Week 6 W&S Chapter 20: Social, Economic, and Political Factors that Influence Occupational Performance

Status

• Related to income and wealth

• Has been linked to chronic stress, heart disease, ulcers, type 2 diabetes, rheumatoid arthritis, certain types of cancer, and premature aging

Progressive and Settlement House Movements

• Developed in the late nineteenth century to address some of the social and economic problems of the times

• Goals were to promote social justice, improve quality of life for all, and, specifically in the case of one of the best known settlement houses, Hull House, help immigrants gain the knowledge and skills to adapt to American life and culture and earn a living

• Influenced the evolution of occupational therapy and the connection between Jane Addams, founder of Hull House, and Eleanor Clarke Slagle

Toxic Stress

• Term used to describe the kinds of experiences, particularly in childhood, that can affect brain architecture and brain chemistry

• Typically experiences that are bad for an individual during development such as severe abuse

• Harms human health

Research in Human Development

• Is showing direct links between childhood misfortune (e.g., poverty, trauma) and elevated rates of obesity, depression, and heart disease for example

Disadvantaged Groups Include

• Elderly

• Poor

• Ethnic and racial minorities

• People with disabilities

Socioeconomic Status (SES)

• Refers to the occupational, educational, and income achievements of individuals or groups

• May overemphasize social prestige and underemphasize the role of material resources in shaping one’s life chances related to health

• Affect health, occupational performance, and participation

• Indirectly determines the access one has to financial resources to purchase adequate food

Class

• Used to indicate social differences between groups, as in lower class, working class, middle class, and upper class

• A group of individuals sharing a common situation within a social structure, usually their shared place in the structure of ownership and control of the means of production

  • In land-based economies, this means class structures are based on one’s relationship to the ownership and control of property

• Affect health, occupational performance, and participation

Social Inequality

• Refers to a situation in which individual groups in a society do not have equal social status

• Is linked to racial inequality, gender inequality, and wealth inequality

• Is the portion of the unequal opportunities and rewards that accrue to these subgroups that are unfair, unjust, avoidable, and unnecessary

• Put people at risk for poorer health

Health Disparity

• A gap in access to health care, treatment provided, and health outcomes that are unfair and may be the direct result of either underlying social inequalities or improper actions by professionals within the health system

Upward Mobility

• Doing better and having more than our parents

• Is not happening as much as in the past

• Some researchers have questioned if it has all but disappeared in the US

Factors that Influence Health and Occupational Performance are Inextricably Linked to the Social Categories Individuals Belong to Including

• Gender

• Ethnic heritage

• Age

• Sexual orientation

• Whether they are disabled or not

Gender Inequalities

• The experience of being a woman continues to be one of inequality

• Ex:

  • Women’s pay is still only 80 cents for every 1 dollar a man earns

  • Women face more systemic barriers to workplace advancement

• Gender exerts a strong influence on health

• Practitioners must recognize that gender differences may lead to health inequalities and, unfortunately, sometimes disparities in the treatment women receive

Ethnic Inequalities

• Ethnicity affects life chances for health but also for a range of other societal opportunities like education or work

• Research shows that discrimination negatively influences educational attainment

• Ex:

  • Studies that show teachers give affluent students more attention, assistance, and higher expectations than their less affluent students

Head Start Program

• A national network of comprehensive child development programs that targeting low-income families and their communities

• Established in the 1950s

Age Inequalities

• Another factor that is closely related to health and occupational performance

• All societies have some shared cultural expectations of its members based on age

• Ageism

• Stereotype is that older workers are less creative and less productive, but the reality is that when it comes to actual performance, research confirms older workers surpass younger workers, scoring high in leadership, commitment, and workplace wisdom—that is, they have learned how to get along with people, solve problems without drama, and call for help when necessary

Ageism

• The term used to describe discrimination based on age

• Ex:

  • Although it is against the law in the United States to discriminate in hiring based on age, the 60-year-old who wants or needs to find a new job does not find many open doors regardless of his or her work experience

Disability

• Is associated with disadvantage regardless of individual skills or financial resources

• People with disabilities also have poorer health than nondisabled

  people

  • Higher rates of diabetes, depression, elevated blood pressure and blood cholesterol, obesity, and vision and hearing impairments

  • Lower rates of positive and recommended health behaviors such as cardiovascular fitness have been found too, as have low rates of patient education and treatment for mental illness

The IOM in its Report The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding

• Has noted that despite the increased visibility of these groups in society, almost nothing is known about their social experiences across the life course, how their health needs may be similar or different from the heterosexual population, and how interventions to address health needs of LGBTQI individuals should best be tailored

Inequalities Based on Sexual Orientation

• Individuals  in same-sex relationships who are also older, or are visible minorities, may face a similar type of “double disadvantage”

• The combined negative effects of occupying two stigmatized statuses may be greater than occupying either status alone

• Fredriksen-Goldsen and colleagues (2012) found that lesbian and bisexual women experience higher rates of chronic diseases such as lifetime asthma, arthritis, and obesity. Higher mental distress prevalence among all of the groups and higher poor physical health among gay men and bisexual women and men are also significant indicators of disability.

