Social determinants of public health

Figure 5.1

Death rate, age standardised, for all causes of death by deprivation twentieth, ages 15–64 years, 1999–2003, UK (England and Wales) (Romeri, Baker & Griffiths, 2006)



The situation among people of poorer countries that have been disadvantaged by ‘historical exploitation and persistent inequity in global institutions of power and policy-making’ (World Health Organization, 2008) is more complex. Most people who are deprived in developed countries are still wealthy by global standards. They have good sanitation, clean water, accessible education and relatively good food supplies. But they will still be better off than the deprived in poor countries – the greater the social disadvantage, the worse the health. Countries in socio-economic transition (like India) are doubly affected: they have high rates of death among those of low socio-economic status and high rates of chronic disease in people of high socio-economic status. The causes of chronic diseases such as heart disease, cancer and diabetes are the same wherever these diseases occur, suggesting there is a need for a coherent framework for global health action (World Health Organization, 2008).



Spotlight 5.5 The Sustainable Development Goals – 17 goals to transform the world by 2030

The Sustainable Development Goals (SDGs) make up a set of 17 international targets that the UN member states will use to frame their political agenda to 2030. Proponents say they are stronger than previous goals because they address the root causes of poverty and recognise the fact that development of countries is interconnected. Importantly, they are underpinned by human rights. They were written after widespread consultation which included ‘global conversations’, national consultation, door-to-door surveys and an online ‘My World’ survey in which individuals could identify the areas they would like to see addressed in the gaols. A role for the business sector has been recognised: to achieve economic growth without environmental degradation. The goals have been signed by 70 countries. Rather than being targets for poor countries to achieve, they are to be enacted by all countries, rich and poor alike. The draft SDGs were sent to the UN General Assembly in September 2014 and were agreed upon in August 2015. Criticisms of the SDGs are that they are too big and ambitious, and that financing them will be problematic. However, the SDGs are an important step in recognising the social determinants of health and reducing the social gradient. They will become operational in January 2016. The SDGS are listed on the UN website (United Nations, 2015).




Question


Access the UN website for SDGs and explore them. How will the targets listed for Goal 1, ‘End poverty in all its forms everywhere’, help reduce the social gradient?




Key social determinants of public health: The Solid Facts


A collaboration between the WHO Centre for Urban Health and the International Centre for Health and Society, University College London, UK, in 2003 resulted in the publication of a key document about the social determinants of health, The Solid Facts (Wilkinson & Marmot, 2003). It was edited by Professor Richard Wilkinson and Professor Sir Michael Marmot and included contributions from numerous scientists in the UK. It was a focal point for discussion about the social determinants of health and advanced thinking in the area.




The Solid Facts

a publication by the Centre for Urban Health, at the WHO Regional Office for Europe. It was edited by Professor Richard Wilkinson, Professor Emeritus of Social Epidemiology at the University of Nottingham, UK and Professor Sir Michael Marmot, Chair Commission on Social Determinants of Health, University College London, UK.


The document identified 10 solid facts. These are the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport (Wilkinson & Marmot, 2003).


In this section, the chapter reviews selected social determinants as outlined in this document. In addition to the social gradient discussed, the chapter explores unemployment (including job insecurity and workplace stress), early life exposures and social exclusion. Students are encouraged to read The Solid Facts in its entirety for coverage of the other factors.



Unemployment


Intensified global economic competition has resulted in labour market deregulation, workplace downsizing, company restructuring and increased use of flexible forms of employment. Other recent trends include the privatisation of industry, streamlining and outsourcing to cheaper suppliers. Technological changes mean that computers and other technology perform many of the jobs that people used to, further reducing job security. Although physical job demands are diminishing for many workers, there is growing complexity in work environments. Unskilled workers are particularly vulnerable to redundancy. While this will achieve short-term profitability goals, it will be at the expense of investment in employee development. These trends are occurring at the same time as businesses are demanding better health from employees to maximise output, without necessarily investing in the health of their employees. These changes have modified the patterns of employment such that jobs are becoming increasingly unstable and insecure. Research suggests that such job insecurity is strongly associated with ill health. For example, a meta-analysis showed that workers in jobs with low security were about 20% more likely to get coronary heart disease relative to those in secure jobs, even after adjustment for socio-economic circumstances (Virtanen et al., 2013).


Unemployment is an extreme form of job insecurity. It results in ‘absolute poverty’ with reduced finances to purchase material possessions such as food, clothing and other resources. This has direct, adverse effects on physical and mental health. Absolute poverty also results in debt and financial difficulties such as inability to pay for transport, telephone and utility bills. Eventually absolute poverty results in social isolation and reduced means to seek employment. Unemployed people may relocate to cheaper areas to live but these tend to be poorer areas, resulting in a further ‘locational’ disadvantage.


