Social Determinants of Health: Causative Agents that Determine Health OutcomesIn Australia, a social model of health has been developed by health professionals and policy makers, in order to study the effects of the social determinants of health upon given populations. Social policy drives a lot of health funding, in particular statistics indicate that the most socially disadvantaged group within a given population also have the highest rate of chronic health problems, and highest number of risk factors leading to the development of chronic health problems (including cardiovascular disease, obesity, cancer, diabetes). The social determinants of health are the causative agents that are studied within social models of health, and examined by epidemiologists (health professionals who study the effects of various factors that cause disease within a particular population). This paper discusses how people's bad health is not a result of their accumulated poor choices; people's bad health is a result of socially determined agents, including a lack of health education, opportunities and lack of access to health facilities, particularly in rural and remote areas. A person can potentially overcome socially caused disease and illness, through the assistance of a health professional such as a nurse.
The Role of the Nurse As a Helper Towards Health
A nurse can work in partnership with a person in building their levels of health literacy, education, referral and help in building confidence towards making healthy choices, regardless of circumstances. Nurses are in particular well positioned to understand a person's social context, and help a patient to overcome the negative factors within the realm of causative agents. The most critical underlying factor in assisting a person to overcome the social determinants of their health is their level general perceived self- efficacy (their belief in their own ability to make and continue making healthy choices, and engage in health protective behaviours.)
A nurse can work in partnership with a person in building their levels of health literacy, education, referral and help in building confidence towards making healthy choices, regardless of circumstances. Nurses are in particular well positioned to understand a person's social context, and help a patient to overcome the negative factors within the realm of causative agents. The most critical underlying factor in assisting a person to overcome the social determinants of their health is their level general perceived self- efficacy (their belief in their own ability to make and continue making healthy choices, and engage in health protective behaviours.)
How a Person Interacts Within the Social Health Model
An individual, within the social models of health, has the power of free agency, and can and does interact with the social determinants of health. Generally, the social determinants of health flow from upstream factors to the midstream, and finally to the downstream factors. Upstream factors are the furthest from the individual, and include the broad aspects of a society that a person belongs to. These include the culture of a society and social cohesion, the stability of the government, health policies and language and media. Midstream factors are more direct in their impact on an individual, and these include factors such access to education, where in the social gradient the person is, their access to health care, where the person is employed, their social network (or lack thereof), the neighbourhood they live in and the built environment in which he or she lives.
An individual, within the social models of health, has the power of free agency, and can and does interact with the social determinants of health. Generally, the social determinants of health flow from upstream factors to the midstream, and finally to the downstream factors. Upstream factors are the furthest from the individual, and include the broad aspects of a society that a person belongs to. These include the culture of a society and social cohesion, the stability of the government, health policies and language and media. Midstream factors are more direct in their impact on an individual, and these include factors such access to education, where in the social gradient the person is, their access to health care, where the person is employed, their social network (or lack thereof), the neighbourhood they live in and the built environment in which he or she lives.
Health Professionals Seeing an Individual in Social Context
A health professional cannot look at a patient's condition in isolation - a health professional should take into account socially determined factors - that contribute to a state of ill health within the person. When determining appropriate treatment and supports for a patient, examining the person in their social context will assist in determining valid treatments, and providing education and referral to services that will assist in mitigating the socially determined circumstances that contributed to the development or onset of the disease or illness state.
A health professional cannot look at a patient's condition in isolation - a health professional should take into account socially determined factors - that contribute to a state of ill health within the person. When determining appropriate treatment and supports for a patient, examining the person in their social context will assist in determining valid treatments, and providing education and referral to services that will assist in mitigating the socially determined circumstances that contributed to the development or onset of the disease or illness state.
Chronic Stress As a Risk Factor
One of the highest contributing factors to ill health is the effects of chronic stress. In a study by Pyter et al. (2014) the effects of abstract stress and social isolation were studied on mice. Social stressors negatively affected healing, increased bacterial load in the body, and also caused high levels of inflammation in the body of the subjects. Inflammation and impaired healing caused from elevated levels of stress, particularly in chronic situations, leads to increased susceptibility to disease.
