What are the social determinants of health?

Social determinants are the conditions of daily life, those in which people are born, grow, live, work and age; some are genetic, many more are socially constructed, and all are interwoven factors such as gender, genetic inheritance, ethnicity, income, education, housing, employment, access to health services and a sense of control over one’s life situation and environment (WHO, 2011a). One of the foundations of health—a sense of empowerment, of being able to have some control in decision making—occurs by participating in education, employment and the healthcare system. Experiencing inequality in (for example) income can lead to inequity, discrimination and unfairness, making social determinants closely bound up with the concept of social injustice; this, according to Marmot (CSDH, 2008), is for many a matter of life and death. Whereas ‘social justice, the fair distribution of society’s benefits, responsibilities and their consequences’ (Edwards and Davison, 2008:130) was once very much a part of public health interventions, evident in the Alma-Ata declaration (WHO, 1978) and the Ottawa Charter (WHO, 1986), the social justice agenda faded in the latter part of the 20th century (Edwards and Davison, 2008). And yet identifying health inequities, and social determinants of health, is key to tackling social injustice. A more recent commitment to the primary healthcare principle of universal access to healthcare when and where it is needed by the Australian and New Zealand governments (Department of Health and Ageing, 2011; Ministry of Health, 2011) could signal a renewed concern for social justice.

With the resurgence of primary healthcare (PHC) came the recognition that health inequities are not inevitable (Bell and others, 2010). Villeneuve (2008) and Smith (2007), among others, see part of the core business of nursing practice as working towards eliminating health inequities and changing the social conditions that influence health outcomes. Warm, dry, well-insulated homes, for example, give children a greater chance of having little or no respiratory health conditions. Such housing is, however, out of the reach of many people, especially families with limited economic resources. Social determinants are, after all, shaped by the society in which we live, where money, power and resources at a global, national and local level are distributed and in turn influenced by international, national and local policy decisions (Marmot, 2010; Robinson, 2009).

We will look briefly at how these ideas work through the determinant of gender, one that affects us every day of our lives. From the moment of birth, and some would argue before birth, the gender binary—the way society classifies us into two distinct groups, women and men—is enforced in subtle and not-so-subtle ways. Constructed and shaped by the way society expects women and men to behave (McGee, 2009), women in Western societies are expected to be gentle, nurturing and caring; men, on the other hand, are rewarded for being competitive, providing resources and leadership. Despite a few women in Australia and New Zealand holding leadership positions, including prime ministerial roles, in recent times, male hegemony remains the norm in both countries; to the detriment, it could be argued, of both women and men.

Putting aside the amount of unpaid work women complete in the domestic realm, women do much of the voluntary community work in New Zealand, and on average earn 80% of what men earn (Ministry of Women’s Affairs, 2010a). In state sector boards in New Zealand women hold 41.5% of positions, and yet only 9.3% of women are board members in the top 100 companies listed on the New Zealand stock exchange (NZX) (Ministry of Women’s Affairs, 2010b). A similar situation is found in Australia, where women hold only 9% of private board directorships (Australian Human Rights Commission, 2010). Using a socioecological lens, we can see that society shapes our understanding of gender roles through the distribution of power and resources at all levels. We see these ideas played out in the media. Women’s magazines devote pages to women’s health, covering all possible topics including nutrition, cervical cancer, endometriosis, menopause, heart disease—while neglecting the biggest threat to women’s health worldwide, one which knows no boundaries, be it age, ethnicity, socioeconomic standing: the issue of violence (Ratcliff, 2002). The latest Progress of the World’s Women report (UN Women, 2011) reinforces Ratcliff’s contention, as out of 22 developed nations identified by the Organisation for Economic Co-operation and Development (OECD), New Zealand is ranked near the bottom for both domestic violence and maternal mortality. According to the WHO (2011b), in Australia, Canada, the United States and South Africa, 40–70% of female murder victims were killed by their partners. And the real tragedy of violence women experience is that everyone suffers, including children, women and men.

If nurses are serious about improving people’s health outcomes, gender inequality must be addressed; and yet, over the decades nurses have consistently shown a reluctance to address gender either with the people they care for, or for themselves at a professional level (McGee, 2009). Viewing healthcare practices through a medical lens, one that is embedded in nursing practice, tends to neglect the social and spiritual context of people’s lives. When it comes to exploring social and structural determinants, power and inequities, the use of a critical approach or ‘critical lens’ enables us to explore and understand people’s social context (Doane and Varcoe, 2005). When looking at power, culture, political decisions, economic position and social justice, a critical lens enables nurses to focus on and understand the way social determinants significantly affect people’s health status.

