Social Determinants of Health & Illness PDF

 Introduction Since the decline in infectious diseases in the 19th and early 20th centuries, the major causes of sickness and death are now circulatory diseases including coronary heart disease (CHD) and stroke (36%), cancers(27%), and respiratory diseases (14%). Taking CHD a...

 Introduction Since the decline in infectious diseases in the 19th and early 20th centuries, the major causes of sickness and death are now circulatory diseases including coronary heart disease (CHD) and stroke (36%), cancers(27%), and respiratory diseases (14%). Taking CHD as an example; whilst physical inactivity, smoking and raised blood cholesterol are the major risk factors for CHD, it is important to look upstream and understand the causes of these causes and their roots in the social context of people’s lives.  Introduction Social and economic disadvantage can give rise to or exacerbate health-damaging behaviors such as smoking or poor nutrition, and so health behaviors should not be separated from their social context (victim blaming).  Introduction The impact of scientific medicine on health is marginal when compared to major structural features such as the distribution of wealth, income, housing and employment.  Introduction In Turkey Ari et al (2021) conducted a survey to capture the role of socio-economic factors in increasing exposure to and infection with COVID. They found having higher income, being employed, and having higher education tend to attenuate the risks, while poverty, low socio-economic status (precarious work and low education) amplified the risks  Introduction In Egypt, CAPMAS’s study of the first and second waves (CAPMAS February 2021) pointed to the neglect of rural and poorer areas. The highest infection rates in the first and second waves were indeed in Assiut and Matrouh respectively, which are among the poorest regions, and had low health system and health outcome indicators. WHAT ARE THE MOST IMPORTANT FACTORS THAT INFLUENCE COMMUNITIES’ Health?  Influences on Health Health Field Model Human Biology (Genetics) Lifestyle (Human Health behaviour) Services Environment  What are the social determinants of health? Social determinants of health are the economic and social conditions that shape the health of individuals, communities, and society as a whole. Social determinants of health include; social class, education, housing, transportation, physical environment, employment, gender, ethnicity, culture, social capital and social relations.  WHO The social determinants of health are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. http://www.who.int/social_determinants/en/  Governments have the main role in improving social and health equity. Policies are the means by which governments show their political will to promote equity.  Health Equity in the Arab World Many Arab countries are laggards in terms of actual policies, with notable difference between de jure and de facto health entitlements and health commitments. Health systems display a number of systemic problems, and clear, persistent health inequities in resources and outcomes. These inequities are related in no small way to the injustices and frustrations that led to the Arab Spring uprisings.  Health Equity in the Arab World Eight Arab countries (lebanon, UAE, Djibouti, KSA, Iraq, Bahrain, Somalia, and Qatar) reported health equity as a part of their health goals but there was no mention of clear strategies to achieve this goal. (Review of Health Systems of the Middle East and North Africa Region International Encyclopedia of Public Health. 2017 : 347–356) (Public Health in the Arab World, Samer Jabbour et al., Cambridge University press, 2012)  Health Equity in the Arab World Except for Qatar, all these countries limited their understanding of health equity to the narrow perspective of equal health services provision not to the wider social determinants of health approach.  Health Equity in the Arab World Interventions based on understanding these determinants would have a different focus. For example, rather than preaching families against early marriage, they may support female education and employment. (youth and drugs).  Health Equity in the Arab World Households have been shouldering a significant part of the burden of the costs of healthcare (Randa Alami, 2017). Arab countries display some of the highest OOP levels in the world, with households shouldering around 50 per cent of the burden of healthcare in Lebanon, Morocco, Syria and Yemen; in Egypt, OOP levels are said to have reached 72 per cent recently (Karshenas et al. 2014,Farag, 2012).  Health Equity in the Arab World Health systems capacity tends to be fragmented along four segments: public, military/special hospitals, private, and voluntary sectors. The weakness of public health systems led to prominence of the private sector. This de facto privatisation reinforces the ability to pay as a basis of accessing healthcare, and is an important factor behind the continued dominance of upfront fees and OOPs. Randa Alami-Economic Research Forum, 2022  Health Equity in the Arab World A study of OOP in Upper Egypt by Farahat et al (2021) found that OOPs were associated with poor income groups, chronic diseases and women of childbearing age, who typically have no insurance (left behind).  Health Equity in the Arab World Accessibility and affordability of health services should not depend on the ability to pay, and citizens should be covered by equitable health financing systems. Randa Alami-Economic Research Forum, 2022  Health Equity in the Arab World Universal Health Coverage (UHC). Almost all Arab countries signed the 2010 Declaration of UHC Randa Alami-Economic Research Forum, 2022  UHC in the Arab World Measuring progress towards universal health coverage in 22 Middle East and North African countries. Dialogues in Health, December 2024  UHC in the Arab World UHC index ranges from a minimum of 48.2 (Somalia) to 90.3 (United Arab Emirates) with a regional mean, of 74.9. Only six of the 22 MENA countries have enacted legislation formalizing their commitment to universal health coverage: Bahrain, Jordan, Kuwait, Oman, Tunisia, and United Arab Emirates. The trend indicates an increase in the UHC index with the country's income, where the lowest UHC index is found in low-income countries and vice versa. Total Health Expenditure in Arab Countries (% GDP), 2019 Algeria 6.24 Bahrain 4.01 Djibouti 1.80 Egypt 4.74 Iraq 4.48 Jordan 7.58 Kuwait 5.50 Lebanon 8.65 Libya 6.05 Morocco 5.31 Oman 4.07 Saudi Arabia 5.69 Sudan 4.57 Tunisia 6.96 Source: World Bank, 2019  Health Equity in the Arab World It is now well-accepted that: Reducing poverty through the trickle-down effect of growth is not enough. Reducing poverty through charity is a short – term solution as direct cash transfers alleviate suffering but do not address the root causes of the problem. Public health needs to be strengthened and reoriented away from focusing on changing behaviors and risk factors towards addressing health inequity and its underlying causes.  