The nature of health can be defined by its social rather than biological context

Determinants of Health and Health Disparities

Fig. 2.1 displays a categorization of the multiple determinants of health and well-being. Applying this categorization to health disparities, conceptualizations of the root causes of health disparities emphasize the most modifiable determinants of health: the physical and social environment, psychology and health behaviors, socioeconomic position and status, and access to and quality of healthcare. Differential access to these resources result in differences inmaterial resources (e.g., money, education, healthcare) orpsychosocial factors (e.g., locus of control, adaptive or risky behaviors, stress, social connectedness) that may contribute to differences in health status.

Fig. 2.2 illustrates the complex relationships among multileveled factors and health outcomes.Social stratification factors such as socioeconomic status (SES), race, and gender have profound influences on environmental resources available to individuals and groups, including neighborhood factors (e.g., safety, healthy spaces), social connectedness and support, work opportunities, and family environment. Much of the differential access to these resources results from discrimination, on a systematic or interpersonal level.Discrimination is defined as negative beliefs, attitudes, or behaviors resulting from categorizing individuals based on perceived group affiliation, such as gender (sexism) or race/ethnicity (racism).

SES, race/ethnicity, gender, and other social stratification factors also have effects on psychological functioning, including sense of control over one's life, expectations, resiliency, negative affect, and perceptions of and response to discrimination. Environmental and psychological context then have influence over more proximal determinants of health, including health-promoting or risk-promoting behaviors; access to and quality of healthcare and health education; exposure to pathogens, toxins, and carcinogens; pathophysiologic (biologic) and epigenetic response to stress; and the resources available to support optimal child development. Variability in these factors in turn results in differential health outcomes.

Determinants of Health

Determinants of health may be biological, behavioral, sociocultural, economic, and ecological. Broadly, the determinants of health can be divided into four, core categories: nutrition, lifestyle, environment, and genetics, which are like four pillars of the foundation. When any one of the pillars of health determinants becomes weak, a support system is needed. This is considered the fifth determinant of health and involves medical care (Figure 3.3). A brief review of these core determinants of health will provide more insight.

Interestingly, two determinants, nutrition and lifestyle, are totally in our hands, and hence are called modifiable factors. Many diseases are caused by bad practices of nutrition and lifestyle. The degraded ecosystem, and environmental pollution are the causes of several disorders and diseases. With the help of powerful technology and screening methods, many disorders of genetic origin can be prevented. If one or more core determinants become weak, then only the support of medical care is needed.

Over 75% or more of the resources allocated in health care budgets, especially from rich countries, are used for the treatment of lifestyle-related conditions. There is a growing consensus that lifestyle modifications should be the foundation of any health care system. According to the American College of Lifestyle Medicine, nearly 80% of all chronic diseases are preventable by readily available means—lifestyle modification as medicine.

People should be empowered to “take their health into their own hands” through lifestyle modifications. This will drastically reduce dependence on doctors. Traditional knowledge can be immensely useful to design appropriate lifestyle interventions. For instance, Swasthavritta, a branch of Ayurveda is dedicated totally to healthy lifestyle. Swasthavritta dictates do’s and don’ts for a healthy daily regimen, and outlines diet and lifestyle modifications appropriate to different seasons. Swasthavritta, and biobehavioral practices suggested by Yoga are very useful sources for lifestyle medicine.

Nutrition is another important determinant. It has individual, family, and community dimensions. The East/West, and rural/urban regions have remarkably different challenges related to nutrition. Generally, at one end of the spectrum, in Western and/or urban spheres, there is less physical activity, calorie overload, but poor nutrition mainly due to junk food consumption. At the other end of the spectrum, in the East and/or rural spheres, there is calorie deficiency, protein malnutrition, and undernourishment. The lower socioeconomic communities may have a greater incidence of premature and low birth weight babies, higher risk of heart disease, stroke, and some cancers. Poor people living in urban areas may have a diet consisting of cheap energy mainly from sugar-rich foods, with little intake of vegetables, fruits, and whole grains. They have relatively less physical activity. On the other hand, poor communities from rural areas might have intense physical activities, but not sufficient energy and protein.

In general, urban communities face problems related to environmental degradation, and air and water pollution; rural communities face problems related to sanitation, hygiene, insecticides, pesticides, and agrochemicals. Thus, the poor are most likely to suffer because of the interplay of the deranged determinants of health.

In the interconnected, borderless world, determinants of health cannot be considered in isolation. They will always be interdependent. The substantial health inequity in different parts of the world is today’s reality. This inequality of health is due to inequalities in income, education, gender, and availability of resources.

