27.11.2020 | Kommentarer

Where the Real Problem Lies with Health Inequality

Social Determinants of Health

Authors:

Sahaita Chugani, Bsc Student, Bachelor in Healthcare, Nursing, Novia UAS
Anita Wikberg, Supervisor, RN, RM, PhD, Senior Lecturer, Novia UAS

1        Introduction

In order to understand health inequalities, we must first define what health means. One common misconception that is highlighted in the way health is perceived by most people is that it is the absence of disease, illness, ailments or infirmity. This is only part of what defines health. Health can be defined, more accurately, as the total physical, mental, and social wellbeing of a person. (World Health Organisation, 2020) As a result, good health is what every individual and society as a whole seeks to achieve, and while many countries are glorified for their health care systems and health policies, and even their population-based life expectancies being comparatively better than others or above a certain threshold, health inequalities still exist. Health inequalities refer to differences in health, between different groups of people within the same country or between different countries, which are unfair and avoidable (Centres for Disease Control and Prevention, 2020; EuroHealthNet, 2019; Appuhamy, 2017).

Such inequalities exist even in Finland, despite being among the Nordic countries that strive to make health care as accessible and high quality as possible, employing evidence-based practice and holistic care methods. Like any other modern welfare state that seeks to promote equality, health inequalities present a major problem for Finland (Finnish Institute of Health and Welfare, 2014). Despite seeing improvement in the average health status in many aspects among Finland’s population, socioeconomic inequalities are either unchanged or in some areas these inequalities have even grown (Finnish Institute of Health and Welfare, 2014), which is a sign for concern and poses the question of whether the current health policies and system, as well as the interventions put in place, are working as they should. Where does the real problem lie? The main issue to discuss and highlight is that while employing research-proven methods, and policies that promote quality care, the social determinants of health are not addressed adequately enough – and this is where the true problem lies when it comes to health inequality.

2        What are Social Determinants of Health?

As noted previously, health inequalities exist among people from different groups within and between countries. This means that health varies between individuals and population groups; this may be between people from different countries, people from the same country but different ethnic or cultural groups, and even among people in the same ethnic or cultural groups. One good example to illustrate this is: the life expectancy in Sierra Leone was noted to be 50 years in 2015, and in the same year, the life expectancy in Australia was recorded as 83 years (difference of 33 years). Notably within Australia too, the life expectancy between indigenous and non-indigenous people had a 10 years difference. To understand why health is so variable, the factors that influence it must first be understood. Factors that influence health are referred to as determinants of health (Centres for Disease Control and Prevention, 2020; EuroHealthNet, 2019; Appuhamy, 2017).

When asked about what such factors or determinants may be that influence a person’s health, the most common answer would be: “who the person is”, i.e. their age, gender, and genetic factors; and “what they do”, i.e. habits, health-seeking behaviours, lifestyle actions such as smoking, drinking alcohol, physical activity, and diet. While these are all important determinants, what a majority of people in the general public are yet to be fully and properly aware of, is that health is also greatly influenced by the conditions in which a person is born, grow, work and age, i.e. the social community networks they build and have, their socioeconomic situation, cultural factors, environmental conditions they live in, and finally the health systems in the country they live in. All these factors together make up and are referred to as the social determinants of health (Centres for Disease Control and Prevention, 2020; EuroHealthNet, 2019; Appuhamy, 2017).

There are many social determinants of health, and these are shaped by distribution of money, power, and resources, working across many different levels (international, national, and local), with complex interactions between them. As such, social determinants of health are an important topic to consider as they are largely responsible for health inequalities between different groups of people (Centres for Disease Control and Prevention, 2020; EuroHealthNet, 2019; Appuhamy, 2017).

2.1       WHO Framework for Social Determinants of Health

Over the years, recognition of these social determinants as important factors that need to be addressed, has spread wide among researchers and specialists. The WHO has, as a result, thoroughly researched and promoted the importance of social determinants of health by creating the Commission on Social Determinants of Health (CSDH) that draws the attention of governments, civil society, international organizations, and donors to pragmatic ways of creating better social conditions for health, especially for the world’s most vulnerable people. The CSDH also works with different countries aiming to support health policy change and promote evidence-based practices that address social determinants of health. The WHO also developed a framework to aid the understanding of what social determinants of health are and how they may function (World Health Organization, 2006; Appuhamy, 2017).

The framework, shown in fig.1, explains that there are two broad groups of determinants influencing health and inequality – structural determinants and intermediary determinants. Structural determinants are made up of the socioeconomic and political context that people are born into and live in, governance, economics, social and public policies, and also the social and cultural value that is placed on health issues. Together, these structural determinants can influence the unequal distribution of material and monetary resources which can shape the socioeconomic position of a person, i.e. a person’s place in society, which can affect their exposure, vulnerability, and outcomes to conditions that impact their health. Education, occupation, income, race/ethnicity, gender, and social class are a few of the factors that can affect a person’s socioeconomic position (World Health Organization, 2006; Appuhamy, 2017).

