Social Determinants of Health and the Effects of Stressful Life Events PSYC 2301A Ava Wolski November 23rd 2023 Introduction • Who am I? • Why am I here today? • Feedback Collection Learning Objectives 1 Define social determinants of health (SDH) 2 3 4 Interpret how SDH can make individuals vulnerable to negative outcomes of Covid-19 Understand how stressful life events can affect postsecondary students Identify study limitations and gaps in the literature Social Determinants of health How SDH affect covid-19 psychosocial outcomes What is a stressful life event Today's Agenda Topic 1: Passing of a loved one Topic 2: Parental Divorce Topic 3: Starting a New School Topic 4: Moving Topic 5: Covid-19 Social Determinants of Health What are Social Determinants of Health (SDH)? • Social Determinants of Health YouTube What are Social Determinants of Health (SDH)? WHO defines SDH as: 1. The non-medical factors that influence health outcomes. 2. The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. 3. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. What are Social Determinants of Health (SDH)? Examples: • • • • • • Income and social protection Education Unemployment and job insecurity Working life conditions Food insecurity Housing, basic amenities and the environment SDH can account for between 30-55% of health outcomes • Early childhood development SDH and Covid-19 The social determinants have exacerbated health differences within and across countries and during the Covid-19 pandemic. The WHO systematic review shows evidence on how disadvantaged population groups are experiencing worse health impacts of the Covid-19 pandemic Ethnic Groups Income levels (World Health Organization, 2021) Disadvantaged Ethnic Groups In general: disadvantaged ethnic groups have higher rates of infection and mortality. Studies in the UK and USA found risk ratios for infection were twice as high for “Black” people and 1.5 times as high for “Asian” people than “White” people. A systematic review on health consequences showed disadvantaged ethnic groups have more severe outcomes (e.g. respiratory difficulties, kidney failure). In Mexico, people who spoke an Indigenous language were 1.6 times more likely to be hospitalized for COVID-19 than those who did not. Poorer Populations In general: higher rates of infection and mortality Lower regional income and household poverty were associated with more hospitalizations and worse COVID-19 outcomes. Ex. In Santiago, Chile, mortality rates per 10,000 were 3 – 4 times higher in the lowest income category than in the highest. Socially Determined Causes of Inequities in COVID-19 Outcomes Poverty and deprivation Crowded housing Poor work safety Inaccessible public health communication Inequitable access to affordable health care and vaccination (World Health Organization, 2021) Poverty and Deprivation Poverty and deprivation is associated with: • reduced household resources • crowding (discussed next) • reduced access to services and support all of which are significant factors for increasing inequities. Crowded Housing Crowded housing is associated with: Increased incidence of and mortality from COVID-19 among the most disadvantaged people Poor households: large families are frequently crowded into small dwellings, hindering the ability to self-isolate and physical distance. A cross-sectional analysis of deaths in England found that relative mortality from COVID-19 was five times higher in households consisting of 9+ members. Poor Work Safety Lack of access to protective equipment in studies of the agricultural, health and care sector increase the likelihood of contracting an infection. Studies highlight that minority, migrant and female workers were most affected Less workplace protective measures were in place in rural locations compared to urban locations. Inaccessible Public Health Communication Health literacy: the ability to obtain, process, and understand health information Limited English proficiency status in the U.S. is associated with poor health outcomes and low health literacy Approximately 25.1 million individuals speak English “less than very well” and may require language assistance to access health-related care and information. (Zong & Batalova, 2015). Technology: Access to relevant information was a barrier particularly for older, poorer, rural, female and migrant populations. In Indonesia, the greatest difficulty was making the information available to students with limited information technology Inequitable Access to Affordable Health Care and Vaccination Within countries: Studies in the US showed that people who had no or low health coverage were up to 2X as likely to be admitted to the hospital for Covid-19 than those with more extensive insurance. Between countries: Immunization rates (accessed 8 July 2021) showed 25% of the world population received at least one dose of a Covid-19 vaccine but only 1% of people in lowincome countries. How Stressful Life Events Effect Post-secondary