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What does it mean to be healthy?: The Medical Model
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-health is the absence of disease, illness, infection, disability, etc.
-individual resiliency/susceptibility (host) determines risk of disease when we face 'threats' based on genetics, exposure to risks (agents)
-individual resiliency/susceptibility (host) determines risk of disease when we face 'threats' based on genetics, exposure to risks (agents)
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Health
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-is a complete state of physical, mental & social well-being and not merely the absence of disease or infirmity (WHO)
-it is the ability to identify and to realize aspirations, to satisfy needs and to change and cope with the environment
-health is therefore a resource for everyday life, not the objective of living
-it is the ability to identify and to realize aspirations, to satisfy needs and to change and cope with the environment
-health is therefore a resource for everyday life, not the objective of living
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health promotion
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-health = positive health and multidimensional concept
-participartory model
-concerns a network of issues that are identified by community
-aimed at the population in its total environment
-diverse and complementary strategies
-changes in society sought
-responsiblity of health, health-related and non-health sectors
-participartory model
-concerns a network of issues that are identified by community
-aimed at the population in its total environment
-diverse and complementary strategies
-changes in society sought
-responsiblity of health, health-related and non-health sectors
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Disease prevention
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-health = absence of disease
-emerged from the medical model
-concerns a specific pathology/risk factors
-changes in individuals' behaviours/physiology sought
-largely initiated/identified by health professionals
-emerged from the medical model
-concerns a specific pathology/risk factors
-changes in individuals' behaviours/physiology sought
-largely initiated/identified by health professionals
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population health
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-focuses on the interrelated conditions and factors that influence the health of populations over the life course
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a population health approach requires...
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-health is seen as a capacity or resource that can be built
-a focus on the root causes of a problem, with evidence to support the strategy to address the problem
-improving the aggregate health status of the whole society, while reducing the inequities in health status of sub-populations
-a focus on partnerships and inter-sectorla cooperation
-public involvement and community participation
-a focus on the root causes of a problem, with evidence to support the strategy to address the problem
-improving the aggregate health status of the whole society, while reducing the inequities in health status of sub-populations
-a focus on partnerships and inter-sectorla cooperation
-public involvement and community participation
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health inequalities
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-patterned differences in disease incidence, disability, and life expectancy between sub-populations.
-health inequalities arise from conditions over which we have no control over, health inequities, social justices, etc.
-health inequalities arise from conditions over which we have no control over, health inequities, social justices, etc.
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health inequities
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-patterned differences in disease incidence, disability, and life expectancy between sub-populations that arise from conditions that can be changed by collective action, such as changes in public policies
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equity
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-the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically
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health equity means...
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-everyone has a fair opportunity to live a long, healthy life
-that health should not be compromised or disadvantaged because of social or demographic factors
-achieving health equity requires creating fair opportunities for health and eliminating gaps in health outcomes
-that health should not be compromised or disadvantaged because of social or demographic factors
-achieving health equity requires creating fair opportunities for health and eliminating gaps in health outcomes
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lifestyle
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- (WHO): a way of living affected by the relationship between an individual's personal characteristics, social interactions and socioeconomic and environmental living conditions
-an expression of identity
-an expression of identity
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social determinants of health
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-factors that determine our ability to make healthy choices
WHO: the conditions in which people are born, grow, live, work and age...[that] are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries
-examples: income & education; whether we have a job and what kind of work we do; how much support we receive from family and friends; opportunities for development that we have as very young children; physical environments in our homes and communities; aspects of our culture that may affect our behaviour and our access to health services; biological sex and gender
WHO: the conditions in which people are born, grow, live, work and age...[that] are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries
-examples: income & education; whether we have a job and what kind of work we do; how much support we receive from family and friends; opportunities for development that we have as very young children; physical environments in our homes and communities; aspects of our culture that may affect our behaviour and our access to health services; biological sex and gender
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epidemiology
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study of patterns, causes, and effects of various health-related features in a population
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epidemiology influences
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snow - cholera epidemic
engels - working class death rates post-industrial era
durkheim - social facts impact health
virchow - systematic and political reform to change health patterns
mcKeown - TB decline due to social not medical changes
engels - working class death rates post-industrial era
durkheim - social facts impact health
virchow - systematic and political reform to change health patterns
mcKeown - TB decline due to social not medical changes
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the lalonde report (1974)
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-first document to suggest "health promotion" as a key strategy for improving health
-internationally renowned as the first official government document to recognize that universal health care does not equal universal health status
-established health promotion infrastructure: the health promotion directorate
-internationally renowned as the first official government document to recognize that universal health care does not equal universal health status
-established health promotion infrastructure: the health promotion directorate
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the declaration of Alma Ata on primary health care 1978
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-international conference on primary health care, 134 countries
