The social determinants of health are the broad range of conditions in which people are born, grow, live, work, and age within. These determinants are significantly shaped by the distribution of money, power, and resources. In turn these determinants shape the opportunities (or lack of) that each person has to attain full health potential (Center for Disease Control & Prevention 2019). These determinants are extremely intertwined with one another, and a deficient in one determinant can act like a domino cascade throughout all of the other determinants.
The main social determinants of health include: (Government of Canada, 2020)
Income and social status
Employment and working conditions
Education and literacy
Childhood experiences/early childhood development
Physical environments
Social supports and coping skills
Healthy behaviours
Access to health services
Biology and genetic endowment
Gender
Culture
Race / Racism
Social determinants can directly impact how the government (municipal, provincial, and/or federal) decides to focus their legislation and funding in relation to health & access across the country. For example, the provincial & municipal government fund a dental clinic in an underserved area of my home city, Halifax. This in return has an immense positive impact on the unmet dental health needs for those within the community. Many of the legislation, policies and funding aim to achieve health equity. Health equity is attainment of the highest level of health for all people. Achieving this requires everyone being valued equally with focused societal policies to address inequalities & social positions, or other socially determined circumstance (Center for Disease Control & Prevention 2019).
Regardless of which end of the spectrum an individual falls these determinants influence their level of health. Many determinants are intertwined with one another, and can perpetuate an individual remaining on the lower end of the spectrum. Some determinants and their relation to health can be clear, such as income and income distribution. Extreme differences in income and wealth, for example, have negative health consequences for those who are living in poverty, with those effects are magnified when these people are congregated in poor regions. In contrast, those who are well-off and living in well-off regions have better overall health.
Higher income levels also can result in higher levels of educational. This can result in individuals having access to less hazardous jobs, reduce their risks associated with workplace injuries (both acute & chronic). In addition, education attainment proves more access to employment with job security, retirement plans, and health insurance that is not covered by government health programs. (Canada Public health association N.D.)
The impact of some determinants are also not always clear. For example social supports - social exclusion (or social inclusion). This does not generally lead straight to thoughts of health, we commonly associated social with how many friends one has. But from the perspective of a single mother social exclusion can mean lack of access to emergency child care when she has to stay late at her job. For a teenager with depression it can mean the one or two people they can reach out to. A neighbour checking in on an elderly woman may be the only means of social inclusion she has. Without that neighbour she may go days without human interaction and, in some cases, personal support care. Social inclusion/exclusion can have a huge impact on our health outcomes (Canada public health association N.D.).
Further education is also associated with improved health literacy. Individuals need to understand the health information they are provided to take control of their health. For one person this may mean being able to follow the directions for taking a prescribed medication, knowing where to go when they have questions about their health, or being able to explain their concerns to a health care provider. Without adequate health literacy a person is dependent on those around them knowing and providing what they need for their best health, which can often result in inadequate care (Canada public health association N.D.).
In Nova Scotia healthcare consumes 46% of the provincial budget. These costs are rising, rising faster than provincial revenue. (Kronstein 2017) One of the biggest social determinants, especially here in NS is income and income distribution. As an individuals income level decreases so do their general living conditions, psychological functioning, diet/exercise, which in turn causes them to be more prone to heath problems. From 1991 to 2007 NS's GDP per capita grew by about 70%, yet the median wage after infiltration for the average nova scotia dropped by 5%, and the lower an individuals income was the more it dropped. This increase in wealth went to those who were already 'rich'. Since 1991 to 2007 the portion of wealth going to the average worker declined by 75%, however the portion that went to the employer, investor, or other owner went up by 140% (Kronstein 2017). While these stats surround just one determinant of health their implications are enormous. Income levels can impact almost every other determinant of health, and cause health equity to be further from attainable.
A classmate shared an excerpt which shows how complex, and how interrelated all of the social determinants are. It is never simply a ‘quick fix’ there is always more behind a situation.
“Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg, and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junkyard next to his apartment building
and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junkyard?
Because his neighbourhood is kind of run down. A lot of kids play
there and there is no one to supervise them.