Students What is a Stressful Life Event? What comes to your mind when you hear “stressful life event”? What is a Stressful Life Event? Textbook Definition: Events that force an individual to make changes in their life; ranging from catastrophic events (passing of one’s spouse), to more mundane but still problematic events (moving to a new home). Holmes and Rahe (1967): Developed an inventory of stressful life events called the Social Readjustment Rating Scale (SRRS) to try and measure stress. They argued: when an organism is forced to make a substantial adjustment to the environment, the likelihood of stress is high. They identified: events that force people to adjust their lives and then assigned point values to demonstrate the amount of change that must be made by the individual Higher # of stressful events Increased vulnerability to illness (Taylor et al., 2020) Topic 1: Passing of a Loved One Grief Versus Bereavement Grief: “A process of having to let go, and adapting to an environment without the object of loss”. (LaGrand, 1985). Bereavement: “The term used to identify the overall experience of losing a loved one”. (Stroebe et al., 2008) Passing of a Loved one (Study 1) Effects on Academics: Undergraduate students who lost a loved one while being a student (n = 272) were administered survey with a 32 item Holistic Grief Scale that ranged from 010. Emotional : Cognitive: Disorganized Spiritual: thinking Anger Social: Rumination Anger at god sadness Withdrawal Loss of meaning Loss of interest in life Physical: Fatigue Change in appetite (Cupit et al., 2020) Results indicated that every one unit increase on the Holistic Grief Scale, increased the odds of a student answering… • Missing class increased (1.92 OR) • Stated that their GPA decrease (2.10 OR) • Considered to withdrawal from school (2.0 OR) Note*Cognitive and emotional components have the largest effect academic success Passing of a Loved one (Study 2) Goal of study: see how grief effected graduate students (n = 1575) emotions, physical wellbeing, cognitive functions, behaviors, world assumptions, and interpersonal relationships over time. Separate analyses were conducted: experiencing a loss within the past 6, 12, 24, 36 and 36+ months Results showed that the prevalence was high: 80.3% reported experiencing a loss within their lifetime 25% of their sample losing a loved one in the past 2 years. *note: pets were included (Varga, 2013) Most frequently reported effects: -Emotional affects Least reported: -Interpersonal effects -Changes in world assumptions What Domain has Longer Lasting Effects? Emotional, Physical and Cognitive Effects Behavioral and Interpersonal Effects Students who lost a loved one in the last 6 months reported significantly more emotional, physical and cognitive grief effects than students reporting loss within the last 13- 24, 25-36, and 36+ months Students who lost a loved one in the last 6 months reported significantly more behavioral and interpersonal effects than students reporting loss at 25-36 months and 36+ months No significant difference with students in the 7-12 months category No significant difference with students in the 7-12 or 13-24 months categories Let’s Discuss… What does this study tell us? • Although emotional effects are brought up most frequently at the 0-6 months mark, behavioral (crying, smoking) and interpersonal effects (feeling isolated) seem to have longer lasting effects on the individual. Why is this study not longitudinal? • Although it looks at the effects of time passage on individual grieving effects, all data is collected at the same time point. Do you see any limitations the two studies discussed? • Self-reported data: self-serving bias, not comfortable disclosing information etc. • Cross-sectional: correlation doesn’t mean causation Topic 2: Parental Divorce Metaanalysis Metaanalysis What is a meta-analysis? • “A statistical technique for combining the results from two or more studies, which addresses a similar hypothesis in a similar way”. • Describes results of each study via a quantitative index of effect size (Kang, 2015). What is an effect size? • Represents the magnitude of a change in an outcome or the strength of a relationship between two variables (Peterson & Foley, 2021) . • Examples: Cohen’s d and Pearson’s r. Some use odd ratios. Topic 2: Parental Divorce (Study 1) Goal of meta-analysis: Investigate long-term effects of parental divorce on mental health Data: 54 studies and 117 effect sizes n = 506,299 Eligibility Criteria: 1. Age of 18 years or above when asked. 