Midterm Notes - Nina Cavey PDF

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Nina Cavey...

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Unit 1: Social Determinants of Health What is SDoH? ●

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Conditions in which people live that affect their health ○ 40% socioeconomic factors (education, job, income, family.. etc) ○ 30% health behaviours (diet and exercise, tobacco and drug use.. etc) ○ 20% healthcare (access to care, quality of care.. etc) ○ 10% physical environment WHO Conceptual Framework

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Inequities lead to intermediary determinants leads to impact on equity in health and wellbeing

Toxic stress has health implications ○ Psychosocial demands (stressors, life events, daily hassles) + Resistance and vulnerability factors (coping responses, personality, social supports) → Psychobiological stress response (neuroendocrine, autonomic/metabolic, immune)

Why Study SDoH? ● ●

To understand societal factors ○ Shape health and help explain health inequities (e.g. income and employment) To understand societal forces ○ Shape the quality and distribution of the factors (e.g. social and political forces)

Main SDoH ● ●

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Having more control over your life leads to better health Income and Health ○ Income inequality = difference in income distributions within the population that result in a small percentage of the population holding a high concentration of income ○ Higher income = more favorable health outcomes Work and Health ○ Longer hours, high stress work, and job insecurity = poorer health outcomes ○ Precariat = precarious (insecure) + proletariat (working class) = less control over life Education and Health ○ Good early childhood education = better adult health Food, Housing, and Health ○ Low income = poor housing and food conditions = poor health ■ 1.7 Canadians live in core housing need ■ 4.4 million Canadians experience food insecurity Gender and Health ○ Gender inequality and gender inequity Racialized Communities and Health ○ Racialized groups more likely to live in poverty due to economic exclusion ○ Indigenous peoples have more difficulty assessing health services and are subject to SDoH inequities (e.g. boiled water problems) Physical Environment and Health ○ Climate change has impacts on physical environment ○ Air pollution, inadequate water, radiation, community noise, agricultural practices.. Etc also play a part Bartley Typology ○ Material: access to food, housing, education, and recreation ○ Psychosocial: stress, sense of control, family environment, social support ○ Political Economy: distribution of power affects distribution of economic resources ○ Cultural/Behavioural: beliefs, norms, and values ○ Lifecourse: events before birth and during childhood

Unit 2: Canadian Healthcare System Healthcare in Canada ● ●

Publicly financed, privately delivered; provides access to universal, comprehensive coverage for medically necessary healthcare services Federal Responsibility ○ Sets and administers national principles or standards

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○ Finances provincial healthcare services through fiscal transfer ○ Delivers direct-health services to specific groups Provincial Responsibility ○ Manages and delivers health services ○ Plans, finances, and evaluates hospital care, physician, and allied healthcare systems ○ Manages some prescription care and public health

History of Healthcare in Canada ●

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1947 Saskatchewan ○ First province to establish public, universal hospital insurance ■ Lead to all provinces and territories to do the same by 1961 ■ Eventually lead to the same happening for physician services outside hospitals by 1972 1974 Lalonde Report - The White Paper ○ Produced because government was spending lots of money on healthcare but overall health of population was improving only marginally ■ Discovered that healthcare was more “sick care”, which was very expensive ■ Decided to aim healthcare towards determinants of health instead (Biological factors, lifestyle, environment, healthcare) ○ Important b/c it is one of the first statements made by a western government that concerned determinants that define health (changed healthcare to healthcare field) ■ Found that preventing illness is better than treating illness ● People must change lifestyle, social, and physical environments to improve their health ○ Gave rise to health promotion programs that increased awareness of health risks from day-to-day lifestyles 1984 Canada Health Act ○ Created after Emmett Hall (1979) warned that extra billing by doctors and user fees could create a two-tiered system that affected care ○ Discourages hospital user charges and extra billing by physicians 1986 Health Promotion Framework and Ottawa Charter ○ Health is a resource for living influenced by our beliefs, culture, socio economic, and physical environments ○ Using self-care, mutual aid, and healthy environments ○ Expanded Lalonde Report by focusing on broader socioeconomic factors that affect health (income, education, physical environment) 1989 Canadian Institute of Advanced Research ○ Interaction among determinants have a bigger impact on health than individual determinants 1994 Strategies for Population Health: Investing in the Health of Canadians ○ Population health approach endorsed by federal and provincial Ministers of Health

