Objectives

By the end of this chapter you will be able to:

1 identify the main influences on health and illness in adulthood

2 explain the social determinants of health, illness, injury and disability among adults

3 examine the cumulative effects of interactions between physical, social and cultural environments along the pathway to adult life

4 outline a health promotion intervention for adults focused on reducing multiple health risks through health literacy

5 explain how the health of adults can be improved using the strategies of the Ottawa Charter for Health Promotion

6 identify gaps in research knowledge that could be reduced by nursing and midwifery research.

have become adults, their innate predispositions combine with their past and current lifestyles and a variety of life circumstances to establish relatively stable patterns for the future. For most, the prospect for a long life free of the burden of illness and disability is good. However, other people achieve less than optimal health because of genetic predisposition, the social determinants of their childhood or current circumstances. Fortunately for most adults in Australia and New Zealand, the environment provides considerable potential for overcoming vulnerability to ill health and achieving high levels of health and wellbeing. Unlike some other parts of the world, most people in this part of the world have access to nutritious food, clean air and water, good housing, education and employment possibilities, scientific and technological expertise, relatively low levels of community violence, and accessible and appropriate health care and social support services. However, environmental factors in Australia and New Zealand also create risks emanating from climate change, which is one of the defining challenges of this century, making it a public health priority (Campbell-Lendrum et al 2009). Climate change risks worsening the health of those already disadvantaged, especially Indigenous people, through natural disasters such as drought, floods and fire, and worsening social inequity. As the impact of climate change cascades through daily life, we will have to work intersectorally to understand the health implications of policies such as carbon pricing, the increased cost of living from energy, power generation, transport and agriculture, and a need for heightened surveillance of community life (Campbell-Lendrum et al 2009). The discussion to follow addresses the strengths, weaknesses, opportunities and threats of adult life in this part of the world, and the effect of global influences on health risks and potential.

A number of factors have been identified as the top 10 causes of mortality throughout the world. These are road traffic accidents, suicide, violence, falling, drowning, poisoning, fire, war, alcohol and drug overdose (Online. Available: www.socyberty.com/death/worlds-top/10-killers-non-disease-related-causes-of-deaths [accessed 30 October 2009]).

The 10 categories represent dramatic, non-disease causes of death, many of which occur in catastrophic circumstances. They are of significant concern to nurses and midwives because they provide an overarching guide to goals for preventative nursing interventions. In addition, priorities for interventions are based on the major causes of the burden of disease. In Australia and New Zealand, as in many other countries, the burden of disease is calculated on the basis of the disability-adjusted life year (DALY), representing each year of potential healthy life lost to disease or injury (Australian Institute of Health and Welfare (AIHW) 2008 Australia’s Health, 2008 and New Zealand Ministry of Health (NZMOH), 2009a). This is linked to population norms for certain conditions and demographic groups. So, for example, if a male has a fatal heart attack at age 50 and the ‘norm’ for heart attack for men with his genetic predisposition and health history is age 70, his individual burden of disease is 20 DALYs. In terms of the total burden of disease among adult Australians, cancers contribute 19% of DALYs, followed by cardiovascular disease (17%), neurological and sense disorders (12%), chronic respiratory diseases and injuries (7% each) (AIHW 2008). The most frequent causes of deaths in Australia are coronary heart disease, lung cancer and cerebrovascular disease (stroke), other cancers, suicide and diabetes (AIHW 2008).

New Zealand also uses a summary measure of population health called Independent Life Expectancy (ILE) — defined as the number of years expected to be lived free of functional limitation needing assistance. ILE extends our understanding of population health from life expectancy to health expectancy. Health expectancy indicators offer the opportunity for policy-makers in the developed world to focus on population health gain, rather than on the traditionally narrow preoccupation on extension of life (New Zealand Ministry of Health & Statistics New Zealand 2009). In New Zealand, the leading causes of death are cancer (28.5% of deaths) and ischaemic heart disease (20.8%), followed by cerebrovascular disease and chronic obstructive pulmonary disease (NZMOH 2009b).

