27.11.2020 | Kommentarer

The social determinants of health

Authors:

Fatimoh Opoola, BSc student Nursing
Anita Wikberg, Supervisor, RN, RM, PhD, Senior Lecturer, Novia UAS

The social determinants of health: Evident determinants of human health from prenatal stage, early childhood and throughout life

Abstract

Social equality of health is a matter of vital importance and a function of life and death. It influences risk to potential illness from prenatal stage, early childhood and throughout life while also posing risk of untimely death. In the past centuries, WHO has placed priorities mainly on specific health problems such as access to health care, maternal health, nutritional health and infectious diseases. While genetics and biology are naturally important to the determinants of an individual’s health, non-physiological factors referred to as social determinant of health (SDH), equally determines the health of an individual and the population to which they belong. This paper gives a descriptive explanation of SDH and factors under its subcategories. Additionally, the article gives suggestions of social and welfare policies that can be put in place to provide an equal and advantageous springboard for all individuals across a population thereby providing health equality.

Introduction

In the past centuries, the world health organization (WHO) has placed priorities mainly on specific health problems such as access to health care, maternal health, nutritional health and infectious diseases. However, recent focus is inclined on addressing the core societal factors that bring about health inequality across populations[i]. Although the social determinant of health (SDH), recently adopted in the 21^st century by WHO and its member states, has been a problem in the world and has been identified by researchers centuries ago. Sociologists and epidemiologists have conducted several studies establishing evidence with instructive frameworks on the reality of social inequalities in health[ii]. Ramon Cajal, a neuroscientist and pathologist, stated in his work that: “There are two aetiology to every disease. Pathophysiology comes first and second is political”   [iii].

In a more refined explanation of this ideology, it states that while genetics and biology are naturally important to the determinants of the health of an individual, there are also other non-physiological factors, which determines the health of an individual and the population to which they belong. These non-physiological factors are referred to as social determinant of health[iv]. Although the list is quite exhausting but the major categorised and recognised factors having direct influence on individual health are;

1. Social determinant of health (SDH)
2. Cultural determinants of health.
3. Political factors which include territory, colonization, globalization, migration, access to services and support etc.

The list gives a peek of the grandness and complexity of why an individual or a population may be less healthy than the rest of the society[v]. The first main categories will be discussed in this paper to stay in focus with the topic.

Social determinants of health (SDH) and its subcategories

SDH refers to the core societal factors that bring about health inequality across populations. These factors can be grouped into subcategories which include;

1. Socioeconomic factors which includes income, employment, social and physical environment, education, and health services.
2. Behavioural/psychosocial factors which include anxiety, insecurity, social isolation and deprivation, low self-esteem, and lack of control over home and work life, coping skills and resilience.
3. Biological factors which includes gender, genetics and childhood development 4.

Socioeconomical factors

A poor socioeconomical status affect the health of an individual and population throughout life. Right from the beginning of life, i.e. during pregnancy, children born to low income mothers have many negative factors influencing their health status. For example, studies have shown that low income women smoke more than others. Lower down the social ladder people get at least twice more susceptible to most diseases and illnesses than others close to the top [vi]. Also, premature death and shorter life expectancy are more common among those who are socioeconomically poor in a society. For instance, a longitudinal study among middle class office workers shows how lower ranking staff suffer from more illnesses and premature death than higher ranked staff ⁷. Social disability has many forms which may include having a poor education, insecure employment, living in a poor housing, trying to raise a family in a difficult circumstance, getting stuck in a job with very high risk of occupational hazards. These disadvantages tend to be common among the same people, accumulating throughout their lifespan. This often leads to an earlier death or unhealthy old age (for people who have lived long in this situation as it causes physiological wear and tear) than for those who have been socially able ⁷.

Behavioural / psychosocial factors

Behavioural factors affect our physical health. Behavioural factors such as alcohol consumption, drug misuse, tobacco use, sexual practices, nutrition, physical activity and lifestyle. Studies have shown that people who are lower down the social ladder do not have a healthy lifestyle. Tobacco use, alcohol consumption and drug abuse are very rampant among men and women with low income and stressful life situation. Children born to such women are bound to suffer right from conception, since it is hard to stop these lifestyles simply because of pregnancy. Likewise, children born to poor families often suffer from malnutrition. They often lack balanced diet and eat more of sweet and fatty foods. These children grow up into adults with overweight, obesity and cardiovascular problems.