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Ensures that residents have access to medical services based on need and not ability to pay

Canada Health Act ●

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Canada Health Act (in detail) ○ Public Administration = healthcare must be administered on a non-profit basis ○ Comprehensiveness/What = all medically necessary services by hospitals and practitioners must be insured (e.g. diagnostic tests, drugs, in-patient care.. etc) ○ Universality/Who = all insured persons must be entitled to public health insurance coverage ○ Portability/Where = coverage for insured services must be maintained when an insured person moves or travels within Canada or outside of the country ○ Accessibility/When = Insured persons must have reasonable access to services unimpeded by barriers Sources of Money ○ Citizens (taxes, purchase of insurance, purchase of medical and nonmedical services) ○ Federal Government (Canada Health Transfer, equalization support to less wealthy provinces, programs for research and public health, direct health services for selected people such as aboriginals and military) ○ Provincial/Territorial Government (Program and service payments to providers, institutions, and health authorities for medically necessary doctor and hospital services) Canada Health Transfer ○ Largest federal transfer to provinces and territories ($41.9 billion total, $1100 per/1) ■ Cash payment and tax transfer allocated to provinces and territories; the provinces and territories have flexibility to allocate the money according to their priorities (only if they adhere to CHA) ○ CHA Annual Report ■ Examines each province and territory and their compliance to CHA ■ Penalties made for extra billing or queue jumping

Health Spending ● ●

⅓ of provincial program expenditures go to healthcare Personal Health Spending ○ 70% public (government money) and 30% private (out of pocket, private insurance) ○ 26.6% hospitals, 15.3% drugs, 15.1% physicians

Weaknesses ●

Home Care: For Independent Living ○ Maintenance/prevention, long-term care substitution, acute care substitution

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■ Governments shifting from delivery models to community modes that place emphasis on health promotion and prevention ○ Includes pharmacare, ambulance services .. etc 2002 Romanow Report (Royal Commission on the Future of Home Care in Canada) ○ Focuses on determinants of health, home care, palliative care, regional and community delivery of health services, primary health-care reform .. etc ○ Covers things that are not covered by Canadian Health Act 2004 Healthcare Reform (First Minister’s Meeting on the Future of Healthcare) ○ Reducing wait times, home care, primary care reform, access to care in the North, public health, health promotion .. etc

Unit 3: Income and Health Defining Poverty ● ●

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3.2 million Canadians live in poverty Poverty: the condition of a person who is deprived of the resources, means, choices, and power necessary to acquire and maintain a basic level of living standards and to facilitate integration and participation in the society ○ Absolute poverty = less than an objectively defined minimum; most severe ○ Relative poverty = having significantly less than the rest of the population ○ Subjective poverty = how much people feel they need to get by ○ Income = earnings, Wealth = assets - debt Inequity and Inequality ○ Inequity = Unfairness or bias, often caused by race, gender, sexuality, disability .. etc ■ 40% of First Nations on reserve are moderately food insecure, 14% are severely food insecure ○ Inequality = Unequal, may or may not be fair

Social Gradient in Health ● ●

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Income of population categorized into quintiles (each 5th is a category) Mean and Median Income: ○ Median income is a better form of measurement as the weighting will not be affected by one individual with a very large income ○ Median after-tax income by family type: ■ Two-parent with kid - $101900 ■ Senior families - $63500 ■ Lone parent families - $52000 Implications of income ○ High income = low mortality rate, better mental health, better sense of community

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belonging, lower preterm/small births Gini Coefficient ○ Measures values of frequency distribution for income inequality ○ 1 = one person has all the income, 0 = everyone has the same income ■ The closer to 0, the better ○ Global Pyramid of Wealth ■ 8.6% of the world population owns 86% of the world’s wealth Low Income Measure (LIM) ○ Defines an individual has having low income if their adjusted after-tax income is below 50% of the median Market Based Measure (MBM) ○ Based on the cost of goods and services required to have a basic standard of living, compared to the disposable income of families ■ To be revised in 2020 as the 2008 version does not include some marginalized groups and prices were cheaper back then)

