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2 most common factors of health in society

1) genetics -> predisposition based on genetic risk factors for disease and responses to treatment
2) behaviours as a matter of choice
- these are important factors but not determining factors


mortality rate in 1800s + life expenctancy

40-50% in Canada
51.7 years in 1921 (Canada)
82.2 years in 2015 (Canada)
- life expectancy increased due to advances in social determinants of health
- not Biomedical research, SDH more important


top 10 causes of death in Canada in 1881

1. Smallpox
2. Typhus
3. Cholera
4. Diphtheria
5. Dysentery
6. Measles
7. Tuberculosis
8. Typhoid
9. Scarlet Fever
10. Meningitis


how vaccines and medical care changed life expectancy in Malawi

44.1 years in 2000 to 62.7 in 2014


top 10 causes of death in Canada present

1. Cancer
2. Heart disease
3. Stroke
4. Chronic lower
respiratory diseases
5. Accidents
6. Diabetes
7. Alzheimer’s
8. Influenza and
9. Suicide
10. Kidney disease

- diseases shifted from communicable to non-communicable


social determinants of health

the social, economic, and environmental conditions key to individual, community, and population health

- Draws attention to non-medical factors determining health risks and health-seeking behaviors
• Impact depends on context


the 14 social determinants

- Aboriginal status
- Gender
- Disability
- Housing
- Early life
- Income and income distribution
- Education
- Race
- Employment and working conditions
- Social exclusion
- Food insecurity
- Social safety net
- Health services unemployment
- Job security


health in the broad sense

Health: “soundness of body and mind”
Wellbeing: “a high level of satisfaction and contentment with one’s life and one’s living conditions of which health would like be an important


life expectancy in Hamilton, ON

- 21 difference
- 42% of that is due to 3 SDH: poverty (low income and working class),
health and aging (access to healthcare), and education


3 Low income disease mechanisms

• Low income > material and social deprivation (esp. in early
years and adulthood)
• Low income> adoption of health threatening behaviours
• Low income > experience of excessive and constant
psychosocial stress


Sherman Wentworth neighbourhood vs Burlington "the orchard"

• 1 in 7 moms teens
• Average household: $36,000
• 1 in 4 adults don’t have High

Not one teen pregnancy in same
4 years
• Average household income
• 2 out of 3 adults have university


Children living in poverty more likely to

are more likely than non-poor children to:
• die during first year of life
• die after first year from injuries, infections, violence,
• have learning difficulties
• leave school before graduating
• experience poor health over the course of their lifetimes


Cumulative effect of social determinants on risks for disease

• Longer exposure = increases impact
• Earlier = increases impact

- Social determinants impact us at every stage in life
• Clustering of disadvantage for
those living in poverty results in
poor health outcomes
- income most important SDH


relationship between income and health can be studied in 2 ways

1) Observe how health is related to the actual income that an individual or family receives
2) Study how income is distributed across the population and how this distribution is related to the health of the population



branch of medicine dealing with the incidence
and prevalence of disease in large populations


Income impacts health

• Material deprivation: can’t buy healthy or sufficient food
• Social deprivation: e.g. can’t get job/schooling want, can’t support kids’ participation in ‘normal’ extra-curricular activities
- more physically risky and/or stressful situations: e.g. taking more dangerous employment; taking a job that requires you to get to or from work late at night; staying in abusive relationship)
• Health management impacts: e.g. late or no cancer screening, failing to renew meds, eating less fresh and more fast processed foods


Job insecurity in Canada

-jobs in Canada shifted last 30 years
-rise in non-standard work:
reduced time, contract, casual, part-time
- migration to mexico (no rights, lower pay)
- canadian service sector increasing
- months of hard work, months of no work


Intensification of work trend

Normative expectation will work at greater speed, with more effort, on tight deadlines
• “ Almost 2/3 Canadians working fulltime working more than 45 hours a week : that’s 50% more than 2 decades ago”
- 50% increase compared to 20 yrs ago (2012)
- 70% of canadians dont take full vacation
- expected to respond to emails on weekends and nights
- impacts family life balance


