strongly enforce anti-discrimination laws • Since people of colour are experiencing especially adverse living circumstances, governments must take an active role in improving their living conditions Disability Why is it important • Too often disability is seen in medical rather than societal terms • The percentage of Canadians reporting a disability is 12.4% • 36% of men and 47% of women with disabilities did not worsen at all in 2000 • Over 40% of Canadians with disabilities are not in the labour force, forcing many of them to rely upon social assistance benefits • Many employers are reluctant to provide accommodation on the job Policy implications • Commit to a framework that will assist individuals to meet the costs of disability related supports • Make a down payment on a transfer to enhance the supply of disability supports and commit to a national program of disability supports Article 2 Closing the gap in a generation – health equity through action on the social determinants of health- WHO The commission calls for closing the health gap in a generation • Social justice affects the way people live, their consequent chance of illness, and their risk of premature death • The conditions in which people live and die are, in turn, shaped by political, social, and economic forces • The development of a society, rich or poor, can be judged by the quality of its populations health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health A new global agenda for health equity • Social gradient: the lower the socioeconomic position, the worse the health • Health inequity: Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair The social determinants of health and health equity • Health inequity is an issue within all our countries and is affected significantly by the global economic and political system • Holistic view: poor social policies • The structural determinants and conditions of daily life constitute the social determinant of health • The global community can put this right but it will take urgent and sustained action, globally, nationally, and locally • The force of civil society and local movements that both provide immediate local help and push governments to change • Climate change has profound implications for the global system how it affects the way of life and health of individuals and the planet • Health equity must be part of the global community balancing the needs of social and economic development of the whole global population, health equity, and the urgency of dealing with climate change A new approach to development Health and health equity may be the aim of all social policies but they will be a fundamental result • Misdistribution of health care is one of the social determinants of health • Premature loss of life arises in large part because of conditions in which people are born, grow, live, work and age • Policies and programmes must embrace all the key sectors of society not just the health sector Closing the health gap in a generation • Optimistic: the knowledge exists to make a huge difference to peoples life chances and hence to provide marked improvements in health equity. We are realistic: action must start now The commissions overarching recommendations 1) Improve daily living conditions 2) Tackle the inequitable distribution of power, money and resources 3) Measure and understand the problem and assess the impact of action Improve Daily living conditions • The inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies Equity from the start • Commit to and implement a comprehensive approach to early life, building on existing child survival programmes and extending interactions in early life to include social/emotional and language/cognitive development • Expand the provision and scope of education to include the principles of early child development • Least 200 million children globally are not achieving their full development protection Evidence for action • Investment in the early years provides one of the greatest potentials to reduce health inequities wihin a generation • Education, lay critical foundations for the entire life course Healthy places healthy people • place health and health equity at the heart of urban governance and planning • promote health equity between rural and urban areas through sustained investment in rural development, addressing the exclusionary policies and processes that lead to rural poverty, landlessness, and displacement of people from their homes • ensure that economic and social policy responses to climate change and other environmental degradation take into account health equity • where people live affects their health and chances of leading flourishing lives Evidence for action • The daily conditions in which people live have a strong influence on health equity. Access to quality housing and shelter and clean water and sanitation are human rights and basic needs for healthy living • policies and investment patterns reflecting the urban-led growth paradigm have seen rural communities worldwide • the current model for urbanization poses significant environmental challenges particularly climate change- the impact of which is greater in low-income countries and among vulnerable subpopulations Fair employment and decent work • make full and fair employment and decent work a central goal of national and international social and economic policy –making • achieving health equity requires safe, secure, and fairly paid work, year-round work opportunities, and healthy work-life balance for all • improve the working conditions for all workers to reduce their exposure to material hazards, work related stress, and health-damaging behaviours • employment and working conditions have powerful effects on health equity • action to improve employment and work must be global, national and local Evidence for action • work is the area where many of the important influence on health are played • flexible workforce is seen as good for economic competitiveness but brings with- it effects on health • evidence indicates that mortality is significantly higher among temporary workers compared to permanent wormers • workers who perceive work insecurity experience significant adverse effects on their physical and mental health Social protection across the lifecourse • establish and strengthen universal comprehensive social protection policies that support a level of income sufficient for healthy living for all • all people need social protection across the life course, as young children, in working life, and in old age need protection in case of specific shocks such as illness, disability and loss of income or work Evidence for action • low living standards are a powerful determinant of health