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Health gap in England and Wales, 2011 Census
The
social determinants of health in poverty describe the factors that affect impoverished populations'
health and
health inequality.
Inequalities in health stem from the conditions of people's lives, including
living conditions, work environment,
age, and other social factors, and how these affect people's ability to respond to
illness. These conditions are also shaped by political, social, and economic structures.
The majority of people around the globe do not meet their potential
best health because of a "toxic combination of bad policies, economics,
and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.
Poverty and poor health are inseparably linked. Poverty has many dimensions – material deprivation (of food,
shelter,
sanitation, and safe drinking water),
social exclusion, lack of education,
unemployment,
and low income – that all work together to reduce opportunities, limit
choices, undermine hope, and, as a result, threaten health. Poverty has been linked to higher prevalence of many health conditions, including increased risk of
chronic disease, injury, deprived infant development, stress, anxiety, depression, and
premature death.
According to Loppie and Wien, these health afflictions of poverty most
burden outlying groups such as women, children, ethnic minorities, and
the disabled.
Social determinants of health – like
child development,
education, living and
working conditions, and
healthcare - are of special importance to the impoverished.
According to Moss, socioeconomic factors that affect impoverished populations such as education,
income inequality, and
occupation, represent the strongest and most consistent predictors of health and mortality. The inequalities in the apparent circumstances of individual's lives, like individuals' access to health care,
schools, their conditions of work and
leisure,
households, communities, towns, or cities, affect people's ability to lead a flourishing life and maintain health, according to the
World Health Organization.
The inequitable distribution of health-harmful living conditions,
experiences, and structures, is not by any means natural, "but is the
result of a toxic combination of poor social policies and programmes,
unfair economic arrangements, and bad politics".
Therefore, the conditions of individual's daily life are responsible
for the social determinants of health and a major part of health
inequities between and within countries. Along with these social conditions, "Gender, education, occupation, income,
ethnicity, and place of residence are all closely linked to people's access to, experiences of, and benefits from health care." Social determinants of disease can be attributed to broad social forces such as
racism,
gender inequality, poverty, violence, and war.
This is important because health quality, health distribution, and
social protection of health in a population affect the development
status of a nation.
Since health has been considered a fundamental human right, one author
suggests the social determinants of health determine the distribution of
human dignity.
Definitions and measurements
Social determinants of health in poverty reveal inequalities in health.
Health is defined "as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do".
Measurements of health take several forms including subjective health
reports completed by individuals and surveys that measure physical
impairment, vitality and well being, diagnosis of serious chronic
disease, and expected life longevity.
The
World Health Organization defines the social determinants of health as "the conditions in which people are born, grow, live, work and age", conditions that are determined by the distribution of money, power, and resources at global, national, and local levels.
There exist two main determinants of health: structural and proximal
determinants. Structural determinants include societal divisions between
social, economic, and political contexts, and lead to differences in
power, status, and privilege within society. Proximal determinants are
immediate factors present in daily life such as family and household
relationships, peer and work relationships, and educational
environments. Proximal determinants are influenced by the social stratification caused by structural determinants. According to the
World Health Organization, social determinants of health include early
child development,
globalization,
health systems, measurement and evidence, urbanization, employment conditions,
social exclusion, public health conditions, and women and
gender equality.
Different exposures and vulnerabilities to disease and injury
determined by social, occupational, and physical environments and
conditions, result in more or less vulnerability to poor health. The World Health Organization's Social Determinants Council recognized two distinct forms of social determinants for health-
social position
and socioeconomic and political context. The following divisions are
adapted from World Health Organization's Social Determinants Conceptual
Framework for explaining and understanding social determinants of
health.
Social position
Poverty gradient and severity
Within the impoverished population exists a wide range of real income, from less than US$2 a day, to the United States
poverty threshold, which is $22,350 for a family of four.
Within impoverished populations, being relatively versus absolutely
impoverished can determine health outcomes, in their severity and type
of ailment. According to the World Health Organization, the poorest of
all, globally, are the least healthy. Those in the lowest economic distribution of health,
marginalized
and excluded, and countries whose historical exploitation and
inequality in global institutions of power and policy-making, suffer the
worst health outcomes. As such, two broad categories distinguish between relative severity of poverty.
Absolute poverty
is the severe deprivation of basic human needs such as food, safe
drinking water and shelter, and is used as a minimum standard below
which no one should fall regardless of where they live. It is measured
in relation to the 'poverty line' or the lowest amount of money needed
to sustain human life.