Health Equity in the Arab World To address the determinants of health inequities, many of which lie outside the health sector, the initiative calls for using intersectoral action (ISA) as a key strategy (whole of Government approach- Health in All Policies approach).  Health Equity in the Arab World There remains a number of Arab countries in which ministries of health are reluctant to move beyond what they regard as their only and unique responsibility, prevention, diagnosis and treatment of disease. The reason is that ISA may appear to endanger the already small funds received from central governments and to upset established practices. WHO  Race, Ethnicity & Health The traditional definition of race and ethnicity is related to biological and sociological factors respectively. Race refers to a person's physical appearance, such as skin color, eye color, hair color, bone/jaw structure etc (Caucasian race). Ethnicity, on the other hand, relates to cultural factors such as nationality, culture, ancestry, language and beliefs. The term ethnic groups is used to denote groups of people who share similar histories and cultural characteristics which give them a distinct identity. The presence of different racial/ethnic groups are only important to health when the society defines one group as different which can result in negative discrimination, usually called racism.  Race, Ethnicity & Health Research denotes that good health and good health care is not as accessible to people in minority ethnic groups as it is to other groups in most societies.  Race, Ethnicity & Health Health profiles of many racial & ethnic minorities reflect social inequalities. In UK, unemployment rates for most minority groups are higher than those of whites. Low income was higher amongst people of Asian origin. Every indicator of poverty shows that black people and other ethnic minority groups are at increased risk of being poor , principally through the effect of racism and negative discrimination.  Race, Ethnicity & Health Racism contributes to: Reduced or unequal access to employment, adequate housing, education, medical care, social support and social participation (social exclusion). Negative emotional reactions that contribute to stress and mental ill health. This also adversely impacts upon the endocrine and cardiovascular systems. Use of substances such as tobacco, alcohol and other drugs Physical manifestations of racism such as physical assault, intimidation etc  Social class & Health Indicators of social class : income, education, living and working conditions Social class is clearly associated to differences in morbidity and mortality rates It is known that the greater the level of personal income, the further up the ‘social gradient ladder’ an individual will be. Health outcomes of people with higher incomes may be related to increased social participation and control and access to safe neighborhoods, healthy foods, education, health care, and clean air.  Social class & Health In contrast, poverty is thought to affect health through material deprivation, decreased social participation, and decreased control over one’s life. The experience of hardship and the effects of social exclusion which often accompany the experience of poverty have been correlated with unhealthy lifestyle choices, food illiteracy, stress, anxiety and a decline in positive health status. Becoming socially marginalized, the poor are less likely to adhere to the norms of society leading to higher levels of crime.  Mortality from Coronary Heart Disease men aged 20-64 by social class, England and Wales, 1991-93 England and Wales = 100 Social Class Professional 63 Managerial 73 Non-manual skilled 107 Manual skilled 125 Partly skilled 121 Unskilled 182 0 50 100 150 200 Standardized mortality ratios Source: Office for National Statistics (ONS), Health Inequalities Image result for mortality rates by social class 2015  Gender There is a distinction between sex and gender, whereby sex refers to physical and biological differences and gender refers to the social definitions of how women and men should behave under certain circumstances. It is the social meaning and beliefs about sexual difference. Society prescribes how the biological sex is transformed into the social gender. Every society produces norms, rules, expectations for each gender (learned roles &tasks) and these differ by place and over time. Gender differences have a greater impact on health and health care than differences in biological sex.  Gender Women’s social position as both carers and workers inside and increasingly outside the home is a dual burden which leads to increased stress and ill health. Gender inequities in income occur such that wages for women may be around 20% lower than those for men. Because single parents are almost always women, the lower income of women also affects their children.  Gender The exploitation of women in the sex trade, in marketing for different goods, in underage marriage, or the sexual harassment at work or in streets is another example of social disparity.  Gender While females are socialized to be passive and dependent, men are encouraged to be aggressive and risk-taking both at work and at leisure time. Thus drinking alcohol, taking drugs , dangerous sports & dangerous driving are more common among men. SOME occupational hazards such as those related to constructions, mining and fishing are mostly seen in men.  Education and Health A high level of education equips individuals with the skills to cope with day to day challenges, and further enables individuals to participate more fully within the employment market, the economic market, and their communities Education also has a more direct influence on health in that it affects a person’s ability to navigate the health care system, to interpret health information and to communicate effectively with physicians and other professionals.  