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Appendix 1: Determinants of Health

Based on "Social, Economic and Cultural Determinants of Health" (Howden-Chapman and Cram, 1998) and Social Determinants of Health: The Solid Facts (WHO, 1998).

It is important to understand the determinants or factors that promote good health in order to be able to improve health for all. Students need to be able to think critically about these factors in relation to health issues if they are to develop as health-literate citizens who can take action to improve health for themselves and others. By adopting a socio-ecological perspective, students can look at health issues as part of a broad social and economic framework. Taking a holistic view of health enables people to recognise its connection to factors outside their own lives.

Determinants of health do not operate independently of each other. They interact, often in unexpected ways, and any one of these determinants may compound or mitigate the effects of the others. Furthermore, determinants of health are not static: as new ones emerge, others change or disappear. Changes in demographic trends (for example, increases in the elderly population, increased resistance to antibiotics and other commonly available drugs, increases in civil and domestic violence, and greater recognition of mental health problems) can threaten the health and well-being of populations.

Determinants that provide the focus for the behavioural change and self-empowerment models of health education and home economics are:

  • personal determinants, which are factors that cannot be altered, such as age, gender, and genetics;
  • lifestyle determinants, which can be influenced by individuals, for example, diet, drug use, and exercise. One lifestyle determinant currently causing concern in many societies is an increase in sedentary behaviour resulting from technological advances, for example, sitting at a computer terminal and sending an email rather than writing a note or memo and delivering it in person.

The following determinants are considered most important in bringing about health improvements across a population. They provide the focus for the collective action model of health education.

Economic determinants reveals that, even in the wealthiest countries, people at the higher end of the socio-economic gradient have better health status than those at the lower end. The global economy, financial markets, and trade can have both positive and negative influences on people's health status. For example, the development of communications technology can increase the potential for better health outcomes (for instance, by enabling agencies to provide famine relief quickly), whereas the international trade in tobacco has a major negative effect on people's health (WHO, 1997).

Cultural determinants include spiritual beliefs, identity issues, and philosophies, practices, and values related to whanau/family relationships (for example, obligations to provide food and accommodation for extended family members).

Environmental determinants include people's access to clean water and air and to recreational and sporting facilities and also include the management of industrial waste.

Political determinants include government laws and policies (for example, the lowering of the drinking age or the impact of 'market rental' housing policies on overcrowding and the consequent spread of infectious diseases) and war.

The following social determinants are identified in Social Determinants of Health: The Solid Facts (WHO, 1998). The explanations of each of these social determinants emphasise how social and psychological environments, early childhood environments, and work affect health.

  • Unemployment has both financial and psychological consequences that affect people's health. Job insecurity has also been shown to have adverse effects on mental health (for example, increased rates of anxiety and depression) as well as on physical health (for example, an increase in heart disease).
  • Social exclusion, which arises from the social and psychological environment, has a major impact on people's health and is linked to premature deaths. A number of groups in society can be vulnerable to social exclusion. These include refugees, new migrants, minority groups, and people with disabilities or mental health problems. People in these groups sometimes have difficulty gaining adequate education or employment.
  • Social support may be based on friendships or on broader elements of social cohesion, including mutual trust, volunteerism, levels of community participation, and relationships between citizens. Social cohesion is closely related to social capital and can have a stronger effect on people's health than either their diet or access to health care.
  • Prenatal and early childhood factors are important foundations for adult life. Prenatal influences such as poor maternal nutrition, maternal use of alcohol, and maternal smoking can affect the infant's cognitive and physical development. Parental poverty can start a chain of social risks relating to readiness for school, learning and behaviour problems, and low-status, low-control jobs in adult life, with all the associated health risks.
  • Access to healthy food is crucial – a nutritious diet is essential to good health. Both a shortage of food (or lack of variety) and an excess of food can lead to a range of diseases. Dietary experts recommend a higher intake of fresh fruit and vegetables and a reduction in fat intake for adults. People on low incomes (for example, young families, the unemployed, and elderly people) are the group least likely to be able to eat well.
  • Access to transport is also important – for example, cycling, walking, and using public transport are health-promoting activities. These options can provide exercise, reduce fatal accidents, increase social contact, and reduce pollution.
  • The social gradient is a continuum based on people's socio-economic status. As indicated above, research shows that people higher on the social gradient have better health than those lower down.
  • Stress caused by social and psychological circumstances can have serious effects on people's mental health and sometimes even leads to premature death. Long periods of anxiety or insecurity (especially in the absence of supportive friendships) are damaging, no matter what parts of a person's life they affect. Social environments in which people participate in decision making and feel that they belong and are valued are healthier places than those in which people feel excluded, disregarded, or 'used'.
  • Work conditions can enhance or harm people's health. When people have little opportunity to use their skills and little control over their work, or when their work makes too many demands on them, their health suffers and absenteeism in the workplace increases. When their work conditions are improved, for example, in terms of money rewards, increased status, or a greater feeling of self-worth, people experience lower stress levels, work better, are more productive, and are healthier.
  • Individuals can develop addiction as a response to a breakdown in their social support systems. People may turn to alcohol, tobacco, or other drugs to escape from adverse life circumstances or a stressful situation. (Poor housing, low income, lone parenthood, unemployment, and homelessness are often associated with unhealthy use of drugs.) Addiction compounds the problem by adding to the addicted person's social and economic disadvantages. People who are addicted often need help and support to address the underlying causes of their addiction as well as the addiction itself.

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