Relative poverty is "the inability to afford the goods, services, and activities needed to fully participate in a given society." Relative poverty still results in bad health outcomes because of the diminished
agency of the impoverished.
Certain personal, household factors, such as living conditions, are
more or less unstable in the lives of the impoverished and represent the
determining factors for health amongst the poverty gradient.
According to Mosley, these factors prove challenging to individuals in
poverty and are responsible for health deficits amongst the general
impoverished population.
Having sufficient access to a minimum amount of food that is nutritious
and sanitary plays an important part in building health and reducing
disease transmission.
Access to sufficient amounts of quality water for drinking, bathing,
and food preparation determines health and exposure to disease.
Clothing that provides appropriate climatic protection and resources to
wash clothes and bedding appropriately to prevent irritation, rashes,
and parasitic life are also important to health.
Housing, including size, quality,
ventilation,
crowding,
sanitation, and separation, prove paramount in determining health and spread of disease.
Availability of fuel for adequate sterilizing of eating utensils and
food and the preservation of food proves necessary to promote health. Transportation, which provides access to
medical care, shopping, and employment, proves absolutely essential. Hygienic and
preventative care, including soap and
insecticides, and vitamins and
contraceptives, are necessary for maintaining health. Differential access to these life essentials depending on ability to afford with a given income results in differential health.
Gender
Gender
can determine health inequity in general health and particular
diseases, and is especially magnified in poverty. Socioeconomic
inequality is often cited as the fundamental cause for differential
health outcomes among men and women. According to the
World Health Organization,
the health gap between the impoverished and other populations will only
be closed if the lives of women are improved and gender inequalities
are solved. Therefore, the
WHO sees
gender empowerment as key in achieving fair distribution of health.
The rate at which girls and women die relative to men is higher in low-
and middle-income countries than in high-income countries. "Globally,
girls missing at birth and deaths from excess female mortality after
birth add up to 6 million women a year, 3.9 million below the age of 60.
Of the 6 million, one-fifth is never born, one-tenth dies in early
childhood, one- fifth in the reproductive years, and two-fifths at older
ages.
Excess female deaths have persisted and even increased in countries
immensely affected by the HIV/AIDS epidemic, like South Africa.
In South Africa, excess female mortality between 10 and 50 years of age
rose from close to zero to 74,000 deaths per year in 2008.
In impoverished populations, there are pronounced differences in the
types of illnesses and injuries men and women contract. According to
Ward, poor women have more
heart disease,
diabetes, cancer, and
infant mortality. Poor women also have significant
comorbidity, or existence of two ailments, such as psychiatric disorders with psychoactive substance use. They are also at greater risk for contracting endemic conditions like
tuberculosis, diabetes, and heart disease.
Women of low socioeconomic status in urban areas are more liable to
contract sexually transmitted diseases and have unplanned pregnancies.
Global studies demonstrate that risk for contracting cervical cancer,
exclusive to women, increases as socioeconomic status decreases.
Household causes
Health
of poor women is impacted by gender inequalities through discriminating
distribution of household goods, domestic violence, lack of agency, and
unfair distribution of work, leisure, and opportunities between each
gender. The way in which resources such as income,
nourishment, and
emotional support are traded in the
household influences women's psychosocial health,
nutrition,
wellness, access to healthcare services, and threat of
violence.
The exchange of these elements in a home mediates in the impacts of
geographical, cultural, and household patterns that result in inequality
in health status and outcomes. Health-related behaviors, access and use of healthcare, stress, and psychosocial resources like
social ties,
coping, and
spirituality all serve as factors that mediate health inequality.
Household discrimination causes missing girls at birth, and the
persistence of discrimination and poor service delivery perpetuates high
female mortality.
Societal causes
Socioeconomic
status has long been related to health, those higher in the social
hierarchy typically enjoy better health than do those below.
With respect to
socioeconomic factors, poor institutions of
public health and services can cause worse health in women. According to Moss, components of the geopolitical system that spawn gender and economic inequality, such as
history of a nation,
geography, policy, services,
legal rights,
organizations, institutions, and social structures, are all determinants of women's health in poverty.
These structures, like socieo-demographic status and culture, norms and
sanctions, shape women's productive role in the workplace and
reproductive role in the household, which determines health.
