Risk Factors of Health
Risk Factors and the Social Determinants of Health
Over the past few decades public health has increasingly focused on the concept of risk factors. The identification of risk factors for particular disease processes has come from the use of epidemiological and statistical methods able to associate particular factors with disease. Thus smoking is related statistically to the occurrence of lung cancer, emphysema, ischaemic heart disease and other vascular disease. These associations are not necessarily causes, but the stronger the statistical association the more tempting it is to conclude that a causal relationship is involved. Thus the health industry has increasingly focused on risk factors as a way of trying to prevent particular illnesses. Risk Factors commonly identified as relevant to Aboriginal health include:
- Poor diet, especially high intake of refined carbohydrates and fat
- Substance misuse - alcohol, opiates, solvents, tobacco, marijuana
- Unhygienic living conditions
- High serum cholesterol levels
- Obesity
- High blood pressure
- Lack of exercise
- Inadequate fluid intake
- Sick dogs
- Unprotected sex
However, extrapolating risk factors derived from population data to individual client risks is somewhat reductionist and has questionable validity. Looking for high cholesterol levels, and treating them is dealing with risk factors as if they were a disease. Some have suggested that this can actually be self-fulfilling. Someone being told that they have high cholesterol levels that can increase their chance of heart disease commonly causes a physiological reaction that can add to the risk of heart disease. Of course, it may also prompt a change in behaviour that can reduce the risk. However the ability to change behaviour is related to broader social questions and where the individual sits within social strata. Thus someone of high socio-economic status and high self esteem is more likely to be able to change their behaviour, whereas people living in poverty and who feel bad about themselves are unlikely to reduce their risk of disease through behaviour change. For Aboriginal people, most of the risk factors listed above are largely related to marginalisation and poverty.
Marmot and others , have written extensively in recent years about social determinants - mortality related to social hierarchy and individual self-esteem; about how the width of the gap between rich and poor is an important determinant of the life expectancy in a society; that it is not just to do with absolute poverty levels. They point out that these are large effects, not just minuscule statistical findings. They estimate that only around 30% of disease is accounted for by risk factors. Thus to some extent risk factors may be determining which disease process is activated rather than whether a disease is activated or not.The World Health Organisation (WHO) asked Marmot to put together 10 key messages for better health based on this new work. They came up with the following:
The Social Gradient - people's social and economic circumstances strongly affect their health throughout life. One implication of this is that health policy should not be confined to Departments of Health, but need to run across the whole of society. Aboriginal society has increasingly been pushed to the margins by the dominant colonial society. Even in remote communities the dominant day-to-day influence tends to be in the realm of non-Aboriginal priorities. Thus this factor is a major factor for Aboriginal society. Stress is harmful, particularly chronic, unresolved stress. We mentioned above how the width of the gap between rich and poor is a major determinant of health. For Aboriginal people, they are surrounded by the physical wealth and power of white fellas. This is a stressful circumstance. It is difficult for people to break out of a life that is marked by stress as a consequence of high levels of substance misuse, poor educational and employment opportunities, and surrounded by a lifestyles of another people that cannot be attained. This is an example of chronic, unresolved stress. The effects of early life last a life time, which means their need to be stronger support for mothers and children. Whilst the development of child and maternal programs can help in this area, the main focus tends to be on the physical welfare of the mother and child that does not really go to the heart of the matter. It may improve people's self esteem and confidence much more if Aboriginal women are seen doing this for themselves, rather than the ‘experts' and the best paid health staff always being non-Aboriginal. Social exclusion is harmful. This relates to poverty, and is particularly relevant for marginalised groups in society. Aboriginal society has been excluded from the dominant society from the time of the missions and government settlements to the settlements on the outskirts of towns, incarceration in gaols and psychiatric wards, and the general discrimination that limits access to jobs, and opportunities in the mainstream. Stress in the workplace increases the risk of disease. This is not referring to the busy executive, but those who lack control in the workplace. Where Aboriginal people do have work, it is often in the lower levels of the organisation, where they can exert little influence over their needs. Unemployment and job insecurity increase the risk of disease. Aboriginal society suffers a high