lOMoARcPSD|32653457

Social- Determinants-OF- Health- Notes

Social Determinants Of Health (La Trobe University)

Scan to open on Studocu

Studocu is not sponsored or endorsed by any college or university

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)
 lOMoARcPSD|32653457

SOCIAL DETERMINANTS OF HEALTH, SEMESTER 2, 2014

WEEK 1: Social Determinants of Health
Social determinants of health approach

- Involves looking beyond the common sense answers to look for answers in the social sphere of culture and
society
o Looks for links between personal issues and culture/society

Determinants of health

Determinants of health are characteristics that bring about a change in health or illness and include:

- Biological and genetic factors

- Health behaviours
- SES and socio-cultural factors e.g. gender, income and education
- Environmental factors e.g. geography, climate, exposure to toxins
- Access to healthcare services

Social determinants of health

The conditions under which people work live and play and impact on health e.g. economy, social support,
environment, education, food availability etc.

Came about because differences are experienced in health outcomes amongst different groups within society, and
people wanted to know why.

The social determinants of health an individual is exposed to often determines whether behaviour change attempts
will work for different groups – different SDH exposure may mean they need different approaches

*health is affected by our background and experiences*

Differential SDH exposure impacts on health example; Pacific islands

The Pacific Islands has some of the highest rates of non-communicable diseases in the world including CVD, cancer,
chronic respiratory disease and diabetes as well as a reduced life expectancy. WHY?!

- Socioeconomic, cultural, political and environmental determinants i.e. SDH have been at play
o Globalization: caused traditional diet to be replaced with unhealthy imported foods
o Urbanization: forcing people out of rural areas to urban areas where they can’t grow their food or use
the environment like they used to
o Ageing population

GLOBALISATION AND URBANISATION;

- Traditional diet replaced with high fat, processed foods due to increased import of such foods and their
relative cheapness causing a decline in local food production, poverty and unemployment
- Reduced access to farming land means they can’t grow their own food, meaning they also have to travel
further for jobs
- Fishing has become a commercial business, meaning a lot of the produce doesn’t go to the community
- Climate change has made it harder to utilise the land etc.

~ EVAN WILLIS: the sociological quest, an introduction to the study of social life~

- Sociological problem is something that demands an explanation VS social problem is a societal problem that
needs fixing
- Can occur at micro (small social groups), meso (community), or macro (whole societies) level
- Sociological imagination: elucidates links between personal troubles and public issues

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

- Reflexivity: being reflexive involves considering your place in the social world
- Continuity and change: why do some things in society stay the same and others change? E.g. social norms

SOCIOLOGICAL IMAGINATION

- Historical: have past events influenced this? What’s the history of the issue? Key historical events?
- Cultural: how has tradition, culture and belief systems influenced the issue? Has cultural change occurred?
What are the cultural beliefs around the issue?
- Structural: what are the structures of society surrounding issue? What’s the role of the governing bodies?
- Critical: why are things the way they are? How could they be different? Who benefits from the status quo?
What alternatives are possible?

Week 2: Health as a social construct

Health and illness are socially distributed

- Some diseases are socially produced due to work, risk of injury, environment, social norms etc.
o As a result some groups have higher morbidity/mortality rates that are beyond the individual’s control
 E.g. cholera – completely avoidable yet due to lack of sanitation experienced in India, Africa etc.
 E.g. under 5 mortality rate – much higher in countries with poor healthcare like Africa
- The health experience is socially constructed, forming our understandings of health and illness
o Is a reflection of our culture, politics and morality in a particular society at a particular time

Social organisation of healthcare

- How a society organises, manages and uses health services

o Includes medical profession’s influence on system – who influences scarce resource allocation?

Models of health

- BIOMEDICAL: illness is a malfunction of body systems, focuses on diagnosis and treatment. Prominent in
Australia
- BIOPSYCHOSOCIAL: blends psychology, biology and social factors. Focuses on reducing risk factors
- SOCIAL: health is influenced by social structures, modification of which alters health – focuses on prevention
- SOCIAL ECOLOGICAL: how micro, meso, exo and macro systems interact to influence health

Agency versus structure

- Extent to which human behaviour is determined by social structure

o STRUCTURE: how social structures like institutions and groups constrain an individual’s choices
o AGENCY: how much control an individual has to change the world – ability of people to influence their
own lives and the society they live in

~BLAXTER: How is health embodied and experienced~

- Many illnesses have social causes

- Embodiment is the physical and mental experience of living
- Health relates to the physical, mental and social existence
- Blaxter found 5 main health categories:
o Health means to be free of illness – this view is held by better educated higher SES
o Health refers to physical fitness and vitality – held by younger people, particularly males
o Health refers to social relationships – more commonly held by women
o Health is the ability to function – held by older people with an importance on self sufficiency
o Health refers to psychosocial wellbeing – people with non-manual jobs, higher education, middle aged
women
- Self-rated health is usually pretty accurate
- Blaxter identified 8 categories that illness/disease could fit into:

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

o Infections and environmental agents o Constraints of poverty and neglect

o Heredity/familial tendencies o Inherent individual susceptibility
o Secondary to other o Voluntary behaviours
diseases/trauma/surgery o Natural degeneration
o Stress and psychological
- It’s easier to talk about illness rather than health
- Health and illness aren’t merely opposites
- Health is holistic and context dependant
- Health is associated with being a good person, youth and strength whilst illness is associated with weakness,
sin and redemption

Week 3: Health and the media

What is the media and why study it?

