Intro Unit Determinants

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TABLE OF CONTENTS

A definition of determinants and health..………………… ………………3 The determinants of health……………………………………… ………...4 The Determinants of Health in NZ…………………………… ……………5 Activity 1: Explaining and linking determinants………… ……………….8 Activity 1A: Determinants of health comparative study………………….9 Activity 2: Linking determinants to health outcomes – market rents……10 Activity 3: Personal Profiles……………………………………… ………12 Activity 4: Determinants of health in our school………… ………………15 Activity 5: In Sickness and Inequity………………………… ……………16 Activity 6: Recommendations for Equitable Outcomes…………………..18 Activity 7: Putting it all together – the overview in health………………20 Getting the Whole Picture of Health.………………………… ……………21 Additional note pages……………………………………………… ……..22

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A definition of “determinants” and “health” We have looked at the determinants of health in year 12 but in year 13 we need to have a wider understanding of what determines our health and how these determinants affect our wellbeing.

Determinant = factor, thing, influence Determinants of health are those factors which influence our health

It is important, when looking at determinants, to define the meaning of “health & wellbeing”. The World Health Organisation: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” The Ottawa Charter for Health Promotion: “health is created and lived by people in settings of their everyday life; where they learn, work, play and love” Whare Tapa Wha (hauora) “The four cornerstones of Maori health that contribute to wellbeing: Taha wairua, taha hinengaro, taha whanau and taha tinana”.

INEQUITY: A lack of fairness or justice in the treatment or situations between individuals or groups. Inequities can be reduced (so people can enjoy equal good health) by taking action to promote social justice. INEQUALITY: A difference in the social or economic status between individuals/groups based on unequal distribution of goods, ie some have more than others. May or may not be linked to inequity issues. It is important to note there is a difference between these two terms, and they are not interchangeable. For instance, if after a major storm a section of the country was without power, we would say there was inequality in the situation because some people had power but some did not. However, it was not an inequitable situation, as it did not involve unfair treatment. If the power companies decided to only supply power to those who were wealthy, then it would become inequitable. However, inequity can sometimes be quite overt. Taking this same analogy, if the power companies decided they would put the power cables underground in Pakeha neighbourhoods, but keep them 3

above ground in predominantly Maori or Polynesian neighbourhoods, then again there is inequity in the situation because the above-ground cables are more susceptible to storm damage, and Maori and Polynesian neighbourhoods run a greater risk of being without power in times of bad weather. For a really good explanation of this, you can look up this article: http://www.beyondintractability.org/essay/power_inequities/

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http://www.who.int/hia/evidence/doh/en/

The determinants of health Introduction Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. The determinants of health include: • • •

the political, economic, cultural, and social environment; the physical environment; and the person’s individual characteristics and behaviours.

The context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the above factors, and many others: •

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Political determinants – who is in power affects health in several ways – type of governing (oppressed versus democratic), funding for social welfare, funding for health and education, laws and policies ie alcohol purchasing age, market rents for state houses and the involvement in any war. Economic determinants – these include the global economy, financial markets and trade that can have a positive or negative effect on health, ie trade in tobacco has a negative effect, but the increased telecommunications that enables health information to be shared can have a positive effect. Environmental determinants – safe water and clean air, access to sport and recreation facilities, healthy workplaces, safe houses, communities and roads all contribute to good health. Cultural determinants – spiritual beliefs, identity issues, philosophies, practices and values all relating to culture can contribute greatly to a person’s health. 5

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Personal determinants – genetics, age or gender play a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Lifestyle determinants – these include our personal behaviours and coping strategies, ie balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health. Social determinants – these include the social and psychological environments, early childhood environments and work conditions that can directly affect health and wellbeing. Everything from where a person is on the social gradient, if they have social support or are socially excluded, in employment or not, access to transport, their early life conditions, any addictions, access to healthy food and stress can have either a positive or negative impact on a person’s health.

The Determinants of Health in NZ: Information and research findings The National Health Committee’s paper “Social, economic and cultural determinants of health” outlines information and research findings about major determinants of health for New Zealanders. • •

Risk Factors: Factors that place people at increased risk of poor health Protective Factors: Factors that increase chances of good health

Within each determinant, there will be risk and protective factors, depending on what is going on in someone’s life in relation to that determinant. Eg: Sociability: Social isolation = risk factor and social support/cohesion = protective factor. Links between Determinants: The determinants all link together to create a picture of overall good/poor health. Eg: Income relates to education, housing, the environment (area in which you live), type of work/ or whether you are employed – this relates to social support/isolation and so on.

