Influences on Health

  • Created by: sikemi__
  • Created on: 18-05-21 18:54

What are the influences of health?

  • Healthcare (access, affordability, quality, R&D)
  • Environmental factors (air quality/pollution, climate/weather, sanitation, water, basic services, green space/housing)
  • Societal factors (GDP, spending, government stability leisure facilities, inequality/resource distribution, social connections, social surroundings, relationships, social capital (explained below), systemic racism, culture)
  • Individual socio-economic factors (wealth, income, education, knowledge, occupation, responsibilities)
  • Behavioural factors/lifestyle choices (detrimental: smoking, alcohol, drugs, work related exposure; beneficial: exercise, good diet; perceptions)
  • Individual factors (age, gender, genetic factors
  • We can't rank these against each other - they are interlinked

Social capital (Putnam, 1993):

- 'features of social organizations, such as networks, norms and trust that facilitate action and cooperation for mutual benefit'

- Different meanings: bourdieu - property of an individual, connected to education, status etc. Putnam - property of a society, connected to civic orientation, networks, trust etc

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Conceptual models of the influences on health

  • In the mid 20th century, policy makers and academics thought about health from a medical background, and in terms of the biological processes of disease.
  • During the 1970s and 1980s, there was a shift in focus to the socio-economic determinants of diseases. Social scientists identified correlations between socio-economic factors e.g. maternal education and health outcomes e.g. child mortality.
  • However, social scientists didn't consider how socio-economic circumstances actually affected health, they only noted the correlation.
  • The social science approach linked socio-economic determinants of mortality but didn't say how they operated. The medical science approach discussed proximate determinants (i.e. things that affected mortality directly), but didn't talk about the socio-economic dteerminants that affect those.
  • Therefore, both approaches only offered a partial picture of influences on health.
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The Mosley and Chen Model

  • An attempt to offer a fuller perspective of influences on health (1984).
  • Argued that socio-economic determinants could be seen as high level or distal influences. They operate through five proximate determinants (for child mortality).
    • Maternal factors
    • Environmental conditions
    • Nutrient deficiency
    • Injury
    • Personal illness control
  • These determined whether a child was healthy or sick. A sick child would either die or become even sicker leading to growth faltering and eventually death, or they could return to being healthy.
  • The model was designed for child mortality and in a context where it was high.
  • They also categorised the socio-economic determinants into three groups...
    • Individual level factors comprised of mothers and fathers education and skills, traditions, norms and attitudes.
    • Household level variables such as income or wealth.
    • Community level variables which included the ecological setting, political economy and health setting.
  • The model showed a hierarchical conceptualisation where the socio-economic influences have to work through one or more of the proximate determinants, showing how the two are integrated. The framework is still used today e.g. Acharya et al. (2020)
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The Dahlgren and Whitehead Model

  • Applicable to a wider range of circumstances and health outcomes. It has been widely used in wealthy countries for adult health (1991)
  • Does almost the same as the Mosley and Chen model by bringing layers of different influences which work at different levels.
  • A broader framework which discusses lifestyle factors and community networks, recognising the complexity of the different pathways and connections that a wider spectrum of health outcomes and circumstances might bring.
  • Hierarchical levels suggests the more distal effects have to work through the next layers to get to the health of the individual.
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Other models

  • Other models try to capture more linkages between factors, or provide more specificity in influences, factors or different levels.
  • E.g. A framework for the determinants of health by the Australian Institute of Health and Welfare. This model provides much more detail in many areas.
  • However, it is still unlikely to be exhaustive, the level of detail might be seen as misleading and the long lists might suggest that it contains everything and other things aren't relevant when they area. This diagram is also difficult to work your way through.
  • In the model by the Australian Institute of Health and Welfare and the Dahlgren and Whitehead Model, health services and healthcare play a small role.
  • In contrast to the Mosley and Chen framework, which was primarily research rather than policy orientated, these were designed as part of the policy agenda and therefore have been said to deliberately downplay medical and curative services primarily in order to try to shift the focus onto the social determinants of health and away from medical services.
  • They also tend to neglect the role than ethnicity/race plays.
  • However, the flexibility of the social determinants models mean that it is quite easy to slot it in and adapt the framework when needed.
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Ethnicity and social determinants

  • It would be misleading to suggest that ethnicity itself is the cause of ill-health.
  • Instead, there is a recognition that the social determinants of health are unequally distributed across ethnic groups, leading to unjust and preventable inequalities in health. Many of these can be seen as part of institutional racism.
  • This became clear in terms of COVID-19, where ethnic minorities tended to have worse access to healthcare, especially where there is no universal health service, worse housing and higher neighbourhood density, were unable to work at home due to type of jobs held, more likely to use public transport, faced stigma surrounding how races deal with health issues and cultural beliefs.
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Sex, gender and social determinants

  • Sex and gender tends to be placed together with age and genetics as something intrinsic to the individual, although...
    • Women live longer than men by 3-5 years on average
    • Biological factors account for 1-2 years in life expectancy at birth
    • Lifestyle factors which decrease male health and longevity include risk taking behaviour, health-seeking behavior, work related hazards (including stress) and smoking.
  • Biological influences include things such as hormonal influences on different sorts of cancers, or the fact that male infants tend to have less developed respiratory systems and are more vulnerable to birth trauma. It is also thought that women's spare copy of the X chromosome makes them less vulnerable to chromosomal damage across their life cycles.
  • It is much easier to see discrimination in genders when there is overt discrimination such as skewed gender ratios at birth, or infant mortality rates that are not favourable to female infants.
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Age and health

  • Health, mortality and the influences on them are strongly dependent on age. Therefore, you must take account of age when making comparisons between individuals or populations.
  • You can do this by using age standardised measures such as life expectancy or by only comparing people or populations in the same age group or of the same age structure.
  • The factors affecting health, whether they be biological, environmental, behavioural, medical or social, are all different at different ages.
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Models of change in health over time

1. Demographic transition model

  • Not useful to explain why change happened but useful to describe the move from high to low birth/death rates.
  • During the demographic transition, falls in death rates were particularly attributable to reductions in mortality from infectious diseases among children and young adults. This observation about changes in the nature of mortality led to a parallel theory called the Epidemiologic transition.

2. Epidemiologic transition model (Omran, 1971)

  • Three stages: Age of pestilence and famine, age of receding pandemics, age of degenerative and man-made (non communicable) diseases.
  • In 1996, Olshansky and Ault suggested a fourth stage in response to continued improved mortality among the elderly. This was the age of delayed degenerative diseases.
  • In 1998, Olshanksky et al. suggested a fifth stage - age of re-emerging infectious diseases. This was in response to the development of drugs, vaccinations and early (yet short lived) development of chemicals such as TDT, so there was a mid 20tth century optimism that mortality from infectious diseases could almost be eliminated.
  • Criticisms of this model surround the terminology used e.g. man-made.
  • However, it is a very useful description of the way that age as a cause of mortality and influences of death have changed over time.

Both models are quite narrow in focus on mortality, disease and the effects on them.

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Models of change in health over time (health trans

  • Incorporated a wider set of influences on how diseases and causes of death might change over time.
  • Frenk et al. (1991) created the first real statement of what a health transition model would look like. The diagram was accompanied with the identification of three major mechanisms of change...
    • Fertility decline and consequent population ageing
    • Changes in risk factors (bioloogical, environmental, occupational, social and behavioural)
    • Improvement in case fatality rates (therapeutic and preventive interventions)
  • This model is arguably much too complex.
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