Risk conditions are social structures such as poverty or poor quality housing that are associated with poor health. Figure 9.2 shows how the effect of risk conditions (e.g. social marginalization) is directly linked to risk factors (e.g. lack of social support) and is also mediated by risky behaviours (e.g. drug use). Risk conditions and risky behaviours give rise to physiological and psychosocial risk factors that are in turn recognized precursors to many causes of ill health and premature and preventable death. Figure 9.2 also shows how certain groups of people are more likely to experience both risk conditions and risky behaviour, leading to poorer health status. For example, unemployed people are more likely than the general population to be living in poverty and to be socially marginalized. This in turn leads unemployed people to be more likely to participate in risky behaviours such as smoking and the use of legal and illegal drugs, and thus to be at increased risk of developing a variety of diseases causing ill health and premature death. Risk conditions, risky behaviours and risk factors tend to cluster together and disproportionately affect certain groups of people.

Addressing the social determinants to enable them to become health promoting is a daunting task that requires many discrete skills. First there is a need to establish the health links, proving that determinants can affect health both positively and negatively. This has already been accomplished by a variety of research studies endorsed by official reports (e.g. Acheson, 1998 and Wilkinson and Marmot, 2003). Most recently, the WHO set up the Commission on the Social Determinants of Health in 2005 to synthesize evidence on how to tackle the social determinants of health in order to achieve health equity, and to prompt different bodies and organizations to strive towards this goal. The Commission published its final report in 2008 (WHO 2008). This report made three recommendations to tackle the social determinants of health:

Although the evidence exists, it still needs reinforcing in many different forums because traditionally public sectors have worked in isolation. Establishing that, for example, regeneration and renewal are part and parcel of health development work leads to the next logical step of joint planning, funding and working. This stage still presents many challenges and dilemmas for practitioners, which have been discussed in detail in Chapter 7.

Structural determinants of health have been recognized by the UK government and included in various health policy and strategy documents. The Acheson Inquiry (Acheson 1998) was a key document that fostered recognition of the need to address health inequalities and their underlying social determinants. Only 3 out of the 39 recommendations made by the Acheson Inquiry were specifically directed at the health service. This was followed by ‘Tackling health inequalities: A programme for action’ (DH 2003) and a review of progress (DH 2008). The 2008 review identified five key areas: early years and parenting, work experience, equality of opportunity, mental health services, and coordination of action locally and nationally.

Whilst there is much support for tackling inequalities and health determinants together, certain strategies need to be implemented in order to achieve results (Exworthy et al 2003):

Legislation and regulation are two of the most effective means to change infrastructure. They demonstrate a common view of what constitutes health risks and what actions should be taken to minimize harm. Legislation often sets minimum standards that have to be met, for example for air quality, wages, safety in the workplace, and housing. This approach requires agreed upon standards based on some form of evidence plus a monitoring and enforcement body to ensure compliance. There also needs to be an adequate infrastructure of trained and resourced inspectors to enforce the standards. Different professions each have a distinctive role to play. For example, environmental health officers (EHOs) are responsible for monitoring and enforcing standards for many health determinants including air pollution, food safety, housing and workplaces, whilst the police force is responsible for public protection and crime detection, and public health specialists are responsible for managing and controlling outbreaks of infectious diseases. Trading standards officers have also been identified as contributing to public health through their role in monitoring faulty goods and workmanship and enforcing the laws regarding the sale of tobacco, alcohol and solvents.

One of the benefits of legislation is that it is an ‘upstream’ intervention that directly addresses the social determinants of health. For example, if poor quality housing is upgraded using minimum standards, then eventually no one will be living in substandard housing. This is of course an over-simplification. In practice, standards are constantly being revised, and there is always a shortfall between standards and what happens in real life. Some practitioners feel in addition that tackling determinants of health is a diversion from their primary role and expertise, which is working with individual clients. Many practitioners shy away from activities at a policy level regarding this as political action. As noted in Chapter 4, practitioners are engaged in political activity when they are implementing policy. They also have a clear role in influencing the policy agenda (e.g. the input of learning disabilities nurses into government policy in the White Paper Valuing People (DH 2001)) and in monitoring the effects of policy.

Strengthening disadvantaged communities through targeted interventions, regeneration and renewal is another popular approach to addressing the social determinants of health. This aims to strengthen the community fabric, building and releasing social capital and thus enhancing skills and self-esteem. Foundations for Health Promotion, edn 3 (Naidoo and Wills 2009) outlines the role and challenges of community development in promoting health including the non-statutory nature of the activity and the ambiguities surrounding professional education and training in a field which aims to break down professional/lay barriers and promote participation and equality.

