Introduction to Health Studies Health Promotion III Dennis Raphael School of Health Policy and Management York University, Toronto, Canada

Social Determinants of Health Early Life as a determinant of health: Illustration of the Individual Approach to Understanding the Impact of Poverty Upon Health

Poor conditions lead to poorer health. An unhealthy material environment and unhealthy behaviours have direct harmful effects, but the worries and insecurities of daily life and the lack of supportive environments also have an influence. Social Determinants of Health: The Solid Facts, World Health Organization,

Infant Mortality by Neighbourhood Income, Canada, 1996 (per 1000) Source: Wilkins et al., 2002

Defining Poverty Individuals, families and groups in the population can be said to be in poverty when they lack the resources to obtain the type of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged, or approved, in the societies to which they belong. They are, in effect, excluded from ordinary living patterns, customs and activities -- Townsend, 1979, p.31

Low Income Refers to income status in relation to Statistics Canada’s low income cut-offs (LICOs). In large urban centres such as Toronto (where population is equal to, or exceeds 500,000), the LICO can be organized by various family sizes: Family size = 1 LICO = $16,874 Family size = 2 LICO = $21,092 Family size = 3 LICO = $26,232 Family size = 4 LICO = $31,753 Family size = 5 LICO = $35,494 Family size = 6 LICO = $39,236 Family size = 7+ LICO = $42,978

Ten Tips for Staying Healthy - Dave Gordon, Don't be poor. If you can, stop. If you can't, try not to be poor for long. 2. Don't have poor parents. 3. Own a car. 4. Don't work in a stressful, low paid manual job. 5. Don't live in damp, low quality housing. 6. Be able to afford to go on a foreign holiday and sunbathe. 7. Practice not losing your job and don't become unemployed. 8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled. 9. Don't live next to a busy major road or near a polluting factory. 10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Critical Periods of the Life Course Foetal development Birth Nutrition, growth and health in adulthood Educational Career Leaving parental home Entering labour market Establishing social and sexual relationships Job loss or insecurity Parenthood Episodes of illness Labour market exit Chronic sickness Loss of full independence -- Shaw et al., The Widening Gap, 1999, p. 106.

Life-Course Approach to Health and Illness In contrast to adult lifestyle approaches, life-course approaches emphasize the accumulated effects of experience across the life span in understanding health and disease.

Life-Course Approach to Health and Illness Early life may be a particularly important period in itself (critical or sensitive period) or it may serve as a marker for a path that a person is set out on. In either event for most people, early life sets them out on a pathway that leads to the accumulation of exposures to either positive or negative effects. This notion of latent, pathway or cumulative effects helps to explain empirical findings. In the end however, policy implications are probably the same, whichever approach is more accurate.

Poverty and Health: Mechanisms Poverty can affect health in a number of ways: income provides the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society; living in poverty can cause stress and anxiety which can damage people’s health; low income limits peoples’ choices and militates against desirable changes in behaviour. - Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Latent Effects I Specific biologic or developmental factors at sensitive periods that have a lifelong effect regardless of later circumstances. Occurring prior to birth: –nutrients, infection, smoking that affect availability of oxygen to organs –affect blood clotting, cholesterol metabolism –contributors to coronary heart disease and diabetes in later life

Latent Effects II Occurring during infancy: –malnutrition and infection Malnutrition affects health, cognitive development and educational attainment Infection has long-term developmental risk e.g., airway and respiratory function.

Pathway Effects Experiences that set individuals unto life trajectories that affect health, well- being and competence over time emotional and personality development educational experiences workplace circumstances income situation

Cumulative Effects Accumulation of advantage or disadvantage over time addition of latent and pathways effects multi-faceted, involving individual, family, and community factors primary explanation for health differences according to the Bristol group in UK.

Determinants of Healthy Child Development (Herztman, 2000) What aspects of society are not included in this table, but should be?

Poverty, Income, and Health: Canadian Perspectives Childhood and adult social circumstances make independent contributions to the risk of dying. - Davey Smith & Gordon, 2000, p.142, Poverty Across the Life-course and Health in Pantazis, C. & Gordon, D. (eds.), Tackling Inequalities: Where Are We Now and What Can be Done?

90% 160% 50% 90% 70% 90% 30% 50% 60% 40% 80% White MalesWhite FemalesBlack MalesBlack Females 0% 40% 80% 120% 160% Low Income Area - Adjusted for Age and Study Site Low Income Area - Adjusted for Preceding and Individual Socioeconomic Character istics Low Income Area - Adjusted for Preceding and All Behavioural and Medical Factor s Figure 9: Greater Risk of Heart Disease in Low Income Areas, USA,

It was found that those living in lower income areas were much more likely to develop coronary heart disease than those in well-off neighbourhoods. These effects remained strong even after controlling for tobacco use, level of physical activity, presence of hypertension or diabetes, level of cholesterol, and body mass index. - Summary of Neighbourhood of Residence and Incidence of Coronary Heart Disease, A. Roux, S. Merkin, D. Arnett, et al. New England Journal of Medicine, 2001, 345,

Low Income and Heart Disease: Researchers’ Conclusions These estimates of risk reduction may be compared with the much smaller estimates of the effects of improvements in adult lifestyle... Our findings add to the evidence that protection of fetal and infant growth is a key area in strategies for the primary prevention of coronary heart disease. -- Early Growth and Coronary Heart Disease in Later Life: Longitudinal Study. J.G. Eriksson, T. Forsen, J. Tuomilehto, C. Osmond, D.J. Barker. British Medical Journal, 2001, 322,