A variety of factors influence people’s health, including genetics, conditioning and personal behavioural choices, however, a growing body of evidence shows that health and illness are, to a large extent, influenced by our environment or context. Put simply, where we live and what we do.
Recognition of these factors provides us with an expanded notion of the environment, beyond the traditional and still important concerns with water, air etc. These influential factors in the human environment – the cultural, political, economic, psychological and spiritual contexts of our lives – are known in the literature as the social determinants of health. They influence our lives in profound ways, either to build and strengthen mental and physical health or to threaten it; they shape morbidity and mortality patterns and there is increasing evidence that behaviours and the possibility of behavioural change are largely influenced by these social determinants.9 This is the case for Australia and internationally. The WHO has vigorously promoted the social determinants of health approach, firstly in Europe10 and more recently with a global perspective,11 and this approach is supported by eminent researchers.12 The WHO Commission on Social Determinants of Health, in its report ‘Closing the Gap in a generation: health equity through action on the social determinants of health’ 13 found that while the ‘poorest of the poor’ have high levels of illness and early death, ill health is not confined only to the worst off. Rather, in all countries at all levels of income, ‘health and illness follow a social gradient: the lower the socioeconomic position, the worse the health’14.
Studies not only show health gaps between countries and between high income and low income groups within countries, but there are large gaps even between suburbs of the same city. For example, the gap in life expectancy at birth between men living in high and low socio-economic suburbs of Glasgow was found to be 28 years15. The Commission on the Social Determinants of Health argues that putting health inequalities right is a matter of social justice and is an urgent ‘ethical imperative’ – something that should not be ignored.
Health inequalities are not only shaped by unequal distributions of material resources, they are also moulded by imbalances in the distribution of power and control. A sense of empowerment over life circumstances is a basic foundation for good health: people need to feel that they have at least some level of control over their lives, their jobs, their housing and their environments. Moreover, different groups have different opportunities to participate in political, economic, social and cultural structures and relationships. Groups that may face barriers to participation include low socio-economic groups and minority groups, such as Indigenous people or men who have been born overseas.
Non-participation, resulting in experiences of disempowerment, generally gives rise to further adverse circumstances, such as low educational achievement and lower levels of service use, including health service use. Typically, so-called behavioural health risks factors, such as smoking, poor diet and low levels of physical activity are firmly embedded in the social exclusion and marginalisation that accompany structural imbalances in power, or men feeling that they do not have the same value as other men. Social inclusion, agency and control, are crucially important for the development of human potential and health.16
The recently released paper, Social Inclusion, Origins, developed by the Institute of Family Studies, as part of the Government’s commitment to social inclusion, discusses a number of aspects of social exclusion. These include locational disadvantage, unemployment, intergenerational disadvantage, children at risk, child poverty, disability and its affects on employment, and homelessness, all of which can contribute to poor health outcomes. Identified in the Social Inclusion Agenda are the following six early Government priorities for social inclusion: 17
- addressing the incidence and needs of jobless families with children;
- delivering effective support to children at greatest risk of long term disadvantage;
- focusing on particular locations, neighbourhoods and communities to ensure programs and services are getting to the right places;
- addressing the incidence of homelessness;
- employment for people living with a disability or mental illness; and
- closing the gap for Indigenous Australians.
The Australian Institute of Health and Welfare (AIHW) also notes the importance of the social determinants, albeit differing from other research by combining behaviours with social determinants.18 The AIHW also suggests that a focus on behaviour and behavioural change is not enough. For example, while introducing the section on the issues of smoking, exercise and alcohol, the document stresses that:
‘ Health behaviours can be influenced by any number of other determinants in combination with a person’s individual makeup. For example, the level and pattern of physical activity can reflect a person’s preferences modified by cultural and family influences. It can also be influenced by climate, availability of space for exercise, and an individual’s personal resources’.19
Berkman and Kawachi in the introduction to their text Social Epidemiology, call for a ‘shift in understanding – specific behaviours once thought of as falling exclusively within the realm of individual choice occur in a social context.’20
Social determinants in men’s health include consideration of such things as education, workplace and environmental factors, social integration, unemployment and disadvantage due to physical location such as living in rural areas or areas where there is limited access to health services.
The AIHW model (above) proposes five categories of health, but does not specify what significance or weighting should be accorded to each category for different health issues.18 The model implies a causal chain from more fundamental factors (those on the left) to the more immediate causes (those on the right). It also incorporates the notion of interaction between these factors, as well as with individual biology, experiences, and age. The model does not address the part played by provision of and access to health services. These have considerable impact on health outcomes, and operate in conjunction with other determinants such as the difficulties of accessing screening and prevention services in rural areas.
9 MacDonald, J. 2005, Environments for Health, Earthscan
10 World Health Organisation, 2003, The Solid Facts: The Social Determinants of Health, WHO, Geneva
11 Marmot, M, 2005, ‘Social determinants of health inequalities’, in The Lancet, Vol. 365, Issue 9464
12 Berkman, F & Kawachi, I, (Eds), 2000, Social Epidemiology, OUP, New York
13 WHO, CSDH, Closing the Gap
15 WHO, CSDH, Closing the Gap
16 Marmot, M. The status syndrome: how your social standing affects your health and life expectancy, Bloomsbury, London, 2004.
18 AIHW, 2008, Australia’s Health 2008, AIHW, Canberra.
19 AIHW, 2008, Australia’s Health 2008, AIHW, Canberra, p. 131
20 Berkman, F & Kawachi, I, (Eds), 2000, Social Epidemiology, OUP, New York, p. 5