Module 2 Flashcards
(104 cards)
1
Q
What is socioeconomic position?
A
The social and economic factors that influences what positions individuals or groups hold within the structure of a society.
Called position rather than status as status is negative term.
2
Q
What are determinants?
A
An event or characteristic that influences a health outcome/brings about a change for better or worse in health.
3
Q
Types of determinants
A
Income, Education, Employment, Housing, Water/shelter/sanitation, social cohesion, Age, gender, ethnicity, crowded houses, access and deprivation.
4
Q
Responses to determinants of health
A
- Encourage governments/agencies to improve living conditions.
- Increase social connections.
- provide opportunities to empower individuals.
- Reduce the barriers to health care/systems.
5
Q
Difference between inequity and inequality
A
Inequity:
- Those inequalities that are deemed unfair or stemming from some form of injustice.
- Health inequities are different in the distribution of resources/services across populations which do not reflect health needs.
- Lack of fairness; there is a difference when there shouldn’t be.
- Both men and women get breast cancer but only mamagrams for women.
Inequality:
- Difference or variation in health.
- Differences in health experiences, and outcomes between different population groups according to SEP, gender, age, ethnicity.
- E.g women do not get prostate cancer.
- Social gradient
6
Q
Measuring the socio-economic determinants of health
A
- Determinants must be objective, meaningful and measurable.
7
Q
Socioeconomic position can also be known as…
A
Can also be recognised as socioeconomic status, social class, socioeconomic background and social stratification.
All have different theoretical bases and interpretations.
8
Q
Why measure socioeconomic position (SEP)?
A
- Its used to quantify the level of inequality within/between societies.
- It highlights patterns over time which can be seen through census periods and even better generations (parents to children).
- Establishes the relationship between health and social variables (age,sex,ethnicity).
- Associated with health and life changes for as long as social groups have existed.
9
Q
Measuring Income with surveys…
A
Income can either be given as a Personal income measure (sensitive) or as a household income measure (which is dependant on the family size- standardisation).
10
Q
Personal income can be split into two…
A
- Absolute measures (exact annual figure)
2. Categorical measures (figure between two points)
11
Q
Measures of income
A
- Have a Dose response associated with health.
- Have a cumulative effect- income builds up over the course of a life time.
- Have the greatest potential to change over a short duration.
- Most directly measures the material resources aspects of socioeconomic position.
12
Q
Household income split up…
A
- Useful indicator for women, who may not be the main income earner.
- Should be ‘equivalised’ for comparisons between populations (requires information on family size/dependants).
13
Q
Measures of Education
A
- Attempts to measure knowledge -related assets of an individual.
- Education can be measured as a continuous variable OR Education can be measured as a categorical variable.
- Capture transition from parents SEP to personal SEP .
- Are believed to be associated with our ability to respond to health promotion messages.
- Are easy to obtain, often have a good response rate and is relevant to all age groups.
- PROBLEMS: cohort effect- different standards of education in different countries.
14
Q
Trend in Education
A
More education results in more likely to pick things up fast and stick with things e.g smoking campaigns and dedication therefore, to give up smoking.
15
Q
How to measure education…
A
Education can be measured as a continuous variable:
- Years of completed education.
- Time in education (considered more important than achievements)
OR Education can be measured as a categorical variable:
- Educational attainment, milestones.
-Specific achievements are important in determining socioeconomic position.
16
Q
Measuring occupation
A
- Jobs are grouped by potential income or SEP.
- (NZSEI) New Zealand socioeconomic index of occupational status (asks what is your job?)
- social class in the UK. - Head of house is transferable
- occupation of ‘head of household” for spouse or dependants. - Closely associated with income
- Reflects social standing
- possibly certain privileges resulting from SEP (lawyers, doctors) automatic respect that these people know their stuff. - The individuals experience occupational or social mobility over the course of a life time.
- Occupation influences/impacts on:
- social networks- cluster of people in same community resulting in break up foundations around better social connectiveness in the community.
- work-related stress = psychosocial effects
- occupational exposure to environmental risks.
