GLPH271 M04 OL-BL OnQ CompanionGuide

GLPH 271
GLOBAL AND POPULATION HEALTH
MODULE 04
CLOSING THE GAP IN HEALTH
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MODULE 04 COMPANION GUIDE GLPH 271
TABLE OF CONTENTS
INTRODUCTION ..................................................................................................................................................... 6
A. Closing the Gap in Health ............................................................................................................................ 6
B. Dr. Carpenter’s Acknowledgement of Territory ........................................................................................ 7
C. Module Introduction..................................................................................................................................... 9
D. Course Icons ................................................................................................................................................10
E. Learning Outcomes.....................................................................................................................................11
F. Module Assignments ..................................................................................................................................12
F.1 Gap in Health Discussion .....................................................................................................................13
F.2 Political Empowerment Discussion Board .........................................................................................14
F.3 Video: Assessment Part 2 .....................................................................................................................15
G. Question 1 of 2: Preliminary Discussion of Course Themes .................................................................16
H. Question 2 0f 2: Preliminary Discussion of Course Themes .................................................................17
I. Module Outline .............................................................................................................................................18
SECTION 01: The Gap in Global Health and Social Determinants of Health ................................................19
1.1 Section 01: The Gap in Global Health and Social Determinants of Health ........................................19
1.2 Video: Measuring and Assessing Health ................................................................................................20
1.3 Advocating for Health at a Global Level .................................................................................................21
1.4 Question: Advocate versus Scientist .......................................................................................................22
1.5 Communicating about Global Health .....................................................................................................23
1.6 The Gap in Global Health .........................................................................................................................24
1.7 Interaction: Life Expectancy Across the Globe ......................................................................................25
1.8 Question: Communicating about Global Life Expectancy ....................................................................26
1.9 Social Determinants of Health.................................................................................................................27
1.10 Social Gradient ........................................................................................................................................28
1.11 A Closer Look Into the Social Gradient .................................................................................................29
1.12 Question: Social Gradient and the S D Hs............................................................................................30
1.13 Video: The Poverty Trap .........................................................................................................................31
1.14 Interaction: G D P Per Capita Across the Globe ..................................................................................32
1.15 Section 01 Summary ...............................................................................................................................33
SECTION 02: The Closing The Gap Report ........................................................................................................34
2.1 Section 02: The Closing the Gap Report .................................................................................................34
2.2 Closing the Gap and the Social Determinants of Health ......................................................................35
GLOBAL AND POPULATION HEALTH | GLPH 271 M04 PAGE 2

2.3 Podcast: W H O Closing the Gap in a Generation Report .....................................................................36
2.4 Question 1 of 3: Gaps in Global Health ..................................................................................................39
2.5 Question 2 of 3: Social Determinants of Health ....................................................................................40
2.6 Question 3 of 3: Understanding of Health .............................................................................................41
2.7 Goals of Closing the Gap in a Generation ..............................................................................................42
2.8 Section 02 Summary .................................................................................................................................43
SECTION 03: Closing The Gap By Improving Living Conditions .....................................................................44
3.1 Section 03: Closing the Gap by Improving Living Conditions ..............................................................44
3.2 Goal 1: Improve Daily Living Conditions .................................................................................................45
3.3 Housing and Home Environment............................................................................................................46
3.4 Video: Harsh Living Conditions of Syrian Refugees ..............................................................................47
3.5 Question: Impact of Poor Living Conditions on Health ........................................................................49
3.6 Living Conditions on Indigenous Reserves ............................................................................................50
3.7 Early Childhood Development & Health ................................................................................................51
3.8 The Jamaican Study...................................................................................................................................52
3.9 Employment and Working Conditions....................................................................................................54
3.10 Question 1 of 2: COVID-19 and Employment ......................................................................................55
3.11 Question 2 of 2: COVID-19 and Employment ......................................................................................56
3.12 Case: Migrant Work and Early Childhood Health & Development ....................................................57
3.13 Question 1 of 2: Mobile Creches Program and Health Outcomes of Children ...............................58
3.14 Question 2 of 2: Mobile Creches Program and Health Outcomes of Children ...............................59
3.15 Neighbourhood and Natural Environment ..........................................................................................60
3.16 Video: The Healthy Cities, Healthy Communities Movement ............................................................61
3.17 Urbanization and Health ........................................................................................................................62
3.18 Question: Impact of Climate Change Across the Globe .....................................................................65
3.19 Governments and Social Policies ..........................................................................................................66
3.20 Social Protection Across the Lifecourse ...............................................................................................67
3.21 Question: The Feasibility of Social Security .........................................................................................68
3.22 Video: Universal Healthcare Policy .......................................................................................................69
3.23 Racial Inequality in Healthcare ..............................................................................................................70
3.24 Video: The A B C Project .........................................................................................................................71
3.25 Section 03 Summary ...............................................................................................................................72
SECTION 04: Closing The Gap By Addressing Inequities ................................................................................73

4.1 Section 04: Closing The Gap By Addressing Inequities.........................................................................73
4.2 Goal 2: Addressing Inequities ..................................................................................................................74
4.3 Optimal Healthcare Systems ...................................................................................................................75
4.4 Health Inequity in the Canadian Indigenous Population .....................................................................76
4.4.1 Access to Quality Nursing Stations ..................................................................................................77
4.4.2 Video: A Locum Nurses Perspective ................................................................................................79
4.4.3 Access to Medical Transportation ...................................................................................................80
4.4.4 Video: Challenges to Increasing Medical Transportation .............................................................82
4.4.5 Support Allocation and Comparable Access ..................................................................................83
4.4.6 Addressing Support Allocation and Comparable Access ..............................................................84
4.5 Actions to Enhance Health Equity in Indigenous Populations .............................................................86
4.6 Equitable Health Policies ..........................................................................................................................87
4.7 Intersectoral Action for Health (I S A) .....................................................................................................88
4.8 Market Responsibility ...............................................................................................................................89
4.9 Video: Social Goods Governed by the Public Sector .............................................................................90
4.10 Gender Equity..........................................................................................................................................91
4.11 Video: Empowering Women ..................................................................................................................92
4.12 Gender Inequality in Healthcare ...........................................................................................................94
4.13 Political Empowerment ..........................................................................................................................96
4.13.1 Top Down and Bottom Up Approaches ........................................................................................97
4.13.2 Political Empowerment: An Example ............................................................................................98
4.13.3 Top Down Promotes a Bottom Up Approach ........................................................................... 100
4.14 Addressing Inequities Through Policy ............................................................................................... 102
4.15 Goal 3: Measuring and Monitoring Health ....................................................................................... 103
4.16 Putting the Recommendation into Practice...................................................................................... 104
4.17 Barriers and Enablers .......................................................................................................................... 105
4.18 Section 04 Summary ............................................................................................................................ 106
CONCLUSION .................................................................................................................................................... 107
Z Z.1 Module 04 Conclusion ........................................................................................................................ 107
Z Z.2 Question: Informed Discussion of Course Themes ........................................................................ 108
Z Z.3 Question: Informed Discussion of Course Themes ........................................................................ 109
Z Z.4 Question Review: Discussion of Course Themes ............................................................................ 110
Z Z.4.1 Discussion of Course Themes: 01 .............................................................................................. 111

Z Z.4.2 Discussion of Course Themes: 02 .............................................................................................. 112
Z Z.5 Module Conclusion ............................................................................................................................. 113
Z Z.6 Credits .................................................................................................................................................. 114
Z Z.7 Module Outline ................................................................................................................................... 115

INTRODUCTION
A. CLOSING THE GAP IN HEALTH

B. DR. CARPENTER’S ACKNOWLEDGEMENT OF TERRITORY
1 OF 8
My gratitude and connection to the land carries me through each day and nourishes my soul. I
recognize that I am the sum of my experiences and that my relationship to the land is steeped in my
attachment to three locations, and the three Nations who cared for the land before the arrival of my
ancestors and still care for it today.
As far back as I can recall, I remember being drawn to a mound in the woods, near my summer home
which is on traditional St-Lawrence Iroquoian territory. I often found myself sitting or dancing there
and revelling in the strength and delight that it brought me. My moments in that place are my first
memories of truly feeling one with the land. When I think back to those times, I can still reproduce the
overwhelming awe and reverence that I felt to those that walked there before me. I remember the
smell of the forest, the brush of the breeze, and the land, supporting me as I thrived, and giving me
strength on difficult days.
Since that time, the strength provided by land beneath my feet, the nourishment that it provides to my
body and soul, and the freedom I feel from the water of its lakes and rivers, have played an important
role in my personal growth.
More recently, I have been privileged to be welcomed to the territory of the Chagga People, in
Tanzania. This land, on the slopes of Kilimanjaro, and its keepers, have brought me peace and the
energy to advocate for health equity in Tanzania and at home.
Kingston, which is on traditional Anishinaabe and Haudenosaunee territory, has welcomed me,
provided me a home and supported me as I raised my children. The beauty and strength of these
lands can be felt in the trees that stand tall and the waters that glisten in the sun.
I acknowledge colonialism, past and present, and I strive to embrace diversity and act in ways that
promote healing. I recognize the atrocities that were born out of greed and lack of humility and I strive
to enable reconciliation.

The land gives us life. We choose how to live it. I choose to live it in reverence and gratitude to the one
who created all of it, and to those that walked the earth before me, and with me now, with humility,
empathy and gratitude. I commit to doing my best to disrupt and dismantle the colonial structures that
still exist today.
Learn more about usage of land acknowledgements at Queen’s University, and a history of the traditional
Anishinaabe and Haudenosaunee territory.
Land Acknowledgements at Queen’s University
Page Link:
https://www.queensu.ca/indigenous/land-acknowledgement
Reference:
Land Acknowledgement. (n.d.). Retrieved August 25, 2020, from

https://www.queensu.ca/indigenous/land-acknowledgement

C. MODULE INTRODUCTION
2 OF 8
In Module 04, you will revisit the social determinants of health and identify important concepts related
to closing the gap in health between high-income and low-income countries. This module outlines key
findings from the 2008 Closing the Gap in a Generation report, which was aimed at drastically
diminishing health inequities between the wealthy and those living in poverty, in one generation. You
will explore how improving living conditions and addressing other inequities, like social security, can
positively impact and equalize health and healthcare access.
This module will prepare you to complete Assessment 02, in which you conduct a Health Needs
Assessment for a population.
Read a unique back-story relating to each image.
Alt Text: Patients waiting for us to arrive for the mobile clinic.
Image 1: My daughter, Sid, painting with children at the Pamoja Boys and Girls Club.
Image 2: Dr. Karen Yeates and Dr. David Walker examining a patient with a Canadian learner and their
interpreter.
The cover image, the images on the introduction and conclusion slides, along with numerous images in
the module were taken during Dr. Carpenter's trips to Tanzania. In a lot of the images, Dr. Carpenter
can be seen providing health services to the people of Tanzania, and interacting with locals and their
culture.

D. COURSE ICONS
3 OF 8
Note that as you navigate this course, you should watch for specific features.
Learn about each icon’s function in this course.
Course Toolbox
This icon lives in the sidebar of your module. Clicking it will open the Tools so you can write notes or
magnify your screen. For more information, visit the Module F A Q.
References
This icon lives in the sidebar of the slide. Clicking it will reveal the references for content and/or images
on the slide.
Listen Up!
Clicking this icon will allow you to hear audio clips from subject matter experts. Captions will appear on
the slide.
Additional Sources
This icon lives in the sidebar. When clicked, it will reveal additional sources provided to supplement
your learning
Equation
Clicking this icon will reveal relevant equations.
Definitions
When you see a word that is bold and coloured orange, hover over it to reveal a definition.

E. LEARNING OUTCOMES
4 OF 8
After successful completion of this module, students will be able to:
• Understand what the global gap in health is and why it needs to be addressed.
• Identify examples of gaps in global health and gaps in health in your own community (home or
school).
• Recognize that health inequities arise because of inequities in the determinants of health.
• Research a top-down (policy) or a bottom-up (grassroots) approach to political empowerment that
addresses a health-related problem.