The third distinct approach is targeted at individuals and aims to provide opportunities for people to tackle or overcome constraining influences on their health. For example, providing opportunities for adult education and training will help people find and retain paid employment, thus enhancing employment and income, two key health determinants. Developing and recognizing skills that people may already have (e.g. child caring) through accreditation may reduce dependency and enhance self-esteem and self-efficacy. Providing services for individuals also has the benefit of providing direct inputs to those most at need. The direct face-to-face interaction implied by such an approach readily conforms to the model of individual client-practitioner relationship underpinning most professional education in the healthcare services. A major limitation of this approach is that it follows a ‘downstream’ rather than an ‘upstream’ approach. Supporting people to overcome the constraints of their circumstances will help those individuals, but if nothing is done at source to tackle the causes of their disadvantage, other individuals will take their place, living in poor housing, on low incomes, without secure employment. This cycle will only be disrupted by removing the causes of disadvantage at their source.

In practice, all three approaches are used by practitioners, and the strongest effects are found when the three different approaches build on and complement each other. Most practitioners will feel more at ease with one approach, and this provides another reason for partnership working (see Chapter 7) where different practitioners work together, developing their own area of expertise but working alongside others. So, for example, in any one locality, EHOs may be working to enforce quality standards in housing and minimum exposure to pollutants in the air; youth and community workers may be facilitating and supporting community projects such as walking and exercise programmes or peer education arts projects to reduce problematic drug use; and health visitors may be providing postnatal support programmes for new mothers to reduce social isolation.

This chapter considers the following socio-economic and environmental health determinants:

For each health determinant, the research showing its impact on health is first reviewed, followed by examples of different kinds of strategies and interventions designed to tackle the determinant. In particular, interventions that can be undertaken by health and welfare practitioners are highlighted. Evidence about the effectiveness of different strategies is reviewed and discussed.

Poverty is acknowledged worldwide as a determinant of ill health. Poor people are unable to afford the basics for good health – for example adequate nutrition, access to clean water, and sanitation. Whilst poverty affects certain regions disproportionately (e.g. sub-Saharan Africa) it also impacts differentially on different demographic groups such as women and children who are typically more vulnerable to poverty and its impact than men.

Extreme poverty means that children cannot access a nutritious diet, clean water, adequate sanitation, preventive health services such as vaccination and immunization, or education.

Tackling the problem of global poverty and its impact on health requires sustained and coordinated action by a variety of stakeholders including affected countries, the developed world, financial and banking institutions and the voluntary sector. The Millennium Declaration, endorsed by world leaders in 2000, is an example of coordinated action. The Millenium Declaration set 2015 as the target date for achieving most of its goals (United Nations 2007). At the midway point, progress has been made, although not sufficient to meet the goals.

However, many key challenges remain:

The current global financial crisis presents a further challenge and will impact negatively on health, with an estimated increase in child mortality of between 200,000 and 400,000, largely driven by malnutrition (http://www.un.org accessed 1/7/09).

Whilst developed countries do not experience the scale of poverty-related health problems seen in developing countries, poverty and income remain key determinants of health status.

In developed countries income is the mediating factor that determines access to a host of variables related to health. The relationship between poverty and ill health is complex and can be seen in:

There is now an accepted evidence base that clearly demonstrates that poverty leads to poor health outcomes and excess mortality (Acheson, 1998, Benzeval et al., 2000 and OECD WHO, 2003). There is on-going debate about whether it is low income per se or income inequality that is the key factor determining poorer health and increased ill health (Shibuya et al., 2002, Sturm and Gresenz, 2002 and Wilkinson and Marmot, 2003). However, Wilkinson and Pickett (2009) provide robust evidence for asserting that inequality is the key determinant of a range of poor quality of life indicators, including poor physical and mental health.

Income, and hence poverty, is both absolute and relative. Absolute poverty refers to an income that is insufficient to pay for the basics of a healthy life – adequate nutrition, heating and housing (although defining basic minimum needs is not easy and is affected by cultural norms). Relative poverty is ‘when (individuals) lack the resources to obtain the types of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies to which they belong’ (Townsend 1979, p. 31). The key issue is whether a poverty line should be set in relation to a basic survival budget, or at a level of income that would enable people to participate in society and meet social and cultural needs. The definition of poverty used by the UK government (DWP 2002) is a household income below 60% of the median income level in that year. Other methods of establishing poverty levels may be the proportion of income needed to cover a basic food basket (used in the USA) or whether people can afford what are perceived to be necessities for life. ‘Necessities for life’ is a relative concept although there is considerable consensus about basic requirements. For example, a survey conducted by the Joseph Rowntree Foundation (Gordon et al 2001) found beds and bedding for everyone and adequate heating were commonly accepted as necessities for life.