The number of deaths from cancers has declined in recent years, because of early detection and better treatment. Colorectal and cervical cancers have shown significant declines, however, lung cancer remains an ongoing problem because it is a preventable cause of death, and because there is a long latency period between the cause (smoking) and the outcome (the disease). Lung cancer is the second most frequent cause of cancer deaths in Australia and the leading cause of cancer deaths in New Zealand, followed by colorectal cancer (Australian Institute of Health and Welfare (AIHW) 2008 Australia’s Health, 2008 and New Zealand Ministry of Health (NZMOH), 2006). Prostate and breast cancers are significant sex-specific cancers causing premature deaths in adults. Breast cancer is the leading cause of death in women aged 45–64 in Australia representing 15% of all deaths for this group (AIHW 2008). It is the second leading cause of death after lung cancer among New Zealand women (NZMOH 2009b). Reductions in the mortality rates have left many adults living with cancer in the community, which has major implications for their quality of life. Breast cancer in particular, is affecting more young women between 20 and 40 than in the past, perhaps because of better surveillance and detection. These younger women have more aggressive forms of disease and lower survival rates than postmenopausal women. They face not only a shorter life span, but longer treatment consequences and the possibility of infertility and premature menopause (Shaha & Bauer-Wu 2009). Like others who are diagnosed with cancers they are confronted with the finiteness of their life; feelings of uncertainty, loss of control and the transitory nature of life (Shaha & Bauer-Wu 2009). This presents a major challenge for nurses working in the home and community to ensure that their psychosocial needs are given as much attention as their physical needs, which are considerable.

Road traffic accidents and suicide are the major causes of injuries and represent the leading preventable cause of death and disability (AIHW 2008). Alcohol, fatigue, sleepiness and speeding are the main causes of motor vehicle accidents, with young men over-represented among the victims, especially those from rural areas (AIHW 2008). Over the past decade, Australia, New Zealand and other Western nations have had significant declines in the rate of motor vehicle injuries due, in part, to improved public education programs, better law enforcement, stricter penalties, better roads and improvement in vehicle safety design. There is also increasing recognition that risky driving behaviours are embedded in a pattern of risky behaviours, as we discussed in Chapter 7. This indicates that the most effective approach for accident prevention is by addressing the cluster of risky behaviours within the context and structures that support them.

Although nursing interventions in the community include injury management, especially in occupational health and rehabilitation settings, most revolve around the more insidious conditions of daily life; the risk factors that cause diseases, premature deaths and reduced quality of life. These include cardiovascular disease, chronic obstructive pulmonary disease (COPD), cancers, asthma and other respiratory conditions, type 2 diabetes, arthritis, sensory impairments (vision and hearing), back pain and mental illnesses (AIHW 2008). Approximately 77% of Australians and 66% of New Zealanders have at least one of these long-term conditions lasting six months or more (Australian Institute of Health and Welfare (AIHW) 2008 Australia’s Health, 2008 and New Zealand Ministry of Health (NZMOH), 2008). Some conditions are more common in different age groups; for example, asthma in younger adults and arthritis in older people. At a population level, these compromises to health are disabling for 20% of the population, many of whom live with chronic pain or restricted mobility (aff4). Many of these conditions and diseases have a biological component in their web of causation, but most are also linked to lifestyle factors. This means that there are modifiable aspects of people’s environments that are amenable to change.

Stress, especially workplace stress, is one of the most significant sources of ill health, which may be modifiable through individual, community and social interventions. A variety of workplace stressors affect members of socio-economic groups differently, but workplace stress is becoming more prevalent across all categories of workers. This is linked to changing social conditions. Life in the 21st century has become fast-paced for many adults, with resounding effects on the family, the workplace and society. The ‘busyness’ of lifestyles has therefore become a public health issue (Bryson et al 2007). It is of particular concern to nurses not only in planning nursing interventions for community living adults, but in dealing with their own work stress, which is among the highest of all occupations. Helping others cope with existing stress or preventing stress from causing unhealthy behaviours is therefore personal. This requires attention to the harmful combination of poor diets, inactivity, alcohol and tobacco consumption (Umberson et al 2008), as well as the social determinants that can either provoke or minimise these behaviours.

