Disease, Illness, and Sickness

• Disease is a biological/physical ailment, illness is the individual's perception of dysfunction, and sickness is the social acknowledgment.

Factors Causing Disease

• Germs, genetics, lifestyle, and multifactorial causes (epigenetics/environment) contribute to disease.

Germ Theory of Disease

• Koch's postulates state germs are present in diseased individuals, can be isolated/cultured, cause disease in healthy hosts, and can be re-isolated.
• Lister advocated for antiseptic surgical conditions using carbolic acid, leading to a decrease in surgical mortality from 45% to 15%.
• Pasteur first postulated the germ theory of disease and discovered microbial fermentation/sterilization principles, including pasteurization.

Genetic and Lifestyle Factors

• Genetic theories emphasize hereditary vulnerability, focusing on individuals rather than society.
• Lifestyle theories focus on behaviorally driven factors, like smoking, alcohol, and diet.

Determinants of Health Introduction

• Populations share a characteristic, and population health involves health outcomes and their distribution within the group.
• Population health aims to improve overall health and reduce health inequities among groups.

Epidemiology

• Epidemiology studies the distribution and determinants of disease in populations.
• Distribution, a focus of descriptive epidemiology, shows health outcomes patterns across a population for hypothesis development and service planning.
• Determinants, the focus of analytical epidemiology, influence individual/population health states.

Determinants of Health Overview

• Determinants of health are interconnected factors that affect an individual's health status.
• Key determinants: income/social status, employment/working conditions, education/literacy, childhood experiences, physical environment, social support, healthy behaviors, access to services, biology/genetics, gender, culture, race/racism.

Social Determinants of Health

• Social determinants are conditions affecting health shaped by money, power, and resource distribution globally, nationally, and locally.
• Policy choices influence these distributions.

Physical Determinants of Health

• The physical environment impacts health risks and outcomes.
• These include air/water quality, soil contamination, occupational hazards, motor vehicle safety, and housing.

Social and Physical Determinants Examples

• Psychosocial: knowledge, attitudes, beliefs about health/illness.
• Biological: inherited disorders.
• Environmental: violence, genocide.
• Policy: access to healthcare.
• Individual behaviors: smoking.

Root, Underlying, and Proximal Determinants

• Root causes include the natural environment, macro issues (historical, demographic, governance), economic/political policies, conflicts, inequalities in wealth, employment, education, and political influence.
• Underlying causes: built environment (land use, transportation), social context (community policies, civic participation, education).
• Proximal causes: material circumstances (income, living conditions, food), behavioral (activity, smoking, diet, sex, healthcare use) and psychosocial factors (education, participation, support).

Risk Factors

• Risk factors are health determinants linked to health outcomes.
• Intrinsic risk factors are non-modifiable (age, sex, genetics).
• Disease-related, behavioral, physical, and social environmental factors also pose risks.
• Common risk factors: nutrition issues, high glucose, BMI, unsafe sex, tobacco/alcohol, sanitation, pollution, trauma/abuse.

Health Inequities

Common Health Status Indicators

• Life expectancy at birth reflects mortality trends, not health quality.
• Neonatal mortality rate is infant deaths under 28 days per 1000 live births annually.
• Infant mortality rate is infant deaths under 1 year per 1000 live births annually.
• Under-5 mortality rate is the probability of death before age 5 per 1000 live births.
• Maternal mortality ratio is deaths due to pregnancy/childbirth complications per 100,000 live births annually.
• Health disparities are differences linked to social/economic disadvantage.

Health Inequality vs Health Inequity

• Health inequities are differences in health status or resource distribution due to social conditions.
• Health inequality provides equal shares.
• Health inequity provides fair shares based on underlying needs.

Applying a Critical Lens

• Definition of health: consider the author's definition (broad/narrow, cultural grounding).

Health Data

• What health indicators are the authors using? What measurable characteristics are they using to describe the health of that population

Methodologies in Health Studies

• Quantitative include statistics, surveys, records.
• Qualitative include interviews, focus groups, community-based studies.

Critical Appraisal Questions

• Is the evidence reputable, evaluated, and up-to-date?
• Were the methods appropriate and trustworthy?
• Are the findings generalizable?
• Is the knowledge biased?

Environmental Determinants: Geography

• Locations include global location, country, region within a country, and urban/rural location.

