Chap-2--Social Factors in Health and Disease

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Social Factors in Health and Disease


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Introduction • Sociologists study health and illness not only because they are intrinsically interesting and go to issues at the centre of human existence – pain suffering and death – but also because they help us to understand how society works. • For sociologists the experience of sickness and disease is an outcome of the organization of society. • For example poor living and working conditions make people sicker and poorer people die earlier than their counterparts at the top of the social system.

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• Even when there are improved living conditions and medical practices but inequalities based on class gender and ethnicity are not tackled the differences between the rich and the poor persist and widen. • Disease and inequality are intimately linked. • The outcome of the unequal distribution of political economic and social resources necessary for a healthy life is the social gradient of health.

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• Those at the top of the social system are healthier and live longer while those at the bottom are sicker do not live as long and die more from preventable disease and accidents. • These links between social factors and health and disease are the focus of this chapter.

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• 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.

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• 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 significant impacts on health whereas the more frequently considered factors such as access and use of health care services often have not as much of an impact.

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Define Health • Health is the level of functional and metabolic efficiency of a living organism. • In humans it is the ability of individuals or communities to adapt and self-manage when facing physical mental or social changes.

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• The definition of health has evolved over time. • Early definitions of health focused on the theme of the bodys ability to function health was seen as a state of normal function that could be disrupted from time to time by disease.

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• An example of such a definition of health is: "a state characterized by anatomic physiologic and psychological integrity ability to perform personally valued family work and community roles ability to deal with physical biologic psychological and social stress".

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• WHO defines health as “Health is a state of complete physical mental and social well-being and not merely the absence of disease or infirmity. ” • This definition has been subject to controversy in particular as lacking operational value the ambiguity in developing cohesive health strategies and because of the problem created by use of the word "complete". • Although this definition was welcomed by some as being innovative it was also criticized as being vague excessively broad and was not construed as measurable.

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Defining Social Health • Social health is ones ability to form meaningful personal relationships with others. • It is also an indication of ones ability to manage in social situations and behave accordingly. • Matters such as stress can damage someones social health. Social health is also described as "social wellness."

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• There are various measures of social health including the development of assertiveness having a group of supportive friends and family and the ability to manage time with friends and alone. • One can determine if their personal relationships are socially healthy by noting elements of trust respect and acceptance.

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• Social health involves one’s ability to form satisfying interpersonal relationships with others. • It also relates to one’s ability to adapt comfortably to different social situations and act appropriately in a variety of settings. • Spouses co-workers and acquaintances can all have healthy relationships with one another. • Each of these relationships should include strong communication skills empathy for others and a sense of accountability.

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• In contrast traits like being withdrawn vindictive or selfish can have a negative impact on one’s social health. • Overall stress can be one of the most significant threats to a healthy relationship. • Stress should be managed through proven techniques such as regular physical activity deep breathing and positive self-talk.

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Developing Relationships • To effectively develop relationships and maintain good social health individuals must be willing to: • Give of oneself: This could include sacrificing time effort energy or money for sustaining relationships. • Have adequate levels of self-esteem: Being mentally and emotionally secure with oneself can help an individual maintain healthy relationships. • Establish a sense of identity: Sacrificing personal characteristics often results in less satisfying relationships while acting like your true self will strengthen social bonds.

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• All relationships will have some level of emotional involvement also known as intimacy. • Determining how intimate a relationship will become is critical to long-term social health. • While acquaintances or co-workers may have very little intimacy family members and spouses often have intimacy levels high enough to be considered love.

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• Characteristics of a healthy relationship include: • Trust - those involved have faith in each other and will do what is best for the relationship. • Compassion - the physical and emotional well-being of others in the relationship is considered important. • Respect - sacrifices made for the relationship such as time effort and money are acknowledged and valued. • Acceptance - changing individual characteristics and personality traits is not an expectation. • Reciprocity - the give and take of the relationship are relatively equal.

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Challenges in Relationships • Relationships may be compromised for a variety of reasons. • A lack of honesty or openness unrealistic expectations and jealousy are all factors that can push relationships to an unhealthy state. • For example a spouse that expects his or her husband/ wife to do the majority of the housework without any display of appreciation may experience a low-quality relationship as a result.

