WYSFO Module 1

• What is population health? How is it different from public health?

Population Health - broader concept of public health; includes all the ways a society as a whole, or communities within a society, are affected by health issues and how they respond to them; uses an evidence-based approach to analyze the determinants; utilizes surveillance mechanisms to provide strategies for intervention

Public Health - provides services for those with special vulnerabilities; determines risks to health and provides successful interventions that are applicable to everyone

• The goal is to prolong life and promote health; Emphasis on quality of life

• Examines the environmental, social, and economic determinants of health

• was initially brought about in the mid-1800s to address social justice

Four components of public health

1. Health issues

2. Population

3. Society’s shared health concerns

4. Society’s vulnerable groups

Health - Encompasses physical and mental health

Population - Global community; focusing more on non geographic communities

Society’s shared concerns - Toxic exposures from environment, transportation safety, cost of health care; Impact of climate change

Vulnerable populations - First, focused on maternal and child health as “vulnerable”; Now includes the disabled, elderly, those without health insurance, the immunosuppressed

Traditional public health - population-based preventive perspective utilizing interventions targeting communities or populations, as well as defined high-risk or vulnerable groups

• Reduction of environmental hazards, food and drug safety, nutritional risk factors

• Different eras of public health and some notable events within each

Health protection - (antiquity - 1830s) focused on individual behaviors; utilized religion and culture to prevent certain practices

• Ex: quarantined during epidemics, sexual prohibitions to reduce transmission, dietary-restrictions to restrict food-borne disease

Hygiene movement - (1840s-1870s) improved sanitary conditions as basis for public health; community wide environmental action

• Ex: John Snow tackled Cholera, Semmelweis identified the importance of hand washing, vital statistics became empirical foundation for epidemiology

Contagion control - (1880-1940) germ theory; demonstration of infectious origins of disease; conducted an outbreak investigation in general population, controlled disease through vaccination, environmental factors, sanatoriums

• Ex: linkage of epidemiology, bacteriology, and immunology to form TB sanatoriums

Filling holes in medical care system - (1950s-mid 1980s) integrated control of communicable disease with modifying risk-factors and caring for high-risk populations; public system for control of specific communicable diseases, care for vulnerable populations, beginning of integrated healthcare systems with preventative services

• Ex: antibiotics, concept of risk factors, surgeon general report on cigarettes

Health promotion/disease prevention - (mid 1980s-2000) focused on individual behavior and disease detection; clinical and population-oriented prevention, focused on individual decision making

• Ex: AIDS epidemic and need for interventions, reductions in coronary heart disease

Population health - (2000s) coordination of public health and healthcare delivery due to evidence-based thinking; focus on harms and costs as benefits of interventions, globalization

• Ex: evidence-based medicine and public health, new approaches to avoid medical errors, tobacco control, climate change

• Population and high risk approach! 

  • Goals, examples, advantages and disadvantages

Population Approach - focuses on entire population, aims to reduce risk for everyone

• Assumes everyone is at some degree of risk and the risk increases with the extent of exposure

Disadvantages

• Minimal benefit to individual

• Limited motivation

• Hard to implement (too expensive)

Advantages

• Large potential for societal impact

• Can lead to substantial change

• Can impact a range of health outcomes by targeting societal norms

High risk approach - focuses on those with a higher probability of developing a disease, aiming to bring their risk level closer to those of the normal population

Disadvantages

• Temporary, may not produce sustainable change

• Limited potential for individual and population

• May not address underlying issue

Advantages

• Strategy is tailored to individuals

• Motivation from patient and provider

• Cost-effective

• Both approaches are important for the success of public health

• Social determinants of health – definition and examples, BIG GEMS

Determinants - underlying factors causing disease

• Go beyond the known

• BIG GEMS - behavior, infection, genetics, geography, environment, medical care, socioeconomic-cultural

Big Gems (determinants)

Behavior - can increase or decrease disease susceptibility

Infection - can directly or indirectly cause some diseases

Genetics - rarely most important

Geography - frequency and presence of disease

Environment - physical, built, or social

Medical care - access and quality

Socio-economic-cultural - resources available (money, family)

Social determinants of health - conditions in which people are born, grow, live, work and age

• How a person’s context shapes their health and influence their health decisions

• Interactions with institutions, society

• What policies in place influence them?