Understanding how social determinants influence health outcomes is one thing; overcoming health inequalities is quite another. Government support from across the political spectrum and goodwill is needed at all levels. Fair society, healthy lives, Marmot’s (2010) strategic review of health inequalities in England, brings together the thinking of the past decade to set out an agenda of six policy objectives to reduce health inequalities (Box 16-1).

Closer to home, Australia and New Zealand find themselves numbered 5 and 6 respectively out of 23 developed countries for income inequality, very close to the United Kingdom (Wilkinson and Pickett, 2010). Income inequality within a country not only disadvantages those with very little resources but also affects all members of unequal societies. Wilkinson and Pickett’s (2010) list of social problems emerging from societies suffering income inequality (outlined in Box 16-2) all relate to health and wellbeing.

Recognising the consequences of inequality in New Zealand, the government has begun to prioritise ways to reduce inequalities in social and economic circumstances, particularly for Māri, the indigenous people of New Zealand, and close neighbours, Pacific Islanders. In doing so the government acknowledges the unique relationship between Māri and the Crown based on New Zealand’s founding document the Treaty of Waitangi. Through this agreement, the government is committed to ensure that accessible and appropriate services are available to those who suffer most from health inequities (Ministry of Health, 2002a): people from lower socioeconomic groups, Māri and Pacific peoples.

Both the New Zealand and the Australian governments acknowledge that their indigenous people, as a result of being socially and economically disadvantaged, have a lower quality of life and die prematurely (Griew and others, 2007; Ministry of Health, 2010a). A range of interventions being taken to improve health outcomes include an increased number of primary healthcare initiatives, specifically targeting those with higher health needs (Australian Institute of Health and Welfare, 2010; Ministry of Health, 2002a).

Fundamental to considering the various aspects of health is to become sensitive to the different expectations between nurses and those they help. One person experiencing an acute injury or serious functional disability may consider themselves to be healthy, whereas another might see themselves as extremely unhealthy—indicating that people do not react to ill-health and accidents in the same way. People’s responses to health, ill-health and disability depend on many factors, in particular the social context of each person’s life at a particular point in time.

Taking all these ideas into consideration, how are we going to define health? Contemporary definitions from New Zealand and Australia incorporate, at a rhetorical level, a socioecological perspective as both countries see health as a dynamic concept; one constantly changing. However, an individual focus, embedded in the biomedical model of health which emphasises the presence or absence of disease and risk-related factors, remains dominant in both countries. Nevertheless, these two governments acknowledge the impact of social and economic determinants on health outcomes (Australian Institute of Health and Welfare, 2010; Ministry of Health, 2011). We will continue our exploration of a broader socioecological perspective of health a little later in the chapter. In the meantime, we focus briefly on the second key component of this chapter, wellbeing and wellness.

Biology

From the time of conception, social determinants embed themselves in our biology to affect certain physiological control systems within us all. This set of controls interacts with the developing child’s environment to evolve and adapt to the many environmental stimuli we are exposed to throughout life. These interactions help establish cognitive, social and emotional coping skills, resiliencies and appropriate physiological responses to stressors and circumstances of daily life. Although each factor exerts a separate influence on health, the interaction between two or more and the body’s response will have the most profound impact on health. For example, a child born into an impoverished environment is disadvantaged in comparison to one whose social, physical and cultural environments enable their full potential to be achieved (McMurray and Clendon, 2011). Figure 16-3 illustrates the ways in which an impoverished environment can form a poverty cycle of interrelated elements.

FIGURE 16-3 Poverty cycle.

Lifestyle choices

Instrumental in developing health and wellness are the lifestyle choices we make. For some these are made on the basis of personal preference, while for others the choices are limited by life circumstances. All choices are shaped, to some extent, by the context of people’s lives, including family, friends, and culture. For example, those who go out for a morning run may discover a sense of wellbeing in the beauty of a new day, the smells, the scenery and the solitude of the activity. For another, a more social venue like a gym for recreation would be preferred. Conversely, choices to be physically active for people with few economic resources and who live in an unsafe neighbourhood or have no child-minding facilities may well be limited. Therefore, health behaviours may be set and reinforced by previous experiences (either positive or negative), biological responses and life situations. Combined, these factors determine short-term and long-term lifestyle choices, and ways of coping with adversity or illness. Biology may act in a relatively positive or negative way, rendering people more resilient in the face of difficulties or conspiring to leave them in a poorer state of health than others in similar circumstances.