THE DETERMINANTS Income Income inequality has increased dramatically in NZ. The number of people on benefits is increasing and Maori and Pacific Islanders are over-represented in low income groups. Housing costs are the largest single cause of poverty (refer to Activity 2 on page xxxx). The strongest evidence about those who are vulnerable to ill health relates to low income. Single-parent households with children are by far the largest household type living in poverty. Housing 6

Houses which are damp, cold and overcrowded are not healthy environments and are associated with higher rates of meningitis, tuberculosis, measles and mental health problems. Rising rental costs and house prices will worsen the problem. Education Education is critical in determining people’s social and economic position and thus their health. Initiatives such as Te Kohunga Reo have improved Maori educational opportunities; however, many more Maori students are leaving school without qualifications, and the gap between Maori and non-Maori achievement is widening. Socio-economic Factors Low birth weight, which is a risk factor for health problems throughout life, has been found to be associated with lower social class. People in higher socio-economic groups are less likely to smoke and rate their health as poor. Chronic infections are more common in lower socioeconomic groups, including HPV (genital warts) which is associated with cervical cancer. Un/employment Occupational injuries are an issue in NZ. Eg: Exposure to toxins, machinery accidents, falls, driving accidents. Position in the workplace is also a factor: Top managers have better health and longer lives than people below them in the workplace. Having control over your work is important for good health. The importance of earning a living is not only for financial reasons, but also mental health and social reasons. Unemployment increases the risk of premature death (particularly men). Distribution of Income Links have been made between the distribution of income in a society and the health of people in that society. Death and poor health is lower in countries with a more egalitarian distribution of income (a narrow gap between peoples’ earnings) than in countries with a large gap between the rich and the poor. Sociability Social support enhances health. Social isolation is associated with illness. People who are married have lower mortality rates than those who are single, divorced or widowed. Individuals with strong ties to family, friends and community have better health than those who live alone or do not belong to any groups. Environmental Factors Environmental pollution causes 2% of cancer deaths throughout the world. Rates for meningitis are 74% higher in overcrowded areas. Low income people have greater exposure to environmental toxins. Some areas are more toxic than others due to industrial waste sites and factories. These areas are also likely to be more deprived in amenable 7

services such as schools, transport, or health care facilities. Employment opportunities may be hard to come by. Gender Women have longer life expectancy than men, but suffer more psychological problems throughout life. Women also have more time off from work due to sickness than men. Women receive less specialist operations in NZ than men. Ethnicity Internationally, being a minority ethnicity is a risk factor for sickness, low birth weight and early death. Maori and Pacific Island life expectancies are lower than Pakeha, and infant mortality is higher. Fewer Maori or Pacific Islanders rate their health as being good compared to Pakeha or Asians. Reference Howden-Chapman, P. & Cram, F (1998). Social, Economic and Cultural Determinants of Health. National Health Committee: Background Paper 1

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Activity 1: Explaining and linking determinants Learning Outcome: Students will investigate and explain the definition of a determinant of health for individuals and groups in society. Use the information provided so far in this workbook to complete the following: 1. Explain a determinant of your choice for each of the following levels. -Personal or Individual (eg: age, gender, personal behaviours) -Interpersonal (eg: Socio-economic/social - sociability, income, employment) -Societal (eg: income distribution, political system) Your explanation should include: -What the determinant is -How it is a risk and protective factor for individuals/groups -What other determinants it links to and how it links to these others. Determinant 1. Personal (Individual)

2. Interpersonal

3. Societal

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Explanation of how this determinant is a risk/protective factor and the links to other determinants

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Activity 1A: Determinants of health comparative study Learning Outcome: Students will demonstrate understanding of how determinants of health impact on the health and wellbeing of NZ youth. Instructions: Below are listed the determinants of Health that WHO and The New Zealand Health Strategy have decided are critical for population health and wellbeing. Individually list the determinants you believe are critical for your health and wellbeing and place these in the third column. Discuss as a class and add ideas. Decide whether these determinants link to the WHO and/or Health Strategy determinants, and tick in the respective columns to the right. WHO: Social Determinants of Health

NZ HEALTH STRATEGY: Determinants of Health

OUR CLASS: Determinants of Health What affects your health and wellbeing?

