Health Sci 1002

14 Social Determinants of Health

1. Aboriginal status

2. gender

3. disability

4. housing

5. early life

6. income and income distribution

7. education

8. race

9. employment and working conditions

10. social exclusion

11. food insecurity

12. social safety net

13. health services

14. unemployment and job security

Health Inequity

Health inequalities that result from social conditions, are systematic across a population, and are unfair because these are avoidable.

Health inequalities or disparities

Differences in the health status of individuals and group

Latino preschool children reading

• Family level – Parents often do not recognize early decay and seek care only when pain appears. Their unstable jobs/farmwork leads to unstable income and insurance coverage.

• Community level – Rural areas have limited dentists, no fluoridated water, poor transport, and environmental concerns.

• Healthcare system – Communication barriers, mistrust, and Medicaid policies.

• Policy level – Insurance restrictions, low reimbursement rates, and immigration-related fears reduce access to consistent care, especially for mixed-status families.

Oral Healthcare Disparities in Canada reading

Oral health in Canada is treated as a private service rather than a public healthcare, because dentistry is largely excluded from the publicly funded Medicare system.

It’s a basic human right:

• Dentists: primary prevention, detection, and management of dental caries, gum disease, oral cancers, and edentulism.

• Canadian Dental Association (CDA) recommends routine re‑examination and preventive care for optimal oral health.

Income and Income distribution

Income is the most important social determinant of health, it shapes overall living conditions, psychological functions, and health-related behaviours (like quality of diet).

1. How health relates to the income a person or family earns.

2. How income is distributed and how it affects the population's health.

Education

1. Level of education is correlated with level of income, employment security, and working conditions. Helps people move up the socioeconomic ladder.

2. Higher education makes it easier to adapt to changes in the Canadian job market. People can retrain if their work changes.

3. Higher education helps people understand how their actions affect their health.

Income

Three ways low income affects health:

1. Material and social deprivation – Less money means less access to safe housing, clean water, and basic needs.

2. Unhealthy behaviours – Lower-income people may have less time, less access to healthy food, less sleep, less exercise, and more smoking.

3. Chronic stress – Worry about money or retirement can strain the body, affect sleep, and increase conflict at home.

Upstream Determinant

Racism, discrimination, social policies, poverty (Structural inequities)

Midstream Determinant

Educational attainment, employment status, safe housing, income stability, food security

Downstream outcomes

Heart disease, asthma, obesity, type 2 diabetes, cancer, COVID‑19 cases/hospitalizations/death

Prevalence

How common a disease is; shows the likelihood someone has it.

Reductionist Statements

Oversimplifying complex issues as fixed or unchangeable.

Social Determinants of Health

The conditions in which people are born, grow, live, work, die. Impacted by structural factors

Call to Action Reading

1. Understand SDOH and commit to health equity

2. Use data to identify vulnerable employees

3. Train staff on equity and bias

4. Listen to employee challenges (financial stress, housing, etc.)

5. Ensure living wages

6. Improve health benefits and access

7. Promote financial literacy and savings

8. Support education and skill development

9. Strengthen Employee Assistance Programs (EAP)

10. Track health equity outcomes over time

TED Talk - Richard WIlkinson

• Health Problems - drug abuse, life expectancy, mental illness, obesity

• Social Relations - homicide, imprisonment, trust

• Human Capital - child wellbeing, drop outs, literacy scores

• All the graphs showed a trend that the countries that do worse, are the unequal ones

More Inequality:

• More superiority vs inferiority

• Status competition and insecurity

Low-income Disease Mechanisms

Ways that poverty harms health and well-being.

Employment

• Security

• Intensity

• Safety

• Feelings of connection and belonging

• Meaning

Non-standard Work

• No job security

• Often multiple employers

• Lacks of benefits of standard work

Allostatic Load

Physiological wear and tear of the body due to chronic stress and repeated activation of the stress response system (blood pressure).

Burnout

Chronic work-related stress; emotional exhaustion, disinterest in work, and lack of motivation.

5 ways job insecurity leads to negative outcomes

1. Increased risk of injuries

2. Increased engagement in risky behaviours

3. Neglect of social support

4. Physiological changes and burnout

5. Inadequate income to ensure one's well-being

Scarcity hypothesis

We only have so much time and energy. When we use too much, we get tired, emotionally distant, and less present at home.

Parent's impacts on children's mental health in 3 ways:

1. Negative impacts on parent mental health

2. Increases irritability in interactions with kids

3. Impacts marital satisfaction

If a parent experiences chronic stress at work this can be replicated at home

Gig Workers

Self-employed people who earn income from short-term or freelance work, with uncertain future jobs.

• Unstable

• Higher rates of anxiety/depression, isolation, and family conflicts

• More likely to be women, 15-24

Anti-Oppressive Framework

Recognizes that people’s experiences are shaped by unequal power and stress, and aims to address these inequalities.

Reflexibility

Reflecting about how your own social position, experiences, and internalized values influence how you see, feel, and understand the world.