The socioeconomic position in turn affects the intermediary determinants of health, which include material circumstances (quality of housing, financial means to purchase healthy food, clothing and other requirements for healthy living, and work environment), psychosocial factors (stressful living conditions, relationships, and social support), behavioural factors, and biological factors (World Health Organization, 2006; Appuhamy, 2017).

Combined with these, health systems also greatly influence the type and quality of health care available to people, and also determines how accessible health care is to people in need. Social cohesion and social capital are factors that act as a bridge between the structural and intermediary determinants. Social cohesion and social capital are the willingness of people living in a community to make compromises and cooperate with one another for a wider, mutual benefit (World Health Organization, 2006; Appuhamy, 2017).

The connection between all of these determinants are not always linear but can be complex, interdependent, and interact in many ways to impact and influence health. One example, as shown in fig.1 is that a person with poor income and education is likely to have poor health since they do not have the means to sustain healthy living and are also not educated enough about factors that affect their health. However, in turn, poor health would limit a person’s ability and opportunities to participate in the workforce, forming a two-way link (World Health Organization, 2006; Appuhamy, 2017).

To change the social determinants present in any country to improve health equality, the structural and intermediary determinants in that country must be identified first, and then interventions may be planned and implemented to improve them. In order to do this, all sectors of society and at all levels (international, national, and local) must take action. These actions will depend on the existing socioeconomic and political context, the resources that are available, and commitment for action (World Health Organization, 2006; Appuhamy, 2017).

3        Social Determinants of Health & Health Inequalities in Finland

To give a wider picture and put this into context; differences in mortality rates are large between different population groups within Finland when compared to other Nordic Countries (Denmark, Sweden, and Norway), and these have continued to increase over the past decades. This can be seen in fig.2 below, which shows the large inequalities in mortality rates between the lowest and highest education groups in the Nordic countries, Finland having the largest disparity between the two population groups. “Long-term morbidity is about 50 % more common in the lowest educational and social groups than in the highest groups. ”(Finnish Institute of Health and Welfare, 2014).

According to the Finnish Institute of Health and Welfare, the health inequalities present in Finland are also largely due to differences in living and work conditions, along with cultural and behavioural differences between socioeconomic groups. The self-rated health, life expectancy, and use of health care depended and varied between people with different socioeconomic conditions. Problems related to mental health and limitations in functional capacity were found more often among people with lower social positions (Finnish Institute of Health and Welfare, 2014).

Some major morbidity causes in Finland such as smoking, alcohol abuse, unhealthy eating, for example, describe a large education-related inequality upon international comparison, and were also found most commonly in lower social positions. Differences in mortality for alcohol-related deaths between blue and white collar workers, for example, are very prominent in Finland. Life expectancy also varies greatly in Finland depending on socioeconomic factors, as seen in Fig.3 below. Highly educated people with managerial positions at work, and people with high incomes were found to have higher life expectancies than people with basic education and low incomes. Vascular diseases and alcohol-related deaths showed great differences depending on the person’s education, employment, and income. All these highlight the importance of social determinants and their impact on the health of the population in Finland (Pensola et al., 2012; Pesonal et al., 2004; Valkonen et al., 2007; Finnish Institute of Welfare, 2014).

3.1       Finnish Health Care System and Health Inequalities

One of the main goals of the Finnish health care system is to provide timely and high quality care that is accessible to all people regardless of their socioeconomic position, economic resources, or region of residence. Despite this, research findings, as reported by the Finnish Institute of Health and Welfare, show that pro-rich difference both in accessibility and quality of health care exist. This shows that the Finnish health care system may not be reducing health inequalities but in fact play a part in increasing them (Finnish Institute of Health and Welfare, 2015).

Outpatient care is one area of the Finnish health care system that seems to have extensive socioeconomic differences. Visits to doctors or dentists, for example, reportedly favour high income groups especially in occupational health care and private outpatient health care (Häkkinen & Nguyen, 2010). In municipal health care, however, the visits have been distributed in favour of lower income groups. Supply of outpatient psychiatric services is low when need is taken into account, and services with specialists target patients with more serious mental health issues. A shortage of care and rehabilitation for people with substance abuse issues is also present. In inpatient care, it is reported that people with higher socioeconomic positions have higher likelihood of getting admission to private or university hospitals. Also, while amenable mortality has decreased rapidly in the 2000s, socioeconomic differences when it comes to amenable mortality have increased (Lumme et al., 2012; Finnish Institute of Health and Welfare, 2015).

