Social Determinants of Health

An Interdisciplinary Approach to Social Inequality and Wellbeing

Adrian Bonner, Bonner, Adrian, Adrian Bonner

• Publisher: Policy Press
• Year: 2017
• ISBN:
  9781447336877
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book provides an applied, interdisciplinary approach to an understanding of the key social determinants of health, essential at a time of increasing inequalities and reductions in existing NHS services and local authority budgets.

A person's health and wellbeing is influenced by a spectrum of socioeconomic, cultural, living and working conditions, social and community networks and lifestyle choices. Based on the 'rainbow model' of the social determinants of health, chapters from experts in a wide range of disciplines examine the key factors which can lead to poor quality of life, homelessness and reduced mortality.

Featuring practitioner, academic and commentator experiences, and clear case studies, this book will enable researchers, front-line workers, managers, service commissioners and politicians to identify and employ the most appropriate health, social and economic interventions to support those at the edge of the community, and the promotion of their inclusion in society.

Part One

Life chances

The interconnectedness and interdependence of socio-economic, cultural, environmental, living and working conditions, social and community networks, and lifestyle choices contribute to a person's health and well-being. Social and health strategies, in the community, clearly need to focus on individual needs and vulnerabilities. As indicated in the 'rainbow' model of social determinants of health, age, sex and constitutional factors should be at the centre of these considerations. This section on 'Life chances' offers an introduction to some of the key biological, psychological and social drivers that lead to social exclusion in some disadvantaged people, necessitating support from outside the family and involving statutory and voluntary agencies, as reviewed in subsequent sections of this book.

ONE

The individual: growing into society

Adrian Bonner

Dahlgren and Whitehead's model of the social determinants of health (Dahlgren and Whitehead, 1991; Dahlgren, 2007) provides a framework from which we can begin to understand the complex interaction of genetic factors and prenatal, perinatal and postnatal events in influencing the development of the individual from childhood, through adolescence and into adult life. The early life stages lay the foundation for adult life and successful ageing. The biological processes of natural selection operate at each of these stages, starting before birth, the outcomes of which are significantly influenced by external factors such as the supply of adequate nutrition, a secure environment and nurturing by parents and others supporting the individual on their journey through life (see Parts Three, Four and Five, this volume). The maturation of the human nervous system, musculature and metabolic processes are essential for independent living; however, the social environment provides the external drivers that shape behaviour, cognitive functioning and decision-making. The primary determinants important in social development include levels of sensory stimulation and prosocial learning, which support communication and the shaping of appropriate behavioural responses, such as positive (eg human bonding) and negative (eg aggressive) relationships, which are prerequisites for healthy relationships within the family, the workplace and the community.

The well-being of children and the safeguarding of vulnerable people generally involves protecting them from abuse, exploitation and physical and psychological damage. Sexual abuse and exploitation, sadly, are not uncommon in modern society. These adverse early life experiences not only affect an individual's relationships with others and mental health in later life, but also impact directly and indirectly on physiological status via the immune system (Baumeister et al, 2016), leading to increased vulnerability to communicable and non-communicable diseases, including childhood cancers (Anon, 2016a). This vulnerability is exacerbated by psychological factors that undermine self-esteem and self-image (see Chapter Sixteen). An overview of the positive aspects of the psychological environment within the wider health context is provided in Chapter Three.

Early childhood experiences and the development of social networks have a major impact on later-life health and well-being, which are mediated by the development of prosocial behaviour, resilience, coping skills and optimal cognitive functioning. These complex issues require a healthy mind and body and the motivation to benefit and learn from a supportive environment. This chapter provides an overview of the main developmental processes underlying future emotional and social behaviours. The key risk factors for becoming homeless, being a survivor of abuse or neglected during childhood, having a learning disability, being arrested or charged with anti-social behaviour, and living in the care system are explored in later parts of this book.