Also, psychosocial factors such as anxiety, insecurity, social isolation and deprivation, low self-esteem, and lack of control over home and work life, all leads to stressful circumstances. The inability to cope, lack of resilience, or even a manageable long-term stress leads to a damaging health and may result to untimely death[vii].  

Biological factors

Although genetics may not be a direct factor of SDH, however childhood development can encompass the explanation for it. Childhood development may be classified as either biological factor or/and psychosocial factors. The health impact of a good start in life for all individual last a lifetime. There are, for example, studies that say that people who have been breastfed are healthier than the ones bottle fed. Observational research has shown that there are connections between adult health and perinatal childhood development[viii]. Poor childhood experience and lack of emotional support for both mother and child slows down growth and becomes embedded in the child biological systems during the child’s developmental process. This increases the risk of poor physical health and mental functioning in adulthood and may affect the individual throughout life span. 

Starting from the prenatal period, poor pregnancy circumstances and inadequate prenatal care resulting from maternal stress, malnutrition and inappropriate behaviours from the mother, are risk to poor foetal development and the child’s future health[ix]. Likewise, as the child grow from one developmental stage to another, emotional, cognitive and sensory variables structures the brain’s responses. Poor brain stimulation and insecure attachment with loved ones results in behavioural problems, low educational readiness and attainment, and risk of social isolation in adulthood ⁹.

Poor growth during infancy is also linked with a decrease in the development and function of the biological system of the individual and pose illness in adulthood. For instance, a longitudinal study on adult men shows that the risk of diabetes increases with decreasing birth weight. These adverse effects of poor early life eventually get embedded in the biological systems and the genetic make-up of the individual or a population and the next generation of such populations are born with gene prone to illness1⁰.

Stressful circumstances may also be categorised as a biological factor. For instance, during emergency situation such as stress or tension, our fight or flight hormones and nervous system deals with the threat, thereby raising the heart rate. In order to increase alertness, stress response diverting stored energy and blood to muscles cutting short the resources from many important physiological processes in the body or even making the cardiovascular, immune and nervous system work more than usual. This may be okay for a short period of time, however, when this process continues for a long period, such a person may be more at the risk of aggression, depression, infections, hypertension, heart attack, stroke etc8.

Gender on the other hand as a factor of SDH refers to how society dictates what each gender can or cannot do. For instance, some societies have made the male gender of the population handle physically demanding job. Studies have shown how men are more prone to cardiovascular and other muscular disease than women. Also, women in most societies are made to handle low income or free jobs at home in the pretence of caring for the home and family. This result in income insecurity for women and grows into anxiety, all leads to stressful circumstances. When this continues for long-term, women become more at the risk of aggression, depression, infections, hypertension, stroke etc8. This situation could be handled if people have choices of profession and what to do irrespective of their genders. Then the consequences of their choices would be, of course, gladly accepted.

Conclusion

Social justice is a matter of vital importance and a function of life and death. It influences the way people live (habits, customs and resulting culture). As a result, it influences risk to potential illness and untimely death. The world is socially and culturally diversified and even within each country, especially capitalist countries, there are unimaginable inequality in health which are closely associated to the extent of social disadvantages. This kind if inequality and social differences should never happen within or between countries[x].

Life encompasses a sequence of critical transitional stages which begins with material and emotional challenges in the immediate environment during early childhood, advancement from the early childhood education to secondary education and possibly higher institution, starting work life, changing jobs, leaving home to start a new family, encountering situational redundancy, and finally retirement. Each one of these stages have a way of influencing a person’s health both physically and mentally depending on how advantageous the stage is to the person 6.

Also, observational studies have shown that people who were disadvantaged in the previous stages tend to be at more risk of been disadvantaged in the subsequent transitional stages. Therefore, policies should be put in place for people’s welfare, not only to provide safety net in subsequent transitions, but to also provide an equal and advantageous starting line for all individuals in the society to neutralise any possible preceding disadvantage 6.

In the pursuit of world health equity, the social determinants of health (SDH) were endorsed and adopted in year 2012 by the world health organization (WHO) member states at the United Nations conference on sustainability development. the agreement document states: “we are convinced that action on social and environmental determinant of health for the vulnerable and the entire population is vital to realise an equitable and economically productive healthy society and to enjoy the highest attainable standard of physical and mental health”                                                                                                                                                                                   ­­­­-WHO 2020[xi]