Chapter 6 Social and emotional determinants of health
After reading this chapter you should be able to:
describe what is meant by socioeconomic differences in health, and the social and emotional determinants of health
Introduction
In Chapter 5, you were introduced to the concept of the determinants of health, and the biological and environmental determinants of the health of Australians. In this chapter, we describe the social, economic and emotional determinants of health. After reading both these chapters, you should be knowledgeable about the links between people’s biological, environmental, social and emotional life circumstances and the impact of these on their health. This information is important. It will help you, as a future health professional, understand the powerful influences that people’s backgrounds, circumstances and the contexts of their everyday lives have on their health choices and health opportunities.
In exploring the central theme of why some people are healthy and others are not, Evans et al. (1994 p 3) claimed that ‘top people live longer’. That is, there is a gap between the health status of those at the top of the socioeconomic scale and those at the bottom (Evans et al. 1994). In Australia, there are differences between the health of urban and rural Australians, between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians, and between different ethnic groups. The observation by Evans et al. (1994) regarding the gap in health status between those at the top of the socioeconomic scale and those at the bottom still holds in Australia and in most other countries; furthermore, the gap in health status is widening in many countries.
The Australian Institute of Health and Welfare (AIHW 2010) also claims that people’s general background has an influence on their health. This background influences the basic levels of security, safety, hygiene, nourishment, technology, information, freedom and the morale of societies. It is difficult to put values and quantities on most of these broad factors, let alone measure them and assess their impact precisely. ‘However, it is widely agreed that, at least up to a fair degree of societal development, they are a vital determinant of a population’s health. They set the background level around which variations then occur between groups and individuals’ (AIHW 2006 p 142).
Over the past 20 years, the evidence regarding health inequalities both within and between countries, and how these inequalities are linked to socioeconomic position in society, is irrefutable (Australian Bureau of Statistics 2010; Evans et al. 1994; Kawachi et al. 1999; Marmot 2006; Turrell et al. 1999). The ongoing challenge for public health is to translate this research into effective policies and programmes to close this health status gap and to explain more clearly the factors implicated in mortality (death) and morbidity (illness).
Socioeconomic determinants and the health inequalities jigsaw
Health status is influenced by a variety of socioeconomic factors, such as income and employment. The reverse also holds – income and education are influenced by one’s health status. For example, if you are disabled, you may have limited work opportunities and this would have an impact on your income. The AIHW suggest that the socioeconomic characteristics that influence health include ‘education, income, wealth, occupation, marital and family status, labour force participation, housing, ethnic origin and characteristics of the area of residence’ (AIHW 2006 p 153). We will be discussing only some of these (for a comprehensive review of these, see the AIHW website). So what is the association between socioeconomic characteristics and health inequalities?
This association began to receive the attention it deserved, particularly with the release of the Black Report (1980), developed by a working group on health inequalities established in the UK in 1977. The report had three components: a description of differences between occupational classes in mortality, morbidity and use of health services; an analysis of likely explanations and recommendations for further research; and a strategy to reduce health inequalities or their consequences (Macintyre 1997). The findings revealed that there were ‘marked differences in mortality rates between occupational classes for both sexes and at all ages, and a class1 gradient can be observed for most causes of death, a lack of improvement and in some cases deterioration of the health experience of unskilled and semi-skilled manual classes and inequalities exist in the utilisation of health services, especially preventive services’ (Townsend et al. 1992 p 198).
The general theme of the Townsend et al. (1992) findings was echoed in the UK’s Whitehall Study of Civil Servants that began in 1967 (Langenberg et al. 2005). The study examined the 25-year mortality of men (aged 40–69 at the beginning of the study), showing the social gradient2 by type of occupation within the civil service (Langenberg et al. 2005). Marmot (2006) claims that men second from the top of the occupational hierarchy within the civil service had a higher rate of death than men at the top, while those who were third from the top had a higher rate of death than those second from the top. He asks, ‘Why among men who are not poor in the usual sense of the word, should the risk of dying be intimately related to where they stand in the social hierarchy?’ (Marmot 2006 p 2083). In Whitehall II, launched 20 years after the first Whitehall study, the observations were extended to women, and the gradient in mortality applied to most of the major causes of death, especially heart disease. The puzzle is, ‘Why there should be social gradient in so many different causes of death?’ (Marmot 2006 p 2083).