The sources of workplace stress are numerous, but globalisation and technological innovations have transformed workplaces today. Where once it was necessary for workers to be completely engaged and active during their work day, current processes often involve passive, monitoring-type activities. Away from the workplace, adults’ busy lives also leave little time for the requisite physical activity levels that would help prevent cardiovascular disease and alleviate stress. A further issue is transportation. The lack of public transportation in many cities has created an automobile-dependent society, where taking the car even to the corner shop is commonplace. Growing urbanisation has also created shrinking spaces for parks and bicycle pathways that would encourage people to cycle to work. As a population group, many urban dwellers also consume too many high-salt, high-fat meals, especially those obtained at fast-food outlets, and this has led to an epidemic of overweight and obesity (Aranceta et al., 2009 and Laforest et al., 2009). Although there have been some improvements in lifestyle behaviours such as alcohol and tobacco consumption, many adults in Australia and New Zealand continue to smoke and drink alcohol at excessive levels. The links between these behaviours, poor nutrition, low levels of activity and the escalating rates of chronic illness are cause for concern (aff4).

Throughout the world, there are many different causes of disease. Among poorer, developing countries, infectious diseases remain a major cause of morbidity and mortality, despite some improvements over the past few decades (WHO 2008). In the industrialised nations, diseases linked to modern lifestyles continue to rise, to where 25% of adults are affected by at least two chronic health conditions, and this rate increases to 50% for those over age 80 (WHO 2008). Tobacco-related illness alone accounts for nearly 10% of all deaths worldwide (WHO 2008), which is the highest burden of disease and injury. Yet, 18% of Australians continue to smoke (Kirby 2009; NZMOH 2008). The second highest risk to health is physical inactivity, with more than one-third of Australians reporting that they undertake little or no regular physical activity (Street et al 2007). Half of all New Zealanders also fail to meet recommended daily physical activity recommendations (NZMOH 2008).

In Australia, chronic conditions account for 70% of all health expenditures and constitute 50% of all GP consultations (Commonwealth of Australia 2009; Kirby 2009). New Zealand data on the cost of chronic or long-term conditions is limited, however it is known that chronic conditions create a significant economic burden for New Zealand, with more than 20% of all visits to a GP being for long-term conditions (New Zealand Ministry of Health (NZMOH), 2008 and New Zealand Ministry of Health (NZMOH), 2006). As we discussed previously, the social environment creates conditions within which people make healthy lifestyle choices, so it is not helpful to blame the victim of ill health. However, research indicates that most of these chronic conditions are preventable through modification of risk factors such as smoking, excessive alcohol consumption, lack of physical activity and low consumption of fruit and vegetables (Cardi et al 2009). So there must be some rearrangement of circumstances that allows people access to, and encouragement for, healthier lifestyles. This is a challenge for those living in poverty or marginalised by social exclusion; the two most important factors in precipitating chronic diseases such as type 2 diabetes (McDermott 1998). Poverty and social exclusion are both community problems, as individuals and families require an enabling community to develop the capacity to maintain the resources for good health. Two strategies for rearranging environments for better health include first, ensuring that local communities are working towards enabling health for the disadvantaged, rather than constraining people’s attempts to lead healthy lives, and second, strengthening workplace-based health promotion programs for those trying to sustain their ability to remain employed.

In recent years, there has been a worldwide decline in heart disease and strokes, which are strongly linked to behavioural risk factors (Commonwealth of Australia 2009). Reductions in morbidity and mortality can be attributed to public awareness, improvements in treatments and increases in the number of people adopting certain healthy behaviours. Paradoxically, the improvements in disease outcomes are accompanied by dramatic increases in the prevalence of overweight and obesity (Rosengren 2009). In 2009, 54% of adult Australians and 63% of adult New Zealanders were overweight or obese, which places them at risk of type 2 diabetes, heart disease and cancer. The increase in obesity among the population is expected to result in three-quarters of the population being overweight or obese by 2020 (Commonwealth of Australia 2009 and New Zealand Ministry of Health (NZMOH), 2008). This mirrors the situation in the United States and Canada and many parts of Europe, where similar patterns of lifestyle behaviours have seen exponential growth in overweight and obesity across all age groups (Aranceta et al., 2009, Cardi et al., 2009, Lee et al., 2009 and Penn et al., 2009).