F. MODULE ASSIGNMENTS
5 OF 8
Activities throughout the module:
Note that text responses and interactions will not be graded unless otherwise notified. However, they
are recorded in the module and viewable by your instructor. For any questions slides, you will not be
able to navigate forward until after you submit a response for the question.
Learn more about the Module 04 assignments.
Section 02: Gap in Health Discussion (Week 7) – Refer to F.1 Gap in Health Discussion Sub Page
Section 04: Political Empowerment Discussion (Week 8) – Refer to F.2 Political Empowerment
Discussion Board Sub Page
Assessment Part 2: Health Needs Assessment – Refer to F.3 Video: Assessment Part 2 Sub Page

F.1 GAP IN HEALTH DISCUSSION
SUB PAGE OF F. MODULE ASSIGNMENTS

SECTION 02: DISCUSSION BOARD
1/1
Based on the information you will learn in this module, there will be a discussion board focused on
identifying gaps in health due in week 7.
You will post a one paragraph response about one example of a gap in health you have witnessed in
your community. To protect the privacy of people in your community, please do not include the names
or any other identifying information of community members.
As you work through the module, consider the following question:
• What is a gap in health you see in your own community (home or school)?

F.2 POLITICAL EMPOWERMENT DISCUSSION BOARD

SECTION 04: DISCUSSION BOARD
1/1
Based on the information you will learn in this module, there will be a discussion board focused
on political empowerment due in week 8.
As you work through the module, think about both top-down (policy) and bottom-up (grassroots)
political empowerment approaches. You will need to select a top-down or a bottom-up approach to
political empowerment to research. In your research, identify:
• The approach being taken

• The health-related problem being addressed
• The proposed solution
• How the solution will be measured/monitored (if applicable)
You will post a two to three paragraph summary of your research to the Discussion Board, Political
Empowerment. You will need to read and respond to at least one colleague who researched a different
approach. For example, if you researched a top-down approach, read and respond to a colleague who
researched a bottom-up approach.

F.3 VIDEO: ASSESSMENT PART 2

PART TWO: VIDEO ASSESSMENT
1/1
For Assessment Part 2, you will perform a needs assessment of a chosen population. This will allow you
to effectively quantify a health need of the population, identify possible root causes of the health need,
and begin to consider barriers and enablers to addressing those causes.
For more information about this assignment please see the Assessment tab in your online learning
environment.
Watch the video of Dr. Jenn Carpenter explaining Assessment Part 2: Health Needs Assessment.
Health Needs of a Population [2:08].
Page Link:
https://player.vimeo.com/video/218624330

G. QUESTION 1 OF 2: PRELIMINARY DISCUSSION OF COURSE THEMES

Activity: Text Entry
Please see the online learning module for the full experience of this interaction.
6 OF 8
Based on your current knowledge of global health and disease, answer the question.
1 of 2: Explain the current gaps in global health.

Feedback:
Please navigate to the next page.

H. QUESTION 2 0F 2: PRELIMINARY DISCUSSION OF COURSE THEMES

7 OF 8
Based on your current knowledge of health measurements, answer the question.
2 of 2: Why do these gaps in global health exist, and why do they need to be addressed?
Feedback:

I. MODULE OUTLINE
8 OF 8
Review a short description for each of the sections.
SECTION 01: The Gap in Global Health and Social Determinants of Health
In this section, you will learn the differences between communicating global health issues as an advocate
versus as a scientist. You will also learn about the health inequities, such as differences in life expectancy,
that exist between low S D I and high S D I countries.
SECTION 02: The Closing the Gap Report
In this section, you will discuss the Closing the Gap in a Generation report established by the W H O to
minimize health inequities, by targeting the social determinants of health.
SECTION 03: Closing the Gap by Improving Living Conditions
In this section, you will explore the five main ideas for improving of living conditions, as outlined by the
Closing the Gap in a Generation report.
SECTION 04: Closing the Gap by Addressing Inequities
In this section, you will read about the four pillar primary healthcare model that makes up an optimal
policies in shaping health and the benefits of intersectoral action for health.

SECTION 01: THE GAP IN GLOBAL HEALTH AND SOCIAL DETERMINANTS OF HEALTH
1.1 SECTION 01: THE GAP IN GLOBAL HEALTH AND SOCIAL DETERMINANTS OF HEALTH

1.2 VIDEO: MEASURING AND ASSESSING HEALTH
1 OF 14
In Module 01, you learned about the social determinants of health (S D Hs), and how aspects of one's
identity, such as race, gender, income, and education can impact their health and well-being. The S D
Hs are closely related to the gap in global health. In 2005, the Closing the Gap Commission was set up
by the W H O as a call for action to address these social issues and achieve global health equity.
Watch the video of Dr. Jenn Carpenter discussing the gap in global health.
Closing the Gap in Global Health [2:00]
Page Link:

1.3 ADVOCATING FOR HEALTH AT A GLOBAL LEVEL
2 OF 14
Recall from Module 01 that there are three levels of advocacy: individual, community, and global
advocacy. The content and strategies in this module specifically focus on global advocacy.
As you navigate through this module and begin thinking about advocacy on a global scale and
advocating for global health, consider these questions:
1. What health needs exist?

2. What is the ideal health state we want to achieve?
3. What are possible health interventions?
4. What are ways to measure and monitor whether the health interventions are working?
References:
Complex systems analysis: Towards holistic approaches to health systems planning and policy. (2011,
April 01). Retrieved from https://www.who.int/bulletin/volumes/89/4/11-087544/en/
Holistic. (n.d.). Retrieved August 19 2019 from: https://www.merriam-webster.com/dictionary/holistic
Richmond, C. A., Ross, N. A., & Bernier, J. (2007). Exploring Indigenous concepts of health: The
dimensions of Métis and Inuit health.

1.4 QUESTION: ADVOCATE VERSUS SCIENTIST

3 OF 14
Although there are noticeable differences between science and advocacy, the two often work together
toward a common goal.
Answer the question regarding communication about global health.
Why is it important to communicate about global health issues as both an advocate and as a
scientist? How do these roles overlap?
Feedback:
Advocacy and science go hand in hand. We must leverage the scientific findings and hard data to
demonstrate and prove the health inequities that exist. Once we are able to prove that these inequities
exist, the role of the scientist and advocate are still collaborative. Advocates and scientists can work
together to come up with implementable strategies and interventions to help eliminate these
inequities. After their implementation, scientists can test the success of these interventions. The
collaboration between scientists and advocates is a continual and iterative process.

1.5 COMMUNICATING ABOUT GLOBAL HEALTH
4 OF 14
In order to demonstrate global health status and show that health inequities exist, scientific data is
used as evidence. Advocacy involves communicating scientific data to inform awareness about global
health issues.
Reveal some of the differences between communicating as an advocate and communicating as a scientist.
Advocacy Science
State your conclusions first, then support them. Build your case gradually before presenting
1
conclusions.
Limit the number of messages. Several points can be made in single research
2
paper.
Too many facts and figures overwhelm the Supporting evidence is vital.
3
audience.
Extensive qualifications can overwhelm the Extensive qualifications can be necessary for
4
audience. scholarly credibility.
Technical jargon can confuse people. Technical jargon can add greater clarity and
5
precision.
Simplification is preferable. 6 Detailed explanations are useful.
Quick, but accurate, preparation and action are Hastily prepared presentations can be
often necessary to take advantage of 7 discredited.
opportunities.
Present a passionate and compelling argument Be objective and unbiased.
8
based on facts.
References:
Complex systems analysis: Towards holistic approaches to health systems planning and policy. (2011,
April 01). Retrieved from https://www.who.int/bulletin/volumes/89/4/11-087544/en/
Holistic. (n.d.). Retrieved August 19 2019 from: https://www.merriam-webster.com/dictionary/holistic
Richmond, C. A., Ross, N. A., & Bernier, J. (2007). Exploring Indigenous concepts of health: The
dimensions of Métis and Inuit health.

1.6 THE GAP IN GLOBAL HEALTH
5 OF 14
The gap in global health can be described as the health inequities that exist between wealthy and
impoverished populations. Populations with the lowest income have high levels of illness and
premature mortality.
Reveal the corresponding percentage of deaths attributed to each disease.
Notice the disease gradient; the low-income countries have more deaths associated with each disease.
Percentage of Total Deaths Caused by Income-Related (Group I) Diseases

% of total deaths 2019 Low-Income Countries High-Income Countries
Enteric Infections 8.18 0.39
H I V, A I Ds, and other S T Is 5.57 0.26
Other Infectious Diseases 5.39 0.22
Respiratory Infections 11.72 2.01
Maternal and Neonatal Conditions 17.79 1.16
Nutritional Deficiencies 3.58 0.48
Neglected Tropical Diseases and Malaria 8.57 0.074
Total 58.05 4.60
References:
Lightman, E., Mitchel, A,. & Wilson, B. (2008). Poverty is making us sick: A comprehensive survey of
income and health in Canada. Wellesley Institute. Retrieved from
http://www.wellesleyinstitute.com/wp-content/uploads/2011/11/povertyismakingussick.pdf
GBD Compare. (n.d.). Retrieved December, 2020 from https://vizhub.healthdata.org/gbd-compare/

1.7 INTERACTION: LIFE EXPECTANCY ACROSS THE GLOBE
6 OF 14
One example of a gap in global health is the stark difference in life expectancy at birth. Life expectancy
at birth varies depending on the country you are born in. In 2018, the lowest average life expectancy
for any country was 53 years, while the highest was 85.
Compare life expectancy values between countries in 2018 by using the map.
Page Link:
https://data.worldbank.org/share/widget?indicators=SP.DYN.LE00.IN&view=map&year=2018
Reference:
The World Bank. (n.d.). Life expectancy at birth, total (years). Retrieved November, 2020 from
https://data.worldbank.org/indicator/SP.DYN.LE00.IN?view=map

1.8 QUESTION: COMMUNICATING ABOUT GLOBAL LIFE EXPECTANCY

7 OF 14
Using what you have learned from the gradient of disease table and the life expectancy map, answer the
question.
What is the trend you see in life expectancy rates between different countries?
Feedback:
People who live in high income countries tend to have greater life expectancy and lower levels of
illness, whereas people who live in low income countries tend to have higher levels of illness and
premature mortality. As of 2018, the average life expectancy for the world is 73. For high income
countries life expectancy is 81 years, middle income countries 72 years, and low income countries only
63 years.

1.9 SOCIAL DETERMINANTS OF HEALTH
8 OF 14
The gap in global health exists because of social determinants. The social determinants of health are
the circumstances in which people grow, live, work, and age, and their accessibility to healthcare, all of
which allow them to deal with illness.
Pause to think about what factors might influence the health of an individual. Then, reveal some social
determinants of health that impact health on an individual level.
Individual
• Unemployment and Job Security

• Gender
• Indigenous Status
• Disability
• Housing
• Early Life
• Income and Income Distribution
• Education
• Race
• Employment and Working Conditions
• Social Exclusion
• Food Insecurity
• Social Safety Net
• Health Services

1.10 SOCIAL GRADIENT
9 OF 14
In Module 01, you learned that as wealth increases so does health, in a stepwise fashion. Consistently,
it is observed that individuals living in extreme poverty have worse health compared to those who are
wealthy. This concept is called the social gradient and is a global phenomenon that occurs both
between and within countries.
Poverty can affect health both directly and indirectly. When living in poverty, it is challenging for
individuals to buy healthy foods, or attain clean and safe living conditions, negatively impacting their
underlying health. Other indirect consequences of poverty include the stressors that are placed on
individuals; which can include the mental burden of financial stress, and the feeling of lacking support.
As you might recall from Module 01, there are a number of health-promoting conditions that
are lacking in Indigenous communities in Canada. The social gradient is found across the globe
and Indigenous populations are not exempt. For example, in 2009 the unemployment rate for
Indigenous People in Canada was double that of the general population. Of those that found
employment, the majority were labour intensive positions. Consider the effect that this would
have on health.
Reference:
Adapted from Statistics Canada. Table 13-10-0097-01 Health characteristics, annual estimates, by
household income quintile and highest level of education. Retrieved November 2020 from,
https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009701

1.11 A CLOSER LOOK INTO THE SOCIAL GRADIENT
10 OF 14
The work environment plays a crucial role in the perpetuation of the social gradient. Just having a job
and earning an income does not guarantee that people will experience greater health outcomes. In the
study illustrated in the figure, those who are employed can be further broken down into various “social
classes” based on education level and occupational position (management versus front-line). Of these
individuals, the lowest income earners tend to work more labour intensive jobs that contribute to poor
health, and this is often attributed to the role and contribution of various physical and psychosocial
working conditions.
As you review the graph, notice how the lower social classes tend to work in fields and hold jobs that
are more dangerous (i.e. more prone to injuries), more physically demanding, and have inflexible work
hours. As you can imagine, such working conditions are less conductive to good health.
Alt Text: Adverse working conditions negatively associated with social class.
References:
Kim, P. J. (2019). Social Determinants of Health Inequities in Indigenous Canadians Through a Life
Course Approach to Colonialism and the Residential School System. Health Equity, 3(1), 378-381.
Retrieved December, 2020 from https://www.liebertpub.com/doi/10.1089/heq.2019.0041
Hämmig, O., & Bauer, G. F. (2013). The social gradient in work and health: a cross-sectional study
exploring the relationship between working conditions and health inequalities. BMC Public Health,
13(1), 1170. Retrieved from, https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-
13-1170

1.12 QUESTION: SOCIAL GRADIENT AND THE S D HS

11 OF 14
On the previous slides, you explored how inequalities in social status translate to inequalities in health
at the population level.
Based on your understanding of the social gradient in health, answer the question.
What are some additional ways in which differences in socioeconomic status might affect
health?
Feedback:
Dr. Carpenter’s Response:
Individuals with a lower level of education are less likely to get a job and be financially stable in the
future. Educated individuals also have more access to health-promoting information and resources.
A lack of culturally sensitive healthcare services prevent racialized individuals from receiving all the
benefits of care. This is particularly relevant in ethnic and racially diverse countries like Canada.
Low-income individuals are more likely to be exposed to the harms of climate change such as floods
and droughts.