-declared health status of millions unacceptable and called for a new approach
-Health for All by 2000: to attain a level of health for all the citizens of the world that would permit them to lead socially and economically productive lives
-declared health status of millions unacceptable and called for a new approach
-Health for All by 2000: to attain a level of health for all the citizens of the world that would permit them to lead socially and economically productive lives
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strategies for achieving health for all by 2000
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1. education about health problems and how to prevent/control them
2. proper nutrition
3. adequate supply of safe water and basic sanitation
4. maternal and child health care
5. immunization
6. appropriate treatment for diseases/injuries
7. provision of essential drugs
2. proper nutrition
3. adequate supply of safe water and basic sanitation
4. maternal and child health care
5. immunization
6. appropriate treatment for diseases/injuries
7. provision of essential drugs
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the ottawa charter 1986
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first assertion: improvement in health requires a secure foundation and basic prerequsities
health promotion actions:
1. build healthy public policy
2. create supportive environments; because of the inextricable links between people and their environment
3. strengthen community action
4. develop personal skills
5. reorient health services
health promotion actions:
1. build healthy public policy
2. create supportive environments; because of the inextricable links between people and their environment
3. strengthen community action
4. develop personal skills
5. reorient health services
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health mechanisms: self-care
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-those things a person does that promotes or maintains their health
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health mechanisms: mutual aid
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-working together as groups to address health issues
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health mechanisms: healthy environments
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-so that the healthy choice is the easy choice, the accessible choice (and socially acceptable) and the affordable choice
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socioecological model
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-recognizes the interwoven relationship between the individual and their environment
-individual - family + friends - organizations + settings - community - policy
-individual - family + friends - organizations + settings - community - policy
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people's health charter, 2000
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-people's health assembly, Bangladesh, brought 1453 participants from 92 countires formulated and endorsed the people's charter for health
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today Canada is a global leader in...
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1. health literacy: the ability to access, understand, evaluate/apply and communicate health information to improve one's health
2. physical literacy: the confidence and competence to engage in a wide variety of physical activities in multiple environemtns that benefit the healthy development of the whole person
2. physical literacy: the confidence and competence to engage in a wide variety of physical activities in multiple environemtns that benefit the healthy development of the whole person
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social epidemiology
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-the study of the health of human populations as it relates to social phenomena, a branch of epidemiology that considers the social determinants of health
i. takes a population level
ii. life-course perspective
iii. concerned with social context of behaviour
iv. relies on multi-level analyses
i. takes a population level
ii. life-course perspective
iii. concerned with social context of behaviour
iv. relies on multi-level analyses
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morbidity
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means any departure from a normal state, such as illness or disability
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incidence
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the number of new cases that arise in a specified population in a specific period of time
-the incidence rate is the number of new cases arising divided by the duration of the defined period
-it is an expression of disease risk (probability) in the population
-the incidence rate is the number of new cases arising divided by the duration of the defined period
-it is an expression of disease risk (probability) in the population
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prevalence
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is not a rate, but rather a simple count of the number of cases in a population at a point in time
-prevalence is a useful measure of the burden of disease on the population (and how much it may be costing to manage that burden), but it tells us nothing about probability or risk
-prevalence is a useful measure of the burden of disease on the population (and how much it may be costing to manage that burden), but it tells us nothing about probability or risk
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crude death rates
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- an estimate of the proportion of people who died within a given period, usually a year
-normally calculated by counting all deaths over the year and dividing by the mid-year population
- lack of comparability due to the differences in the characteristics of the people making up the population, rates to be comparable, have to be standardized for age and sex
-normally calculated by counting all deaths over the year and dividing by the mid-year population
- lack of comparability due to the differences in the characteristics of the people making up the population, rates to be comparable, have to be standardized for age and sex
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life expectancy
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-the average number of years members of a given population can be expected to live given that current mortality (death) rates apply
- generally speaking it is wise to seperate out under-five mortality from over-five mortality to avoid skewing results
- generally speaking it is wise to seperate out under-five mortality from over-five mortality to avoid skewing results
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premature mortality
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is a calculation of years of life lost before age 70
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health adjusted life expectancy
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only years spent in good health are counted in calculating life expectancy - the disability adjusted life year (DALY) is a related measure that discounts years of life spent disabled
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infant mortality
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deaths of children less than one year old - the rate is calculated by dividing the number of infant deaths by the total number of live births occuring within one year x 1000
-is generally regarded as a reliable summative measure of the health of a population combined with the availability and quality of health care
-is generally regarded as a reliable summative measure of the health of a population combined with the availability and quality of health care
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risk factors
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variables that contribute to the probability of an adverse health outcome
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Transitions: demographic transition