Women's social capital, gender roles, psychological stress, social
resources, healthcare, and behavior form the social, economic, and
cultural effects on health outcomes. Also, women facing financial difficulty are more likely to report chronic conditions of health,
which occurs often in the lives of the impoverished. Socioeconomic
inequality is often cited as the fundamental cause for differential
health outcomes among men and women.
Differences in socioeconomic status and resulting financial
disempowerment for women explain the poorer health and lower healthcare
utilization noted among older women compared to men in India, according
to a study. According to another study, psycho-social factors also contribute to differences in reported health.
First, women might report higher levels of health problems as a result
of differential exposure or reduced access to material and social
factors that foster health and well-being (Arber & Cooper, 1999). Second, women might report higher health problems because of
differential vulnerability to material, behavioral, and psychosocial
factors that foster health.
Prenatal and maternal health
Prenatal care
also plays a role in the health of women and their children, with
excess infant mortality in impoverished populations and nations
representing these differentials in health. According to Ward, poverty
is the strongest predictor of insufficient prenatal care,
which is caused by three factors that reduce access. These include
socieodemographic factors (such as age, ethnicity, marital status, and
education), systematic barriers, and barriers based on lack of
knowledge, attitudes and life-styles. Several studies show the complex associations between poverty and
education,
employment,
teen births, and the health of the mother and child. In 1985, The World
Health Organization estimated that maternal mortality rates were 150
times higher in developing countries than developed nations. Furthermore, increased rates of postpartum depression were found in mothers belonging to low socioeconomic status.
Differential health for men
There also exist differentials in health with respect to men. In many post-transition countries, like the
Russian Federation, excess female mortality is not a problem, but rather there has been an increase in mortality risks for men.
Evidence suggests that excess male mortality correlates with behavior
considered socially acceptable among men, including smoking, binge
drinking, and risky activities.
According to Moss, "Women are more likely to experience role strain
and overload that occur when familial responsibilities are combined with
occupation-related stress."
Age
Social determinants can have differential effects on health outcomes based on age group.
Youth health
Adolescent
health has been proven to be influenced by both structural and proximal
determinants, but structural determinants play the more significant
role. Structural determinants such as national wealth, income
inequality, and access to education have been found to affect adolescent
health.
Additionally, proximal determinants such as school and household
environments are influenced by stratification created by structural
determinants, can also affect adolescent health. Access to education was
determined to be the most influential structural determinant affecting
adolescent health.Proximal determinants include household and community
factors, such as household environment, familial relationships, peer
relationships, access to adequate food, and opportunities for recreation
and activity. The most influential proximal determinant has proven to be family affluence. Family affluence directly affects
food security,
which correlates with adolescent nutrition and health. Family affluence
also influences participation in regular physical activity. While
nutrition and physical activity promote physical well-being, both
promote psychological health as well.
Thus family affluence is correlated with reduced psychological stress
during adolescence. Family affluence also affects access to healthcare
services; however, in countries with universal healthcare systems, youth
belonging to less-affluent households still display poorer health than
adolescents from wealthier families.
One study (that followed individuals from childhood to adulthood)
showed that housing environment impacted mortality, with the main cause
of death being the presence of pollutants in the house. Higher rates of chronic diseases such as obesity and diabetes, as well as cigarette smoking were found in adolescents aged 10–21 belonging to low socioeconomic status.
Infant health
Poverty
during pregnancy has been reported to cause a wide range of disparities
in newborns. Low maternal socioeconomic status has been correlated with
low infant birth weight and preterm delivery,
physical complications such as ectopic pregnancy, poorer infant
physical condition, compromised immune system and increased
susceptibility to illness, and prenatal infant death. Sixty percent of children born into poor families have at least one chronic disease. Infant mental complications include delayed cognitive development, poor academic performance, and behavioral problems. Poor women display greater rates of smoking, alcohol consumption, and engagement in risky behaviors.
Such risk factors function as stressors that, in combination with
social factors such as crowded and unhygienic living environments,
financial difficulties, and unemployment, affect fetus health.
Ethnicity
Ethnicity
can play an especially large part in determining health outcomes for
impoverished minorities. Poverty can overpower race, but within poverty,
race highly contributes to health outcomes.
African Americans, even in some of the wealthiest cities in the
United States, have lower life expectancy at birth than people in much poorer countries like
China or
India.
In the United States, specifically for African American women, as of
2013 for every 100,000 births 43.5 black women would not survive
compared to the 12.7 of white women According to studies, black individuals in
South Africa suffer worse morbidity and mortality rates due to the limited access to social resources. Poverty is the chief cause of the endemic amounts of disease and
hunger and
malnutrition among this population.