level of unemployment, so this too is relevant. Strong social support can prevent disease. This refers to friendships, supportive networks, and good social relationships at home, work and in the community. Aboriginal society has tended to form strong networks as a means of survival. These networks are a positive feature that can be strengthened and nurtured, or weakened by government interventions. Community controlled health services are based on these networks and work to strengthen them. Control of services outside those networks can be potentially damaging to them by creating division within communities. Addictions. Misuse of alcohol, tobacco and other drugs are damaging to health. However, the use of these drugs is influenced by the social gradient with the lowest socio-economic group having the highest rates of misuse. Thus the social position and poverty are themselves are determinant of addictive behaviours. Clearly this is a major issue in Aboriginal society. The provision of high quality food, including the recognition of this as a political matter, not just of individuals choosing to eat good food. This can be seen particularly in some remote communities where the quality of food provided in the store is very poor, and very expensive. Transport also relates to health. Using forms of transport that encourage exercise - walking, bicycles, etc. has a positive impact where continuing reliance on motor vehicles not only does not involve exercise, but also contributes to pollution, greenhouse effect, etc. However, for Aboriginal people access to transport is critical to health in many other ways - getting food, shopping, education, health care, etc. and many lack personal transport. Thus there are two sides to this question for Aboriginal society.
Education should be added to this list. Improving the level of educational attainment is critical to accessing information, making informed decisions, improving chances of getting a job, improving self-esteem and consequently, health status.
There are a few common factors that emerge from this list:
Stress and powerlessness. Poverty. Social relationships.
Clearly the health sector cannot address all of these issues directly. However, how services are delivered and who controls them are critical factors in terms of a health services moving beyond just treating sick people (as important as that is) or telling people what they should do.
Significance for Aboriginal PHC.
Sanders and Werner have written about the problems that comprehensive PHC has faced since that practice was acknowledged and enshrined in the WHO Alma Ata Declaration in 1978 . Comprehensive PHC was community driven and based - that is it was a horizontal process with priorities and directions being driven from the community. At their best ACCHSs work this way to great effect. However over the years many agencies including the WHO, UNICEF and the World Bank, along with national governments and professional bodies have opted for selective rather than comprehensive PHC.
Werner has described three major obstacles in implementing comprehensive PHC:
Selective PHC that was introduced on a broad scale in the early 1980s. Structural Adjustment policies including cost recovery or user-financed health services. This has particularly been imposed on poor debt laden countries by the World Bank, but has also been a persisting political influence in health service development in Australia. The takeover of Third World health policy by the World Bank marked by its 1993 Report Investing in Health.
Some examples of selective PHC are seen in immunisation programs organised from central agencies (ie vertical programs). Sanders and Warner document the negative impact of packaged and marketed Oral Re-hydration Salts that have in some places increased the dependency of people on a supply system for dealing with diarrhoea, rather than maintaining knowledge about the effective use of locally available and cheap alternatives .
The World Bank in its 1993 Report took an approach using economic rationalist language (eg best buys). This report essentially recognised that poor, marginalised populations were not useful to the world economy, and that providing support, albeit targeted and selective according to the estimated ‘worth' of the individual using a measure of Disability Adjusted Life Years (DALYs), was an investment in economic terms .
These obstacles that undermine the functioning and further development of comprehensive PHC is driven by a range of influences, but at the centre is an economic system that makes profit out of ill health. Thus commercial interests (the market place) are more interested in developing products that can be marketed rather than support for a self-reliant alternative. This encourages a focus on technical fixes, rather than people led solutions.
The recent evidence in regard to the determinants of health as outlined above suggest that comprehensive PHC may have the capacity to impact on a range of these determinants linked to power and self esteem which selective interventions from outside the community actually exacerbate.
This is relevant to Aboriginal communities. More Aboriginal people delivering services may be more important than precisely which services are delivered. Comprehensive PHC services have the potential to be a vehicle for community action in regard to problems they perceive, and in the wider sense assist the reconstruction of Aboriginal society.