• Children raised in same-sex households may not receive adequate health care if the parents’ nontraditional partnership is not recognized as legal

Deferred Action for Childhood Arrivals (DACA)

• The Obama-era program shielding undocumented immigrants brought to the United States as children from deportation and allowing them to work legally in the country

Comparisons Between the United States and Other Countries

• Despite the huge amount spent, the United States ranks low on many health indicators, and there is mounting evidence that the system is plagued with serious problems at all levels

• Life expectancy in the United States stands at 78.2 years, 1 year less than the average for the 30 developed countries that belong to the OECD

• Infant mortality in the United States is worse, too: 5.8 deaths per 1,000 live births in 2016, above the OECD average of 4.4

Low SES and Healthcare

• Those those with low SES are at a distinct disadvantage

• Without this care, low-SES patients will come to OT in worse health and with fewer opportunities to benefit from our interventions and recommendations than their high-SES counterparts

The Role of Health/Medical Insurance in the United States

• Is important because access to health care in the mostly private U.S. system requires either a job with health benefits or the financial means to pay out of pocket

• Health care providers must be aware of the political controversies surrounding access to care and health insurance and thus require continued vigilance to be aware of how the status of health care insurance influences coverage and what the course of action should be for the uninsured or underserved ethnic and racial minority

  groups

Poverty

• Refers to the lack of material resources that are necessary for subsistence

• Is bad for health

• Increases exposure to factors that make people sick, and it decreases the chances of having high-quality medical insurance when the person needs it

• Children, older adults, new immigrants, persons with disabilities, and members of ethnic minorities are at the greatest risk for this

The Working Poor

• People who work full-time but whose wages do not raise them above the poverty line

New Poor

• People who have fallen into poverty because of sudden or unexpected circumstances such as serious illness, divorce, or sudden job layoffs related to changes in the structure of our economy, including technology which continues to replace human workers

Money

• Can can buy health services, but it provides safe neighborhoods and pays for better food and for costs related to participating in sports and

  staying fit

• Is necessary to pay college and university tuition fees that will provide the education needed to compete successfully for a well-paid job

Lack of Financial Resources

• Can can produce prolonged stress, which in turn negatively affects health

Low SES

• Influences prenatal care and the health of the unborn child/fetus

• Compared to women with high SES, women with low SES experience

  higher levels of stress, higher infection rates, and poorer nutrition during pregnancy that, in turn, lead to low birth weight and premature delivery

Lack of Early Stimulation from Books, Computers, and Parental Communication

• Inhibits the development of language skills such as acquiring vocabulary and interpreting verbal cues

• Compromised memory function, executive function, and neural processing of emotions are far more evident in low-SES children with far-reaching effects as one grows older

Social Inequalities Over the Life Course

• Contribute to occupational performance deficits in adults

• Occurs in all areas of occupational performance from social relationships to work

• Rates of anxiety, substance abuse, and depression are all higher in populations in which unemployment is high

Chronic Stress Impact on Human Body

• Weakens the immune system and, in turn, places individuals at greater risk for heart disease, stroke, cancer, and other chronic illnesses

Occupational Apartheid

• The segregation of groups of people based on lack of meaningful participation in daily life occupations

After Developing Greater Awareness of the Influence of Social Inequalities on Health and the Extent of Health Disparities Among the Clients OT Practitioners Serve, What are the Next Practical Steps?: Step 1

• Occupational therapists can apply the small but growing body of research evidence available that focused interventions early in a vulnerable child’s life can produce lasting benefits throughout their life

  • Ex: OT can effectively address sensory motor performance deficits, lack of peer-play relationships, and maladaptive family interactions, which all may be more prevalent in socioeconomically disadvantaged families

After Developing Greater Awareness of the Influence of Social Inequalities on Health and the Extent of Health Disparities Among the Clients OT Practitioners Serve, What are the Next Practical Steps?: Step 2

• Occupational therapists are experts at person–environment fit and recognize the centrality of meaningful occupations to good health but, there are serious gaps in knowledge

  • Ex: Little is known about meaningful occupational engagement for chronically unemployed people and what kinds of interventions might be effective

