Social Determinants Of Health

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Introduction

Social determinants of health refers to the social and economical factors which affect one's health based on the environment in which individuals are born, grow, live, work, and age.[1] The risk for a disease, or vulnerability to disease or injury are often affected by social factors instead of individual risk factors such as genetics or behaviours. These social factors create health inequalities between different countries, for example, individuals living in first-world countries may have better health in general as compared to individuals living in third-world countries, who suffer from poorer health.

Factors affecting social determinants of health

The following is a list of 14 social determinants of health.[2] [3] [4]

Income and Income Distribution

Income is the most important social determinant of health. The level of one’s income will affect the individual in various ways such as shaping his/her living conditions, psychological functioning, and health-related behaviours such as the level of physical activity, usage of tobacco and alcohol, food security, and housing.

There are 2 different ways to study the relationship between income and health. The first way would be to study if health affects the actual income received by the individual or his/her family and the second way would be to study the distribution of income across the population and how it relates to the population’s health. The top predictor of a healthy society is equal income distribution.

Wolfson et al Study. Average Annual Income and Mortality Rate for 500,000 Canadian Men

An example of the relationship between income and health can be seen in a study conducted by Wolfson and colleagues.[5] They looked at the relationship between past earnings and mortality for more than half a million male retirees and contributors to the Canada Pension Plan. By looking at the mortality rate in the 65-to-70 age range and each individual's average level of earned income between ages 45 and 65, it is evident that as income increases, the mortality rate decreases.

Income level is vital in societies that are less able to provide important services and benefits. Individuals with low income are often deprived of certain material and services, which could lead to social exclusion as they are unable to participate in cultural, educational, and recreational activities. Therefore, in the long run, individuals may feel left out and this would affect their health and reduce their ability to live a fulfilled life.

Education

Across different ethnic groups, adults with greater education areless likely to rate their health as less than very good

Individuals who attained higher education would be healthier as compared to those with lower education.

Firstly, it has been found that level of education is highly correlated with other social determinants of health such as income level and working conditions.[6] Therefore, educated individuals are more likely to be aware of societal and economic resources.

Next, a higher education level facilitates individuals to make changes to the Canadian employment market as these individuals are often more exposed to more opportunities. Moreover, these individuals would be able to have a better understanding of the world and be aware of the societal factors influencing their health.

Lastly, education helps to improve the overall literacy and allow individuals to be responsible for their own health through their actions. Individuals who are educated would have skills that allow them to determine if their behaviour is beneficial or harmful to their health. They would also have more resources, which allow them to achieve a healthy lifestyle or work balance. For example, higher literacy rates has been found to correlate with lower tobacco use [7] and those with lower literacy rates tend to make less use of heath services. [8]

However, having education is not entirely the main reason for poor health. For example, if necessary healthcare and services are available to everyone, having education would not matter as much as these individuals are well covered.

Unemployment and Job Security

Employment provides income, creates a sense of identity, and structure one’s day-to-day life. However, unemployment causes material and social deprivation, mental stress, and a likelihood of adopting health-threatening coping mechanisms. Also, there is a high possibility that individuals may encounter physical and mental health problems such as depression, anxiety, and suicide. A recent study conducted at Zurich University’s Psychiatric Hospital revealed that unemployment leads to nine times as many suicides as an economic crisis. [9]

Although unemployment may cause health-related issues, insecure employment such as flexible working hours or intense working conditions may also be a problem. There is a high chance that individuals who are faced with insecure employment would be at risk of stress, bodily pains, and sleep deprivation. [10]

Employment and Working Conditions

Working Conditions and Health

It is important to have good working conditions as we spend a huge amount of time at our workplaces. Individuals who have a lower income and education are more likely to be the ones who experience bad working conditions. There are various factors at work which affects health outcomes, such as employment security, physical conditions at work, work pace, working hours, opportunities to grow and develop.

It was found that when there is a high demand in tasks to be completed with poor reward might lead to various health problems. Employees may be demoralized and be vulnerable to physical and mental illnesses when they feel that their efforts are not rewarded accordingly. [11] Also, when employees feel that they have little control to complete the high demand tasks, they may also be more susceptible to health problems. For example, individuals with high-stress have a higher probability to get high blood pressure, cardiovascular diseases, and development of physical and psychological difficulties such as depression and anxiety. [12]

Early Childhood Development

Early childhood experiences help individuals to gain better coping skills, be resistant to health problems and have lasting biological, psychological and social effects upon health.

“Latency effects” refer to how early childhood experiences predispose children to either good or poor health regardless of future experiences. It is the result from biological processes that are linked to pregnancy such as poor maternal diet and parental risk behaviours.