- Means of communication including television, magazines, newspapers, radio etc. ; all reach a large audience
o Print media: magazines, billboards, newspapers, brochures
o Electronic/social media websites: radio, TV, PowerPoint, film, twitter, Facebook, YouTube, blogs
- The media is often the primary information source regarding health shaping our behaviours, body image etc.
and has the ability to spread things quickly on a global scale

Agenda setting theory

- Developed by McCombs and Shaw, suggests issues thought to be important are brought to your attention
via the media
o Therefore, the media tells us what’s deemed important, and tells us what to think about

Framing

- Developed by McCombs: the presentation of an issue in a certain light to elicit a specific response
o Issues arise when certain elements are left out of stories to frame them in a certain way, often
meaning we miss vital information
o Frames are reflected in the language used and the connotations it carries
o Reinforces social norms and values
 EPISODIC FRAMING: framing it around the individual’s situation and the individual’s responsibility
 THEMATIC FRAMING: framing it around the environment and society

Media concentration

- The bulk of the media is owned by 3 major companies, meaning they control what is brought to our
attention
- Social media is assisting to negate this, with information being presented from more sources
- What we receive is often however highly filtered and only half the story, so we need to actively question it
and be sure to do our own research
o E.g. stories focusing on the negative aspects of indigenous health are far more often reported on than
those focusing on advancements, perpetuating negative stereotypes

~ LANCASTER ET. AL.: Illicit drugs and the media ~

- Illicit drugs feature in thousands of media stories through the year across all different mediums
- Clearly priority for the news outlets to report on – sells papers, draws attention etc.
- The media has significant influence over our thoughts and behaviours
- AGENDA SETTING: defines salient issues, captures attention and shapes public opinion
o Only a limited number of issues can remain newsworthy though, so things excluded escape public
interest
o Public concern is generally directly proportional to the amount of media attention an issue receives

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

- FRAMING: how to think about an issue

o Influences decision making and opinion formation
o Influences type of public debate that results
- INFLUENCING ATTITUDE: influences perception of risk and public behaviour
o Understanding and perception of risk is culturally built, thus the media heavily influences this
- INFLUENCING POLITICS: influences the public profile of problems and the political response elicited
o Media more strongly pushing issue = more interest from policy makers and politicians

~HOGUE, DORAN & HENRY: media and health info seeking behaviour~

- Information from the media about health issues isn’t always correct
- ‘ask your doctor’ campaigns are often really ploys by manufacturers to promote their product
o Hearing a specific brand name in the media made patients more likely to request it
- Misinformed consumers make it harder for doctors to treat due to heightened concerns and thinking they
know better
- The media is in the top 4 places people go for medical information , the internet is a very common media
outlet for this

Week 4: Language and culture in health

Culture and language

- Systems of shared meanings, representations and practices that make up our social life
o Affects how and what we absorb from our surroundings and experiences
o Subcultures are different groups within a bigger culture
o NOT EVERYONE IS THE SAME IN THE SAME CULTURE – beware of stereotyping
- Culture and language are inextricably linked
o People who speak linguistically similar languages tend to have similar cultures and values
o Language structures impact on perception and event categorisation
o Differences in language affect the way different people think
o If something is not prevalent in a culture, they often don’t have the lexicon for it
 E.g. exercise is a western thing – in many cultures there aren’t any words for it
- E.g. of cultural impact on health: Indigenous Australian’s see health as emotional and cultural wellbeing
- Not speaking the same language can also hinder health care and treatment access
o People with poor language abilities also more frequently report poor health and is also tied to low SES
 Interpreters can help, but this doesn’t increase the patient’s knowledge and interpreters may also
apply their own biases when interpreting
 Also increases the difficulty of obtaining a job – immigrants often end up working hazardous jobs
because they don’t need to constantly talk to people, however this also means they can’t
communicate risks
 Those that were resultantly injured were less likely to know of work insurance etc.

