Determinant of Health of Income

Determinant of Health of Income and Social Status

Definition of Determinants of Health

Since the 1990's, a very important body of research (Wilkinson and Marmot, 2001) has emerged about the determinants of health. Evidence has been systematically collected about how path- ways through societal, political, environmental and economic determinants become translated into illness and disease, and how social conditions and settings in which people live their lives not only influence how they behave, but also have a direct impact on their health. The social determinants approach seeks to address the social dimensions of health and illness that arise at the level of populations. Thus it is a population health approach, concerned with improving the health of whole populations or specific sub-groups of the population. It aims to reduce inequities through policies, programs, research and interventions that are designed to support, protect and enhance health (Keleher and Murphy, 2004). The following is a brief explanation of each of the main social determinants of health categories.

Income and Social Status

As you read, note the connections or inter-relatedness between determinants. The social gradient: income and social status People's communal and economic circumstances powerfully affect their health all through life. People additional down the social ladder frequently run at least twice the risk of serious illness and premature death faced by those near the top (Marmot and Wilkinson, 1999). And it is not just a matter of the poor vs. The rest. The social gradient is continuous, so that even in the public service, junior office staff tend to suffer worse health and earlier deaths than more senior staff. This gradient holds right even after factoring in difference in smoking, exercise and other behaviors. Sometimes referred to as a hierarchy based on income distribution and the level at which one is positioned in society, the social gradient demonstrates the need for notions of equity for health. The social gradient includes gaps between the rich and poor, and also the degree of wealth held by a given proportion of the population (Bezrucha, 2001). The relationship between the health of populations and socio-economic position is now well established both in overseas countries (Wilkinson, 1996) and in Australia (Dixon, 1999).

Stress

Stress harms health. Enduring anxiety, insecurity, low self-esteem, social isolation and lack of control over work and residence have powerful belongings on health (Bunker et al., 2003). Such psychological risks accumulate throughout life and increase the chances of poor mental health and premature bereavement. Being stressed from persistent poverty and having low control over one's life circumstances has a direct impact on health, irrespective of other behaviors such as poor diet and smoking.

Health Effect That "Income and Social Status" Can Have

Unemployment is directly associated with poor health. Unemployment and employment are related to one's position in the social hierarchy and access to resources (Marmot and Wilkinson, 1999). Employment opportunities are directly related to educational opportunities, while race and ethnicity mediate employment opportunities. Unemployment puts health at risk, and the risk of poor health is elevated in regions where unemployment is prevalent. The health effects of unemployment are linked to both its psychological penalty and accompanying financial problems-especially debt. Low-paid, dangerous or stressful work also has an impact on health. Negative stress in the workplace increases the risk of disease (Marmot and Wilkinson, 1999). However, it is not just having a stressful and demanding job that is the problem. It is stress in the context of having little control or authority in relation to work decisions.

Lack of recognition and reward can add to the health burden even more- the effort/reward imbalance is a very significant determinant of health. Stress is created when people feel their jobs are threatened, and so job insecurity-not just unemployment-has a significant impact on health (Wilkinson and Marmot, 2001). Social connectedness and social support friendship, good social relations and physically powerful supportive networks improve health at home, at work and in the group of people. Be in the right place to a social network of mutual obligation makes populace feel cared for, loved, esteemed and valued. This translates not just into improved psychological health, but also to improved physical health. For example, the evidence is clear that married men have better physical health and greater life expectancy than single men. People who have good social and emotional support have markedly greater chances of surviving a heart attack should this occur. Social capital is related to social connectedness. Social capital is defined as 'the resources available to individuals and to society through social relationships' (Kawachi et al., 2002). Social capital has a number of key components (Health Education Authority, 2002):

* social resources, such as informal networks and friendships between neighbors, or members of any community (e.g. church, school);

* collective resources such as self-help groups, community banks, community gardens;

* economic resources, such as levels of economic participation, employment opportunities, access to green spaces, farmers' markets;

* cultural resources such as libraries, community arts facilities, neighborhood houses, schools. These social capital resources are seen as facilitating cooperation within or among groups.

Local Effect

Community development is an approach to working with communities that has the intention of change, transformation, strengthening of a community's capacity to affect social processes, and ultimately to effect social change. Community development is a field of social practice that is more directed at social outcomes than health outcomes. Broadly, community development means there is an 'active involvement of people sharing in the issues that affect their lives, by drawing on existing human and material resources to enhance self-help and social support' (WHO, 1986). For many communities, social well-being needs to occur before health outcomes can be improved. This is because powerlessness, lack of opportunity, low income and stress are key determinants of illness and disease. Empowerment, a sense of control and hope are linked to better health (Syme, 2003). Community development is used in health practice to facilitate social change that enables people to have better control over the structures and social processes that influence their health and well-being.

The aim is to enable changes that enhance health, and for these changes to become embedded into the fabric of the community. Community nurses engaged in health promotion program work are in a prime position to engage in partnerships, collaborations and transformative community development work. However, too often community-based work-including health promotion-is conducted using top-down processes in opportunistic, short-term pro- grams that result in very little change. There is good evidence that the drivers for change need to emerge from within community groups and organizations rather than from structures imposed by professionals or outsiders-this is because community groups and organizations are the glue that connects people to each other and to their communities. Community nurses should be aware of the likely outcomes of their approaches to practice and strive for the most valid and genuine forms of participatory community development in health in order to increase effectiveness and sustainability of change.