17
Q
NZSEI vs prevalence of smoking
A
Occupations that are more upper class generally have less people smoking while those in lower occupational groups according to NZSEI have more smokers. This shows a social gradient.
18
Q
NEET - Not in education, employment or training
A
- A relatively new indicator of SEP, considering the ‘ideal pathways’ for school leavers at different levels of achievement.
- The term ‘NEET’ is NOT used to describe the identity of individuals or groups but their situation or official status. Where are they going after school etc.
19
Q
Trend of life expectancy and education
A
Educational training after school results in higher life expectancy compared to those who do not go into extra educational training after school.
20
Q
Difference between odds ratio and relative risk
A
- Where the data comes from.
- a/EG = RR
- OR= (a/c) / (b/d)
However, interpretation is very similar in which the odds of …. being a smoker is 20x less likely than a particular group.
21
Q
Major arguments for attempting to reduce inequalities in health
A
- They are unfair- inequality becomes unfair when poor health is the of unjust distribution of social determinants in health (unequal opportunities in education etc)
- They are avoidable- Making things accessible by changing the distributions those gaps are avoidable.
- They affect everyone- Some types of health inequalities have obvious spill over effects on the rest of society e.g spread of infectious disease, crime and violence.
- Reducing inequities can be cost effective
22
Q
Odds ratio = 1.99
Smoking in maori vs non maori
A
Maori are 2 times more likely than non maori to be cigarette smokers.
23
Q
Social Mobility defintion
A
The movement go individuals, families, households, or groups of people within or between social strata in society.
24
Q
Intra-generational mobility
A
Refers to the movement up or down the social ladder in an individuals life time.
25
Inter-generational mobility
The change in socioeconomic position between a parent and their children.
26
Equality of opportunity
That everyone has the same chance of moving up the social ladder.
27
Social mobility trend - countries
The more income inequality, the less social mobility within that particular country.
28
The Lorenz Curve (Gini Coefficient)
```
Gini= (A)/(A+B) where A= line between perfect equal line and curved line.
0= very equal society
1= every unequal society
```
29
Implications of (income) inequities
1. An unequal society- a gap between the rich and the poor.
2. Less social cohesion (members of society coming together)
3. Less trust between groups- People talking to people that are similar to them.
4. Increased stress- to find money for food etc increases as gap between rich and poor increases.
5. Reduced economic productivity
6. Poorer health outcomes - damper homes results in increased sickness and parents have to take time off work to look after children resulting in less pay etc.
30
How to reduce inequities?
Redistribution of resources according to need. E.g not giving the same to everyone but giving the amount of resources dependant on the death rate etc.
- Using the best practise may be a possible way to improve performance of others and therefore, reduce inequity. E.g free 50 hours of child care increases child development.
31
Determinants of health vary at different life stages. Theses life stages are...
1. Pre-birth
2. childhood
3. Adolescence
4. Adulthood
5. Older-Age
32
Three ways in which life course events can interact to influence long term health and well being...
1. Cumulative- poor income results in poor diet, effecting education and therefore less advantaged in larger population. (POVERTY TRAP)
2. Multiplicative- Increasing age accommodation of age and ethnicity. (CVD)
3. Programming- what happens in the embryo may result in outcomes later in life. E.g lack of oxygen is related with diseases later on in life.
33
Downstream interventions
operate at the micro level, including treatment systems, and disease management. E.g own treatment
34
Upstream interventions
Operate at the macro level, such as government policies and international trade agreements. E.g sugar tax: reducing harm before it happens.
35
The dahlgren and whitehead model
Centre: Age, Sex and Constitutional factors e.g particular disease.
Individual lifestyle factors: choices the individual choices to do.
Social and community network: exposures to family and friends.
Living and working conditions: Occupational hazards and effects on the health of occupational group. Eg forestry workers- tags that determine blood pressure
General socioeconomic, cultural, and environmental conditions: international trade agreements, government policies.
36
Three levels of Influence:
The Personal
The community
The environment
37
The personal level of influence
Age, Sex, constitutional factors and individual lifestyle factors.
- Found at the core of the Dahlgren and whitehead model are factors that are sometimes referred to as 'non-modifiable' determinants.