Cultural competency

- Behaviours, attitudes and policies that allow organisations, systems and individuals to work effectively in
cross cultural situations
o Everyone has the right to the healthcare they need, so healthcare professionals need to be more aware
of the diverse cultures to ensure they can provide them with the care they need

-Guide to cultural competency-

1) Engage consumers and communities in sustaining reciprocal relationships

2) Leadership and accountability for sustained change
3) Building on strengths – know the community and thus what works
4) Shared responsibility- create partnerships and sustainability

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

Cultural respect in Aboriginal health services

- Educate health care staff on their culture, employ aboriginal health care workers, improve access
- Eliminate jargon and racist language and actions
- Tailor programs to suit their needs – health care ISN’T one size fits all

Attitudes to immigrants

- Largely negative due to media perceiving them as threats to our way of life, as threats to our values
o Many people opposed to asylum seekers etc. are those who have low SES – they feel the asylum
seekers are getting what they deserve, that the government is failing them and thus take it out on the
asylum seekers

~ PAVLISH & NOOR ET. AL.: Somali women in the American healthcare system~

- Significant health disparities between immigrants and locals

o Declining immigrant health due to poverty, stress, environmental risk factors, lifestyle change and poor
healthcare access
- Somali and western medicinal practices are very different – Somali women see health as holistic and with a
strong impact from spirituality : misunderstandings between doctors and patients arose
o Somali medicine want immediate treatment and results, western medicine takes time
o Avoidance of doctor as they associate them with getting sick, also costs money
o Don’t like how impersonal the health care system is
o Sex is taboo in their culture thus talking about reproductive health is embarrassing – can’t protect
themselves
o Sadness (aka depression, anxiety etc.) caused by having to move, but won’t talk about it as it’s not the
done thing in their culture
o Don’t understand the point of screening for diseases and can’t grasp the concept of chronic diseases

Week 5: the nature of HIV/AIDS, a global pandemic (social determinants on a global scale)
Health around the world

- Over time healthcare has improved, improving health worldwide

o However disparities exist between rich and poor, urban and rural, high SES and low SES etc.
- Poverty, unsafe living and working conditions, racial discrimination and gender discrimination are all risk
factors for poor health

Structural determinants

- Political, educational, health etc. system factors

o ‘macro level factors’ : apply at the higher level, but influence micro factors too
- Health system factors
o Ineffective systems, shortage of staff, research and development focusing on trivial things like baldness
etc., underinvestment on health care infrastructure, inefficient use of funding
 All these factors more severely impact developing countries
- Global economic and political factors
o Unequal power, money and resource distribution, globalisation, third world debt, spending restrictions
placed on governments, transnational corporations aren’t interested in helping

Global burden of disease

- Seeing a re-emergence of old infectious diseases as well as new infectious diseases occurring in addition to
the burden of non-communicable diseases
o All disproportionately experienced by poor countries in comparison to wealthy countries e.g. HIV/AIDS,
TB, malaria

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

-HIV/AIDS-

- Caused by a virus
- There are more people living with HIV now as treatment prolongs life, but infection incidence is decreasing
as are AIDS related deaths
- Sub-Saharan Africa is the most severely affected by HIV/AIDS
o Women and young people are becoming increasingly affected
o Children who’ve lost parents to HIV/AIDS are subjected to neglect, discrimination adverse SDH

-TB-

- Spread by coughing, decreasingly experienced as living improvements occurred, hard to treat

- Common amongst people with HIV
o Drug resistance, inefficient controls and treatments, HIV/AIDS spreading and SDH: like poverty, poor
nutrition and poor living conditions all pose problems

-Malaria-

- Caused by plasmodium, uses mosquito as vector

- Susceptible population is increasing due to deteriorating health systems, drug resistance, climate change and
civil unrest resulting in people migrating

Healthcare system factors

- Access to medications, vaccines and treatments

o Not enough money is allocated to diseases affecting 90% of the population as it won’t make the drug
companies money
- Workforce shortages
o Moving from rural to urban and poor to rich countries as people can’t get work
o Not enough health care workers willing to stay in poorer countries where they’re needed

Non-communicable diseases (NCDs)

- Largest cause of diseases

o Largely preventable and due to lifestyle factors e.g. smoking, unhealthy diet, binge drinking and
alcoholism, insufficient PA
o Increasing in prevalence more rapidly in low and middle income countries due to
 little political emphasis
 minimal engagement in sectors other than the healthcare sector
 lack of resources
 globalisation (growing economy through movement of goods/services/technology) and trade
liberalisation (removing barriers to trade)– traditional diet is replaced with high fat/sugar diet
- transnational corporations
o increasingly market to poorer countries,
o pharmaceutical countries won’t invest in treatments to diseases affecting poor countries because they
won’t make much money from them
o provide false information tricking people into using their products
- NCDs and poverty are linked – NCD means they can’t work, so they lose money, therefore can’t access
healthcare and so the cycle continues

Fixing the problem

- Lots of sectors working together to strengthen health systems, provide sustainable development and
address unequal power distribution