These issues make community control not just a slogan and rhetoric but a key determinant for improved health in the longer term.Risk Factors and the Social Determinants of Health Over the past few decades public health has increasingly focused on the concept of risk factors. The identification of risk factors for particular disease processes has come from the use of epidemiological and statistical methods able to associate particular factors with disease. Thus smoking is related statistically to the occurrence of lung cancer, emphysema, ischaemic heart disease and other vascular disease. These associations are not necessarily causes, but the stronger the statistical association the more tempting it is to conclude that a causal relationship is involved. Thus the health industry has increasingly focused on risk factors as a way of trying to prevent particular illnesses. Risk Factors commonly identified as relevant to Aboriginal health include:
Poor diet, especially high intake of refined carbohydrates and fat Substance misuse - alcohol, opiates, solvents, tobacco, marijuana Unhygienic living conditions High serum cholesterol levels
Obesity High blood pressure Lack of exercise Inadequate fluid intake Sick dogs Unprotected sex
However, extrapolating risk factors derived from population data to individual client risks is somewhat reductionist and has questionable validity. Looking for high cholesterol levels, and treating them is dealing with risk factors as if they were a disease. Some have suggested that this can actually be self-fulfilling. Someone being told that they have high cholesterol levels that can increase their chance of heart disease commonly causes a physiological reaction that can add to the risk of heart disease. Of course, it may also prompt a change in behaviour that can reduce the risk. However the ability to change behaviour is related to broader social questions and where the individual sits within social strata. Thus someone of high socio-economic status and high self esteem is more likely to be able to change their behaviour, whereas people living in poverty and who feel bad about themselves are unlikely to reduce their risk of disease through behaviour change. For Aboriginal people, most of the risk factors listed above are largely related to marginalisation and poverty.
Marmot and others , have written extensively in recent years about social determinants - mortality related to social hierarchy and individual self-esteem; about how the width of the gap between rich and poor is an important determinant of the life expectancy in a society; that it is not just to do with absolute poverty levels. They point out that these are large effects, not just minuscule statistical findings. They estimate that only around 30% of disease is accounted for by risk factors. Thus to some extent risk factors may be determining which disease process is activated rather than whether a disease is activated or not.The World Health Organisation (WHO) asked Marmot to put together 10 key messages for better health based on this new work. They came up with the following:
The Social Gradient - people's social and economic circumstances strongly affect their health throughout life. One implication of this is that health policy should not be confined to Departments of Health, but need to run across the whole of society. Aboriginal society has increasingly been pushed to the margins by the dominant colonial society. Even in remote communities the dominant day-to-day influence tends to be in the realm of non-Aboriginal priorities. Thus this factor is a major factor for Aboriginal society. Stress is harmful, particularly chronic, unresolved stress. We mentioned above how the width of the gap between rich and poor is a major determinant of health. For Aboriginal people, they are surrounded by the physical wealth and power of white fellas. This is a stressful circumstance. It is difficult for people to break out of a life that is marked by stress as a consequence of high levels of substance misuse, poor educational and employment opportunities, and surrounded by a lifestyles of another people that cannot be attained. This is an example of chronic, unresolved stress. The effects of early life last a life time, which means their need to be stronger support for mothers and children. Whilst the development of child and maternal programs can help in this area, the main focus tends to be on the physical welfare of the mother and child that does not really go to the heart of the matter. It may improve people's self esteem and confidence much more if Aboriginal women are seen doing this for themselves, rather than the ‘experts' and the best paid health staff always being non-Aboriginal. Social exclusion is harmful. This relates to poverty, and is particularly relevant for marginalised groups in society. Aboriginal society has been excluded from the dominant society from the time of the missions and government settlements to the settlements on the outskirts of towns, incarceration in gaols and psychiatric wards, and the general discrimination that limits access to jobs, and opportunities in the mainstream. Stress in the workplace increases the risk of disease. This is not referring to the busy executive, but those who lack control in the workplace. Where Aboriginal people do have work, it is often in the lower levels of the organisation, where they can exert little influence over their needs. Unemployment and job insecurity increase the risk of disease. Aboriginal society suffers a high level of unemployment, so