sphg 352 unit 2 exam

inequality/disparity

• unequal access to opportunities

• observed differences between groups

• who differs, by how much, over what period?

equality

evenly distributed tools and assistance

equity

custom tools that identify and address inequality

justice

fixing the system to offer equal access to both tools and opportunities

health equity

• absence of unfair, avoidable, or remediable differences among groups of people

• everyone being able to attain their full potential for health and well-being

• focuses on systemic disadvantage and modifiable conditions

• may require unequal allocation of resources to achieve fair opportunity

health inequity

• unfair, avoidable, or remediable differences among groups of people

• requires evidence and reasoning about mechanisms

health equality

• are outcomes/resources the same?

• a difference can be measured without deciding whether it is unjust

• useful for describing population patterns

“Health Inequalities, Disparities, Equity: What’s in a Name?” - Paula Braveman

• concepts shape what we see

• definitions determine which differences become visible in surveillance and research

• measurement choices determine which groups appear in the comparison and which disappear in pop. averages

• a useful equity definition must be specific enough to guide measurement and accountability

• language is consequential → it can redirect attention and resources

what must be known before calling a gap an inequity?

• mechanisms/determinants

• modifiability

• social advantage/disadvantage

• historical context

• alternative explanations

social determinants of health

• conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risk

• non-medical factors that influence health outcomes

health people 2030

• economic stability

  • income, employment, food/housing security

• education access and quality

  • early education, literacy, attainment

• healthcare access and quality

  • coverage, primary care, health literacy

• neighborhood and built environment

  • housing, transport, air/water, food, safety

• social and community context

  • cohesion, discrimination, civic life, incarceration

causal pathway from policy to physiology

policy/institution → places and resources → exposure and opportunity → behavior/stress/care → biology → health outcome

upstream

• laws and policies

• economic and educational systems

• housing and land-use decisions

• distribution of power and resources

midstream/downstream

• neighborhood and workplace conditions

• access to food, transportation, care

• stress, behavior, exposure

• clinical disease and treatment

redlining

• neighborhood grading using racial composition as a central factor in mortgage “risk”

• predominantly Black neighborhoods frequently classified as hazardous investments and denied access to favorable credit

• civil-rights and fair-housing laws prohibited discrimination, but they didn’t erase accumulated disinvestment

diabetes and loss of water rights

• diversion of Gila River and loss of water access

• disrupted agriculture and food systems contribute to economic, dietary, and lifestyle change

• high burden of type 2 diabetes for Akimel O’odham (Pima) people

redlining → health

• mortgage exclusion → lower wealth + disinvestment → schools/care/transport/food → stress + exposures → opportunity + access → health patterns

• present day health outcomes:

  • diabetes

  • hypertension

  • heart-disease mortality

  • worse self-rated mental health

  • preterm birth

  • gunshot-related ED visits

  • covid-19 outcomes

“Modern Day Consequences of Historic Redlining: Finding a Path Forward” - Egede et al

• housing: repair, affordability, mixed-income zoning, protection against displacement

• education: early childhood programs, educator investment, reconsideration of funding structures tied to local tax base

• healthcare: Medicaid expansion, clinic/hospital access, nonclinical services, incentives to address social needs

• economic empowerment + built environment + food: employment, homeownership, transit, greenspace, sidewalks/bike lanes, healthy retail access

mechanism

the process or pathway through which a social condition produces a health outcome

risk factor

specific things social conditions expose people to

protective factor

things that may decrease the likelihood of experiencing adverse experiences

social ecological framework

• a way to examine how health can be produced based on differing levels of influence

• at what level of this framework does influence or mechanisms operate?

• individual/social network/neighborhood/society

life course perspective

• a way to examine how health can be produced across differing time periods in our lives

• at what stages of life and how, does influence at various levels unfold?

four broad ecological levels of SEF framework

• individual

  • knowledge, physiology, behavior, skills

• family/social network

  • caregiving, peer norms, social support

• neighborhood/city

  • housing, schools, services, built environment

• country/society

  • state and national policy, economic systems, global agreements

levels, determinants, and mechanisms of SEF framework

• level

  • where does influence operate?

• determinant?

  • what condition matters?

• mechanism?

  • how could it affect health?

life stages and opportunities for prevention

• perinatal period (conception - 7 days after birth)

  • health prenatal environments and supportive care

• infancy and childhood

  • safe housing and supportive learning environments

• adolescence/young adulthood (15-24)

  • supportive peers and prevention of initiation

• adulthood (25-64)

  • accessible services and healthy work conditions

• older adulthood (65+)

  • accessible communities and caregiver support

critical period

• exposure during a specific developmental window

• ex: prenatal exposure affecting fetal development

• does age or developmental timing change the effect?

sensitive period

• exposure has a stronger effect during a vulnerable stage

• ex: adolescent substance exposure during brain development

• does age or developmental timing change the effect?

chain of risk

• one exposure can change the likelihood of a later exposure

• a later exposure can then influence another opportunity or outcome

• the links require explanation and evidence

• an intervention may interrupt a link

• does one exposure help produce a later exposure?

accumulation of risk

• duration and repeated exposure can add to risk over time

• different risks can also combine

• exposures do not need to cause one another

• does repeated or combined exposure increase total burden?