~DE COCK, JAFFE & CURRAN: the evolving epidemiology of HIV/AIDS~

- AIDS first appeared in 1981

o 3 years later they identified birth, blood contact and sex could transmit it

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

o 1985 – they developed a test for it

- Began in American, then cases in Haiti popped up and then the epidemic began to spread
- HIV thought to have been contracted from chimpanzees in 20th century
- Blood transfusions, prolonged breast feeding, multiple sexual partners and being uncircumcised all increase
the risk of HIV infection
- Sub-Saharan Africa is the most severely affected population
o Reduced breastfeeding, prophylaxis treatment and ART treatment helps, but MSM transmission is still
high

Week 6: the life course of HIV/AIDS and global variances

Life course approach

- The life course refers to the course of our lives from birth to death
- Life course approach sees life as a winding path
o Events from earlier in life affect later life
o Cultural and social structures impact severity of situation – do they have support?
- Core concepts include
o Cohorts: groups of people subjected to the same experiences (helps to understand distribution and
reactions to health)
o Life transitions: moving from one life stage to another, often marked by key events
o Trajectories: the path towards particular life destinations
o Life events: sudden or unexpected changes
o Turning points: particular points in time that change trajectories

Elder’s four themes

- Focuses on social and biological interaction

- LIVES AND HISTORICAL TIMES
o Historical events can affect our life course – may change trajectory, cause a life even to occur
o May have intergenerational effect
o May be refined to a cohort
o Individual agency determines the impact of events on the life course
o Major life events that changed the trajectory for many people in that specific cohort e.g. black Saturday
- TIMING OF LIVES
o The impact of events depends on the life stage e.g. pregnancy during adolescence vs adulthood
- LINKED LIVES
o Interdependence and embeddedness in social relationships across the life course
 These social relationships influence the effects on the life course
- HUMAN AGENCY
o People’s own plans and decisions on their life course; the exercise of free will
o Interacts with social structures in influencing life course

Effects on the life course

- LATENT EFFECTS: effects that present after exposure to risk factor e.g. biological exposure to heavy metals
- PATHWAY EFFECTS: affects pathway/trajectory which later results in health issues
- CUMULATIVE EFFECTS: combination of latent and pathway effects to either improve or hinder health

Social gradient and Blane’s 3 processes

- Health is better in high SES/social standing people and worsens and SES/social standing does
- BLANE’S 3 PROCESSES – accumulation of social disadvantage can occur by:
o Social accumulation: social class of parents and throughout your childhood affects yours in later life
 Chain of disadvantage: disadvantage just keeps adding

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

o Social mobility: movement to/from a higher or lower social position

 when people move up SES scale, they will never be more advantaged than those who were
already at that level and vice versa
o social protection: previous SES moderates effect of new disadvantage on health
 E.g. high SES person who develops chronic illness is less likely to lose their job than someone of
low SES in their position

Policy implications

- We need to intervene at earlier life stages

o Will prevent the cumulative and latent affects later in life
o Will break the chain of disadvantage over generations and the life course

~ POUNDSTONE, STRATHDEE & CELENTRANO: social epidemiology of HIV/AIDS~

- Social epidemiology is the study of the distribution of health outcomes and their social determinants
o Individual level: biological, demographic and behavioural risk factors
o Social level: community and network structures linking people with society - helps understand
distribution of HIV/AIDS
o Structural level: social economic factors, law, politics – helps understand transmission and distribution
of HIV/AIDS
- 4 social level factors were found to be important to HIV/AIDS epidemiology
o Cultural context - IDUs
o Social network- social influence, engagement in certain behaviours, prevalence of disease in
community, access to information, social support
o Neighbourhood effects – likelihood of coming into contact with disease, SES, employment, drug use
o Social capital – aspects of social structures that facilitate collective action e.g. health promoting
behaviours, access to services, trust within community, political participation
- Structural level factors affecting HIV/AIDS
1. Structural violence and discrimination – based on race, ethnicity, gender, sexual orientation, HIV
status
a. Leads to avoiding testing, stigma etc.
2. Legal structures - laws underline key social determinants of HIV/AIDS
a. i.e. housing, poverty, income equality, racism, community social organisation
3. Demographic change – affects HIV/AIDS patterns through population mobility, urbanisation, age and
gender structures
a. Increased mobility and high male to female ratio increases transmission rate in community
4. Policy environment – guides resource distribution and health care policies which can reduce rates
5. War and militarisation – greater risk taking behaviours, disruption to social networks, little medical
care, increased poverty – all causes increased HIV rates

Week 7: Stigma, discrimination and health

Stigma

- Meaning mark – a mark of disdain or disgrace on one’s reputation, usually for life
o Stigmas is a relationship between and attribute and a stereotype
o Stigmatised individuals have a devalued social identity e.g. HIV/AIDS sufferers, emos, bikies etc.

