Welcome to HLTA03 Foundations

in Health Studies II

Course Instructor: Nida Mustafa, PhD

Office Hour: Thursday evenings (7:00 – 8:00 pm),

or by appointment
1

Course Email: HLTA03.2021@gmail.com

 Written Assignment Part 1:
2
 Choose the health issue you would like to focus on for your final critical commentary
paper (the list of topics is provided at the end of the assignment package)
 Provide a two-page double spaced description of the topic (to help think through
the topic and population of interest)

The two-page description should include:

• Detailed description of the health issue you are exploring. Provide a reasonable
discussion on the who, what, where, when, and how.
• Context of the health issue with respect to geography, population, and political and
economic setting.
• Evidence (e.g., statistics, data, quotations, etc.) from reputable resources to support
your claim that your chosen topic is indeed a health issue of importance.

Due: THIS Sunday January 31st, at 11:59 PM via Quercus

TA Office Hours on BB Collaborate: Thursday, Jan. 28th from 5-6pm

3 Today’s Lecture

 Social Determinants of Health (SDOH) and Health

Inequities

 Examine models used to understand and explain health

inequities:

 Lifestyle and Behavioural Model

 Psychosocial Model
 Political Economy of Health Model
 Eco-social Model
4
Contemporary Approaches
to Social Determinants of
Health

•Ottawa Charter for Health Promotion*

•Social gradient in health*

•Dahlgren & Whitehead rainbow model of the main

determinants of health
5 Dahlgren & Whitehead Rainbow
Model of the Determinants of
Health
6 Current Themes in the Social
Determinants of Health Field
•Theme 1: Empirical evidence of the importance
of the social determinants of health
•Theme 2: Mechanisms and pathways by which social
determinants of health influence health
•Theme 3: The importance of a life-course
perspective
•Theme 4: The role of public policy and policy
environments
•Theme 5: Policies, political ideology, and the social
determinants of health
7
“What good does it do to treat people’s
illnesses… [and] then send them back to the
conditions that made them sick?”
Sir Michael Marmot
8
Key Concepts: Social Determinants of Health

“Conditions in which people are born, grow, live, work and age.
These circumstances are shaped by the distribution of money,
power and resources at global, national and local levels. The social
determinants of health are mostly responsible for health inequities
- the unfair and avoidable differences in health status seen within
and between countries.”
(World Health Organization’s definition)
9
10 Key Concepts: Socio-Economic Status (SES)

 SES: Is a construct that is concerned with the social and

economic standing of individuals or groups
 Various scales exist to measure SES

 A variety of variables may be considered: SES =

income x education x occupation

 Each variable predicts health outcomes on their own, and

they are not interchangeable.
11 Key concepts: Social Disparities in Health

•Social disparities in health = health differences:

1)by racial or ethnic groups, and
2)by socioeconomic factors (like income and education)

 Need solutions that address their root causes

 Key indicators: infant mortality rate (IMR), life expectancy,

income, education, activity limitation, perceived health,
race/ethnicity differences
12
13
14
15 Key Concepts:

 Health Inequity: describes differences that are unfair;

stem from some injustice; It is a difference or disparity in
health outcomes that is systematic and avoidable

 Health inequities: avoidable inequalities in health between

groups of people within countries and between countries.

 Social and economic conditions and their effects on

people’s lives determine their risk of illness and the
actions taken to prevent them becoming ill or treat
illness when it occurs.
16 Inequities Between Countries

 Examples of health inequities between

countries:

 The infant mortality rate (the risk of a

baby dying between birth and one year of
age) is 2 per 1000 live births in Iceland
and over 120 per 1000 live births in
Mozambique

 The lifetime risk of maternal death during

or shortly after pregnancy is only 1 in
17,400 in Sweden but it is 1 in 8 in
17 Model Used to Understand and Explain
Social Inequities in Health

Lifestyle and Behavioural Model

Psychosocial Model

Political Economy of Health Model

Eco-Social Model
 Lifestyle And Behavioural Model
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 Advanced in the Lalonde Report (1974):

• Health = personal responsibility; individuals CHOOSE to be

healthy or unhealthy.