“Pathway effects” refer to a situation whereby up of one’s exposures to risk factors do not have immediate health effects but it has future health consequences. For example, there will not be an immediate health issue if a child lacks the motivation to study, however, there may be future health consequences due to lower educational attainment.

“Cumulative effects” refer to the build up of one’s experiences or living conditions that leads to adverse health consequences such as being deprived of materials and social life. These may cause one to lack the maturity and cause one to be helpless.

Food Insecurity

Food is essential and required for survival. Food insecurity occurs when people feel insecure about not having adequate food in terms of quantity and quality. These would cause them to consume lesser fruits and vegetables, milk products, and vitamins. When individuals lack the nutrition required by the body, they would be faced with consequences such as dietary deficiencies. Also, the feeling of insecurity would have an impact on their mental health as individuals feel uncertain and stress.

Housing

Housing and homelessness lead to health issues and having a house is a prerequisite to good health. It is necessary to own a house in order to be able to obtain a health life and living in an unsafe housing heightens the risk of various health problems. Also, individuals who do not have housing may feel insecure and this is linked to income insecurity, which leads to illness.

There are various ways as to how housing affects health. Overcrowding and poor heating lead to easy transmission of respiratory and other illnesses. Some individuals may lack the access of clean water and basic sanitation, and this may facilitate a widespread of disease in the neighbour. Both high and low cost of housing also plays a role in influencing health. High housing costs limit the resources available for people to support other social determinants of health. In contrast, low housing costs affects people as it makes them stress and encourage unhealthy means of coping such as substance abuse.

Social Exclusion

Social exclusion refers to the unbalanced relations of power among groups in society, which cause unequal access to economic, social, political, and cultural resources. Individuals who are socially excluded by society tend to be unemployed or earn lower salary and they tend to have a limited access to health and social services, education, and participation in politics. Hence, social exclusion affects health as it creates poor living conditions and personal experiences.

There are four aspects to social exclusion: denial of participation in civil affairs, denial of social good, exclusion from social production, and economic exclusion.

Denial of participation in civil affairs is the outcome of legal sanction as non-status residents or immigrants are not able to participate. There are also some individuals who are being discriminated against based on race, gender, ethnicity, or disabilty status. Secondly, denial of social goods occurs when people are not given health care, education, housing, and income security. Next, exclusion from social production refers to individuals who lack the ability to take part in social and cultural activities, as they do not have enough money or resources. Lastly, economic exclusion occurs when individuals, especially minorities, are prevented from having access to economic resources and job opportunities.

Social Safety Network

The social safety net is a range of benefits, program, and supports, which the governments provide to protects citizens from life changes that would affect their health such as raising children, education, jobs, and housing. To counter these adverse life changes, the government provides support such as providing family allowances, childcare, counselling, and job training.

However, there may also be unexpected situations such as road accident, family break-ups, and unemployment. All of these are tyipcally beyond one’s control and it threatens individuals’ health when they feel insecure which leads to psychological stress.

Health Services

Having a universal health care system protects people’s health and divides health costs across society. It is more effective as individuals gets to benefit from health care, especially those of lower incomes. It is believed that everyone should get equal access to health care and no one should be discriminated based on their physical appearance.

Aboriginal Status

There are a number of Aboriginal people in Canada and it is important to ensure that they receive equal healthcare treatment. However, Aboriginals and non-Aboriginals are on different level in many aspects. The average income of Aboriginal men and women is only 58% of the average income of non-Aboriginals. [13] Also, the education level differs between the two groups. For example, only about 50% of the Aboriginal population receive a high school diploma. [14] Moreover, the rates of several infections and chronic diseases are higher in the Aboriginal population.[15] Therefore, Aboriginals are more likely to be faced with food and housing insecurity, live in crowded houses.

Gender

Median annual earnings and earning rations by gender

One's gender, both self-perceived and perceived by others, is important in health and care.

Women are more susceptible to social determinants of health than men. There are various reasons to support this point, for example, women have more responsibilities, as they are needed to raise their child as well as take care of housework. Thus, women tend to be unable to work full time and being eligible for unemployment benefits.[16] Single mothers especially are at risk of entering poverty due to the lack of affordable child-care services, resulting in an inability to work. Also, women are more likely to be faced with discrimination in the workplace. For example, women are less likely to be employed and are more likely to be working part-time[17] and women on average earn much less than men. [18]

Men are more likely to be working full-time and they are more likely to feel socially excluded and this can be seen in homelessness and addiction to substance. They are also the main victims of suicide and be involved in robbery and physical assault.