Process of stigmatisation

1. Find a difference
2. Link the person with a difference to a negative stereotype
3. Create a separation – us vs them
4. Labelled person experiences status loss and discrimination

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

5. Social, economic and political power is used to identify the above and cause rejection and exclusion

Why do we stigmatise?

- All diseases including HIV/AIDS carry a negative social value

o Allows for a pecking order to be established ( we want to know who we’re above or below)
- Stigmatisation occurs for a number of reasons:
a) COPING MECHANISM- makes people feel more secure to belittle others
b) IGNORANCE – people don’t have the knowledge about a condition and therefore belittle it
c) EVOLUTIONARY PSYCHOLOGY – natural selection: we avoid what lessens our chance of survival
d) ASSOCIATIONS – as with HIV/AIDS it’s associated with ‘immoral’ behaviour e.g. homosexuality,
promiscuity, drug users etc.

Who do we stigmatise?

- Those more likely to be stigmatised include individuals and population who

o Have a low SES
o Are already marginalised
o Have certain health conditions e.g. mental illness, HIV/AIDS
- Examples of stigmatised groups include
o Cancer sufferers
o Mental illness patients
o Urinary incontinence sufferers
o Exotic dancers
o Leprosy sufferers

Effects of stigmatisation

- INDIVIDUAL
o Depression, withdrawal, non-compliance with treatment, low self-esteem, self-stigmatisation (take on
stigmatisation and start believing it), feel responsible for their illness, denial
- PUBLIC HEALTH
o Concealment of conditions, avoidance of testing, non-adherence to treatment (don’t want to be seen
taking the medicine for it), fear of repercussions
- HIV/AIDS specifically
o Poor treatment: denied opportunities, exclusion
 Results in: poor healthcare treatment, erosion of human rights, psychological trauma, shunning

Discrimination

- The making of a difference in particular cases – acting on stigmatisation

Fighting stigma

- Education, careful word choices and challenging stereotypes are our biggest defences!
o Share your story, let others know they aren’t alone and support the stigmatised
- Anti-discrimination laws in Australia help to minimised stigma and discrimination, but they are often
overruled and don’t promote equality
o Gender identification, religion, social status and sexual orientation aren’t protected under anti-
discrimination laws
- As healthcare professionals:
o Respect, advocate, maintain confidentiality, avoid derogatory language, don’t judge, don’t threaten, be
responsive to individual needs

~ANDERSON ET. AL.: HIV/AIDS related stigma and discrimination~

- Stigma often comes from fear of contamination, homophobia, ignorance and religious beliefs
o Religion can have a two part effect though – either condemn HIV/AIDS sufferers or help them cope

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

- HASD has an emotional, intellectual, financial and social effect

- Sufferers fear ostracism, violence, blame, malicious disclosure, being referred to as lepers
o Due to such vilification depression, alcoholism, suicidal intentions and internalisation of stigma occurs
- Discrimination by the family sometimes occurs, discrimination in healthcare is more common
- In order to limit stigma placed on them, sufferers often limit disclosure, lie and either avoid relationships or
don’t tell their partners

Week 8: Economic effects of HIV/AIDS

Economics, health and disease

- The scarcity of resources means we need to make choices on how we use them
o Forces prioritisation to occur
- Economics takes place in both the macro and micro levels of society
o can be at the individual and community/environment/cultural level
- social determinants are those in which we live, eat, work, play and make a life
o e.g. healthcare access, safe home, ethnicity, addiction, education, gender, access to food, social
exclusion

Making connections

- the following factors are all interlinked (thus have a domino effect) and impact on health
o being an immigrant
o limited access to healthcare , good food and transport
o low SES and/or poor job security and conditions
- E.g. of interlinking- getting sick = getting poor?
o Dependant on illness type; chronic illness will have a greater effect
o Having a sick family member can push families across the poverty line and it becomes a struggle of
daily living vs medical needs
o Medically indigent - people who become poor due to medical bills. Access to any medical care even
with health insurance requires co-payments
o Catastrophic payments: healthcare costs above 10% of the household’s total consumption
o Double disadvantage: e.g. birth of Indian girl disadvantages her as she will be treated poorly, but also
disadvantages the family as they must pay $$$ for dowry

Income and health

- Low income creates greater risk of premature illness and death and poorer health outcomes
o Comes as a result of:
 Reduced access to other health determinants like clean water, food, shelter, transport etc.
 Greater exposure to health risks e.g. water and air pollution, auto injuries, greater pop. Density
 Increased stress and loss of control
 Greater marginalisation, less sense of social cohesion
 Can’t afford medical costs, therefore forgo medical treatment
 Emotional and social cost is too much to bear
 Need to pay for what you can no longer do and loss of job– e.g. child care, cleaning, cooking etc.