Unemployment and job insecurity are chronic stresses. The longer they are sustained, the greater the ill effect. How might stress cause poor health? In healthy individuals, stressful situations result in the release of cortisol-releasing hormone from the hypothalamus; this increases cortisol and catecholamine secretion. These chemicals cause an increase in heart rate, blood pressure and circulating glucose, assisting with the ‘fight or flight’ response; that is, they prepare us to deal with the stressful situation. This is a normal reaction to stressful events. However, when stress is prolonged (that is, chronic stress), it is damaging. This is because psychological resources are diverted to dealing with the perceived constant emergency and away from processes that are needed for health maintenance. The immune system is affected and such people become more susceptible to a range of inflammatory conditions such as depression, cardiovascular disease, diabetes and obesity.


Unemployment is associated with increased morbidity and a 20–30% excess mortality (Morris, Cook & Shaper, 1994). Unemployment also has effects on mental health. Long-term unemployment (unemployed for over one year) has an impact on families and children. Children in these households are more likely to leave school early, have teenage pregnancies and be reliant on income support. Thus, there is a cumulative disadvantage in families of the long-term unemployed.



Workplace stress


Workplace stress arises from having low control over a work environment (job control). It partly explains why managers and executives of companies have less illness than workers doing more routine tasks. Having high job control – being able to delegate, being flexible about when tasks can be done, being flexible in working hours and organising schedules – is associated with better health. Less job control (for example, working on an assembly line in which a person’s work rate is determined by production targets) is highly stressful and is associated with poorer health.


Workplace stress also arises from effort–reward imbalances in which employees do not feel that self-esteem indicators, self-identity and personal recognition match financial remuneration; that is, employees feel poorly treated and underpaid. Recent changes in working practices that have resulted in job insecurity, work intensification, expansion of shifts and changes in shift times also contribute to stressful working environments which adversely affect health.


Workplace stress also arises out of the organisation of work, including organisational change. For example, the Whitehall II study of civil servants in the UK showed that white-collar workers under the threat of major organisational change showed adverse self-rated health, chronic illness, poorer sleep patterns, psychological symptoms and a number of physical symptoms (Ferrie, Shipley, Marmot, Stansfeld & Smith, 1995). Other areas covered include employee motivation, communication and leadership within organisations, organisational hierarchy, the working culture, management styles, and the degree of bullying and harassment. Mental health in the workplace is particularly important in relation to organisational behaviour. Typically, hard-to-reach groups in relation to mental health include companies with largely male, blue collar workforces who may be unaware of the effects on stress on their mental health, what the early signs are or the strategies to deal with it. Good mental health in employees is very important as it contributes to productivity as well as individual employee job satisfaction.


The policy implications of work as a social determinant of health are that policies that provide jobs and job security, reduce workplace stress and increase financial security are needed.



Early life exposures


Professor David Barker was one of the first to propose that early life experiences can affect health outcomes in adults (Barker, 1992). His hypothesis states that in utero, foetuses can be programmed at specific times (called periods of ‘plasticity’) to particular exposures in pregnancy. The consequence of this is that if the ‘environment’ changes either during pregnancy or after birth, the programming may no longer be appropriate, putting the child at risk of chronic diseases such as diabetes and obesity. For example, a child used (programmed) to a certain blood sugar level during pregnancy may not be able to deal with a ‘high’ sugar environment after birth. Other early life exposures in children, such as parental attachment and family functioning, are also known to influence health outcomes; hence, early life exposures are viewed as a social determinants of health.


A measure of in utero exposure that is commonly used is birth weight. Adverse exposures in pregnancy such as poor maternal nutrition, smoking or excessive alcohol consumption may result in low birth weight (under 2500 grams). There is strong evidence that low birth weight is associated with non-communicable diseases in adulthood, including obesity, hypertension and type 2 diabetes (Barker, 1992; Singhal, 2006). In Australia, about 6% of all babies born have low birth weight, a rate that has remained relatively stable since 2006 (Australian Institute of Health and Welfare, 2013).


What is the evidence that disadvantaged people have low birth weight babies? Studies have found a relationship between the mother’s socio-economic status (defined by education, occupation or income) and having a low birth weight baby (Hughes & Simpson, 1995; Reichman, 2005). A systematic review has shown significant positive associations of low birth weight with higher levels of income inequality (Spencer, 2004). Individual risk factors for low birth weight also vary by level of disadvantage. For example, smoking exhibits a clear social class gradient in most developed countries with the poorest mothers smoking the most (Siahpush & Borland, 2002). Smoking has a pronounced effect on foetal growth, and at least some of the social class gradient in low birth weight can be explained by differences in smoking habits (Horta, Victora, Menezes, Halpern & Barros, 1997).