After Developing Greater Awareness of the Influence of Social Inequalities on Health and the Extent of Health Disparities Among the Clients OT Practitioners Serve, What are the Next Practical Steps?: Step 3

• A unique strength of the profession is its appreciation for the person

  • This means therapists must learn about clients in the terms of their world, their perceptions, their experiences, and their realities

  • This is easy to say but difficult to do

After Developing Greater Awareness of the Influence of Social Inequalities on Health and the Extent of Health Disparities Among the Clients OT Practitioners Serve, What are the Next Practical Steps?: Step 4

• To act on issues of occupational deprivation and occupational injustice requires that therapists become more educated about economic and other institutional and structural barriers to treatment and fair allocation of rehabilitation services

• There is growing research in the United States and around the world to show that OT services are not equally distributed

  • Clients who lack financial resources will not access needed services, or they will receive a lower quality of services unless they are able to access alternative private pay or charity

After Developing Greater Awareness of the Influence of Social Inequalities on Health and the Extent of Health Disparities Among the Clients OT Practitioners Serve, What are the Next Practical Steps?: Step 5

• Occupational therapists must leverage their position in the health care system to reduce the negative consequences of SES and social conditions on their clients’ health and occupational performance

  • Ex: Therapists can enlighten insurance payers about the needs of their low-income clients by recommending the ideal OT services for their clients in addition to the documentation required for services currently eligible for reimbursement

Social Determinants of Health

• The non-medical factors that influence health outcomes and equity

  • Economic stability

  • Education

  • Healthcare access

  • Neighborhood and built environment

  • Social and community context

• Shape people's living and working conditions, ultimately impacting their health and well-being. 

In America Wealth Equals

• Health

• For each step along the wealth gradient, you have a corresponding step of health

Latino Immigrants in the U.S.

• Are 1 and ½ times more likely to have high blood pressure and to be more obese after only 5 years in the United States

Looking at Different Measures of Stress

• Different types of hormones

  • Cortisol

  • Epinephrine (adrenaline)

• The hormone chemicals affect blood pressure

• Make it more difficult to control diabetes

Living in an Impoverished Community

• Schools might not have the resources to pay for physical education and healthy food in the schools

• Limited resources

• Use things like vending machines to try to raise money

Chronic Stress

• The body pumps out cortisol and adrenaline

• Too much of the stress hormones over time can increase arterial plaque, raise blood pressure, and weaken our immune system while increasing our risk for almost every chronic disease, including heart disease (leading killer in America)

• 50-80% increased risk of heart disease

Health Inequities

• Systemic, ingrained and unjust barriers that prevent segments of the population from the opportunity achieving their highest chance/opportunity of health leading to health disparity

• Ex:

  • Lack of doctors and hospitals in low income and minority communities

  • If doctors and hospitals are available in low income minority communities, increased wait times and sometimes unequal treatment in these facilities

  • Lack of affordable, high quality housing that leads to subpar densely packed communities, which increase the risk of infectious disease

• Effect communities big and small

• Create health disparities

Cortisol

• A hormone that you release in your fight or flight response

• Increase your blood sugar so that you can fight or run

• Increases your heart rate and blood pressure so that you can pump blood and nutrients to your muscles to stay alert in a dangerous situation

• Is great for short periods of time

• Can cause low birth weight and it’s a hormone that’s released during pregnancy

Cortisol-Effect

• A well-established hypothesis in the public literature and promoted by the CDC as the cause for negative birth outcomes in African-American women

• A result of racial bias

  • Effects individuals’ health

• Constant increased heart rate, blood pressure, and blood sugar

Atlanta Regional Community Health Initiative (ARCHI)

• Business community decided that they were going to address health inequities and disparities because they saw the cost associated with that

• An interdisciplinary, coalition working to transform the region’s health through a collaborative approach to community health assessments and improvement strategies

• The collaborative envisions an environment where interests, incentives, and investments are aligned to generate and sustain a healthy population and a vibrant economy for all

OT’s as a Group

• Are overwhelmingly white and middle class and live more privileged lives than most of our clients

• Competent and ethical practitioners need to recognize their social position relative to their clients and actively reflect on how these differences create assumptions, unfound judgements, and biases in the delivery of care

Model of Socioeconomic Status (SES) Influences and Interactions on Health

What Can OT’s Do?

• Focused early childhood intervention can produce lasting benefits throughout their lives (sensory motor development, play, support families)

• P-E (person-environment) fit, and the importance of meaningful occupations to good health

• Work to understand cultural and socioeconomic differences

• Act on issues of occupational deprivation and occupational injustice

• Advocate for services for those with low SES and social conditions