Class 1-4: Barriers to Wellness

Overview

Today's Class Overview

In today's class, you will learn about the barriers that often prevent individuals from maintaining their health, meeting their needs, and working towards well-being across the dimensions.

Today's Class Objectives

By the end of today's class, you should be able to:

1. Define the Built Environment.
2. Identify major Social Determinants of Health.
3. Explain the "Health Gradient" and how it relates to personal health and wellness behaviors.
4. Discuss how communities can support personal wellness behaviors.
5. Define "Health Literacy" and explore how individuals navigate their health care.
6. Connect with resources for mental health support.

Outline of Today's Class

• Materials
  1. Overview
  2. Review Last Class
  3. Wellness and the Shared Environment
  4. Social Determinants of Health
  5. The Health Gradient
  6. Health Literacy and Self Advocacy
  7. Mental Health
  8. Summary

Review

Reviewing 1-3: Strategies for Wellness

• Stress is the response of the mind and body to demands.
  • Stress can be beneficial or negative depending on our ability to manage and adapt to it.
  • Stress can have physical effects on the body, especially chronic stress.
  • Stress can motivate performance up to a certain point, after which performance declines.
  • Stress can be managed in many ways.
• "Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, and non-judgmentally.”
  • Mindfulness is not a technique or practice, but a state of being.
  • To be mindful is to see the world as it is, avoiding the types of preconceived judgments (cognitive distortions) we explored earlier.
  • Mindfulness activities can take many forms, such as breathing, walking, eating, or praying.
    • Difficulty in being mindful is a normal and helpful part of developing mindfulness.
  • S.T.O.P. for Mindfulness and Metacognition
    • Stop and take a moment.
    • Take a conscious breath or two to relax the nervous system.
    • Observe what is happening in your body at a distance.
    • Proceed with your next step from a place of intention and relative calm.
• Journaling
  • Researchers have shown that journaling can contribute to health and success.
  • Journaling can:
    • Reduce stress
    • Provide a safe place for emotions
    • Improve physical health
    • Help with problem solving
    • Provide perspective
• Healthy relationships are built on respect.
  • Love is Respect.org is a resource for learning about healthy relationships.
  • 7 C's of Healthy Relationships:
    • Conflict Resolution
    • Checking In
    • Consent
    • Courage
    • Compassion
    • Celebration
    • Communication
  • Grief is a natural experience of loss.
    • There are no standards for grieving and each person's experience of grief is unique.
    • Resources are available to help you as you encounter and process grief.
• Sleep is a survival need.
  • Inadequate sleep can inhibit your ability to learn, make decisions, and exhibit self-control.
  • Adequate sleep supports learning and performance.

What is the Built Environment?

In 2006, UCLA Professor Emeritus Doctor Richard Joseph Jackson spoke with Metropolis Magazine about an eye-opening experience on his way to the Centers for Disease Control and Prevention in Atlanta, Georgia, two hours north of Columbus State University.

The following is adapted and excerpted from the British Columbia Provincial Health Services Authority's "Foundations for a Healthier Built Environment" Report under fair use:

One Hot Day on Buford Highway in Atlanta, Georgia

“The head of the CDC invited his dozen directors to the central office to work on a paper about the ten leading diseases of the twenty-first century.

I’m driving over there, and as always I’m thinking about pesticides, herbicides, cancer, and birth-defect clusters—you name it.

I’m late, stuck in traffic on Buford Highway, voted one of the ten worst streets in North America.

It’s a seven-lane road surrounded by garden apartments, mainly for poor immigrants, with no sidewalks and two miles between traffic lights.

It’s 95 degrees out, 95 percent humidity. I see a woman on the right shoulder, struggling along, and she reminds me of my mother.

She’s in her seventies, with reddish hair and bent over with osteoporosis.

She has a shopping bag in each hand and is really struggling.

If that poor woman had collapsed from heat stroke, we docs would have written the cause of death as ‘heat stroke’ and not lack of trees and public transportation, poor urban form, and heat-island effects.