The ‘obesity epidemic’ is placing large numbers of adults at risk for metabolic syndrome, type 2 diabetes and cardiovascular disease (CVD) as well as some cancers (Aranceta et al., 2009, Brown et al., 2008, Cardi et al., 2009, Lee et al., 2009 and Martinez-Gonzalez et al., 2009). CVD includes coronary artery disease (CAD) and stroke, which are responsible for the largest proportion of deaths throughout the world, including Australia and New Zealand (AIHW 2008). The cluster of factors that create the highest risk for CVD includes hyperlipidaemia (high LDL cholesterol), high plasma glucose, hypertension and type 2 diabetes (Deambrosis et al., 2009, Grundy et al., 2005 and Jones, 2008). Metabolic syndrome, which often precedes type 2 diabetes, is a particular problem, as it represents a constellation of inter-related metabolic risk factors for CVD (Grundy et al 2005). The prevalence of these risk factors in the adult population is alarming, and they are rapidly increasing in younger adults (Lee et al 2009). Establishment of new drug therapies, such as statin treatment to lower LDL cholesterol for those with existing risk factors, has reduced the incidence of cardiovascular events (Korber 2008). But although this treatment is seen as clinically effective, it is also associated with increased liver- and muscle- related adverse outcomes (Morrissey et al 2009). Attempts to address the risk through early detection and intervention include cardiovascular risk assessment such as those implemented by many primary health organisations (PHOs) in New Zealand (for example, see www.nzgg.org.nz/guidelines/0035/CVD_Risk_Summary.pdf).

Behaviour changes in relation to better diets and less smoking have been responsible for a continuing decline in mortality from CAD (Rosengren 2009). However, these improvements have not been experienced evenly across the population. Disadvantaged people continue to have a higher rate of smoking, especially among those with lower education, lower income, unskilled workers or the unemployed, or those on social welfare benefits (Tsourtos & O’Dwyer 2008). This is also the population group with high levels of stress, which often act as a deterrent to quitting smoking, or adopting other healthy behaviours (Raphael et al 2003). Studies have also found that smoking tobacco may actually ameliorate stress. This occurs through the action of the anti-stress hormone dehydro-epiandrosterone (DHEA) which has positive effects against stress and anxiety (Tsourtos & O’Dwyer 2008). Many disadvantaged people also live in neighbourhoods with a high concentration of convenience stores where they can purchase cigarettes. So they experience more barriers than others to quitting smoking through a combination of biological, environmental and social factors (Tsourtos & O’Dwyer 2008).

Unlike smoking, obesity remains problematic across all socio-economic groups (Chaturvedi, 2004 and Lee et al., 2009). Obesity is not only a constraint on the health, wellbeing and quality of life of the population, but also presents a significant drain on health care resources (WHO 2000a). This is expected to worsen with higher rates of obesity among children and younger adults creating longer-term, and therefore more costly, treatment (Aranceta et al 2009; AIHW 2008). The need for behavioural interventions to help stem the epidemic of overweight and obesity is clear, particularly in balancing exercise and a healthy diet. However, as with smoking, the environment cannot be overlooked. Obesity is considered a product of obesogenic environments, where calorie-dense foods are marketed and accessible throughout the community, and lifestyles require low physical exertion (Aranceta et al., 2009 and Rosengren, 2009). This needs to be recognised by health professionals as well as the general public, to counter the stigma attached to obese people in the community. Discriminatory hiring practices and ongoing denigration or ridicule of obese people have been described as ‘civilised oppression’ (Maclean et al 2009:89). Stigmatising people for being overweight is based on a common view that weight is easily controlled by disciplined individual decisions to exercise more and eat less, which misinterprets the role of environmental determinants (Maclean et al 2009). Even though personal resources for behaviour change and social support can act as buffers for socially patterned stressors, stigmatisation can constrain an obese person’s attempt to conform to behavioural norms (Meyer et al., 2008 and Umberson et al., 2008).