Wider determinants of health

Wider determinants of health (WDHs) are the broader social, economic, political and environmental circumstances that influence health outcomes throughout life. Dahlgren and Whitehead (1991), subsequently modified by Barton and Grant (2006), developed an influential model of the main determinants of health, in which, at the core, are constitutional factors such as sex, age and genetics; overlapping layers represent individual lifestyle factors, followed by the wider determinants(Fig. 14.4). The core attributes are relatively fixed but, as the layers of influence extend outwards, the determinants are amenable to change:

The first layer represents individuallifestyle behaviours, e.g. diet, physical activity, smoking and alcohol consumption.

The second layer represents thecommunities in which individuals live – social networks that influence health and the health behaviours we exhibit.

Next,living and working conditions have an impact on health, e.g. the quality of an individual’s employment, housing and education.

Finally, the prevailingsocioeconomic, cultural and environmental conditions affect the health of the whole population, and these are influenced by local, regional, national and international factors.

These overlapping layers exert an influence over each other and there is a complex interplay between them.

Determinants of Health

The term ‘determinants of health’ was introduced in the 1970s and it refers to those factors that have a significant influence, whether positive or negative, on health. The term should not imply a cause–effect relationship between a risk factor and a health status. Health is the result of multiple factors including those genetic, biological, and lifestyle factors relating to the individual and those factors relating to the structure of society and its policies. Figure 1 presents eight classes of factors that can have a significant influence on health and well-being. One class of factors, such as national and local policy definition and implementation, can influence a multitude of health issues within and beyond the health sector. The improvement of population health status implies that policies and interventions outside the health sector should be addressed at the same time as conventional biomedical and public health approaches.

Among those factors that have a significant influence on health are the environmental and social conditions in which people live. There is a large amount of empirical evidence that shows that social inequalities, especially poverty, affect inequalities in health and well-being. The poor are more likely to suffer illness during their life span because they have more exposure to risk factors. In 1998, the WHO established the Commission on the Social Determinants of Health. The commission recommended policies and interventions according to ten important topics. These topics are addiction, early life, food, stress, social exclusion, social gradient, social support, unemployment, work, and transportation. The commission differentiated between structural determinants (including the labor market, education system, and welfare state), the individual's social status (gender, ethnicity, socioeconomic rank, and social cohesion), and intermediary factors (lifestyle and living and working conditions).

In the field of health promotion, health is not considered as an abstract condition, but as the ability of an individual to achieve his/her potential and to respond positively to the challenges of daily life. Hence, health is an asset or a resource for everyday life, rather than a standard or goal that ought to be achieved. This redefinition is pertinent for QOL studies because the environmental and social conditions of human habitats do affect human relations, and they can have positive or negative impacts on the health status of groups and individuals. It also implies that the capacity of the health sector to deal with the health and well-being of populations is limited and that close collaboration with other sectors would be beneficial.

Abstract

Nutrition is a powerful determinant of health and well-being. In the modern environment where energy-rich foods are prevalent, challenges exist to improve diets that will provide an appropriate energy density while maintaining the required nutritional value. A recent concept in nutrition is that components of food which are not abundant in the diet may exert a regulatory effect on physiological and biological processes. Some of these components appear to act as hormetins, i.e., they exert a mild stress and in turn elicit and adaptive response that offers greater health advantages than the stress itself. Therefore, nutritional hormesis play a vital role in the modern aging population by modulating the susceptibility to diseases. Adequate and appropriate dietary levels of hormetic phytochemicals; polyphenols, carotenoids, sulforaphane, and other bioactive compounds have been recognized as activators of intracellular signaling cascades and modifiers of gene expression with health benefits. Research to date has focused on individual hormetins in isolation, however, the bioavailability, bioaccessibility, and potential for interaction of these compounds in combination through acting on distinct intracellular signaling pathways are of significance in the human body. As the modern world’s population ages chronologically, yet biologically at different rates, it is increasingly important to understand how nutrition and hormetins within the diet could reduce risk for age-associated disease. Further work is needed in the field of nutrigenomics to identify the key biochemical targets that are modifiable by hormetins.

Introduction

Nutrition is a key determinant of health of a population, and of growth and development in children. Dietary guidelines are tools that translate the science of nutritional requirements to a practical pattern of food choices for the general population. On a national level, they provide guidance for health promotion and risk reduction, and often form the basis of national food and nutrition policies and education programs. Over time, these guidelines are constantly revised to include up-to-date evidence from experimental studies and large population databases, to which sophisticated dietary analyses have been applied.