1.13 VIDEO: THE POVERTY TRAP
12 OF 14
The poverty trap is the mechanism that explains how individuals who are in poverty are trapped in
poverty unless an external force intervenes by providing them with a significant amount of money and
resources. The actions of those who are in poverty become self-reinforcing mechanisms that will keep
them in poverty. For instance, if an individual working a low-paying job increases their working hours to
make money for essential needs, they are more likely to get sick and have less time to improve their
skills for a better job.
Watch the video to learn more about The Poverty Trap.
The Poverty Trap [3.30]
As you watch, think about what government policies and support are required to help those in poverty
break out of the poverty trap.
Page Link:
https://www.youtube.com/embed/KxjW-HU1BCM
References:
Chen, J. (2020). Poverty Trap Definition. Retrieved November, 2020, from
https://www.investopedia.com/terms/p/poverty-trap.asp
International Hub (2019). The Poverty Trap. YouTube. www.youtube.com/watch?v=KxjW-

HU1BCM&ab_channel=InternationalHub

1.14 INTERACTION: G D P PER CAPITA ACROSS THE GLOBE
13 OF 14
Every country has a Gross Domestic Product (G D P). The G D P is divided by a country’s population to
get the G D P per capita. This measure is used as a comparative measure of economy and standard of
living between countries. Values are normally presented in $U S currency.
Compare G D P per capita across the world to observe how economic disparities related to the S D Hs may
influence rich and poor countries.
Definition:
Gross Domestic Product (G D P): Gross domestic product is an annual monetary measure of all the
goods and services produced by a country.
Page Link:
Reference:
The World Bank. (n.d.). Life expectancy at birth, total (years). Retrieved November, 2020 from
https://data.worldbank.org/indicator/NY.G D P.MKTP.CD?type=shaded&view=map&year=2019

1.15 SECTION 01 SUMMARY
14 OF 14
In Section 01, you learned that scientists and advocates must work together to help identify and bring
awareness to global health issues and inequities. You specifically learned the differences in how
scientists and advocates communicate with the public.
You learned how the social determinants of health shape individual health, and by extension, global
health. You then learned that health inequities, such as differences in life expectancy, exist between
low and high S D I countries. You further explored this by learning about the social gradient, a
worldwide phenomenon where one’s wealth and health are directly correlated. You concluded the
section by examining the poverty trap, which is the mechanism where those in poverty are trapped in
poverty unless there are external financial and resource assistance provided.

SECTION 02: THE CLOSING THE GAP REPORT
2.1 SECTION 02: THE CLOSING THE GAP REPORT

2.2 CLOSING THE GAP AND THE SOCIAL DETERMINANTS OF HEALTH
1 OF 7
As you have learned, health inequities can arise because of inequities in the S D Hs. However, if we
overcome the inequities in the S D Hs, then many of these health inequities and unequal health
outcomes can be eliminated.
In an attempt to determine the most effective way to mediate the effect of the S D Hs, the W H O
created the Commission on Social Determinants of Health. In 2008, the commission called on the W H
O and all governments to lead global action towards closing the health gap in a generation. The call to
action was published in a report entitled Closing the Gap in a Generation: Health equity through action
on the social determinants of health.
For your interest, read the Closing the Gap in a Generation report.
“Social justice is a matter of life and death. It affects the way people live, their consequent chance of
illness, and their risk of premature death. We watch in wonder as life expectancy and good health
continue to increase in parts of the world and in alarm as they fail to improve in others.”
– The Commission on Social Determinants of Health
Page Link:
https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf;jsessionid=AC69B98
4F1B0A8947A498833CC01D8F4?sequence=1
Reference:
CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants
of health. Final Report of the mission on Social Determinants of Health. Geneva, World Health
Organization. Retrieved from

2.3 PODCAST: W H O CLOSING THE GAP IN A GENERATION REPORT
2 OF 7
In the report Closing the Gap, the W H O’s commission found clear evidence of health inequity
throughout the world. They identified key social determinants of health that are crucial to creating this
gap in health.
Listen to the W H O podcast about the W H O’s Commission on the Social Determinants of Health.
W H O PODCAST: Episode 44 [7:48]
As you listen, consider the questions, which you will answer on the upcoming slides:
1. What are some examples of gaps in global health?

2. What are the social determinants of health? Why are these important?
3. How should we broaden our understanding of health?
Start of Audio Transcript:
Veronica Riemer: You’re listening to the W H O podcast. My name is Veronica Riemer and this is episode 44.
In this episode, we talk about the World Health Organization's Commission on the Social Determinants of
Health.
Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness,
and their risk of premature death.
A child in a Glasgow suburb in Scotland can expect a life 28 years shorter than another living only a few
kilometres away.
A girl in Lesotho is likely to live 42 years less than another in Japan. In Sweden, the risk of a woman dying
during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8.
Biology does not explain any of this. Instead, the differences between -- and within -- countries result from
the social environment where people are born, live, grow, work and age. These "social determinants of

health" have been the focus of a three-year investigation by a group of policy-makers, academics, politicians
and former ministers of health. This week, the Commission presented its findings to the W H O Director-
General Dr Margaret Chan.
Five of the commissioners from this eminent group have given us their views on the social determinants of
health around the world.
David Satcher is Director of the Center of Excellence on Health Disparities and the Satcher Health Leadership
Institute Initiative. He spoke to Dick Thompson about the meaning of social determinants and why we should
care about them.
David Satcher: I think when we talk about the determinants of health, we are talking about the major
factors that influence health outcome. And, certainly one of those factors relates to social policies and social
conditions that affect the way in which people are born, where they grow, where they learn, where they live,
even where they age. So those social policies and social conditions which impact the environment in which
people live and develop, are social determinants of health.
Dick Thompson: You said that these are the major factors that influence health outcomes, but isn't it the
availability of doctors and technology and medicines that really determines that?
David Satcher: It is interesting because clearly one of the determinants of health outcome is access to
quality health care. It is only one and it accounts for probably no more than 15% of the variation in
outcome. But I want to make it clear that, when people live in a situation where they don't have access to
health care, then access to health care becomes a social determinant of health.
Veronica Riemer: Denny Vågerö, Professor of Medical Sociology and Director of the Centre for Health Equity
Studies in Sweden spoke to us about how we need to change the way we think about our health.
Denny Vågerö: Traditionally we have thought about health like something medical, something you fix at the
doctors. We have to think much more about health as something that is routed in daily life, everything we do,
everything we experience has potential impact on our health and we need to understand that much more
and think about the policies which could address conditions in daily life, improve daily life so that we get
healthier.
My personal message is that business as usual is not an option any more. We have to treat the global health
problem on the same level as we discuss poverty or climate change. It is one of the fundamental human
struggles to improve global health and in particular to make sure that everyone is on the boat, that we don't
leave people behind as we do now.
Veronica Riemer: We spoke on the telephone to Frances Baum who is a Professor of Public Health at
Flinders University and Foundation Director of the South Australian Community Health Research Unit.
Frances Baum: We need to decide as a society and in our governments that promoting health and well-
being is absolutely crucial to all areas of activity in our society and that we should establish that as a goal of
our society. We should start looking at our health as a measure of how well we are doing as a global society
and we should really strive to make as many countries as equal as possible and also do that at a national
level.

Veronica Riemer: Ndioro Ndiaye is the Deputy Director-General of the International Organization for
Migration and was formerly Minister for Social Development and Minister for Women’s, Children’s and
Family Affairs in Senegal. We asked her about the main goal for the members of the commission in writing
this report.
Voiceover: Under the leadership of Sir Michael Marmot we tried to help countries understand what changes
they can introduce, to help ministers of health work more closely with their colleagues in the same
government, to put in place programmes that will help ministries of health when preparing their
programmes. The social determinants of health steered us to adopt a multi sectoral approach, an integrated
approach to health problems, to build an efficient health system that will help the population as a whole.
Mirai Chatterjee is the Coordinator of Social Security for India’s Self-Employed Women’s Association, a trade
union of over 900 000 self-employed women. She spoke to us about the implications of gender in social
determinants of health.
Women in country after country, do not have equal access. It is not just a question of access to health
services, it is a question of the status of women. Persistent discrimination against women in country after
country has a direct impact on their health in so many ways. Access, but also violence against women, so
many issues. Women get the worst work, so occupational health also has a differential impact on women as
opposed to men in every community wherever we visited all over the world. If you are disempowered, you
have no voice, if you are not organized like how our sisters were 40 years ago, then how can you be healthy.
Because all the conditions that keep us sick and in ill health, have to do with inequality, injustice, gender
discrimination and they cannot be addressed until we come together, organize, build strong people's
organizations and really struggle and fight against the forces that keep us sick, poor and constantly in debt.
Veronica Riemer: You can learn more about this report by going to the W H O web site at
www.who.int/social_determinants/.
That's all for this episode of the W H O podcast. Thanks for listening. If you have any comments on our
podcast or have any suggestions for future health topics drop us a line. Our email address is
Podcast@who.int.
End of Audio Transcript.
Page Link:
https://terrance.who.int/mediacentre/podcasts/WHO_podcast_044.mp3?ua=1
References:
World health organization podcast. (n.d.). Retrieved February 24, 2021, from
https://www.who.int/mediacentre/multimedia/podcasts/all/rss.xml

2.4 QUESTION 1 OF 3: GAPS IN GLOBAL HEALTH

3 OF 7
Using your previous knowledge and what you learned from the audio clip, answer the questions.
What are some examples of gaps in global health?

Feedback:
There are many examples of the gaps in health or health inequities that exist around the world. For
instance, a girl born in Lesotho, a poorer country, has a life expectancy 42 years less than another born
in Japan. A pregnant person giving birth in Sweden has a very low risk of dying during pregnancy and
childbirth at 1:17,400. This risk is significantly lower when compared to a 1:8 risk in Afghanistan. Gaps
in health also exist within countries. For example, 20 years ago, in Scotland, two neighbourhoods
(Calton and Lenzie) just kilometres from each other, had vastly different life expectancies (54 and 82
respectively). Although the life expectancy in Calton has improved over the last two decades, it is still
significantly lower than in Lenzie.

2.5 QUESTION 2 OF 3: SOCIAL DETERMINANTS OF HEALTH

4 OF 7
What are the social determinants of health? Why are these important?
Feedback:
The social determinants of health are the social conditions of where people are born, live, grow, work,
and age. They are important because they impact the health of individuals, and by extension,
populations.

2.6 QUESTION 3 OF 3: UNDERSTANDING OF HEALTH

5 OF 7
How should we broaden our understanding of health?

Feedback:
Traditionally, health is thought of in medical terms. In reality, health should also be viewed socially, so
that changes can be made to social and economic conditions that will have positive impacts on health.