- Genes are importants, but too is the influence of the environment. Therefore, the exposure to culture has an impact on our health seen by CVD prevalence and traditional Japanese vs non traditional Japanese upbringing.
- The choices you make as an individual impact on the likelihood that you will have good health outcomes. (social gradient).
- your choices as an individual impact the likelihood of having good health
- Habitus: Values installed by parents. Social gradient included in spectrum e.g wealthy environment resources to change- more likely too. From poorer environment- less likely due to lack of money.
38
The environmental level of influence
-cultural factors, physical environment and socioeconomic general factors
39
The important distinctions between the impacts on individuals and populations
- SINGLE gene disorder: rare amongst the population
| - POLYGENIC inheritance: influences likelihood of offspring developing a disease. E.g diabetes
40
Social and community networks and living working conditions influences
- Family and friends allow normative behaviour development - attitudes formed.
- Attitudes and behaviours of people living and working in the local community influences the sense of what is normal and acceptable
- Social capital.
41
Social Capital
The value of social networks that facilitates bonds between similar groups of people.
"Its not what you know, its who you know".
42
maori health is...
exemplified by systematic disparities in
- health outcomes
- exposure to the determinants of health
- health system responsiveness
- representation in health workforce
43
Inequity between maori and non maori
Despite decreasing gap between life expectancy of the two, there is still extreme inequity. Other disparities/differences include CVD, cancer, injury, diabetes, disability,mental health including self harm and participation in the health workforce.
44
Determinants of ethic inequities in health
1. differential access to the determinants in health leading to differences in disease incidence.
2. differential access to health care e.g access to angioplasty and CABG, where maori receive less treatment relative to the death rate, compared to non maori treatment and death rate.
3. difference in quality of care received.
45
International evidence- minorites report (common wealth fund):
minorites are:
- less likely to feel they have been listened to
- less time spent with health care provider
- less likely to have received adequate explanations
- more likely to have unanswered questions
- more dissatisfaction with health service and system.
46
Contributes to ethnic inequalities in health
| Structural and societal
Structural- that the power, resources and opportunities of NZ society are organised by ethnicity (as well as deprivation) in NZ.
Societal- That there are values and assumptions widely held in NZ society about the deservedness of different groups of people.
Both have historical drivers and underpinnings.
47
Historical outlook
| What started depopulation, disease and dispossession for maori?
Complex changes involving legislation and the establishment of New Zealand, including the declaration of independence and treaty of Waitingi.
48
Historical outlook
| What started the inequalities in NZ today?
Colonisers assumptions, of the superiority of the coloniser, and the inferiority (less significant) of the colonised, set the scene for the inequalities in NZ today.
49
What did the treaty of waitangi bring about?
The creation of the government, with the construction of the state sector, justice system, education, welfare, health, who was able to vote decided, as well as laws and policies of the established state.
50
Why were maori resentful of non maori colonisers after signing of the treaty?
The possession of land by non maori alienated communities, broke down alliances between maori and depleted (used up supply) of economic resources and resulted in resentment.
51
old age pension inequity due to the treaty
Maori access to the pension very difficult, Asians excluded, maori regulatory being removed from the pension role and the amount paid to maori was reduced (continued until WW2)
52
Effects of colonisation in NZ
colonisation= reduction in land and policy alienation, as well as unequal citizenship (entrenchment of poverty and dependancy, increased barriers to development, acceptance of inequity by non-indigenous groups, resentment, frustration and anger, social break down, crime, high risk behaviours.) All of which have a direct relation with poor health.
53
General trends of non maori and maori
1. non maori (generally older people) seem to have lower rate of suicides compared to maori (generally youth).
2. maori have higher death rates in terms of CVD, cancer, diabetes, accidents and obesity.
3. In the most deprived areas (NZDep index) maori are in larger proportions while non maori have a slow decile from least to most deprived deciles. (increasing dep = increasing death rates).
4. Life expectancy is higher for non maori (85+ years) and particularly females compared to maori (60-69 years) and men. Although the gap is decreasing.
54
Why is comparison difficult between groups for education?