If she had been killed by a truck going by, the cause of death would have been ‘motor-vehicle trauma,’ and not lack of sidewalks and transit, poor urban planning, and failed political leadership.

That was the ‘aha!’ moment for me. Here I was focusing on remote disease risks when the biggest risks that people faced were coming from the built environment.”

What is The Built Environment?

As he explains, the simple answer of "heat stroke" has many factors that underlie it - the lack of shade that trees can provide over walkways, for instance, and the decisions behind the placement of those roads and businesses. Just as our behavior is often directed by our needs, the choices and opportunities available are often determined by our surroundings.

The phrase ‘built environment’ refers to the surroundings that we humans have created.

These surroundings include both indoor and outdoor places and vary from large-scale urban areas to smaller rural development and personal spaces.

Recently, there is a growing understanding about how the choices we make about our built environment impact health.

Consider, for instance, the distances people must travel to work, the convenience of buying healthy foods, or the safety of a park: all of these factors can promote good nutrition and physical activity, leading in turn to better mental and physical health.

See Figure 2 (below)

Having well-designed homes, sidewalks, transportation systems and playgrounds promotes activity for all ages.

For instance, we know that urban environments that lack public gathering places encourage sedentary habits, while attractive parks and open spaces create opportunities for exercise; Protection from physical injuries [while being active] is a key concern of parents and of the elderly.

Other examples [of how the built environment can encourage physical activity] would be reducing the speed of vehicular traffic and providing safe cycling and walking routes.

People want to live in places where they are able to be active and are also more likely to walk when land use is mixed (i.e., locating shops, schools, and workplaces close to homes).

According to the World Health Organization, 80% of some chronic diseases can be prevented.

The global rise in childhood asthma, for instance, is attributed to poor air quality from industrial activity and vehicle emissions.

Diabetes and cardiac disease are related to obesity and physical inactivity.

These conditions in which people live and work are sometimes called ‘the causes behind the causes’ of ill health.

Many cannot be tackled directly by our health care system.

Even more basic, the lack of safe, affordable housing severely impacts health, with the most marginalized – such as people living with mental illness – suffering the worst effects.

We know that walking and biking to school have become much rarer, in part because of planning and investment policies (approvals for new development are not tied to spending to improve pedestrian and bicycle infrastructure), urban form patterns (school sites are not easy for children to walk or bike and because our communities are not built to support those activities).

The result on individual behaviour?

Only 10% of students use active transport to get to school.

The result on population health?

Thanks to rising obesity rates – what some call the new tobacco – we’re faced with the very real possibility that the current generation of children may actually be the first to have a lower life expectancy than their parents.

The interior design of homes, schools, workplaces and other buildings also affects health.

For example, public buildings can encourage physical activity with attractive, convenient staircases.

Well designed schools improve children’s educational achievement. However, indoor environments can also have negative effects such as when harmful substances contaminate indoor air and cause respiratory diseases such as asthma.

Personal space, temperature, lighting, humidity and noise are other factors of the indoor built environment that affect health in different ways.

In sum, personal health behaviors are made easier by supportive settings that promote healthy human habitats and healthy social interaction: access to recreation, schools, jobs, health and social care, strong social networks, good air and water quality, and opportunities for physical activity.

Social Determinants of Health

The following has been excerpted and adapted from the U.S. Department of Health and Human Services' "Healthy People 2030 - Social Determinants of Health" page under fair use:

What are social determinants of health?

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

SDOH can be grouped into 5 domains:

Economic Stability

Goal: Help people earn steady incomes that allow them to meet their health needs.

In the United States, 1 in 10 people live in poverty,¹ and many people can’t afford things like healthy foods, health care, and housing. Healthy People 2030 focuses on helping more people achieve economic stability.

People with steady employment are less likely to live in poverty and more likely to be healthy, but many people have trouble finding and keeping a job. People with disabilities, injuries, or conditions like arthritis may be especially limited in their ability to work. In addition, many people with steady work still don’t earn enough to afford the things they need to stay healthy.