1. The social gradient

1. Genetic inheritance

2. Stress

2. Age

3. Early life

3. Gender

4. Social exclusion

4. Ethnicity

5. Work

5. Income

6. Unemployment

6. Employment

7. Social support

7. Education

8. Addiction

8. Housing

9. Food

9. Sense of control over life circumstances

10. Transport 10. Access to health care services

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LINKS TO WHO AND NZ HEALTH STRATEGY WHO

NZ HEALTH STRATEGY

Activity 2: Linking determinants to health outcomes – market rents Learning Outcome: Students will demonstrate understanding of the links between a determinant and health outcomes for a particular situation. Using the PHAC model, choose any specific determinant and plot similar links to the effects on the health outcomes of the people affected on the next page.

Increase in People living in substandard housing

Introduction of market-related rents for state housing

Housing insecurity

Stress

Higher rents

Reduced disposable income

Overcrowding

Possible causal pathways between a housing policy change and adverse health outcomes Sourced from Public Health Advisory

Stress

Increase in people living in cold and damp conditions

Increase in respiratory disease eg asthma

Poorer mental health

Reduced access to health care

Poorer health

Increase in infectious diseases eg meningococcal disease

Poorer mental health

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Possible causal pathways between _____________________________ and health outcomes for people in this situation:_____________________________________. 14

Activity 3: Personal Profiles Learning Outcome: Students will demonstrate knowledge and understanding of the effects the determinants of health have on individuals, including themselves. Task One: For the profiles below, suggest the determinants of health that could be affecting the person and how these determinants could be helping/harming their health. Write your answer in paragraph form. Refer to all of the determinants that you believe are relevant, such as: Lifestyle (personal behaviours), social status, social support, physical environment, education, gender, political system, age. ONE Sarah is 43 years old. She has a high-stress job and she often has to work late. Consequently she doesn’t get much exercise and has to eat on the run. Sarah lives by herself in an apartment in the middle of Auckland city. She earns a good salary and can afford health insurance. Lately she has been smoking and drinking more than normal because work is extra-busy. TWO Jeff is in his mid-30’s. He is a fitness-freak – he goes to the gym every day of the week. He is a vegetarian and eats a lot of fresh fruit and veges. Jeff does not smoke and drinks socially with his friends (they get together a couple of times a week). Jeff loves his job – he is an architect and gets to go out on work sites quite often. Jeff lives in a small city in Canada and enjoys the free health care system and political stability his country has to offer. THREE Nkosi lives in South Africa in a shanty town. He lives just out of a main city, where 20% of the population is HIV positive. Nkosi does not have HIV. Nkosi has a job that gives him an average wage in his area – this converts to about $25 NZ dollars a month. He walks 10KM each morning and night to get to work. Nkosi does not smoke or drink alcohol, and his diet is very limited because he can’t afford to spend much on food (he eats mostly rice).

Task Two: Write a page on the topic: “What are the main determinants that affect my health”. Include: --Helping and harming factors --A mix of all levels of the determinants --Reasons why these determinants are the main determinants that affect your health --What determinants could be altered to improve your health (if any). --Make some comparisons between you and someone who has a life like Nkosi. 15

 Compare (what is the same?)  Contrast (what is different?)

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Task One: The main determinants that are affecting each person’s health Sarah: _____________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Jeff: _____________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Nkosi: _____________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Task Two:

The main determinants that affect my health

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Activity 4: Determinants of health in our school Learning Outcome: Students will investigate the links between the determinants in the school and the effects on the health or well-being of the students enrolled at that school. Use the profile of our school below to suggest the determinants of health

that could be affecting the students/teachers at this school and how these determinants could be helping/harming their health. Write your answer in paragraph form. Refer to all of the determinants that you believe are relevant, such as: Lifestyle (personal behaviours), social status, social support, physical environment, education, gender, political system, age.

[insert profile information for relevant school. The latest ERO report is a good source of information]

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Activity 5: In Sickness and Inequity Reference: The Ministry of Education (2004). The Curriculum in Action: Making Meaning, Making a Difference. Learning Media; Page 56. Learning Outcome: Students will identify and explain how the determinants of health contribute to inequities in the health outcomes of various populations and explore the ethical issues relating to inequity in health outcomes. Use the article: In Sickness and Inequity to complete this activity. Read the article provided and answer the following questions: 1. What is the most important determinant of health, according to Ichiro Kawachi? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

2. What evidence does he have to support this view? (Try to find 3 excerpts). ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

3. Do you agree or disagree with this point of view? Explain your answer in relation to the determinants of health. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