Natural Environment

• The natural environment includes air, water, soil, trees, and green space, encompassing both biotic and abiotic factors.

Built Environment

• Refers to housing, community structures, roadways and transportation.

Food Systems

• Includes food distribution, food security, and concepts such as food deserts.

Macro-Environmental Factors

• Includes political, economic, and national factors such as governance, climate change, war, and disasters.

Environmental Health

• The natural environment is the life's support system.
• Environmental health includes health aspects determined by physical, chemical, biological, social, and psychosocial factors - WHO

Environmental Health Burdens

• Poor sanitation and water access.
• Air pollution (indoor/outdoor).
• Inadequate housing.
• Changing land use and climate affecting food production, culture, and livelihoods.
• Pollution and exposure to toxins.

Air Pollution Problem

• Outdoor air pollution is worse in lower-income urban communities with environmental/industrial pollutants.
• Indoor air pollution is worse in lower-income rural communities due to solid biomass fuels for heating/cooking.

Urban Outdoor Air Pollutants

• Particulate matter (PM10) inflames nasal/bronchial passages.
• PM2.5 penetrates lungs/bloodstream.
• Other pollutants: ozone, nitrogen oxides, sulfur dioxide, carbon monoxide, ammonia, lead, PAHs, VOCs.

Indoor Pollutant Sources and Risks

• Burning solid fuels creates breathable particles, gases, and chemicals.
• Smoke causes conjunctivitis, respiratory irritation/infections.
• Carbon monoxide causes poisoning.
• Long-term effects include cardiovascular/pulmonary disease, cancer, adverse reproductive outcomes.

Health Effects of Indoor Air Pollution

• Causes miscarriages, early delivery, and low birth weight.
• Accounts for up to 10% of mortality in children under 5.
• Harms development of healthy childrens' brains.

Air Pollution Exposure and Inequities

• Urban: industrial sites, dumps, generators.
• Rural: unventilated homes, cook stoves.
• Refugees/Migrants: tents with wood smoke, inadequate housing/heating/healthcare.

Aggravating and Intersecting Factors

• Low SES increases risk for adverse health effects from pollution.
• Climate change: pollution contributes to greenhouse gas and threatens livelihood.

Causes and Consequences of Unsafe Water

• Causes: pollution, contamination, toxic exposure, sanitation, hygiene.
• Consequences: diarrheal illnesses, vector-borne diseases.

Access to Safe Water

• 1.1 billion lack clean drinking water globally around the world.

Global Health Water-Related Infections

• Water-borne through ingestion of water. Ex: Cholera.
• Water-washed is due to poor hygiene and lack of clean water. Ex: Hepatitis A.
• Water-based uses an aquatic intermediate host. Ex: Schistosomiasis or Guinea worm.
• Water-related insect vectors use insects that need water to reproduce. Ex: Mosquitoes transmit malaria/dengue.

Schistosomiasis

• Mature flukes reproduce sexually in human hosts.
• Fertilized eggs excreted into water via feces develop into larvae, and infect snails.
• Asexually reproduced larvae penetrate human skin in contact with water.
• Causes fluid buildup in the abdomen (ascites).
• Mature flukes reside in blood vessels of the intestines in a human host.

Housing Health Effects

• Internal Housing Conditions include biological, chemical, and physical hazards as well the physical design and organization of space
• Area Characteristics include social benefits; location; proximity to services hazards, community life
• Housing Tenure: Psychological benefits; financial; owning/renting and affordability.

Housing and Living Spaces Impacts

• Pollutants: building materials, mold, fireplaces, cleaning products.
• Irritants: fumes, solvents, cigarettes.
• Gases.

Canadian Context and Housing

• Unsheltered homelessness have lived in shelters, on streets, or in abandoned buildings.
  • 2.6% of male population
  • 2.3% of female population
• Hidden homelessness have temporarily lived with family/friends.
  • 15% of population

Core Housing Need

• Lack of affordability - when tenants pay more than 30% of their income on housing
• Lack of suitability - living in overcrowding conditions
• Lack of adequacy - when a tenant’s home lacks a full bathroom or requires significant repair

Health Opportunity Structures

• Physical Features
• Shared air, water, grocery stores
• Availability of Healthy Environments
• Secure housing, non-hazardous work, safe play areas
• Services Provided
• Education, transport, health
• Socio-Cultural Features
• Political and economic history, crime, support networks
• Reputation of an Area
• How neighbourhoods are perceived, self-esteem & morale

