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
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