4 potential impacts on health

1. Stress induced physiological changes (CVS, immune)
2. Increased risky behavior
3. Loss of social support (dont call friends back, divorce)
4. Inadequacy of income


Physically demanding jobs

- More accidents
• Concussions, cuts, burns, punctures
• 20% Canadians work in manufacturing and construction but account for 40% of injuries


Stress impacting mental health

- Burnout & overwork
- burnout is cortisol imbalance
• Link mental illness and job insecurity, under-employment


Allostatic load

- physiological changes across different biological regularly systems in response to chronic social and environmental stress
- working more than 50 hours a week and stressed linked to risks of high blood pressure and heart disease
• Cellular aging faster when under chronic stress and night shift work
• Dysregulation of hormone production


Night-Shift Work and Risk of Colorectal Cancer in
the Nurses’ Health Study

- Working a rotating night shift 3x month (min) may increase risk of colorectal cancer in women
- Nightly exposure to light = ↓ melatonin (anticarcinogenic) production
- Working on rotating night shifts was associated with an increased risk of colorectal cancer among the female nurses tested



- term for foreign owned assembly plants in low or tariff-free zones throughout the Americas
- Imported parts assembled maquilas and exported
- Characterized by low wages, minimal environmental protections


Social capital

refers to the quality and level of social relations, networks, norms, trust and reciprocity between individuals that facilitate cooperation for mutual benefit


Mexican border industrialization program (BIP)

- started 1960s: no tariffs on imports or exports
- Free Trade Zones throughout the Americas
- Heavy goods (e.g. fridges) made in mexico because cheaper export
- GOAL: economic stimulus for mexico and less illegal immigration for the US


Mexico NAFTA

- tripled U.S.-Mexico trade
• unprecedented growth of Mexican manufacturing
• promised increase in working conditions have worsened
- rural to urban migration


Objective impacts

can be observed and proven
- e.g. daily exposure to lead is bad for health
- e.g. contract that can be terminated at any moment = job insecurity
- e.g. having a full-time job plus being single parent w limited childcare = less time to sleep
- systemic issues -> historical and ongoing norms of exportation for lower classes in Mexico and globally


Contextual impacts

impacts depend on patient's social, cultural, economic environment; depends on context
- e.g. being single teen mom may be stigmatizing in some communities or households, but not in others


Subjective impacts

an individual's experience of an response to objective and contextual conditions
- impact of same conditions will be different for diff individuals
- everyone has diff attitudes, experiences, abilities to manage, etc
- response to conditions is subjective -> some find energy and time to fight for change, others do not


Limited protection for worker health and safety

- companies not required to fund infrastructure around factories
- In 2012, 48.49% of mexican population had no effective access to health services
- hard to organize; in mexico, independent unions must be federally approved which is rarely granted


Work family conflicts (WFC)

the strains (time-based and attention-based) that arise for parents when work and family demands are incompatible
- Greenhaus and Beutell 1985
- spill-over effect -> impact of work translates into home
- father stooped WFC -> normal health resumed
- mother stopped WFC -> bad effects lasted 2 years
- worst scenario -> both parents WFC


Who uses food banks

- 33% kids
- 32% disability
- 5% senior citizens
- on social assistance, 80% income goes to food


Nunavut food insecurity

- 41% on social assistance
- Systemic factors: changes in traditions, dependence
on imports, poverty, residential schools, poor housing, inability to practice traditional hunting and gathering


Food stamps (SNAP)

- up to 2013, only US had it
- in kind approach, not cash transfer
- many states have work requirement after 3 months


Disadvantages to food stamps

- defines problem as lack of food
- still stigma
- indignities
- paternalism/ dependency


2 main critiques of food stamps/ soup kitchens

1. No evidence makes people food secure
2. Erodes dignity and against values of autonomy

- just because food banks don't stop poverty, doesn't mean it should be stopped


Case study: Sally 3rd year UWO student

- lives on broughdale with 5 roomates and her room is in a basement
- trouble sleeping, cough, etc
- due to bad ventilation, darkness