inequity • 4/5 people worldwide lack the back up of basic social security coverage • Redistributive welfare systems , in combination with the extent to which people can make a healthy living on the labour market, influence poverty levels • Budgets for social protection tend to be larger • Extending social protection to all people, within countries and globally securing health equity within a generation Universal health care • Build health-care systems based on principles of equity, disease prevention and health promotion • Build and strengthen the health workforce, and expand capabilities to act on the social determinants of health • The health care system is itself a social determinant of health • Leaders in health care ensure that policies and actions in other sectors improve health equity Evidence for action • Without healthcare many of the opportunities for fundamental health improvement are lost • Systems with inequitable provision, opportunities for universal health as a matter of social justice are lost • Universal coverage requires that everyone within a country can access the same range of good quality services according to the needs and preferences regardless of income level, social status or residence, and that people are empowered to use these services • The policy imposition of user fees for health care in low- and middle income countries has led to an overall reduction in utilization and worsening health outcome s • Primary health care model that emphasizes locally appropriate action across the range of social determinants • Investment in training and retraining health care workers is vital to the required growth of health Tackle the inequitable distribution of power, money and resources • Inequity produced social norms, policies, and practises that tolerate or actually promote unfair distribution of and access to power, wealth and other necessary social resources Health equity in all policies, systems and programmes • Place responsibility for action on health and health equity at the highest level of government, and ensure its coherent consideration across all policies • Adopt a social determinates framework across the policy and programmatic functions for the ministry of health and strengthen its stewardship role in supporting a social determinants approach across government • Every aspect of government and the economy has the potential to affect health and health equity Evidence for action • Good public policy can provide health benefits immediately and in the future • Policy coherence is curucuial this means that different government departments policies complement rather than contradict each other in relation to the production of health and health equity • The increased incorporation of community engagement and social participation in policy processes helps to ensure fair decision making on health equity issues • Making health and health equity a shared value across sectors is a political challenging strategy but one that is needed globally Fair financing • Strengthen public finance for action on the social determinates of health • Increase international finance for health equity, and coordinate increased efficacy through a social determinates of health action framework • Fairly allocate government resources for action on the social determinants of health • Public finance to fund action across the social determinates of health is fundamental to welfare and to health equity • Socioeconomic development of rich countries as strongly supported by publicly financed infrastructure and progressively universal public services • Emphasis on public finance implies strong public sector leadership and adequate public expenditure • Low income countries often have relatively weak direct tax institutions and mechanisms and a majority of the workforce operating in the informal sector • Economic agreements between rich and poor countries that require tariff reduction can reduce available domestic revenue in low-income countries before alternative streams of finance have been established • As globalization increases interdependence among countries, the argument for global approaches to taxation becomes stronger • Recipient governments should strengthen their capacity and accountability to allocate available public finance equitably across regions and among population groups Market responsibility • Institutionalize consideration of health and health equity impact in national and international economic agreements and policy making • Reinforce the primary role of the state in the provision of basic services essential to health and the regulation of goods and services with a major impact on health • Markets bring health benefits in the form of new technologies goods and services and improved standard of living, but the marketplace can also generate negative conditions Evidence for action • There are three linked issues 1) Experience shows that to commercialization of vital social goods such as education and health care produces health inequity 2) There needs to be public sector leadership in effective national and international regulation of products, activities, and conditions that damage health or lead to health inequities 3) Regular health equity impact assessment of all policy making and market regulation should be institutionalized nationally and internationally • The commission views certain goods and services as basic human and societal needs and health care • Conditions of labour and working conditions are- in many countries, rich and poor- all too often inequitable • Processed foods and alcohol are two prime candidates for stronger global, regional and national regulatory controls • In recent decades under globalization market integration has increased Gender equity • Address gender biases in the structures of society- in laws and their enforcement, in the way organizations are run and interventions designed, and the way in which a countries economic performance is measured • Develop and finance policies and programmes that close gaps in education and skills, and that support female economic participation • Increase investment in sexual reproductive health services and programmes, building to universal coverage and rights • Reducing the health gap in a generation is only possible is gender inequities are addressed • Empowerment of women is key to achieving fair distribution of health Evidence for action • The position of women in society is also associated with child health and survival- of boys and girls • Gender inequities are socially generated and therefore can be changed • Maternal mortality and morbidity remain high in many countries, and reproductive health services remain hugely inequitably distributed within and between countries