Employment programs, career counseling, and high-quality child care opportunities can help more people find and keep jobs. In addition, policies to help people pay for food, housing, health care, and education can reduce poverty and improve health and well-being.

Education Access and Quality

Goal: Increase educational opportunities and help children and adolescents do well in school.

People with higher levels of education are more likely to be healthier and live longer. Healthy People 2030 focuses on providing high-quality educational opportunities for children and adolescents — and on helping them do well in school.

Children from low-income families, children with disabilities, and children who routinely experience forms of social discrimination — like bullying — are more likely to struggle with math and reading. They’re also less likely to graduate from high school or go to college. This means they’re less likely to get safe, high-paying jobs and more likely to have health problems like heart disease, diabetes, and depression.

In addition, some children live in places with poorly performing schools, and many families can’t afford to send their children to college. The stress of living in poverty can also affect children’s brain development, making it harder for them to do well in school. Interventions to help children and adolescents do well in school and help families pay for college can have long-term health benefits.

Health Care Access and Quality

Goal: Increase access to comprehensive, high-quality health care services.

Many people in the United States don’t get the health care services they need. Healthy People 2030 focuses on improving health by helping people get timely, high-quality health care services.

About 1 in 10 people in the United States don’t have health insurance.¹ People without insurance are less likely to have a primary care provider, and they may not be able to afford the health care services and medications they need. Strategies to increase insurance coverage rates are critical for making sure more people get important health care services, like preventive care and treatment for chronic illnesses.

Sometimes people don’t get recommended health care services, like cancer screenings, because they don’t have a primary care provider. Other times, it’s because they live too far away from health care providers who offer them. Interventions to increase access to health care professionals and improve communication — in person or remotely — can help more people get the care they need.

Neighborhood and Built Environment

Goal: Create neighborhoods and environments that promote health and safety.

The neighborhoods people live in have a major impact on their health and well-being.¹Healthy People 2030 focuses on improving health and safety in the places where people live, work, learn, and play.

Many people in the United States live in neighborhoods with high rates of violence, unsafe air or water, and other health and safety risks. Racial/ethnic minorities and people with low incomes are more likely to live in places with these risks. In addition, some people are exposed to things at work that can harm their health, like secondhand smoke or loud noises.

Interventions and policy changes at the local, state, and federal level can help reduce these health and safety risks and promote health. For example, providing opportunities for people to walk and bike in their communities — like by adding sidewalks and bike lanes — can increase safety and help improve health and quality of life.

Social and Community Context

Goal: Increase social and community support.

People’s relationships and interactions with family, friends, co-workers, and community members can have a major impact on their health and well-being. Healthy People 2030 focuses on helping people get the social support they need in the places where they live, work, learn, and play.

Many people face challenges and dangers they can’t control — like unsafe neighborhoods, discrimination, or trouble affording the things they need. This can have a negative impact on health and safety throughout life.

Positive relationships at home, at work, and in the community can help reduce these negative impacts. But some people — like children whose parents are in jail and adolescents who are bullied — often don’t get support from loved ones or others. Interventions to help people get the social and community support they need are critical for improving health and well-being.

Personal Choices and Community Health

Earlier in the course, we discussed personal wellness behaviors from the perspective of individual needs. Today, you've explored how the built environment and one's greater community can affect the opportunities for these behaviors. The following figure visually represents the idea that addressing these underlying causes of illness and other issues in the built environment can make it easier and more sustainable for individuals to make positive choices for themselves:

The following image has been excerpted from the British Columbia Provincial Health Services Authority's "Foundations for a Healthier Built Environment" Report under fair use:

Food Deserts

Food deserts, areas where residents have limited access to healthy food options, demonstrate how extrapersonal (outside the individual) pressures can raise the "slope" of the challenges to regularly engaging in wellness behaviors.

We'll explore food deserts in more detail when we discuss nutrition later in the course.

For now, watch this brief (3.5 minute) video for an introduction to food deserts.

How are personal choices related to food affected by the built environment around us?