Across and within countries, the evidence of social and economic determinants and health inequalities is compelling, whether the examination is within developed countries such as the UK, the United States, Canada or Australia, within newly developed countries such as Brazil and India, or developing countries in Africa. On life expectancy measures alone, an individual’s position within society influences his or her health. In other words, while health is multi-factorial and influenced by one’s genetic make-up and biology (as discussed in Chapter 5), there is a strong correlation between social conditions and a person’s position within society, and their health. As Turrell and Kavanagh (2004) put it:
While health inequalities often differ in magnitude among these countries (reflecting in part differing social, political, economic and cultural systems) the overall picture is very similar. Illness and death are patterned in ways that indicate that those with the least access to social and economic resources are the most disadvantaged in terms of their health. (Turrell & Kavanagh 2004 p 393)
Marmot (2006) gives an example of these differences in a study on health disparities. There was a large difference in male life expectancy between two suburbs in London even though they were within close proximity of each other (the boroughs of Camden and Hampstead). ‘The life expectancy gap between men living in these two areas is 11 years – from 70 years to 81 years for men’ (Marmot 2006 p 2086).
Increasingly, then, there is evidence to suggest that people’s health is produced and sustained by the social and economic circumstances that they experience differentially throughout their life. ‘Those at the lower end of the socioeconomic hierarchy have poorer health partly as a consequence of material disadvantage such as living on a low income or working in a hazardous job, partly as a result of less healthy behaviours, and partly as a result of psycho-social factors such as anxiety, stress, social isolation and feelings of lack of control’ (Turrell & Kavanagh 2004 p 392).
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Socioeconomic characteristics that influence health
Education
Education is an important determinant of health, as it enhances skills, job opportunities and mobility within the workforce. One of the measures of the education level within society is the measure of retention rates in Year 12. Overall, in Australia, the retention rate of students in high school, and therefore their attainment, has increased over the past 25 years. In 1980, 32% of males and 37% of females completed Year 12, compared with 70% of males and 81% of females in 2004 (AIHW 2005a). In 2008, the national retention rate was 75% (ABS 2009), an increase from 72% in 1998. Rates were higher for females (81%) than for males (69%) (AIHW 2010 p 79). ‘From 2002 to 2008, there have been steady increases in Aboriginal and Torres Strait Islander Australian retention rates from 38% to 47%’ (AIHW 2010 p 79). In addition, the percentage of Australians with post-school qualification has also increased – 54% in 2008 compared to 42% in 1998 (ABS 2008 in AIHW 2010).
So why is education important to health? Analysis of data from the Swedish Census showed ‘a remarkable social gradient in mortality’ (Erikson 2001 p 2084). Erikson (2001) discovered that in men, the higher the educational level, the lower the mortality risk. What is it about having an education that has a protective effect against behavioural risk factors such as tobacco smoking and being overweight, and risk conditions, (sometimes called material circumstances) such as, poor and unstable housing, lower income, and fewer work choices?
A number of authors argue that education provides opportunities for income and job security and gives people a sense of control over their life choices. Dutton et al. claimed that ‘human capital dimensions of education that link it to health are apparent in its close connections to work and economic circumstances, psychosocial resources and health behaviours’ (2005 p 37). Human capital refers to the value of skills, education, health, and training of individuals for the economy and society (Becker 1993).
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We now introduce income as one of the interrelated socioeconomic characteristics under discussion.
Income
The AIHW (2006 p 154) claim that ‘income has been shown to relate strongly to health, especially in lower income countries’. ‘For individual citizens, higher incomes give greater access to goods and services that provide health benefits – for example, better food and housing, health care and other healthy pursuits’ (AIHW 2010 p 79) and ‘may provide psychological benefits such as a greater sense of control’ (AIHW 2006 p 154). This makes intuitive sense, and is borne out in Australian data. ‘Nineteen percent of the mortality burden for males and 12% for females have been associated with socioeconomic disadvantage’ (AIHW 2006 p 154). The challenge for public health researchers, policy-makers and planners is to build evidence about the interrelationships between income and the other socioeconomic characteristics in order to understand how they influence health.