nonmodifiable risk factors

• age

• biological sex at birth

• race/ethnicity

modifiable risk factors

• smoking

• diet

• physical activity

• elevated blood pressure

• elevated LDL cholesterol

• elevated BMI

not all modifiable risk factors are modifiable for everyone

• opportunity to change varies with income, work, housing, and safety

• theoretical modifiability doesn’t mean practical control

• opportunities to act are unequally distributed

Bernal family case study

• Bernardita works long shifts packing mushrooms

• Alfredo describes late work and unfinished homework

• family earning and housing costs constrain daily decisions

• family protective factors

  • shared mobility (transportation, goods, practical assistance)

  • family connections as a stress buffer

  • community access/resources that strengthen health opportunities

from dyads to networks

• dyad

  • two person connection

• network

  • nodes connected by dyads

• highly connected nodes can amplify influence, or exposure

networks change over the life course

• infancy

  • caregivers + household

• adolescence

  • peers + schools

• adulthood

  • partners, coworkers, friends

• older adulthood

  • caregivers

5 pathways from networks to health

• support

  • emotional, practical, and informational help

• influence + norms

  • expectations, modeling, and social control

• engagement

  • participation creates purpose and connection

• contact

  • person-to-person ties can carry pathogens

• resources

  • ties open access to material and informational assets

networks can protect + transmit risk

• protection

  • trusted messages travel

  • amplified resources

  • support buffers stress

• risk

  • direct contact carries pathogens

  • harmful practices become normal

  • exposure can concentrate

vaccination as a network intervention

• susceptibility

  • vaccination reduces individual susceptibility

• spillover protection

  • reduced transmission protects others

• system conditions

  • coverage, contact patterns, and effectiveness matter

vaccine hesitancy

• access of vaccines or health institutions (eg: cost)

• access barriers (transportation, childcare, language barriers, etc)

• misinformation and health media

• social relationships and norms

• experience and acceptance

networks and noncommunicable disease

• activity (shared routines)

• social norms (approval, modeling shapes behavior)

• practices (socially organized events and expectations)

• stress + self management (support affects coping, adherence, and confidence)

belonging as a protective condition

• positive connections

• acceptance + inclusion

• SEF levels matter

neighborhood

a local area with physical and social boundaries

city

multiple neighborhoods linked by systems and governance

place

a producer of exposure, resources, and opportunity

Kennett Square as a community case

• community organizations connecting residents with info and resources

• clinics that support access, continuity, and trusted care

• youth programs that create connection, support, and opportunity

sankofa

we should retrieve things of value from our knowledge of the past

public health in ancient Egypt

• state funded healthcare

• paid sick days

  • social safety nets

the building of the Hoover Dam

• water divergence for farming and irrigation

• increased tourism - golf

• displacement of thousands of native tribes and culture

Medicaid: new eligibility documentation

• before: eligible adults could qualify for medicaid

• what changed: adults ages 19-64 in the Medicaid expansion group must demonstrate 80 hours/month of qualifying work or community service, meet an education or earnings alternative, or qualify for an exception

• who is affected: certain applicants and enrollees

vehicle greenhouse gases: EPA rule rescission

• before: EPA’s 2009 greenhouse-gas endangerment finding underpinned federal greenhouse-has standards for new motor vehicles and engines

• what changed: EPA rescinded that finding and repealed federal greenhouse-gas emission standards for light, medium, and heavy-duty on highway vehicles

• who is affected: vehicle and engine manufacturers and indirectly, people affected by transportation emissions and climate-related risks

political choices shape social determinants directly and indirectly

• direct

  • healthcare coverage

  • vaccination policy

  • drinking water safety

• indirect

  • housing + transportation

  • employment conditions

  • environmental standards

PEPFAR

• launched under George W Bush

• large investment in HIV prevention, treatment, and care across countries

• supported medicines, clinics, and health workeers

• credited w/ saving millions of lives

USAID

• foreign-aid pause and end of USAID’s operating role

• most USAID awards terminated, remaining programs moved to State

• HIV services disrupted despite limited waivers

corporations influence health

• products

  • what is made and sold

• marketing

  • norms and behavior

• workplaces

  • conditions and wages

• policy

  • lobbying and regulation

Universal Declaration of Human Rights

• adopted by the UN General Assembly in 1948

• a common standard for Human Dignity and Fundamental Rights

• not a binding treaty

Origins of “Health as a Human Right” - 1946

the WHO constitution declared that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”

Origins of “Health as a Human Right” - 1948

the Universal Declaration of Human Rights Article 25 recognized the right to a “standard of living adequate for health”

Origins of “Health as a Human Right” - 1966

the International Covenant on Economic, Social and Cultural Rights Article 12 reaffirmed this right and specified state obligations

US position on the Universal Declaration of Human Rights

• US supports principle of health as a human right but does not legally recognize it

• health is treated as a policy goal rather than a legally enforceable right in US law

sustainable development goals

• shared targets for global progress

• 17 goals adopted in 2015 as part of the 2030 agenda

sdg:3

• good health and well-being

• connected to poverty, food, education, water, inequality, climate

global health inequities between countries

different resources, institutions, and exposure

global health inequities within countries

• inequality also exists in the country

• experiences may differ based on income, race, gender, disability, immigration status, geography, religion, or social class