• Ideologically consistent with (and justifies) policies aiming to

enhance the role of the private sector and diminish the
responsibility of government in providing for social welfare.

• In reality, decisions are influenced by more than one’s will;

context matters!

• Lifestyle alone does not explain patterns of social inequalities

in health.
19

Psychosocial Model

Factors in our social environments, acting through the nervous system, can influence biology to cause ill health
 Key Concepts:
20 Social Gradient and Social Position

PSYCHOSOCIAL MODELS: assume that health/illness is a consequence of the

psychosocial effects of inequality –the physiological response they generate in the
body.
SOCIAL GRADIENT: the poorest of the poor have the worst health outcomes
within countries;
• the lower an individual’s socioeconomic position the worse their health;
• social gradient in health runs from top to bottom of the socioeconomic
spectrum;
• a global phenomenon, seen in low, middle and high income countries (WHO,
2008).

SOCIAL POSITION: one’s place in the social hierarchy;

• translates into physiological response of stress that impacts health; determines
21 Linking Social Structure to Health/Illness
The influences of social structure operate via 3 main pathways:
22
Psychosocial Model Framework

Marmot and Wilkinson (2005)

23 What are the big questions
behind this approach?

•How does the social environment impact on biology to

cause disease?

•The effects of social organization on population health are

mediated by psychological and biological processes.

•Psychological and biological processes are important in

understanding health inequities within and between
populations.
24
What is stress?

Biological response of the individual to the social

environment acting upon him or her

(Marmot and Wilkinson, 2005, p.3)

25 Stress & Health

 Fight or Flight Response

 Cascade of stress hormones and nervous system preparedness to
deal with brief stress
 Physical, psychological or biological short-term stressors (or a
combination of all three)
 Humans in modern society face psychological demands and
challenges that may trigger our stress response too hard too often
 Fight or flight response adaptive to acute stress but maladaptive in
chronic stress in today’s environment
26 Stress & Health
Two main Neuroendocrine pathways of the
Fight or Flight Response:

1. Sympatho-adrenaline pathway (FAST component of stress response):

• Instantaneous release of adrenaline and noradrenaline throughout
the body
• Resulting in psychological arousal and energy mobilization
• Function: to prepare for, or to maintain, physical exertion
• Effects: accelerated heart rate, increased blood pressure, dilated
pupils, dilated airways, increased sweat secretion
27 Stress & Health

2. Hypothalamic-pituitary-adrenal axis (SLOW component of stress

response):
• Results in cortisol release into bloodstream from adrenal glands
• Effects: rise in blood glucose, promote fatty acid release from fat
tissues, increase energy through cholesterol carrying particles
from the liver into the blood
• Increased levels of cortisol may provoke paranoia and depression
28 Stress & Health

Acute and Chronic Stress

• Fight or Flight response is a means to survive in the face of

environmental challenge (survival advantage)

• However, repeated and frequent exposure of stress can activate

the fight or flight response over long periods = chronic disease

• Ill health is associated with prolonged exposure to psychological

demands when possibilities to control the situation are
perceived to be limited and chances of reward are small
29 Stress & Health

Evidence for the physiological effects of stress:

•Disruptive effects of stress on pre-existing medical conditions

• May disrupt existing disease processes (trigger acute events like
heart attack)

•Blood clotting system

• Fight or Flight Response: increased cortisol levels produce
increased “stickiness” of blood platelets, blood becomes more
concentrated (formation of plaque in arteries, increasing risk of
heart disease and stroke)
30 Stress & Health

•Infection, inflammation, and immunity

• Chronic stress may alter susceptibility to infection and its severity
(colds, flu)
• Disturbance of homeostatic equilibrium (increased risk of
illness/disease)

•Interconnections between the neural, endocrine, and immune

systems
31
Movie Time
“Stressed to the Limit”
 Questions to think about:

• How does stress get “under the skin”?

