HLTB16 – Lecture 10: Health Inequity

Differences between groups or populations (defined socially, economically, demographically or geographically) that are unfair and avoidable or remedial rather than to any innate differences between these groups.

-Health inequities tend to show a gradient across societies
-Our health will be better than those below but
worse than those above us.
-This means that inequalities in health affect the whole population, not just the poor.

-Despite sustained improvements in life expectancy and average population health, inequalities have been widening over the last few decades
-While generally, income inequality between countries has improved, income inequality within countries has become worse

-Morbidity (disease): the condition of suffering from a disease or medical condition.
-The rate of disease in a population
-Mortality (death): a measure of the number of deaths in a particular population from a particular disease or medical condition

Incidence rate:
-Numerator: Number of new cases of disease
during specified time interval
-Denominator: Summed person-years of
observation or average population during time
interval
Incidence Proportion / Culminative Incidence:
-Numerator: Number of new cases of disease
during specified time interval
-Denominator: Population at start of interval
Point Prevalence:
-Numerator: Number of current cases (new and
preexistng) at a specified point in time
-Denominator: Population at the same specifiied
point in time
Period Prevalence:
-Numerator: Numer of current cases (new and
preexisting) over a specified period of time
-Denominator: Average or mid-interval population

Crude Death Rate:
-Numerator: Total number of deaths during a given
time interval
-Denominator: Mid-interval population
-10^n = 1000 or 100 000
Cause-Specific death rate:
-Numerator: Number of deaths assigned to a
specific cause during a given time interval
-Denominator: Mid-interval population
-10^n = 100 000
Infant Mortality Rate:
-Numerator: Number of deaths among children <1
year of age during a given time interval
-Denominator: Number of live births during the
same time interval
-10^n = 1000
Maternal Mortality Rate:
-Numerator: Number of deaths assigned to
pregnancy-related causes during a given time
interval
-Denominator: Number of live births during the
same time interval
-10^n = 100 000

-Mortality rates can compare the rates in one area with the rates in another area, or compare rates over time
-Since mortality rates increase with age - a higher mortality rate in one population might reflect that fact that the population is older
-Statistical techniques are used to adjust or standardize the rates among the populations to be compared

Years of potential life lost (YPLL): an estimate of the average years a person would have lived if they had not died prematurely.
-A measure of premature mortality
Disability-adjusted life year (DALY): expressed as the number of years lost due to ill-health, disability or early death.
-A measure of overall disease burden
-Mortality and morbidity are combined into a single
metric

-The social determinants of health are mostly responsible for health inequities
-SDOH are shaped by the distribution of money, power and resources

-Those with low socioeconomic status lack resources to protect and/or improve health
-Social disadvantage approaches focus on the link between health and neighborhood conditions, working conditions, education, income and wealth, and race/ethnicity and racism
-Stress and coping are potential causal links between these factors and health outcomes

-Behavioural mechanism: There are social class differences in health- damaging or health-promoting behaviours
-Materialist mechanism: Poverty exposes people to health hazards.
-Psycho-social mechanism: Social inequality may affect how people feel
which in turn can affect body chemistry (E.g., stress)
-Life-course model: Health reflects the patterns of social, psycho-social and biological advantages and disadvantages experienced by an individual over time.

Neighbourhoods can influence health through:
-Physical characteristics: air and water quality,
exposures, access to parks
-Availability and quality of services: transportation,
schools, employment resources, housing
-Social relationships: mutual trust among
neighbours, lower homicide rates

-Stress links upstream social determinants with health through neuroendocrine, inflammatory, immune, and/or vascular mechanisms.
-Allostatic load, i.e., the biological "wear and tear" resulting from chronic exposure to social and environmental

A social class is a set of concepts in the social sciences and political theory centered on models of social stratification that occur in a class society, in which people are grouped into a set of hierarchical social categories

Membership in a social class in most modern societies is based on differences in:
• Income, a person's wages, salary, or investment dividends
• Wealth, the net value of money and assets a person has
• Education, which impacts access to jobs and other resources