2.7 GOALS OF CLOSING THE GAP IN A GENERATION
6 OF 7
The W H O is committed to the goal of closing global health gaps in one generation, and they propose
three ways this can be accomplished.
Learn about each of the three ways the global health gap can be closed.
Improve Daily Living Conditions
Improve the conditions in which people work and live, and implement a universal social protection
policy to protect all individuals from insecure employment. Also, improve the circumstances in which
children are born, and put an emphasis on equal childhood development and education between boys
and girls to promote lifelong health.
There are five areas that can be addressed to improve living conditions:
• Equity from the Start

• Healthy Places, Healthy People
• Fair employment and healthy work
• Social protection throughout life
• Universal health care
Address Inequalities in Power, Money, and Resources
Address the inequalities that occur in the division of resources and power across the public and private
sectors through effective health policy.
Measure and Understand the Problem and Assess the Impact of Action
Increase global health research through implementing effective measurement of health and the social
determinants of health, as well as evaluate the impact that policies have on health.
References:

Icon pond. Doctor free icon. Retrieved November 18 2019, from

https://www.flaticon.com/free-icon/doctor_387569?term=doctor&page=1&position=40
Freepik. Real Estate. Retrieved September 2020, from

https://www.flaticon.com/free-icon/house_589521?term=house&page=2&position=74
Freepik. Briefcase. Retrieved September 2020, from

https://www.flaticon.com/free-icon/briefcase_3170729?term=work&page=2&position=90
7 OF 7
In this section, you discussed the Closing the Gap in a Generation report established by the W H O,
which aimed to minimize health inequities by targeting specific social determinants of health. You
learned about the three goals established in the report. The first goal was to improve daily living
conditions. The second goal was to address inequalities in power, money, and resources. The final goal
was to measure and understand the problem and assess the impact of action. You will learn more
about each of these goals throughout the remainder of the module.
Now that you can appreciate what a gap in health is, think about gaps in health you see in your own
community (i.e. home, school). Keep these gaps in health in mind as you navigate through the rest of
the module, because these ideas pertain to your Gap in Health Discussion Board.

SECTION 03: CLOSING THE GAP BY IMPROVING LIVING CONDITIONS
3.1 SECTION 03: CLOSING THE GAP BY IMPROVING LIVING CONDITIONS

3.2 GOAL 1: IMPROVE DAILY LIVING CONDITIONS
1 OF 24
The first recommendation in the Closing the Gap in a Generation report was to improve daily living
conditions. The report recognized five main areas that need to be addressed to improve daily living
conditions:

• Healthy Places Healthy People
• Fair Employment and Decent Work
• Social Protection Across the Lifecourse
• Universal Healthcare
“Health is created and lived by people within the settings of their everyday life; where they learn, work,
play, and love.”
– The Ottawa Charter, 1986
Reference:

3.3 HOUSING AND HOME ENVIRONMENT
2 OF 24
Housing is a key social determinant of health. It can be further understood by exploring its three main
dimensions. These include the physical and structural elements, the social meanings attached to a
house, and the spatial location of a house.
Learn more about the physical, social, and spatial dimensions of a healthy home.
Physical Dimension
The physical condition of a house should meet all of an individual’s basic survival needs. This includes
having clean water and sanitation, electricity, plumbing, heating, proper ventilation, and a safe
infrastructure.
Poor housing conditions are associated with high rates of communicable diseases, injuries, violence,
poor nutrition, and mental health problems.
Social Dimension
The social dimension of housing involves aspects such as affordability and home ownership, which
contribute to a person’s sense of belonging and control over their home.
Moreover, the domestic environment is also central to this dimension, where a personal sense of
safety and stability and lack of overcrowding lead to the health and well-being of a household.
Spatial Dimension
The spatial dimension of housing refers to the location of a house in relation to other things in its
environment. This includes the distance to schools, healthcare services, recreation areas, and grocery
stores.
The proximity to industrial waste and other environmental contaminants is also important to consider.

3.4 VIDEO: HARSH LIVING CONDITIONS OF SYRIAN REFUGEES
3 OF 24
As you just learned, living in unsafe, unaffordable, or insecure housing increases the risk of many
health problems.
Watch a video that highlights the health problems that may arise from the extremely poor living conditions
of Syrian refugees in Lebanon.
Start of Video Transcript:
He wants to leave for Australia. Because no we can’t stay here. No work, no anything, no house and we can't
come to Syria because there are bombs, fire, everything.
More than 500,000 people like Ahmad have fled Syria to take refuge in Lebanon. Finding a place to live is
becoming increasingly difficult, especially for the poorest refugees who have often lost everything because of
the war. Some have had to sell their possessions to raise money so they could reach neighboring countries,
they often lack money for rent.
So, refugees are scattered all over the region, and other main challenge is definitely shelter. Places are
saturated. People are living in unfinished shelters in garages. Even two, three families were observed in one
single room. So, living conditions are terrible, poor, and also people are eventually forced to live in tented
settlements.
The MSF teams must deal with the impact of these living conditions on the refugees’ health. In winter, more
than 50% of patients developed respiratory infections. Some refugees had no choice but to burn plastic or
whatever they could find for heating. Crowded conditions and meager, poorly ventilated housing also
contribute to the spread of contagious diseases. Lack of proper hygiene has also led to an increasing number
of skin infections among refugees. Now with the arrival of summer, the situation is unlikely to improve.
They have very limited access to water and hygiene. I was in a shelter this week where there's about one
toilet for every 60 people. Not good enough. So, their risk of communicable diseases very high. Very limited
access to food. So yes, we can afford to buy rice, but we can afford nothing else.

The continuing inflow of new refugees across Lebanon has resulted in growing health needs and MSF has
thus expanded its activities in recent months. The organization is providing free medical care in the Bekaa
Valley and in the cities of Tripoli and Sidon. MSF also provides mental health care to the most vulnerable
among the Lebanese population and to people who fled Syria, who in addition to experiencing war-related
trauma must now deal with life as refugees in Lebanon.
Many of them lost also houses, they lost their work, they lost everything. They came in very bad conditions.
Plus, they came into places in Lebanon that they are economically disadvantaged, you know, they don't have
this fancy living now they are living in very crowded places, and they are trying as much as they can to
integrate into the community. We are afraid to see more major depression among these people because the
frustration is very hard. And because they are not being able at all to understand the situation, to cope with
this new situation. That is putting them under too much pressure.
End of Video Transcript.
Lebanon: Syrian Refugees in Harsh Living Conditions, With Growing Health Needs [3:09]
Page Link:
https://www.youtube.com/embed/b_2JktYJcbY
References:
Doctors Without Borders/MSF-USA. (2013). Lebanon: Syrian Refugees In Harsh Living Conditions, With
Growing Health Needs. Retrieved May, 2017, from https://www.youtube.com/embed/b_2JktYJcbY

3.5 QUESTION: IMPACT OF POOR LIVING CONDITIONS ON HEALTH

4 OF 24
Using what you learned from the video about the living conditions of Syrian refugees, answer the question.
How do poor living conditions, particularly those of refugees, impact health?

Feedback:
Poor sanitation, crowded living quarters, and poor ventilation contribute to the spread of
communicable diseases. Refugees also struggle with mental health issues due to difficulties integrating
with the community, which builds up into frustration.

3.6 LIVING CONDITIONS ON INDIGENOUS RESERVES
5 OF 24
You may recall from earlier in the course that many Indigenous Peoples living on reserve have many
health outcomes that fair worse than the general Canadian population. As discussed, many of these
outcomes are a result of poor living conditions. One example of these below standard living conditions
are long-term drinking water advisories.
As of December 2020, there were a total of 59 long-term drinking water advisories in 41 communities;
many of which are on Indigenous reservations. One such community, the Neskantaga First Nation,
has been under a long-term drinking water advisory for over 25 years.
Alt Text: A sample from the Neskantaga water system in 2019.
Definitions:
Long-term drinking water advisories: A drinking water advisory states that the water is not safe to drink
as is. The advisory becomes long-term when it has been in place for more than a year.
Neskantaga First Nation: An Oji-Cree First Nation band government in northern Ontario, situated along
the shore of Attawapiskat Lake in the District of Kenora.
Reference:
APTN National News. (2020). Neskantaga evacuees to return home in December but still won’t have
access to drinking water. Retrieved February, from https://www.aptnnews.ca/national-
news/neskantaga-evacuees-to-return-home-in-december-but-still-wont-have-access-to-drinking-water/

3.7 EARLY CHILDHOOD DEVELOPMENT & HEALTH
6 OF 24
Adequate living conditions are particularly important to ensure healthy early childhood development.
In the first six years of life, a number of instrumental developmental changes occur that allow children
to reach their full potential. In particular, the healthy development of the brain allows for progression
of linguistic, cognitive, and psychosocial development.
At least 200 million children globally are not achieving their full development potential due to poor
living conditions in early life.
Further your understanding of equity from the start in the Closing the Gap in a Generation report.
Equity from the Start
To close the gap in health inequities in the population, it is vital to understand how those early
childhood development years are critical to the health of an individual, and further set the stage for
health outcomes of the population. Equity from the start means that every child is given the same
opportunities and access to services such as education, food and nutrition, health care, and that they
grow up in safe and healthy environments.
A comprehensive, upstream approach to the protection and promotion of the well-being of children
prevents larger inequalities in population health.
Reference:
CSDH, World Health Organization. (2008). Closing the gap in a generation: health equity through action
on the social determinants of health. Final Report of the Commission on Social Determinants of Health.
Retrieved from,
https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

3.8 THE JAMAICAN STUDY
7 OF 24
The Jamaican Study was a longitudinal study that looked into the relationship between ensuring the
healthy development of children, both physical and psychosocial, and a child’s later development in
life.
Alt Text: Mean Development Quotients (DQ) of stunted groups adjusted for initial age and score compared
with nun-stunted group adjusted for age only.
Listen to Dr. Carpenter explain the Jamaican Study (1:52).
Start of Audio Transcript:
As you saw on the last slide, early childhood development is a key determinant of how well a person is going
to do in their life. There’s so much development that happens in the first eight years of life on a psychosocial
basis and on a neurological basis, and so focusing in on those first eight years of life have been shown to
have a huge impact on closing the gap in global health.
In this slide, you can see the results of a study that was done in Jamaica where they tried to show these key
factors. It was done over a 24-month period. What they did was they took children who were stunted, so
weren’t growing or developing as would be expected, and they had four different groups. They kept one
group as a control, just allowing them to continue in their normal life with no interventions, and you can see
that is the line with the open circles, and then they also had three other groups. One of the groups was
supplemented with high nutrition, and another group was stimulated psychosocially, and then the fourth
group was both stimulated psychosocially and also had the nutrition. And you can see that their mean
development scores were much better when they had the increased nutrition and also the stimulation. So,
this was a study that just highlighted what people already knew, which was that early childhood
development is a really key time to be able to make a huge impact on the social determinants of health as
well as on the health of an individual in the future and on closing that gap in global health.
End of Audio Transcript.
Reference:

Reprinted, with permission of the publisher, from Grantham-McGregor et al. (1991).

3.9 EMPLOYMENT AND WORKING CONDITIONS
8 OF 24
The employment and working conditions of individuals can have profound effects on health and health
equity. When individuals work in healthy conditions, they gain financial security, social status, personal
development, social relations, self-esteem, and protection from physical and psychosocial illness.
Learn more about how working conditions and job security affect health.
Working Condition
Adverse working conditions tend to be clustered in lower-status occupations. They are associated with
poor physical and psychosocial health and stress, which has been shown to increase risk of coronary
heart disease (C H D) by 50%.
Some examples of adverse working conditions include a physically or psychologically demanding job,
low job autonomy, inflexible working hours, and an effort-reward imbalance.
Job Security
In addition to working conditions, job security is a S D H. Unemployment can have a profound

negative effect on physical and mental health through financial insecurity, material deprivation, a lack
of opportunities for personal development, and increased stress.
Definition:
Job Security: The probability that an individual will keep their job.
Reference:
Flickr. “Hire Me” caps at commencement. Retrieved from,
https://www.flickr.com/photos/19219926@N04/42045021091

3.10 QUESTION 1 OF 2: COVID -19 AND EMPLOYMENT

9 OF 24
During the COVID-19 pandemic, around 40% of workers in Canada found themselves working from
home compared to only 10% in 2018. Additionally, the COVID-19 pandemic caused a huge economic
disruption with businesses closing down and employees losing their jobs.
Using your knowledge, answer the questions.
Reflecting on this situation, how do you think the COVID-19 pandemic has disproportionately
impacted workers socially, economically, and physically in different fields?
Feedback:
There are many professions, such as manual labourers and those in retail, that do not have the luxury
of working from home. Individuals in these positions barely make enough money to survive on a daily
basis, and so they’ve had to choose between not earning enough money to meet their basic needs or
returning to work and putting themselves (and their families) at risk of becoming infected with the
virus.
In addition, with children being out of school, the cost of childcare can be far too high to make it worth
going to a low-paying job, and so some people have had to stop working.
For individuals that do have the ability to work from home, the home environment can be a source of
domestic violence and abuse. Thus, working from home can potentially be a threat to one’s safety and
well-being.
Reference:
Neustaeter, B. (2020). More Canadians will be working from home post-pandemic, StatCan data
suggests. Retrieved November, 2020, from https://www.ctvnews.ca/health/coronavirus/more-
canadians-will-be-working-from-home-post-pandemic-statcan-data-suggests-1.5023822