Populations Most Affected by Low Income ● ●

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Women and children (esp female lone-parent households) Older adults (65+) ○ 14% LIM rate, 3.5% MBM rate ○ Many retiring without employer pension plan, challenging to live solely from Ontario retirement pension plan; cannot save enough for retirement Homeless people ○ Most live below LICO (Low-income cutoff) → this is not used anymore ○ Devoting 20% more on shelter, food, and clothing than the average family/individual Racialized groups ○ Affected by immigration status, level of education, language

Income Influencing Health ● ● ●

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Health influenced by both depth and duration of poverty Poverty during childhood contributes to poor health over the entire lifespan Why income influences health ○ Underinvestment in human capital ■ Not investing in public infrastructure ○ Underinvestment in social capital ■ Diminishing community solidarity and cohesion ○ Psychosocially mediated effects ■ Frustration and harmful biological processes Recommendations to decrease the effect ○ Access to education, employment opportunities, affordable housing, transportation and

food.. Etc

Screening for Poverty ● ● ●

Screen everyone (Do you have difficulty making ends meet?) Consider poverty as a risk factor for health conditions (especially for new immigrants, aboriginals, women, LGBTQ) Intervene (ask more questions, ask about benefits they can receive, educate them)

Unit 4: Work and Health Precarious Employment ●

Precarious jobs = jobs that are poorly paid, insecure, and/or unprotected ○ More than ⅕ Canadians have precarious jobs, with women accounting for 60% of them ○ The elderly are more likely to have precarious jobs

Labour Market Transformation ●

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Timeline: ○ Farming/Agriculture: living off the land ○ 1st and 2nd Industrial Revolution: mechanical and mass production, birth of unions ○ Tech and Knowledge Economy: jobs requiring specialized skills and globalization ○ Artificial Intelligence: 4th industrial revolution, in the future Labour Transformation ○ More careers related to the development of projects ○ Most people work in several jobs in their life ○ Distinction between boundaryless careers and vertical ladder careers ■ Boundaryless careers ● Tech/knowledge economy, mobile work, virtual communities ● More flexibility in employment ○ False sense of self employment ○ Precarious work (lack of stability or benefits) ○ New classifications of employment (casual, contract, part-time.. etc) ○ Affects the “active” labour force calculation

Employment ●

Active Labour Force ○ Unemployment rate = number of people in the labour force (15-64 yrs) actively looking for a job

Employment rate = number of people employed in the total labour force Precariat = precarious (insecure) and proletariat (working class) = less security = less control Precarious Employment and Social Policy ○ Laissez-faire countries ■ Less government intervention ■ Markets self regulate (hard-working ppl will find work) ■ E.g. USA, UK ○ Social democratic states ■ Welfare state involved in labour force integration ■ More unions ■ E.g. Nordic countries (Sweden, Norway) Job Security vs Income Security ○ Job security = economic and social inclusion (Tremblay proponent) ○ Income security = economic inclusion ○ ○

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Intersectional Lens ● ●

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Gender based inequity ○ Non racialized women earn 69 cents for every dollar non-racialized men earn Race based inequity ○ Racialized men earn 76 cents for every dollar non-racialized men earn ○ Racialized women each 85 cents for every dollar non-racialized women earn Gender-based and race-based inequity ○ Racialized women earn 58 cents for every dollar non-racialized men earn Degree based ○ Those with a degree have a higher chance of secure employment

Health Consequences of Precarious Employment ●

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Flexible production in the new economy ○ Goods are produced fast and cheap, people always want the latest product and change brands often → forces companies to cope ■ Functional Flexibility ● Workers work harder and longer ● Focus on outcomes/lean production ■ Numerical Flexibility ● Downsizing ● Part-time/Contract jobs ● Focus on cost reduction Flexible production and health ○ Intensification of work: leisure sickness, repetitive strain injuries