The diet industry has some responsibility for marketing appropriate foods, but there is considerable public misinformation about diets, particularly in purveying the idea that low-fat products will solve the problem of overweight. In fact, a person’s diet is influenced by a range of biological, cultural, economic and social factors, not just marketing by food producers (Coveney 2007). A large body of evidence points to the healthful effects of a Mediterranean diet. This consists of high consumption of olive oil, legumes, unrefined cereals, fruits and vegetables, moderate consumption of dairy products (cheese and yoghurts), moderate to high consumption of fish, low consumption of meat, and moderate wine consumption(Martinez-Gonzalez et al 2009).

The Mediterranean diet is known to have a higher protective effect against CVD risk factors compared with a low-fat diet. Equally as important is the fact that those who consume a Mediterranean diet tend to have greater adherence than those who eat low-fat diets, perhaps as a function of family lifestyle, which also illustrates the cultural context of healthy eating (Martinez-Gonzalez et al 2009).

Nutrition counselling is often a first step in helping people with lifestyle improvements once they are diagnosed with chronic illness. This needs to be tailored to individual needs, as a one-size-fits-all prescription for healthy eating may present barriers for certain individuals. Any of the chronic conditions may change a person’s appetite and attitude to food as well as their access to preferred products. Some diabetics, for example, have difficulty with the constant food vigilance. Some do not feel comfortable eating with others, which changes their social circumstances (Telford et al 2006–07). Treatment regimes can also be a problem. Statin treatments come with contraindications for certain foods because they effect changes to metabolism. Motivation can also be a challenge. Individuals who suffer from loneliness, anxiety or depression as well as diabetes or CVD can experience low motivation to eat a nutritious diet (Haddad 2009). In these cases, the combination of decreased functional abilities, limited financial resources, psychological responses to deprivation such as feeling worthless or disempowered, can mitigate against a whole range of healthy behaviours, including good nutrition.

Social and environmental factors are also important in promoting exercise, and health education strategies are often planned around the social environment. Organised physical activities provide opportunities to develop supportive social networks as well as helping manage obesity (Street et al 2007). Group recreation has been found to enhance value, belongingness and attachment to others. Community activities can also help reduce violence in the neighbourhood and promote social capital (Raphael, 2009 and Street et al., 2007). At a personal level, exercise boosts immune functions, enhances anti-tumour activity and has shown positive effects on depression, anxiety, stress, self-esteem, Alzheimer’s disease, pain and premenstrual syndrome (Street et al 2007). For this reason, ‘sweat’ has been called the natural antidepressant.

However, much remains to be learned about exercise, as research into the dose, intensity and environments for exercise has shown mixed results among different groups (Gillison et al., 2009 and Street et al., 2007). One meta-analysis of quality-of-life improvements from exercise interventions showed that exercise had less effect on those with chronic disease than rehabilitation patients or well adults (Gillison et al 2009). Factors such as lack of time, motivation, health and weight restrictions, cost and disinterest can be deterrents to regular exercise, especially for men (Burton et al 2008). Interestingly, Australian men reported one barrier to adult exercise as being less enjoyable than sports, especially compared with the team spirit and obligation to team-mates they had enjoyed in younger years (Burton et al 2008). The implication for health promotion suggests that even for older persons, exercise programs need to be socially contextualised and fun.

The relationship between health and place is relevant to the level and type of risks to adult health. People living in regional or rural areas are at significantly higher risk of being overweight or obese than urban dwellers, particularly Indigenous residents (National Rural Health Alliance [NRHA] 2009a). Some of the factors related to high rates of obesity in rural areas include poor health literacy, inherited behaviours, low levels of education, poor access to fresh foods with a disproportionate amount of processed foods, a shortage of dietitians and other health professionals, insufficient resources for maternal and child health, and a lack of funding and personnel available to run exercise and other health promotion activities (NRHA 2009a).

