Psychology

Healthy People 2010 postulates that social determinants are critical to understanding and eliminating health disparities and inequities. Social determinants include differential access to and distribution of resources, services, and structures. As noted previously, when access and distribution to resources, services, and structures is limited health inequities ensue.

The resources, services and structures that comprise the social determinants are not solely medical or behavioral, therefore Healthy People 2010 suggests that the traditional focus of health education as practiced in the United States is too narrow. Instead, they call for more equitable access to and distribution of factors including education, housing, labor, justice, transportation, agriculture and the environment, a few of the factors categorized in the literature as social determinants of health (Baker et al, 2005 Marmot  Wilkinson, 1999 Schulz  Northridge, 2004). To some this shift of focus may seem novel. However, since the early 19 century people have understood that ones social position and living conditions influence their health (Kelly, Bonnefoy,Morgan,  Florenzano, 2006). Many of the strategies employed to eliminate the spread of infectious disease had little to do with medicine and more to do with changing the environments in which people lived and worked and increasing access to nutritious food (Kelly et al., 2006).

Social determinants of health are the social, political and economic resources, services and structures that shape our living and working circumstances and ultimately influence the health of communities and individuals alike (Baker et al., 2005 Graham, 2004 Marmot  Wilkinson, 1999 Picket  Pearl, 2001 Smith, Hart, Watt, Hole,  Hawthorne, 1998). Typically, policies and practices are the mechanism through which this influence is exerted because they regulate access to and distribution of resources like money, power and social support (i.e., social determinants) across individuals and communities (Graham Schulz et al., 2005). Characteristically, the inequality in access to and distribution of these resources creates health inequities. For example, an economic policy that creates tax incentives for the creation of grocery stores in underserved areas provides access to nutritious foods. In the absence of a grocery store, many communities lack access to nutritious food options completely. Therefore, individuals living in communities with limited access are more likely to develop certain diseases (e.g., cardiovascular disease) than those that have access.

The demographic makeup of the Canada like that of the U.S. has changed dramatically in recent decades families are shrinking, highlighted by decreasing birth rates in the past generation. Death rates have also declined for quite some time (Preston 1977), creating a large cohort of individuals who live well into retirement and old age (Waite 2004). In fact, people aged 65 and older in the U.S. make up approximately 13 of the population, and this proportion is growing (Waite 2004). With a growing older population come implications of a changing demographic makeup. The increase in life expectancy may add to the number of years in which people live with illnesses and disabilities (House, Kessler and Herzog 1990 Manton 1982). Other elderly people will live better quality lives in accordance with their increased life expectancy as a resulteither way, the government is burdened with increasing medical expenses from the fastest growing segment of the countrys population, the elderly (Waite 2004).

In recent decades, the Canadian government has instituted social policies with the intent of increasing the quality of life among the elderly from an economic and health standpoint. While this intended effect has been successful in many cases, these policies have the latent effect of decreasing the amount of inequality experienced by this growing segment of the Canadian population. Specifically, Social Security and Medicare are designed to help the elderly. Social Security is structured such that the current working populations income benefits the current 65 population. Similarly, Medicare is the health insurance coverage issued by the federal government to all individuals aged 65 and above in Canada. Additionally, Medicaid provides long-term care coverage, which is an increasing proportion of states budgets (Waite 2004).

These programs specifically provide benefits to the elderly, enabling the convergence of health inequalities in old age. Using social policies to explain converging health inequalities over the life course is a macro-level explanation of the SES-health gradient. Typically, explanations of the gradient are micro-level in nature, associated with personal factors such as education, income, job status, stress, and lifestyle behaviors. Ecological explanations are less common, but not less important. Blane (1999) argues that social policies take account of life course influences. For instance, critical social transitionssuch as entering the age group of 65 and aboveidentify at-risk individuals who are likely to require frequent welfare, health, and social support. Effective policy interventions are able to prevent the accumulation of further disadvantage from past damage, and set people on a more advantaged life trajectory (Blane 1999 77). So, disadvantaged people may finally gain some advantages in old age through social policy, which has the potential to affect the trajectory of health advantages and disadvantages.