Parental attachment is also viewed as an early life exposure which influences subsequent health. Parental attachment refers to the strong emotional bonds which children form with caregivers in childhood (Bretherton, 1992). Disruption of these bonds may have lifelong consequences. Studies have shown that high quality maternal infant bonds result in fewer adverse outcomes in several ‘domains of development’ in early childhood and in adulthood (Cooper et al., 2009). In early childhood, secure attachment in infancy results in good peer relationships and emotional adjustment; in adulthood, they are associated with lower rates of mental ill health (Cooper et al., 2009). Secure attachment in infancy also benefits physical health. In early childhood, it results in less failure to thrive and better growth. In adulthood, it is associated with better lifestyle choices (Cooper et al., 2009).


The policy implications of early life exposures as social determinants of health are that interventions are needed that encourage healthy life choices in pregnancy and early postnatal life (for example, breastfeeding). Policies such as parental leave schemes that optimise parental attachment are to be encouraged. Policies that support families to optimise growth and health of infants in the first years of life should receive priority.



Social exclusion


Friendships, good social relations and strong supportive networks improve health at home, at work and in the community. These lead to improved self-esteem and interpersonal skills. They are a buffer to stress, providing security and a sense of empowerment. Social exclusion, in contrast, arises from processes that prevent people from participating in society, such as unemployment, discrimination and stigmatisation. These processes are psychologically damaging, materially costly and harmful to health. Social exclusion is closely linked to poverty. People who live in or have recently left institutions (for example, residential care homes, prisons) are particularly vulnerable. The greater the length of time that people experience social exclusion, the more likely they are to suffer adverse health outcomes.


Much of the early thinking on the benefits of social integration came from the work of Emile Durkheim, a French sociologist in the 19th century who wrote about social integration in relation to suicide. He wanted to understand individual pathology as a function of social dynamics. In 1897 he published a seminal monograph, Suicide, in which he reported how ‘social facts’ can be used to explain changing patterns of suicide in Catholic and Protestant populations. He described a clear patterning of suicide by social class. He theorised that different suicide rates, say between different religious groups, could be accounted for by the strength of bonds that tie the individuals to the group (social cohesion). Social exclusion substantially weakens these bonds, increasing the risk of suicide. Durkheim (1897, p. 209) concluded: ‘[S]uicide varies inversely with the degree of integration of the social groups of which the individual forms a part.’


Social exclusion is a risk factor for illnesses and early mortality. For example, inadequate social support frequently results in elevated depressive symptoms (Cacioppo, Hughes, Waite, Hawkley & Thisted, 2006); (Lauder, Mummery, Jones & Caperchione, 2006) and coronary heart disease (Lett et al., 2005).


A review found that low social support is associated with the development and progression of coronary heart disease in healthy populations (Lett et al., 2005). Social isolation is also associated with coronary heart disease mortality in prospective studies (Brummett et al., 2001). Multiple indices of social isolation, including living alone (Case et al., 1992), lack of available support (Gorkin et al., 1993), low social support (Frasure-Smith et al., 2000), lack of a confidant (Williams et al., 1992) and low emotional support (Berkman, Leo-Summers & Horwitz, 1992), have been found to be independent risk factors for coronary heart disease prognosis.


Mechanisms by which social exclusion results in illnesses have been suggested to be poor health behaviours. For example, it has been found that lonely individuals are more likely to be smokers and obese (Lauder et al., 2006). Single mothers (compared with partnered mothers) have been found to have higher rates of risk factors for coronary heart disease such as smoking (Young, James & Cunningham, 2004), low levels of education and income, less social support, and more anxiety and depression (Young et al., 2004). Social isolation has also been postulated to result in coronary heart disease through biological mechanisms such as blood pressure, C-reactive protein, fibrinogen levels (Shankar, McMunn, Banks & Steptoe, 2011) and inflammation (Koster et al., 2006).


The policy implications of social exclusion as a social determinant of health are that policies are needed for individuals, groups and society that seek to reduce social exclusion. Given the links between poverty and social exclusion, all citizens should be protected by minimum income guarantees, minimum wages legislation and access to services. Legislation is needed to protect vulnerable groups, such as those who have been institutionalised for long periods, from social exclusion. Public health policies should remove barriers to health care, social services and affordable housing.


Apr 1, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Social determinants of public health

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