A disproportionate number of cases of the AIDS epidemic in North
America are from American minorities, with 72% of women's AIDS cases
among Hispanic or African-American women.
Among those American minorities, African Americans comprise 12% of the
American population yet, made up 45% of new HIV diagnoses. Blacks in
American account for the highest proportion of those living with HIV and
AIDS in America.
Farmer says the growing mortality differentials between whites and blacks must be attributed to class differentials-
which includes recognizing race within impoverished populations.
Recognition of race as a determining factor for poor health without
recognizing poverty has misled individuals to believe race is the only
factor.
A 2001 study showed that even with health care insurance, many African
Americans and Hispanics lacked a health care provider; the numbers
doubled for those without insurance (uninsured: White 12.9%, Black
21.0%, Hispanics 34.3%). With both race and insurance status as
obstacles, their health care access and their health suffered.
Health differentials amongst races can also serve as determining factors for other facets of life, including income and marital status.
AIDS-affected Hispanic women hold smaller salaries than average women,
are part of poorer families, and are more likely to head households.
According to one study, black teenage women living in dysfunctional
homes were more likely to have serious health issues for themselves or
children.
Education
Education plays an especially influential part in the lives of the impoverished.
According to Mirowsky and Ross, education determines other factors of
livelihood like occupation and income that determines income, which
determines health outcomes.
Education is a major social determinant of health, with educational
attainment related to improved health outcomes, due to its effect on
income, employment, and living conditions. Social resources, such as education, determine life expectancy and infant mortality, which measures health. Education has a lasting, continuous, and increasing effect on health.
Education is a special determinant of health because it enables people
toward self-direction, which leads them to seek goals such as health.
Education helps the impoverished develop usable skills, abilities, and
resources that help individuals reach goals, including bettering
health.
Parent's educational level is also important to health, which
influences the health of children and the future population. Parent's
education level also determines child health, survival, and their
educational attainment (Caldwell, 1986; Cleland & Van Ginneken,
1988).
"Children born to more educated mothers are less likely to die in
infancy and more likely to have higher birth weights and be immunized.
Studies in the United States suggest maternal education results in
higher parity, greater use of prenatal care, and lower smoking rates,
which positively affects child health.
An increase in child schooling in Taiwan during the educational reform
of 1968 reduced the infant morality rate by 11%, saving 1 infant per
1000 births.
"Fig. 2.1 shows variation between countries in infant mortality from just over 20/1000 live births in
Colombia to just over 120 in
Mozambique.
It also shows inequities within countries – an infant's chances of
survival are closely related to her mother's education. In
Bolivia,
babies born to women with no education have infant mortality greater
than 100 per 1000 live births; the infant mortality rate of babies born
to mothers with at least secondary education is under 40/1000.All
countries included in Fig. 2.1 show the survival disadvantage of
children born to women with no education."
Political education and Engagement
Mortality inequalities are produced and reproduced by policies that promotes
structural violence for those who are already vulnerable to poverty, while reinforcing the paradigm and the
ontological order of power hierarchy.
Hence, the political engagement of an individual and their communities
play an important factor in determining their access to health care. The
Commission on the Social Determinants of Health discusses that explicit
commitment to action through multidisciplinary public policies are
required for better access to healthcare. One of the recommended action is to expand knowledge and empower the participation of broad segment of society.
A manifestation of such action is the mobilization of the population
that has been historically oppressed and to raise question about the
systemic issues affecting their life.
According to WHO, civic participation does not just better physical
health, but also mental health status, and overall life quality.
History exhibits that when the masses become politically aware of the
problems around them, they are more empowered to find their own voice
and revolt against systemic inequalities to take control of their lives
and improve healthcare accessibility and affordability.
On the contrary, nations that do not empower its citizens to be
politically educated have way worse health outcomes than nations whose
citizens are politically engaged.
For instance, there has been a surge in mortality differentials and
unwavering decline in health benefits coverage, especially among for the
population living under poverty line. As stated in
Global Health Promotion, over the last 10 years there has been a steady loss of health coverage for 1 million people every year.
Losing health coverage means that an individual could no longer seek
affordable treatment or access healthcare, so their health quality would
eventually deteriorate. However, if the citizens were to raise their
concerns collective to the government, they would have been able to
address this systemic factor and subsequently improve their health
outcomes.