Neuropsychological development

Problems of cognitive dysfunction and mental ill health, as reviewed in Part Five, begin in the early developmental stages as a result of cumulative developmental issues such as poor nutrition and the presence of harmful substances in the prenatal blood supply. The impact of external stress in the mother, resulting in higher levels of the stress hormone cortisol, has an important influence on cognitive functioning. This series of threats increases the vulnerability of the child, adding to a vicious circle of events exacerbated by alcohol misuse in the later years, possibly leading to alcohol dependence or dependence on other drugs that increase the probability of brain damage (see Chapters Five, Six, Seven and Eighteen). The maximum rate of brain growth occurs during the first two years of life. Genetic information, inherited from the parents, directs growth and the development of the nervous system, as is the case with other systems in the body. This information, encoded in DNA molecules, is translated andtranscribed into a diverse range of proteins that form the material basis of body structures, such as skin, muscle and nervous tissue, and (protein) enzymes that control the body's metabolism, some of which are produced on a regular basis and others are induced briefly for specific purposes. These processes are dependent on adequate nutrition (see Chapter Four).

Although the basic infrastructure of the brain is genetically preprogrammed, an overproduction of neurons occurs in some regions such as the olfactory and hippocampal regions, where the fine neuronal structure is tuned by the pruning of neuronal axons, dendrites and synapses that are not utilised. This process is influenced by sensory stimulation and increasing efficiency of specific neuronal pathways, an aspect of the process of learning. Neuronal pathways not used will degenerate according to the concept of Neural Darwinism (Edelman, 1987), which provides an explanation, based on the principles of natural selection, of the way by which neurones are influenced by brain stimulation via sensory inputs from the environment. This physiological process of learning is perceived as a behavioural output originating from neurobiological mechanisms at cellular and molecular levels. The concept of Long Term Potential (LTP) provides a useful conceptual framework for understanding the cellular basis of learning (Okada et al, 2003). Emotional behaviour, a specific form of learning, results from sensory inputs, which are assimilated and processed in association within existing memories within the limbic system. Prenatally and postnatally, the development and maintenance of this neuronal infrastructure is significantly influenced by the internal biochemical status of the brain.

Affection, fear and anxiety in early development

The role of stress and anxiety in mental health will be explored in Part Five, but in view of the role of developmental stressors in children and their impact on later-life mental health, a brief review of social anxiety and the links between anxiety and the physiological events in mother–infant relationships will be given here.

At the time of puberty, gender identity, gender role and sexual orientation become incorporated into the formation of and maintenance of emotional relationships, and sexual orientation becomes organised and relatively fixed. The origins of affection and trust begin in the secure nurturing relationship between the infant and its mother. In both males and females, affectionate relationships in these early years and later stages of childhood lay the foundations of later sexual relationships between adults. Various studies indicate that fearful children are at a high risk of later emotional distress. Kagan and colleagues (1988) have shown that a child who is profoundly shy at the age of two years is more likely to suffer from anxiety and depression later in life than a less inhibited child. Children who become severely inhibited in unfamiliar places produce high levels of stress hormones, including cortisol from the adrenal gland. Cortisol, a stress-related hormone, is produced at elevated levels at times of crisis and is part of the 'fight or flight' reaction, which includes maximising energy for use by the muscles. Cortisol results in a number of other physiological changes occurring at times of 'fight or flight'; however, long-term elevations of this stress hormone may contribute to gastric ulcers, cardiovascular disease and neurotoxicity. Fearful children enter a vicious circle leading from isolation and lowered self-esteem, through underachievement, to possibly anxiety and depression.

There is some evidence that unusually fearful children are prone to physical illness, for example, fearful children and their families are more likely to suffer from allergic disorders. In animal studies, the persistent elevation of cortisol increases the vulnerability of neurons in the hippocampus to damage by other substances. This region is involved in memory, motivation and emotion and so fear-related responses involving chronic elevated levels of cortisol are thought to have a negative effect on brain function.