But why does he live in that neighbourhood?
Because his parents cannot afford a nicer place to live.
But why can’t his parents afford a nicer place to live?
Because his Dad is unemployed, and his Mom is sick.
But why is his Dad unemployed?
Because he does not have much education and he cannot find a job.
But WHY...?” (Federal & Provincial Population health Advisory Committee, 1999)
The Social Determinants of Health & Dental Hygiene.
Income and Social Status - If someone has a lower SES they may not have funds to receive costly dental care. Here in Nova Scotia a routine hygiene visit/xrays/checkup is approximately $120 without private insurance coverage.
Employment and Working Conditions - If someone doesn’t have dental insurance through work, or if they don’t have access to paid appointment/sick time they may not have time available, or funds to access dental care.
Education and Literacy - If an individual, or their family growing up, has a lower education level they may not place importance on proper dental care, if they have a lower education level they may have a lower health literacy, which may make it difficult to understand 'dental language' and could impact the quality of care they receive. In dental patients are presented with options regarding a dental treatment, along with the costs (unfortunately this is always a large decision making factor), and then the patient can hopefully make an informed decision from that.
Childhood experiences/Early Childhood Development - As sad as it is many children have poor experience as a child visiting the dentist this can cause them to be apprehensive for any future dental visits. Their caregivers as a child may not place a large emphasis on dental care which can result in a lifelong decrease in good oral hygiene.
Physical Environment - If an individual is in a remote/rural location, they may not have access to dental care, or dental care access may be hours of travel away.
Social Supports and Coping Skills - If family members do not place an emphasis on dental care (both growing up & current circle of support) an individual may not place emphasis on proper preventative and maintenance care. If an individual does not have good coping skills when they do have a dental issue they may choose not to deal with a more complex treatment option such as (cost aside) a root canal/crown compared to just extracting a tooth (3-4 long appointments compared to 1 for an extraction).
Healthy Behaviours - if individuals do not eat healthy foods (for a variety of reasons that stem from other social determinants) & drinks their dental health may suffer. If they do not practice regular dental care at home they have a higher risk for decay & periodontal disease (They many not practice proper dental home care for a variety of reasons/social determinants).
Biology and Genetics - Some people are more prone to decay and/or biofilm accumulation than others (teeth morphology, salivary flow, salivary content, etc). Also teeth are more ‘self cleansing’ when in proper alignment - if someone is born with misaligned teeth & does not have funds/access to an orthodontist they may be more prone to decay and periodontal disease.
Gender - An individual may be concerned that they will be misgendered, or judged going to a dental visit. Dental visits are an extremely up close and personal appointment, which may many some apprehensive.
Culture - Dental care does not always have a large emphasis in certain cultures, in some places dental hygiene is non-existent. Individuals only go to the dentist if and when they have a dental concern.
Race - An individual may be concerned about possible racism attending an office, especially If an individual only has access to a dental clinic with predominantly staff from another race.
References
Canadian Public Health Association. (N.D.) What are the social determinants of health? (Accessed on feb 7th 2021) https://www.cpha.ca/what-are-social-determinants-health
Center for disease Control and Prevention. (December 19th 2019) Frequently asked questions: Health Equity. https://www.cdc.gov/nchhstp/socialdeterminants/faq.html
Goverment of Canada. (October 2020) Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Kronstein, Alex. (May 11 2017) The Social determinants of health in Nova Scotia. Part 1: Poverty makes you sick. https://nsadvocate.org/2017/05/11/the-social-determinants-of-health-in-nova-scotia-part-1-poverty-makes-you-sick/
Federal, Provincial, and Territorial Advisory Committee on Population Health. The (1999). Toward a healthy future : Second report of healthy Canadians. Ottawa : Minister of Public Works and Government Services Canada.http://publications.gc.ca/collections/Collection/H39-468-1999E.pdf
Mikkonen J., Raphael, D., (2010) Social Determinants of Health: The Canadian Facts. https://thecanadianfacts.org/The_Canadian_Facts.pdf
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