Education and health Educational attainment can also act as a risk factor for certain conditions; dementia offers an example: Here, a lack of education may lead to careers that expose the worker to neurotoxic substances that damage brain function. Conversely, higher education, and the stimulating careers that go with it, may build complex neural networks that protect the aging brain. Female education is associated with lower infant mortality  Education and Health “‘Health literacy” refers to individual’s ability to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.  Education and Health Being health literate allows individuals to: Improve their knowledge regarding health related information. Make informed decisions regarding their personal health Raise their own awareness of the social, environmental and economic determinants of health. Read medicine labels and instructions. Read and understand health promotion information. Act upon necessary procedures and directions given from medical personnel as well as appointment schedules.  Employment The WHO recognizes fair employment and decent work as a cornerstone of health, and advocates for fair minimum wages, full employment, and occupational health and safety standards. Work stress affects individuals’ health. It originates from factors such as income, job insecurity and dissatisfaction. Workers who perceive work insecurity experience significant adverse effects on their physical and mental health. Work strain also arises from psychosocial factors such as high work demands, low control over work decisions and low social support. Moreover, a mismatch between work effort and reward produces feelings of strain that predict poor health.  Employment Apart of its effect on health arising from material disadvantage, unemployment has a profound effect on mental health, damaging a person’s self-esteem and social structure (social isolation). Studies show that suicide rates are twice as high among the unemployed as among the employed.  Culture A culture is a way of life of a group of people-- the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next. Culture explains what one must know and do to function in a given society.  The relevance of culture for health Culture influences health through many channels: 1. Positive or negative lifestyle behaviours. 2. Beliefs and attitudes. 3. Reactions to being sick. 4. Communication patterns. 5. Status.  Culture When knowledge is lacking, cultural beliefs often take over. Social networks and social support social network refers to the web of social relationships that surrounds individuals. The provision of social support is one of the important functions of social relationships.  Social networks and social support Social support is always intended to be helpful thus distinguishing it from intentional negative interactions within social networks (for example angry criticism and undermining). Social support serves as a protective psychosocial factor that reduces individual’s vulnerability to the negative effects of stress on health.  Types of social support Emotional support: Expressions of empathy, love, trust and caring. Instrumental support: Tangible aid and services. Informational support: Advice, suggestions, and information. Appraisal (Esteem, Affirmation) support: pointing out the strengths you are forgetting you have. Companionship support: sense of belonging  Social networks and social support It has been documented that emotional support provided by intimate ties increases survival rate among people with severe cardiovascular disease. A positive role for emotional support in the processes of coping with and recovering from serious illness has been consistently documented.  Social support is now proven to be a literal life – saver. Social support is one of the Key elements that influence self-esteem especially the support of one’s parents early in development. In his experiment on conformity (1951), Asch obtained convincing evidence that social support increased resistance to social influence and pressure. When participants had no social support, they conformed to the group on up to 37% of trials. In contrast, they conformed on only 5% of trials, when participants had one supporter.  Social support Social support is expected from the family, friends, community and governments.  Social support Arab governments in general do not provide major support to mentally ill individuals beyond basic medical care. Family members are left alone as the sole providers of health, economic and social support.  Image result for social capital 2015 Social capital Social capital is one of the social determinants of health. By social capital we do not refer to real-estate or personal property or cash but rather to good will, sympathy, cooperation, trust and positive social interactions.  Social capital It is defined as those specific processes among people and organizations working collaboratively in an atmosphere of trust that leads to accomplishing a goal of mutual social benefit.(Young 2001).  Types of social capital Bonding social capital refers to relationships amongst members of a network who are similar in some form such as neighbors, friends and family.(Putnam, 2000). Bridging social capital refers to relationships amongst people who are dissimilar in a demonstrable fashion, such as background, age, socio-economic status, race/ethnicity and education (Szreter and Woolcock, 2004)e.g., distant friends, colleagues and associates.  Types of social capital Linking social capital is the extent to which individuals build relationships with institutions and individuals who have relative power over them (e.g. to provide access to services, jobs or resources) (Woolcock, 2001; Szreter and Woolcock, 2004).  Social capital Image result for social capital 2015  Social Capital Social capital may contribute directly to health or may result in policies that are more supportive of healthy outcomes. Low social capital was related to higher mortality, while membership in social groups was linked to lower all-cause mortality.  Social capital Research identified links between social capital and improved health, greater well- being, better care for children, and lower crime.  Social Capital Low social capital is characterized by an unwillingness to collaborate with others who are perceived as different and typically occurs where there are wide disparities in income and a perception of social inequalities.  Social Capital Key indicators: – Trust (in others, in institutions) – Reciprocity. – Civic participation – Political engagement – Diversity of social networks – Social Cohesion (sense of belonging ) – Voluntary activity – Income distribution