In Australia, when issues of health status are discussed, these discussions are often influenced by bigger issues affecting health outcomes including housing, education, transport, employment, income and access to health-care services. There is strong evidence that these social determinants impact on the health and well-being of individuals and communities. Health-care providers and their agencies, however, are not deemed responsible for addressing these determinants of health – they are seen as too big and intractable for the health sector alone.
In this editorial, it will be suggested that there is in fact space and need for health providers to incorporate and address these social determinants. After all, if it is not the job of health professionals working at the ‘coalface’ and seeing the results of long-standing often preventable disease, then whose responsibility should it be? Is it the distant government, the extended family or is it community leaders with or without legal authority? In short, we argue that the health sector itself should play a more constructive and active role in addressing these broader determinants of health.
If the health sector is to be more influential regarding the social determinants, it must first define more clearly what these determinants are. The World Health Organization's Commission on Social Determinants describes these as the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries. The determinants include the distribution of power, income, goods and services. Also, the circumstances of people's lives, such as: their access to health care, schools and education; their conditions of work and leisure; and, the state of their housing and environment. The term ‘social determinants’ is thus shorthand for the social, political, economic, environmental and cultural factors that greatly affect health status.
Increasingly, it is recognised that fundamental to these distributional and circumstantial determinants are issues of personal, family and community empowerment to control life events as well as the concepts of self-esteem and social inclusion/exclusion. A conceptual model that was first applied to the issue of racism might be useful in providing a framework for better linking the less acknowledged personal dimensions of the social determinants to the familiar generic socioeconomic elements. In his essay on the impact of racism, Awofeso uses three classifications. Contextual determinants incorporate influences of racial discrimination, exclusion and isolation. Distal determinants encompass more generic influences such as low socioeconomic status, unemployment, inadequate housing and poor access to health care. Proximal determinants are more personalised elements closer to the individual and include self-esteem, individual and community empowerment, control over life events and consequent healthy behaviours.
This framework highlights that social determinants should not be considered simplistically as individual determinants, but as complex interplays between numbers of factors often evolving over generations. As a recent example, the Closing the Gap measures under Council of Australian Government's National Indigenous Reform Agreement has sought to deliver outcomes through invoking intergovernmental cooperation to focus on distal determinants, such as housing and education as well as health care. Despite being one of the first Commonwealth agreements to recognise the multiplicity of influences, it has been strongly criticised as adopting a simplistic approach by underplaying the relevance of the proximal determinants. Factors such as engagement, inclusion, empowerment, and individual and community control have been largely ignored in the top-down processes where politicians and bureaucrats have determined the priorities for action and funding. Subsequently, it has been argued, the Indigenous community has been excluded from consultation and decision-making and the Closing the Gap measures have had less impact than they otherwise might.
This point can be illustrated using the case of housing. Improving housing can certainly contribute to significant health benefits. It is also the case, however, that factors such as community participation and inclusion are also vital. In Australia, there is good evidence about the lasting benefits of ‘housing for health’ that is supported and enabled by communities. These projects which often have long lead times and can produce positive health outcomes well beyond the mere provision of better housing alone. How should health professionals respond?
It could be that we already know what to do – for example improve housing, assist with education, increase access to health care, etc. The social determinants framework described in this paper, however, provides a way of understanding how to do this effectively. If an intervention succeeds in helping individuals have more control over the things in their lives that are important to them, then it is more likely to be successful. If control at the individual and local level is absent, the success of the intervention is likely to be compromised regardless of how much money, promotion and key performance indicators have been employed.
Consequently, a key issue becomes not what intervention or resource to provide but which intervention or resource will help people within a community increase control over their lives at the same time. This implicitly incorporates the practice of consultation and engagement. The housing support required by a family in a remote Indigenous community in Central Australia is likely to be very different from that required by a rural family in Gippsland having lost their home to bush fires. Both these families need to be empowered to ensure the maintenance or enhancement of health through adequate and appropriate housing. The idea of control and empowerment, therefore, could be used to link the proximal and distal determinants and also to guide decisions about how interventions should be applied for maximum effect. Helping to link the proximal and distal determinants is a tangible and very useful role for the health sector. A better understanding of the social determinants and a clearer conceptualisation of what they are and how they arise might assist health professionals and advocates to support meaningful and effective actions. The framework for social determinants put forward here defines the concept more clearly and delineates two clear dimensions of the determinants, proximal (close to the individual and family) and distal (general and socioeconomic), both of which need addressing to bring about health improvements. Topical health issues affecting rural and remote Australians can therefore usefully be reviewed using this framework to produce practical and meaningful priorities for change. Whilst the voice must come from community members, health service providers who are on the ground in communities and who have established relationships with the community have an important role in ensuring their voices are heard. We can no longer invoke ‘social determinants’ before dismissing them as key influences that are beyond our control.