Adequate housing

quality + accessibility (affordable)


infectious diseases can be spread by:

- lack of clean/ hot / running water
- overcrowding
- poor ventilation
- damp+cold+moldy = asthma and other chronic respiratory symptoms
- improper waste disposal
- air quality
- noise pollution
- can also affect mental health (e.g. depression)


Affordable housing (accessibility)

Affordable housing is defined as a living situation where <30% of the total income is spent on shelter
- 1 in 5 canadians spend more than 50% income on shelter
- fear of losing shelter = psychological stress
- Toronto, Vancouver, Calgary most affected due to job opportunities


Race + chronic diseases reading

- in order from most to least discriminated: blacks, aboriginals, asians, whites
- we underestimate how much blacks are discriminated against and overestimate how much asians are discriminated against
- obesity high in all races
- binge drinking and hypertension high in blacks and aboriginals
- in Canada, discrimination is associated w chronic disease and risk factors


Health vs Disease vs Disability/ Injury

- not just absence of disease (WHO)
- created and lived by people in their everyday health (ottawa)
- Injury - impairment of physical daily life


Chronic vs Acute

chronic - long term w varying progressive effects
acute - fast onset (almost leading to death)


Noncommunicable vs communicable

Noncommunicable - not infectious; often chronic
Communicable - infectious disease; often acute


WHO definitions for obesity; BMI

- Underweight - <18.5 BMI
- Healthy weight: 18.5-24.9 BMI
- Overweight (Grade I obesity): 25.0-29.9 BMI
- Obese (Grade II): 30.0-39.9 BMI
- Morbidly obese (Grade III): 40 or above BMI
- Super obese (Grade IV): BMI >50


Determinants of population health

- social characteristics
- discrimination
- total ecology
- food dessert
- genes and biology
- health behaviours
- medical care
- accessibility to health care


Projected main cause of death (2005)

- cardiovascular disease, communicable disease, etc
- obesity is not separate disease, rather precursor for CVD
- developed = chronic



- complex
- biological, behavioural, social factors
- distal indirect factors affect obesity (income, rural, minority status, etc)
- WHO -> obesity rates doubled since 1980 (2012)
- 1/4 kids in Canada are overweight or obese
- Childhood obesity can lead to long-term health
problems later in life


Preventing childhood obesity (federal, provincial, territorial)

- Making the environments more supportive
- Identifying the risk of obesity in children and addressing it early
- increasing the availability and accessibility of
nutritious foods.

3 strategies:
1) Making childhood overweight and obesity a
collective priority for action
2) Coordinating efforts
3) Measuring and reporting on collective progress


Long-term consequences of obesity

- high healthcare costs (direct costs)
- loss of productivity as a result of greater level of absenteeism and weight-related illnesses (indirect costs)


Ottawa charter for health promotion

- Nov 1, 1986
- goal was to achieve health by 2000
- health is a resource for everyday life (positive health)
- not just an objective

- Advocacy - bring favourable political, economic, social, culture, environmental, behavioral and biological factors for health
- Enabling - take control of the factors influencing health
- Mediation - bring multi-sectorial actions


Ottawa charter actions

- Build up healthy public policy to foster equity
- Create supportive environment
- Support community actions
- Develop personal skills
- Reorienting health services


Inequality vs Inequity

- Health Inequalities -> Differences in health status
or in the distribution of health determinants
amongst different population groups

- Health Inequities -> Differences in health which are
unnecessary, avoidable, and considered unfair and


Food security

all people at all time have physical and economic access to safe and nutritious food to meet their daily needs and food preferences for an active and healthy lifestyle


Determinants of healthy eating in Canada
(Individual vs Collective)

Individual determinants:
- physiological state
- food preference
- nutritional knowledge
- perceptions of healthy eating
- psychological factors

Collective determinants:
- environmental determinants as context for eating behaviour
- public policies as creating supportive environments for healthy eating