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• Conflict resolution methods that attempt to solve relationship problems such as empathy and negotiation may be needed to help the situation. • If attempts to improve the situation fail an unhealthy relationship may need to end. Being honest tactful and compassionate is the healthiest way to maintain a relationship.

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Social determinants of health SDOH • The SDOH are the economic and social conditions and their distribution among the population that influence individual and group differences in health status. • They are health-promoting factors found in ones living and working conditions such as the distribution of income wealth influence and power rather than individual risk factors such as behavioral risk factors or genetics that influence the risk for a disease or vulnerability to disease or injury.

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• According to some viewpoints the distributions of social determinants are shaped by public policies that reflect the influence of prevailing political ideologies of those governing a jurisdiction.

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• The WHO says "This unequal distribution of health-damaging experiences is not in any sense a natural phenomenon but is the result of a toxic combination of poor social policies unfair economic arrangements where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer and bad politics."

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Commonly Accepted Social Determinants • In 2003 the WHO recommended that the social determinants of health included:  Social gradients inequalities in social status  Stress including stress in the workplace  Early childhood development  Social exclusion  Unemployment  Social support networks  Addiction  Availability of healthy food  Availability of healthy transportation / active travel  Religion caste all the social diversities

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Role of Social Factors in Health and Disease

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Income • Income – alone or in concert with other factors – is a significant contributor to health and consequently health inequalities. • Poverty rates are estimated to be significantly higher than average among certain groups: lone parents work limited persons recent immigrants and tribal peoples. • Lower-income families and individuals at the lowest income levels tend to be concentrated in lower-income neighborhoods.

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• As a result they not only deal with individual poverty but with the impacts of living in the economically disadvantaged community around them. • The concentration of poverty adds to the total impact of individual poverty on health when this results in neighborhoods with fewer resources and services more crime and less social support.

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Employment and working conditions • Employment provides people with economic opportunities which can influence individual and family health. • However the working environment can also significantly impact physical and mental health through the type of work and working conditions.

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• Stress related to employment in the form of job strain satisfaction the perception of physical risk and issues of job security is a significant health concern for many Indians. • Generally more women than men report feeling work-related stress. • However those in the lowest income households also report experiencing high rates of stress coinciding with job insecurity and job dissatisfaction. • Longer hours and less predictable hours at work can also impact the home/family environment.

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Food security • Healthy eating requires being ‘food secure’ i.e. having physical and economic access to sufficient safe and nutritious foods to meet the needs of a healthy and active life. • It is evident that individuals with higher social and economic status more regularly consume nutritious foods fruits and vegetables dairy products lean meats whole grains than individuals with lower social and economic status.

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• When children go to school hungry or poorly nourished their energy levels memory problem-solving skills creativity concentration and behavior are all negatively impacted. • As a result of being hungry at school these children may not reach their full developmental potential – an outcome that can have a health impact throughout their entire lives.

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Environment and housing • Where a person lives is very important because both natural and built environments influence health. • It creates the context for determinants of health such as income employment social networks and personal behaviors.

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Physical environment • The physical environment can also contribute to health inequalities e.g. adequacy of housing indoor air quality and water supply. • Environmental challenges associated with changing conditions particularly climate are expected to place increased health burdens on society and the infrastructure now and towards the foreseeable future.

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• Outdoor air pollution causes health problems that include coughing aggravation of asthma and other respiratory diseases as well as the exacerbation of cardiovascular disease. • This results in increases in emergency room visits hospital admissions and premature death as air quality degrades. • Also for the majority of Indians water quality is not considered to be safe.

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Built environment • The built environments can influence physical and mental health through factors such as community design adequate housing access to safe water good sanitation safe neighborhoods and adequate access to education recreational services public transit and child care. • In essence the built structure provides the setting for many of the social determinants of health.

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• The built environment can also provide opportunities for social interaction through an array of social networks and organizations. • Generally the larger the urban center the greater are the number and complexity of social networks. • Social engagement in the community builds trust efficacy and a sense of belonging that is associated with improved mental and immunological health. • Urban centers tend to be less culturally and socially homogeneous and have diverse populations. • Within these cities communities comprised of close networks of people of similar cultural and social perspectives offer the benefits of the community such as social support.

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• Although urban areas provide many opportunities for social contact with others they can also create anonymity and isolation. • Regardless of neighborhood density many urban dwellers say that they do not know their neighbors a number of elderly residents live alone and those who are not connected with the greater community can experience isolation.

