Health is determined by a complex interaction between genetic inheritance, health behaviours, access to quality healthcare and the social determinants of health.
While our genetic makeup, our health behaviours and our access to healthcare impact our health, they are outweighed by the overwhelming impact of social and economic factors – the material, social, political and cultural conditions that shape our lives and our behaviours (Australian Institute of Health and Welfare 2017; Department of Health and Human Services 2017a; Marmot and Allen 2014).
Moreover, the social determinants are largely responsible for inequalities in health outcomes across populations (Department of Health and Human Services 2017a;Marmot and Allen 2014).
Figure 1: The determinants of health and their relative impact
Source: Marmot and Allen 2014
The problem with focusing on individual behaviour
In Australia and internationally, primary prevention of ill-health can sometimes be dominated by a focus on addressing the health behaviours of individuals.
This approach largely ignores the social determinants of health. While individual behaviours such as smoking, diet, exercise and alcohol and drugs are important issues to address, concentrating our efforts too much on individual behaviours may come at the expense of addressing the social determinants of health – the ‘causes of the causes’ (Department of Health and Human Services 2017a; Marmot and Allen 2014).
What are the social determinants of health?
The social determinants of health are shaped by the distribution of money, power and resources and are mostly responsible for health inequities – the health inequalities that are unfair and avoidable.
Social determinants include but are not limited to:
- socioeconomic status
- education
- housing
- transportation
- food security
- psychosocial risk factors
- the social environment
- social support networks
- community and civic engagement
- social and civic trust
- the physical environment, including the natural environment (Department of Health and Human Services 2017a).
Social determinants such as socioeconomic status have long been well-understood to have significant impacts on an individual's health status – the lower the socioeconomic status, the worse the health status (Department of Health and Human Services 2017).
The 20 per cent of Australians living in the lowest socioeconomic areas in 2014–15 were 1.6 times as likely as the highest 20 per cent to have at least two chronic health conditions, such as heart disease and diabetes (Australian Institute of Health and Welfare 2016).
Mothers in the lowest socioeconomic areas were 30 per cent more likely to have a low birthweight baby than mothers in the highest socioeconomic areas in 2013 (Australian Institute of Health and Welfare 2016).
Aboriginal and Torres Strait Islander Australians – who can experience significant social and economic disadvantage - have a life-expectancy approximately 10 years lower than non-Indigenous Australians (Department of Health and Human Services 2017b).
Social connectedness
In many cases, the relationship between social determinants of health and poor health is obvious. It is easy to comprehend how an individual who lives in insecure housing interspersed with periods of homelessness would have poorer health due to the stress and anxiety of unstable accommodation.
Similarly, many people can understand the connection between low income leading to poor nutrition and poorer health outcomes.
Yet the social determinants of health can also lead to outcomes that may not be readily identified as linked.
Social connectedness is now considered to play a significant role in health outcomes, particularly in relation to heart health.
A 2001 study showed that the risk of cardiac death among adults with coronary heart disease was 2.4 times greater for those who were socially isolated compared with those who were socially connected (Brummett, et al. 2001).
Another example of links between social determinants and health that may not be readily identified is found in people who are intolerant of diversity having higher risk of psychological distress than those who are tolerant (Department of Health and Human Services 2017).
Climate change
Climate change has also been identified as another social determinant of health, through its influence on people’s daily living conditions and their access to resources (World Health Organization 2009).
The impacts of climate change are being experienced now in Australia, and they are likely to become greater in coming years.
Victoria has already become warmer and drier and this is likely to continue into the future (Department of Environment, Land, Water and Planning 2015).
As these changes occur, they in turn can impact the social determinants of health by influencing food and water security, the ability to respond to natural disasters, and changing disease distribution (World Health Organization 2009).
Improving the social determinants of health
Much can be done to improve health.
Some of this comes from Australia’s universal health system, designed to allow equitable access to health services.