Occupation
Impoverished
workers are more likely to hold part-time jobs, move in and out of
work, be migrant workers, or experience stress associated with being
unemployed and searching unsuccessfully for unemployment, which all in
turn affects health outcomes. According to the
World Health Organization, employment and working conditions greatly affect health equity (Kivimaki et al., 2003).
This occurs because poor employment conditions exposes individuals to
health hazards, which are more likely for low-status jobs.
Evidence confirms that high job demand, low control, and low rewards
for effort in these low status jobs are risk factors for mental and
physical health problems, such as a 50% excess risk of heart disease
(Stansfeld & Candy, 2006).
The growing power of massive, conglomerate global corporations and
institutions to set labor policy and standards agendas has disempowered
workers, unions, and the job-seeking by subjecting these individuals to
health-damaging working conditions. (EMCONET, 2007).
In high- income countries, there has been a growth in job insecurity
and precarious employment arrangements (such as informal work, temporary
work, part-time work, and piecework), job losses, and a weakening of
regulatory protections. Informal work can threaten health through its
precarious job instability, lack of regulation to protect working
conditions and occupational health and safety. Evidence from the
WHO suggests mortality is greater among temporary workers than permanent workers. (Kivimaki et al., 2003). Since most of the global workforce operates under the informal economy, particularly low- and middle-income countries, impoverished populations are greatly affected by these factors.
Socioeconomic and political context
Location
Nation-state/geographical region
Which
particular nation an impoverished person lives in deeply affects health
outcomes. This can be attributed to governmental, environmental,
geographical, and cultural factors. Using life expectancy as a measure
of health indicates a difference between countries in likeliness of
living to a certain age. Where people are born dramatically impacts
their life chances. High-income countries like
Japan or
Sweden have a life expectancy of 80 years,
Brazil-72,
India-63. The
WHO
cites that for rich countries, only 56 (Iceland) to 107 (US) of 1000
adults between 15 and 60 years old will die each year, while Western and
Central African countries have adult mortality rates exceeding 300 and
400 of every 1000. The rates are even higher in African nations
suffering the AIDS epidemic, such as
Zimbabwe where 772 of 1000 adults die each year (WHO 2010). Also, the type of health affliction varies by countries for populations in poverty. Over 80% of
cardiovascular disease deaths, that totaled 17.5 million people globally in 2005, occur in low- and middle-income countries. According to the
WHO,13500
people die from smoking every day, and soon it will become the leading
cause of death in developing countries, just as in high income
countries. (Mathers & Loncar, 2005).
Infant and
maternal mortality
also reveals disparity in health between nations. There exist great
inequalities in infant death rates within and between countries, ranging
from 20/10000 births in Columbia to 120/10000 in Mozambique.
In 1985, The World Health Organization estimated that maternal
mortality rates were 150 times higher in developing countries than
developed nations.
Urban or rural location
Urban
The location where people live affects their health and life outcomes, which means impoverished people's health outcomes are especially determined by whether they live in a
metropolitan area or rural area.
In the 19th and 20th century, slums developed in cities and the ensuing
crowding, poor sanitation, and inadequate dwellings brought infectious
disease and illnesses, causing public health concerns. With the prevalence of inner city
ghettos and
slums around the globe in cities, with approximately 1 billion people living in slums globally,
living situation is an especially strong determinant of health in
poverty. Urban areas present health risks through poor living
conditions, limited food resources, traffic accidents, and
pollution.
Urbanization is immensely altering public health problems,
particularly for the poor, by directing it towards non-communicable
diseases, accidental and violent injuries, and death and health impacts
from ecological disaster. (Capbell &Campbell, 2007; Yusuf et al.,
2001). Daily living conditions enormously impact health equity too.
Equity in living conditions, such as access to quality housing and
clean water and hygiene, have been greatly degraded in urban areas by
increasing
car dependence,
land use for roads, inconvenience of non-car transportation, air
quality, greenhouse gas emissions, and lack of physical activity (NHF,
2007).
The challenges of urban areas, such as high population density,
crowding, unsuitable living conditions, and little social support,
provide a special challenge to the disabled and populations in low and
middle income countries(Frumkin et al., 2004).
- Obesity: Obesity is a paramount problem, especially among the poor and socially disadvantaged, in cities worldwide, according to the WHO (Hawkes et al., 2007; Friel, Chopra & Satcher, 2007). The increased amount of obesity can be contributed to the nutrition transition
that describes how people are now increasingly turning to high-fat,
sugar, and salt food sources because of their availability and price.