2. Parental divorce took place before the children turned 18. (Auersperg et al., 2019) Significant positive associations between parental divorce and the following were found: 1. Depression 2. Anxiety 3. Suicide attempt 4. Suicidal ideation 5. Distress 6. Alcohol 7. smoking 8. Drugs Demonstrates that there is consistent evidence regarding the long-term effects of parental divorce on the children Reducing the Negative Effects of Parental Divorce Students of divorced parents (divorce occurring between 8-18) report more: - Antisocial behavior - Anxiety Protective factors: Parental support during childhood Current family cohesion Friend support - Depression than students of married parents and of deceased parents. All significantly negatively related to their reports of antisocial behavior, anxiety, and depression (Short, 2022) Effects on Education: Soria and Linder (2014) found first year students (n = 4,693) whose parents were divorced were significantly less likely to continue onto second year and had lower GPA’s on average then their fellow peers. Effects on Relationships: Mohi (2015) explored the effects of parental divorce on young adults’ ability to form and maintain romantic relationships. A mixed study design collected survey data from 233 university students in addition to faceto-face interviews (n = 10) have unique findings Quantitative Data 45.5% of students experienced at least one divorce. 15% of respondents reported feeling relieved, relaxed, or happy at the time of their parents’ divorce. No impact on: Young adults’ attitudes towards relationships. How respondents’ romantic relationships would turn out Qualitative Data: Most common theme: Participants try to perform better in their own relationships by learning from their parents’ mistakes rather than repeat them Casey reminds herself to take things slow as her parents got married way to quickly and ended up divorced Many mentioned they wanted to have better communication skills than their parents Topic 3: Starting a New School Starting a New School (Study 1) Bewick and colleges (2010), investigated the psychological well‐being of UK university students (n = 24,234) across their undergraduate degree from pre‐registration to third year. Methodology: Cross-sectional: Most students only participated in one survey per academic year (n = 14,555 surveys) Longitudinal: Students responded to all surveys within an academic year T1–T2–T3 T4–T5 T6–T7 The survey: 14 items pertaining to subjective well‐being, symptoms (anxiety, depression and physical problems) and life functioning. Year one: Psychological well‐being decreased significantly from pre‐registration to sem.1, and then slightly increased again in sem.2. Year two: Psychological well‐being was slightly poorer during sem.2 compared to sem.1 Note: Higher scores on the GP‐CORE indicate higher levels of psychological distress Year 3: Psychological well‐being was poorer during sem.2 compared to sem.1 Overall: Largest changes in psychological well‐being were between: 1. Pre‐registration and sem. 1 2. Year 2 and year 3 Psychological well being never restores to pre-registration levels Starting a New School (Study 2) Cloney et al. (2020) conducted a longitudinal study to examine the multiple aspects of adjustment in college students (n = 5,532). Data was collected from 2 weeks before starting college and at the end of each of academic years. (Total of 5 time points) Psychological functioning • self-esteem • psychological distress depression, anxiety, and stress Cognitive-affective strategies • active emotional coping • avoidant emotional coping Social well-being • social support from friends Psychological Functioning Domain Self-esteem: Psychological distress: Rosenberg Self-Esteem Scale Depression Anxiety Stress Scale-21 This 10-item Likert-type scale is measured from 0 (strongly disagree) to 3 (strongly agree) This 21 item Likert-type scale from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time) “On the whole, I am satisfied with myself” “I couldn’t seem to experience any positive feeling at all” Results for Self-Esteem Men and woman Significantly worse self-esteem from T0 to T1 and from T1 to T2. Significantly improved self esteem from T3 to T4 Men Higher self esteem on average at all time points, although they begin to converge in year 4. No significant difference between time 2 and 3 Woman Significant improvements in self esteem between T2 and T3 Return to their baseline levels of self-esteem Results for Psychological Distress Men and Women Increase in depression, anxiety, and stress from: T0 and T1 T1 and T2 Women Decrease in depression, anxiety and stress from T2 to T3 Plateau from T3 to T4 Men: Plateau from T2 to T3, Improvement from T3 to T4 Overall: Depression, anxiety, and stress never returned to baseline levels Cognitive-Affective Strategies Domain: Active Emotional Coping Avoidant Emotional Coping Brief COPE subscales is 10-item Likert-type scale from 1 (I usually don’t do this at all) to 4 (I usually do this a lot). Brief COPE subscale used. Topics include: Topics include: Cognitive-Affective Strategies Domain: Active Emotional Coping Avoidant Emotional Coping Brief COPE subscales is 10-item Likert-type scale from 1 (I usually don’t do this at all) to 4 (I usually do this a lot). Brief COPE subscale used. Topics include: Venting, positive reframing, humor, acceptance, and emotional support. Topics include: Self-distraction, behavioral disengagement, self-blame, denial, and substance use. “I say things to let my unpleasant feelings escape” “I say to myself ‘this isn’t real’” “I give up the attempt to cope” Results for Active Emotional Coping Results for Active Emotional Coping Overall Decline in active emotional coping from: T0 to T1 T1 to T2 Plateau between T2 and T3 Improvement from T3 to T4 (Returns to baseline) Woman Always used active emotional coping more in comparison to men Results for Avoidant Emotional Coping Men and Woman Increase in avoidant emotional coping from: T0 to T1 T1 to T2 Women Decrease from T2 to T3 Plateau from T3 to T4 Men Continue to show a significant increase in avoidant emotional coping. Social Well-Being Domain: Social support The 7-item friends Likert-type subscale that ranges from: 1 (strongly disagree) to 4 (strongly agree) Questions reflected perceived social support from friends. “My friends respect me” “I can rely on my friends” Results from Social Support Men and woman Decrease in perceived support from: T0 to T1 T1 to T2 Increase from T2 - T3 Women Continues to increase from T3 - T4 Men Plateau during Time 3 -4 The Authors’ Take-Home Message • There is a general worsening of psychosocial adjustment to starting college over the first 2 years, followed by some improvement in the following 2 years. • Thus, the transition to college might best be viewed as a 2-year challenge, with the following years giving an opportunity for students to grow and recover. Let’s Brainstorm… • What can institutions do to reduce the psychological distress associated with the initial transition to school? What programs can be implemented? What can teachers do? Let’s Brainstorm… • What are some other factors that may have an effect or influence an individual's initial adjustment to post-secondary school? (Think SDH) Topic 4: Moving Movin g Effects on School Adjustment: Students who moved away from home to attend university had lower overall adjustment to university scores compared to students who did not move (Mcdonald et al. 2018). Timing Matters for Mental Health: Residential mobility during different developmental stages (i.e., early childhood, late childhood, and adolescence) have long term effects on university students’ mental health and academic performance (Li et al., 2019). Data:3753 first-year students from a university in mid-West of China. Results: Moving in late childhood (ages 6-12) and in adolescence (12+) predicted poorer mental health, while early childhood did not. Buffer: High family income King and colleges (2011), focused on the health and well-being of first year health-science students. Compared differences between relocators (n = 43) and non-relocators (n = 88). Relocators were more likely to indicate: A decline in diet: increased snacking and takeaway food A decline in exercise A higher incidence in poor sleep quality A higher incidence in stress and anxiety Increased loneliness A decline in overall mental and physical health Let’s Discuss… Did you notice any differences in your eating/exercising habits after coming to university? Have they improved in second year? What are some ways to increase health behaviours in student populations? Topic 5: Covid-19 Covid-19 (Study 1) Goal of study: to establish early estimates of the effect of the Covid-19 pandemic on anxiety and depression symptoms of first year students. Data: Longitudinal data to compare pre-covid and during covid (n = 419) • Wave 1: October/November 2019 • Wave 2: June/July 2020 (roughly 4 months after the start of the pandemic) (Fruehwirth et al., 2021) Prevalence Rates Anxiety: The prevalence rate of moderate-severe anxiety symptoms increased from 18.1% - 25.3% That’s a 40% increase! Depression: The prevalence rate of moderate-severe anxiety symptoms increased from 21.5% - 31.7% That’s a 54% increase! Covid-19 (Study 2) Goal of meta-analysis: “Provide estimates of the global prevalence of clinically elevated depression and anxiety symptoms during the COVID-19 pandemic among postsecondary student samples”. Data: 176 studies, n = 1,732,456 Pooled Prevalence of Clinically Elevated Depressive Symptoms: 30.6% Pooled Prevalence of Clinically Elevated Anxiety Symptoms: Prevalence was lower in East Asia Prevalence was lower in East Asia Every 1- month increase, results in a 0.16% increase in depression prevalence Every 1- month increase, results in a 0.18% increase in anxiety prevalence (Zhu et al. 2021) 28.2% Covid-19 (Study 3) A four-wave longitudinal study on French university students (n = 91) highlighted the negative effects of lockdowns specifically. April 23rd - May 8th 1st National Lockdown June 9th-23rd After Lockdown Both anxiety and depressive symptoms were highest during T1 and T4 October 23rd 12th- When University was Open November 20th – December 11th 2nd National Lockdown Anxiety specifically rose during T3 and remined high during T4 (Charbonnier et al. 2021). Thank you QUESTIONS & FEEDBACK https://www.surveymonkey.com/r/58DPG7L