Family

Another key element contributing to health status is family. In the first critical thinking exercise where we asked you to consider your health definition, you may well have found that your family’s values, norms and conditions significantly contributed to your current thinking about health. Gender roles played out and shaped in families strongly influence health status. While traditional gender roles are changing as, for example, more men take on domestic and childcare responsibilities, these frequently remain women’s concerns. Gender can affect a person’s employability, which in turn can determine a family’s financial status. Family structure also influences financial opportunities, as does geographical mobility needed to seek employment, recreation or educational opportunities. Following decades of homogeneity in family structure, social norms have seen major changes in recent decades as traditional family structures are replaced by greater family diversity such as blended, gay and single-parent families (Families Commission, 2008). What is also vital for health and wellbeing in families, according to Hartrick Doane (2003:31), is how people come to experience:

Nevertheless, we know that not all families provide nurturing environments, nor are there capabilities necessary to support all family members to flourish. Family violence and child abuse remain unresolved concerns worldwide, including in Australia and New Zealand and especially amongst indigenous families and those with few economic and social resources (Australian Institute of Health and Welfare, 2009; Ministry of Health, 2002b). Violence is one of a number of global social problems that Wilkinson and Pickett (2010) found prevalent in unequal societies, as shown in Box 16-2. What the following clinical thinking exercise does is reminds us of the dangers inherent in making assumptions in nursing practice.

Tackling these complex issues is fundamental to reducing health inequity. One new initiative in New Zealand is Whaānau Ora, a health service that enables Whaānau/families to build strengths and capabilities, and take responsibility for Whaānau/families with support from coherent, relevant and connected Whaānau services (Ministry of Health, 2010b).

Culture

Once seen as referring to a person’s ethnicity, the concept of culture nowadays, particularly in healthcare, recognises many different cultures, such as the culture of poverty, of age and of sexuality. McMurray and Clendon (2011:1) define culture as ‘the accumulation of beliefs, values, and knowledge that are determined from one generation to another and that determine social behaviour’. Nurses wanting to work effectively with people to preserve and value their cultural identity must first be aware of their own cultural attitudes, patterns of behaviour and language (Nursing Council of New Zealand, 2011). Respecting and protecting another’s culture, known as cultural safety, was first defined to acknowledge the importance of Māri, the indigenous people of New Zealand (see Chapter 17).

Evaluating whether care is culturally safe belongs to the person or family receiving the care, not the nurse (Richardson and Carryer, 2005). Cultural safety is not a matter of knowing about all cultures, but about being sensitive to and respectful of people’s/families’ differences, while recognising the social, physical and economic elements that may have impacts on their health (DeSouza, 2008). For example, despite legislative changes decriminalising homosexuality 20 years ago Neville and Adams (2010) believe a level of homophobia remains in primary healthcare in New Zealand, suggesting that some men may have difficulty receiving culturally safe healthcare.

Health literacy

Key elements in determining health and wellness include having the cognitive and social skills to seek out, understand, interpret, evaluate and use health information and health services (Robinson and McCormick, 2011). Just as we need to stay abreast of changing communication and advances in information technology (IT), so too must we maintain health literacy (US Department of Health and Human Services, 2011). Health-literate people read critically and understand health promotion messages, treatment options, what services are available and healthcare professionals’ instructions, and are more likely to explore and use multiple websites and populist media. However, being health-literate is more than just being able to read health pamphlets and access relevant health services. Also necessary is self-efficacy: the ability to make key decisions about health and wellness, to provide a sense of empowerment, a feeling of personal control over one’s life, of having power to make decisions.

Self-efficacy allows people to engage in and navigate healthcare systems, a key characteristic of health literacy. People with limited reading or comprehension skills are disadvantaged, as health information is mostly presented in a written format. While popular media such as television, the internet and other digital media devices are increasingly being used to broadcast health promotion messages, without additional support many people may not consider that these messages apply to their situation. Inadequate use of health services and poor health outcomes are associated with low health literacy rates (Berkman and others, 2011). Improved access to health information, and the capacity to use it effectively, bestows personal and social benefits, particularly within the context of family. Health-literate parents grow health-literate children, who in turn grow health-literate communities and societies. If we think back to the discussion about social determinants of health, it is clear that without a certain level of education people are disadvantaged when it comes to making health decisions. Helping people to develop health literacy skills is a challenge for nurses, but one that goes hand in hand with assessing people’s health and wellness needs.