• Ex: employment, income, housing, safety, language, education, hunger, community engagement, quality of care

Framework 

1. Economic stability

2. Education

3. Social and community context

4. Health and healthcare

5. Neighborhood and built environment

• 1.5 million people are homeless

• 3.6 mil cannot access medical care due to lack of transportation

• 40mil face hunger

• 11.8% of households are food insecure

• 20% of a person’s health is related to access to care and quality of services

How do social determinants give rise to different health outcomes?

1. Differences in quality of care

2. Differences in access to health care

3. Differences in life opportunities, exposures, and stresses

Root cause

= structural discrimination

• Laws, injustice, regulations

EXAMPLES:

1. Low income can lead to food insecurity, which impacts health

2. Lack of education limits job opportunities and income, which impacts health

3. Racism and other discrimination can lead to health inequities

• Key social determinants of health: race and racism, SES, work, neighborhoods

  • Mechanisms linking them to health, definitions, measurement, advantages and disadvantages 

RACE/RACISM:

Racism - structured system assigning value based on the social interpretation of how we view race

• Leads to unfair disadvantages

• Systematic 

Institutionalized racism - systematic distribution of resources, power, and opportunity in our society where groups are excluded/targeted based on race

• Initial historical insult, structural barriers, societal norms

Interpersonal racism - prejudices leads to differential assumptions

• Unintentional, acts of commission and omission, condoned by societal norms

Internalized racism - acceptance by members of the stigmatized races of negative messages about their abilities and intrinsic worth

• Reflects systems of privilege, societal values

Racism and health

• Institutional discrimination

• Segregation creates pathogenic residential conditions

• Internalized racism

• Can create conditions that increase exposure to traditional stressors

**We must consider racism on the individual level to explore it on a structural level

• We need to investigate race and social class related differences

• Raise equations, generate science, advocate for change

• Bring forward new perspectives and new solutions

• Race is a social construct

  • No biogenetic sense

  • No genes are exclusively map into “Black” or “White” races

  • Should be considered as a social factor when describing health inequities

• Discrimination and racism are the reasons behind discrepancies in health

Structural racism - system of interconnected institutions reinforcing racial discrimination in housing, education, employment, health care, and criminal justice

• Intergenerational impact on wealth, education, healthcare access

  • Ex: first generation college students

• Cultural and policy reinforcements of racial disparities

  • Ex: NIH funding forcing studies to remove words like “discrepancies”

Core argument: structural racism is a fundamental cause of racial health inequities

HIstorical: institutionalized racism has shaped health outcomes from colonial times to present

Structural Vs. Institutional

Structure

• Overarching system reinforcing inequalities

Institutional

• Specific policies and practices within organizations that disadvantage racial groups

Statistical disparities

• Black Americans have higher infant mortality rates, lower life expectancy, and increased rates of chronic diseases

• Indigenous populations face elevated diabetes risk and heart disease

Scientific studies

• Research linking structural racism to stress biomarkers and adverse health outcomes

• Impact of discriminatory policies on health access and longevity

Pathways of racism affecting health

1. Residential segregation

   1. Redlining and discrimination in housing

   2. Increased exposure to environmental hazards, poor living conditions, lack of access to quality health services

2. Economic inequities

   1. Disparities in income, employment, financial security

   2. Occupational segregation into lower-paying, high-risk jobs

3. Health care disparities

   1. Racial biases in medical treatment and diagnosis

   2. Limited access to health insurance preventive care

4. Criminal justice system

   1. Racial profiling, higher incarceration rates, legal penalties

   2. Long-term health impacts

5. Psychosocial stress and health outcomes

   1. Chronic stress from systemic discrimination leads to hypertension, mental health issues, increased mortality

• Robert F. Kennedy believed Black people could endure more pain due to their race (2025)

