HS 1002

Topic: Income as a social determinant of health Video 3

Okay, so these are your learning objectives for this second week, and our focus in this
video will be on objectives one and two. When we are talking about income as a social
determinant of health, we're talking about more than money. Of course, I think that's been
clear from the last lecture. But just to reinforce that point, we're talking about the ways in
which one's access to health-enhancing or protective resources—whether that's via food,
housing, healthcare, social interaction, social activities, and social status—impacts on one's
health. Income is considered one of the most important determinants of health inequities,
alongside occupation, social class, education, race or ethnicity, and gender.

For all of these major social determinants of health, research has shown that their impacts
operate in a dose-response manner. The more one of these social determinants limits
one's access to health-enhancing or protective resources, the greater its impact on material
and psychosocial circumstances that have direct implications on health. The dose here can
be concentrated in a short period of time and harmful in that way, or its harms can be
cumulative over the life course. We're going to take a closer look at the power of income
inequities to impact on short- and long-term health impacts with a case study.

Sometimes a newspaper does something really impressive and does a series of articles
that grabs your attention and tells you, "I'm so happy that we still have journalism." *Code
Red* is one of those projects. In 2010, it was launched by the Hamilton Spectator, exploring
and explaining for a general public audience how social determinants of health were
powerfully impacting the lives of people in the southern Ontario city. The series launched
with a dramatic statistic—a 21-year difference in life expectancy between the wealthiest
neighborhoods and neighborhoods with the lowest incomes—was cited in week one in its
first article. Subsequent articles published in the series went on to outline all sorts of other
health disparities within the Hamilton region. The key drivers of health disparities identified
were poverty, access to healthcare, and education, accounting for or responsible for at
least 42% of the underlying causes of disparities between the higher and lower-income
neighborhoods.

I'm going to focus on one case study in the *Code Red* series called "Mothers Too Soon."
This article was published in 2011 and focuses on rates and experiences with teen
pregnancy in the Hamilton region. The article takes a deep dive into what it explains as a
health problem and demonstrates why teen pregnancy connects to various social
determinants, while also perpetuating social inequalities. At the time of writing the article,
Hamilton was amongst the cities in Ontario with the highest teen pregnancy rates. From
2006 to 2010, 3.5 girls aged 15 to 19 out of 100 were getting pregnant in this region of the
city. These were not the highest rates in the province. The five communities with the

page 1 of 5
 HS 1002

highest rates of teen moms at the time the article was published were located in the
Kenora district of Northwestern Ontario, where one in three births were to a teen mom. In
Hamilton, the numbers were not that high, but they were high, with several neighborhoods
reporting some of the highest urban teen pregnancy rates in the province.

The Hamilton Spectator article *Mothers Too Soon* focused on the disparity in teen
pregnancy rates between two neighborhoods. Neighborhood one is the Sherman-
Wentworth neighborhood, where from 2006 to 2010, one in seven pregnancies had been
teen pregnancies. Neighborhood two is a neighborhood in Burlington called The Orchard,
where in that same period, not one but zero teen pregnancies were reported.

So what's going on in the Sherman-Wentworth neighborhood? Why these high rates of teen
pregnancies? When we look at risky behaviors, in this case, unprotected sex—or one might
even consider becoming a teen mother risky for one's health, for reasons we're going to
look at more closely in a couple of minutes—one can think of decision-making around
taking these risks as connected to opportunity deficits in a low-income context. In this case,
some of the opportunity deficits that are identified in the *Mothers Too Soon* article
include limited support for and success in school, limited jobs in sight, good jobs to look
forward to, and also a limited sense of meaning and purpose.

There are also some attitudinal determinants for the decision to become a teen mother or
to not have an abortion in this particular population. This includes family norms and
patterns. Many of the young women who are described in this article are also born of teen
mothers, and it's quite normal within the neighborhood to be and to know teen mothers.
There's also a value of motherhood, a perceived increased value of yourself as a woman,
when and if you're in a serious relationship and you're a mother. So those are some of the
attitudinal determinants of decisions to proceed with full pregnancy to term in this
particular neighborhood, compared to other parts of Canada, where perhaps there's less
pregnancy, but there certainly are also more documented rates of abortion. So those are
different attitudes and different patterns of health seeking.