Poverty is both a structural issue, affecting large sections of the population in a patterned and predictable way, and an individual issue, affecting and constraining every aspect of an individual’s life. Practitioners need to be aware of the constraints poverty places on people’s lives, and take this on board in their interactions with clients living in poverty.

The biggest and most significant anti-poverty policy is the social security system. Each year over £100 billion in social security benefits is distributed to over half the population (Alcock 2002). Universal benefits are paid in the UK on the basis of age or family circumstances, for example pensions and child allowances, but a significant element also constitutes welfare benefits, such as income support or unemployment benefit, which aim to relieve poverty. In addition to social security benefits, policies such as the introduction of a minimum wage, changes to the tax system, for example working tax credit and child tax credit, and changes to the national insurance system, are designed to ensure that being in employment leads to a higher income than being on benefits, and to help working people escape the trap of low income. Practitioners can help to ensure that clients are receiving their full benefit entitlement. Some practitioners may view such work as beyond their remit and area of expertise, but such schemes are practical and effective (see Chapter 5).

At a local level, initiatives such as credit unions or local exchange trading schemes (LETS), which allow local trade by using credits instead of money, are an important means of facilitating and supporting local economies (http://www.letslinkuk.net/). LETS are also intended to maximize employment opportunities by building up skills. Schemes that maximize or increase income, or provide services and stimulate trade via credits, provide the most direct example of tackling the links between poverty and health.

Other strategies to tackle poverty may aim to strengthen individuals. For example, brief behavioural counselling to increase the consumption of fruit and vegetables amongst low income adults was found to be more effective than nutrition education counselling, leading to a 42% increase in the proportion of participants eating five or more portions a day (Steptoe et al 2003). Other interventions may focus on ‘living on a budget’, such as community kitchens. These schemes can be effective in getting people together to think about common problems and encourage social support networks. The challenge for practitioners is to avoid exacerbating problems by blaming people, explicitly or implicitly, for any unhealthy behaviour.

There is ample evidence of the link between low income and poor health, but historically there has been a separation between health and social care professionals, with income support work being undertaken by social care professionals. However, there are examples of interventions tackling poverty and low income where health practitioners play a key role. With training, support and resources, addressing low income and its effects on health can become a realistic and effective task for health practitioners. At a basic level, awareness and acknowledgement of the effects of low income on clients can enable practitioners’ core work, for example health promotion advice and education, to become more sensitive, appropriate and effective.

There is a strong link between employment and health. For some people, the work environment can present hazards and health risks. Health and safety legislation covers employers’ statutory responsibilities to protect the health of their employees, but occupational ill health remains a significant problem. Social inequalities are reflected in the workplace, with workers from low socio-economic positions, Black, Asian and minority ethnic (BAME) groups and migrant workers disproportionately employed in the most hazardous and unhealthy jobs.

Common mental health problems and musculoskeletal disorders are the main causes of ill health amongst the working age population. Stress at work plays an important role in contributing to the large differences in health, absence due to sickness, and premature death related to social status (Black 2008). Ill health amongst the working age population is estimated to cost Britain over £100 billion each year – more than the annual budget for the NHS (Black 2008). One way to reduce this burden is to shift practice from the cautionary ‘risk avoidance sick note’ culture to a more proactive approach focusing on what people can do rather than what they cannot do. A growing evidence base suggests that early interventions directed at people with short-term absence due to sickness is effective in reducing long-term absence due to sickness and the financial costs involved. This approach – the fit for work approach – is recommended in Carol Black’s (2008) review of workplace health.

For the majority of people, the association between paid employment and health is overwhelmingly positive. Paid employment provides people with an income, feelings of self-esteem, purpose and self-efficacy, and a social network. Employment provides goods or services that contribute to the national economy. Unemployment is a greater health risk than employment, and is strongly related to ill health and mortality. A good case can be made for targeting unemployed people and supporting them to move into paid employment as a health-promoting strategy.

Getting people into paid employment is a key national policy that is supported by many local initiatives. The approach is many pronged, and includes providing skills and training to enhance employability, helping people apply for jobs, supporting flexible hours through the provision of childcare, and providing transport to enable people to get to work. A pilot project – Pathways to Work – has been shown to be effective in increasing the employment of people on incapacity benefits, with the exception of those whose health condition is a mental illness (Black 2008). Specialist mental health services therefore need to be integrated into all ‘back to work’ services. Occupational health services need to be reinvigorated and integrated into mainstream healthcare provision.