• How do social support, availability of coping
resources, sense of control and resiliency play a
role in stress?
• What are some limitations of the film’s analysis?
What factors related to stress are not identified?
(tip: what about context?)

https://video-alexanderstreet-com.myaccess.library.utoronto.ca/watch/stre
ssed-to-the-limit
32 Social Organization, Stress & Health

People’s social and psychological circumstances seriously damage

their health in the long term
 Increased heart rate
 Increased anxiety
 Increased alertness
 Blood diverted to muscles
33 Social Organization, Stress & Health

Chronic anxiety, insecurity, low self--esteem, social isolation, and lack

of control over work appear to undermine mental and physical
health.
• These include depression, increased susceptibility to infection,
diabetes, high blood pressure, high cholesterol, with attendant
risks of heart attack and stroke.
• These health problems increase progressively down the social
hierarchy
34 Whitehall Studies, Great Britain

Marmot (2006) argues that health follows the social gradient.

The challenge is to understand how position in the social
hierarchy is related to health.

 A series of longitudinal studies of 17,350 British civil servants

 Uncovered a “social gradient in health” in the absence of
poverty or material deprivation.
 Found an inverse relationship between employment, class,
and death from coronary heart disease.
 Men in the lowest occupational grades had highest rates of
death from heart disease, with the rate decreasing
progressively from lowest to highest class.
35

Whitehall Study II:

Stress and control of work
 Material Advantage (living and working conditions)
36

Optimal stress response

Rapid return to baseline resting levels of nerve activity and hormone

release

High resistance to stress related disorders

Take a brief moment to consider what would
happen if there is material deprivation, and
the individual does not have the adequate
coping resources and opportunity to control
Better health outcomes
his or her environment
37

Political Economy of Health Model

Intersections among the state, the economy and health of the general population
38 Political Economy of Health Model

 Health/care is political

 Critical macro-sociological analysis

 Exposes the structures that create inequalities in society:

 Inequity and conflict from competing economic + political interests
39 Political Economy of Health Model

 Assumes that class structure of society is the primary cause

of social inequalities in health.

 Causes of social-class differentials in health related to

material conditions of life and the structures of power in
society and the workplace (power, modes of production,
patterns of consumption).

 political inequality = redistribution of material resources =

social and health inequity.
40 What are the big questions
behind this approach?
 Who has power?

 Who controls resources?

 How is wealth produced and distributed among the population?

 How does this impact health?

41

In Birn, Pillay & Holtz, 2016, p.103

42

Eco-social Model

Integrative model: assumes unequal power manifests itself

at all levels
 Eco-social
43
Model
• Health outcomes are the biologic
expression or “embodiment” of living
conditions, social relations, and structur
of power over the life course and acros
generations.

• Attempts to integrate political, social, an

biological understandings of the
determinants of health.

• Embodiment and the “cumulative interp

of exposure, susceptibility, and resistanc
 Do these models, perspectives and theories really matter?
44

Absolutely, because the explanatory model used

(whether implicitly or explicitly) determines:

How we define and measure the problem.

Potential interventions to remedy social inequalities, reduce

health disparities, and improve the health of individuals
and populations.

Can also be used to help us hold people accountable.

45
Policy Interventions

“Many questions remain, and support for high-quality

research to identify, develop, and implement the most
effective and effıcient approaches will be crucial, but
we know enough to act now
in a number of important areas”

(Braveman et al., 2011, p. S14)

46 Examples of Potential Policy Interventions
47

Topic: Indigenous People’s

Health
Readings:

Allan and Smylie (2015): First peoples, second

class treatment: The role of racism in the health
and well- being of Indigenous peoples in Canada.
Toronto, ON: The Wellesley Institute. Exec.
Summary.Preview the document