The history of official guidance for food intake dates back to the first half of the twentieth century. Dietary guidelines were initially targeted at preventing deficiencies of micro- and macronutrients. In the United States, the first daily food guides aimed at improving the health of the population were published in 1916 by the Department of Agriculture. They identified five food groups: milk and meat, cereals, vegetables and fruits, fats and fat foods, and sugars and sugary foods. This later became the ‘Basic Seven’ in 1942, the same year that Canada's Official Food Rules were first issued (Health Canada, 2002). At that time in the midst of wartime food rationing, nutritional deficiencies were a prominent concern, and alternate choices were suggested in case of shortages.

With lifestyle-related diseases rising in prominence throughout the world, the focus of dietary guidelines in many parts of the world has shifted to preventing chronic diseases such as diabetes and cardiovascular diseases. In addition, along with the recognition that patterns of food intake are more predictive of health outcomes than individual components of the diet, the emphasis has been toward providing guidelines which are food-based and flexible. At the same time, there is a growing understanding of cultural dietary traditions and development of ways to incorporate them into national guidelines

Conclusion

Health literacy is a key determinant of health and is influenced by multiple, complex, interacting factors. To improve health literacy requires a collaborative approach involving government and policymakers, and front-line professionals responsible for health and education. For policymakers, an example of a system-based intervention is ensuring that the marketing and labelling of food is clear, transparent and accessible to consumers. This will support the public in making better health choices. Similarly, interventions through the education system, particularly in the early years, can embed the foundations of health literacy which is vital for lifelong health and well-being. For health practitioners, developing systems to support people with poor literacy through improved communication and training for all staff will help empower individuals to take control of their own health.

Summary

Health literacy is a key determinant of health, associated with significant economic implications.

Those with poor health literacy have more adverse health outcomes, including increased morbidity and increased risk of premature death.

For practitioners to support those with poor health literacy:

There should be training in and awareness of health literacy in healthcare settings.

Communication, both written and verbal, should be patient centred and appropriate to an individual's level of understanding.

Patients should be empowered to take control of their health and well-being.

Conceptualizing Racism

In conceptualizing racism as a determinant of health, it should first be recognized that racism is only one of several causes of ethnoracial disparities in health. Genetic, sociocultural, and socioeconomic differences between ethnoracial groups are also responsible for such disparities. While the latter two factors are substantial drivers of ethnoracial health disparities and are themselves strongly influenced by racism, genetic variation accounts for only a tiny fraction of health disparities across ethnoracial groups.

To the extent that racism drives health outcomes, it does so in interaction with other oppressions such as sexism, ageism, and classism. Oppression is manifested in societies through the unequal distribution of power among social groups resulting from attitudes, beliefs, behaviors, norms, and practices relating to these social groups. The phenomenon of oppression is also intrinsically linked to that of privilege. In addition to disadvantaging minority racial groups in society, racism also results in groups (such as Whites) being privileged and accruing social power.

Figure 1 is a representation of how privilege/oppression may act as a determinant of health. The processes shown in this figure occur across the dimensions of both time (history) and space (geography) as well as across the life course.

In the structural realm, fundamental features of society, as encapsulated by the terms culture, ideology, and worldview, interact with societal institutions and are influenced by and produce systemic privilege/oppression. Systemic privilege/oppression can be defined as the production, control, and access to material, information, and symbolic resources within a society that serve to increase power differentials between social groups. Systemic racism, which has also been referred to as institutional (or institutionalized), structural, cultural, societal, and civilizational racism, is an example of systemic privilege/oppression. As shown in Figure 1, systemic oppression acts to differentially construct and constrain the interpersonal realm as represented by an individual's social identities (or locations). As a form of oppression, systemic racism is a strong determinant of an individual's place of residence, living conditions, and socioeconomic position (SEP).

An individual's social locations then become the basis on which interpersonal and internalized oppression is perpetrated. Interpersonal oppression is the interactions between individuals that serve to increase power differentials between social groups. Using the framework presented by Jones (2000), internalized oppression can be defined as the incorporation of attitudes, beliefs, or ideologies within an individual's worldview that result in the unequal distribution of power among social groups. There are two forms – internalized dominance (i.e., privilege) and internalized oppression (i.e., oppression). Internalized dominance is the incorporation of attitudes, beliefs, or ideologies about the inferiority of other social groups and/or the superiority of one's own social group. Conversely, internalized oppression is the incorporation of attitudes, beliefs, or ideologies about the superiority of other social groups and/or the inferiority of one's own social group.