Racism - multidimensional and systematic

• Combination of laws, policies, rules embedded within society and organization generating inequities

• Systemic encompassess all forms of racism

  • How racism in itself is harmful

Interventions to dismantle racism

1. Policy reforms and anti-discrimination laws

   1. Strengthens civil rights protections

2. Health equity initiatives

   1. Expand medicaid and community health programs

3. Criminal justice reform

   1. Addressing sentencing disparities and policing biases

   2. Reducing mass incarceration through policy changes

4. Educational and economic investments

   1. Equitable funding for schools is marginalized communities

   2. Job training and economic development programs

5. Community-based approaches

   1. Advocacy and participatory policymaking

   2. Initiatives like Purposes Built Communities and Promise Neighborhoods

Key Takeaway

1. Racism and SES are not individual issues but deeply embedded in societal structures

2. Structural racism is a fundamental determinant of health disparities

3. Addressing systemic inequities requires policy changing

4. Sustained efforts to dismantle institutional discrimination and promote health equity for all

WORK

• Occupational status is a key determinant of health

  • Better jobs = better outcomes

  • Strong inverse relationship between job status and chronic disease incidence

  • Research focuses on understanding causal mechanisms linking work and health disparities

• Higher job status is associated with lower chronic disease prevalence and mortality rates

• Health disparities persist even after adjusting SSES factors

1. Reverse causation: poor health leads to lower job status

2. Social selection: privileged backgrounds lead to better health and higher job status

Occupational hierarchy and status:

• Professionals enjoy greater autonomy, job security, and social prestige

Psychosocial factors

• High job demand with low control leads to stress related illness

• Effort-reward imbalance

Physical and chemical exposures:

• Blue-collar workers face greater exposure to hazardous conditions

• Contribute to respiratory and cardiovascular disease

Link from work to health

1. Work organization

   1. Job stability, flexibility, and social capital affect long-term health

2. Precarious employment

   1. Contract, shift, and gig work increase stress, job insecurity, and health risks

3. Gender and occupational health

   1. Women in blue-collar jobs face unique risks

      1. Greater injury

      2. Job strain

Challenges

• Difficulty in separating job-related stress from overall SES influences

• Longitudinal studies needed to track cumulative psychosocial and physical risk factors

Intervention

1. Workplace policies

   1. Promote job security, fair wages, better conditions

2. Occupational health

   1. Regulations should address physical and psychosocial hazards

3. Future research

   1. Integrate social, economic, and biomedical factors to fully understand health disparities

Key Takeaways

1. Work is crucial in shaping health disparities across the social gradient

2. Interdisciplinary research

3. Addressing precarious employment and gender disparities

NEIGHBORHOODS

Neighborhoods - geographic boundaries; in health, immediate residential communities

• Material and social characteristics related to health

• Defined by zip codes and census data

How do living in particular neighborhoods affect our health?

• Air we breathe, water we drink, food we eat

• Neighborhoods are marked by profound racial, ethnic, and socioeconomic differences

Physical environment - built environment, land use, access to healthy food, pollution

Social environment - social cohesion, safety, violence, collective efficacy

• Health behaviors (diet, physical activity) and stress pathways are key mediators

• Link between neighborhood SES to health outcomes

  • Associations between neighborhood deprivation and mortality, chronic disease, and mental health

• Less consistent findings for self-related health, mortality, and chronic disease risk factors

Challenges in Studying Neighborhood effects

1. Causal inference issues

   1. Selection bias

   2. Unmeasured confounding

2. Defining neighborhoods

   1. No standard geographic definition, varies by health outcome

3. measurement issues

   1. Reliance on self-reports induces bias

   2. Need for standardized assessment tools

Future directions

1. Longitudinal and life course studies

2. Intervention research

3. Natural experiments

4. Systems thinking and simulation models

5. Gene-environment interaction

• People choose the foods available to them

• 23.5 million people live in food deserts

  • Due to:

