Factors Influencing Health

Introduction

Identifying factors that affect health and wellness is a key component in guiding health promotion
activities and preventive behaviors. Understanding the effects of these factors affords the nurse an
opportunity to effectively initiate the steps of the nursing process to assess, plan, and implement
individualized care.

Upon completion of this lesson, you will be able to:

 Describe factors influencing health.

Overview of Biologic and Genetic Determinants of Health

Many factors influence health and illness, including biologic, genetic, environmental, educational, and
social factors. Factors influencing health are commonly referred to as determinants of health.

There are two major determinants of health:

 Biologic and genetic

 Social

Biologic and genetic determinants of health include:

 Age

 Biologic gender

 Genetics

Determinant of Health: Age

The chronologic age of an individual is a strong determinant of susceptibility to disease or disabling

conditions.

 The very young, especially neonates and infants born prematurely, are more susceptible to
infections because of the immaturity of their immune systems.

 Older adults have decreased immune system function as a result of the aging process. Older
patients are at risk for opportunistic infections caused by harmless organisms that become
pathogenic and illness from the spread of community-acquired disease. Complications from
decreased cognitive and physical function and comorbidities of chronic disease may also have
significant impact in the health of older adults.

Determinant of Health: Gender

A person's biologic gender (male or female) influences his or her health risks and health-promotion
behaviors.

Nurses are often the first health care providers to approach individuals about gender-specific health and
wellness issues. Preventive screenings for both genders take into account reproductive anatomy and
address gender-specific health risks.

Screenings Specific to Men

 Adolescent and young adult males should be educated about testicular self-examination
practices.

 Older males should have an annual examination.

 Although the risk for breast cancer in men is low compared with the risk for women, all men
past puberty should be taught and encouraged to perform breast self-examinations for cancer.
This is particularly important if there is a family history of malignancies.

Screenings Specific to Women

 All women past puberty should be taught and encouraged to perform breast self-examinations.
 Regular Papanicolaou (Pap) testing is recommended following current professional guidelines
such as those summarized by the Centers for Disease Control (CDC).
 Genital human papillomavirus (HPV) testing is recommended for all women who are sexually
active. Although there are no definitive tests for the 40 strains of HPV that cause infection in
humans, tests for HPV strains that cause cervical cancer are available and are performed at the
same time as the Pap test (CDC, 2012).
 Pregnancy and childbirth issues, such as gestational diabetes, gestational hypertension, or
rectoceles and cystoceles, should be evaluated by the nurse as potential alterations in health
status specific to child-bearing women that may need continued monitoring.

Determinant of Health: Genetics

Genetics encompasses the principles and mechanics of heredity, specifically the means by which traits
are passed from parents to offspring, and the causes of the similarities and differences between related
organisms. Genetic vulnerability, or risk of disease expression based on genotype, is a determinant of
health involuntarily passed from biologic parents to their offspring. Clinical genetics is a branch of
genetics that studies inherited disorders and investigates the possible factors that may influence the
occurrence of pathologic conditions.

Examples of diseases with known genetic components include:

 Sickle cell anemia

 Cystic fibrosis

 Down syndrome (Trisomy 21)

 Diabetes
  Cardiovascular disease

 Cancer

 Mental illness

 Renal disease

Controlling risk factors that place stress on physiologic function can reduce disease expression in
individuals with high genetic vulnerability for a condition. For example, a person with a family history of
hyperlipidemia and atherosclerosis is at risk for developing cardiovascular disease later in life. Lifestyle-
modifying factors, such as weight reduction, daily exercise, and balanced nutritional intake, can help
reduce the likelihood that the genetic risk factor for heart disease will be expressed.

Overview of Social Determinants of Health

Social determinants of health are defined as the conditions in the environments in which people live,
learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks (Healthy People 2020). Social determinants of health influence individual behaviors
and risk factors affecting health.

There are five key areas of social determinants of health as outlined by Health People 2020:

 Economic stability

 Education

 Social and community context

 Health and health care

 Neighborhood and built environment

Each of these five areas reflects a number of key issues that make up the underlying factors in health
determinants.

Economic Stability

 Poverty

 Employment

 Food security

 Housing stability

Education

 High school graduation

 Enrollment in higher education
 Language and literacy
 Early childhood education and development
Neighborhood and Built Environment

 Access to healthy foods

 Quality of housing
 Crime and violence
 Environmental conditions

Health and Health Care

 Access to health care

 Access to primary care
 Health literacy

Social and Community Context

 Social cohesion
 Civic participation
 Discrimination
 Incarceration

Economic Stability

Economic stability is a leading health indicator. Poverty, employment, food security, and housing
stability all can have significant impacts on an individual's health.