To finish this section, we briefly look at assessing people’s health needs. Thoughtful, evidence-based nursing practice is foremost about meeting people’s health needs and preferences within the context of each person’s life. Identifying health needs involves several steps.

First, an examination of various indicators of personal health, such as a health history, vital signs readings, weight, height, diet and physical activity levels. Second, an understanding of health beliefs; a person’s ideas, convictions and attitudes about health and illness based on factual information, misinformation, common sense, cultural beliefs, myths or differing expectations affect health behaviours. Positive health behaviours, such as sufficient sleep, taking exercise and having an adequate, nutritious diet, are about achieving, maintaining or regaining good health and preventing illness. Smoking, drug or alcohol abuse, poor diet, little or no physical activity and/or refusal to take necessary medications—negative health behaviours—are potentially harmful to health. Understanding people’s health beliefs, their attitude towards health behaviours and the extent to which they believe themselves to be healthy and/or capable of meeting their health needs is essential.

The third step is to link people’s information with known health risks for their population group. For example, providing someone suffering a chronic health condition with a clear rationale of the benefits of having a flu vaccination enables them to make a fully informed decision. The final step, a community assessment, explores available resources and barriers to health to determine people’s access to appropriate environmental supports (e.g. recreational facilities, health services for their particular needs). All of this is completed while keeping in mind the social determinants of health.

Having navigated our way through what constitutes health and wellness, we move to exploring nurses’ roles in promoting health and wellness and preventing disease, at both a personal and a population level.

Healthy public policy

Health public policy ensures that health is uppermost in the mind of all policy makers. Healthcare professionals often see first-hand the health concerns people face every day where they live and work. Consequently, healthcare professionals need to be involved in health issues affecting community, local and national government politics and policy development. Ensuring safe roads, sufficient recreational facilities, green spaces, pollution-free towns and cities, safe and clean working environments and industries, health education curricula, public transport, social welfare and, of course, adequate healthcare facilities provide some examples.

Creation of supportive environments

The inextricable link between people and their environment is recognised in the second strategy to encourage us to support and look out for each other, our communities and the cities in which we live, to ensure equality and a commitment to the poorest members of the community and to reduce specific health issues experienced by minority groups and people with disabilities. To enable people to be healthy, this strategy encourages all people to recognise the importance of conserving and sustaining physical and social resources.

Strengthening of community action

Community ownership and control over their endeavours and destinies are at the heart of the third strategy. Empowering communities to make informed choices for better health involves healthcare professionals adopting the role of support person and facilitator, while providing information and learning opportunities.

Development of personal skills

Providing adequate and appropriate education and opportunities for skill-development guides the fourth strategy to enable people to support their communities in local decision making for effective use of resources to attain health.

Reorientation of health services

To shift the focus from managing illness to promoting health, preventing illness and providing healthy environments, the final strategy calls for an acknowledgement of local and cultural needs. This call challenges healthcare professionals to provide people, families and communities with tools to self-manage their healthcare, reduce reliance on health services and facilitate self-efficacy.

Each of these strategies calls for nurses to be involved in policy development, as only through political processes can meaningful change occur. Nurses’ involvement with people, families and communities places them in the best position to argue for well-thought-out, practical and effective health policy interventions, ones that can work towards eliminating health inequities (Villeneuve, 2008).

Following on from the Ottawa Charter, international health-promotion conferences held at regular intervals have endorsed and developed this charter’s five strategies. Charters emerging from each conference were named after the country in which each conference was held (Box 16-4).

The 4th International Conference on Health Promotion, the Jakarta Declaration, directed health promotion towards social responsibility for health. A plea was made to reframe health as an investment in the future, establish partnerships between healthcare professionals and communities to achieve health and advocate for community empowerment (WHO, 1997). By investing in people and their health, communities can help build social capital, a concept that, while difficult to define, involves encouraging community relationships, social cohesion and trust to give people a sense of belonging and connection (Ching-Hsing, 2008). Networks of social ties, often families or communities, are emphasised in social capital, which encompasses people cooperating collectively to achieve common goals such as safe neighbourhoods or providing community facilities (Goodrich and Sampson, 2008). The decline in social capital occurring since the late 1980s (Putman, 2000) has more recently been linked to poorer health outcomes and the widening gap between those with and those without economic and health resources (Wilkinson and Pickett, 2010). The Jakarta Declaration identified poverty as the single greatest threat to health, and reinforced the five strategies of the Ottawa Charter to create equal opportunities for health and health promotion at a global level (WHO, 1999).