    • Large-chain supermarkets

    • Closure of smaller grocery stores

    • Access to healthy foods is challenging

  • Minorities more likely to live in food desert

    • Higher risk of noncommunicable diseases

    • Leads to poor diet, obesity, heart disease

Examples:

1. Los Angeles, CA

   1. Low poverty

   2. Predominantly white have 3.2x as many supermarkets as predominantly white neighborhood

2008 farm bill - farmers were given financial assistance due to excess crop supply, creating low prices and controlling and ensuring an adequate food supply

Healthy food financing initiative - launched by Obama administration, equips grocery stores and farmers market to sell healthy food in underserved areas

Key Takeaways

1. Neighborhoods are key determinants of health 

2. Policies shaping neighborhoods should be leveraged for health improvements

3. Interdisciplinary research and interventions are needed to address structural determinants of health inequities

SES

Socioeconomic status - individuals position within a hierarchical social structure in relation to others 

• Typically based on income, education, occupation

• Reveals differences in access to resources, exposure to toxic substances and hazards

Material resources: access to nutritious food, safe housing, health care services

Psychosocial factors: stress levels, social support, sense of control

Health behaviors: variations in smoking, exercise, dietary habits

Stress exposure - higher chronic stress in lower socio-economic groups, leading to adverse health effects

Control and autonomy - lower socio-economic individuals experience less control over life circumstances, impacting health

Health behaviors - differences in behaviors that contribute to health disparities

Access to information - lower socio-economic status may limit access to health-related information and resources

Comprehensive approaches - need for policies addressing material, psychosocial, behavioral factors

Early interventions - important to target early life stages to mitigate long-term health disparities

Call to action: emphasis on multi-faceted strategies to reduce these health disparities in socio-economic status

How do we measure SES?

1. Education

2. Total income

3. Occupation 

Why do we measure SES?

• There is an evident socioeconomic gradient in health

• The lower an individuals SES, the worse their health

Socioeconomic status - individual’s position within a hierarchical social structure in relation to others typically based on income, education, occupation

• Reveals access to resources and other differences

• Health inequities are not the result of singular factors; they are the outcome of intersections of different social locations, power relations, and experiences

GENDER

Gender-health paradox - females have higher life expectancy, however, they suffer from more chronic and non-life threatening illnesses; males have higher mortality due to life-threatening conditions; females experience more depression/anxiety while males have higher substance abuse and antisocial behaviors

Cardiovascular disease

• Males have early onset at earlier age

• Females have increase risk postmenopausal

• Historical research bias toward men has delayed understanding of females

Immune function and disorders

• Females have stronger immune response but higher risk

• Hormonal differences contributed to immune function variations

Depression and mental health

• females have higher rates of depression; men have more externalized disorders (aggression)

• Gendered coping mechanisms influence mental health disparities

Medical exploitation of enslaved Black women

• 1808; ban on slaves, owners encouraged to focus on reproductive of slaves

• Dr. Sims is praised as father of OB/GYN; committed heinous crimes against women in Alabama (Anarcha, Lucy, Betsey)

• 1830s, Dr. Prevost practiced C-section on enslaved women without anesthesia

  • Believed Black people experienced less pain than White’s

• Racial bias in pain persists today

• Black and American Indian women have higher pregnancy-related death compared to White women

Forced sterilization of colored women

• Sterilized them to lower population rates

• Didn’t have to deal with the mental illnesses that people of color had (illness was that they wanted civil rights)

• 1927 US Supreme Court affirmed the Sterilization Act of 1924

Gender bias - prejudice that favors one gender over another

Sex - biological characteristics that determine person’s sexuality

Gender - based on how someone identifies

• Almost everyone has gender bias (masculine vs feminine)