3.11 QUESTION 2 OF 2: COVID -19 AND EMPLOYMENT

10 OF 24
During the COVID-19 pandemic, around 40% of workers in Canada found themselves working from
home compared to only 10% in 2018. Additionally, the COVID-19 pandemic caused a huge economic
disruption with businesses closing down and employees losing their jobs.
Using your knowledge, answer the questions.
Reflecting on this situation, how do you think the mental and physical health of people with
jobs that have higher job security fared compared to more volatile positions?
Feedback:
In most cases, individuals with higher job security experience less mental and physical hardships.
However, the pandemic still had an impact on the mental health of many, regardless of their job
security.
Reference:
Neustaeter, B. (2020). More Canadians will be working from home post-pandemic, StatCan data
suggests. Retrieved November, 2020, from https://www.ctvnews.ca/health/coronavirus/more-
canadians-will-be-working-from-home-post-pandemic-statcan-data-suggests-1.5023822

3.12 CASE: MIGRANT WORK AND EARLY CHILDHOOD HEALTH & DEVELOPMENT
11 OF 24
Early childhood health and development is crucial in preventing future illnesses and diseases.
Read about a case that describes issues related to both the work environment and childhood health and
safety.
As you read, think about some of the major health and development problems associated with
children being on unsupervised construction sites.
Alt Text: A photograph of children sitting inside, and standing on top of concrete cylinders.
The construction industry is the second largest employer in India, employing almost 30 million
workers. Migrant construction workers in India cannot afford to pay for childcare for their children. As
a result, 3 million children can be found unsupervised on construction sites across India.
Reference:
The Guardian. (2013). Best pictures of the day-live. Retrieved January, 2021 from
https://www.theguardian.com/news/2013/oct/10/best-pictures-of-the-day-live

3.13 QUESTION 1 OF 2: MOBILE CRECHES PROGRAM AND HEALTH OUTCOMES OF

CHILDREN
12 OF 24
The problem of unsupervised children on construction sites across India was identified by Meera
Mahadevan in 1969. To address this issue, Meera founded the Mobile Creches program, which runs
daycare centres at construction sites in India, providing a safe and enriching environment of children
of migrant workers.
Using what you have learned about the Mobile Creches program, answer the question.
How might the Mobile Creches program benefit the health outcomes of children?
Feedback:
The Mobile Creches program provides children with a safe, nurturing, and stimulating environment.
This type of environment promotes healthy development allowing the children to reach full potential
and is associated with positive health outcomes throughout life.
Definition:
Creches: A child care centre where an organization of adults take care of children in place of their
parents.
Reference:
Our story: Mobile creches. (n.d.). Retrieved February 08, 2021, from
https://www.mobilecreches.org/our-story

3.14 QUESTION 2 OF 2: MOBILE CRECHES PROGRAM AND HEALTH OUTCOMES OF

CHILDREN
13 OF 24
The problem of unsupervised children on construction sites across India was identified by Meera
Mahadevan in 1969. To address this issue, Meera founded the Mobile Creches program, which runs
daycare centres at construction sites in India, providing a safe and enriching environment of children
of migrant workers.
Using what you have learned about the Mobile Creches program, answer the question.
Explain how the Mobile Creches program promotes social and economic productivity.
Feedback:
Removing children from constructions sites increases worker productivity by eliminating the workers'
need to worry about the whereabouts and safety of their children. The Mobile Creches program
creates employment opportunities for people in the community to work with children. Investing in
early childhood development will result in future economic gain, with adults who are more capable,
productive, and valuable to the workforce.
Definition:
Creches: A child care centre where an organization of adults take care of children in place of their
parents.
Reference:
Our story: Mobile creches. (n.d.). Retrieved February 08, 2021, from
https://www.mobilecreches.org/our-story

3.15 NEIGHBOURHOOD AND NATURAL ENVIRONMENT
14 OF 24
In the Closing the Gap in a Generation report, the second goal for "Improving Living Conditions" was
"Healthy Places Healthy People". In addition to the home environment, discussed before, this also
involves improving the larger built-in environment where people live, which has a large impact on
physical and mental health.
Related to this is the W H O’s Healthy Cities program, which is a long-term international development
initiative that aims to create an environment that supports health and a good quality of life.
Navigate to the following page to learn more about this initiative.

3.16 VIDEO: THE HEALTHY CITIES, HEALTHY COMMUNITIES MOVEMENT
15 OF 24
With a growth of urbanization, people living in cities usually have better access to opportunities and
healthcare. However, city life leads to sedentary lifestyles, pollution, and crowded living conditions,
which can negatively impact population health.
Watch the W H O Director-General, Dr. Tedros Adhanom Ghebreyesus, discuss how healthy cities impact the
health of the citizens.
W H O: Making Cities Healthier: Improving health for all [3:30]
As you watch, consider how your own health has been impacted by the environmental conditions of
your community.
Page Link:
https://www.youtube.com/embed/cmSLlKLHjVo
Reference:
World Health Organization (2018). W H O: Making cities healthier - improving health for all [Video].
Youtube. Retrieved from,
https://www.youtube.com/watch?v=cmSLlKLHjVo&ab_channel=WorldHealthOrganization%28WHO%29

3.17 URBANIZATION AND HEALTH
16 OF 24
Urbanization is an important driver in reshaping population health problems.
Learn how urbanization has reshaped population health problems.
Crowding
With an increase in urbanization comes an increase in population density. If the volume of stores and
access to services does not keep up with this increased population demand, then the increased
population must compete for the limited daily resources. Such resources include grocery stores,
healthcare services, community centres, etc. In order to keep up with demand, urban centres get more
investment, while rural communities, including many Indigenous communities, end up suffering from
underinvestment and lack of access to essential services.
Urbanization also leads to city level crowding, because a greater population must live in the same
geographical area. With limited space, the cost of housing increases, which can then lead to crowding
at the family level. For example, due to cost, sometimes multiple generations are forced to live in small
living quarters and unsuitable conditions.
Violence & Injuries
With increased urbanization and crowding, there tends to be an increase in disparities in the standards
of living amongst citizens, which may lead to conflicts over resources. As well, urban cities tend to have
areas with higher crime rates, which create insecurity for much of the population. Often women,
migrants, and refugees bear the brunt of this lack of security, with significant impacts on their
livelihoods, health, and access to basic services. Higher levels of violence and this lack of security have
both economic and social impacts on the entire population.
Diseases
In urban centres that experience crowding and urbanization, there is an increased risk of the spread of
communicable diseases due to a large population living in a close proximity. Research has shown that

urbanization accounts for significant changes in dietary patterns and physical activity levels, which
increase the risk of obesity in children, and increase both injuries and non-communicable diseases in
the urban-poor.
Additionally, there is increasing evidence that the design of a city strongly impacts the walkability and
access to services. For instance, if there are sidewalks and safe neighbourhoods, individuals are more
likely to take active forms of transportation. Conversely, if there are more fast food restaurants than
grocery stores, it is easier for individuals to pick up less healthy fast food
Pollution & Climate Change
Although climate change affects the entire world, the impact is disproportional, with those living in low
SDI countries which have poor health infrastructure, people living on small islands, and those living in
mega cities, mountain ranges, or the polar regions being more vulnerable to climate change.. In 2008,
decreased air quality as a result of pollution contributed to 1.4% of all deaths. Urbanization has also
led to increases in greenhouse gas emissions, which is the main cause of climate change. Climate
change is also a major health issue as it impacts air and water quality, sanitation, sufficient food
production, and secure shelter, all of which are needed for a healthy quality of life.
Although climate change affects the entire world, the impact is disproportional, with low S D I countries
which have poor health infrastructure, people living on small islands, those living in mega cities,
mountainous regions, and the polar regions being more vulnerable to climate change. The W H O
reported that climate change is expected to cause approximately 250 000 additional deaths per year
between 2030 and 2050, with the main causes of death being heat exposure in elderly individuals,
childhood malnutrition, diarrhoea, and malaria.
Gentrification
Gentrification is the process through which low-value neighborhoods experience an influx of affluent
residents and business, transforming the neighborhoods to high-value areas. Gentrification tends to
occur once the other impacts of urbanization have happened. Although gentrification may sound like a
good way to ‘clean up’ a city, there are some major consequences. Gentrification drives up rent and
property values, leading to the forced displacement of low-income individuals, and changes in the
racial and ethnic composition of a neighborhood. If individuals are not displaced, then often they can
no longer afford the daily basics, such as healthy food. These social and economic changes are
associated with a loss of community identity and social bonds.
Definition:
Urbanization: The gradual increase in the proportion of people living in urban areas.
Underinvestment: Many Indigenous communities in Canada face barriers to investment. These barriers
include a legal and regulatory environment that is unfavourable for economic development, barriers to
control over lands and resources, underinvestment in housing and infrastructure, low rates of financial
literacy, higher costs of doing business, a lack of support for business growth, and a complex
government funding regime.

Urban-poor: People who live in urban areas who do small jobs like farming, potting, and dyeing. These
people do not earn a proper income, have extremely limited access to essential services such as water,
sanitation, electricity, and healthcare.
References:
CSDH, World Health Organization (2008). Closing the gap in a generation: health equity through action
on the social determinants of health. Final Report of the Commission on Social Determinants of Health.
Retrieved from,
https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf
World Health Organization. (n.d.). Climate change and health. Retrieved November, 2020, from
https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
The National Aboriginal Economic Development Board. (2017). Recommendations report on improving
access to capital for Indigeous Peoples in Canada. Retrieved December, 2020 from
https://nacca.ca/wp-content/uploads/2017/04/NAEDB_ImprovingAccessToCapital.pdf
Patel, R. B., & Burkle, F. M. (2012). Rapid urbanization and the growing threat of violence and Conflict: A
21st century crisis. Prehospital and Disaster Medicine, 27(2), 194-197. Retrieved January, 2021 from
https://doi.org/10.1017/s1049023x12000568
Hämmig, O., Bauer, G.F. (2013). The social gradient in work and health: a cross-sectional study
exploring the relationship between working conditions and health inequalities. BMC Public Health,
13(1170). Retrieved December, 2020 from
https://doi.org/10.1186/1471-2458-13-1170

3.18 QUESTION: IMPACT OF CLIMATE CHANGE ACROSS THE GLOBE

17 OF 24
As you learned, the health of a population is directly impacted by the quality of the environment.
Individuals living in poorer countries tend to experience unhealthier environments, which negatively
impact their health.
Using this knowledge, answer the question.
What are some of the ways in which developing countries experience worse environmental
conditions, and how do these impact health?
Feedback:
There are many ways in which developing countries experience worse environmental conditions, some
of which include:
• Lack of policy (or implementation of policy) to control pollutants, including those in foods
(pesticides, etc)
• Lack of social security/insurance helping those living in poverty to be able to afford to live in
decent areas/housing conditions
• Crowded living
• Lack of universal healthcare and health promotion interventions
As you can appreciate, each of these prevents an individual from having the means to meet their basic
needs, which include a healthy diet, a secure living environment, and access to health services.

3.19 GOVERNMENTS AND SOCIAL POLICIES
18 OF 24
The Closing the Gap in a Generation report identified two areas of improvement that lie within the
policy level of global and population health. These two areas are:
1. Social Protection Across the Lifecourse

2. Universal Healthcare
These two areas focus on the broader, structural forces that play a significant role in determining the
health of the population. You will learn more about them for the remainder of this section.

3.20 SOCIAL PROTECTION ACROSS THE LIFECOURSE
19 OF 24
Only 29% of the world’s population have a form of social security to protect them against emergencies
such as illness, disability, or loss of income and work.
The W H O has identified that a universal comprehensive social protection policy is needed, because
greater social security has been associated with better population health. Implementing a universal
social protection policy is critical for improving health in poor countries as most of the population
works in the informal sector or domestically.
Reference:

3.21 QUESTION: THE FEASIBILITY OF SOCIAL SECURITY

20 OF 24
As important as it is to provide all people with social security, there are barriers to implementing a
universal comprehensive social security plan.
Using what you have learned so far about social security and global health plans, answer the question.
Identify some potential barriers that may be faced in trying to implement social security
globally.
Feedback:
Limited institutional infrastructure and financial capacity in low income countries are barriers to
implementing a universal comprehensive social security plan.
Another barrier pertains to political ideologies and economic policies that favour economic growth and
prosperity over the well-being of the population. A clear example of this can be seen with neoliberal
political and economic ideologies that seek to reduce the state’s intervention in social and economic
affairs, and thus reduce social spending on services such as healthcare.