One of the highest contributing factors to ill health is the effects of chronic stress. In a study by Pyter et al. (2014) the effects of abstract stress and social isolation were studied on mice. Social stressors negatively affected healing, increased bacterial load in the body, and also caused high levels of inflammation in the body of the subjects. Inflammation and impaired healing caused from elevated levels of stress, particularly in chronic situations, leads to increased susceptibility to disease.
Examining Socio-Economic Disadvantage
The most disadvantaged parts of society - in Australia - rural and remote areas in particular, have high levels of unemployment and general disadvantage economically. Statistically in demonstrated in the Australian Institute of Health and Welfare (2012) paper, the most economically disadvantaged groups coincided with both rural and remote communities, and they had the highest incidence of both risk factors for chronic disease, and incidence of chronic disease.
The most disadvantaged parts of society - in Australia - rural and remote areas in particular, have high levels of unemployment and general disadvantage economically. Statistically in demonstrated in the Australian Institute of Health and Welfare (2012) paper, the most economically disadvantaged groups coincided with both rural and remote communities, and they had the highest incidence of both risk factors for chronic disease, and incidence of chronic disease.
Contributors to Chronic Diseases
With a combination of high stress levels due to social stressors and economic disadvantage and high risk factors, rural and remote areas of Australia are a melting pot for high rates of chronic disease. High levels of stress are particularly noted in rural and remote areas, for example, due to the high number of disparate suicides by men in rural and remote areas compared to men living in urban environments. A paper by Beaton (2012) outlines the statistics demonstrating that men are more likely to commit suicide who are living in rural and remote areas.
With a combination of high stress levels due to social stressors and economic disadvantage and high risk factors, rural and remote areas of Australia are a melting pot for high rates of chronic disease. High levels of stress are particularly noted in rural and remote areas, for example, due to the high number of disparate suicides by men in rural and remote areas compared to men living in urban environments. A paper by Beaton (2012) outlines the statistics demonstrating that men are more likely to commit suicide who are living in rural and remote areas.
Self Medicating to Relieve Stress
When experiencing stress, patients are noted to desire to self-medicate using substances that produce mind-altering effects and moderate anxiety levels, such as alcohol and tobacco. Alcohol and tobacco use, in particular excessive alcohol and daily tobacco use, are two of the focus risk factors that are used in studying the risk of developing chronic diseases. Le, Funk, Lo, and Coen (2014) demonstrated that alcohol and nicotine are often taken together, and a cyclical relationship happens between excessive drinking and increased tobacco use. Further evidence indicates that stressed people in a study self-reported functional addiction to alcohol and tobacco use as mood regulation tools (Snel, 1998).
When experiencing stress, patients are noted to desire to self-medicate using substances that produce mind-altering effects and moderate anxiety levels, such as alcohol and tobacco. Alcohol and tobacco use, in particular excessive alcohol and daily tobacco use, are two of the focus risk factors that are used in studying the risk of developing chronic diseases. Le, Funk, Lo, and Coen (2014) demonstrated that alcohol and nicotine are often taken together, and a cyclical relationship happens between excessive drinking and increased tobacco use. Further evidence indicates that stressed people in a study self-reported functional addiction to alcohol and tobacco use as mood regulation tools (Snel, 1998).
Poorer Leads to Higher Risk Factors
The effects of daily smoking and excessive tobacco use are known high risk factors for cardiovascular disease, and lung disease, and some cancers. Statistically, in the paper by the AIHW (Australian Institute of Health and Welfare, 2012), the most socially disadvantaged individuals, in rural and remote areas, had the highest number of reported risk factors: daily tobacco use, obesity, poor nutrition, excessive alcohol use, and lack of exercise; and the highest rates of chronic diseases. Comparatively, people in urban and regional areas with higher population density had less rates of disease, and also a lower incidence of risk factors for chronic disease.