Four main social classes in Canada:
-The upper class
-The middle class
-The working class
-The lower class

-Investigated social determinants of heart and lung health and mortality rates
-British male civil servants age 20-64
-Men in lowest status jobs had mortality rate 3x higher than men in highest grade jobs
-Low job status was associated with obesity,
smoking, reduced leisure time, higher blood
pressure

-Work can influence health through exposure to different:
-Physical conditions: sedentariness, repetitive strain, ventilation, noise level
-Psychosocial aspects: high demand with low control, perceived imbalance of efforts and rewards
-Social aspects: mutual support among coworkers
-Employment-related earnings and work-related benefits: medical insurance, paid leave, schedule flexibility, workplace wellness programs, retirement benefits, child and elder care resources

-Race: a group of people identified as distinct from other groups because of supposed physical or genetic traits shared by the group.
-Racism: the belief that race accounts for differences in human character or ability and that a particular race is superior to others.

-A social construct based on physical characteristics and/or shared ethnic heritage
-Humans, as a species, share 99.9% of our DNA with each other

-The false belief in the superiority of one group of people over another based on race
-Unfairly advantages some communities/ individuals while disadvantaging others

-Racial Inequity is the result of structural racism that is embedded in our historical, political, cultural, social, and economic systems and institutions.
-It works cumulatively and produces vastly adverse outcomes for people of color in areas such as health, wealth, career, education, infrastructure, and civic participation

-Complex system of organizations, institutions, processes, and policies that create and perpetuate social/economic/political arrangements that are harmful to people of color and to our society as a whole

-Range of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to people on a differential basis.
-Gender is relational—gender roles and characteristics do not exist in isolation

-Biological
-Genetics, physiology,hormones, anatomy
-Sex isn't binary and up to 1% of the population is born intersex.

-Social construction with real- life impacts
-Informed by society, culture, norms, history, responsibilities, expectations, roles

-"Women get sicker, but men die quicker" sums up the morbidity and mortality patterns of men and women in developed countries
-Women are more likely than men:
-To visit health professionals
-Make more frequent visits
-Use emergency health services
-Have recent check-ups
-Use more antidepressant drugs than men -
consistent with their higher levels of depression

-GBV has significant and long-lasting impacts on physical and mental health
-Women, girls, and Two-Spirit, trans, and non-binary people experience violence at higher rates than cis-men
-More than 4 in 10 women have experienced some
form of intimate partner violence (IPV) in their
lifetimes
-Approximately every six days, a woman in Canada
is killed by her intimate partner

-Emotional and material support from spouses impacts health outcomes from acute and chronic health conditions
-Women are more likely to provide support for family members (informal caregiving)
-Women report more often than men missing work for caring for sick family members rather than their own illness

-People's lives are shaped by multiple identity factors.
-e.g., ethnicity/ "race", Indigeneity, gender, class,
sexuality, geography, age, disability/ability,
migration, status, religion
-"Intersectionality is a lens through which you can see where power comes and collides, where it interlocks and intersects.." -Kimberle Crenshaw

-The application of principles of justice to society.
-Social justice implies: Equity; equal access to societal power, goods and services; and universal respect for human and civil rights

-"Health equity means that everyone has a fair and just opportunity to be as healthy as possible.
-This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care."

-Over the last decade many governments have developed public health policies that aim to tackle health inequalities
-Three main approaches:
-1.Focus on improving the health of the worst-off in
society
-2.Reduce health inequalities by narrowing the
health gap between the poorest and the 'average'
for the population - 'raising the health of the
poorest, fastest
-3.Focus on reducing the social gradient in health across society.

-1.Adopt a human rights approach to action on the social determinants of health and health equity.
-2.Intervene across the life course with evidence-informed policies and culturally safe health and social services.
-3.Intervene on both proximal (downstream) and distal (upstream) determinants of health and health equity.
-4.Deploy a combination of targeted interventions and universal policies/ interventions
-5.Address both material contexts (living, working, and environmental conditions) and sociocultural processes of power, privilege, and exclusion
6. Implement a "Health in All Policies" Approach