Political empowerment – inclusion and voice • Empower all groups in society through fair representation indecision-making about how society operates, particularly in relation to its effect on health equity, and create and maintain socially inclusive framework for policy-making • Enable civil society to organize and act in a manner that promotes and realizes the political and social rights affecting health equity • Being included in the society in which one lives is vital to the material, psychosocial and political empowerment that underpins social well-being and equitable health Evidence for action • Social inequality manifests across various intersecting social categories such as class, education, gender, age ethnicity, disability and geography • Signals hierarchy and reflects deep inequities in the wealth, poorer and prestige of different people and communities • Any serious effort to reduce health inequities will involve changing the distribution of power within society and global regions, empowering individuals and groups to represent strongly and effectively their needs and interests and in so doing to challenge and change the unfair and steeply graded distribution of social resources to which all as citizens have claims and rights Good global governance • Make health equity a global development goal, and adopt a social determinants of health framework to strengthen multilateral action on development • Strengthen WHO leadership in global action on the social determinants of health, instructionalising social determinants of health as a guiding principle across WHO departments and country programmes • Dramatic differences in the health and life chances of peoples around the world reflect imbalance in the power and prosperity of nations Evidence for action • The post war period has seen massive growth but growth in global wealth and knowledge has not translated into increased global health equity Measure and understand the problem and assess the impact of action • The world is changing fast and often it is unclear the impact that social, economic, and political change will have on health in general and on health inequities within countries or across the globe in particular The social determinants of health: monitoring, research and training • Ensure that routine monitoring systems for health equity and the social determinants of health are in place, locally, nationally, an internationally • Invest in generating and sharing new ways in which social determinants influence population health and health equity and on the effectiveness of measures to reduce health inequities through action on social determinants • Provide training on the social determinants of health to policy actors, stakeholders, and practioneers and invest in raising public awareness Evidence for action • Countries without basic data on mortality and morbidity by socieoeconomic indicators have difficulties moving forward on the health equity agenda • Most health research funding remains overwhelm biomedically focused • Much research remains gender biased • Policy actors need to understand what affects population health and how the gradient operates Week 2! Neuroscience, molecular biology, and the childhood roots of health disparities • Early experiences can affect adult health in 2 ways 1) Cumulative damage over time 2) The biological embedding of adversities during sensitive developmental periods • Development biology thinks about health promotion and disease prevention that focuses on the origins of persistent disparities in morbidity and mortality in the early years of life • Translation of this evolving science base into innovative policy an generate new approaches to reducing the burden of preventable disease • Reducing significant disadvantage early in life may be a powerful strategy for reducing the population-level burden of chronic morbidity and premature death Emergence of a new scientific approach for healthy policy • Persistence of social class gradients in disease prevalence and mortality rates in nations that provide universal access to health care services • Pulmonary disease in adulthood is commonly associated with a history of respiratory illnesses in childhood • Early social environments have been shown to play formative roles in cognitive and socioemotional development • Cardiovascular disease in later life can be linked to nutritional deficits and growth impairments in the prenatal period • Early experience can affect adult health in at least 2 ways 1) By accumulating damage over time 2) By the biological embedding of adversities during sensitive developmental periods Latent effects of adversity during sensitive periods • Adult disease and risk factors for poor health can be embedded biologically during sensitive periods in which the developing brain is more receptive to a variety of environmental signals, whether positive or negative o Ex. Poor living conditions early in life are associated with increased rates of cardiovascular, respiratory and psychiatric diseases in adulthood • Early experiences of child maltreatment and poverty have been associated with heightened immune responses in adulthood Central role of the brain • The brain is the primary organ of stress and adaptation, the brain is both vulnerable an d adaptable • Adaptive and maladaptive effects of stress hormones throughout the life course, with early life events influencing lifelong patterns of emotionality and stress responsiveness as well as altering the rate of brain and body aging The complexity of heterogeneous response • Found that 61% of individuals reporting significant emotional abuse in childhood developed major depression as adults • Early life experiences suggests underlying differences in vulnerability of gene environment interaction • Individual differences in neurobiological sensitivity to social environments can bias outcomes both positively and negatively, depending on the protective vs injurious nature of early exposures Biological embedding • Fetus in an intrauterine environment characterized by poor nutrition may undergo energy-sparing, metabolic changes that are designed to be adaptive in a postnatal environment of food scarcity • The risk of later obesity and other metabolic disorders can begin very early in life • Children from families and communities with low income and low education levels may be especially vulnerable to the biological embedding of disease risk because of their disproportionate exposure to highly stressful influences • Stress-related changes can persist into adult life and alter emotional states, decision- making capacities, and bodily processes that contribute to emotional instability, substance abuse, aggression, obesity, and stress-related