Different countries value education differently.
55
Who is household income a good measure for?
Household income is a good measure for women who may not be the main income earner.
56
Why is NZSEI (New zealand socioeconomic index) used?
To group jobs on potential income.
57
Why is comparison of occupations hard?
This is because different individuals have different ideas and different values of occupation.
58
Occupation impacts on...
Social connections, work-related stress, and exposure to environmental risks.
59
Which group is used as the exposure group when measuring inequalities?
The most deprived group.
60
Resulting factors of reducing inequality
A healthier society with greater productivity (less people off work and greater work outcome) and other benefits. May be more cost effective e.g emergency admission is greater than re-assessing at a GP level.
61
What is neighbourhood deprivation?
Neighbourhood deprivation is state of observable and demonstrable disadvantage related to the local community, wider society or nation to which an individual, group of people or family belong.
62
Why is neighbourhood deprivation measured?
It is a way to measure ones relative position in society.
63
What does neighbourhood deprivation measure?
Deprivation is the measure of material resources in which one is measured on what they don't have. Deficit (what people don't have) approach.
64
Measures of deprivation include? With census questions?
communication (access to internet or phone)- people over 65 having no internet access.
income- People aged 18-64 receiving a means tested benefit and people living in equalised household with income below an income threshold.
employment- people aged 18-64 unemployed
qualifications- people aged 18-64 without any qualifications
owned home- people not living in own home
support- people aged less than 65 living in a single parent family.
living space- people living in equalised households below a bedroom occupancy threshold
transport- people with no access to a car.
65
What is NZDep2013
NZDep2013 divide NZ into regions and give them a decile number. This calculation can be used in determining development and recourse allocation.
66
The ecological fallacy?
The error that arises when information about groups of people is used to make inferences about individuals.
67
How long has NZDep been around?
Been around since 1991 and is used in every census.
68
How resources were allocated before NZDep?
Through funding modules based on numbers of individuals.
69
Deprivation trends
people living in higher deprived areas have a higher mortality rate.
70
Why is NZ Dep used?
Advocacy (health needs for neighbours)
research
planning and resource allocation
71
How do we state interpretations of NZDep correctly?
We say that "people living in the most deprived neighbourhood" NOT "the most deprived people".
72
Link of upstream and downstream and the dahlgren and whitehead model
Upstream- outtermost arch of the dahlgram and whitehead model.
73
Addressing variations in health
| -upstream
Upstream interventions can target the individual, family and community, or the environment.
- Flouridation in water
- taxation schemes
74
Adressing variation in health
| -downstream
Include:
| -Green prescriptions- allowing substitution of gym and YMCA for those with diabetes.
75
What is a healthy environment?
The physical, social and political setting that prevents disease while enhancing human health and well-being.
76
determinants of a healthy environment? (6)
- Clean air and water
- appropriate housing
- access to wholesome food
- safe community
- access to transport
- opportunity to incorporate exersize as part of daily life
- these are needed to maintain good health amoung the population.
77
The built environment definition
All the buildings, spaces and products that are created, or at least significantly modified by people.
78
Levels of the whitehead and dahlgran model from inside out
1. Age, gender, ethnicity, behavioural risk factors, consitutional factors.
2. individuals lifestyle factors
3. social and community networks (health care etc)
4. living and working conditions
5. General socioeconomic, cultural and environmental conditions
79
Parts of the built environment
1. structural: homes, schools and workplaces which promote collaboration.
2. Urban design: parks, business area and workplaces, streets and roads promotes saftey.
80
Urban design can be:
- Above ground: electric transmission lines.
- below ground: waste disposal, subway trains
- Across land: motorways/transportation network.
81
Community resource accessibility index. What is it?
Like NZ Dep however, is about the potential access to community resources. For example access to - recreational aspects, public transport, education, shopping facilities, health and social aspects (marae etc)
82
Urban forms of characteristics
1. street network characteristic and design (increasing physical activity) - interconnecting roads (grid like pattern), traffic calming and other street design features.
2. land use mix- food retail, mix of residential, commercial and business use (increases opportunity for active transport), public open spaces and physical activity spaces.