Burden to caregivers

- Caregivers are often family members who must give up employment to care for their sick loved one
o Aren’t able to maintain paid job, so their income is lost
o Emotional strain and social exclusion due to enormity of time spent caring for them
o Minimal support is provided for carer

The cost of illness

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

- Even going to the hospital is expensive – food, parking, childcare for other kids, loss of income for time spent
in hospital, medication costs
o WHO PAYS? Family/individual, a portion from taxes, health insurance and charities
 Unfortunately the government can’t cover it all as there are so many illnesses and treatments that
require funding
 PBS – government subsidises the cost of certain medications so only a minimal co-payment is
required from the individual
 Not all medications are listed though, particularly the more expensive ones
 Medicare co-payment is now in place – no GP visits for free anymore, PBS co-payment has also
increased

Economic impact of disease

- Diseases preventing people from working lead to a decrease in national economic growth
o Traps families and individuals in a downward spiral of poverty, marginalising them and limiting
healthcare access
 Results in missing school and work leading to no education -> decreased job prospects -> decrease
in future SES
o Human resources are thus more widely needed, so these become scarce
 Pricing of resources therefore increase, making them even more unreachable for the poor
- War is prevalent in 3rd world countries, further perpetuating these conditions and inducing death, emotional
and physical scarring and a loss of housing and resources

Health expenditure and its determinants

- the world and national economy dictates health expenditure

- health vs other needs must also be weighed up – there are so many other things that also need to be
addressed
- Australia: the ageing population means a lot of health care is utilised by them, but they only represent a
small amount of the population
- Policies are vital in terms of funding allocation, input to health care systems , prices , health outcomes
- If social determinants are addressed in Australia, much less money would be spent, as illnesses would be
avoided and funding could thus be directed elsewhere

Specific examples

- RURAL AREAS- experience higher burden of illness, poverty and a higher cost of healthcare
o need access to better info, allied health services, bulk billing , closer facilities
- SUB-SAHARAN AFRICA – has grown poorer with people living on under $1 a day
o No one wants to invest as it’s too risky
- INDIA – increased population has increased the pressure on health care and the spread of disease
o Has become all about money: if you can’t afford the treatment, you can’t have it

~BONNEL: HIV/AIDS: does it increase or decrease growth in Africa~

- HIV/AIDS has reduced Africa’s growth per capita income by .7 percentage points per year
o Malaria further reduces it by .3 per year
- Poverty, inequality, gender inequality, labour mobility and ethnic functionalization facilitate HIV spread
- HIV has eroded main determinants of economic growth like social capital, domestic savings and human
capital
o HIV is thus also an economic disease, impairing economic and social development
- HIV/AIDS epidemic also increases poverty
- A VICIOUS CYCLE

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

Week 9: HIV/AIDS and the living environment

Models of health

- SOCIAL MODEL: social structures influence health by promoting or inhibiting it – focuses on prevention
- SOCIAL ECOLOGICAL MODEL: micro, meso, exo and macro systems – focuses on relationship between
individuals and their environment

Social and environmental correlations with ill health

- Some groups have higher mortality and morbidity than others due to social factors e.g. workplace exposures
o These conditions are beyond the control of the individual
- Poor people live in the worst environments that have health-damaging effects
o They have less resources, protection, are vulnerable to climate change and are attractive to
multinational companies

Health and the living environment

- The living environment impacts on vulnerability and exposure to diseases

o Disease and illness also impacts the environment we’re exposed to
- Universal declaration of human rights: states everyone has the right to a standard of living that facilitates
health i.e. food, HOUSING and security
- Ottawa charter: points out importance of a stable ecosystem, shelter and sustainable resources
o also talking of creating supportive environments -> we have a responsibility to take care of each other

Climate change and health’

- has effects on health at 3 different levels

o PRIMARY: direct relationship between weather and health e.g. heat waves causing illness
o SECONDARY: changes to the ecosystem leading to health issues e.g. mosquito breeding areas increase
o TERTIARY: how the environment on a global scale changes thus causing issues e.g. increased conflict
due to increased water scarcity
- Climate change in Australia means more heat waves, increased fire danger etc.
o However Australia is fairly well equipped to deal with this due to a good financial standing

Environmental impacts on health

- KIRABATI: consists of many small islands and has a high poverty rate
o Increasing sea levels and reduced rainfall is making it uninhabitable
- CHINA: air pollution is a massive health risk factor
o People seen wearing masks outside
- INDOOR AIR POLLUTION: use of gas, building materials, ventilation issues, cleaning agents etc.
o Cause two million premature deaths globally
o Results in mild to severe health effects that can range from acute to chronic
- URBAN SPRAWL: houses are built bigger and closer, creates more air pollution, road traffic etc.
o Results in isolation – everyone just stays in their houses
o heat islands – proximity of houses and minimal environmental concern results in heat being trapped
- INDIGENOUS COMMUNITIES: experience higher incidence of overcrowding, poor sanitation, poor
community functioning, isolation from services due to location of villages
- WORKPLACE EXPOSURE: agriculture, forestry and fishing is shown to be the most dangerous injury
o Not having a job also poses risk factors: isolation, worthlessness etc.
- ASBESTOS: used widely for construction until 1980
o Exposure causes mesothelioma many years later
- BHOPAL: Indian disaster, exposure to methyl isocyanate
o Resulted in many deaths and still causing more today