Teen pregnancy, pregnancy by someone who is 18 years old or younger, does not present
a social abnormality in many contexts. It nevertheless does present some clinically
demonstrated risks for the health and well-being of the mother and the child compared to
pregnancies in older women, and those have short- and long-term impacts on both the
mother and the child. Risks that can be faced by a teen mother include clinically inadequate
access to nutrition and prenatal care that can result in unaddressed risks such as high
blood pressure and pregnancy-induced hypertension and anemia or iron deficiency, higher
likelihoods of C-section for their deliveries, which implies risks for infections and increased
likelihoods of complications in future pregnancies. Also, having an underdeveloped body
and cervix in particular can lead to difficulties at birth and a higher risk of hemorrhage.

page 2 of 5
 HS 1002

Canadian data suggests that up to 20% of young mothers struggle with postpartum
depression, and worldwide, studies indicate that as high as 44% of adolescent mothers
develop postpartum depression, which is twice the rate of older mothers and twice the rate
of childless female teenagers. Becoming pregnant as an adolescent can further limit one's
educational and career opportunities, can render one vulnerable to dependency on
unhealthy relationships, and can increase one's stress through the additional
responsibilities.

Carlin Miller, a professor of psychology at Windsor University, notes that teen pregnancies
not only change the life course of the teen mother, but for generations afterward. And it's
important to consider the impacts of teen pregnancy on the infants and children born of
those pregnancies. Being born of a teen mother is associated with a range of health risks in
Canada, both in the neonatal period and throughout the child's life. These include risks of
visual and hearing impairment, respiratory illness, gastrointestinal issues, cerebral palsy,
learning challenges, developmental issues, as well as risks for chronic health problems
such as diabetes, hypertension, and cardiovascular disease being higher for this
population.

There are also more chances that an infant, that a child born of a teen mother, will end up
in the foster care system. Within Ontario, as this has been demonstrated, children who are
born at or under the poverty line in Canada are more likely than non-poor children to die
during the first year of life, to die after the first year from injuries, infections, violence and
asthma, to have learning difficulties, to leave school before graduating, and to experience
poor health over the course of their lifetimes.

Because the majority of children born to teenage moms are born to mothers who are
facing low-income situations, the reality is, as Dr. Chris MacKay, associate medical officer of
health in Hamilton, stated, "The reality is that children born to teenage moms don't tend to
do as well." The higher pregnancy rates for teenagers in some parts of Hamilton reflect a
wider trend across Ontario. To quote the *Mothers Too Soon* article, "Teen mother rates
are highest in places where incomes and educational achievements are low and poverty
levels are high, while low rates of teen mothers are closely linked to higher incomes, higher
levels of educational achievement, and lower poverty levels."

There is a clustering or accumulation of disadvantage that arises for those born and
subsequently living in poverty, and that accumulation of disadvantages reproduces
disadvantage in future generations, at least partially because of the way it reproduces
social inequalities in something called health capital.

page 3 of 5
 HS 1002

Health capital refers to the accumulation of health resources—both physical and

One's health capital can impact one's economic productivity, with higher health capital
being linked to increased productivity, as somebody who's healthier will generally be able
to work more efficiently, effectively, and longer. It will also impact educational attainment.
Whether you are able to perform well academically depends on your focus, whether you're
hungry, your cognitive function, and your stress levels—all of which have been shown to
increase if one has more stress linked to a lower income level. Life satisfaction and well-
being will also be part of how health capital can impact one's well-being, because one's
overall well-being and emotional health and life satisfaction can be connected to the other
two elements of health capital's impacts.

When we talk about health capital in public health, we're talking about the ways people's
capacity for health and well-being and potential for health and well-being are informed by
their past experiences. And it's a term that's often brought in within a long view on the
impacts of health inequities, one that considers the ways in which social determinants not
only have direct consequences for health now, but also generate inequities in people's
potential to access health and well-being across the life course and even across
generations.

In an earlier part of the lecture, we talked about three low-income disease mechanisms.
Pregnancy is definitely not a disease, but we can use those three mechanisms introduced
earlier as useful guides for directing our attention to the mechanisms by which low income
can—and in this case, the study of teen mothers in Hamilton—does contribute to health
risks for female adolescent mothers and their children. Whether one becomes pregnant as
a teen mom in the Sherman-Wentworth neighborhood, or one is born of a teen mom in
this neighborhood or another region of Canada marked by similar disadvantage, how being
in that position will impact your health and well-being, both in the long and short term,
cannot be disconnected from the context of living in conditions of lower income and the
negative health and social impacts that can derive from being in that situation.

So what do we do with this knowledge? We're interested in this course in getting to the root
causes of health inequities, and when we understand those root causes, we can identify
entry points and strategies for addressing these. So, in your tutorials this week, you will

page 4 of 5
 HS 1002

take a first step to applying your understanding of low-income disease mechanisms to

Okay, that's it. You've made it to the end of the second week of video lectures. See you
later. Bye.

page 5 of 5