Models of health and illness

One of the analytical approaches used by social scientists to conceptualise and manage health and illness is to differentiate between the ‘biomedical’ versus ‘social’ models of health.

Social determinants of health

The social determinants of health consider the social conditions in which people live and work. The Declaration of Alma-Ata in 1978 recognised these, and they have been described by the WHO in every publication about health, and in particular primary healthcare, since then. While at an individual level a sense of health and wellbeing will vary from person to person, at a population level there are some common characteristics.

Recently there has been renewed interest in the social determinants of health, which are best described by the WHO’s Commission on the Social Determinants of Health (CSDH) (2008).

The CSDH’s focus is on those social determinants that are amenable to change. It aims to mobilise emerging knowledge on social determinants in a form that can be turned swiftly into policy change, especially where needs are greatest (WHO 2008, p 6). There are strong associations between socioeconomic status (measured by variables such as level of income, education and occupational status) and access to resources and political power, and health right across the lifespan. The use of the term ‘determinants’ does not imply a deterministic relationship between the determinants and health outcomes; nor does it imply the absence of free will about ‘life choices’. Instead, determinants refer to macrosocial influences that affect health, such as poverty, that prove very difficult for individuals to alter.

The WHO’s (2008) report confirms that poor social and economic circumstances affect health throughout the lifespan. Life expectancy is shorter and most diseases are more common, the lower down the social ladder people fall in any society. This social gradient is not confined to the poor. Its effects run across all social strata; among middle-class office workers, for example, lower-ranking employees suffer much more disease and earlier deaths than do higher ranking people (WHO 2008, p 10). Disadvantage has many forms and may be relative or absolute. It can range from having few family assets, little education in adolescence, being unemployed, having a dead-end job, living in substandard housing, trying to bring up children in difficult and deprived circumstances, to living on inadequate pensions in older age (WHO 2008, p 10).

A social determinants model of health distinguishes between notions of disease, health and wellbeing, enabling a comprehensive and holistic method of determining health status in similar ways to the strategies used in models of primary healthcare. Proponents utilise a multidisciplinary approach, one which unites biomedical sciences, public health, psychology, statistics and epidemiology, economics, sociology and education. This is because the interrelationships between social, environmental, economic and genetic factors significantly contribute to disparities in health status and these need to be acknowledged in the formulation of effective intervention strategies. For example, family structure is known to have an effect on children’s physical and mental health, and the mother’s years of formal education is robustly related to age-adjusted mortality.

The physical environment affects wellness and illness in wide-ranging ways—exposure to toxic substances increases risk of asthma; inadequate and unsafe housing and overcrowding multiplies the chances of violence, transmission of infectious diseases and mental health problems as well as contributing to urban–rural differences in survival from cancer. Exactly how and why these variables interact are not fully understood; for example, it is clear that high socioeconomic status reduces the negative impact of high umbilical lead levels on children’s mental development (Bellinger et al 1993), but it is less clear why this happens. However, social class is an additional and well-documented determinant of factors associated with deprivation—including smoking, drinking and an unhealthy diet, all of which predispose women to diseases such as breast cancer. A 2010 survey (Baker et al 2010) found that women from socially deprived backgrounds are more likely to suffer a relapse and die from breast cancer because their lifestyle can cause the crucial p53 gene to mutate. The researchers suggest that the link between poor outcome, socioeconomic deprivation and p53 mutation may be related to the inflammatory response, because p53 plays a role in the inflammatory stress response pathway. They conclude that their findings ‘underline the need to address the broader environment and social context of patient care alongside our increasing molecular understanding of cancer’ (p 726).

Social capital

The term ‘social capital’ was first used in the 1970s by Bourdieu. Drawing on Bourdieu’s work, Coleman (1988) acknowledges two distinct components of social capital: (1) as a relational construct, and (2) as providing resources to others through relationships with individuals. The concepts of primary healthcare, social determinants and social capital are closely aligned with a social model of health. Robert Putnam (2001) uses the term ‘social capital’ to describe ‘connections among individuals’ and to highlight the ‘social networks and the norms of reciprocity and trustworthiness that arise from them’. The interaction between these networks and the norms which make them work well calls attention to the fact that ‘civic virtue is most powerful when embedded in a dense network of reciprocal social relations’ (Putnam 2001, p 19).

Lomas (1998) suggests that the concept of social capital can be operationalised as the way society organises itself, the extent to which individuals trust and associate with one another. Social capital is the basic material of civil society. It refers to the processes between people which establish networks, norms and social trust and facilitate coordination and cooperation for mutual benefit. These processes are also known as social fabric or glue.