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birth and death rates are related to affluence and resources of that era
-societal affluence impacts health even at these basic markers
-societal affluence impacts health even at these basic markers
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transitions: epidemiologic transition
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disease type shifts with societal affluence
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types of epidemiological studies: descriptive
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-correlational, case reports, cross-sectional surveys
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types of epidemiological studies: analytic studies
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observational or experimental
-case-control; cohort; RCTs - intervention/clinical trials; ecological
assembling individuals to systematically determine whether or not the risk of disease is different for individuals exposed or not exposed to a factor or interest
-can be retrospective or prospective
-case-control; cohort; RCTs - intervention/clinical trials; ecological
assembling individuals to systematically determine whether or not the risk of disease is different for individuals exposed or not exposed to a factor or interest
-can be retrospective or prospective
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prospective cohort studies
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a group of individuals with one or more similar characteristics is enrolled or recruited at one point in time then followed over time with respect to one or more outcomes of interest in order to determine which factors contribute to those outcomes
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relative risk
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estimates the probability of developing a disease in those exposed to a risk factor relative to those not exposed
-RR > 1 = increased risk amon those exposed
-RR < 1 = decreased risk among those exposed
HERE WE ARE ASKING: how much more likely am I to develop a disease if I am exposed to a risk factor?
-RR > 1 = increased risk amon those exposed
-RR < 1 = decreased risk among those exposed
HERE WE ARE ASKING: how much more likely am I to develop a disease if I am exposed to a risk factor?
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odds ratio (OR)
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is an expression of the association between a risk factor and health outcome by comparing the likelihood of the outcome under two circumstances
HERE WE ARE ASKING: what are the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occuring in the absence of that exposure?
HERE WE ARE ASKING: what are the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occuring in the absence of that exposure?
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population attributable risk (PAR)
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-the proportion of cases that is attributable to an exposure/risk factor
-the proportion of cases (incidence) that would not occur in a population if the factor were eliminated (e.g., how many lives would by saved if people no longer smoked?)
HERE WE ARE ASKING: based on the risk ratios and prevalence of a disease, how many deaths, disabilities, or sustained illness would have been avoided if a certain risk factor wasn't there?
-the proportion of cases (incidence) that would not occur in a population if the factor were eliminated (e.g., how many lives would by saved if people no longer smoked?)
HERE WE ARE ASKING: based on the risk ratios and prevalence of a disease, how many deaths, disabilities, or sustained illness would have been avoided if a certain risk factor wasn't there?
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what are the 8 epidemiological criteria for establishing causal inference?
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1. consistency
2. temporality
3. strength of associatiokn
4. dose-response relationship
5. cessation of exposure
6. consideration of alternative explanation
7. biological plausibility
8. coherence
2. temporality
3. strength of associatiokn
4. dose-response relationship
5. cessation of exposure
6. consideration of alternative explanation
7. biological plausibility
8. coherence
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epidemiological criteria for establishing causal inference: consistency
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an association has been replicated in different methodological, geographical and time settings
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epidemiological criteria for establishing causal inference: temporality
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the 'cause' must precede the effect; an indisputable criterion
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epidemiological criteria for establishing causal inference: strength of association
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the stronger an association is the less likely it is that there is an unknown, alternative explanation
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epidemiological criteria for establishing causal inference: dose-response relationship
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increased exposure is related to increased outcomes
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epidemiological criteria for establishing causal inference: cessation of exposure
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if the exposure changes, positively or negatively, the incidence or the outcome will rise or fall
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epidemiological criteria for establishing causal inference: consideration of alternative explanation
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the association is not confounded by one or more other factors
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epidemiological criteria for establishing causal inference: biological plausibility
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the association fits with existing biological knowledge/evidence
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epidemiological criteria for establishing causal inference: coherence
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the association is supported by other scientific knowledge/evidence
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epidemiology and levels of analysis: individual level
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susceptibility/resilience to disease
-how biomedical (host-agent interaction) and behavioural variants interact to create susceptibility to, or risk of, disease
-age, sex, genetics are key characteristics of the host influencing their susceptibility
-often individual factors are RISK factors, not CAUSAL factors
-how biomedical (host-agent interaction) and behavioural variants interact to create susceptibility to, or risk of, disease
-age, sex, genetics are key characteristics of the host influencing their susceptibility
-often individual factors are RISK factors, not CAUSAL factors
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Rose and the population health approach
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1. initiatives should address the populations as a whole rather than focusing on specific risk factors and high risk individuals
2. address the root (distal) causes of disease (primary prevention) rather than 'band-aid' approaches (secondary/tertiary prevention)
3. focusing solely on behaviours (ignoring the context within which they are made) is inadequate
4. distinguish between risks/probabilities applied to populations compared to individuals
2. address the root (distal) causes of disease (primary prevention) rather than 'band-aid' approaches (secondary/tertiary prevention)
3. focusing solely on behaviours (ignoring the context within which they are made) is inadequate
4. distinguish between risks/probabilities applied to populations compared to individuals
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epidemiological research has...