At the level of the individual, a biopsychosocial approach represents the interaction of interpersonal and internalized oppression with psychosocial and behavioral factors as well as biophysical (including genetic) processes. Individuals with various social identities who have disparate exposure to interpersonal and internalized oppression experience differential health outcomes by way of the processes shown. These processes also feed back into the interpersonal and structural realms, such that these three levels together enact on each other. The first step toward measuring the effects of racism, as represented in Figure 1, is to understand how racism can be operationalized as a determinant of health.

Conceptualizing Racism

In conceptualizing racism as a determinant of health, it should first be recognized that racism is only one of several causes of ethnoracial disparities in health. Genetic, sociocultural, and socioeconomic differences between ethnoracial groups also contribute to such disparities. Sociocultural and socioeconomic factors are substantial drivers of ethnoracial health disparities that are both strongly and bi-directionally influenced by racism. On the other hand, aside from the case of epigenetics touched on briefly below, genetic variation accounts for only a small fraction of ethnoracial health disparities (Diez Roux, 2012).

To the extent that racism drives health and well-being, it does so in interaction with other oppressions such as sexism, ageism, and classism (Bauer, 2014). Oppression is manifested in societies through the unequal distribution of power (resources, opportunities, benefits, capacities, etc.) among social groups resulting from attitudes, beliefs, behaviors, norms, and practices relating to these social groups (Berman and Paradies, 2010). The phenomenon of oppression is also intrinsically linked to that of privilege. Specifically, in addition to disadvantaging minority racial groups in society, racism also fundamentally results in some groups (e.g., Whites) systematically accruing unearned advantage (Monahan, 2014).

Systemic oppression can be defined as the production, control, and access to material, information, and symbolic resources within a society that serve to increase power differentials between social groups. Systemic racism, which has also been referred to as institutional (or institutionalized), structural, cultural, societal, and civilizational racism, is an example of systemic oppression which profoundly shapes an individual's place of residence, living conditions, and socioeconomic position (SEP).

An individual's social locations then become the backdrop upon which interpersonal and internalized oppression are perpetrated. Interpersonal oppression is the interactions between individuals that serve to increase power differentials between social groups. Internalized oppression can be defined as the incorporation of attitudes, beliefs, or ideologies within an individual's worldview that result in the unequal distribution of power among social groups. There are two forms – internalized dominance (i.e., privilege) and internalized oppression (i.e., oppression). Internalized dominance is the incorporation of attitudes, beliefs, or ideologies about the inferiority of other social groups and/or the superiority of one's own social group. Conversely, internalized oppression is the incorporation of attitudes, beliefs, or ideologies about the superiority of other social groups and/or the inferiority of one's own social group (Berman and Paradies, 2010).

Above and beyond the complexity of conceptualizing racism, its impact in society is mediated through expression in individual behaviors and institutional practices. These action-oriented aspects of racism are often encompassed by the term ‘racial discrimination’ which can be broadly defined as differential and unfair/negative treatment centered on notions of ethnoracial difference, which can also include distinctions relating to culture, accent, language, nationality, and religion (on this last, see also Taras, 2013; Meer, 2013). The study of racism as a determinant of health has, to date, predominately focused on understanding how discrimination impacts upon health via several recognized pathways: (1) reduced access to social outcomes such as employment, housing, and education, and/or increased exposure to risk factors (e.g., racial violence); (2) negative cognitive/emotional and related pathopsychological processes (hyper-vigilance (Clark et al., 2006; Hicken et al., 2013), anticipatory/attributional anxiety (Sawyer et al., 2012; Mendes et al., 2008) and rumination (Borders and Liang, 2011; Borders and Hennebry, 2015)); (3) allostatic load and concomitant pathophysiological processes; (4) diminished participation in healthy behaviors (e.g., sleep and exercise) and/or increased engagement in unhealthy behaviors (e.g., alcohol consumption and smoking) either directly as stress coping or indirectly via reduced self-regulation (Smart Richman and Lattanner, 2014); (5) physical injury as a result of racially motivated violence (Paradies, 2006b; Brondolo et al., 2011; Harrell et al., 2011; Pascoe and Richman, 2009; Priest et al., 2013; Gee et al., 2009). Building on conceptual diagrams in existing scholarship (Paradies, 2006a; Harrell et al., 2011; Pascoe and Richman, 2009; Williams, 1997), Figure 1 broadly details these multiple pathways linking discrimination to ill-health.

Above and beyond clearly delineated definitions and conceptual models detailing plausible pathways leading from racial discrimination to ill-health, empirical research to measure and assess these impacts require further explication of how racism can be operationalized as a determinant of health.