Structural Discrimination vs Individual Discrimination

Structural Discrimination	Individual Discrimination
Macro-level conditions that limit resources, opportunities, and the well being of less privileged groups Widespread, normalized	Negative interactions with another person (health care provide, salesperson, etc.) Based on characteristics (race, gender, etc.)

Implicit Bias How it Affects Healthcare

1. Interpersonal interactions - treating patients differently without realizing it

2. Internal dynamics - affects teamwork and workplace, influence hiring

3. Costs/waste - unnecessary tests, misdiagnosis, or delayed care

Equity vs. Equality

Equity - providing individuals with necessary resources to bring everyone to the same starting point

Equality -  treating everyone the same by giving the same resources, regardless of different needs or starting points.

Food Insecurity

The Inability to access food. Not knowing whether you will have food or sufficient food today or tomorrow

3 Levels of Food Insecurity in Canada

Marginal - worrying about running out of food or having limited sources

Moderate - compromising the quality and quantity of food

Severe - missing meals, reduced food intake, at the most extreme it's going days without food

Nutritional Deficiencies

• Iron deficiency: lead to anemia and cognitive delays/behavioural problems in young children

• Protein-Energy Malnutrition (PEM): low intake of calories and protein impacts physical growth and brain function, also vulnerable to infections

SNAP Program Pros and Cons

Pros: reduce food insecurity and poverty

Cons: stigma, paternalism, doesn’t solve poverty

Paternalism

Giving people what they need without freedom of choice.

• Example: Food banks decide what, how much, and who gets food, rather than letting people make their own choices.

• Problem: Can create dependence and doesn’t fix the root causes of food insecurity.

Food (in)security Policies

1. reduce food insecurity at community level

2. increase household incomes

Barriers Accessing Information

• A person with dyslexia/can’t read need to ask someone else to help fill it out and that would expose their private information

• A person who can’t physically hold a pen

Accessible Housing

Allows people with physical disabilities to live in accommodated places; washrooms that accommodate a wheel chair, automatic doors, etc.

Individual Model (Traditional)

Disability = problem within the person
Focus: treatment, rehabilitation

• Sees disability as a problem in the person and focuses on treatment

Social Model (Oliver’s Approach)

Disability = problem in society

• Focus: accessibility, rights, removing barriers

• Improved media representation

• Increased accessibility (transport, buildings)

Ableism

• A belief system that favours able-bodied people

• Views people with disabilities as less capable or less valuable

• Leads to stigma and unfair treatment

• Can be conscious or unconscious

UN Convention on the Rights of Persons with Disabilities (UNCRPD)

Designers and planners lack understanding of disability

States to ensure full and equal access to the built environment for people with disability

Climate Change

Long-term shifts in temperatures and weather patterns. Climate change is the greatest threat to global health

Anthropogenic

The outcome of human activities; weak environmental policies, environmentally destructive gas industries, emission of CO2

UHI - Urban Heat Island effect

Urban areas are hotter than surrounding areas

• 1-5 degrees higher

• caused by construction materials, lack of ventilation and green spaces

Drought

A period of time when an area or region experiences below-normal precipitation (any liquid or frozen water that forms in the atmosphere and falls back to the earth).

Droughts lower water levels in:

• Aquaspheres – underground layers of water (aquifers)

• Wells – places where people pump water from the ground

• Reservoirs – man-made lakes that store water

Droughts = less productive fields/loss of crops

Zambia Reading

Looks at how severe drought in Zambia affects people’s lives, especially women

• Women took on physically demanding tasks (e.g., collecting wild tubers), men entered sectors traditionally held by women (e.g., brewing).

Dose Impact

The more a social determinant factor (like income, housing, or education), the bigger the effect on their living conditions, stress, and overall health.

Health Capital

The physical and mental health resources a person builds early in life that shape their current and future health.

Climate Change Resilience

The ability to recover from challenges, depends on access to resources to maintain or recover health.

Climate Justice

Recognizes that climate change affects people unequally, especially marginalized groups, and requires an intersectional/fair approach to solutions.

Pulmonary Tuberculosis

Most common form and can start in lungs and spread

Extra-pulmonary Tuberculosis

Enters body through a wound and destroy tissue outside lungs, less contagious

TB Transmission Ways

1. Main one is human to human; through coughs, spit, sneezes

2. From contaminated animals - droplets or under-cooked meat

3. Potentially through contaminated soil and water

Adherence Challenges

• Access; some parts of the world doesn't have access, distance, low stock

• Required monitoring, like taken at same time daily

• Hard on the body - side effects and damage to organs

World Health Organization Goal on TB Pillars

1. Integrated patient-centred care and prevention

2. Bold policies and supportive systems

3. Increased research and Innovation

Impact of DrOTS in Madagascar (individual, community, national, and international)

1. Individual - better understanding of TB and improved treatment

2. Community - better access to local healthcare

3. National - government support and fundings

4. International - sharing knowledge/tech and continued research to improve

Ryan & Gross’ S Curve 5 Stages (IEELL)

Showing how innovations move from early adopters to the majority "laggards"

