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The different aspects of health and social care

In addition, a growing body of research has documented associations between social and cultural factors and health Berkman and Kawachi, 2000 ; Marmot and Wilkinson, 2006. For some types of social variables, such as socioeconomic status SES or poverty, robust evidence of their links to health has existed since the beginning of official record keeping.

For other kinds of variables—such as social networks and social support or job stress—evidence of their links to health has accumulated over the past 30 years. The purpose of this chapter is to provide an overview of the social variables that have been researched as inputs to health the so-called social determinants of healthas well as to describe approaches to their measurement and the empirical evidence linking each variable to health outcomes.

Genes, Behavior, and the Social Environment: Moving Beyond the Nature/Nurture Debate.

It should be emphasized at the outset that the social determinants of health can be conceptualized as influencing health at multiple levels throughout the life course. Thus, for example, poverty can be conceptualized as an exposure influencing the health of individuals at different levels of organization—within families or within the neighborhoods in which individuals reside.

Moreover, these different levels of influence may co-occur and interact with one another to produce health. For example, the detrimental health impact of growing up in a poor family may be potentiated if that family also happens to reside in a disadvantaged community where other families are poor rather than in a middle-class community.

Furthermore, poverty may differentially and independently affect the health of an individual at different stages of the life course e. In short, the influence of social and cultural variables on health the different aspects of health and social care dimensions of both time critical stages in the life course and the effects of cumulative exposure as well as place multiple levels of exposure.

The contexts in which social and cultural variables operate to influence health outcomes are called, generically, the social and cultural environment. Comprehensive surveys of current areas of research in the social determinants of health can be found in existing textbooks Marmot and Wilkinson, 2006 ; Berkman and Kawachi, 2000. These variables are highlighted because of their robust associations with health status and their well-documented and reliable methods of measuring these variables, and because there are good reasons to believe that these variables interact with both behavioral as well as inherited characteristics to influence health.

Socioeconomic differences in health are large, persistent, and widespread across different societies and for a diverse range of health outcomes. In the social sciences, SES has been measured by three different indicators, taken either separately or in combination: Although these measures are moderately correlated, each captures distinctive aspects of social position, and each potentially is related to health and health behaviors through distinct mechanisms.

Educational Attainment Education is usually assessed by the use of two standard questions that ask about the number of years of schooling completed and the educational credentials gained.

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The quality of education also may be relevant to health, but it is more difficult to assess accurately. An extensive literature has linked education to health outcomes, including mortality, morbidity, health behaviors, and functional limitations. The relationship between lower educational attainment and worse health outcomes occurs throughout the life course. For example, infants born to Caucasian mothers with fewer than 12 years of schooling are 2.

An association between education and health in observational data does not necessarily imply causation. Alternatively, the association between education and health may partly reflect confounding by a third variable, such as ability, which is a prior common cause of both educational attainment and health status.

The totality of the evidence suggests, nonetheless, that education is a causal variable in improving health. Natural policy experiments—such as the passage of compulsory schooling legislation at different times in different localities within the United States—suggest that higher levels of education are associated with better health lower mortality Lleras-Muney, 2002.

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It is therefore likely that the association between schooling and health reflects both a causal effect of education on health, as well as an interaction between the level of schooling and inherited characteristics.

Several causal pathways have been hypothesized through which higher levels of schooling can improve health outcomes.

They include the acquisition of knowledge and skills that promote health e. Although it is not established which of these pathways matter more for health, they each are likely to contribute to the overall pattern of higher years of schooling being associated with better health status. Moreover, the evidence points to the importance of improving access to preschool education as a means of enhancing the health prospects of disadvantaged children Acheson, 1998.

Income The measurement of income is more complex than assessing educational attainment. Survey-based questions inquiring about income must minimally specify the following components: In addition to the higher rate of measurement error for income as compared to educational attainmentthis variable also is associated with higher refusal rates in surveys that are administered to the general population.

As with education, an extensive literature has documented the association between income and health. For example, even after controlling for educational attainment and occupational status, post-tax family income was associated with a 3.

That is, the excess risks of poor health are not confined simply to individuals below the official poverty threshold of income. That is, the relationship between the two variables is acknowledged to be dynamic and reciprocal. Ill health is a potent cause of job loss and reduction in income. Indeed, income as an indicator of SES is more susceptible to reverse causation than education, which tends to be completed in early adult life prior to the onset of major causes of morbidity and functional limitations.