Explicit bias - person is aware

Implicit bias - person is unaware

Ex of gender bias:

1. 2018 study revealed doctors view men with chronic pain as brave, but view women as emotional

   1. Doctors were more likely to treat women’s pain as a product of mental health condition rather than a physical ailment

2. Gender bias can lead to discrimination against health workers

   1. 2020 study revealed older women doctors found age and gender based harrassment, discrimination, and salary inequity persisted throughout their careers

3. Lack of inclusivity in studies, leaves doctors with a limited understanding of female and intersex health

• Healthcare stigma against transgender individuals and persons of color

Consequences

1. Knowledge gap

   1. Lack of inclusivity

2. Lack of women in leadership

3. Delayed diagnoses

4. Inadequate symptom management

5. Avoidance of medical care

6. Abuse, neglect, and death

Affordable Care Act - health insurance reform law that was signed into law in 2010

Abortion ban - 14 states enforcing total bans; 2022, US Supreme Court overturned abortion rights

• 43 states prohibit some abortions after a certain point in pregnancy

• Impacts services available, where physicians will want to practice

• Proactive policies

• Health disparities, health inequities, health equity

Health disparities - differences in the incidence and prevalence of health conditions and health status between groups closely linked with economic, social, or environmental disadvantage

• Adversely affect groups of people who have systematically experienced greater or social economic obstacles based on race, religion, SES, gender identity, sexual orientation, etc.

Health equity - opportunity for everyone to attain their full health potential

• This is the goal; can be achieved by treating everyone equitably, not equally

• Health disparities are the metrics we use to measure progress towards achieving health equity

Inequality - unequal access to opportunities

Equality - evenly distributed tools and substance

Equity - custom tools that identify and address inequality

Justice - fixing the system to offer equal access to both tools and opportunities; systematic fair treatment of people of all races; sustains racial equity through proactive and preventative measures

**think the apple tree and student example

• Examples from readings to support concepts

RACE EXAMPLES

Classification of race on birth

• If parents were of different races and one is white, child is assigned the other parent’s races

• Discouraged inter-racial marriage

Home Owners Loan Corporation Act (1933) - residential neighborhoods are graded based on mortgage security

• Low risk for banks and other mortgage lenders were marked green

• Hazardous neighborhoods were marked red (redlining)

• One determinant was community’s racial makeup

Redlining - results from racial segregation and large inequities in economic opportunity that have ongoing negative associations with health today

• Includes disproportionate exposure to environmental health risks, like extreme heat

Fair housing act (1968) - expanded on previous legislation, prohibited discrimination based on race, religion, national origin, sex, disability, family status

• Racial disparities persist today

• Cities continue to be divided

Indian removal act of 1830 - Johnson v. Mcintosh, which established legal law around indigenous land ownership

• American Indian people did not have legal ownership over land they lived on 

• Forced removal of indian tribes

• Kicked off the Trail of Tears

SODH

The article argues that these disparities necessitate Arabs being formally recognized as a health disparity population by institutions like the NIH and NIMHD.

1. Structural Violence – The classification of Arabs as White leads to their cultural invisibility, preventing recognition of their health disparities.

2. Discrimination and Stigma – Arabs in the U.S. experience systemic stigma, especially post-9/11, which contributes to mental health issues such as depression and distress.

3. Language Barriers – A significant portion of Arabs in the U.S. speak a language other than English at home, which can limit access to healthcare services.

4. Economic Disparities – Higher poverty rates compared to non-Arab White Americans, with nearly a quarter of Arabs living in poverty.

5. Healthcare Access – Arabs in the U.S. face barriers to cancer screenings and vaccinations due to lack of culturally sensitive providers, language barriers, and fear tied to immigration status.

6. Workplace Discrimination – Reports indicate that around 60% of Arabs experienced workplace discrimination after 9/11, affecting economic stability and mental well-being.