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

 Interestingly, a sister company in the US produced the same product however was under much
stricter conditions so nothing like this could have occurred – shows how social environment can
reduce or increase risk factors

~DAVID ET AL.: prevention and control of HIV/AIDS, TB and vector borne diseases in informal settlements~

- Cities in developing worlds can’t handle ecological and social pressures caused by rapid population growth
o Urban population growth without economic development results in poverty in urban areas
- Infectious disease epidemics are typically associated with
o Population growth and mobility, crowding, no effective public health interventions, ecologic and
environmental changed
 Therefore rapid urbanisation in underdeveloped settings sees resurgence of old infectious
diseases and new infectious diseases
- Poverty acts as a structural determinant, exposing people to disease through social inequity
- Developing countries have higher HIV/AIDS, TB and malaria incidence and prevalence
o Due to the poorness though, their voices and concerns aren’t heard so these issues goes untreated
o Results in intra urban health differences
 Gender inequality: women can’t negotiate safe sex and receive poorer care
- Informal settlements: settlers have no power, limited resources and higher HIV/AIDS, TB and malaria risks,
limited resources to cope with diseases, experience significant financial barriers
- Need to recognise these communities and empower them to improve their conditions

Week 10: Health and social justice

Causes of health inequalities

- Access, funding, facilities, work related injuries, morbidity and mortality and susceptibility to infectious
diseases are disproportionately experienced in different countries
- Inequalities can be due to:
o Genetics o Access to healthcare
o Gender o Education
o Behaviours o Income disparities
- In terms of HIV/AIDS – Africa has the highest prevalence
o Also the country with the least wealth
- A very small amount of people control a large majority of the world’s wealth

Achieving equity

- Equity: when different people of different social standings DON’T experience health inequalities due to their
social standing
- Health is a human right
o Need to employ policies that protect this human right
- We’ve seen as with the GFC that if money is really needed, we can rally around and accumulate it
o So why hasn’t this occurred to solve the health crisis?
 Does justice begin with the government, or do we implement it at the grass roots level?
 BOTH!
- Fairness is central to social justice – however what is fair is subjective and often quite complex

Theory of justice

- ARRANGEMENT FOCUSED – focuses on structure; fair society comes from institutional arrangements
o Focuses on perfect justice rather than something being more or less just
 Prevalent in developed countries
- REALISATION FOCUSED- focuses on agency; focuses on removing the injustice
 Prevalent in developing countries

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

Capabilities

- People have a range of capabilities that they require to effectively function in society
o E.g. access to education, able to drive a car, able to cope with English speaking lectures, emotions,
bodily integrity, play, affiliation with others etc.
o If people lack key capabilities, life choices will be constrained and they’ll be at a disadvantage
- Everyone has the right to develop their capabilities
o Structures exist in which people can evoke their agency
- Community capabilities include:
o preserving community life o Just resource distribution
o a healthy community o Institutions reflecting community
o Sharing joys, sorrows and preferences
responsibilities
Social exclusion

- A consequence of poverty and inequity

- The denial of access to situations where capabilities could be developed
o Reduces quality of life, participation and resources
- Achieved through stereotyping, systematic discrimination and stigmatisation
- The social inclusion principles for Australia policy has disappeared, which acted as a protective factor

Social inclusion

- Giving people the opportunity and resources to develop the capabilities they need to learn, work, engage
and have a voice
- Benefits of a social inclusion agenda include:
o Understanding disadvantage isn’t just concerned with $$
o Allows barriers to social inclusion to be identified
o Identification of social/systemic characters of disadvantage
o Prompts action to be taken to address this
 Social inclusion agenda could however cause further stigmatisation of groups (who’s included in
the agenda?)
 By trying to involve the whole of government – responsibility can be diffused resulting in no one
doing anything

AS PROFESSIONALS

- Be aware that when intervening with an individual you intervene with their network too
o Is the intervention therefore just?
o Treat, but also refer and advocate when you aren’t the suitable professional to treat them

~RUGER: ethics of the SDH~

RAWLASIAN APPROACH

- Justice requires the fair distribution of primary goods

o Primary goods are allocated to individuals on the basis of fair equality of opportunity
 If we did this, the socioeconomic gradient would flatten
- Government should aim to equalize individual life opportunities via social strategies e.g. basic education,
affordable housing, income security, and other antipoverty policies
- Important to acknowledge differentials in health within multiple groups
- Resources and means are only good insofar as they promote human function (they don’t have an intrinsic
value)
o Thus, ensuring possession of primary good mightn’t address health inequalities