The explicit links between social capital and health outcomes have been the focus of considerable research (Reidpath 2003; Wakefield & Poland 2005). There is good evidence that more socially cohesive societies are healthier, with lower mortality (Kawachi et al 1997; Putman 2001; Woolcock 2001). Communities increase their social capital by working together voluntarily in egalitarian organisations. Learning about how community groups function (and do not function) has the advantage of connecting with other members of the community. Accumulated social trust allows groups and organisations, and even nations, to develop the tolerance sometimes needed to deal with conflicts and differing interests. For example, social capital is important because it is a potential mechanism for preventing illness within the community. It is also thought to influence the health of individuals via psychosocial processes providing effective support and acting as a source of self-esteem and mutual respect. Bridging social capital can also unite marginalised groups with the mainstream and promote a more inclusive approach to the provision of mainstream services and resources to people. Social capital also promotes rapid diffusion of health information and therefore may affect health and wellbeing. At the individual level, bridging social capital facilitates social integration that contributes to better health for the individual.

Social capital—the trust, reciprocity and cooperation among members of a community who aim to achieve common goals—may help to explain differences in adolescent pregnancy rates. A significant number of teenage girls experience unintended or unwanted pregnancies; although for some young people pregnancy is a positive life decision, for many others unexpected pregnancy is not welcomed. First, adolescent pregnancy is associated with increased medical risks during pregnancy and poorer perinatal outcomes (Gaudie et al 2010). Further, adolescent mothers have poorer life-course outcomes in adulthood, such as a higher risk of dependence on welfare, being a sole parent, being a smoker, and having a lower socioeconomic status (Gaudie et al 2010). Elsewhere it is well documented that particular forms of social capital—for example that between a teenage girl, her parents and with community groups such as school, church, and social clubs—significantly reduces the odds of an unplanned teenage pregnancy by the ninth year of schooling. Indeed, there is a strong positive correlation between social and economic deprivation, environmental stressors and adolescent pregnancy rates: the more socially and economically deprived the community, the higher the conception rate (Gaudie et al 2010).

Millennium Health Goals

In September 2000, building upon a decade of major United Nations conferences and summits, world leaders came together at United Nations Headquarters in New York to adopt the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of eight time-bound targets—with a deadline of 2015—that have become known as the Millennium Development Goals (MDGs). In his 2008 report, the Secretary-General of the United Nations, Ban Ki-moon, summarised the MDGs thus:

The United Nations’ Millennium Declaration was signed by 189 countries, and so the MDGs benefit from international political support.

The eight MDGs represent a unique global compact. As such, they reflect an unprecedented commitment by the world’s leaders to tackle the most basic forms of injustice and inequality in our world: poverty, illiteracy and ill-health. The health-related MDGs do not cover all the health issues that matter to poor people and poor countries, but they do serve as markers of the most basic challenges ahead: to stop women dying during pregnancy and childbirth; to protect young children from ill-health and death; and to tackle the major communicable diseases, in particular HIV/AIDS. Unless we can deal with these fundamental issues, what hope is there for us to succeed in other, equally important areas of health?

The MDGs, particularly the eradication of poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote women’s rights, and greater investment in education and health, including reproductive health and family planning. The fifth MDG is very important for midwives to understand as they work in partnership with women, and so it is explored in more detail here.

Social determinants, social capital and the influence of health and culture

The CSDH report (WHO 2008) provides good evidence that gender and/or race affects many health outcomes. For instance, a girl born in Sweden will live 43 years longer than a girl born the same year in Sierra Leone. The mortality differentials among countries are enormous. But such inequalities also appear within each country, including the so-called rich or developed countries; again, quoting from the report (WHO 2008): in Glasgow, an unskilled, working-class person will have a lifespan 28 years shorter than a businessman in the top income bracket in Scotland.

Authors such as Eckersley (2005) argue that much of the literature dealing with the social determinants of health neglect the effect of ‘culture’ on health and health outcomes. Cultures bring order and meaning to our lives. Only humans require a culture to make life worth living, to give us a sense of purpose, identity and belonging—personally, socially and spiritually—and a framework of values to guide our actions. Eckersley (2005, p 252) comments that his writing about the effects of contemporary Western culture on health is not to suggest that an individual’s culture exerts a uniform effect on everyone, regardless of gender, class and ethnicity; or that individuals passively absorb cultural influences rather than interacting actively with them; or that there is not a variety of subcultures marked by sometimes very different values, meanings and beliefs. Just as inequality is explored at both population and individual levels, so too is culture. Variations among and between cultures can be measured as disparities between societies (reflecting differences in cultural consensus), or as differences between individuals and groups within a society (reflecting degrees of cultural consonance)’ (Eckersley 2005, p 252). For instance, Eckersley (2008) points out that some societies are more materialistic or individualistic than others (even among Western nations), and some individuals and groups within any one society exhibit these qualities more than others. Cultural factors, especially materialism or consumerism, are also implicated in adverse social trends such as growing obesity and inactivity, which in turn are linked to a wide range of physical health problems including heart disease, diabetes and cancer.