This food transition has fueled the obesity epidemic. This nutrition
transition tends to start in cities because of "greater availability,
accessibility, and acceptability of bulk purchases, convenience foods,
and 'supersized' portions" (Dixon et al., 2007).
Physical activity and exercise is strongly determined by the design of
cities, including density of homes, heterogeneous land uses, the extent
to which streets and sidewalks connect, the walkability, and the
provision of and access to local public accommodations and parks for
recreation and play.
These factors, along with increasing reliance on cars, results in the
shift of the population toward physical inactivity, which damages health
(Friel, Chopra & Satcher, 2007).
- Crime: Violence and crime are major urban health challenges.
Worldwide, 90% of the 1.6 million annual violent deaths occur in low and
middle income counties(WHO, 2002). A large number of deaths and injuries occur because of crime, which affects health.
- Traffic: Individuals in ghettos and urban areas are the most
affected by traffic injuries and vehicle-created air pollution, which
causes 800,000 annual deaths due to air pollution, and 1.2 million from
traffic accidents. (Roberts & Meddings, 2007; Prüss- Üstün &
Corvalán, 2006). This results in greater health risks, like death, for impoverished populations in cities.
- Mental illness: Living in a ghetto increases the likelihood of
developing a mental illness, especially in children. People in this
environment are less likely to receive effective mental health services.
Children exposed to ongoing poverty, present in a ghetto, present a
high level of depression, anxiety, social withdrawal, peer conflict and
aggression.
Mental health symptoms are increased in the ghetto due to exposure to
community crime, gang induced violence, neighborhood drug infestations,
and substandard housing conditions.
- Other: In the United States, HIV is more prevalent in cities along
the east coast, with prevalence among African-American women in cities 5
to 15 times higher than for women in all areas of that state.
"Inner-city women are the most likely of all in the United States to
birth dead or extremely sick babies, partially because the massive
erosion of prenatal care availability in their area.
Slums, made up exclusively of extremely poor populations, provide a
particularly strong threat for poor health. Child mortality in the slums
of Nairobi, which 60% of the population inhabits, is 2.5 times greater
than in other areas of the city. In the slums of Manila, 39% of children have TB, which is twice the national average.
The term ‘housing instability’ describes a condition in which people
have been or will be homeless in the future. People facing such
instability have poorer health care access and more acute health
problems than the rest of the population.
A city populations grew and rents rose, those receiving Section 9
housing vouchers could no longer afford the rising rents and were forced
to move away.
Rural
Living in a rural community, whether in the United States, or around the globe, reduces access to medical services,
health insurance, and changes health culture.
Differentials exist between rural and urban communities, and some
health disadvantages exist for impoverished rural residents. Since
health of a population increases in geographical locations that have a
higher prevalence of primary care physicians,
rural areas face worse health. According to certain studies, measures
of health and well-being indicate that rural populations have worse
health outcomes. Rural residents have a greater rate of premature mortality (less than age 75 at death) than urban residents.
According to certain studies in the United States, the death rate of
individuals age 1–24 years was 31% higher than those in urban counties.
The death rate of adults 25 to 64 years old was 32% higher among rural
residents than those of suburban counties and of urban counties. These higher death rates were contributed to unintentional injuries, suicide, and chronic obstructive pulmonary disease.
In 1997 in the United States, 18% of adults in rural areas had chronic
health conditions, compared to only 13% of suburban adults. The National Health Interview Survey indicated that in 1998, 16% of rural adults reported poor health. Poor rural residents have only 21% Medicaid coverage, while poor urban populations report 30% coverage. Demographic and socioeconomic factors vary between rural and urban areas, which contributes to some health disparities.
For extremely poor rural communities, variables in the community, like
ecological setting, including climate, soil, rainfall, temperature,
altitude, and
seasonality greatly impact health.
"In rural subsistence societies, these variables can have strong
influence on child survival by affecting the quantity and variety of
food crops produced, the availability and quality of water, vector-borne
disease transmission"
Governance/policy
Type
and structure of governments and their social and economic policy more
deeply affects the health of the impoverished than other populations. Every component of government- from finance, education, housing, employment, transportation, and
health policy- affects population health and health equity. Life expectancy variation between countries can be partially attributed to the type of political regime, whether that be
fascist,
communist,
conservative, or
social-democratic.