The effects of daily smoking and excessive tobacco use are known high risk factors for cardiovascular disease, and lung disease, and some cancers. Statistically, in the paper by the AIHW (Australian Institute of Health and Welfare, 2012), the most socially disadvantaged individuals, in rural and remote areas, had the highest number of reported risk factors: daily tobacco use, obesity, poor nutrition, excessive alcohol use, and lack of exercise; and the highest rates of chronic diseases. Comparatively, people in urban and regional areas with higher population density had less rates of disease, and also a lower incidence of risk factors for chronic disease.
Contributors to Stressful Environments
A number of determinants are thought to cause higher rates of stress within low socio-economic populations, including social isolation, high rates of stress caused by major life changes (such as family breakup, divorce, unemployment, lack of stability), and these leads to the use of tobacco and alcohol to self-medicate during times of stress (as per Snel, 1998). In rural and remote areas, Australia has traditionally had difficulty placing medical facilities due to isolation and cost of establishing large facilities in rural and remote locations. Generally due to lack of access to cheaper fresh fruit and vegetables, access to primary health care and prevention and health promotion services, inexpensive exercise facilities and incentives, the socially determined elements, amongst the rural and remote poor lead to high rates of chronic disease when compared to healthier and wealthier urban populations (Australian Institute of Health and Welfare, 2012).
A number of determinants are thought to cause higher rates of stress within low socio-economic populations, including social isolation, high rates of stress caused by major life changes (such as family breakup, divorce, unemployment, lack of stability), and these leads to the use of tobacco and alcohol to self-medicate during times of stress (as per Snel, 1998). In rural and remote areas, Australia has traditionally had difficulty placing medical facilities due to isolation and cost of establishing large facilities in rural and remote locations. Generally due to lack of access to cheaper fresh fruit and vegetables, access to primary health care and prevention and health promotion services, inexpensive exercise facilities and incentives, the socially determined elements, amongst the rural and remote poor lead to high rates of chronic disease when compared to healthier and wealthier urban populations (Australian Institute of Health and Welfare, 2012).
Barriers to Experiencing Wellness
In addition to the social determinants of health acting upon an individual, a number of barriers are potentially experienced by people when attempting to improve their health status. A study in Sweden by Hammarstrom, Wiklund, Lindahl, Larsson, and Ahlgren (2014) studied a number of barriers to women who were attempting to lose weight. They discovered that a number of social stressors, and difficulty with the self (adjustment to diet and self-belief) impaired the ability to lose weight. They conversely discovered that receiving social support, and determining goals and improving self-determination facilitated in weight loss and subsequent improvement in health.
In addition to the social determinants of health acting upon an individual, a number of barriers are potentially experienced by people when attempting to improve their health status. A study in Sweden by Hammarstrom, Wiklund, Lindahl, Larsson, and Ahlgren (2014) studied a number of barriers to women who were attempting to lose weight. They discovered that a number of social stressors, and difficulty with the self (adjustment to diet and self-belief) impaired the ability to lose weight. They conversely discovered that receiving social support, and determining goals and improving self-determination facilitated in weight loss and subsequent improvement in health.
Hopping Over the Barriers to Health
In more studies of how improving self-efficacy and working in partnership with health professionals, it was demonstrated that an active improvement of general perceived levels of self-efficacy and motivation led to better health outcomes for the patient. These studies include Wood, Englander-Golden, Golden, and Pillai (2010), where self-empowerment and social support improved health outcomes for people experiencing substance abuse, and Mohebi, Azadbakht, Feizi, Sharifirad, and Hozori (2014) determined that patients' levels of micronutrient intake improved as they had better levels of general perceived self-efficacy.
In more studies of how improving self-efficacy and working in partnership with health professionals, it was demonstrated that an active improvement of general perceived levels of self-efficacy and motivation led to better health outcomes for the patient. These studies include Wood, Englander-Golden, Golden, and Pillai (2010), where self-empowerment and social support improved health outcomes for people experiencing substance abuse, and Mohebi, Azadbakht, Feizi, Sharifirad, and Hozori (2014) determined that patients' levels of micronutrient intake improved as they had better levels of general perceived self-efficacy.