Community Initiatives

Though these issues can seem insurmountable, community efforts to lower the "slope" of the built environment's barriers can create can empower individuals to improve their health and well-being. Public health researchers, community investment professionals, and other stakeholders work to address these barriers.

Watch this video from NPR to learn about some initiatives and how they are helping to offer citizens the choices and opportunities needed to lead healthier lives.

Health Literacy

The following has been excerpted and adapted from The United States Centers for Disease Control and Preventions' Health Literacy page under fair use:

Health Literacy

The CDC currently identifies two facets to health literacy:

• Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
• Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Health literacy is important for everyone because, at some point in our lives, we all need to be able to find, understand, and use health information and services.

This brief (2-minute) video, offered by Blue Cross Blue Shield of Michigan, will give you an overview of this topic.

Mental Health

The following has been excerpted and adapted from the National Alliance on Mental Illness under fair use:

Mental Health Conditions

NAMI recognizes that other organizations have drawn distinctions between what diagnoses are considered “mental health conditions” as opposed to “mental illnesses.” We intentionally use the terms “mental health conditions” and “mental illness/es” interchangeably.

A mental illness is a condition that affects a person's thinking, feeling, behavior or mood. These conditions deeply impact day-to-day living and may also affect the ability to relate to others. If you have — or think you might have — a mental illness, the first thing you must know is that you are not alone. Mental health conditions are far more common than you think, mainly because people don’t like to, or are scared to, talk about them. However:

• 1 in 5 U.S. adults experience mental illness each year
• 1 in 20 U.S. adults experience serious mental illness each year
• 1 in 6 U.S. youth aged 6-17 experience a mental health disorder each year
• 50% of all lifetime mental illness begins by age 14, and 75% by age 24

A mental health condition isn’t the result of one event. Research suggests multiple, linking causes:

• Genetics, environment and lifestyle influence whether someone develops a mental health condition.
• A stressful job or home life makes some people more susceptible, as do traumatic life events.
• Biochemical processes and circuits and basic brain structure may play a role, too.

None of this means that you’re broken or that you, or your family, did something “wrong.”

Mental illness is no one’s fault.

And for many people, recovery — including meaningful roles in social life, school and work — is possible, especially when you start treatment early and play a strong role in your own recovery process.

The following has been excerpted and adapted from the Mayo Clinic under fair use:

What's considered normal mental health?

By Mayo Clinic Staff

What's the difference between normal mental health and mental disorders? Sometimes the answer is clear, but often the distinction isn't so obvious. For example, if you're afraid of giving a speech in public, does it mean you have a mental health disorder or a run-of-the-mill case of nerves? Or, when does shyness become a case of social phobia?

Here's help understanding how mental health conditions are identified.

Mental health is the overall wellness of how you think, regulate your feelings and behave. Sometimes people experience a significant disturbance in this mental functioning. A mental disorder may be present when patterns or changes in thinking, feeling or behaving cause distress or disrupt a person's ability to function.

A mental health disorder may affect how well you:

• Maintain personal or family relationships
• Function in social settings
• Perform at work or school
• Learn at a level expected for your age and intelligence
• Participate in other important activities

Cultural norms and social expectations also play a role in defining mental health disorders. There is no standard measure across cultures to determine whether a behavior is normal or when it becomes disruptive. What might be normal in one society may be a cause for concern in another.

A diagnosis of a mental health condition may be made by a psychiatrist, psychologist, clinical social worker or other mental health professional. Your primary care doctor may also be involved in a diagnostic assessment or make referrals to a mental health specialist.

Each mental health condition has its own signs and symptoms. In general, however, professional help might be needed if you experience:

• Marked changes in personality, eating or sleeping patterns
• An inability to cope with problems or daily activities
• Feeling of disconnection or withdrawal from normal activities
• Unusual or "magical" thinking
• Excessive anxiety
• Prolonged sadness, depression or apathy
• Thoughts or statements about suicide or harming others
• Substance misuse
• Extreme mood swings
• Excessive anger, hostility or violent behavior

Many people who have mental health disorders consider their signs and symptoms a normal part of life or avoid treatment out of shame or fear.