3.22 VIDEO: UNIVERSAL HEALTHCARE POLICY
21 OF 24
A key global aspiration is universal healthcare coverage for all individuals, regardless of their ability to
pay. There are a number of innovative, needs-based, primary healthcare models aiming to achieve this
goal.
Watch the video about universal healthcare.
W H O: The many paths towards universal health coverage [10:27]
As you watch, consider the benefits of universal healthcare on a global level. You will learn more about
Universal Healthcare in Module 6.
Page Link:
https://www.youtube.com/embed/VQ3sHfYzcv8

3.23 RACIAL INEQUALITY IN HEALTHCARE
22 OF 24
Canada prides itself as a diverse and immigration-friendly country. In 2016, 22.3% of Canadian citizens
self-identified as a visible minority. Unfortunately, visible minorities in Canada experience healthcare
inequities, which can be attributed to a lack of minority healthcare workers, meaning the current
Canadian healthcare system lacks the ability to deliver culturally sensitive care. The language, cultural,
and spiritual differences between physicians and patients is a huge barrier to healthcare for many
racialized minorities in Canada, including immigrants and Indigenous Peoples.
Reveal some statistics regarding racial health disparities in Canada.
Some Canadian Racial Health Disparities Statistics
• Between 2010 and 2013, 14.2% of Black Canadians over the age of 18 reported their health to be
fair or poor, compared to 11.3% of White Canadians.
• For First Nations individuals, the infant mortality rate is twice as high as that for the rest of the
Canadian population.
• Immigrant men are at an increased risk of work related injuries that require medical attention in
their first 5 years in Canada.
References:
Statistics Canada. (2019). Census Profile, 2016 Census Canada and Canada. Retrieved November, 2020,
from https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E
Racial inequality in access to health care services. (2004). Retrieved November, 2020, from
http://www.ohrc.on.ca/en/race-policy-dialogue-papers/racial-inequality-access-health-care-services

3.24 VIDEO: THE A B C PROJECT
23 OF 24
The A B C project was a longitudinal study that followed children from a disadvantaged area of North
Carolina for 35 years. The study included both a control group, and a treatment group which received
an enriched preschool experience and access to healthcare in early childhood.
Watch Professor Heckman discuss the A B C project and how it relates to the importance of early health and
education in preventing chronic disease.
Early Health & Education Prevent Chronic Disease [1:54]
As you watch, reflect on these questions:
1. How effective was the intervention? Why?

2. How does this intervention relate to the role the government plays in facilitating access to
education and universal health care to ensure healthy early childhood development?
Page Link:
https://www.youtube.com/embed/6l1XXm5KDNI

24 OF 24
In this section, you took a more in-depth look into the five main areas of improvement of living
conditions, as outlined by the Closing the Gap in a Generation report. You first read about how the
home environment and early childhood development affect health, and how these aspects relate to
“Equity from the start”. Next, you learned about the relationship between fair employment and decent
work, and how these impact the health of a population. You then read about the impact that one’s
broader physical environment has on their health. Finally, you learned about how the government and
policymakers play a central role in health equity by enabling Social Protection through the life course,
and Universal Healthcare.
You will now learn about addressing inequities in the next section.
You learned about the five main areas that need to be addressed to improve daily living conditions:

• Fair Employment and Decent Work
• Healthy Places Healthy People
• Social Protection Across the Lifecourse
• Universal Healthcare

SECTION 04: CLOSING THE GAP BY ADDRESSING INEQUITIES
4.1 SECTION 04: CLOSING THE GAP BY ADDRESSING INEQUITIES

4.2 GOAL 2: ADDRESSING INEQUITIES
1 OF 17
The second major recommendation of the Closing the Gap in a Generation report identified the need
to tackle inequalities in power, money, and resources. Given that inequity in daily living conditions is
shaped by deeper social structures, including governmental policies and institutions, the report
suggests the need to develop policies that promote equity.

4.3 OPTIMAL HEALTHCARE SYSTEMS
2 OF 17
Given that optimal healthcare systems are characterized by an equitable system that does not rely on
an individual's ability to pay for health care, there is a need for equitable health policies.
Learn the four main pillars that healthcare systems should be built on to have better outcomes.
1. Local Action
Appropriate local action across the range of social determinants.
2. Primary Level of Care
Emphasis on the primary level of care with adequate referral to higher levels.
3. Equitable System
An equitable system not relying on ability to pay.
4. Prevention, Health Promotion, and Intervention
Preventions and health promotions valued just as highly as curative interventions.

4.4 HEALTH INEQUITY IN THE CANADIAN INDIGENOUS POPULATION
3 OF 17
Although the Canadian healthcare system is built on the four pillars of optimal healthcare systems, not
every individual in Canada has equal access to health services, nor do they experience an equal quality
of services. Specifically, individuals living in remote, Indigenous communities in Canada have less
access to quality healthcare.
In the 2015 Spring Reports of the Auditor General of Canada, Report 4 summarized Access to Health
Services for Remote First Nations Communities in Manitoba and Ontario. The findings demonstrated
that Health Canada was not providing enough support to First Nations individuals living in remote
communities.
Learn about the health inequities that Indigenous communities face.
Nursing Stations – Refer to 4.4.1 Access to Quality Nursing Stations to 4.4.2 Video: A Locum Nurses
Perspective Sub Pages
Medical Transportation – Refer to 4.4.3 Access to Medical Transportation to 4.4.4 Video: Challenges to
Increasing Medical Transportation Sub Pages
Support Allocation & Comparable Access – Refer to 4.4.5 Support Allocation and Comparable Access to
4.4.6 Addressing Support Allocation and Comparable Access Sub Pages
Reference:
Government of Canada, O. (2015). Report 4-Access to Health Services for Remote First Nations
Communities. Retrieved November, 2020 from https://www.oag-
bvg.gc.ca/internet/English/parl_oag_201504_04_e_40350.html

4.4.1 ACCESS TO QUALITY NURSING STATIONS
SUB PAGE OF 4.4 HEALTH INEQUITY IN THE CANADIAN INDIVENOUS POPULATION

NURSING STATIONS
1/2
In healthcare interactions, nurses provide primary care, typically acting as the first point of contact.
Because of this important role, adequate staffing of nursing stations is extremely important for
clinical interactions and client care services. Unfortunately, in many Indigenous communities, nursing
stations are not adequately staffed. Additionally, according to Report 4 (2015), only one in 45 nurses
working in First Nations communities have completed all five of Health Canada’s mandatory training
courses. These findings are important because First Nations individuals in remote communities should
have equal access to essential health services from qualified nurses who have the authority to provide
these services.
It is required that nursing facilities undergo an inspection every five years; however, Report 4 found
that out of eight stations in First Nations communities, only five were inspected within the designated
time period. Nursing stations that are non-compliant with health and safety requirements or building
codes can put patients and staff at risk and may limit access to health services.
Read an example of a Nursing Station.
Many nursing stations are no larger than homes, much like this one in Old Crow, Yukon. This building
houses a clinic, offices for staff, a visitor's suite, two apartments, a furnace room, and a storage space.
It is staffed year round by one "Nurse in Charge" and one full-time registered nurse, a receptionist, and
a custodian. For better context, note that Old Crow has a population of 221.
Definitions:
Nursing Stations: Clinics that are healthcare facilities which offer primary care for the local community.
These clinics tend to care for outpatients, in contrast to hospitals which are larger and have the
capacity and resources to admit inpatients. This is different from a nurses station, which is found in
hospitals and other healthcare facilities, and is the designated area where nurses reside when not
working directly with patients and when doing their administrative duties.

Report 4: Report called ‘Access to Health Services for Remote First Nations Communities’.
References:
Old Crow Nursing Station. (n.d.). Retrieved from http://www.oldcrow.ca/ns1.htm

4.4.2 VIDEO: A LOCUM NURSES PERSPECTIVE

NURSING STATIONS
2/2
It is clear that many rural and remote Indigenous communities have limited access to travel and
community nurses, and lack the resources that non-remote communities have.
Listen to Cathryn Britton, a Northern Ontario travel nurse, speak about some of the challenges she has
experienced in her practice.
Cathryn Britton: Nurses Perspective [04:35]
As you watch, think about how Cathryn Britton’s scope of practice and access to diagnostics and
treatments is different compared to nurses working in urban centres. Also think about some of the
personal sacrifices Cathryn Britton makes for her work.
Page Link:
Reference:

4.4.3 ACCESS TO MEDICAL TRANSPORTATION

MEDICAL TRANSPORTATION
1/2
Another issue experienced within remote Indigenous communities is a lack of proper and reliable
medical transportation into bigger city centers which have more healthcare resources. Although
medical transportation benefits exist, according to Report 4, Indigenous individuals who are not
registered in the Indian Registration System can be denied the medical transportation benefit. In some
communities, approximately half of the children are not registered.
In addition to issues with accessing the medical transportation benefit, Report 4 identified that there
was no transparency from Health Canada. Health Canada did not analyze the denied requests for
medical transportation benefits to explain the reasons for denial. Further, Health Canada also failed to
maintain sufficient documentation to demonstrate that medical transportation benefits were
administered.
Read an example of medical transport between two rural northern communities.
Recall the small community of Old Crow. During medical emergencies patients are medevaced from
Old Crow by air to Inuvik, Northwest Territories, the closest hospital to Old Crow. It takes just under
four hours - depending on the weather - to medevac a patient to the Inuvik Hospital.
Definitions:
Medical transportation benefits: Benefits that cover the cost of transportation for First Nations
individuals so they can access medically required services.
Medevaced: Transport of persons, especially by helicopter, to a place where they can receive medical
care.
References:

Old Crow Nursing Station. (n.d.). Retrieved from http://www.oldcrow.ca/ns1.htm

4.4.4 VIDEO: CHALLENGES TO INCREASING MEDICAL TRANSPORTATION

MEDICAL TRANSPORTATION
2/2
Often when improving and increasing medical transportation, the focus is on improving ways that
patients are taken from their communities to larger centres. However, rarely do interventions consider
or address the challenges faced by medical professionals traveling to these rural and remote locations.
Watch Dr. Karen Yeates, a nephrologist from Kingston who travels to Moose Factory to see patients, speak
about her experiences working in a Northern community.
Dr. Karen Yeates [05:26]
As you watch, think about the challenges Dr. Yeates faces in reaching Moose Factory, and the limited
resources she has in Moose Factory when treating her patients.
Page Link:

4.4.5 SUPPORT ALLOCATION AND COMPARABLE ACCESS

SUPPORT ALLOCATION & COMPARABLE ACCESS
1/2
The report showed that Health Canada did not take into account the health needs of remote First
Nations communities when allocating its support. Health Canada also did not establish specific and
measurable criteria when comparing First Nations communities and other remote communities in
terms of access to clinical and client care services.
Report 4 highlighted a lack of effectiveness in the established committees towards developing

workable solutions to the interjurisdictional challenges that negatively affect First Nations individuals’
access to health services.
Reference:

4.4.6 ADDRESSING SUPPORT ALLOCATION AND COMPARABLE ACCESS

SUPPORT ALLOCATION & COMPARABLE ACCESS
2/2
Accommodating the unique needs of each rural and remote community, Indigenous or not, is a
complicated but achievable task. Recently, several new initiatives were created and are currently being
implemented to help increase access to healthcare in remote and rural communities.
Read about two initiatives helping to increase access to healthcare in remote communities.
Telehealth
Programs such as Telehealth (or sometimes referred to as TeleMedicine) allow for long-distance
patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote
admissions. In many locations, Telehealth is free for all users, and is often offered with translation
support for more than 300 languages.
NOSM
The Northern Ontario School of Medicine (N O S M) is a medical school in Ontario, created through a
partnership between Laurentian University and Lakehead University. N O S M is mandated to both
educate doctors and to contribute to care in Northern Ontario's urban, rural, and remote communities.
All medical students complete various placements in Aboriginal or Métis communities throughout the
four-year program, which has led to the establishment of a close relationship between the school and
various communities and First Nations throughout the region.
References:
Northern Ontario School of Medicine delivers more doctors to the north. (2015). CBC News. Retrieved
February, 2021 from https://www.cbc.ca/news/canada/thunder-bay/northern-ontario-school-of-
medicine-delivers-more-doctors-to-the-north-1.3203678
Shaw, D. (2009). Overview of Telehealth and Its Application to Cardiopulmonary Physical Therapy.
Cardiopulmonary Physical Therapy Journal. 20(2). 13-18. Retrieved February, 2021 from

https://journals.lww.com/cptj/Abstract/2009/20020/Overview_of_Telehealth_and_Its_Application_to.3.a
spx