Compassionate Health Care
Nurses have a vital role in helping a patient: advocating for the patient, using motivational interviewing, developing therapeutic partnership, educating regarding appropriate health protecting behaviours, and encouraging the development of social support and increasing levels of self-motivation within the patient. Hybels et al. (2014). Benzo et al. (2013) discusses the importance and success outcomes of motivational interviewing to discuss behaviour changes in patients diagnosed with COPD.
Nurses have a vital role in helping a patient: advocating for the patient, using motivational interviewing, developing therapeutic partnership, educating regarding appropriate health protecting behaviours, and encouraging the development of social support and increasing levels of self-motivation within the patient. Hybels et al. (2014). Benzo et al. (2013) discusses the importance and success outcomes of motivational interviewing to discuss behaviour changes in patients diagnosed with COPD.
Empowerment to Be Healthy Happy and Strong
A nurse has an empowering role, and can point the patient towards developing healthy social networks, and making health protecting choices. The role of social support, such as in the study by Harvey, where it was noted that social support can improve health outcomes cannot be understated. For people who are in faith communities, social support is evidenced by improved general biological health markers compared to other populations, this was studied by Hybels et al. (2014).
Nurses also have a unique position as health professionals to use motivational interviewing and therapeutic partnership with patients, in order to empower them and remove barriers to obtaining better health outcomes. Benzo et al. (2013) discusses the importance and success outcomes of motivational interviewing to discuss behaviour changes in patients diagnosed with COPD.
A nurse has an empowering role, and can point the patient towards developing healthy social networks, and making health protecting choices. The role of social support, such as in the study by Harvey, where it was noted that social support can improve health outcomes cannot be understated. For people who are in faith communities, social support is evidenced by improved general biological health markers compared to other populations, this was studied by Hybels et al. (2014).
Nurses also have a unique position as health professionals to use motivational interviewing and therapeutic partnership with patients, in order to empower them and remove barriers to obtaining better health outcomes. Benzo et al. (2013) discusses the importance and success outcomes of motivational interviewing to discuss behaviour changes in patients diagnosed with COPD.
Nurses and Advocacy
As members of the community in which they live, nurses have the opportunity not only to act as treating health professionals, and part of medical and allied health teams, but also to act as advocates in the community for the most vulnerable members of the community. Nurses have a role to play in building the ability of individuals in the most disadvantaged areas to build social capital and develop healthy social networks of supportive individuals. Nurses can be community champions, social role models and professionals who educate individuals, groups and communities that they can make changes, both as individuals and groups to improve their capacity to make health decisions, thereby improving the health outcomes for everyone in the community.
As members of the community in which they live, nurses have the opportunity not only to act as treating health professionals, and part of medical and allied health teams, but also to act as advocates in the community for the most vulnerable members of the community. Nurses have a role to play in building the ability of individuals in the most disadvantaged areas to build social capital and develop healthy social networks of supportive individuals. Nurses can be community champions, social role models and professionals who educate individuals, groups and communities that they can make changes, both as individuals and groups to improve their capacity to make health decisions, thereby improving the health outcomes for everyone in the community.
REFERENCES
Australian Institute of Health and Welfare, AIHW. (2012). Health Determinants, the key to preventing chronic disease. Canberra: Australian Institute of Health and Welfare.