Non-standard work hours: long hours, physiological and psychological health issues, family conflict ○ Precarious work: poor conditions, low control over life ○ Job insecurity: associations between illness and downsizing, family dynamics and parenting ○ Employment insecurity: stress of no employment options ○ Income insecurity: income inadequacy/poverty leading to ill health Employment Strain Model ○ How mental well-being is affected by precarious employments with all the factors tied in ○

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■ Influences by coping strategies and resources, perception of rewards, personal preferences and expectations, personal social characteristics, and former experiences affect mental well-being given precarious employment ■ Can either lead to strain (negative well being) or activation (positive well being) ○ Components of the model ■ Employment relationship uncertainty = employment fragility, uncertainty of earnings and schedule ■ Employment relationship effort = effort to remain employed, constant evaluation effort ■ Employment relationship support = union support, economic support, social supports Most impacted populations ○ Women, youth, new immigrants, racialized minorities, disabled, lower education ○ Flexibility mostly benefits high-skilled and educated workers

Key Dimensions ●

Key Dimensions of a Good Job ○ Secure - permanent w/ benefits

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○ Addresses workplace injuries - e.g. seasonal migrant workers ○ Control and autonomy ○ Opportunities for self-development - allows for paid advancement ○ Free time - vacation and sick days ○ Work-life balance - time stress with managing family life ○ Attention to social aspects of job - both positive and negative Key Dimensions of Work-Related Health ○ Job strain - low autonomy, limited use of skills, high psychological demands ○ Effort-Reward imbalance - compensation (tangible and intangible) not in line with effort ○ Organizational justice - people must be treated fairly ○ Work hours - preference matters ○ Work life conflict - overload (too much work, too little time) and interference (having to be at home and work at the same time) ○ Precarious work - instability, lack of protection, socially and economically vulnerable ○ Status inconsistency - overqualified for job, having stress regarding to not meeting aspirations

Possible Solutions ● ● ● ● ●

Research and education - Finding link between precarious employment and health Institutional change - Free trade vs fair trade Cultural change - More employer and social accountability Power and equity - Address that those already economically marginalized are being disproportionately impacted by “flexible” workplace strategies Policy and legislation - Increase minimum wage, hire permanent staff, give people more access to training opportunities and benefits

Unit 5: Education and Health Early Childhood Education and Care ● ● ●

Used to be called daycare (1970s), childcare (70s-90s), childhood education AND care (present) Education positively associated with income, income positively associated with health Better socioeconomic position = better health ○ Women with bachelor’s degree earn 63% more than women without ○ Men with bachelor’s degree earn 45% more than men without

ECEC Policy and Context ● Policy Goals 1. Enhancing well-being, healthy development, and lifelong learning

a. Quality matters (having a well educated and adequate staff) i. Low staff: child ratios ii. Staff should have decent wages and working conditions iii. Staff should be trained in ECEC iv. Challenging, enjoyable, play based, non-didactic activities should be provided (early, intensive, and systematic) 2. Supporting parents in education, training, and employment a. Childcare allows parents to upgrade their education and increase income 3. Building strong communities a. Helps children and parents connect + embrace diversity 4. Creating equity a. Basic ECEC human right (esp for those with disabilities.. etc) ●

Canadian Context ○ Responsible for social programs in provinces and territories ○ Reliance on market-based solutions (in-formal for-profit childcare) until kindergarten ○ Testing for subsidies ??

Critiques of ECEC in Canada and Ontario ●

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Critiques ○ No systematic/integrated/universal approach ○ Disconnect between ECEC and education system ○ Eligibility criteria depends on race, class, income (siloed programming) ○ Has user fees ○ Not enough funding to cover capital costs (e.g. building maintenance) so parents must cover it ○ Inadequate wages and training ○ Limited monitoring about effects on ECEC on children over time Response to critiques ○ GoC will provide provinces and territories with 1.2 billion dollars for early learning and childcare programs ○ 3-year bilateral agreements with federal government as part of the FederalProvincial/Territorial Early Childhood Learning and Care Agreement (ECLC); money to be used for funding standardized program materials and ensure resources will be delivered in all official languages ○ EarlyON child and family centers started in 2018 that combined 4 programs Effect of provincial election ○ Lots of funding for specialized scho...