If you're concerned about your mental health, don't hesitate to seek advice.

Consult your primary care doctor or make an appointment with a psychiatrist, psychologist or other mental health professional. It may be important for you to find a professional who is familiar with your culture or who demonstrates an understanding of the cultural and social context that's relevant to your experiences and life story.

With appropriate support, you can identify mental health conditions and receive appropriate treatment, such as medications or counseling.

The following has been excerpted and adapted from MentalHealth.Gov's website under fair use:

Get Immediate Help

People often don’t get the mental health services they need because they don’t know where to start.

Emergency Medical Services—911

If the situation is potentially life-threatening, get immediate emergency assistance by calling 911, available 24 hours a day.

Talk to your primary care doctor or another health professional about mental health problems. Ask them to connect you with the right mental health services.

National Suicide Prevention Lifeline, 1-800-273-TALK (8255) or Live Online Chat

If you or someone you know is suicidal or in emotional distress, contact the National Suicide Prevention Lifeline. Trained crisis workers are available to talk 24 hours a day, 7 days a week. Your confidential and toll-free call goes to the nearest crisis center in the Lifeline national network. These centers provide crisis counseling and mental health referrals.

SAMHSA Treatment Referral Helpline, 1-877-SAMHSA7 (1-877-726-4727)

Get general information on mental health and locate treatment services in your area. Speak to a live person, Monday through Friday from 8 a.m. to 8 p.m. EST.

Summary

Major Points

During today's class, you have learned about:

• The Built Environment
  • The physical surroundings humans have created, such as streets, buildings, parks, etc.
  • Researchers have found that the design of the built environment can encourage or discourage physical activity and other wellness behaviors.
• Social Determinants of Health
  • External conditions that influence the health of individuals.
  • Five categories and goals identified by The United States Department of Health and Human Services' Healthy People 2030 initiative:
    • Economic Stability - Goal: Help people earn steady incomes that allow them to meet their health needs.
    • Education Access and Quality - Goal: Increase educational opportunities and help children and adolescents do well in school.
    • Health Care Access and Quality - Goal: Increase access to comprehensive, high-quality health care services.
    • Neighborhood and Built Environment - Goal: Create neighborhoods and environments that promote health and safety.
    • Social and Community Context - Goal: Increase social and community support.
• The Health Gradient
  • Imagine "health" as a hill that each person is climbing.
  • The barriers, hazards, and difficulties that limit health and wellness raise the angle or "slope" of the hill.
  • Decreasing social and environmental barriers makes the hill easier to climb and empowers individuals to maintain health and work toward wellness.
  • Food Deserts
    • Food deserts are one example of the barriers above.
    • Many areas in the United States have limited access to nutritious foods.
    • We will explore this complex issue further in the final portion of the course.
  • Community initiatives bring in health professionals, business interests, and community interests to lower barriers, increase opportunity, and support economic activity.
• Health Literacy
  • The degree to which information and services related to health are accessible and comprehensible to individuals.
  • Self-advocacy in healthcare means being knowledgeable and invested in your health, asking questions and collaborating with your medical professionals, and ensuring clarity in communication about your health.
• Mental Health Conditions
  • It is normal and healthy to experience anxiety, depression, boredom, unpleasant emotions, and intrusive thoughts.
    • Mental health professionals can assist with learning skills and tools to manage these normal experiences.
  • Mental health conditions are very common and can generally be improved with treatment.
  • It can be difficult to tell "normal" mental health challenges from ones that may require more assistance.
    • A mental health professional can help you navigate and understand your mental health.
      • Some signs that professional help may be indicated include:
        • Marked changes in personality, eating or sleeping patterns
        • Feeling of disconnection or withdrawal from normal activities
        • Prolonged sadness, depression or apathy
        • Excessive anger, hostility or violent behavior
    • 24/7 helplines include the SAMHSA Treatment Referral Helpline, 1-877-SAMHSA7 (1-877-726-4727) and the National Suicide Prevention Lifeline, 1-800-273-TALK (8255) or Live Online Chat