Gay, lesbian, and transgendered are often victims of discrimination and this may cause them to feel stress, which leads to adverse health effects.

Race

Racialized and immigrant groups are often victims of the labour market segregation, unemployment and income inequality, and poverty. Racism can affect one’s health in 3 different forms. Instituitionalized racism occurs when a certain group is targeted and discriminated due to their race in both the social and political institutions of society such as housing and education. Mediated racism refers to prejudice and discrimination, and can be demonstrated as lack of respect, de-humanization. Internalized racism is individuals who are stigmatized acknowledge that their own abilities and lack of worth. All of these can cause resignation, helplessness, and hopelessness. Some studies demonstrate the link between race and health. Racialized immigrants were found to be 2 times more likely to report health problems and were 50% more likely to frequently visit doctors than the Canadian born population. [19]

Disability

Individuals with disabilities often experience physical, social, civic, economic, and cultural rights. These individuals often feel left out without proper support and opportunities from society. Also, they are more likely to be unemployed and discriminated. An employer may not be willing to accommodate and be lenient to these individuals, which can be frustrating and disheartening for them.

People with disabilities are often lagging behind when it comes to the social determinants of heath. For example, people with disabilities are less likely to be employed. In Canada, only 35% of men and 23% of women were employed full time in the year 2000, whereas the statistics for non-disabled men and women were 53% and 37%, respectively. [20] Thus, a lack of employment will result in less income, which will again affect food security, housing, and many other determinants.

Theoretical approaches to explain inequalities in health

Materialist/ structuralist theory

The materialist/structuralist theory suggests that individuals with low income have lesser alternatives to available resources that could help them cope with stressors of life, which leads to poor health. Also, the theory considers the fact that the conditions are a result from one's income such as the psychosocial and physical factors. [21] [22] These availability of resources includes amenities of life, working conditions, quality housing and food.

Psycho-social model

Psycho-social model suggests that an individual's position in the social hierarchy leads to stress, especially those in the lower level of the hierarchy. This will lead to a neuroendocrine response that produces disease.[23] [24] [25]

Social production of health model

Social production of health model is based on the belief that the accumulation of wealth, power, prestige and material asserts are gained at the cost of the disadvantaged. [26]

Eco-social theory

The eco-social theory combines both psycho-social and social production of health models to look at how social and physical environments merge with biology and how individuals integrate aspects of their environment.[27] It builds on the collective approach that lifestyle choices are a result of the one's physical environment. [28]

Life-course perspective

The life course perspective highlights the importance of the amount of experience gained throughout the life span in understanding health maintenance and the possible disease symptoms for diagnosis.[29] Adopting a life course perspective allows one to realize that social determinants of health can immediately influence health and provide insights for future health outcomes; it also functions at every level of development: early childhood, childhood, adolescence, and adulthood.[30] The probability of developing a disease is dependent upon the way individuals live their lives, adverse economic and social conditions across the life span. One's health is seen as a continuum instead of disconnected and unrelated stages. There is a strong interaction between social and environmental factors with biological, behavioural, and psychological issues that ultimately determine the health outcomes across the life span of individuals.

The idea of life-course perspective is similar to early childhood development, which is one of the social determinants of health. There are 3 effects that are found to be relevant to the life-course perspective: Latency, Pathway, Cumulative periods.[31]

The latency period refers to how early childhood exposures predispose children to either good or poor health regardless of future experiences. It is the result from biological processes that are linked to pregnancy such as poor maternal diet and parental risk behaviours. “Pathway effects” refer to a situation whereby up of one’s exposures to risk factors do not have immediate health effects but it has future health consequences. For example, there will not be an immediate health issue if a child lacks the motivation to study, however, there may be future health consequences due to lower educational attainment. “Cumulative effects” refer to the build up of one’s experiences or living conditions that leads to adverse health consequences such as being deprived of materials and social life. These may cause one to lack the maturity and cause one to be helpless.