Poverty

"The biggest enemy of health in the developing world is poverty." - Kofi Annan

 Poverty creates health risks because it forces individuals to live in potentially unsafe
environments, often without decent shelter, clean water, or adequate sanitation.

 Approximately 1.2 billion people in the world live in extreme poverty (less than one dollar per
day) (WHO, 2016).

 Individuals or families living in poverty may be reluctant to seek preventive care or screening
examinations, not only because of the cost of care, but because of the apprehension of having a
disease that requires ongoing care and expense. The financial impact of health care for a chronic
condition can be devastating to families or individuals who have a limited or fixed income.

Employment

 Steady employment can provide the income, benefits, and stability necessary for good health.
 Employers can institute a variety of strategies to keep employees healthy while also protecting
the company's financial health. They may include:
o Workplace wellness programs
o Job safety training
o Education initiatives
Food Security

 Food security contributes to health by supplying adequate nutrients to prevent illness and
promote optimal health.
 Food security includes:
o Adequate household food security, with access to affordable and nutritious food
o Sufficient national and regional food supplies to feed a population
o Safe transport and storage of food products to reduce the risk of food-borne illness
(WHO, 2016)

Housing Stability

 Stable housing is well understood to be an important determinant of physical and mental

health.
 Stable and affordable housing supports mental health by limiting stressors related to financial
burden or frequent moves, or by offering an escape from an abusive home environment
(Maqbool, Viveiros, and Ault, 2015).

Education

Higher education levels are associated with:

 Longer life expectancy

 Improved health and quality of life

 Health-promoting behavior, such as regular physical activity, not smoking, and going for routine
checkups and recommended screenings.

Lower education levels are linked with poor health, more stress, and lower self-confidence (WHO, 2016).

Certain standards for education are recognized to positively influence health, including high school
graduation, enrollment in higher education, language and literacy skills, and early childhood education
and development.

High School Graduation

 Statistics show that individuals who do not graduate from high school will most likely earn
substantially less than their graduating classmates, potentially reducing their access to health
care, nutritious food, and better working and living environments.

 High school graduation, specifically graduation of students with a regular diploma 4 years after
starting 9th grade, is a leading health indicator of Healthy People 2020. Leading health indicators
are high-priority health issues identified by the U.S. Department of Health and Human Services.

Enrollment in Higher Education

Individuals with higher levels of education show lower rates of chronic diseases compared to those with
less education (CDC, 2012).
Significant findings include:

 In households where the head of household had a bachelor's degree or higher, obesity rates
among boys and girls were lower.
 In 2010, 31 percent of adults 25-64 years of age with a high school diploma or less education
were current smokers, compared with 24 percent of adults with some college and 9 percent of
adults with a bachelor's degree or higher.
 On average in 2006, 25-year-old men without a high school diploma had a life expectancy 9.3
years less than those with a bachelor's degree or higher. Women without a high school diploma
had a life expectancy 8.6 years less than those with a bachelor's degree or higher.

Language and Literacy

 Low functional language and literacy skills limit the ability of individuals to read and
comprehend health education and illness prevention materials, resulting in worse health
outcomes.

Early Childhood Education and Development

 Early childhood education and development is increasingly recognized as an important

determinant of health.
 Positive home and learning environments in early childhood affect child development and shape
cognitive, social, emotional, language, and physical development.
 Early and middle childhood experiences provide the physical, cognitive, and social-emotional
foundation for lifelong health, learning, and well-being.

Social and Community Context

Social and Community Context are critical determinants of health for both communities and individual
members of communities. Social and community context includes issues such as social cohesion, civic
participation, discrimination, and incarceration.

Social Cohesion

 A cohesive society is defined by the United Nations as a society in which individuals are
protected against life risks, trust their neighbors and the institutions of the state, and can work
towards a better future (United Nations, 2012).

 Numerous epidemiological studies have shown that people who are socially integrated live
longer.

 Socially isolated people die at two to three times the rate of well-connected people (Kawachi
and Kennedy, 1997).

Civic Participation

 Civic engagement creates healthier communities by utilizing the political process to influence
health policy and public health outcomes.
  A higher level of civic engagement through ties to community groups has been associated with
better recall of health messages, suggesting that community group membership can provide a
critical pathway for social capital to influence health promotion and public health outcomes
(Viswanath, Steele, and Finnegan, 2006).

Discrimination

 Discrimination is exclusion or differential treatment of an individual based on a personal

characteristic.
 Discrimination historically has been directed toward minority groups of a particular race or
ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or physical
or cognitive disability.
 Discrimination results in social or economic disadvantage and greater obstacles to health,
creating health disparities.