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1. identified the influence of risk factors or behaviours on health status
2. discovered inequities in health across populations - higher incidence of disease and illness among certain segments of the population within and between countries due to avoidable factors
3. recognized that risky behaviours alone do not explain the prevalent health inequities
4. examined the impact of our environment (living conditions) that "determine" our ability to make healthy lifestyle choices - social determinants of health
2. discovered inequities in health across populations - higher incidence of disease and illness among certain segments of the population within and between countries due to avoidable factors
3. recognized that risky behaviours alone do not explain the prevalent health inequities
4. examined the impact of our environment (living conditions) that "determine" our ability to make healthy lifestyle choices - social determinants of health
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Glasgow initiatives
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-achieving our potential: to tackle poverty and income inequality
-equally well: to address health inequities
-early years framework: to ensure that all children are given the best possible start in life
-equally well: to address health inequities
-early years framework: to ensure that all children are given the best possible start in life
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absolute or material deprivation
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struggle to meet basic needs
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relative deprivation
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status relative to others
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gradient in health
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-the near universal findings that health and life expectancy improve and disease incidence falls as income, education level, quality of job, or quality of neighbourhood rise.
-a hierarchy; or stepwise unequal distribution of income or resources that leads to poorer health; it's the size of the gap that matters for health
-those higher in a hierarchy (social, economic, education) experience better health
-a hierarchy; or stepwise unequal distribution of income or resources that leads to poorer health; it's the size of the gap that matters for health
-those higher in a hierarchy (social, economic, education) experience better health
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Framingham studies
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started in 1948 to identify the common factors that contribute to CVD in a large, CVD healthy cohort over a long period of time (prospective cohort study)
-over the last 50 years the study has identified key 'risk factors' to CVD: high BP; smoking; physcial inactivity; overweight and obesity; diabetes; age; gender; psychosocial issues
-over the last 50 years the study has identified key 'risk factors' to CVD: high BP; smoking; physcial inactivity; overweight and obesity; diabetes; age; gender; psychosocial issues
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risk factor calculations
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-as a result of findings from Framingham study, developed score sheets and calculators for assessing an individual risk of CVD and associated health concerns
-Framingham is where the idea of "risk factors" became common terminology - "Framingham score"
-there are score sheets now available for: atrial fibrillation, CVD, congestive heart failure, diabetes, stroke, coronary heart disease
-Framingham is where the idea of "risk factors" became common terminology - "Framingham score"
-there are score sheets now available for: atrial fibrillation, CVD, congestive heart failure, diabetes, stroke, coronary heart disease
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Framingham study and contexts
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Framingham evidence also points strongly to the influence of environmental factors in shaping lifestyle practices - most recently investigated how obesity is contagious
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Health & Ways of Living: Alameda County Study (Berkman & Breslow)
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-1965 survey of almost 7000 people over 20 years of age, re-surveyed 5 times up to 1999
-reviewed how ways of living (lifestyle habits), social support and demographic variables are related to health
-reviewed how ways of living (lifestyle habits), social support and demographic variables are related to health
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Results of the Alameda County Study
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-identified 5 risk behaviours which significantly influence mortality:
1. smoking
2. excessive alcohol consumption
3. low levels of exercise
4. over/under weight
5. less than 7 or more than 9 hours of sleep per day
*exercise and smoking were the most powerful predictors of mortality
-persons with the lowest # of high risk behaviours consistently had the lowest mortality rates regardless of age, sex, income, race and inital health status
-people's social support network (marital status, contacts with friends/family, church &/or organizational membership) also significantly predicted death
-the least socially connected persons had 2x the risk of dying from all causes
-persons practicing healthy behaviours were also more likely to be socially well connected
1. smoking
2. excessive alcohol consumption
3. low levels of exercise
4. over/under weight
5. less than 7 or more than 9 hours of sleep per day
*exercise and smoking were the most powerful predictors of mortality
-persons with the lowest # of high risk behaviours consistently had the lowest mortality rates regardless of age, sex, income, race and inital health status
-people's social support network (marital status, contacts with friends/family, church &/or organizational membership) also significantly predicted death
-the least socially connected persons had 2x the risk of dying from all causes
-persons practicing healthy behaviours were also more likely to be socially well connected
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Results of the Alameda County Study 18 years later...