For example, the different aspects of health and social care do not normally contribute to household incomes, yet their health is strongly associated with levels of household income in both the Panel Study of Income Dynamics and the National Health Interview Surveys Case et al.

  1. PMC1447206 ] [ PubMed. Finally, measures of income, poverty, and deprivation have been extended to incorporate the dimension of place.
  2. In summary, there is good evidence linking each of the major indicators of SES to health outcomes.
  3. As with the demand-control model, a self-administered questionnaire has been developed and validated.

An alternative possibility is that the relationship between income and health is explained by a third variable—such as inherited ability—that is associated with both socioeconomic mobility and the adoption of health maintenance behaviors. Yet, in the National Health Interview Survey, the impact of family income on child health has been found to be similar among children who were adopted by nonbiological parents compared to children who were reared by their biological parents Case et al.

The causal pathways linking income to health are likely to be different from those linking education to health. Most obviously, income enables individuals to purchase various goods and services e.

Additionally, secure incomes may provide individuals with a psychological sense of control and mastery over their environment. See Chapter 4 for a detailed discussion of psychological factors and health.

  1. Finally, measures of income, poverty, and deprivation have been extended to incorporate the dimension of place. Growing research, utilizing multilevel study designs, has conceptualized economic status as an attribute of neighborhoods Kawachi and Berkman, 2003.
  2. Oxytocin increases trust in humans.
  3. Alternatively, the association between education and health may partly reflect confounding by a third variable, such as ability, which is a prior common cause of both educational attainment and health status. There also may be critical stages in the life course during which the social environment has a stronger impact on later life health outcomes.
  4. As with the demand-control model, a self-administered questionnaire has been developed and validated.
  5. New England Journal of Medicine.

That said, it has also been observed that higher incomes are associated with healthier behaviors such as wearing seatbelts and refraining from smoking in homes that do not, in themselves, cost money Case and Paxson, 2002. Debate also exists in the literature concerning whether it is absolute income or relative income that matters for health Kawachi and Kennedy, 2002.

Many definitions of poverty, for example, are based upon the concept of the failure to meet a minimal standard of living defined in absolute terms e. The concept of relative income has been operationalized in empirical research by measures of relative deprivation at the individual level as well as by aggregate measures of income inequality at the community level.

Measures of relative deprivation involve assessments of the income distance between individuals and their comparison or reference group—that is defined by others who are alike with respect to age group, occupational class, or community of residence.

The causal the different aspects of health and social care underlying the relationship between absolute income and health are linked to the ability to access material goods and services necessary for the maintenance of health.

Relative income is hypothesized to be linked to health through psychosocial stresses generated by invidious social comparisons as well as by the inability to participate fully in society because of the failure to attain normative standards of consumption. Growing evidence has suggested an association between relative deprivation measured among individuals and poor health outcomes Aberg Yngwe et al.

A related literature has attempted to link the societal distribution of income as an aggregate index of relative deprivation to individual health outcomes, although the findings in this area remain contested Subramanian and Kawachi, 2004 ; Lynch et al. Variables other than household income also may be useful for health research—such as assets including inherited wealth, savings, or ownership of homes or motor vehicles Berkman and Macintyre, 1997.

While income represents the flow of resources over a defined period, wealth captures the stock of assets minus liabilities at a given point in time, and thus indicates economic reserves.

In this section

Measuring wealth is particularly salient for studies that involve subjects towards the end of the life course, a time when many individuals have retired and depend on their savings.

In the Panel Study of Income Dynamics, for example, only a weak association was seen between post-tax family income and mortality among post-retirement-age subjects, while measures of wealth continued to indicate a strong association with mortality risk Duncan et al. Finally, measures of income, poverty, and deprivation have been extended to incorporate the dimension of place. Growing research, utilizing multilevel study designs, has conceptualized economic status as an attribute of neighborhoods Kawachi and Berkman, 2003.

These studies have revealed that residing in a disadvantaged or high-poverty neighborhood imposes an additional risk to health beyond the effects of individual SES.

A recent Department of Housing and Urban Development randomized experiment in neighborhood mobility, the so-called Moving To Opportunity the different aspects of health and social care, found results consistent with observational data: Moving from a poor to a wealthier neighborhood was associated with significant improvements in adult mental health and rates of obesity Kling et al.

Disadvantaged neighborhoods are often characterized by adverse physical, social, and service environments, including exposure to more air pollution via proximity to heavy traffic, a lack of local amenities such as grocery stores, health clinics, and safe venues for physical activity, and exposure to signs of social disorder Kawachi and Berkman, 2003. Occupational Status The third standard component of SES that typically is measured by social scientists is occupational status, which summarizes the levels of prestige, authority, power, and other resources that are associated with differ ent positions in the labor market.