disorders • Early adversity can lead to greater vulnerability later in life, positive experiences can decrease such risk Complexity of early childhood stress as a policy issue • Little attention has been paid to the development of health promotion and disease prevention strategies based on the reduction of significant stressors affecting everyday life for vulnerable young children and their parents this could be the result of a generalized misunderstanding about the nature and effects of childhood stress • 3 categories of stress experience that can affect the development of young children - Stress refers to the physiological expression of the stress response system - Biological principles 1) Positive stress • moderate, short-lived increases in heart rate, blood pressure, and stress hormone levels o Ex. challenges of dealing with frustration • important aspect of healthy development that is experienced in the context of stable and supportive relationships that facilitate adaptive responses 2) Tolerable stress • Physiological state that could potentially disrupt brain architecture buffered by supportive relationships that facilitate adaptive coping o Ex. Death or serious illness of a loved one, homelessness, or a natural disaster 3) Toxic • Strong, frequent and or prolonged activation of the body’s stress-response systems in the absence of the buffering protection of adult support o Ex. Extreme poverty, family violence • Disrupts brain architecture, affects other organ systems, and lead’s to stress- management systems that establish relatively lower thresholds for responsiveness that persist throughout life • Useful approach for helping policy makers differentiate normative life challenges that are growth promoting from significant adversities that threated long term health and development Health promotion and disease prevention within a science based early childhood framework • 3 strategies 1) Focuses on the provision of immunizations, anticipatory guidance, and early identification and management of problems in the context of primary health care for children • Model of individually focused medical services for children 2) Directed toward programs that encourage health-promoting behaviours in adults, such as better nutrition and increased exercise • Theory of change based on the capacity to modify the behaviour of adults 3) Focused on reducing health- threatening behaviours in adults such as smoking • Theory of change based on the capacity to modify the behaviour of adults • Limited by 3 constraints 1) Burdened by the increasing difficulty of changing behaviour and lifestyles as individuals grow older 2) Faces the difficult challenge of overcoming biological vulnerabilities that may have been embedded physiologically as a result of early adversity 3) Addressing adult behaviours, instead of the conditions faced by children and their families • reducing toxic stress in early childhood • reduction in the number and severity of early adverse experiences ill lead to a decrease in the prevalence of a wide range of health problems • the relatively high prevalence of early childhood trauma across all income groups underscores the need for greater attention, in both medical education and primary care practice to its potential effects on lifelong health Early childhood programs benefit lifelong health, not just education • cost-benefit assessments of effective early childhood intervention for low-income children have documented significant financial returns to society through greater economic productivity, decreased welfare dependence, and lower rates of incarceration • strengthening the capacity to address stress related problems within the context of existing early care and education programs is likely to augment their effects Child welfare services: missed opportunity for health promotion • child welfare services have focused exclusively on issues related to physical safety, reduction of repeated injury, and child custody • greater public understanding of the effects of early abuse and neglect on lifelong health could help build support for more informed policy and practice Summary and future directions • the origins of many adult diseases can be found among adversities in the early years of life that establish biological memories that weaken physiological systems and produce latent vulnerabilities to problems that emerge well into the later adult years • the design and implementation of new approaches to both the prevention and treatment of toxic stress and its consequences, beginning in the early childhood years, must be another key priority • focusing on access problems and differential treatment in the health care system is certainly important, but confronting the early childhood origins of disparities in physical and mental health Week 3! Eric Brunner and Michael Marmot Introduction • 2 major health problems of social determinants of health 1) The social gradient in disease • Runs right across the social hierarchy • Position in the hierarchy determines health o Relative deprivation=psychosocial concept 2) The striking differences in life expectancy between the countries of western Europe and those of central and eastern Europe that have emerged over the last 30 years • Hypothesis = right; psychosocial factors, including financial insecurity and hopelessness, play an important role in accounting for the worse health of those countries compared to the more favoured countries of the ‘west’ • Variety of biological pathways can plausibly change the risk of developing major disease • Biological plausibility = causation? • Does low socio-economic status lead to poor health, or does poor health lead to low socio-economic status = endogeneity, reverse causation The personal and the social • Stress seen as a property of individuals • We relate the biological response of the individual to the social environment action upon them • Social environments impacts biology to cause disease • Fight or flight response is adaptive in acute stress but may be maladaptive in chronic stress in today’s urban environment • Psychosocial factors is important in improving public c health in both economically developed and developing countries Biological pathways in a social context • Factors operating beyond the level of the individual as well as the individual characteristic is recognised as a prevention rather than a cure in a public health framework • Social structure influences well-being and health • Social structure operates in 3 pathways 1) Material circumstances are related to health directly via the social and work environment 2) These in turn shape psychological factors and health related behaviours, earl
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