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Housing • Availability of housing or lack of it is a critical component of an individual’s environment. • In India majority of people do not have acceptable housing. • The term acceptable housing used here refers to housing that is affordable does not require major repairs and is not overcrowded.

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• Health outcomes related to housing are complex as housing can directly or indirectly impact health. • The inadequate housing may produce direct effects in extreme climates. • Respiratory disease/poor lung function and allergies related to molds from cold damp or poorly ventilated houses may develop. • Other health conditions can arise related to exposure to specific toxic substances like lead and asbestos from substandard plumbing and insulation and environmental tobacco smoke.

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• Overcrowding and poorly ventilated houses can also increase susceptibility to disease. • The number of people per dwelling has been known to greatly impact the physical and mental health of inhabitants including raising the risk of acquiring tuberculosis. • This is especially true for many Indian tribal populations and for immigrants from some countries where older generations infected with tuberculosis in childhood may experience disease reactivation later in life that can infect others in the home.

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• Homelessness is also a health issue. • It is difficult to measure how many people in India are homeless as homelessness is a continuum with a variety of short and long-term experiences. • Some of these people become homeless as a result of inadequate income living in a community with inadequate housing or having a mental illness which may hinder opportunities for employment and income. • People living on streets/roadsides report trading sex for shelter money and substances and have higher rates of STIs and blood-borne infections than people in the general population.

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Early childhood development • The initial years are pivotal to a child’s growth and development. • Nurturing caregivers positive learning environments good nutrition and social interaction with other children all contribute to early physical and social development in ways that can positively affect health and well-being over a lifetime. • A poor start to life often leads to problems that can impact health and long-term prospects.

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There are three main areas critical to healthy child development: • Adequate income – family income should not be a barrier to positive childhood development and support mechanisms should be in place for all children to have a good start in life • Effective parenting and family functioning– effective parenting skills are fundamental to child development however parents may also require employer support for flexible work hours and maternity/parental leaves as well as broader social support for family-based opportunities and resources and • Supportive community environments – all members of the community have a responsibility for the healthy development of children. Communities need to provide accessible health and social programs and resources for families with children.

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• There is evidence that a health gradient in childhood development exists according to social and economic factors. • Generally children from families with lower income and lower levels of education have poorer overall health and higher rates of cognitive difficulties behavioral issues hyperactivity and obesity through childhood. • Readiness to learn a measure of children’s early success in terms of abilities attitudes and behaviors as children start school is an indicator of the benefits of positive early experiences.

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• Tribal and immigrant children may experience additional barriers if local child programming is not culturally relevant or delivered in a familiar language. • The consequences of these disadvantages include children growing into adults with lower educational attainment weaker literacy and communication skills fewer employment opportunities and poorer overall physical and mental health.

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Education and literacy • Generally being well-educated equates to a better job higher income greater health literacy a wider understanding of the implications of unhealthy behavior and an increased ability to navigate the healthcare system – all of which lead to better health.

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• Completing high school can help improve the quality of life for young people by providing them with the tools and confidence they need to lead healthier more productive and prosperous lives that benefit them as individuals and in turn benefit their communities. • Education and income are often inter-related in terms of their impacts on health. • Median earnings by education level attained indicate that the higher the education obtained the higher the average earnings.

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• In general there is a correlation between levels of education and literacy where the more educated a person the more likely he or she is to have a comparable ability to read and comprehend written material. • The term ‘literacy’ is now understood to include not only the ability to read write and calculate but also to understand and apply learned information to everyday life activities and decisions. • Illiteracy can have a direct impact on health for example through the incorrect use of medications or safety risks associated with the misuse of potentially hazardous chemicals in the home or workplace.

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Social support and connectedness • Family friends and a feeling of belonging to a community give people the sense of being a part of something larger than themselves. • Satisfaction with self and community problem-solving capabilities and the ability to manage life situations can contribute to better health overall. • The extent to which people participate in their community and feel that they belong can positively influence their long-term physical and mental health.

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• Most of the Indians report that in times of crisis they rely on someone e.g. friends family members as a confidante for advice and for care. • Relying on individuals or communities for assistance during these times is considered essential for good mental health and coping skills.