Beaton, Susan and Forster, Peter. (2012). Insight into Men's Suicide. Retrieved 24th April 2014, from http://www.psychology.org.au/inpsych/2012/august/beaton/
Benzo, R., Vickers, K., Ernst, D., Tucker, S., McEvoy, C., & Lorig, K. (2013). Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies. J
Cardiopulm Rehabil Prev, 33(2), 113-123. doi: 10.1097/HCR.0b013e318284ec67
Hammarstrom, A., Wiklund, A. F., Lindahl, B., Larsson, C., & Ahlgren, C. (2014). Experiences of barriers and facilitators to weight-loss in a diet intervention - a qualitative study of women in Northern Sweden. BMC Womens Health, 14(1), 59. doi: 10.1186/1472-6874-14-59
Hybels, C. F., George, L. K., Blazer, D. G., Pieper, C. F., Cohen, H. J., & Koenig, H. G. (2014). Inflammation and Coagulation as Mediators in the Relationships Between Religious Attendance and Functional Limitations in Older Adults. J Aging Health. doi: 10.1177/0898264314527479
Le, A. D., Funk, D., Lo, S., & Coen, K. (2014). Operant self-administration of alcohol and nicotine in a preclinical model of co-abuse. Psychopharmacology (Berl). doi: 10.1007/s00213-014-3541-2
Mohebi, S., Azadbakht, L., Feizi, A., Sharifirad, G., & Hozori, M. (2014). Predicting of perceived self efficacy in the amount of macronutrients intake in women with metabolic syndrome - 2012. J Educ Health Promot, 3, 21. doi: 10.4103/2277-9531.127608
Pyter, L. M., Yang, L., McKenzie, C., da Rocha, J. M., Carter, C. S., Cheng, B., & Engeland, C. G. (2014). Contrasting mechanisms by which social isolation and restraint impair healing in male mice. Stress, 17(3), 256-265. doi: 10.3109/10253890.2014.910761
Snel, J. & Lorist, M.. (1998). Nicotine, Caffeine and Social Drinking. Australia: Harwood Academic Publishers.
Wood, T. E., Englander-Golden, P., Golden, D. E., & Pillai, V. K. (2010). Improving addictions treatment outcomes by empowering self and others. Int J Ment Health Nurs, 19(5), 363-368. doi: 10.1111/j.1447-0349.2010.00678.x
Australian Institute of Health and Welfare, AIHW. (2012). Health Determinants, the key to preventing chronic disease. Canberra: Australian Institute of Health and Welfare.
Beaton, Susan and Forster, Peter. (2012). Insight into Men's Suicide. Retrieved 24th April 2014, from http://www.psychology.org.au/inpsych/2012/august/beaton/
Benzo, R., Vickers, K., Ernst, D., Tucker, S., McEvoy, C., & Lorig, K. (2013). Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies. J
Cardiopulm Rehabil Prev, 33(2), 113-123. doi: 10.1097/HCR.0b013e318284ec67
Hammarstrom, A., Wiklund, A. F., Lindahl, B., Larsson, C., & Ahlgren, C. (2014). Experiences of barriers and facilitators to weight-loss in a diet intervention - a qualitative study of women in Northern Sweden. BMC Womens Health, 14(1), 59. doi: 10.1186/1472-6874-14-59
Hybels, C. F., George, L. K., Blazer, D. G., Pieper, C. F., Cohen, H. J., & Koenig, H. G. (2014). Inflammation and Coagulation as Mediators in the Relationships Between Religious Attendance and Functional Limitations in Older Adults. J Aging Health. doi: 10.1177/0898264314527479
Le, A. D., Funk, D., Lo, S., & Coen, K. (2014). Operant self-administration of alcohol and nicotine in a preclinical model of co-abuse. Psychopharmacology (Berl). doi: 10.1007/s00213-014-3541-2
Mohebi, S., Azadbakht, L., Feizi, A., Sharifirad, G., & Hozori, M. (2014). Predicting of perceived self efficacy in the amount of macronutrients intake in women with metabolic syndrome - 2012. J Educ Health Promot, 3, 21. doi: 10.4103/2277-9531.127608
Pyter, L. M., Yang, L., McKenzie, C., da Rocha, J. M., Carter, C. S., Cheng, B., & Engeland, C. G. (2014). Contrasting mechanisms by which social isolation and restraint impair healing in male mice. Stress, 17(3), 256-265. doi: 10.3109/10253890.2014.910761
Snel, J. & Lorist, M.. (1998). Nicotine, Caffeine and Social Drinking. Australia: Harwood Academic Publishers.
Wood, T. E., Englander-Golden, P., Golden, D. E., & Pillai, V. K. (2010). Improving addictions treatment outcomes by empowering self and others. Int J Ment Health Nurs, 19(5), 363-368. doi: 10.1111/j.1447-0349.2010.00678.x
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