Occupational status has the advantage over income of being a more permanent marker of access to economic resources. Three main traditions can be discerned in the way in which different disciplines have approached the measurement of aspects of occupations relevant to health.

In the traditional occupational health field, researchers have focused on the physical aspects of the job, such as exposure to chemical toxins or physical hazards of injury Slote, 1987.

In the fields of occupational health psychology and social epidemiology, researchers have focused on characterizing the psychosocial work environment, including measures of job security, psychological job demands and stress, and decision latitude control over the work process Karasek and Theorell, 1990.

Finally, the sociological tradition has tended to focus on occupational status, which includes both objective indicators e. Several alternative approaches currently exist for the measurement of occupational status. For a detailed description, see Berkman and Macintyre 1997 as well as Lynch and Kaplan 2000. For example, the Edwards classification U.

  • Among adults, social support predicts lower levels of HPA axis and sympathetic nervous system reactivity in laboratory-based challenge paradigms Seeman and McEwen, 1996;
  • The New Press; 2002;
  • These studies have revealed that residing in a disadvantaged or high-poverty neighborhood imposes an additional risk to health beyond the effects of individual SES;
  • Old measures and new formulations;
  • Although it is not established which of these pathways matter more for health, they each are likely to contribute to the overall pattern of higher years of schooling being associated with better health status;
  • Although the adverse health impact of job loss e.

Census Bureau, 1963 is a scheme based upon the conceptual distinction between manual and nonmanual occupations. An alternative and commonly used measure of occupational status is the Duncan Socioeconomic Index SEIwhich combines subjective ratings of occupational prestige with objective measures of education and incomes associated with each occupation.

These prestige rankings were then combined with U. Census information on the levels of education and incomes associated with each Census-defined occupation. The resulting SEI scores have been updated several times Burgard et al.

In the Wisconsin Longitudinal Survey of men and women who graduated from Wisconsin high schools in 1957 53 or 54 years old in 1992-1993Duncan SEI scores were inversely associated with self-reported health, depression, psychological well-being, and smoking status Marmot et al.

As is the case with both education and income, an association between occupational status and health may partly reflect reverse causation.

Social Aspects of Health, Illness and Healthcare

That is, ill health e. Although the adverse health impact of job loss e. As noted above, existing measures of occupational status such as the Duncan SEI combine measures of prestige with indicators of education and income that are thought to affect health independently.

In addition, there are uncertainties regarding the optimal time point for measuring occupational status, especially since individuals change occupations over their life course. The potential pathways linking occupational status to health outcomes are again distinct from those linking either education or income to health. First, higher status and nonmanual occupations are less likely to be associated with hazardous exposures to chemicals, toxins, and risks of physical injury.

Higher status jobs also are more likely to be associated with a healthier psychosocial work environment Karasek and Theorell, 1990including higher levels of control decision latitude as well as a greater range of skill utilization lack of monotony.

A greater sense of control in turn implies improved ability to cope with daily stress, including a reduced likelihood of deleterious coping behaviors such as smoking or alcohol abuse.

Undoubtedly, a major intervening pathway between occupational status and health is through the indirect effects of higher incomes and access to a wider range of resources such as powerful social connections.

In summary, there is good evidence linking each of the major indicators of SES to health outcomes. Together, education, income, and occupation mutually influence and interact with one another over the life course to shape the health outcomes of individuals at multiple levels of social organization the family, neighborhoods, and beyond. Social Networks, Social Support, and Health An independent social determinant of health is the extent, strength, and quality of our social connections with others.

Recognition of the importance of social connections for health dates back as far as the work of Emile Durkheim. More recently John Bowlby 1969 maintained that secure attachments are not only necessary for food, warmth, and other material resources, but also because they provide love, security, and the different aspects of health and social care nonmaterial resources that are necessary for normal human development Berkman and Glass, 2000.

Certain periods during the life course may be critical for the development of bonds and attachment Fonagy, 1996. According to attachment theory, secure attachments during infancy satisfy a universal human need to form close affective bonds Bowlby, 1969.

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Two social variables are of particular interest in characterizing social relationships: Its assessment includes the structural aspects of social relationships, such as size the number of network membersdensity the extent to which members are connected to one anotherboundedness the degree to which ties are based on group structures such as work and neighborhoodand homogeneity the extent to which individuals are similar to one another.