However, changing the status of government regime does not always end
the type of policies in place, as seen in South Africa. The end of South
Africa's apartheid regime has still not dismantled the structures of
inequality and oppression, which has led the persistent social
inequality to perpetuate the spread of HIV, diminishing population
health. Also, the political economy, encompassing production organization, physical
infrastructure, and political institutions play a large role in determining health inequalities.
Social service and healthcare availability
Impoverished people depend on healthcare and other social services to be provided in the
social safety net,
therefore availability greatly determines health outcomes. Since low
living standards greatly influence health inequity, generous social
protection systems result in greater population health, with lower
mortality rates, especially in disadvantaged populations.
A successful example of such social service program is the Senior
Companion program, an extension of the United States federal program
Senior Corps. The program provides assistance for adults who have physical and mental disadvantages.
It pairs up senior volunteers with patients who come from low-income
background to help them increase their social capability, ability to
live independently and more accessibility to healthcare. A mixed-method
study explores that the program does target various social determinants
of health and have positive effects on enrolled elders' health status
(although less positive correlation long-term). It concludes that the program does have enthusiastic impacts on clients and volunteers' overall wellness.
The result is homogeneous with conclusions from other studies, with
emerging themes include: companionship, reduced depression, access to
healthcare, isolation, and increased social network.
Nations that have more generous social protection systems have better population health (Lundberg et al., 2007). More generous family policies correlate with lower infant mortality.
Nations that offered higher coverage and reimbursement for pensions and
sickness, unemployment, and employment accident insurance have a higher
LEB (Lundberg et al., 2007), as well as countries with more liberal
pensions have less senior mortality. (Lundberg et al., 2007)
Healthcare
The
health care system represents a social determinant of health as well as
it influences other determining factors. People's access to health
care, their experiences there, and the benefits they gain are closely
related to other social determinants of health like income, gender,
education, ethnicity, occupation, and more. For poor people, systematic barriers in the social structure are formidable, especially financing.
Medicaid and maternity coverage structures have complex and
time-consuming registration processes, along with long waits and unsure
eligibility.
A study of the Emergency Department found that the majority of patients
presenting with mental illness were those on Medical (20.4%) and
Medicare (31.5%), whereas only 12.4% of privately insured patients
presented with mental illness. California has expanded its eligibility
of Medi-Cal under federal law to cover as many people as possible.
Inequalities in health are also determined by these socioeconomic and cultural factors. Health care is inequitably distributed globally, with pronounced inequality for the poor in low- and middle-income countries.
One study demonstrated that doctors treat poor populations differently,
showing that disadvantaged patients are less likely to receive the
recommended diabetic treatments and are more likely to undergo
hospitalization due to the complications of diabetes (Agency for Health
Care Research and Quality, 2003). According to the
WHO,
healthcare systems can most improve health equality when institutions
are organized to provide universal coverage, where everyone receives the
same quality healthcare regardless of ability to pay, as well as a
Primary Healthcare system rather than emergency center assistance.
These structural problems result in worse healthcare and
therefore worse health outcomes for impoverished populations. Health
care costs can pose absolutely serious threats to impoverished
populations, especially in countries without proper social provisions.
According to US HHS, "In 2009, children 6–17 years of age were more
likely to be uninsured than younger children, and children with a family
income below 200% of the poverty level were more likely to be uninsured
than children in higher-income families." In elderly populations, individuals below 400% of the poverty line were between 3 and 5 times more likely to lack insurance. Children below 200% of the poverty line were also less likely to have insurance than wealthier families.
Also, in 2009 in the US, 20% of adults (ages 18–64) below 200% of the
poverty line did not receive their necessary drugs because of cost,
compared to only 4% of those above 400% of the poverty line. Increasing healthcare costs (including higher premiums) imposed a burden on consumers.
In 2010, President Obama introduced the Patient Protection and
Affordable Care Act (ACA), expanding health care to many that lacked
coverage. The U.S. had the highest rate of uninsured people, and the
highest health care costs, of all industrialized nations at the time.
The ACA helped 20 million Americans get coverage and decreased the rates
of uninsured from 16% in 2010 to 8.6% in 2016. The ACA brought coverage
to people who had suffered from downgrades in Employee Insurance
programs, by providing a health insurance marketplace, giving them
access to private insurance plans along with income-based government
subsidies.
This can be seen in other nations, where in Asia, payments for
healthcare pushed almost 3% of the population of 11 countries below 1
US$ per day.