7. Adverse Birth Outcomes – Increased stress due to discrimination has been linked to higher rates of low birth weight infants among Arab mothers.

The article uses an allegory of a gardener with two flower boxes (one with rich soil and one with poor soil) to illustrate how systemic inequities affect health outcomes over generations. This framework highlights how structural racism contributes to disparities in health and calls for systemic interventions to address them.

1. Institutionalized Racism – Differential access to resources like quality education, housing, healthcare, and economic opportunities based on race. It is embedded in societal structures and often perpetuates health disparities.

2. Personally Mediated Racism – Prejudice and discrimination that manifest in differential treatment, such as lower quality medical care, police profiling, or workplace bias.

3. Internalized Racism – Acceptance by marginalized groups of negative societal beliefs, leading to lower self-esteem, resignation, or behaviors reinforcing racial hierarchies.

The article by Diez Roux and Mair examines how neighborhood environments contribute to health outcomes and health inequalities. Key social determinants of health identified in the article include:

1. Neighborhood Socioeconomic Status – Lower-income neighborhoods often have fewer resources, which impacts health outcomes such as obesity, diabetes, and depression.

2. Residential Segregation – Segregation contributes to disparities in access to healthcare, education, and employment, reinforcing racial and socioeconomic health inequalities.

3. Access to Healthy Foods – Low-income areas often lack supermarkets with fresh food, leading to poorer diet quality and higher obesity rates.

4. Built Environment & Walkability – Neighborhoods with poor infrastructure, lack of parks, and unsafe streets discourage physical activity, increasing chronic disease risk.

5. Social Cohesion & Support – Strong social networks within communities can buffer stress and promote mental well-being, while social isolation contributes to depression.

6. Exposure to Violence & Crime – High-crime neighborhoods are associated with chronic stress and adverse mental and physical health effects.

7. Healthcare Accessibility – Limited access to healthcare facilities and providers in disadvantaged neighborhoods leads to worse health outcomes.

8. Environmental Hazards – Poorer neighborhoods often face greater exposure to pollution, hazardous waste, and inadequate housing, affecting respiratory and overall health.

The article emphasizes that policy changes in urban planning, housing, and economic development are essential to reducing these health disparities.

HEALTH DISPARITIES

The Braveman (2014) article provides several examples of health disparities, emphasizing that they result from social and economic disadvantage rather than just any health difference. Here are some key examples:

1. Racial and Ethnic Health Disparities

   • Higher infant mortality rates among Black and Indigenous populations compared to White populations.

   • Increased rates of diabetes, hypertension, and heart disease among Black and Hispanic communities.

   • Disproportionate exposure to environmental hazards (e.g., air pollution, toxic waste sites) in communities of color.

2. Socioeconomic Health Disparities

   • Higher rates of chronic diseases (e.g., obesity, cardiovascular disease) in low-income populations due to limited access to healthcare and healthy food.

   • Poorer mental health outcomes, including higher rates of depression and anxiety, among economically disadvantaged individuals.

   • Shorter life expectancy for lower-income individuals compared to wealthier individuals.

3. Geographic Health Disparities

   • Higher rates of preventable diseases in rural areas due to fewer healthcare facilities and providers.

   • Increased health risks in neighborhoods with concentrated poverty, including limited access to nutritious food, safe housing, and recreational spaces.

4. Disabilities and Health Disparities

   • Individuals with physical or cognitive disabilities often face barriers to healthcare access and preventive services.

   • Higher rates of unemployment and economic disadvantage among people with disabilities, further impacting their health.

5. Gender and Sexual Orientation Health Disparities

   • Higher rates of mental health issues and suicide among LGBTQ+ individuals due to discrimination and social stigma.

   • Women, particularly those in lower-income groups, experiencing higher maternal mortality rates due to inadequate access to quality prenatal care.

These examples illustrate that health disparities are not just differences in health but are linked to social, economic, and environmental disadvantages. The article argues that addressing these disparities requires policy changes and targeted interventions to promote health equity.