DIsasters definition

• Natural: “Any occurrence that causes damage, ecological disruption, loss of human life of deterioration of health and health services on a scale sufficient enough to warrant an extraordinary response from outside the affected community or area” — WHO
• Complex Humanitarian Emergencies (CHEs) characterized by: Extensive violence and loss of life, displacement of populations, widespread damage to societies and economies, and the need for large-scale, multi-faceted humanitarian assistance

Factors Affecting CHE Management

• Population Migration
• Corruption
• Disruption of Supply Chains
• Collapse of State or National Level Institutions
• Breakdown of Law and Order

Climate Change Threats

• Rising temperature
• More extreme weather
• Rising sea levels
• Increasing CO2 levels

Minimizing Environmental Threats

• Outdoor Air Pollution: minimize vehicle usage, use less energy, avoid burning garbage.
• Indoor Air Pollution: use indoor stoves with efficient fuels.
• Water Supply/Hygiene: promote hand-washing.
• Sanitation: implement low-cost systems.
• Housing: construction suited to climate; avoid harmful chemicals.
• Climate Change: reduce greenhouse gas emissions through clean energy; reduce overconsumption.

Social Determinants Examples

• Social relationships/supports, norms, policies, societal features, political/economic systems influence health.

Lifestyle Perspective Health Advice

• Don't smoke, eat balanced diet, exercise, manage stress, drink moderately, protect from sun, get cancer screening, be safe on roads, practice safe sex, learn first aid.

Cultural Influences on Health

• Shared beliefs/values form the basis of a group's identity, linking ideology to behavior.
• Culture impacts nutrition, gender roles, substance use, relationships, hygiene, and rites.

Culture Impacting Health Negatively

• Food Preferences: Undercooked meats and fishes, unpasteurized milk
• Settlement patterns that can increase risk for the spread of infectious disease
• Historical racism that can affect access to services and resources

Culture Positively Impacting Health

• Vietnamese Stilt Houses: malaria protection above mosquito flight ceiling.
• Sardinian Inverse Transhumance - cattle patterns to avoid peak mosquito concentrations

Social Connectedness

• Has higher chances of reporting very good / excellent general health, and very good or excellent mental health
• Increases healthy lifestyles
• Declines in health were also associated with low levels in community belonging

Socioeconomic Status (SES)

• SES is an individual's/group's position in a hierarchical social structure, influencing their position in society.

Measuring Socioeconomic Status

• Area-Level Indicators and Individual Indicators (education level, annual/family income and occupation).

Indicators for Measuring Life Course SES

• Childhood: parental education/occupation, household income/conditions.
• Young Adulthood: education.
• Professional Life: occupational class, unemployment, income, wealth, partner's SES.
• Retirement: wealth, household conditions.

Relationship Between SES and Health

• SES (education, occupation, income, subjective SES, inequality) affects health outcomes through connecting pathways, self-perception, and abilities.
• Cognitive and physical functioning, disease onset, disease process and mortality are all affected.

SES and Health

• Critical Period: early life influences later outcomes.
• Pathway: early experiences set health trajectories.
• Cumulative: day-to-day adversity accumulates to adverse health outcomes.

Low SES

• Psychosocial factors related affect brain neuroplasticity.
• Limbic regions regulate neuroendocrine, autonomic, and immune systems.
• A low SES can lead to a large allostatic load on the body and brain and increase one’s risk for poor health

Adverse Childhood/Community Enviornments

• Childhood: violence, abuse, neglect, witnessing violence, suicide.
• Community: lack of social support/safety.

Income

• Higher average increase of life based on income

Education

• Increased rates are associated with improved health outcomes

Occupation

• There are gender patterns in may jobs, and gender and occupation influences often act synergistically
• Occupational measures don’t always capture unemployed or retired positions, persons in transient jobs, or students
• Occupational realities may differ between societies and there may be quite a bit of variation within any one occupation

Health Inequalities

• Life Expectancy different between rich vs poor
• Majority of premature deaths occur in middle/lower income families
• Relative gaps between poorer and richer subgroups for diseases
• Under-5 mortality higher in Africa

What Causes Health Inequalities

• Different groups in society have different access to resources.
• Some people are at greater risk of experiencing or being exposed to factors that can negatively affect their health
• Health may not be affected in the same way, even if everyone is exposed to the same health risks
• Illness and chronic disease can have a more serious impact for some groups in society compared with others
• Early experiences, disadvantage early in a person’s life can accumulate and lead to poor health in adulthood and old age

Social Staircase

• Bottom level: lower quality of food, less education, insufficient housing, and very little power over their circumstances
• Middle levels: sufficient resources and power over their circumstances
• Top levels: higher quality food, greater access to education, good housing, and power over their circumstances

Income Inequality

Underinvestment in social support causes disruption of social cohesion and harmful psychosocial effects from social comparison.