1. Innovators (2.5%) - the first to try; risk-takers

2. Early adopters (13.5%) - these "influencers"/leader are trusted and encourage others in their communities

3. Early majority (34%) - waiting until the benefits more established, then adopt

4. Late majority (34%) - skeptical/resistant to change, adopts when it becomes the norm

5. Laggards (16%) - the last group to adopt; due distrust

Techno-optimism

Belief that we can use technology to address our patient’s barriers to health, and will spread to all populations, reducing health disparities

Techno-skeptical - don't assume tech automatically solves healthcare problems especially for marginalized groups

Diffusion of Innovations (DOI) theory

• Trusted network matters - more likely to adopt when recommended by someone they trust

• Interpersoal communication - media

• Leaders - influential people validating the innovation and using it

Aboriginal 3 Nations in Canada

Indians, Inuit, and the Metis

Indian

• Term is based on colonialism

• Derogatory and racist, not used unless you self-identify

First Nation

• Mostly used by Indigenous groups

• Status: registered as Indians under the Indian act

• Non-Status: denied status or ancestors lost their status

Inuit

Term chosen by and traditional to Indigenous people living above the treeline

Metis

Term for mixed indigenous and non-indigenous ancestry

• Identifies as metis, metis ancestry, or is distinct from other Indigenous groups

Iluqlutiq

Involves ways of thinking, acting, and doing that are specific to Inuit

• Living off the land

• Eating blood-rich animals

• Social actions linked to history, knowledge, and practices on/off land

Plusiq

Ways of doing that belong to the community and how these values are known and shared

• Sense of trusting people and working together

• Interdependence, sharing ways of doing and resources

• Feeling associated, free of pain and worry

Ilusirsusiarniq

Physical well-being (body health, functioning)

Qanuinngisiarniq

Mental/emotional well-being (peace of mind, feeling okay)

Inuuqatigiitsianiq

Social/cultural well-being (relationships, harmony, connection to others and culture)

The Indian Act 1876

• Controlled First Nations people and denied basic rights

• Banned language, culture, religion, and voting

• Caused loss of status (e.g., education, marriage)

• Forced children into Residential Schools

On Reserves:

• Limited rights (land, movement, services)

• Government controlled land and resources

Residential Schools (1883):

• Goal: erase Indigenous culture

• 150,000+ children taken from families

• 42% died before 16

Inuit Suicide

Rates are 5-25x higher in areas of Nunangut compared to non-Indigenous populations

Youth Suffering

• Feeling lack of connection to family and community

• Lack of purpose and meaning

• Chronic stress exposure/trauma and substance misuse

Deficit-Based Approach vs. Strength-Based Approach

Deficit	Strength
Focuses only on problems Sees Indigenous health as something to “fix” Colonial: centers Western views and ignores Indigenous knowledge	Focuses on community Values Indigenous knowledge and culture Uses storytelling and cultural practices in healing Addresses systemic racism and inequities

Health Disparities

The differences in health and gaps among groups with specific characteristics. They result in inequalities and are interdependent.

Suffering

State of ongoing pain, distress, or hardship

3 Issues of Nursing Homes

1. Boredom

2. Loneliness

3. Helplessness

Loneliness vs Social Isolation

The subjective perception of isolation

• Shortens lifespan

• Linked to anxiety, depression, and dementia

• Linked to obesity, smoking, high blood pressure

Social isolation - Objective and can be quantifiable

• A few social connections and interactions

Eden Alternative

Emphasizing life-enhancing elements like animals, plants, and children in nursing homes.

Green House Model

Home-like nursing homes designed to maximize autonomy, privacy, and community engagement.

Culture

Multi-dimensional - it's not only defined based on only certain rules/laws

• Shared, learned, dynamic (constantly changing)

• Respect for culture = respect for persons and humanity

• Culturally sensitive care = high quality patient and family-centered care

• Denial of cultural differences can lead to inequities and increase suffering

Culturally Competent Care

• Being aware of your own culture

• Having a sense of what you define as important

• Being aware of own biases, beliefs, and assumptions

Incrementalism

Michael Brownstein argues that real political change happens through small, steady steps

Anti‑Incrementalism Bias

The tendency to overlook or undervalue partial successes, favoring only dramatic, total outcomes.

Life expectancy in Hamilton

Low-income 65.5 years compared to 85 in high income neighbourhoods

Teen Pregnancy

• Hamilton 3.5/100 aged 15-19 would get pregnant

• 20% of young mothers experience postpartum depression

• World wide, 44% of adolescent mothers develop PPD, 2 x more than older mothers

Burn Out Stats

Almost ¼ of workers in Canada (22%) reported feeling exhausted and burnt out

Racism Stats

• 81% of self-identify as visible minority have experienced discrimination

• In Toronto 62% live in poverty identify with a racial group

• 1 in 5 racialized families live in poverty

• 5x higher COVID cases

Food Insecurity

• 1 in 5 children experiencing food insecurity

• 16% of households food insecure

• 42.4% of Canadian food bank users are disabled

TB Stats

• A total of 1.25 million people died from tuberculosis (TB) in 2023

• 1.3 million children world wide fell ill with TB

• 95% of cases in low and middle income countries