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-18 years later they also found a relationship between family income and health - the poor had greater than 2x the risk of dying than the rich
-impacts of a social support network significantly predicted mortality independent of SES, age, race, level of preventitive care
-impacts of a social support network significantly predicted mortality independent of SES, age, race, level of preventitive care
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1972 Multiple Risk Factor Intervention Trial (MRFIT)
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-tested hypothesis that Coronary Heart Disease (CHD) could be reduced if people changed their behaviour
-6500 men at high risk of CHD - high cholestrol, high blood pressure and smokers
-each agreed to alter eating and smoking habits and adhere to medication
-received state-of-art behaviour modification and personal attention for 7 years vs. control group
-6500 men at high risk of CHD - high cholestrol, high blood pressure and smokers
-each agreed to alter eating and smoking habits and adhere to medication
-received state-of-art behaviour modification and personal attention for 7 years vs. control group
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Results of MRFIT
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-40% quit smoking
-64% reduced blood pressure
-6.7% reduction in cholestrol
-no significant difference in mortality between experimental and control groups
-64% reduced blood pressure
-6.7% reduction in cholestrol
-no significant difference in mortality between experimental and control groups
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What explains the less than stellar results of the MRFIT study?
answer
-focus exclusively on individual behaviour without tending to context
-in one-to-one programs, such as MRFIT, nothing has been done to influence those forces in society that caused the problem in the first place
-cannot account for secular changes resulting from population wide changes in norms, policies, regulation, etc.
-in one-to-one programs, such as MRFIT, nothing has been done to influence those forces in society that caused the problem in the first place
-cannot account for secular changes resulting from population wide changes in norms, policies, regulation, etc.
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The Whitehall studies 1967
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-prospective cohort study following the health of 18,000 male British civil servants in office-based jobs
-hierarchy of income and rank in British govt. well defined (administrative, professional, clerical, unskilled manual)
-data were person-specific (measures taken at work and home) and longitudinal
-hierarchy of income and rank in British govt. well defined (administrative, professional, clerical, unskilled manual)
-data were person-specific (measures taken at work and home) and longitudinal
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Phase II of Whitehall Study
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-studied subjective social status as a predictor of ill-health in addition to demographic, lifestyle, psycho-social factors & clinical exam to 10,308 Whitehall male and female workers
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Baboon Study
answer
-baboons are ideal to study because they eat the same things & are all active; have pretty close genetic make-up; don't drink/smoke/take lots of medication
-yet they experience stress and stress-related diseases to almost the same degree as humans because of their social hierarchy
-the subordinate animals experienced more stress, coped with it less well and were sicker and died younger than those higher up in baboon society
-Saplosky's conclusion: stress is entirely socially generated
-yet they experience stress and stress-related diseases to almost the same degree as humans because of their social hierarchy
-the subordinate animals experienced more stress, coped with it less well and were sicker and died younger than those higher up in baboon society
-Saplosky's conclusion: stress is entirely socially generated
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GRadient in Health
answer
G - gibbons (really, baboons)
F - relative deprivation
- Alameda, Whitehall, Sapolsky = evidence that deprivation relative to others in your neighbourhood, workplace, troop, contributes to disease regardless of specific risk factors
- Framingham, MRFIT = evidence that focusing on individual risk factors to the exclusion of context/circumstances/environment will only contribute to nominal improvements in health
F - relative deprivation
- Alameda, Whitehall, Sapolsky = evidence that deprivation relative to others in your neighbourhood, workplace, troop, contributes to disease regardless of specific risk factors
- Framingham, MRFIT = evidence that focusing on individual risk factors to the exclusion of context/circumstances/environment will only contribute to nominal improvements in health
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relative deprivation
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-comparative measure of poverty based on what the standard of living is around us
-the chronic stress of comparing oneself to others makes people sick
-what materials, education and civic power do those around us have? What do we feel entitled to have?