Addressing Social Determinants

• Focus on the circumstances in which people are born, grow, live, work, and age
• Tackle inequitable distribution of power, money, and resources particularly through economic policies and better governance
• Need to measure and understand the problem and assess the impact of action
• Create a a workforce that is trained in understanding Social Determinants of Health and Disease
• Need to raise public awareness about Social Determinants of Health and Disease

Factors Influencing Privilege

• Sexual orientation, class/SES, geography, religion, gender identity, employment, ability, appearance, handedness, language, nation of origin, ethnicity, family factors

Health Factors based on behaviour

• Smoker / Subtance / Stress

Oppression Breakdown

• Societal/Cultural - Collective ideas about what is “right”
• Institutional- Legal system, Education sysem, Public policy, Hiring practices, Media images
• Interpersonal - Actions, Behaviors, Language
• Individual - Feelings, Beliefs, Values

Race and Ethnicity

• Race is a social structure based on characteristics
• Ethnicity is a term used to describe a cultural group

Racial Categories

• There is greater genetic variability within racial categories than across racial groups
• Conceptions of racial identity over time and location
• Racial categories are contextually-based
• Historically, racial categorization was used to enforce/reinforce power differentials between groups

Levels of Racism

• Personally-mediated/Interpersonal
• Internalized
• Institutional/systemic

Structural/Systemic/Institutional Racism Examples

• Racial Segregation and Education (BIPOC communities quality and funding of school systems)
• Justice System (Drug Use and disproportionately high incarceration rate)
• Policy, Work, Religion, Administrative: Racial injustices in policies, Discrimination, Ignorance of minority groups

Racial Equity and Inequity

• Racial Equity: Just and fair inclusion into a society in which all people can participate, prosper, and reach their full potential (someone’s racial identity does not influence how they fare in society)
• Racial Inequity: Can result from any form of racism, but especially structural racism - historical, political, cultural, social, and economic systems and institutions
• Ideologies: White/antiindigenous

Pathway to Racial Health Inequity

• Colonial and Racist Ideology
• Stereotypes
• Prejudice
• Racial Discrimination
• Inequitable social/health outcomes.

Income

• Impacts access to education/employment, good health, concentrates poverty/wealth, access to infrastructure/healthcare, exposes to toxins.

Bias and Discrimination in Health Care

• Socio-economic factors/under-representation/limitations in communication/ Lack of culturally sensitive care/Discrimination in clinical-decision making and its related health outcome disparities

Health Disparities

• Less of preventative health care, such as mammograms and Pap smears
• Lower levels of mental health services
• Inappropriate care of diseases

Research on Race, SES, and Health Findings

• Racism is a cause of stress.
• Racism is a structural force.
• Racism is not a question of the past
• Everyday discrimination and a variety of mental health and cardiovascular diseases + others

Anti-Racist Action Steps

• Individual transformation
• Organizational change
• Community change
• Movement-building
• Anti-discrimination legislation
• Racial equity policies in health, social, legal, economic, and political institutions

Impacts of Decolonial Practice

• Makes Indigenous self-determination and resurgence a priority
• Provides Indigenous and racialized peoples with the tools to understand how racism distorts interactions with each other and acts on opportunities for solidarity across different Indigenous and racialized peoples
• Questions settler privilege for non-Indigenous people (racialized and non-racialized)
• Equips white people to act against structural racism and settler colonialism
• Analyzes the ways in which anti-racism can reinforce or disrupt ongoing colonial and racist practices and processes

Types of Migrants

• Broad Term
• Immigrant
• Refugee
• Asylum Seeker

The Health of Migrants

• Pre-, Movement-, Arrival-, Return- phases all have effects on health

Challenges Facing Migrants

• Health service shortages w/ lack of records, limits
• Finances, living and working conditions, and migration of healthcare workers