Societal psychological influences
In impoverished communities, different
social norms and stressors exist than in other populations, which can greatly affect health outcomes in disadvantaged populations.
According to the National Institutes of Health, "low socioeconomic
status may result in poor physical and/or mental health ... through
various psychosocial mechanisms such as poor or 'risky' health-related
behaviors, social exclusion, prolonged and/ or heightened stress, loss
of sense of control, and low self-esteem as well as through differential
access to proper nutrition and to health and social services (National
Institutes of Health 1998)."
These stressors can cause physiological alterations including increased
cortisol, changed blood-pressure, and reduced immunity which increases
their risks for poor health.
Structural violence
Underlying social structures that propagate and perpetuate poverty and suffering-
structural violence-
majorly determine health outcomes of impoverished populations. Poor and
unequal living conditions result from deeper structural conditions,
including "poor social policies and programs, unfair economic
arrangements, and bad politics,"
that determine the way societies are organized. The structure of the
global system causes inequality and systematic suffering of higher death
rates, which is caused by inequity in distribution of opportunities and
resources, which is termed
structural violence.
Definition
Structural violence is a term devised by
Johan Galtung and
liberation theologians
during the 1960s to describe economic, political, legal, religious, and
cultural social structures that harm and inhibit individuals, groups,
and societies from reaching their full potential.
Structural violence is structural because the causes of misery are
"embedded in the political and economic organization of our social
world; they are violent because they cause injury to people."
Structural violence is different from personal or behavioral violence
because it exclusively refers to preventable harm done to people by no
one clear individual, but arises from unequal distribution of power and
resources, pre-built into social structure.
Structural violence broadly includes all kinds of violations of human
dignity: absolute and relative poverty, social inequalities like gender
inequality and racism, and outright displays of human rights violations. The idea of structural violence is as old as the study of
conflict and
violence, and so it can also be understood as related to
social injustice and
oppression.
Effects
Structural
violence is often embedded in longstanding social structures,
ubiquitous throughout the globe, that are regularized by persistent
institutions and regular experience with them.
These social structures seem so normal in our understanding of the
world that they are almost invisible, but inequality in resource access,
political power,
education,
healthcare, and legal standing are all possible perpetrators of structural violence. Non citizens do not have access to medical insurance and healthcare and must seek care in clinics and outpatient departments.
Structural violence occurs "whenever persons are harmed, maimed, or
killed by poverty and unjust social, political, and economic
institutions, systems, or structures"
Structural violence can contribute to worse health outcomes through
either harming or killing victims, just like armed violence can have
these effects. This type of unintended harm perpetuated by structural violence progressively promotes misery and
hunger that eventually results in death, among other effects.
Ehrlich and Ehrlich reported in 1970 that between 10 and 20 million of
the 60 million annual deaths across the globe result from starvation and
malnutrition.
Their report also estimated that structural violence was responsible
for the end of one billion lives between 1948 and 1967 in the third
world.
Structural violence connection to health
Inequality in daily living conditions stem from unseen social structures and practices.
This systematic inequality is produced by social norms, policies, and
practices that promote the unfair distribution of power, wealth, and
other social resources,
such as healthcare. "The poor health of the poor, the social gradient
in health within countries, and the marked health inequities between
countries are caused by the unequal distribution of power,
income,
goods, and
services, globally and nationally." First, structural violence is often a major determinant of the distribution and outcome of disease. It has been known for decades that epidemic disease is caused by structural forces. Structural violence can affect disease progression, such as in
HIV, where harmful social structures profoundly affect
diagnosis,
staging, and
treatment of HIV and associated illnesses.
The determinants of disease and their outcome are set by the social
factors, usually rampant with structural violence, that determine risk
to be infected with the disease.
Understanding how structural violence is embodied at the community,
individual, and microbial levels is vital to understanding the dynamics
of disease.
The consequences of structural violence is post pronounced in the
world's poorest countries and greatly affects the provision of clinical
services in these countries. Elements of structural violence such as "social upheaval, poverty, and
gender inequality decrease the effectiveness of distal services and of
prevention efforts" presents barriers to medical care in countries like Rwanda and Haiti
Due to structural violence, there exists a growing outcome gap where
some countries have access to interventions and treatment, and countries
in poverty who are neglected. With the power of improved distal
interventions, the only way to close this outcome gap between countries
who do and do not have access to effective treatment, lies on proximal
interventions to reduce the factors contributing to health problems that
arise from structural violence.
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