4. Use your understanding of the determinants of health to explain some implications of “social capital”. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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5. What are the advantages and disadvantages of an egalitarian society? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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In sickness and inequity In an interview with Kelly Andrew for The Press (Christchurch, 4 August 2001), Professor Ichiro Kawachi, an ex-New Zealander and now an associate professor at the Harvard School of Public Health, expressed concern that the growing gap between the rich and the poor in New Zealand could be hazardous to its health. Extracts from the article follow. Eating the right food, exercise, and well-funded public hospitals are virtually irrelevant to the good health and longevity of a society. Instead, the most important determinant of health is living in an egalitarian society. "What really makes a difference for wellbeing is whether there's equality in growth of incomes and standard of living. It's well documented that as a result of the economic policies of the 1980s, New Zealand has become a much more unequal society." But, he reassures, we are nowhere near the level of his home for the past 10 years. The United States is one of the unhealthiest countries in the world, and the most unequal. The US spends 13 per cent of its gross domestic product (GDP) on health care. New Zealand spends about half that amount. Yet New Zealanders have a longer life expectancy and lower infant-mortality rate than US residents. "There is zero correlation between how much is spent on health care and how healthy society tends to be ... Americans are obsessed about maintaining their health ... but they have terrible health statistics." By contrast, in Japan, where many businessmen are chain smokers, the life expectancy is eight years longer than in the US. Professor Kawachi says this is because Japanese society is more egalitarian. In the US, a top chief executive would earn 400 times the income of a blue-collar worker. In Japan, typically the highest paid would earn just seven times [as much as] their lowest paid employee. "I firmly believe in the benefits of the free market. I believe the market should deliver what people want. But there are things that the market does poorly, like trying to provide for social cohesion." The former Soviet Union is an example. As it moved rapidly into a free market environment, social values disintegrated and life expectancy slipped by eight years within two years of the economic transformation. He believes inequality has a devastating effect on social capital – which he defines as relationships between citizens, trust, volunteerism, and community participation – as well as [on] health. "When the gap between rich and poor widens there's an accompanying erosion of social capital. People become more selfish, less trusting of each other. Volunteerism and civic engagement goes down and we become a careless society." 25

from Andrew, K., 'In Sickness and Inequity', The Press (Christchurch), 4 August 2001, page 6

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Activity 6: Recommendations for Equitable Outcomes Learning Outcome: Students will investigate and explore the health promoting strategies and recommendations for ensuring more equitable outcomes for different individuals and groups in society. By now you will have a very good understanding of the determinants of health and how they work together to influence whether people are healthy or unhealthy. Most of the achievement standards in level 3 health require you to come up with recommendations for future action in relation to a health issue. Choose three determinants of health and give recommendations for action to create equitable outcomes for health (where people are treated fairly in having good health) in relation to that determinant. You will need to give details of your recommendations and explain why you believe this would be useful. Refer back to the information on determinants (particularly the NZ information and research) to help you. Example: Distribution of income: I recommend a taxation system to reduce inequities between what people are earning in NZ. People who are earning more pay a higher level of tax. People who are earning less pay a lesser level of tax and so have more money in their pocket. This will enable them to improve their living conditions and it will bring income differences between rich and poor closer. I also recommend re-training people with low/no qualifications. If NZ had a more skilled and educated workforce (at the lower end of the pay scale) they would demand higher salaries and these people’s pay conditions would improve. This would also reduce the difference in income between the highest and lowest income earners.

Determinant 1:__________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Determinant 2:__________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Determinant 3:__________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

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Activity 7: Putting it all together – the overview in health Learning Outcome: Students will demonstrate knowledge and understanding of how the determinants of health link into the ‘bigger picture’ of the underlying concepts in the health curriculum. By now you should have a solid understanding of how the determinants can affect an individual’s or group’s health status, and that to make things more equitable there needs to be action taken to ensure social justice. The NZ Health curriculum is based on four underlying concepts; that of Hauora, Health Promotion, a Socio-ecological Perspective, and Attitudes and Values to enhance the wellbeing of individuals and society. On the following page, fill in the blanks with the four underlying concepts that you see best fit into the diagram of the overview in health. Put the relevant determinants into the spaces that contribute to health issues for individuals and groups in society.

From: HPE Curriculum, Ministry of Education 1999

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Getting the Whole Picture of Health OVERALL UNDERLYING CONCEPT

UNDERLYING CONCEPT

UNDERLYING CONCEPT UNDERLYING CONCEPT

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6. 5.

Personal, interpersonal and societal INFLUENCES on the stated health issue

4. 3. 2. 1.

CONSEQUENCES for personal, interpersonal and societal well-being related to the health issue

Sustainable health strategies need to emphasise the actions needed to change the factors that influence the health issue

Personal, interpersonal and societal STRATEGIES to bring about healthenhancing change

…sometimes, consequences can’t be ignored and need to be addressed as well

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