Introduction to Health Studies Health Promotion III

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Introduction to Health Studies Health Promotion
III

• Dennis Raphael
• School of Health Policy and Management
• York University, Toronto, Canada

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Social Determinants of Health

• Early Life as a determinant of health
  
• Illustration of the Individual Approach to
  Understanding the Impact of Poverty Upon Health

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Poor conditions lead to poorer health. An
unhealthy material environment and unhealthy
behaviours have direct harmful effects, but the
worries and insecurities of daily life and the
lack of supportive environments also have an
influence. Social Determinants of Health The
Solid Facts, World Health Organization, 1999. .
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Infant Mortality by Neighbourhood Income, Canada,
1996 (per 1000)
Source Wilkins et al., 2002
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Defining Poverty

• Individuals, families and groups in the
  population can be said to be in poverty when they
  lack the resources to obtain the type of diet,
  participate in the activities and have the living
  conditions and amenities which are customary, or
  at least widely encouraged, or approved, in the
  societies to which they belong. They are, in
  effect, excluded from ordinary living patterns,
  customs and activities
• -- Townsend, 1979, p.31

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Low Income Refers to income status in
relation to Statistics Canadas low income
cut-offs (LICOs). In large urban centres such
as Toronto (where population is equal to, or
exceeds 500,000), the LICO can be organized by
various family sizes Family
size 1 LICO 16,874
Family size 2 LICO 21,092
Family size 3 LICO 26,232
Family size 4 LICO 31,753
Family size 5 LICO 35,494
Family size 6 LICO 39,236
Family size 7 LICO 42,978
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Ten Tips for Staying Healthy - Dave Gordon, 1999.

• 1. Don't be poor. If you can, stop.
• If you can't, try not to be poor for long.
• 2. Don't have poor parents.
• 3. Own a car.
• 4. Don't work in a stressful, low paid manual
  job.
• 5. Don't live in damp, low quality housing.
• 6. Be able to afford to go on a foreign holiday
  and sunbathe.
• 7. Practice not losing your job and don't become
  unemployed.
• 8. Take up all benefits you are entitled to, if
  you are unemployed, retired or sick or disabled.
• 9. Don't live next to a busy major road or near a
  polluting factory.
• 10. Learn how to fill in the complex housing
  benefit/ asylum application forms before you
  become homeless and destitute.

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Critical Periods of the Life Course

• Foetal development
• Birth
• Nutrition, growth and health in adulthood
• Educational Career
• Leaving parental home
• Entering labour market
• Establishing social and sexual relationships
• Job loss or insecurity
• Parenthood
• Episodes of illness
• Labour market exit
• Chronic sickness
• Loss of full independence
  
• -- Shaw et al., The Widening Gap, 1999, p. 106.

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Life-Course Approach to Health and Illness

• In contrast to adult lifestyle approaches,
  life-course approaches emphasize the accumulated
  effects of experience across the life span in
  understanding health and disease.

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Life-Course Approach to Health and Illness

• Early life may be a particularly important period
  in itself (critical or sensitive period) or it
  may serve as a marker for a path that a person is
  set out on. In either event for most people,
  early life sets them out on a pathway that leads
  to the accumulation of exposures to either
  positive or negative effects. This notion of
  latent, pathway or cumulative effects helps to
  explain empirical findings. In the end however,
  policy implications are probably the same,
  whichever approach is more accurate.

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Poverty and Health Mechanisms

• Poverty can affect health in a number of ways
• income provides the prerequisites for health,
  such as shelter, food, warmth, and the ability to
  participate in society
• living in poverty can cause stress and anxiety
  which can damage peoples health
• low income limits peoples choices and militates
  against desirable changes in behaviour.
• - Benzeval, Judge, Whitehead, 1995, p.xxi,
  Tackling Inequalities in Health An Agenda for
  Action.

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Latent Effects I

• Specific biologic or developmental factors at
  sensitive periods that have a lifelong effect
  regardless of later circumstances.
• Occurring prior to birth
• nutrients, infection, smoking that affect
  availability of oxygen to organs
• affect blood clotting, cholesterol metabolism
• contributors to coronary heart disease and
  diabetes in later life

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Latent Effects II

• Occurring during infancy
• malnutrition and infection
• Malnutrition affects health, cognitive
  development and educational attainment
• Infection has long-term developmental risk e.g.,
  airway and respiratory function.

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Pathway Effects

• Experiences that set individuals unto life
  trajectories that affect health, well-being and
  competence over time
• emotional and personality development
• educational experiences
• workplace circumstances
• income situation

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Cumulative Effects

• Accumulation of advantage or disadvantage over
  time
• addition of latent and pathways effects
• multi-faceted, involving individual, family, and
  community factors
• primary explanation for health differences
  according to the Bristol group in UK.

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Determinants of Healthy Child Development(Herztma
n, 2000)
What aspects of society are not included in this
table, but should be?
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Poverty, Income, and Health Canadian Perspectives

• Childhood and adult social circumstances make
  independent contributions to the risk of dying.
• - Davey Smith Gordon, 2000, p.142, Poverty
  Across the Life-course and Health in Pantazis, C.
  Gordon, D. (eds.), Tackling Inequalities
  Where Are We Now and What Can be Done?

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Figure 9 Greater Risk of Heart Disease in Low
Income Areas, USA, 1988-97
160
160
120
90
90
90
80
80
70
60
60
50
50
40
40
30
0
White Males
White Females
Black Males
Black Females
Low Income Area - Adjusted for Age and Study Site
Low Income Area - Adjusted for Preceding and
Individual Socioeconomic Character
s
istics
Low Income Area - Adjusted for Preceding and All
Behavioural and Medical Factor
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It was found that those living in lower income
areas were much more likely to develop coronary
heart disease than those in well-off
neighbourhoods. These effects remained strong
even after controlling for tobacco use, level of
physical activity, presence of hypertension or
diabetes, level of cholesterol, and body mass
index. - Summary of Neighbourhood of Residence
and Incidence of Coronary Heart Disease, A.
Roux, S. Merkin, D. Arnett, et al. New England
Journal of Medicine, 2001, 345, 99-106.
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Low Income and Heart Disease Researchers
Conclusions

• These estimates of risk reduction may be
  compared with the much smaller estimates of the
  effects of improvements in adult lifestyle... Our
  findings add to the evidence that protection of
  fetal and infant growth is a key area in
  strategies for the primary prevention of coronary
  heart disease.
• -- Early Growth and Coronary Heart Disease
  in Later Life Longitudinal Study. J.G.
  Eriksson, T. Forsen, J. Tuomilehto, C. Osmond,
  D.J. Barker. British Medical Journal, 2001, 322,
  949-953.