Indigenous Peoples - Broad Definition

• Those who inhabited a country or region prior to the arrival of later settlers and immigrants

Indigenous Populations in Canada

• Multiple Identities / Inuit / Metis / Others / First Nations

Colonization Definition

• The process of establishing a colony or group of settlers in a new land
• Exploiting it economically
• Centrality of Medicine to the Colonial Enterprise ( spreading benefits, desire to keep settlements and workforce healthy)
• Residential Scool System and Aims included the removal from home, families, traditions and cultures; and to assimilate into the dominant culture

Impacts of Colonization

• Violence, land appropriation, oppression, loss of livelihoods/culture, negative health impacts, anti-Indigenous racism.

Health Concerns

• Changes to Lifestyle and Diet -> Cardiovascular disease / Obesity / Diabetes
• Poverty and Living Conditions ->TB / Exposure to toxins / Injuries
• Trauma Social Exclusion -> Substance abuse / Family violence / Mental health

Colonization and Food Insecurity

• Non-Indigenous Non-racialized / Indigenous / First-Nation groups

Breaking the Cycle

• Colonial system is the root - system of purposefully put beliefs among Indigenous people
• Health Care and other systems built on racist belifs
• Stereotypes are "unworthy of care"
• May include abusive interactions, denial of service, and lack of respect for cultural protocols
• Resulting in less access and poor outcomes

Determining Indigenous Health

• Financial Security/Insecurity / Housing Conditions / Water Safety / Food Security/Insecurity / Experiences of Discrimination and Injustice / Loss/Strength of Language, Culture, and Heritage / Connection to the Land / Self-Determination / Level of Access to Services

Indigenous Well-Being Determinants

• Distal: self-determination, language, land resources, racism, poverty, residential schools.
• Intermediate: health/education systems, location, early childhood, environmental stewardship.
• Proximal: employment, income, food security, social support.

Determinants of Health in Different Indigenous Communities

• Remote: reliant on hunting/fishing, food insecurity, limited education, housing quality.
• Reserve: lower public service quality, limited space, and formal governance.
• Urban: access to traditional foods/land differences.

Moving Forward

• Ongoing process between Indigenous and non-Indigenous for respectful living and Canada

Recent Events

• 2008 Formal apology for school system
• 2015 Release of TRC report
• 2016 growing
• 2019 Launched investigation in missing Indigenous women
• 2021 Unmarked graves

Indigenous/Community Protocol

Gender: Sex

• Refers to biological attributes and women/men classification

Gender: Gender

• Social construct referring to identities, roles, behaviors, and expressions with power and resource influences.

Gender Identity

• Can be personal and align or not align with their gender assigned at birth, but does have a continuum, and is seperate from sexual orientation

Gender Expression

• Express and present their gender via behavior and what that expression is understood by other according to norms

Norms, Values Affect Relations

• Shapes family, culture, media, education, the law, politics, and religion with expectations
• Influence aspects such as relationships, parenting, schooling, work, and health practices
• Can have unique exposures and vulnerabilities

Gender Concepts

• Gender Relations
• Institutionalized Gender
• Trans PULSE : all have significant findings and disparities in treatment compared to Male/Female

Mental Health Statistics

• Transgender and Gender Non-binary individuals are more liekly to have increased Depression/ Suicide / Poor Mental Health

2SLGBTQIA+

Mental Health Issues

• Feeling different from other people
• Feeling unsupported or misunderstood
• Feeling worried about coming out, and then being rejected or isolated
• Feeling pressure to deny or change their sexuality or gender expression

Additonal Issues

Health by Sex

• Can be due to biological or societal structures and their expected norms

Genders as Health Determinants

• Nutrition
• Gender-Based Violence and Sexual Abuse: Women, girls, and non-binary
• Female Genital Mutilation / selective practices
• Mental Health
• Norms of Behaviour
• GBV risk can be low SES / inequality / paternalistic cultures

Overcoming Gender Issues

Gender Mainstreaming

• Working towards systematic and consistent consideration of sex, gender, and sexuality
• Evaluating studies/policies
• Sex and Gender Based Analysis

Legislative Recognition

• Government ameded the Canadian Human Rights Act to protect individuals from discrimination and hate crimes based on gender identity and expression