Some authors distinguish between social and cultural capital. For example, maternal social capital would include social support from families and paternal support, and a lack of social capital might be lone caregiver status. Maternal cultural capital would be related to religious affiliation and church attendance and attachment to race/ethnic heritage. It is crucial that midwives recognise sources of social capital such as school work and intervention programs conducted in school settings as important components of prevention services. Second, it is important to identify fathers and help them to become involved and connected with their families. Finally, midwives need to become more aware of the role of culture and its relationship to social capital in young families as the effect of cultural capital on parenting behaviours becomes better understood.

Social capital—racism, racial identity, and health

It is widely recognised that indigenous peoples are among the most marginalised and vulnerable groups and are afflicted by the most intractable material poverty. People, not nature, create our identities. Ethnicity refers to selected cultural and occasionally physical characteristics employed to classify people into groups or categories thought to be significantly different from others. A race is a biological subspecies or variety of a species, consisting of a more or less distinct population with anatomical traits that distinguish it clearly from other races. Nonetheless, ethnicity and supposed ‘racial’ groups are largely cultural and historical constructs. They are primarily social rather than biological phenomena. This does not mean that they do not exist. To the contrary, ‘races’ are very real in the world today.

Most Australians and New Zealanders are probably aware of the social harms of racism, although they may not be able to articulate the concepts very clearly. Racism is not some vague thought or practice: it operates through identifiable and addressable mechanisms. These dynamics are the context in which individual behaviours develop. The societal determinants of context influence the social determinants of health. Societal determinants (or social determinants of equity) can in some contexts determine the range of differences that stratify and force people into groups. Segregating practices like racism, sexism and capitalism create an environment where one group will succeed over others because of race. Overt racism discriminates against individuals or groups on the basis of race. An example is laws which prevent property from being sold to a member of a racial group or prevent such a person enrolling in university. Institutional racism includes the social and institutional structures that, as a matter of fact, disadvantage certain racial groups; for example standardised aptitude and achievement tests, which disadvantage some groups.

Kickett-Tucker (2009) argues that racial identity is probably linked to Indigenous mental health through its interaction with racism in either positive or negative ways: racism experienced by Indigenous Australian children and adolescents poses a threat to the maintenance of their racial identity. However, a strong racial identity can buffer the effects of racism on mental health and mitigate the effects of the social determinants described above.

It is beyond the remit of this chapter to explore the destructive impact of colonisation on Indigenous peoples in Australia and New Zealand in any depth. However, recognising the impact of colonisation is central to addressing inequalities in the social determinants of health. Australians Yin Paradies and Joan Cunningham (2007) discuss the damaging effects of racism, most notably documenting the strong relationship between experiencing racism and poor mental health. In Australia one of the worst manifestations of racism was the forced removal of children from their parents, now called the ‘Stolen Generation’ (see Ch 2).

Social determinants, social capital, and gender

Previous sections in this chapter have shown that many of the inequalities in health, both within and between countries, are due to inequalities in the social conditions in which people live and work. The low status of women in some societies is one of the key underlying social determinants of health. Poverty, a key determinant of health and longevity, is more common in women. It is associated with many of the leading causes of sickness, disability and death.

Sex and gender differences in access to healthcare and poor health indicators for women and girls in many countries have resulted in differences in mortality and morbidity between male and female infants. Within some cultures and societies, gender determinants that have an adverse effect on the health of girls and women include:

Summary

The health, medical and social science literature has long thought of our individual behaviours as the main determinants of health. However, as this chapter shows, encouraging individuals to adopt healthier habits is not the key to ending health disparities. People’s choices about how they live and work are either constrained or facilitated by the social determinants of health. This section has discussed the robust associations between socioeconomic status, measured by such variables as level of education, income, occupational status and the degree of access to resources and political power, and an individual’s health and wellbeing; all of which are well established before birth and evident throughout life. Other determinants of health include access to individual resources (such as income), educational level and socioeconomic status. Housing, public safety, transportation and exposure to toxic environments are also public resources that affect individual health. Moreover, the importance of social capital in maintaining and improving health and the deleterious effects of racism on health is well documented in the literature and summarised in this chapter.