Ways to improve conditions of health worldwide

To improve conditions of health, it is extremely important for the respective governments to make the change. The primary method is through enactment of public policies that provide the living conditions required for good health.[32] Here are some examples of possible public policies[33]:

  • Improve income and poverty by increasing minimum wage and adopting progressive taxation
  • Improve education by adequately funding the education system (both secondary and post-secondary)
  • Improve on gender inequality by enforcing a pay equity legislation along with more affordable childcare services
  • Aid organizations can develop 5-10 year plans alongside local governments to transition the provision of health-related social services from private and independent institutions to governmental, public institutions

However, there are several ways the general public can help improve the determinants of health by increasing public awareness.[34] First, we can urge the government to address the inequalities in health and implement the public policies listed above. Individuals should also support candidates of political parties that are interested to the social determinants of health concept.is creating health supporting public public and ensuring that its citizens are in good hands. Second, we need to be more involved in educating the public and ourselves about the social determinants of health and convert the knowledge into action. In British Columbia, a non-profit organization called the BC Health Coalition is just one example of a group whose sole purpose is to educate the public about health care issues, and to advocate for improvements to the public health care system. It is important to build a connection with agencies, organizations and institutions to help promote healthy living and preventing illness. For example, different health foundations, hospitals and health care professionals should educate themselves and their patients on the social determinants and how they affect one's health. Hopefully, with the support from the general public, the government can create solid plans to ensure everyone receives equal and quality health care.

Social determinants of health and health-seeking behaviour

Health-seeking behaviour is type of social behaviour used to determine one's action to seek assistance related to their health conditions. There are various reasons as to why individuals would be willing to either seek help or ignore their health condition, however, it also depends on one's ability to be able to seek help. It is crucial to understand the reasons behind individuals' actions with regards to health-seeking behaviours in all aspects such as medical conditions and psychological health. Social determinants of health strongly affects various factors of health-seeking behaviour such as social-economic status (SES), gender, race, and education.[35]

Socioeconomic status (SES) and health-seeking behaviour

Socioeconomic status (SES) is defined as one's standing in the stratification system and it is usually determined by level of education, occupation, employment, income, and wealth.[36] There are various underlying reasons to explain the inverse relationship between SES and detrimental behaviours such as tobacco use, lack of physical exercise, poor nutrition intake. Limited access to resources produced by the unequal distribution of power in society and lack of health literacy are causes of patient dissatisfaction, which reduces health-seeking behaviour. Individuals who are classified under the low SES often have lesser opportunities to have regular medical checkups and screenings, more likely to work at places with contact with hazardous materials, and live in safe neighbourhoods with less pollution. In addition, illegal behaviours which includes drugs and involvement in criminal acts would also put an individual at risk to poor health.

Gender and health-seeking behaviour

Gender differences (men and women) is important in describing the patterns of health-seeking behaviour. Generally, compared to men, women are less likely to seek health treatments.[37] There are three components that a women would use to make decisions to seek healthcare. The first component would be that women are less likely to acknowledge the fact that they have some sort of health issues. It is vital that one recognizes that he/she has health issues or be aware of the symptoms that lead to an issue. The second component would be that women are more inhibited as they feel restricted in getting support and accessing health treatments. Lastly, women might be less likely to inquire information about their health issues and seek treatment to find a cure for themselves. This could be due to the restricted accessibility that restricts certain women from getting access to proper healthcare. Men, on the other hand, worry more about loss of income and other financial difficulties.[38] They are more fearful of how much the treatment would cost if they were to seek diagnosis and treatment from professions, which cause a delay in health-seeking behaviour. Also, men would typically neglect the symptoms of the illness until it has reached the severe stage, and by the time it reaches the serious stage, they would go directly to public health services as it is cheaper compared to private health practitioners.

Race/Culture and health-seeking behaviour

The culture values differs among people and these differences contributes to the possibility of one to seek healthcare. The Asian-American culture is typically influenced by Confusion values which emphasized on family and social harmony.[39] As a result of these values, individuals from these culture would therefore place their family needs before their own, which may prevent them from actively pursue healthcare. It also suggest that one's illness such as physical and mental illness are a result of family issues instead of individual issues, and these prevented them from exposing their family issues to public or people who are not related such as government, doctors, health care professionals. Therefore, this may cause a delay in one's act to pursue proper health treatment.

Education and health-seeking behaviour

The level of education plays a role in determining if one would pursue health-seeking behaviour. When an individual is not well-educated and does not know how to seek proper healthcare treatment or have some knowledge of various symptoms of a variety of disease, they would not seek healthcare in the first place. They may be kept ignorant and this may prolong their symptoms and cause it to be more serious in a matter of time. For example, an elderly who has low level of education would consider Tuberculosis to be dangerous and perceive it to be an incurable disease, however, a young well-educated individual would consider the illness to be curable as he knows more about the illness.[40] In another instance, girls who experience menstruation for the first time may be anxious and eager to find out more about this natural phenomenon, but some of them, especially the less educated, may not get a chance to learn about it.[41] Therefore, they may not be able to gain appropriate knowledge or ways to take care of this and it may lead to mental health issues such as anxiety, or infection as they are not aware of how they should take good care of themselves when having menstruation.

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