-how much money you have is not as important as how much you have relative to others in society (the status syndrome)
-the chronic stress of comparing oneself to others makes people sick
-what materials, education and civic power do those around us have? What do we feel entitled to have?
-how much money you have is not as important as how much you have relative to others in society (the status syndrome)
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Psychosocial Theory
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-the joint contentions that (a) psychological states arise in interaction with social environments, and (b) those psychological states have biological implications
-we see poorer health where there is more hierarchy, more gaps in general social status
-fosters envy, lack of solidarity, lack of social connection when steeply hierarchical = stress
-we see poorer health where there is more hierarchy, more gaps in general social status
-fosters envy, lack of solidarity, lack of social connection when steeply hierarchical = stress
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Survival in Academy Award Winners
answer
-examined life expectancy and all-cause mortality rates of 1649 performers
-found that success confers a survival advantage: winners lived an average of 3.9 years longer, or experienced a 28% lower death rate, than either nominees or fellow cast members
-found that success confers a survival advantage: winners lived an average of 3.9 years longer, or experienced a 28% lower death rate, than either nominees or fellow cast members
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GrADIent in Health
answer
A - absolute deprivation
D - distribution of
I - income
D - distribution of
I - income
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absolute deprivation
answer
-absolute or material deprivation at the individual level - income, education, lack of the basic material necessities of life such as food, housing, etc.
-related to the minimal material requirements to survive (food, shelter, clothing)
-absolute poverty is objective, not a social comparison or relative monetary amount
-the same across geographic and social contexts
-related to the minimal material requirements to survive (food, shelter, clothing)
-absolute poverty is objective, not a social comparison or relative monetary amount
-the same across geographic and social contexts
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Income and Health
answer
-as evidence by hundreds of studies, in general, lower income families and individuals reveal a greater incidence or higher rates of...mortality (all age categories); heart disease; obesity; diabetes; survival of ovarian cancer; risk factors such as smoking, inactivity, poor eating habits. - this was regardless of age, gender and income
question
3 explanations explaining how money exerts its influence on health
answer
1. absolute deprivation
2. income distribution hypothesis
3. social exclusion/social capital
2. income distribution hypothesis
3. social exclusion/social capital
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explanation 1: absolute deprivation
answer
-the Materialist (individual resources) and Neo-Materialist (collective resources) hypotheses
-not having enough $ to live healthfully
-differential access to health care and public services
-the poor live admist health risks and less access to health promoting resources
-education leads to better health
-not having enough $ to live healthfully
-differential access to health care and public services
-the poor live admist health risks and less access to health promoting resources
-education leads to better health
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explanation 2: income distribution hypothesis
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-having wide gaps in income is bad for everyone, even after controlling for individual income
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explanation 3: social exclusion/social capital
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-process by which people are denied the opportunity to participate in civil society and access goods or services normal to all citizens
-material deprivation impacts transportation and the means to be physically present
-lack of participation in common societal activities
-exclusion from decision-making and civic participation
-this has been described as poverty: not just inequality and not just low income, being so poor that you are seperated from the community > widely used indices of poverty define it as income half that of the median
-material deprivation impacts transportation and the means to be physically present
-lack of participation in common societal activities
-exclusion from decision-making and civic participation
-this has been described as poverty: not just inequality and not just low income, being so poor that you are seperated from the community > widely used indices of poverty define it as income half that of the median
question
Income distribution and inequality
answer
-distribution of income across a population - the gap between the rich and the poor is a strong indicator of the health of a population
-in developed countries, income differences - or distribution - relate very closely to health and life expectancy
-furthermore, greater inequality in a society is related to: higher rates of obesity; higher teenage pregnancy rates; greater prevalence of mental illness; decreased levels of social interaction, trust and social capital (civic participation)
-in developed countries, income differences - or distribution - relate very closely to health and life expectancy
-furthermore, greater inequality in a society is related to: higher rates of obesity; higher teenage pregnancy rates; greater prevalence of mental illness; decreased levels of social interaction, trust and social capital (civic participation)
question
GINI coefficient
answer
-a widely used measure of income inequality where "0" is assigned to a hypothetical population that shares everything equally and "1" is assigned to a population where one individual has everything.