this too is relevant. Strong social support can prevent disease. This refers to friendships, supportive networks, and good social relationships at home, work and in the community. Aboriginal society has tended to form strong networks as a means of survival. These networks are a positive feature that can be strengthened and nurtured, or weakened by government interventions. Community controlled health services are based on these networks and work to strengthen them. Control of services outside those networks can be potentially damaging to them by creating division within communities. Addictions. Misuse of alcohol, tobacco and other drugs are damaging to health. However, the use of these drugs is influenced by the social gradient with the lowest socio-economic group having the highest rates of misuse. Thus the social position and poverty are themselves are determinant of addictive behaviours. Clearly this is a major issue in Aboriginal society. The provision of high quality food, including the recognition of this as a political matter, not just of individuals choosing to eat good food. This can be seen particularly in some remote communities where the quality of food provided in the store is very poor, and very expensive. Transport also relates to health. Using forms of transport that encourage exercise - walking, bicycles, etc. has a positive impact where continuing reliance on motor vehicles not only does not involve exercise, but also contributes to pollution, greenhouse effect, etc. However, for Aboriginal people access to transport is critical to health in many other ways - getting food, shopping, education, health care, etc. and many lack personal transport. Thus there are two sides to this question for Aboriginal society.
Education should be added to this list. Improving the level of educational attainment is critical to accessing information, making informed decisions, improving chances of getting a job, improving self-esteem and consequently, health status.
There are a few common factors that emerge from this list:
Stress and powerlessness. Poverty. Social relationships.
Clearly the health sector cannot address all of these issues directly. However, how services are delivered and who controls them are critical factors in terms of a health services moving beyond just treating sick people (as important as that is) or telling people what they should do.
Significance for Aboriginal PHC.
Sanders and Werner have written about the problems that comprehensive PHC has faced since that practice was acknowledged and enshrined in the WHO Alma Ata Declaration in 1978 . Comprehensive PHC was community driven and based - that is it was a horizontal process with priorities and directions being driven from the community. At their best ACCHSs work this way to great effect. However over the years many agencies including the WHO, UNICEF and the World Bank, along with national governments and professional bodies have opted for selective rather than comprehensive PHC.
Werner has described three major obstacles in implementing comprehensive PHC:
Selective PHC that was introduced on a broad scale in the early 1980s. Structural Adjustment policies including cost recovery or user-financed health services. This has particularly been imposed on poor debt laden countries by the World Bank, but has also been a persisting political influence in health service development in Australia. The takeover of Third World health policy by the World Bank marked by its 1993 Report Investing in Health.
Some examples of selective PHC are seen in immunisation programs organised from central agencies (ie vertical programs). Sanders and Warner document the negative impact of packaged and marketed Oral Re-hydration Salts that have in some places increased the dependency of people on a supply system for dealing with diarrhoea, rather than maintaining knowledge about the effective use of locally available and cheap alternatives .
The World Bank in its 1993 Report took an approach using economic rationalist language (eg best buys). This report essentially recognised that poor, marginalised populations were not useful to the world economy, and that providing support, albeit targeted and selective according to the estimated ‘worth' of the individual using a measure of Disability Adjusted Life Years (DALYs), was an investment in economic terms .
These obstacles that undermine the functioning and further development of comprehensive PHC is driven by a range of influences, but at the centre is an economic system that makes profit out of ill health. Thus commercial interests (the market place) are more interested in developing products that can be marketed rather than support for a self-reliant alternative. This encourages a focus on technical fixes, rather than people led solutions.
The recent evidence in regard to the determinants of health as outlined above suggest that comprehensive PHC may have the capacity to impact on a range of these determinants linked to power and self esteem which selective interventions from outside the community actually exacerbate.
This is relevant to Aboriginal communities. More Aboriginal people delivering services may be more important than precisely which services are delivered. Comprehensive PHC services have the potential to be a vehicle for community action in regard to problems they perceive, and in the wider sense assist the reconstruction of Aboriginal society.
These issues make community control not just a slogan and rhetoric but a key determinant for improved health in the longer term.