3. housing density- density (increases active transport)
4. site design- food production (education + mental health benefits), street aesthetics (lighting-safety)
5. Transport planning- improve/develop public transport systems
83
Trends for built environment
living closer to a recreational centre resulted in lower overweight proportion and increased chances of doing physical activity.
84
Access definition? Distinguished by 5 aspects
Access is defined as a set of more specific areas of fit between the patient and the health care system. Including the aspects of
- Avaliablity
- accessibility
- accommodation
- affordability
- acceptability
85
Definition of availability
The volume of health services in proportion to the volume of clients and type of need
86
Trend of availability
Maori males have less availability to interventions. This is know as inequality.
87
Definition of Accommodation
The relationship between the manner in which supply resources are organised and the expectation of clients.
(organisational barriers)
88
Defintion acceptability
The relationship between clients' and providers' attitudes to what constitutes appropriate care. (psychosocial barriers) e.g neighbourhood, how satisfied are you with other patients at the service?
89
Definition of accessibility
The relationship between the location of supply and the location of clients, taking into account client transportation resources and travel time, distance and cost. (geographical barriers)
90
Define Affordability
The cost of the provider services in relation to the clients ability and willingness to pay for these services.
91
Difference between potential access and realised access
Potential access: Potentially have the opportunity to utilise health care service but may or may not.
Realised access: Whether or not actually accessed health care service.
92
Examples of barriers to access demonstrated by chinese according to the 5 A's in access.
Accommodation- opening hour services (usually within the working hour thereby, doesn't suit working individuals)
-may require interpretation services if from a foreign country which takes more effort.
Availability- Type of health service available e.g chinese medicine which may not be subsidised like normal medicine, lack of knowledge of the service and eligibility.
Affordability- Value of cost, after hours, GP surcharge
Accessability- Transportation for the elderly
Acceptability- use of an interpreter e.g 3rd person in the consultation, health benefits, and cultural appropriate services vs guidelines.
93
Difference between indirect and direct cost
indirect cost- the costs not specifically related e.g not the costs related to GP visit but the costs such as petrol money to get there, cost for babysitter, to leave early from work etc.
Direct cost- the cost of the visit.
94
How can we measure inequities
1. relative measures (NO UNITS)
- risk ratio (EGO/CGO)
- external quotient (highest rate-lowest rate)
2. Absolute measures (UNITS)
- risk difference (EGO-CGO)
- range (highest -lowest)
95
What is the external quotient
The highest value minus the lowest value.
96
Which example was hung on the gate frame to measure variations in population health?
Cholesterol levels in Auckland regional DHBs
97
What is usually the comparison group when comparing ethnicity?
NZEO (new zealand european)
98
When carrying out a study of the variation in individuals in a given area it is important that:
-all of the data of the patient is present (demographic information).
-those included are in the area being explored.
-are of the correct age being investigated.
For example in the AUCKLAND REGION VASCULAR ATLAS PROJECT clients must:
-have been enrolled in an auckland PHO during the first quarter of 2011
-be aged 25 years and over as of 1 jan 2011
-have complete data for patient demographic information on age, gender, ethnicity, area of residence and NZDep2006 score.
99
People excluded from the Auckland region vascular atlas project (cholesterol testing variations amongst male):
- homeless
- people not apart of the PHO
- missing information people
- deaths
- people who already have the disease of interest
- people who didn't include there address- thereby unable to use deprivation/decile score.
100
PHO IS?
primary health organisation
101
Trend of the cholesterol testing variation by ethnicity amongst males:
Maori are tested far less than indian and european. Indian have the most testing rate.
-people from deprived areas are more likely to have disease and less people having more or equal to 5 tests between the time of 2006-2011.
102
What is the inverse care rule?
The availability of good medical care tend to vary inversely with the need of the population served.
103
Thereby how do we reduce inequity in NZ?
Must increase interventions in maori in order to decrease death rates. This may mean that more interventions are given to maori then non maori (based on their death rate for that particular disease).
104
What is the social gradient?
The social gradient in heath refers to the fact that inequalities in population health status are related to inequalities in social status.