National Effect

From these perspectives, community nurses can position themselves as change agents for better health outcomes for the communities in which they work. Community development is frequently a strategy to reach vulnerable populations such as marginalized youth, homeless people, isolated elderly, refugees and culturally and linguistically diverse (CALD) communities. Nonetheless, the drivers for community development must come from within a community if change is to be achieved, and people must feel sufficiently empowered to take action to have some control over those determinants that influence their health.

Global Effect

Community development in health sits side by side with, and is complementary to, primary health care and health promotion, and is often the strategy used to influence longer term or macro issues that affect health and well-being. Community development is based on widely accepted key principles, which are the basis of both the Alma Ata Declaration for Primary Health Care (WHO, 1978) and the Ottawa Charter for Health Promotion (1986), which both emphasize the importance of strengthening the capacity of local people, communities and their institutions: * Community development requires processes that are built on understandings of the influence of particular determinants of health in people's lives.

* Community development practitioners need to understand and respect the spirit within each community and that it is necessary to relinquish control in order to establish power-sharing responsibilities with people in the community. Community development is therefore built on understandings that health promotion is directed towards action on the determinants or causes of health through effective and concrete public participation (WHO, 1984).

* Community development is a process that is connected to strengthening community action, the engagement and empowerment of communities, and facilitation of their ownership and control of their own endeavors and destinies (WHO, 1986). In deciding where action might be taken to improve health and well-being, the connections between social and health outcomes may not be discernible. Environmental factors of health determine the status and experiences of a community and its social and health outcomes. A central concern of community development in health is with combined with low socio-economic income, poverty and marginalization that is likely to result in adverse health outcomes. Community development is concerned with tackling inequities, and with understanding the interconnections and pathways between the various determinants of health for particular communities.

The effectiveness of community development in health is enhanced by partnerships between health and other sectors such as education, housing, arts or sport, or in programs such as community building and neighborhood renewal. Community development approaches to health promotion are generally poorly identified in planning and practice. Concepts such as empowerment, community engagement and participation are commonly referred to as either processes or out- comes, but often given token effort and paid only lip service. Community development is not a single track in health promotion programs. Health promotion practice entails the planning and implementation of interventions which may take many forms. Evidence about the effectiveness of health promotion demonstrates that one-off programs at a single level of intervention have little value, and that multi-level approaches delivered intensively over longer periods of time are much more likely to create sustainable change. The Framework for Health Promotion Action (Murphy, 2004) illustrates the different levels of health pro- motion interventions and shows where community/health development is situated in relation to other interventions.

Community participation, engagement, empowerment and action Consumer participation in health service development has been built into the planning of health services for at least 20 years, and there is a substantial body of literature about strategies which are designed to improve health services through consumer participation. There are many excellent resources such as kits, fact sheets and reviews to assist health services with community participation strategies and consultation processes. However, there are challenges in achieving effective consumer participation strategies. Token or symbolic community representation on advisory groups can allow health services to 'tick the box' those consumers have been consulted, based on the erroneous belief that one or two selected (rather than elected) people can genuinely represent the diversity and complexity of consumers in any community.

Further, organizations are not usually provided with adequate resources to undertake consultation with the communities they are supposed to represent. Genuine participation actually involves more than token consultation with one, or even a few, people from the community. Another criticism of consumer participation is that its strategies are much more likely to give voice to people who are already empowered by education and who are in relatively comfortable circumstances. There also appears to be very little evaluation available of consumer participation activities or strategies.

Health Promotion Strategies Related to "Income and Social Status"

Consumer engagement is a term that is somewhat more in its infancy (Bush, 2002) than consumer participation. Consumer engagement is emerging in relation to health promotion as a strategy to improve the use of, and access to, services. In this context, consumer engagement seeks to increase the uptake of health services by a more diverse range of consumers, particularly vulnerable population groups including those experiencing disadvantage and/or social exclusion.

The processes and philosophy of consumer engagement include the enhancement of services so that they are more likely to be used or taken up by those consumers. Through engagement with consumers and their subsequent participation, enhancement and quality improvement of services is more likely to occur. Thus community engagement is also about issues of reach as well as shared power and shared decision-making.

A theory of motivation that may be used to change behaviors towards health promotion actions related to "Income and Social status"

When members of a community are engaged with an issue of concern to them-that is, an issue that they have defined as being a determinant of their health-more effective engagement with the processes of community action are likely to result. For example, communities feeling threatened by plans to locate a facility that will have a negative impact on their locale (e.g. A toxic waste facility) often show remarkable capacities to organize and resource themselves in order to mount a campaign to oppose the planning scheme. They will often demonstrate a sophisticated understanding of the problem-for example that a toxic waste facility needs to be located away from sensitive environmental areas, from waterways and agricultural land because contamination will pose threats to the health of people or native habitat that may come into contact with toxic waste. Such communities become empowered by this theory of motivation.

Brief Overview of the Theory

A different example is when a health practitioner has developed a program that he/she then attempts to implement in a community setting. For example, a diabetes / healthy lifestyles education program that has been developed on the basis of staff, consumer and key service provider consultation will have limited appeal to marginalized groups.