-real world countries range from very equal score around 0.20 to very unequal scores of around 0.50
-in places with a GINI index > .30, the negative effects (premature death and poor self reported health) are strong
-real world countries range from very equal score around 0.20 to very unequal scores of around 0.50
-in places with a GINI index > .30, the negative effects (premature death and poor self reported health) are strong
question
Preston Curve
answer
-the cross-sectional relationship between different countries' life expectancy per capita income that forms a concave curve that increasingly "flattens" as income rises
-suggests that absolute deprivation is important up to $10 000 per capita and then there is diminishing marginal returns
-after this 'ceiling' or threshold of income is reached the influence of income on health is called relative deprivation
-suggests that absolute deprivation is important up to $10 000 per capita and then there is diminishing marginal returns
-after this 'ceiling' or threshold of income is reached the influence of income on health is called relative deprivation
question
average income matters most in...
answer
poorer societies
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income distribution matters most in...
answer
wealthier societies
question
Challenges to Wilkinson and Pickett's idea of relative deprivation
answer
-issues with scale: strongest evidence for relative deprivation at aggregated (state, province, country) level rather than at local level where we would expect to see such a relationship play out
-inconsistent relationships from cross sectional data only and ruling out poverty..."cherry picking" the data
-baboons do not = humans
-what about helping those experiencing psychosocial stress to better cope with it in order to reduce negative health outcomes?
-Lavis et al. removed income from social standing to demonstrate that personal resources drive health outcomes, not one's place in the social hierarchy
-inconsistent relationships from cross sectional data only and ruling out poverty..."cherry picking" the data
-baboons do not = humans
-what about helping those experiencing psychosocial stress to better cope with it in order to reduce negative health outcomes?
-Lavis et al. removed income from social standing to demonstrate that personal resources drive health outcomes, not one's place in the social hierarchy
question
A Canadian example: child fitness tax credit
answer
-using income tax refund data, this study found that higher income families receive greater benefit because they can afford to claim the credit and wait until income tax time to benefit from the deduction.
families in most need, earning less that $20K, are unable to claim it because they do not earn enough
families in most need, earning less that $20K, are unable to claim it because they do not earn enough
question
absolute (material) deprivation matters in...
answer
developing countries (with infectious disease)
question
relative deprivation matters in...
answer
developed countries (with chronic disease)
question
Why does it matter if your neighbours are substantially wealthier than you?
answer
-some Canadian research has indicated that, poor people living in proximity to rich people may benefit from externalities improved by their wealthy neighbours (e.g., municipal services, more local taxes and donations to schools, etc.)
-diversity gives opportunity to see health to see health enhancing behaviour in action
-diversity gives opportunity to see health to see health enhancing behaviour in action
question
What's luck got to do with it?
answer
-about 60% of your likely income is determined at birth by what country you live in; 20% is determined by the income class of your parents
-if you are born in a rich country, your income level - even if you are in a low-income group within your country - is likely higher that that of most people in the world
-if you are born in a rich country, your income level - even if you are in a low-income group within your country - is likely higher that that of most people in the world
question
proportionate universalism
answer
-to reduce the steepness of the social gradient in health, actions must be universal, but with scale and intensity that is proportionate to the level of disadvantage
-greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient and will only tackle a small part of the problem
-greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient and will only tackle a small part of the problem
question
positive externalities
answer
poorer people benefit from living in wealthier neighbourhoods
question
tax progressive vs. tax resistant societies
answer
-in countries where the wealthier pay higher taxes to fund public programs, those programs are used more by the less wealthy and the less healthy, which serves to equalize health between the income groups
question
latency effect
answer
crossectional studies cannot account for the latency effect on inequity on health over time (5-7 years for psychosocial stressors to influence biology)
-countries experiencing rapidly increasing inequality are creating a legacy of serious ill health and premature mortality
-countries experiencing rapidly increasing inequality are creating a legacy of serious ill health and premature mortality
question
influence of redistribution on economic growth
answer
-redistribution through the tax and transfer system positively relates to economic growth for most countries because the wealthy spend a lower fraction of their income than do middle/lower income groups
question
progressive tax systems
answer
-to be truly progressive, public programs need to be paid for through taxing the wealthy and targeted at the poor: the person paying and the person receiving the benefit are different
-Australia is more progressive than Canada, Britain or U.S. in that 60% of benefits are true redistributions, and spending 41.5% of public dollars to the lowest income group
-Australia is more progressive than Canada, Britain or U.S. in that 60% of benefits are true redistributions, and spending 41.5% of public dollars to the lowest income group
question
The swiss paradox
answer
-one of the highest average incomes in OECD with high quality of life measures; little poverty; progressive tax structure; low unemployment; longlife expectancy (80.5-84.7); state of the art healthcare with universally mandated health insurance BUT...