Changes must also come, however, from wider social and economic changes.
This means all levels of government, along with non-government organisations and others, must work together to make social and economic changes in order to have real impact on the social determinants of health (Marmot and Allen 2014).
Intergenerational disadvantage
In some communities, there are groups of people who have a disproportionate need for welfare support, including successive generations of individual families.
This entrenched disadvantage is often associated with significantly worse health and wellbeing (Australian Institute of Health and Welfare 2017; Public Health Association of Australia, 2018).
Households experiencing intergenerational disadvantag tend to experience limited mobility across income distribution ranges. They remain in the lowest income levels (Australian Institute of Health and Welfare 2017).
This persistent and recurrent poverty, especially in families with long-term parental unemployment, can impact the health and wellbeing of adults and children, and risks entrenching the disadvantage (Public Health Association of Australia, 2018).
Certain groups are more likely to experience persistent disadvantage – defined as experiencing a measurable socioeconomic score for four or more years (Australian Institute of Health and Welfare 2017). They include:
- people living in public housing
- people dependent on income support
- the unemployed
- single parents
- people with a long-term health condition or disability
- Aboriginal Australians
- those with educational attainment of Year 11 or below.
Within these groups, some have a higher risk of passing on that disadvantage than others. For example, children are 1.8 times more likely to receive social assistance if their parents receive single parent payments or disability payments (Cobb-Clark et al 2017). In contrast, other forms of disadvantage, such as parental unemployment seem to be easier for young people to overcome (Cobb-Clark et al 2017).
A number of authors conclude that individuals experiencing persistent disadvantage also experience higher rates of ill-health (Australian Institute of Health and Welfare 2017; Baxter 2012; Productivity Commission 2017).
This further highlights the need to address the social determinants of health if the health of Victorians is to be sustainably and equitably improved.
Find out more
Access the Victorian population health survey for more on the social determinants of health in Victoria.
Access the department's Inequalities in the social determinants of health and what it means for the health of Victorians report.
References
Australian Institute of Health and Welfare 2016, Australia's health 2016, Australian Institute of Health and Welfare, Canberra.
Australian Institute of Health and Welfare 2017, Australia's welfare 2017, Australia's welfare series, no. 13, AIHW, Canberra.
Baxter 2012, 'Family joblessness and child well-being in Australia', in Haskins and Chesters Kalil, eds, Investing in children: work, education and social policy in two rich countries, Brookings Institution Press, Washington DC.
Brummett B, Barefoot J, Siegler I, Clapp-Channing N, Lytle B, Bosworth H, Williams R and Mark D 2001, ‘Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality’, Psychosomatic Medicine, vol. 63, no. 2.
Cobb-Clark D, Dahmann S, Salamanca N and Zhu A 2017, ‘Intergenerational disadvantage: Learning about equal opportunity from social assistance receipt’, Life Course Centre Working Paper Series, University of Queensland, Brisbane.
Department of Environment, Land, Water and Planning 2015, Climate-ready Victoria, State Government of Victoria, Melbourne.
Department of Health and Human Services 2017a, Inequalities in the social determinants of health and what it means for the health of Victorians: findings from the 2014 Victorian Population Health Survey, State Government of Victoria, Melbourne.
Department of Health and Human Services 2017b, Korin Korin Balit-Djak Aboriginal Health, wellbeing and safety strategic plan 2017–27, State Government of Victoria, Melbourne.
Marmot M and Jessica Allen 2014, 'Social determinants of health equity', American Journal of Public Health, vol. 104, no. S4.
Productivity Commission 2017, Rising inequality? A stocktake of the evidence, Productivity Commission, Canberra.
Public Health Association of Australia 2018, Submission to the House of Representatives Select Committee on Intergenerational Welfare Dependence, PHAA, Canberra.
World Health Organization 2009, Natural and unnatural synergies: climate change policy and health equity, World Health Organization, Geneva.