CAPABILITY APPROACH

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

- Calls for multifaceted approach to health improvement involving multiple institutions to make progress on
various fronts
- Applies SDH but is more agency and people centred
- Number of approaches must be combined
o Public policies should focus on progression in different fronts which support each other
- Must determine how to weight different social issues so we know how to distribute resources

Week 11: SDH and the healthcare system

Health systems as a SDH

- Health systems act as SDHs

o When well-designed they can protect from disadvantage, rid health inequalities and support
governments to address health issues
o When not well designed, they can exacerbate injustice and disadvantage
- Healthcare systems that address social determinants of health well:
o Provide everyone, regardless of SES, access
o Redistribute resources to those most in need
o Have a strong primary health care approach
o Works across sectors to promote health
o Incorporates community input into decisions
Australian healthcare system

- Hospitals rapidly developed after white settlement and were very expensive
o At this time the healthcare system was largely biomedical in terms of the approach to health
- FUNDING IN AUS:
o Federal government proves ≈40%
o Other governments (state, local) ≈30%
o Non-government (private, out of pocket, injury compensation) ≈30%

Government funding

- Federal government funds:

o GP and specialists o Public health activities
o PBS o Public hospitals (subsidises private
o Health research health insurance)
o Public hospitals
- State/Territory government funds
o Community health services o Public health activities e.g.
o Patient transport immunisations
o Public hospital services
- NT spends more on health due to larger population of indigenous Australians who have worse health
outcomes
- Australia as a whole spends an average amount on health care

Medicare

- Funded by the Medicare levy (tax)

- Provides health insurance to all Australians and those with reciprocal rights in Australia
- Is a universal system – you pay a % of what you earn , so it’s fair for all

Healthcare workforce

- Medical practitioners: make up the most powerful and best paid of the workforce
o have a high degree of autonomy and control other workers

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

o majority are employed in the private sector

- Nurses: the largest healthcare occupation in Australia
o Female dominated
o Mainly work in hospitals
- Allied health workers: includes dentists, physios, osteos, chiros etc.
o Large range of wages
o An increased demand is being seen for these services
o Mainly privately funded

Federal health budget 2014

- Introduced co-payments for Medicare services

- Increase in PBS co-payment
- Abolished Australian National Preventative Health Agency
- Reduced funding to state and territory governments
- Cuts to indigenous health programs
o Will all result in people forgoing services and increasing health disparities

HIV burden of disease on healthcare system

- Increased demand for medical care

- Increased emotional, physical and mental stress on workforce – poor morale as patients rarely live
- Increased rate of opportunistic infections
- Poorly funded hospitals like those in sub-Saharan Africa carry the majority of the burden
o Countries in need don’t have the healthcare workforce they need to cope with the burden

HIV and the Australian healthcare system

- PLWHA still have difficulties accessing healthcare, insurance, housing, employment and education
o Leads to social isolation
- 1/3 of PLWHA are below the poverty line
o Struggle to meet daily needs

Challenger for Australia

- Increase training in HIV for healthcare workers as well as specialised training on ageing HIV patients
- Training for HIV nurses
- Cultural diversity training
- Minimising stigma and discrimination

~BLANKENSHIP ET AL.: structural interventions~

- Structural interventions are public health interventions promoting health by altering the structural context
within which health is produced and reproduced
o Often locate the cause of health problems being contextual or environmental factors or other SDH,
rather than characteristics of individuals
- Structural interventions presume a degree of causation of public health problems to try and change social,
economic, political and physical environments
- Fundamental causes: the primary causes of illness e.g. SES
o Proximate causes will change over time, but fundamental causes will remain, thus more focus should
be placed on them
- Structural interventions have the potential to impact on many and produce longer lasting change
- Structural interventions often have to occur first before a program can be implemented
o Once a program is in place, extra structural interventions may also be necessary
- Types of HIV intervention
o COMMUNITY MOBILIZATION: raising consciousness of issue in affected group and informing them of
their rights and strategies to overcome issue through their active involvement

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)

 lOMoARcPSD|32653457

o INTEGRATION OF HIV SERVICES: integrating different medical processes that have a correlation e.g. HIV
into family planning services, HIV and HCV testing into one, integrating contraception and ART services
 Potential to overwork staff as they have to take on too much
o CONTINGENT FUNDING: aka incentive funding – utilises federal/state funds to implement laws or
policies seen to promote public health
o ECONOMIC AND EDUCTIONAL INTERVENTIONS: economic disadvantage and poor education,
specifically for women, significantly increases HIV risk. Empowering women, providing education and
financing opportunities will assist in reducing these effects
- For the future…
o Analyse structural determinants of HIV risk and transmission
o Analyse impacts of structural interventions
o Evaluation of systematic interventions
 Factors are not static – constantly changing

Downloaded by chelsea pasiah (chelseapasiah97@gmail.com)