Responses to these issues require political commitment to ensure that adequate nutritious foods are not only available but affordable in rural areas. Health promotion strategies that revolve around health literacy and empowering people to take control over their lifestyles are sometimes moderated by access to resources. For example, the ‘digital divide’ between those with and without access to internet information can worsen inequities. Although internet information is gaining favour with older people, it is not always available for rural people (Wilson et al 2007). In addition, many regional towns and rural areas do not have access to green parks, exercise playgrounds for children or safe walking trails to school. Rural people have also experienced substantial stress due to economic pressures and environmental degradation (NRHA 2009a). Those who suffer from cancers are also disadvantaged by having to travel long distances for specialised treatment. As a result, many cancers among rural people are diagnosed later than those in urban dwellers (NRHA 2009b).

Rural people also have considerable lifestyle stress due to their occupations. Living and working on the land offers rural families few opportunities for respite (NRHA 2009c). Stress from the constancy of their work life is compounded by droughts, floods and bushfires as well as the economic uncertainty of their lifestyles (NRHA 2009c). For young adults, the loneliness of life in rural and regional areas can be problematic. This can lead to relationship breakdown and depression, which can set individuals on a path to over-consumption of alcohol or other substances (NRHA 2009c). Rural residents with same-sex preferences can also be alienated from others in the community, especially given the cultural dominance of values such as masculinity and rugged individualism. Mental health issues emanating from these situations are often ignored by rural residents who tend to be stoical, believing they can take care of things themselves. The lack of counsellors or health professionals who could provide support also leaves many without mental health care. A further deterrent to help-seeking lies in the desire to avoid being stigmatised by seeking help in a small community, where others would take note of their actions. In some cases, unacknowledged depression and other mental health issues can lead to suicide, especially where firearms and poisons such as pesticides are readily available. These reasons are often cited as explanations for the relatively high rate of suicide among rural males (NRHA 2009c).

As we have discussed previously, the social gradient and income inequality are major elements of the social determinants of health (SDOH). Analysis of population data from 60 million people in 30 OECD countries has confirmed unequivocally, that the health of any society is better when wealth is more equally distributed (Kondo et al 2009). Educational, economic and social inequality and unequal distribution of resources lead to higher risks for mortality for those who are disadvantaged (Kondo et al., 2009 and Wilkinson, 1996). The impact of inequality is profound in low-income families (Raphael & Farrell 2002). Low income leads to material deprivation, chronic stress, adoption of unhealthy coping behaviours, poor mental health, and exposure to unhealthy environmental conditions at home and at work (CSDH 2008; Feldman et al., 2009 and Raphael and Farrell, 2002; WHO 2009). Stress is even greater for those with chronic conditions, disabilities or those without transportation, as they rely more heavily than others on local services and facilities. For these groups, the effects of incivilities, such as neighbourhood crime, vandalism and conflict, are also experienced more intensely than others (Raphael, 2009 and Warr et al., 2009).

To redress the disadvantage of inequitable societies and neighbourhoods, redistributing wealth to provide better food, housing and material resources for those who are disadvantaged seems like an appropriate solution. However, simply providing resources would not be effective without opportunities for disadvantaged people to achieve equitable social status, friendship, social capital and a sense of control (Pickett and Wilkinson, 2009 and Raphael, 2009). These factors are instrumental to mental health as they provide the resilience, health assets, capabilities and capacity for adaptation that help people cope with adversity and realise their full potential and humanity (WHO 2009). This is the basis of arguments for reversing Indigenous disadvantage, which we will address in Chapter 11. When conditions can be rearranged to reduce the gap between the rich and poor in an empowering way, there is a greater likelihood of social pathways that will have a protective effect on the whole of the population. This can help reduce the prevalence of violence, bullying, teenage births, rates of imprisonment, low educational attainment, social mobility and trust, and longer working hours (Pickett & Wilkinson 2009). The impact can be felt at both the individual and community level.

At the individual level, chronic stress ‘gets under the skin’ through the neuro-endocrine, cardiovascular and immune systems (WHO 2009:iii). This occurs through disruptions to neuro-endocrine and metabolic systems from the constant stress of living disempowered lives (Raphael 2009).

