Principles of Public Health Practice/The determinants of health and public health

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Reynaldo Rodriguez with his paint "Majestad Cultural" representing various socio-cultural, political, economic and environmental factors influencing life.

In this topic we look at public health responses to a natural disaster in Australia - the 2011 Queensland Floods. We'll discuss a range of issues and ideas around a response to this event, looking at short videos about the floods. We will also progress your Literature Analysis assignment further, looking at more example literature and discussing them in the tutorials.

Learning activity instructions[edit]

Each week we hold a lectorial and a tutorial. A lectorial is a short lecture followed by a group activity, and the tutorials are for discussion and practising group activities.

Lectorial

  1. View the playlist here.
  2. Read through the topic
  3. Attend the lectorial

Tutorial

  1. Download the tutorial guide and prepare as instructed
  2. Progress your Literature Analysis assignment
  3. Attend the tutorial

How do the various determinants of health influence the manner in which public health might be practiced and why?[edit]

Have you seen the film, Amazing Grace, starring Ioan Gruffudd? If you have, then you understand the tremendous influence that sugar had in the dislocation of hundreds of thousands of people from West Africa to the "New World". Yes, sugar. Not tobacco, nor cotton. Sugar and the processes of commercialisation that made it cheap enough to lace English tea and coffee with.

Now, sugar added beverages are potentially shortening the lives of millions of children around the world. But, then, it was the issue of obtaining cheap and manageable labour. Africans were captured in their homelands and transported in bulk crowded in slaves ships. They worked in appalling physical, social and moral environments that resulted in the death and destruction of most. This practice continued more recently in Australia. It was called "blackbirding" and supplied Aboriginal and Torres Strait Islander people and South Sea Islanders as cheap labour for the Australian cane fields.

The former slaver turned clergyman, John Newton, wrote the hymn, Amazing Grace, as an expression of his gratefulness for 'God's forgiveness'. But, gaining the forgiveness of the flesh and blood people he helped to destroy was not so easy. In the film, Newton is portrayed as living a life of penury and penance until his death. Perhaps more importantly, his personal and pastoral influence on a young boy, William Wilberforce, was of the greatest moment in his campaign to right the wrong he had done to twenty thousand humans. Like Edmund Burke, who sought justice for India, the Americas and Ireland, Wilberforce expended his life's energies to exterminate the slave trade.

He could not do this alone. He was guided and shaped by Hannah More and the other members of the Clapham Sect. They spread out through the world gaining facts, figures and accounts [monitoring and surveillance] of what the slave trade was doing. They engaged the imagination and the compassion of a nation to ensure the enactment of legislation that crippled the slave traders' means of transportation [policy, legislation and regulation]. Eventually, they were able to enact legislation that abolished the trade in its own right. In the film, those who would profit from the misery of others sought every means to foil their adversaries. So, we see what personal character, friendship, loyalty to a cause, physical environment, social conventions, cultural proclivities and political coalitions can do to shape our lives for good or for ill.

But, now sugar endangers a new generation. It does this without regard for nationality, class, ethnicity or gender. In Canada, the health promotion authorities in Ontario are indicating that the youth of today will live, on average, three to five fewer years than recent generations. Who will be the new Wilberforces, Newtons, Pitts, Clapham Sect members in society? Will they literally spend their lives to bring evidence to bear on the complicated interplay of the personal, social and environmental determinants involved?

Background[edit]

Many things have a significant influence on our health. To help us keep track of these, we typically speak about personal (sometimes referred to as individual), social and environmental determinants. Since we are involved in a web of relationships with others, we can only make these distinctions for analytic or philosophical purposes. For instance, where does the person end or begin. Some would say that everything under the skin is the domain of the person. Yet, in some cultures that is not true as a matter of course. We still have vestiges of this in modern or post-modern societies. We still talk about a child who steals our hearts because of its precocity. Or, we speak of someone getting under our skin. Perhaps you have noticed that different people have different comfort zones in terms of how close they will allow another. We can talk about the 'egg of proximity'; many people will generally be more comfortable allowing another closer to their face-side than their back-side (hence, the egg shape zone of proximity). Yet, while what is personal, social and environmental can differ among various people or people groups, there is a fairly common understanding of the following in public health.

Personal might be best thought of the as the person within their immediate circles of influence. Here we are speaking of the person as an individual or as a member of a small grouping such as a family or friendship network with more intense face-to-face links. A personal determinant of health might be a genetic predisposition towards hypertension, or a strong immune system that easily handles bacterial or viral infections. It would include the person's general level of psychological resilience or their ability to bounce back when they have been let down by themselves or others. It would have to do with the resources that they can engender (either consciously or unconsciously create), access and use to deal with the issues that they face. It would include their literacy levels and capacity for further development. It would also include habits and inclinations, as well as attitudes and dispositions. We need to keep these things in mind as we consider how we assess a circumstance or organise groups to make decisions about how we might intervene in a situation.

Social determinants are probably best thought of as pertaining to the network of relationships that we create, use or respond to beyond our immediate circles of influence. For instance, the relationship with a beloved teacher may be a personal determinant, but the ability to access a robust and well provisioned local school is probably better thought of as social determinant. The social determinants are typically mediated through various roles and institutions. They include, in addition to education, employment, health, justice, recreation, transportation and other systems. But, there is a certain interaction that occurs between the personal and social determinants. For instance, a person might exhibit a very definite disposition towards a particular way of thinking that influences their health. Yet, with a little research we can easily see that many people of that class, gender or ethnic group share similar dispositions. In other words, in many cases, how a person thinks or acts is already heavily influenced by their social arrangements. When planning, implementing and evaluating an intervention, we need to keep these dimensions in mind as there will be a number of unintended consequences of activities.

In a sense, our social networks and the relations that obtain within them are an environment for us. Of course, our own bodies are an environment. You would have learned from Anatomy and Physiology that some people speak of homeostasis as the maintenance of an optimal internal environment required for healthy human functioning. So in some ways, we are our own environments. It is important to recognise this. One of the ways to distinguish between an environment and a person or group in the environment is to ask how much immediate control we have over the context. You have little direct control over 'homeostatic' functioning. (Because I am referring to contexts, hypertension would still be personal rather than environmental, as it is a condition or characteristic.) It makes sense to speak of your local school as your entry point into education as a social determinant. (However, asbestos in the ceiling of the school is an environmental issue.) On the other hand, a nation's laws and policies relating to education is probably more of an educational environment. Having employment within a local industry is probably best thought of as a social determinant. The employment 'climate' of a state might be better considered as an environment. Of course, environments influence social determinants which influence personal determinants.

The physical environment is probably the easiest to separate from either the personal or the social. But, not always. Remember we ourselves are embodied and so are our family, friends and employers!

References and Resources

Learning Outcomes[edit]

How do the various determinants of health influence the manner in which public health might be practiced and why?

Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:

  1. Formulate a variety of personal factors that influence health outcomes among people across populations and identify their importance for PH interventions.
  2. Relate the various social factors that may have an affect on the health outcomes of people within populations and indicate their significance for PH interventions.
  3. Outline the types of environmental factors that are known to have an impact on the health outcomes of people within populations and appraise their salience for PH interventions.
  4. Devise a means of explaining the interconnectedness of these various factors through an ecological model that can inform development of PH interventions.