Blane (1999) also indicates that the most crucial stages of life in which social policies effect people are late middle and early old age, simply because of their impact on health and welfare expenditures. In sum, social policies serve an important role in the convergence-divergence debate over SES and health inequalities. Most likely policies, such as Social Security, Medicaid, and Medicare, have important life course effects on the health-education relationship more so in the U.S. than in Europe, where health insurance is available throughout the life course. Low socioeconomic groups have higher mortality (Hummer, Rogers, and Eberstein 1998), morbidity (Link and Phelan 1995), and disability (Molla, Madans, and Wagener 2004) than high socioeconomic groups (House, Kessler, and Herzog 1990 Kitagawa and Hauser 1973) due to unhealthy lifestyle choices such as alcohol use and smoking, unstable working conditions characterized by high stress levels and job insecurity, low levels of social support and networks, little sense of control, and exposure to physical and environmental hazards (Mirowsky and Ross 1989 Mirowsky 1999 Rogers, Hummer and Nam 2000 Mirowsky and Ross 2003).

Interestingly, little literature exists on how exposure to these risk factors affects individuals as they age. That is, at what point do health inequalities associated with risk factors between socioeconomic groups peak Do socioeconomic-based health inequalities rooted in health behaviors converge or diverge in old age House, Kessler, and Herzog (1990) investigate the issue of convergencedivergence of socioeconomic-based health inequalities and risk factors, arguing  INCLUDEPICTURE httpsapi.turnitin.comimagesspacer.gif  MERGEFORMATINET  HYPERLINK javascriptvoid(0) that the impact of risk factors on health INCLUDEPICTURE httpsapi.turnitin.comimagesspacer.gif  MERGEFORMATINET  should be the greatest in middle and early ages. These risks are greatest during middle and early old age because smoking, drinking, exposure to harmful conditions, and other factors have had years to take effect on an individual and manifest their harmful consequences at this later stage in life. While this maximum level of inequality is likely to exist between the ages of 35 and 65, it reduces after age 65 due to U.S. government assistance and a reduction of harmful exposures at this stage in life (House, Kessler and Herzog 1990). It is less common for elderly people to drink, smoke, or engage in risky behaviors as younger people do also, harmful work conditions are no longer in effect due to retirement in old age (House, Kessler and Herzog 1990). Eliminating exposures in old age may also have an additive positive effect on health. That is, reducing exposure to risk factors in old age benefits health because the elderly are more susceptible to these things in old age (House et al. 1994). By eliminating dangerous risk factors, the health status of the elderly can potentially get much better.

Education and income are closely related to the amount of exposure one has to social, psychological, and physical risk factors. Less-educated people have a greater propensity to work in an environment characterized by more demanding physical labor, greater stress due to lower job security, unsafe working conditions, longer hours, and a variety of other taxing conditions (Ross and Mirowsky 1999). The accumulation of these factors leads to heightened levels of health inequality between members of different socioeconomic groups (Molla, Madans, and Wagener 2004). Where these levels of inequality are smallest and where they are greatest is yet to be determined, although evidence exists that they do not continue throughout the entire life span (Johnson 2000).

Theories of converging inequality take four different approaches selective survival, social policy, proximity to education, and exposure to risk factors. Each of these four areas has been used as an approach in current literature to explain unique and specific ways in which the socioeconomic gradient in health is minimized in time. The selective survival (Beckett 2000 Johnson 2000 Elo and Preston 1994) and social policy (Waite 2004 Blane 1999 House, Kessler, and Herzog 1990) explanations are more recent explications. The selective survival explanation is also commonly used in literature on the racial mortality crossover in the U.S. (Johnson 2000 Preston et al. 1996 Mutchler and Burr 1991).

Alternatively, at least one theory of diverging inequality has also recently received a great deal of attention in the literature.