Incarceration

 Incarceration threatens physical and mental health directly via exposure to violence, infectious
disease, and stress, and indirectly via the deprivations inherent with incarceration.
 A history of incarceration increases an individual's likelihood of severe health limitations
(Schnittker and John, 2007).
 The stigma associated with incarceration is recognized as a contributing factor to health
disparities among former inmates.
 An understanding of the impact of incarceration on an individual's capacity to function in free
society is essential for health care providers working with this population (Marlow and Chesla,
2009).

Health and Health Care

Effective health care depends on individuals being able to access and utilize health resources. The topic
of health and health care as a social determinant of health includes the key issues of access to health
care, access to primary care, and health literacy.

Access to Health Care

Access to quality health care is important for the achievement of health equity and for improving health
for everyone.

Access to health care requires:

 Gaining entry into the health care system

 Accessing a health care location where needed services are provided

 Finding a health care provider with whom the patient can communicate and trust

Access to health care impacts:

 Physical, social, and mental health status

  Illness, disease, and disability prevention

 Quality of life

 Preventable death

 Life expectancy

Barriers to health care services include:

 Lack of availability

 High cost

 Lack of insurance coverage (Healthy People 2020)

Access to Primary Care

Individuals with a primary care provider as their regular source of care have better health outcomes,
fewer health disparities, and lower health care costs.

Having a primary care provider is associated with:

 Greater patient trust in the provider

 Good patient-provider communication
 Increased likelihood that patients will receive appropriate care (Healthy People 2020)

Health Literacy

Health literacy, as defined by The Patient Protection and Affordable Care Act of 2010, is the degree to
which an individual has the capacity to obtain, communicate, process, and understand basic health
information and services to make appropriate health decisions (CDC, 2015).

Low health literacy is associated with poorer health outcomes and poorer use of health care services
(Berkman, Sheridan, Donahue, et al, 2011).

The National Action Plan to Improve Health Literacy seeks to engage organizations, professionals,
policymakers, communities, individuals, and families in an effort to improve health literacy, and is based
on two core principles:

 All people have the right to health information that helps them make informed decisions.
 Health services should be delivered in ways that are easy to understand and that improve
health, longevity, and quality of life (U.S. DHHS, 2010).

Neighborhood and Built Environment

Neighborhood and built environments determine an individual's food access and exposure to a number
of environmental health risks. Neighborhood and built environment issues include access to healthy
foods, quality of housing, crime and violence, and environmental conditions.

Access to Healthy Foods

  Lack of access to healthy foods is one reason why many people do not receive recommended
daily levels of fruits, vegetables and whole grains.

 More than 23 million Americans, including 6.5 million children, live in low-income urban and
rural neighborhoods that are more than a mile from a supermarket. These communities are
known as "food deserts" since they lack access to affordable, nutritious food.

 A USDA report showed that in 2008, an estimated 49 million people, including 17 million
children, lived in households that experienced hunger multiple times throughout the year (Let's
Move! 2016).

Quality of Housing

 High quality housing limits exposure to environmental toxins or other unsafe living conditions,
and provides individuals with privacy and security.
 Poor quality and inadequate housing contributes to health problems such as infectious and
chronic diseases, injuries, and poor childhood development.

Crime and Violence

 Exposure to crime and violence is associated with stress and negative physical and mental
health outcomes.
 Children are more likely than adults to be exposed to crime and violence (Finkelhor, Turner,
Ormrod, et al, 2009).
 Adolescents who are exposed to violence during childhood are at increased risk for developing
posttraumatic stress symptoms and negative effects on school functioning (McGill, Self-Brown,
Lai, et al, 2014).

Environmental Conditions

 Indoor environments may harbor chemicals (e.g., radon, carbon monoxide, cleaning agents),
tobacco smoke, mold, household pets (e.g., dust mites, cockroaches, spiders), and unsanitary
living conditions. Exposure to such irritants in enclosed spaces increases the likelihood of
respiratory illness and skin disorders.
 Outdoor environments affect individual health in the areas of sanitation and waste disposal,
water quality, air quality, and safety. Children and adults living in areas with outdoor safety
issues related to gang activity, sexual predators, or heavy traffic are less likely to engage in
outdoor activities. Limited access to safe outdoor recreation space increases the likelihood of
sedentary behaviors, excessive calorie intake, and obesity.

Summary

Many factors influence health and illness, including: genetic and biologic determinants, such as age,
gender, and genetics; and social determinants, such as economic stability, education, social and
community context, health and health care, and neighborhood and built environment. Awareness of
major health factors allows nurses to tailor public health campaigns to populations with health
disparities or specific risk factors, and to create customized, patient-centered health promotion care
plans for individuals.