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Work and employment status
There has been a slight increase in unemployment in Australia from 4.5% (AIHW 2006) to 5.1% (ABS 2011). There is continuing evidence that unemployment is linked to health status (AIHW 2006). The Whitehall study found that those civil servants at the lower end of the employment hierarchy had higher rates of mortality than those at the top end of the occupation scale. Draper et al. (2004 in AIHW 2006 p 155) claim that there is evidence of an association between occupation and mortality – ‘persons employed in manual occupations have higher mortality rates for most causes of death than those employed in clerical or managerial professional occupations’. This could be related to more hazardous work, such as in factories, farming, forestry and mining, where there is a higher risk of workplace injury. Research is ongoing into the impact of occupational status, above and beyond those workplace hazards.
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We now turn our discussion to the influence of place or location on health inequalities.
Place or geographical location
There is growing research that demonstrates that health outcomes and health-related behaviours can be affected by the neighbourhood in which one lives (Botticello 2009; Godley et al. 2010; Marmot 2006; Turrell et al. 2010). Marmot (2006) studied the differences in male life expectancy between two suburbs in London. Despite their being in close proximity to each other, the suburbs had different socioeconomic profiles. The suburb with the poorer male life expectancy was much more deprived socioeconomically. Godley et al. (2010) discovered a statistical link between self-reported poorer health status and socioeconomically disadvantaged neighbourhoods in Calgary, Canada. In addition, in a multi-level longitudinal study of physical activity (PA) in middle-aged men and women (40–65 years) in 200 neighbourhoods in Brisbane, Turrell et al. (2010 p 2) concluded that ‘… levels of PA varied significantly across Brisbane’s neighborhoods, and neighborhood disadvantage accounted for some of this variation’ and ‘[N]eighborhoods may exert a contextual effect on residents likelihood of participating in PA’.
A number of authors have proposed hypotheses about the relationship between geographical location and health. For example, a cross-sectional analysis of 4286 women aged 60 to 79 years old from 457 British electoral areas found that the odds of coronary heart disease was 27% greater for those women living in electoral ‘wards’ (electorates) that are ‘deprived’ (Lawlor et al. 2005). The more deprived an area, the higher the odds of coronary heart disease.
Giskes et al. (2006) followed a group of 404 smokers in 83 areas in the Netherlands, for 6 years. The authors first gathered data on smoking habits and other lifestyle characteristics to ascertain whether people’s likelihood of quitting smoking was related to the area in which they lived. They concluded that ‘living in a deprived area seems to reduce the likelihood of quitting smoking’ (Giskes et al. 2006 p 485); in other words, the socioeconomic factors of the areas where people live impact on their ability to stop smoking (Giskes et al. 2006).
‘Contextual effects’ are those that demonstrate that place/area is significantly connected to health and wellbeing, as the above citations demonstrate. On the other hand, ‘compositional effects’ describe the socioeconomic position we hold in terms of income, education and employment status; and, as we have seen, these are generally predictors of positive health behaviours and subsequent health outcomes. Yet, ‘contextual area effects’ can exert more influence than ‘compositional effects’ on health, although there is variance in explaining the causes of such differences. Is it because there are better and more accessible ‘collective resources in better-off neighbourhoods or is worse/better health because of the discrepancy between an individual’s situation and those around them?’ (Stafford & Marmot 2003 p 357).
The work by Carroll et al. (2007, 2008) corroborate these study findings, and, importantly, propose that there is a need for further research to explain in more depth the reasons why area contextual effects influence health behaviour and health outcomes.
The health of rural Australians is an interesting example of area effects and health. Thirty-four per cent of Australians live in rural and/or remote communities. One would assume that access to health services such as doctors and hospitals would be an influential factor, but even with that factor taken into account, health profile differences between rural and urban Australians are significant (AIHW 2006). Compared with Australians living in major cities, those living in rural or remote communities are more likely to be smokers, drink alcohol in harmful quantities, and be overweight/obese and physically inactive (AIHW 2005b). While there would be individual socioeconomic differences between individuals in these communities, the collective health profile of rural Australians is poorer than that in urban areas. Studies examining the contextual and compositional effects of living in rural Australia are warranted.
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