Underlining the need for a focus on global health promotion, the Bangkok Charter for Health Promotion in a Globalised World (WHO, 2005) drew attention to social life as a source of health or ill-health globally. This Charter, in underlining the need for interventions to counter social changes affecting working conditions, learning environments, family patterns and the culture and social fabric of communities, took a more socioecological approach to global health. Nurses and all healthcare professionals were urged to understand the importance of good governance, tolerant and trusting societies and fair corporate practices including world trade and financing (WHO, 2005).

The most recent charter, the Nairobi Global Conference on Health Promotion held in Kenya in 2009, being mindful of recent global events affecting the health and development of so many countries, builds on the work of the international health community. Global warming, climate change, terrorism and the ongoing financial crises embroiling many countries were identified as continuing to jeopardise health for many. Ensuring that health promotion remains a key component of each country’s health mandate, along with strong leadership capacity, was identified as crucial to forge ahead with institutionalised health promotion (WHO, 2011c).

Chinese culture

Whereas Western healthcare has a strong focus on the mind/body split, the Chinese see the mind, body and spirit as being inextricably linked (Kwok and Sullivan, 2007). Health is reliant on the flow of the body’s vitality (qi), balance of opposing forces (yin–yang) and harmony in the main organs (wu-shing) (Ariff and Khoo, 2006). Controlling the flow of energy (qi-gong) with exercise such as meditation and rhythmic exercises including Tai Chi promotes qi and remove any blocks that may occur. Diet and traditional Chinese medicine are used to maintain or regain balance and harmony (Figure 16-5) (Davidson and others, 2003).

FIGURE 16-5 Early-morning Tai Chi.

Image: Shutterstock/vanHurck.

Many Chinese people value Western healthcare practices, especially surgical procedures, as a way of managing acute illness (Pang and others, 2003). However, there is a belief that Western medicine is aggressive, can cause side effects and imbalance and does not care for the ‘whole person’, leading to the belief that such care should only be sought in times of serious illness, often after traditional medicines have been tried (Kwok and Sullivan, 2007). Seeking health interventions without symptoms is a difficult concept for many Chinese people to comprehend, a key factor identified in the low uptake of health-screening programs (Goa and others, 2008; Kwok and others, 2010). While Chinese people are generally self-motivated to manage their health, this is set within a social context where there is heavy reliance on family and community support to achieve health and wellness (Chun and others, 2011).

Islamic culture

Unlike Western and Chinese cultures, which are based on geographical traditions and philosophical underpinnings, Islamic influences on health are set within the religious doctrines of Allah (God), as interpreted and set down by the last prophet, Mohammed. Muslims can have what appears to be a conflicting attitude to health by holding both a fatalistic attitude to their health and an expectation to care for the body, which is on loan from Allah and as such must be well cared for (Sheik and Gatrad, 2008). Insha’Allah—if it be the will of God—is the cornerstone belief of Muslims. This leads to a fatalistic approach to health and life (Hjelm and others, 2009), as it is God who determines who will get ill and who will recover, and only God has any control over the time of death. Many Muslims believe that illness of any kind is God’s will and a way of testing their belief in God (Padela and others, 2011).

Together with the need to accept God’s will, the Prophet Mohammed conveyed that ‘There is a cure for every malady save one—that of old age’, charging every Muslim to take responsibility to seek out a remedy for what ails them. The Prophet Mohammed also prophesied ‘that whosoever saves a human life, it is as if they have saved the whole of humankind’, ensuring that Muslims hold medical staff in high regard (Ahmed, 2008). Muslims are more inclined to seek expert help with care rather than be self-caring (Hjelm and others, 2009).

As Muslims see the mind, body and spirit as inextricably linked (Figure 16-6), their definition of symptoms such as ‘aches and pains’ or ‘chest pain’ are more likely to refer to distress, anxiety or depression (Ahmed, 2008). Although there are differences in Muslim and Chinese health beliefs, a three-fold balance between body, mind and soul is fundamental to both. In Western culture, with its individualistic orientation and despite the rhetoric of holistic healthcare, the spirit is generally neglected. Having said that, it is important to remember that stereotyping or making assumptions about people’s health beliefs, attitudes, values and behaviour will only impede a nurse’s ability to create a therapeutic relationship.

FIGURE 16-6 Three dimensions of health.