These responses can elevate cortisol, cholesterol, blood pressure and inflammation. Psychosocial reactions such as anger and despair related to occupational insecurity, poverty, debt, poor housing, exclusion or other indicators of low status can lead to health-damaging behaviours such as smoking, excessive alcohol consumption or poor dietary habits. These impact on intimate relationships, self-care and the care of children, and they can be either a cause or consequence of anxiety and depression (WHO 2009). This insight into the psycho–biological pathways to ill health, highlights the integral nature of mental and physical health.

How people think, feel and relate to one another is crucial to good health and it is socially determined. It is linked to their social position and sense of coherence or meaning in life, as well as their cognitive, emotional and social relations with others. Unequal life conditions therefore have a major impact on mental health, if how they think, feel and relate causes low self-esteem, shame and disrespect (Raphael 2009; WHO 2009). Psycho-social factors such as mood disorders, lack of social support and isolation create the same level of risk to health as smoking, high blood pressure and elevated cholesterol (WHO 2009). This represents a multiplier effect, placing people with mental health conditions at greater risk of CVD, stroke, metabolic syndrome, diabetes, infections and respiratory diseases (WHO 2009). The way these conditions are intertwined is widely recognised today, with global figures showing that mental illness, including suicide, is responsible for 30% of the total burden of morbidity and disability (WHO 2009).

Positive mental health has a powerful effect on individuals and the community. People with positive mental health tend to be more socially connected, to volunteer, to have better social networks and high health assets, or quality of life. Those who have developed positive mental health skills such as resilience, optimism, self-esteem and self-efficacy are better able to buffer stress, resulting in high emotional and cognitive capital. They do so within resilient neighbourhoods and communities with high social and environmental capital, which also buffers the cumulative effects of deprivation with feelings of hope, trust and social support (WHO 2009). In addition, mental wellbeing has a powerful effect on job performance, worker productivity, creativity and absenteeism (WHO 2009). Workers who feel in control of their work life, and who feel they are treated fairly at work have been found to have lower stress levels (Fujishiro and Heaney, 2009, Lawson et al., 2009, World Health Organization (WHO), 2009 and Ylipaavalniemi et al., 2005). This has a reciprocal effect on the workplace, as individual employees feel empowered to participate in decision-making, provide mutual support, engage in employee health promotion programs and work towards achieving team goals.

Education is one of the most valuable assets for positive mental health. Education plays a powerful role in mediating social inequalities and in creating a pathway to better physical and mental health in adult life. This occurs because individuals with better health are more likely to achieve higher levels of education. The reverse is also true. Having an education leads to better health (Topitzes et al 2009). Being educated helps those at the lower end of the health gradient alter their life course to a higher socio-economic level in society. This can lead to better adult lifestyle behaviours. Those in higher socio-economic groups tend to smoke less, achieve better rates of smoking cessation, consume less alcohol and have lower levels of depressive disorders (Topitzes et al 2009). This begins in childhood. Participating in school programs and activities during the developmental years facilitates cognitive growth, social adjustment and school commitment, all of which foster social and emotional maturity for a stable, healthy adult life (Topitzes et al 2009). As we mentioned in Chapter 7, having a high-quality preschool experience and staying in the education system plays a role in emotion regulation, which reduces the propensity for tobacco smoking and substance use. Education is therefore empowering, and provides the preparation to function as a healthy adult.

Some social conditions surrounding adult life can cause stress and stress-related disease for disadvantaged individuals not only through economic deprivation, but also through structures that allow disproportionate exposure to prejudice and discrimination (Meyer et al 2008). Obvious examples of discrimination are perpetrated on the basis of race, gender or other personal characteristics. In the absence of social support, some people are socially excluded on a number of fronts. They may be marginalised through exclusion from certain social activities in their local community because of non-conformity or personal behaviours. At a societal level, they may be excluded from secure, permanent employment, sufficient earnings, access to credit or land; housing and adequate consumption of necessities; education, skills and cultural capital; welfare, citizenship and legal equality; democratic participation, public goods, family and sociability, humanity, respect, fulfilment and understanding (Meyer et al 2008).

All of these aspects of social exclusion constitute structural stressors. In addition, many individuals experience the added burden of acute stressors, which can range from unemployment to prejudice-related life events (Meyer et al 2008).