4.5 ACTIONS TO ENHANCE HEALTH EQUITY IN INDIGENOUS POPULATIONS
4 OF 17
In 2015, the Truth and Reconciliation Commission (T R C) of Canada compiled a report that highlighted
calls to action to the government to close inequality and inequity gaps.
The T R C’s suggestions regarding Indigenous healthcare included:
• Recognizing the Indigenous health care rights enshrined in international and national law.
• Establishing a dialogue with Indigenous peoples to identify and eliminate health care inequities.
• Acknowledging, respecting, and addressing the distinct health needs of Métis, Inuit, and off-
reserve First Nations Peoples.
• Providing sustainable funding for existing and new Aboriginal healing centres to address the
harms caused by Residential Schools.
• In collaboration with Indigenous healers and elders, recognizing as medically legitimate the value
of traditional healing practices.
• Hiring and retaining Indigenous health care professionals, as well as ensuring that all staff have
cultural competency training.
Reference:
Truth and Reconciliation Commission. (2015). Honouring the truth, reconciling for the future: Summary
of the final report of the Truth and Reconciliation of Canada. Retrieved from,
https://ehprnh2mwo3.exactdn.com/wp-content/uploads/2021/01/Executive_Summary_English_Web.pdf

4.6 EQUITABLE HEALTH POLICIES
5 OF 17
Given that optimal healthcare systems are characterized by an equitable system that does not rely on
individuals’ abilities to pay for health care, there is a need for equitable health policies. Equitable health
can be determined by a number of government and economic factors including finance, education,
housing, employment, transportation, and health itself. To address this issue from a government
perspective, it is essential that policies across departments align in their goal to produce health equity.
Read an example of how policies can impact health equity.
Policy for High Fat and Sugar Foods
If a trade policy encourages the free production, trade, and consumption of high-fat and high-sugar
foods, this would contradict a health policy which recommends consuming relatively little high-fat and
high-sugar foods and encourages the consumption of fruits, vegetables, nuts, and seeds. A trade policy
that promotes the production and trade of fruits and vegetables would be better aligned with the
health policy and make such products more accessible to all consumers, likely reducing the consumer
costs on healthy products.

4.7 INTERSECTORAL ACTION FOR HEALTH (I S A)
6 OF 17
Aligning health policies across a number of government departments to promote health equity is
called intersectoral action for health (I S A). It implies the inclusion of several sectors, in addition to the
health sector, when attempting to design public policies meant to address health outcomes.
I S A is crucial because most of the decisions that impact the health of a population lie beyond the
health sector. The health sector must work with other sectors of government and society to address
the S D Hs. Canada has played an important role in intersectoral approaches. The Public Health Agency
of Canada (P H A C) and W H O have been working collaboratively since 2006 to establish effective
intersectoral approaches.
Equitable Health Outcomes
• Education
• Health
• Trade
• Industry
Reference:
World Health Organization. (n.d.). Intersectoral action. Retrieved November, 2020 from
https://www.who.int/social_determinants/thecommission/countrywork/within/isa/en/

4.8 MARKET RESPONSIBILITY
7 OF 17
Industry, or the market, can have a large impact on health. The market can bring health benefits
through new technologies, and goods and services. However, it can also adversely affect the social
determinants of health through economic inequalities, resource depletion, environmental pollution,
unhealthy working conditions, and the circulation of dangerous goods. There are three main aspects of
market responsibility that can be optimized for health.
Explore the three aspects of market responsibility that can be optimized for health. You will learn more
about each aspect in the remainder of this section.
Social goods should be governed by the public sector.
Legislation should promote gender equality.
Promote political empowerment.
References:
Freepik. Gender equality concept with scale. Retrieved from, https://www.freepik.com/free-
vector/gender-equality-concept-with-
scale_9884751.htm#page=1&query=gender%20equity&position=0
Freepik. Hands with placards. Retrieved from, https://www.freepik.com/free-vector/hands-with-

placards_9082513.htm#page=1&query=political%20empowerment&position=2

4.9 VIDEO: SOCIAL GOODS GOVERNED BY THE PUBLIC SECTOR
8 OF 17
Commercialization of education, healthcare, and other basic human and societal needs produces
health inequity. Thus, it is advisable for these social goods to be governed by the public sector.
As an example, the video highlights the transition of water services in some regions of the world to
public governance. For this to be effective, public sector leadership is required for national and
international regulation of products, activities, and conditions that damage health. Additionally, the
assessment of impact of market regulation and all novel policies should be conducted on both a
national and international scale.
Watch the video Remunicipalisation: Putting water back into public hands.
Remunicipalisation: Putting water back into public hands [5:03]
Page Link:
https://www.youtube.com/embed/BlSM1TPm_k8
Reference:
MSP Alternatives. (2013). Remunicipalisation: Putting Water Back into Public Hands. Retrieved May,
2017 from https://www.youtube.com/embed/BlSM1TPm_k8

4.10 GENDER EQUITY
9 OF 17
Gender inequities appear to pervade in all societies, with women tending to have less power,
resources, entitlements, and social value than men. As seen in the figure, women across the globe earn
significantly less income than men. Further, girls and women often do not have the same opportunities
for education and employment as boys and men.
Empowerment of women and reducing gender inequities is essential to reducing health inequity.
View the graph in more detail.
Alt Text: Nominal wages for women are significantly lower than for men.
Reference:

4.11 VIDEO: EMPOWERING WOMEN
10 OF 17
Empowering women can occur through many changes made to policy that affect societal structures.
Examples of such changes include:
• Legislation that enforces equity and equality

• Making discrimination on the basis of gender illegal
• Investing in formal and vocational education for girls
• Guaranteeing pay equity
• Increasing investment in female sexual and reproductive health
Watch the video to discover the benefits of empowering women.
Empowering Women [1:58]
Start Video Transcript:
Today four out of ten workers globally are women. By 2023 one billion will enter the workforce, yet the
majority have insecure jobs, earn on average 20% less than men, and do most of the unpaid work. However,
raising female employment to male levels could raise GDP by up to 34% and economically empower women
… improve workplace performance, raise agricultural productivity, increase household income, raise
healthier, better-educated children. EmpowerWomen.org is the new global platform where we can connect
partners from the private sector, civil society, government, and international organizations with women
everywhere; providing opportunities to learn, share, grow, lead. When women and girls are empowered,
economies grow, families flourish, societies prosper. Join us at EmpowerWomen.org.
End Transcript
Page Link:
https://www.youtube.com/embed/xX6fyrNcecM
Reference:

United Nations. (2013). EmpowerWomen.org. Retrieved May, 2017 from

https://www.youtube.com/embed/xX6fyrNcecM

4.12 GENDER INEQUALITY IN HEALTHCARE
11 OF 17
Although there have been major improvements throughout the centuries in closing the gap in health
for individuals based on gender and sexual orientation, disparities in healthcare are still prevalent.
Read more about inequality in healthcare in South Asia and North America.
SOUTH ASIA
South Asia is a region where gender bias towards males is socially acceptable and commonly seen.
Sadly, girls in most areas in South Asia are falling behind nutritionally as a result. This negative health
impact continues to magnify when these girls grow up to be mothers. For example, over half of the
women in Bangladesh are undernourished at reproductive age. As you learned in Module 03, maternal
conditions directly impact the health of offspring health. Thus, the female offspring may begin life in a
malnourished state, and continue to live in a vicious cycle of poor health and malnourishment.
NORTH AMERICA
In North America, gender inequality in healthcare is most observable in the L G B T I Q youth

population. Compared to their heterosexual peers, L G B T I Q youth face greater risks to their health
and well-being. Exclusion, isolation, and fear of homophobia from healthcare workers, peers, and
family are barriers to accessing healthcare for this vulnerable population. L G B TI Q youth are at a
higher risk of mental health issues. Gay, bisexual, or others that have male-to-male sexual contact are
at the highest risk of contracting H I V, with almost 70% of the new H I V cases in 2018 reported in the U
S amongst gay and bisexual men.
References:
Osmani, S., & Sen, A. (2003). The hidden penalties of gender inequality: fetal origins of ill-health.
Economics & Human Biology, 1(1), 105-121. Retrieved from, https://doi.org/10.1016/S1570-
677X(02)00006-0

Centers for Disease Control and Prevention. (2020). HIV and Gay and Bisexual Men. Retrieved
November, 2020 from https://www.cdc.gov/hiv/group/msm/index.html
Dysart‐Gale, D. (2010). Social justice and social determinants of health: Lesbian, gay, bisexual,
transgendered, intersexed, and queer youth in Canada. Journal of Child and Adolescent Psychiatric
Nursing, 23(1), 23-28. Retrieved from, https://doi-org.proxy.queensu.ca/10.1111/j.1744-
6171.2009.00213.x

4.13 POLITICAL EMPOWERMENT
12 OF 17
Political empowerment represents the ability of individuals to contribute to and be included in political
processes. Having the freedom to participate in political decision-making is important for citizens
because it gives them autonomy, provides an opportunity to voice their needs and interests, and
allows them to challenge unfair, graded distribution of social resources.
Currently, there is inequity in who participates in political decision-making, with those who are most
disadvantaged having the least amount of political power. This leads to an unfair distribution of
societal power and resources, which contributes to health inequity. In order to reduce health inequity,
ways to increase the political empowerment of disadvantaged people must be identified and
implemented.
Learn about two main methods of political empowerment. Please be aware that some of these slides will
discuss Female Genital Mutilation. This content is sensitive and might be uncomfortable for some individuals.
POLITICAL EMPOWERMENT – Refer to 4.13.1 Top Down and Bottom Up Approaches to 4.13.3 Top Down
Promotes a Bottom Up Approach Sub Pages
Reference:

4.13.1 TOP DOWN AND BOTTOM UP APPROACHES
SUB PAGE OF 4.13 POLITICAL EMPOWERMENT

POLITICAL EMPOWERMENT
1/3
Two main methods for political empowerment include a top down approach and a bottom up
approach.
Learn about the two approaches to increase the political empowerment of disadvantaged people.
Top Down
Top-down approaches are when the state works to guarantee a complete set of rights for all citizens,
and a fair distribution of resources across society.
Bottom Up
Bottom-up, or grassroots approaches are founded by self-organization of disadvantaged groups.

4.13.2 POLITICAL EMPOWERMENT: AN EXAMPLE

2/3
Female Genital Mutilation (F G M) has been a strongly-entrenched practice in many of the tribes in
Tanzania. Traditionally, it has been seen as a rite of passage prior to marriage, and in many cultural
groups, was carried out in a ritualistic way when the girl was in her early teens. Although there is no
physical benefit to the girls, in fact causing significant emotional and physical trauma, the practice has
continued, with the perpetrators often believing that they were doing what was best for the girl. The W
H O and the U N have clearly stated that this practice is a violation of the human rights of women and
girls.
In response to pressure, Tanzania passed a law criminalizing the act in 1998. Although this has allowed
prosecution of the parents and the cutters, the cultural beliefs that it is essential for the health and
well-being of the girl have remained strong. In many cases, the fear of prosecution has caused tribes to
perform the act at a much younger age (often in babies), so that the girls are not old enough to have
learned that it is an unhealthy and unfair practice and therefore cannot resist.
Pause and think about whether the law criminalizing F G M in 1998 was a top down or bottom up approach.
Then, navigate to the next page.
Definition:
Female Genital Mutilation: The partial or total removal of external female genitalia or other injury to
female genital organs for no medical reasons. There are no documented benefits of female genital
mutilation.
References:
Female genital mutilation. (n.d.). Retrieved February 2021, from https://www.who.int/news-room/fact-
sheets/detail/female-genital-mutilation
Female circumcision. (n.d.). Retrieved February 2021, from

https://www.nafgemtanzania.or.tz/index.php/what-we-do/female-circumcision

Makoye, K. (2015). Tanzanian universities to offer courses on treating FGM: DW: 17.12.2015. Retrieved
February 2021, from https://www.dw.com/en/tanzanian-universities-to-offer-courses-on-treating-
fgm/a-18923966

4.13.3 TOP DOWN PROMOTES A BOTTOM UP APPROACH

3/3
The top down approach of criminalisation of F G M has allowed the empowerment of grassroots
organizations (bottom up) founded by women and girls, many of whom have escaped their family and
village to avoid the cutting.
One such organization, N A F G M, carries out a set of complementary actions to combat the practice
at the grassroots and community level. Some of the work that they do includes:
• running rescue homes with education and vocational school for girls that have escaped the
practice,
• educating both boys and girls about the trauma caused by F G M, and
• educating midwives and the cutters in the community.
One of the many tactics that has been used by N A F G M is recognizing the status and large financial
reward that cutters have in the community. Thus, N A F G M finds other high-status roles for cutters
when they finally reject the job. This picture is of a display case of instruments that were given to the
organization by cutters that gave up their roles, and was taken by Dr. Carpenter while in Tanzania.
Definition:
N A F G M: Network Against Female Genital Mutilation.
References:
Female genital mutilation. (n.d.). Retrieved February 2021, from https://www.who.int/news-room/fact-
sheets/detail/female-genital-mutilation
Female circumcision. (n.d.). Retrieved February 2021, from

https://www.nafgemtanzania.or.tz/index.php/what-we-do/female-circumcision

Makoye, K. (2015). Tanzanian universities to offer courses on treating FGM: DW: 17.12.2015. Retrieved
February 2021, from https://www.dw.com/en/tanzanian-universities-to-offer-courses-on-treating-
fgm/a-18923966

4.14 ADDRESSING INEQUITIES THROUGH POLICY
13 OF 17
Health policies are aimed at reducing health inequities.
Reveal the types of policies that help eliminate health inequities.
1. Social goods being governed by the public sector.