Decreasing the availability of municipal outpatient services in many parts of Finland, along with the three-tier structure of outpatient services (municipal health centres, occupational health care, and private outpatient services) also affect the use of specialised inpatient services through referral. Together these have an effect on the availability and quality of health care services in Finland. People with higher level of education are more likely to have awareness of what health care services are available and how they can be accessed, as well as all alternative care pathways available to them. They are also more likely to demand consultations, examinations, and specialised health care as a result (Finnish Institute of Health and Welfare, 2015).

4        Conclusion

Social determinants of health, as a whole, is a very important concept to learn and understand, not just for specialists and health care professionals, but also for people working in government, politics, education, safety, and all other sectors of society, as well as the general public, due to its large impact on the health of individuals and populations. Awareness is particularly important, especially since this is not a problem that only affects developing countries with health care systems that are underdeveloped but also developed countries’ modern welfare and health systems which are acknowledged for being high quality, such as Finland. It is a global issue that cannot be fixed by one part of society alone (Appuhamy, 2017).

This essay seeks to encourage that whenever considering a health issue, not only the questions of “who the person is” or “what they do” should be considered and addressed, but also the conditions that they are born in, grown in, live in, work in, and age in are taken into account. If these social determinants are understood, identified properly, and collectively acted upon, a healthier world can be built and unfair inequalities can be reduced (Appuhamy, 2017).

5        References

• Appuhamy, R. 2017. Social Determinants of Health - An Introduction. [online] Let's Learn Public Health. Available at: <https://youtu.be/8PH4JYfF4Ns> [Accessed 1 November 2020].
• Centres for Disease Control and Prevention. 2020. About Social Determinants of Health (SDOH). [online] Available at: <https://www.cdc.gov/socialdeterminants/about.html> [Accessed 1 November 2020].
• EuroHealthNet. 2019. Infographic on Health Inequalities in Europe | Eurohealthnet. [online] Available at: <https://eurohealthnet.eu/HI-factsheet?gclid=Cj0KCQjwufn8BRCwARIsAKzP6963bvti2zr6nGT-XEdbHWF8YDq2NTzNgzCHP0F-R8a0iJZP2KDMuc8aAseXEALw_wcB> [Accessed 1 November 2020].
• Finnish Institute for Health and Welfare. 2014. Health Inequalities - Health and Welfare Inequalities - THL. [online] Available at: <https://thl.fi/en/web/health-and-welfare-inequalities/health-care-cervices> [Accessed 1 November 2020].
• Finnish Institute for Health and Welfare. 2015. Effect of Health Care Services on Health Inequalities - Health and Welfare Inequalities - THL. [online] Available at: <https://thl.fi/en/web/health-and-welfare-inequalities/health-care-cervices/effect-of-health-care-services-on-health-inequalities> [Accessed 1 November 2020].
•   Finnish Institute for Health and Welfare. 2019. Differences in Life Expectancy - Health and Welfare Inequalities - THL. [online] Available at: <https://thl.fi/en/web/health-and-welfare-inequalities/health-care-cervices/differences-in-life-expectancy> [Accessed 1 November 2020].
• Koskinen S, et al. (2016) Elinajanodotteessa suuria eroja tuloryhmien välillä. Tesso 4/2016.
• Manderbacka, Peltonen, and Martikainen: Amenable mortality by household income and living arrangements: a linked register-based study of Finnish men and women in 2000 – 2007. J Epidemiol Community Health 2014;68:965-70. doi: 10.1136/jech-2014-204272
• Pensola T, et al. (2012) Palkansaaja, yrittäjä, työtön. Kuolleisuus Suomessa 2001–2007. Kuntoutussäätiön tutkimuksia 84/2012.
• Pensola T, et al. (2004) Ammatit ja kuolleisuus − työllisten ja työttömien ammattiryhmittäinen kuolleisuus 1996–2000. Tilastokeskus.
• Lumme, Sund, Leyland, and Keskimäki: Socioeconomic equity in amenable mortality in Finland 1992 – 2008. Soc Sci Med 2012;75: 905-913. doi:10.1016/j.socscimed.2012.04.007
• Häkkinen and Nguyen: Rikas käy edelleen lääkärissä köyhää enemmän (in Finnish)(The rich still visit the doctor more often than the poor). Optimi 2010;2
• Valkonen T, et al. (2007) Sosioekonomiset kuolleisuuserot. Teoksessa Terveyden eriarvoisuus Suomessa, STM julkaisuja 2007:23
• World Health Organization. 2006. Commission on Social Determinants of Health. [online] Available at: <https://www.who.int/social_determinants/resources/csdh_brochure.pdf?ua=1> [Accessed 1 November 2020].
• World Health Organization. 2020. Constitution. [online] Available at: https://www.who.int/about/who-we-are/constitution [Accessed 1 November 2020].