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• Social cohesion is a measure of social connectedness that is based on how much people participating in their community and how satisfied they are with their lives in those communities. • Levels of social connectedness are also shaped by how safe a person feels and the level of violence to which he or she is exposed or perceives a threat – both of which can impact mental and physical health.

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• Often violence and maltreatment occur in places where individuals should expect to feel the safest. • The disturbing problem of family violence continues and involves a range of abusive behaviors on the part of someone in a relationship of trust and/or dependency. • Children are also victims of violence and maltreatment. Children who witness family violence often exhibit negative behaviors physical aggression emotional disorders hyperactivity and destructive behaviors.

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• Loneliness and isolation can have adverse impacts on the health of many Indians particularly some seniors. • Those seniors who reported having no friends are also less likely to report being in excellent or very good health.

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• Social exclusion is experienced when some people or groups have limited control and access to social economic political and cultural resources. • Tribal Peoples and marginal groups of people have a long history of unequal access to and control over education and healthcare as well as lands and natural resources which has resulted in social disconnection. • High rates of suicide among migrants particularly among youth are linked to social exclusion and disconnection from their traditions and culture.

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Health behaviours • Individual behaviors such as staying physically active and eating well can contribute to good health. • Other behaviors such as smoking heavy drinking and illicit drug use can have detrimental health effects. • Ultimately health behaviors are individual choices that people make. However these behaviors are influenced by the social and economic environments where individuals work live and learn.

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Smoking • Smoking is responsible for high rates of disease and death. • It is a risk factor for lung cancer head neck and throat cancers heart disease stroke chronic respiratory disease and other conditions. • Most smokers report beginning to smoke during their teens. However most do not quit until later in life. For some exposure to smoke is not a choice. • The majority of children under the age of 12 and 15 of Indian households are regularly exposed to environmental tobacco smoke – often called ‘second- hand smoke’. • Smoking during pregnancy is a known risk factor for unhealthy fetal growth and development.

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Physical activity • Research studies report a linear relationship between physical activity and health such that the most physically active are at the lowest risk of poor health. • Physical inactivity is a modifiable risk factor for a wide range of chronic diseases including cardiovascular disease diabetes mellitus cancer and depression. • Compared to people who are physically active those who report being physically inactive are also more likely to report their mental health as fair or poor.

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Healthy eating • The types quantity and quality of food eaten also affect health. • Aside from nutritional value the availability and affordability of nutritious food and the individual food choices made are important. • Less healthy eating combined with inadequate physical activity can lead to increased body weights. • For adults obesity is a risk factor for many chronic diseases including hypertension Type 2 diabetes gallbladder disease coronary artery disease osteoarthritis and certain types of cancer.

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• Eating healthy foods – such as fresh fruit and vegetables fiber-rich foods and those with a lower fat content – is related to their accessibility and affordability. • A further challenge to healthy eating is the availability of quick less expensive and less healthy foods. • Parental practices such as breastfeeding can positively influence an infant’s start in life.

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Alcohol consumption • The excess alcohol consumption over both the short and long term can negatively influence health. • Alcohol abuse also has high economic and social costs. • Excessive alcohol consumption may lead to alcohol-related acute-care hospitalizations deaths due to liver cirrhosis motor vehicle crashes and suicides. • Drinking during pregnancy can result in serious health and development problems for children as a result of Foetal Alcohol Spectrum Disorder FASD – a preventable life-long disability.

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Illicit drug use • The drug use related deaths are primarily due to overdose drug- attributable suicide and infectious diseases hepatitis C and HIV infections acquired as a result of drug use activities.

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Sexual health • Unsafe sexual practices – including early initiation infrequent use of condoms and multiple partners – increase the risk of acquiring sexually transmitted infections STIs and unplanned pregnancies.

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Access to health care • Access to health care is fundamental to health. • Not only do people seek treatment through the government-funded health care system they benefit from a number of disease prevention and health promotion services. • These services are generally integrated into ‘primary care’ and range from childhood vaccinations to disease screening to advice on healthy living and mental health counseling.

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• Unfortunately some people face barriers to health care services including physical inaccessibility socio-cultural issues or the cost of health services e.g. eye and dental care mental health counseling and prescription drugs. • Access to health care is also an issue for rural or tribal populations who live in remote places.

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Figure-X: Social Determinants of Health

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