2. Legislation that promotes gender equity.
3. Promoting political empowerment, especially for disadvantaged populations.

4.15 GOAL 3: MEASURING AND MONITORING HEALTH
14 OF 17
The third and final recommendation of the Closing the Gap in a Generation report identified the need
to continuously measure health problems and solutions to design effective, targeted interventions.
Continuous measurement may involve using resources like the G B D study, which provides
information on the magnitude of health problems. Reports such as the M D G Task Force Report done
in 2015 at the conclusion of the Millennium Development Goals, provide critical information about the
successes and short-comings of interventions as a way to improve the future interventions.
Visit each resource.
G B D Compare Tool
Millennium Development Goals
Page Links:
https://vizhub.healthdata.org/gbd-compare/
https://www.un.org/millenniumgoals/

4.16 PUTTING THE RECOMMENDATION INTO PRACTICE
15 OF 17
Assessment Part 2 of this course is a Health Needs Assessment that provides you with an opportunity
to put the recommendation of measuring and monitoring health into practice.
As part of your health needs assessment, you will quantify a health need of a population, identify a
root cause of a health problem, and consider a possible intervention to address the health need.
Understanding the concept of barriers and enablers will help you to think about the feasibility of your
health intervention.
Navigate to the next page to learn about these two concepts.

4.17 BARRIERS AND ENABLERS
16 OF 17
All health interventions have barriers (obstacles) and enablers (supports), which can include health
policy.
Learn about each concept. Consider these examples as you work through Assessment Part 2.
Definition Examples
Barriers Barriers are understood as obstacles • Civil unrest
that could harm the feasibility of a policy • Governmental policies or agendas
or intervention. • Physical barriers (e.g. lack of
infrastructure)
• Cultural barriers (e.g. mistrust of
Western medicine)
Enablers Enablers relate to factors or resources • The willingness of a community to
that can be leveraged to increase the accept a policy or participate in an
feasibility or effectiveness of a policy or intervention
intervention. • Governmental programs that make
additional resources available for
addressing the health issue

17 OF 17
In this section, you learned about the four pillars of primary health care that create an optimal
healthcare system. You then learned about the health inequity experienced in rural Canadian
Indigenous communities. The three main factors causing this health inequity are underfunded nursing
stations, the inability to access medical transportation, and insufficient support allocation compared to
non-Indigenous rural communities. You also learned about the Truth and Reconciliation Commission (T
R C) of Canada and their report that discussed calls to action for the Canadian government to close the
health gap between Indigenous and non-Indigenous Canadians.
You also explored the importance of equitable health policies in shaping health, and about the benefits
of intersectoral action for health. You learned about market responsibility and how having social goods
governed by the public sector reduces health disparities. You then explored the two political
empowerment methods - top down and bottom up approaches. You concluded the section by learning
about the importance of measuring and monitoring health.

CONCLUSION
Z Z.1 MODULE 04 CONCLUSION

Z Z.2 QUESTION: INFORMED DISCUSSION OF COURSE THEMES

2 OF 7
Now that you have completed Module 04, answer the question a second time.

Feedback:

Z Z.3 QUESTION: INFORMED DISCUSSION OF COURSE THEMES

3 OF 7
Now that you have completed Module 04, answer the question a second time.
Feedback:

Z Z.4 QUESTION REVIEW: DISCUSSION OF COURSE THEMES
4 OF 7
Compare your answer from prior to completing Module 04 to your answer now that you have completed the
module and are more informed about global health.
Question 01 Review – Refer to Z Z.4.1 Discussion of Course Themes: 01 Sub Page
Question 02 Review – Refer to Z Z.4.2 Discussion of Course Themes: 02 Sub Page

Z Z.4.1 DISCUSSION OF COURSE THEMES: 01
SUB PAGE OF Z Z.4 QUESTION REVIEW: DISCUSSION OF COURSE THEMES

QUESTION 01 REVIEW
1/1

Original Answer:
Informed Answer:

Z Z.4.2 DISCUSSION OF COURSE THEMES: 02
SUB PAGE OF Z Z.4 QUESTION REVIEW: DISCUSSION OF COURSE THEMES

QUESTION 02 REVIEW
1/1
5 OF 7
Original Answer:
Informed Answer:

Z Z.5 MODULE CONCLUSION
5 OF 7
Throughout Module 04, you revisited the social determinants of health and identified the important
concepts related to closing the gap in health between high S D I and low S D I countries. You read
through key findings from the 2008 Closing the Gap in a Generation report, which was aimed at
drastically diminishing inequities, in one generation, between those living in wealthy conditions and
those living in poverty. You concluded the module by learning about some of the health inequities
faced by the Canadian Indigenous population. Further, you explored some of the current steps and
initiatives that have been started to help minimize and eliminate these inequities.
Read a unique back-story relating to this image.
Alt Text: Patients waiting for us to arrive for the mobile clinic.

Z Z.6 CREDITS
6 OF 7
This module was created by Dr. Jennifer Carpenter in collaboration with Lindsay Brant from the Centre
for Teaching and Learning, and the Course Development Team within the Office of Professional
Development and Educational Scholarship.
A big thank you to Dr. Carpenter’s team of Teaching Assistants, Aleksandra Velickovic and Mitchell
Profeit for their contributions during module development.
The personal images within this module were taken by Ms. Suzy Lamont and used with her permission.
To see more of her work, visit www.SuzyLamont.com.
Do not distribute this online learning module to any learners who are not affiliated with Queen’s
University as it is a direct violation of the Queen’s Academic Integrity Policy. All materials in this module
are protected by copyright and must not be distributed to third party sites. Learners found in violation
can face sanctions.
Page Link:
www.SuzyLamont.com

Z Z.7 MODULE OUTLINE
7 OF 7
Review a short description for each of the sections or click to begin a section.
SECTION 01: The Gap in Global Health and Social Determinants of Health
In this section, you will learn the differences between communicating global health issues as an
advocate versus as a scientist. You will also learn about the health inequities, such as differences in life
expectancy, that exist between low S D I and high S D I countries.
SECTION 02: The Closing the Gap Report
In this section, you will discuss the Closing the Gap in a Generation report established by the W H O to
minimize health inequities, by targeting the social determinants of health.
SECTION 03: Closing the Gap by Improving Living Conditions
In this section, you will explore the five main ideas for improving of living conditions, as outlined by the
Closing the Gap in a Generation report.
SECTION 04: Closing the Gap by Addressing Inequities
In this section, you will read about the four pillar primary healthcare model that makes up an optimal
policies in shaping health and the benefits of intersectoral action for health.

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GLPH 271

GLOBAL AND POPULATION HEALTH

A. Closing the Gap in Health ............................................................................................................................ 6

B. Dr. Carpenter’s Acknowledgement of Territory ........................................................................................ 7

D. Course Icons ................................................................................................................................................10

F. Module Assignments ..................................................................................................................................12

F.1 Gap in Health Discussion .....................................................................................................................13

F.2 Political Empowerment Discussion Board .........................................................................................14

F.3 Video: Assessment Part 2 .....................................................................................................................15

G. Question 1 of 2: Preliminary Discussion of Course Themes .................................................................16

H. Question 2 0f 2: Preliminary Discussion of Course Themes .................................................................17

I. Module Outline .............................................................................................................................................18

1.2 Video: Measuring and Assessing Health ................................................................................................20

1.3 Advocating for Health at a Global Level .................................................................................................21

1.4 Question: Advocate versus Scientist .......................................................................................................22

1.5 Communicating about Global Health .....................................................................................................23

1.6 The Gap in Global Health .........................................................................................................................24

1.7 Interaction: Life Expectancy Across the Globe ......................................................................................25

1.8 Question: Communicating about Global Life Expectancy ....................................................................26

1.9 Social Determinants of Health.................................................................................................................27

1.10 Social Gradient ........................................................................................................................................28

1.11 A Closer Look Into the Social Gradient .................................................................................................29

1.12 Question: Social Gradient and the S D Hs............................................................................................30

1.13 Video: The Poverty Trap .........................................................................................................................31

1.14 Interaction: G D P Per Capita Across the Globe ..................................................................................32

1.15 Section 01 Summary ...............................................................................................................................33

SECTION 02: The Closing The Gap Report ........................................................................................................34

2.1 Section 02: The Closing the Gap Report .................................................................................................34

GLOBAL AND POPULATION HEALTH | GLPH 271 M04 PAGE 2

2.3 Podcast: W H O Closing the Gap in a Generation Report .....................................................................36

2.4 Question 1 of 3: Gaps in Global Health ..................................................................................................39

2.5 Question 2 of 3: Social Determinants of Health ....................................................................................40

2.6 Question 3 of 3: Understanding of Health .............................................................................................41

2.7 Goals of Closing the Gap in a Generation ..............................................................................................42

2.8 Section 02 Summary .................................................................................................................................43

SECTION 03: Closing The Gap By Improving Living Conditions .....................................................................44

3.2 Goal 1: Improve Daily Living Conditions .................................................................................................45

3.3 Housing and Home Environment............................................................................................................46

3.4 Video: Harsh Living Conditions of Syrian Refugees ..............................................................................47

3.5 Question: Impact of Poor Living Conditions on Health ........................................................................49

3.6 Living Conditions on Indigenous Reserves ............................................................................................50

3.7 Early Childhood Development & Health ................................................................................................51

3.8 The Jamaican Study...................................................................................................................................52

3.9 Employment and Working Conditions....................................................................................................54

3.10 Question 1 of 2: COVID-19 and Employment ......................................................................................55

3.11 Question 2 of 2: COVID-19 and Employment ......................................................................................56

3.15 Neighbourhood and Natural Environment ..........................................................................................60

3.16 Video: The Healthy Cities, Healthy Communities Movement ............................................................61

3.17 Urbanization and Health ........................................................................................................................62

3.18 Question: Impact of Climate Change Across the Globe .....................................................................65

3.19 Governments and Social Policies ..........................................................................................................66

3.20 Social Protection Across the Lifecourse ...............................................................................................67

3.21 Question: The Feasibility of Social Security .........................................................................................68

3.22 Video: Universal Healthcare Policy .......................................................................................................69

3.23 Racial Inequality in Healthcare ..............................................................................................................70

3.24 Video: The A B C Project .........................................................................................................................71

3.25 Section 03 Summary ...............................................................................................................................72

SECTION 04: Closing The Gap By Addressing Inequities ................................................................................73

GLOBAL AND POPULATION HEALTH | GLPH 271 M04 PAGE 3

4.1 Section 04: Closing The Gap By Addressing Inequities.........................................................................73

4.2 Goal 2: Addressing Inequities ..................................................................................................................74

4.3 Optimal Healthcare Systems ...................................................................................................................75

4.4 Health Inequity in the Canadian Indigenous Population .....................................................................76

4.4.1 Access to Quality Nursing Stations ..................................................................................................77