In some cases, cultural norms may exacerbate states of mental ill health. Certain cultures recognise anxiety, depression, grief, stress or worry as merely problems in living, and therefore they do not warrant help-seeking (Tyson & Flaskerud 2009a). Those who seek help may be devalued and stigmatised, considered to have brought shame on the family (Tyson & Flaskerud 2009b). Other cultures have a broader perspective on mental health and ill health. An Australian study of people’s perceptions of mental health found that the three most common factors contributing to positive mental health were having good friends to talk problems over with, keeping an active mind and having control over one’s life (Donovan et al 2007). The same cohort described being mentally unhealthy in terms of excessive use of alcohol or drugs, having no friends or support network, and life crises or traumas (Donovan et al 2007). At the extreme end of the continuum is homelessness, where those disadvantaged by a lack of employment and housing live in a vicious circle of vulnerability to ill health, injury, violence and a lack of social support

.

In 1997, New Zealand began a publicly funded campaign called Like Minds Like Mine. The campaign was one of the first in the world aimed at reducing discrimination and stigma associated with mental illness. Using a combination of community action at a local level with nationwide strategies and media advertising, the campaign has led to increased acceptance and openness in the community about mental illness (NZMOH 2007). Although change has occurred in people’s attitudes towards those with mental health issues, the campaign continues today to ensure changes in behaviour, policies and practice follow the changes already achieved in attitudes (NZMOH 2007).

The unhealthy coping behaviours people use to deal with stress can reverberate throughout the adult life course, having a cumulative effect on health and causing mental illness (Umberson et al 2008). Behaviours such as consuming high-fat diets, increased alcohol consumption and lower levels of physical activity may help alleviate psychological and physiological arousal and regulate mood (Umberson et al 2008). On the other hand, stress can also lead some people to engage in healthier behaviours, such as physical activities to buffer stress. As a person ages, the coalescence of psychological, physical and social factors may change their coping style, making them less reactive to stress and allowing existing stress to dissipate (Umberson et al 2008). In some cases, this is because, as adults age, they may begin to focus less on themselves and more on others. It has also been explained on the basis that behaviours such as eating, drinking and smoking may be less effective in reducing the arousal of stress among older age groups (Umberson et al 2008).

Among the most pronounced sources of stress in adult life are those related to family events. These include separation, divorce, death or illness of a family member, abuse or economic hardship. Early family life can have a cumulative effect across the adult life span. As we mentioned in Chapter 5, adults exposed to inter-parental violence, poor parent–child relationships or parental psychopathologies in childhood can experience serious negative impacts on health in their adult lives that become chronic conditions (Nicolaidis and Touhouliotis, 2006 and Roustit et al., 2009). As adults, marital quality plays an important role in psychosocial functioning. Poor relationships can have a negative influence on cardiovascular, endocrine, immune and neurosensory function, while positive relationships can provide a supportive context for dealing with stress or illness (Windsor et al 2009). This underlines the importance of social support in health and wellbeing. Close relationships, such as marriage, can moderate health, overcoming some of the negative aspects of earlier years (Windsor et al 2009).

For spouses with a good relationship, health and wellbeing tend to become similar over time, acting as a protective mechanism in controlling stress or external forces in their environment (Windsor et al 2009). Adults in marriage and de facto relationships tend to have fewer mental health issues and a lower rate of suicidal thoughts and behaviours than those who live their adult lives alone (Johnston et al 2009). This is related to the interdependency, rather than dependency of the relationship, wherein people are able to develop a sense of control or mastery over their environments (Windsor et al 2009).

Workplace stress is a serious problem in today’s society, incurring a cost to industry and the health system, as well as the personal costs of distress. Because it affects adults at all stages of their working life, it is also becoming an increasing issue for nurses working in home, family and community settings. Job strain and stressful working conditions, can create multiple pressures for the individual, especially where they are worried about job security (Lander et al 2009). Studies have shown that job strain, and its consequent stress, is a risk factor for major depression, which is the most prevalent mental disorder in the working population (Wang et al 2009). Sources of job stress can include overwork or shiftwork as well as workplace relationships.