Nonetheless, by themselves none of these explanations can fully explain the pervasive social and health gradients and health inequalities so consistently evident across time and space and between groups. However, it is clear that the above theoretical explanations jointly influence, mediate or moderate each other to produce health as well as ill-health. Moreover, access to social support and social capital contributes to positive health outcomes. ‘Closing the Gap’ requires equity in access to health and healing services; a holistic approach to problems, their treatment and prevention; authority over healthcare systems and community control over services; and diversity in the design of systems and services to accommodate differences in culture and community realities.

Women and mental health

Depression is a significant health issue for both men and women in Australia and New Zealand. Some researchers have suggested that up to one-third of the difference in prevalence rates for depression in women is accounted for by increased rates of childhood sexual abuse. Other research reveals that women who experience social adversity have a poorer response to antidepressants than do other women (Plous 1993). Morrow and Chappell (1999) argue that women’s mental health cannot be

The consequences of mental health problems are profound primarily because individuals with mental illnesses often engage in ‘high-risk’ behaviours. Many factors can trigger the onset of a mental illness, including stress, bereavement, relationship breakdown, violence, child sexual and physical abuse, unemployment, social isolation, accidents and life-threatening illnesses. Research shows that socially constructed differences between women and men in roles and responsibilities, status and power interact with biological differences between the sexes to contribute to differences in the nature of mental health problems, health-seeking behaviours and responses of the healthcare sector and society as a whole. While men and women have similar overall prevalence rates, men are more likely to have substance-use disorders and women are more likely to experience anxiety disorders (generalised anxiety and obsessive compulsive disorders, social anxiety, panic disorder and phobias). According to the latest Australian Bureau of Statistics data (2008), women experienced higher rates than men of anxiety disorders (18% and 11% respectively) and affective disorders (7.1% and 5.3% respectively). However, men had twice the rate of substance-use disorders (7.0% compared with 3.3% for women).

Everyone is vulnerable to mental health distress, although some mental illnesses, such as schizophrenia, appear to be more frequent in some families. Schizophrenia has a significant genetic component. It seems that a number of genes contribute to susceptibility and the pathology of schizophrenia, but none exhibit full responsibility for the disease. Environmental factors (possibly even as early as pregnancy, during early childhood and adolescence) can increase the risk of schizophrenia, or lessen the expression of genetic or neurodevelopmental defects and thus decrease the risk of schizophrenia.

A determinants approach incorporates appreciation of how behaviour influences both social processes and illness, and risk; and how social and structural conditions augment or lessen opportunities for communities and populations to be healthy and, at the other end of the continuum, the risk of illness. A determinants approach highlights the significance of inter-sectoral interventions that are designed and implemented at multiple levels, with the emphasis on influencing one or more determinants of health, rather than an illness. The substantial literature on the determinants of health identifies the multifaceted interactions among determinants and across social, environmental, economic and biological dimensions. Policies for mental health and wellbeing can be developed in any organisation, association, club or workplace, and at any level of government. Policy is part of the necessary infrastructure to support health promotion. Its development involves key health promotion personnel, the development of shared understandings and identifies society’s commitment to, and vision for, mental health promotion.

To address both positive and negative influences on mental health and wellbeing as well as illness, four variables need to be addressed:

Mental health in Indigenous communities

Many communities, including Indigenous Australians, prefer the term ‘social and emotional wellbeing’ to ‘mental health’ because it is perceived as reflecting a more positive approach to health (Australian Health Ministers 2003). In this chapter the terms are used synonymously.

Māori perspectives of mental health and illness view the development and recognition of a positive Māori cultural identity as central to optimal mental health. For many Māori, health is about ensuring that the māori (life-force, essence and ethos) of Māori people is allowed to find its full expression. It encompasses te taha wairua (spirit), te taha tinana (body), te taha hinengaro (mind) and te taha mana (personal authority) (Durie 1995). According to Alison Taylor (2003), good health is recognised as being dependent on a balance of factors. Hauora is a Māori philosophy of health unique to New Zealand and is closely aligned to the principles of primary health. It comprises taha tinana, taha hinengaro, taha whānau, and taha wairua. ‘For Māori, then, mental health is more complex than a series of disorders that are subject to curative treatment. Good Māori mental health is more than just efficient health services. It demands that, the institutions of society are nurturing, that families, whānau and communities are strong and supportive, and that the policies and laws of the nation are consistent with the dignity of individual’ (Taylor 2003, p 3). He Korowai Oranga (Māori Health Strategy) literally translated means ‘the cloak of wellness’ (Ministry of Health 2006b). For Māori, this strategy symbolises the protective cloak and mana o te tangata—the cloak that embraces, develops and nurtures the people physically and spiritually. He Korowai Oranga states that its specified outcomes are more likely to be achieved if whānau:

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