-there is geographic variability in income and has a GINI index ranging from 0.28 to 0.34
-there is geographic variability in income and has a GINI index ranging from 0.28 to 0.34
question
What is an explanation for the swiss paradox?
answer
-if overall income is high, even if inequality exists, this allows communities with progressive tax structures to invest in facilities and services that benefit everyone's health
-In Switzerland, inequality reflects gaps between moderate rate and very high incomes, rather than low vs. high incomes; social cohesion/capital is less compromised
-In Switzerland, inequality reflects gaps between moderate rate and very high incomes, rather than low vs. high incomes; social cohesion/capital is less compromised
question
More taxes = greater happiness?
answer
-Danes and Swiss pay some of the highest taxes in the world but they are rewarded with generous public services and a world-renowned welfare state
-switzerland and Denmark score #1 and #3 in the World Happiness Report
-this reduces extreme unhappiness and lowers stress by making sure that everyone has a roof over their head, job security, access to healthcare and the opportunity to send their children to university - no matter what their income
-switzerland and Denmark score #1 and #3 in the World Happiness Report
-this reduces extreme unhappiness and lowers stress by making sure that everyone has a roof over their head, job security, access to healthcare and the opportunity to send their children to university - no matter what their income
question
Welfare 'generosity' and population health
answer
-among countries that devote larger amounts to welfare resources, population health outcomes improve
-this study investigated provincial commitments to welfare resources (community and social services, recreation and culture, education, social assistance, environment housing...) and mortality rates
-specifically: medical care, preventative care, social services and access to post secondary education are recommended
-this study investigated provincial commitments to welfare resources (community and social services, recreation and culture, education, social assistance, environment housing...) and mortality rates
-specifically: medical care, preventative care, social services and access to post secondary education are recommended
question
What does a low inequality country look like?
answer
-appropriate living wages, policies at supporting job search and skill matching can be imporant
-job protection against temporary/contract positions
-tax reforms on policies that benefit only the wealthy and corporations (remove tax relief on mortgage interest, capital gains, inheritances, stock gains, etc.)
-more accessible education/training opportunities
-invest in affordable housing and accessible/affordable childcare.
-job protection against temporary/contract positions
-tax reforms on policies that benefit only the wealthy and corporations (remove tax relief on mortgage interest, capital gains, inheritances, stock gains, etc.)
-more accessible education/training opportunities
-invest in affordable housing and accessible/affordable childcare.
question
GradiENT
answer
E - exclusion from community life because of extreme poverty
N - networks that can buffer stress
T - translation socio-biologically into health outcomes
N - networks that can buffer stress
T - translation socio-biologically into health outcomes
question
Buffering income inequality
answer
-countries like Sri Lanka and Costa Rica with long life expectancies, despite low incomes, have certain characteristics in common:
-egalitarian, inclusive society-female independence; high spending on education & welfare; higher adult literacy rates; and open political system & loosely structued class system; civil community; increased levels of social capital
-egalitarian, inclusive society-female independence; high spending on education & welfare; higher adult literacy rates; and open political system & loosely structued class system; civil community; increased levels of social capital
question
Social cohesion
answer
-the extent to which bonds form among members of a group and between groups
-how tightly woven a community is...how many organizations serve the collective 'good'
- high social cohesion = health
-how tightly woven a community is...how many organizations serve the collective 'good'
- high social cohesion = health
question
social capital
answer
-collective benefits arising from cooperative attitudes and practices, grounded in trust and reciprocity
-network resources that facilitate individuals and collective action, and valuing human connection; high social capital = better health
-how many people vote, read the newspaper, know their neighbours' names, volunteer, are members of local organizations, etc.
-more civility, trustworthiness, reciprocity = less psychosocial stress
-seeing people from different social groups, interacting with them positively, finding areas of common ground, etc.
-network resources that facilitate individuals and collective action, and valuing human connection; high social capital = better health
-how many people vote, read the newspaper, know their neighbours' names, volunteer, are members of local organizations, etc.
-more civility, trustworthiness, reciprocity = less psychosocial stress
-seeing people from different social groups, interacting with them positively, finding areas of common ground, etc.
question
social exclusion
answer
-a process of excluding non-members of a group from interactions and associated benefits of group membership
-arises from social structures and ongoing processes in society
-e.g., varied access to education, employment opportunities, shared opportunity and leadership roles, access to health services, etc.
-as social exclusion increases, social capital decreases
-arises from social structures and ongoing processes in society
-e.g., varied access to education, employment opportunities, shared opportunity and leadership roles, access to health services, etc.
-as social exclusion increases, social capital decreases
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