Brain regions, primarily the limbic system, regulate fearfulness and are thought to develop at 9–12 weeks. This system is linked to the 'prefrontal cortex', which is an area of the brain concerned with cognitive and emotional responses, brought about by the interpretation of sensory stimuli. This is possibly the site where potential danger is assessed. The 'amygdala', part of the limbic system, is involved in generating fear, which is expressed via the 'hypothalamus', which secretes cortico releasing hormone (CRH) stimulating the pituitary to produce adrenocorticotropic hormone (ACTH), which, in turn, causes the adrenal gland to release cortisol and prepares the body to defend itself.

In human maturation, when an infant reaches 12 months of age, the 'prefrontal cortex' increases in activity and enables the child to distinguish between threatening cues. During this developmental stage, children begin to show marked fear of strangers and become skilled at social referencing. They regulate their level of fear based on interpretation of the expressions they observe on a parent's face. Animals have been used to explore mother–infant relations, and the effects of maternal deprivation (Bowlby, 1977). The work by Kagan (Kagan et al, 1988) provides an important insight into the physiological mechanisms that underpin mother–infant bonding and anxiety produced by disruption of the bond as a result of maternal separation. The conclusion from animal studies is that opiate-using neural pathways regulate affiliative (mother–infant) behaviours. In summary, when a young monkey is separated from its mother, opiate-releasing and opiate-sensitive mechanisms become inhibited. This gives rise to yearning for the mother and a generalised vulnerability and resulting vocalisations. This reduction of activity in opiate-sensitive systems enables motor systems in the brain to produce cooing, an outward expression of fear. When a potential predator appears, neurons that secrete endogenous benzodiazepine become suppressed to some degree. This leads to elevated anxiety and the appearance of behaviours and hormones that accompany fear. As a sense of alarm grows, the system prepares for fight or flight. The benzodiazepines thus alter opiate systems, which results in cooing behaviour during threatening situations.

Social anxiety

An insight into the linkage between anxiety and exclusion from social groups in the early years is provided by Gazelle and Ladd (2003). In studying 388 children, equal numbers of boys and girls, the authors observed social behaviour, peer exclusion and emotional adjustment at kindergarten (primary school). Observations, primarily by the teacher, were made at entry and every spring thereafter through to the fourth year. These observations indicated that soon after joining the primary school, anxiety (due to solitude) and peer exclusion co-occur in the children. Anxious solitude became more entrenched in those anxious solitary children who were excluded early on, in comparison with their non-excluded anxious solitary counterparts. The diathesis-stressmodel proposed by the authors indicated that the joint forces of individual vulnerability (anxious solitude) and interpersonal adversity (peer exclusion) were strongly associated with symptoms of depression, noted in the children and young people (Griffin, 2010). In Chapter Eight, Nathan Critchlow reviews social anxiety in relation to digital social media.

Communication and socialisation

The term 'prosocial behaviour' is used to describe 'voluntary actions that are intended to help or benefit another individual or group of individuals' (Dennis, 1975). These anthropological studies have suggested that prosocial behaviours may be motivated by selfish reasons, for example, to gain a reward or gain approval, or he/she may be displaying sympathy and caring (Dennis, 1965: 3). These apparently empathetic behaviours are sometimes described as altruistic, driven by internal values, which include a belief in the importance of the welfare or social justice of others. An inability of a child to conform to learned social norms may result in inappropriate responses in particular situations (Eisenberg, 1989). Moral judgement could be considered to be a cognitive aspect of morality involving reasoning about moral issues and conceptualisations and is quite distinct from prosocial behaviour. Learning social norms, having moral concepts, being able to make moral judgements and being motivated to act in certain ways are important contributions to an individual's capacity to become a member of the functional community.

Biological factors, noted earlier in this chapter, contribute to the process of socialisation; these include the genetic vulnerability to prenatal exposure to alcohol (Ungerer and Ramsey, 2013) and hyperactivity (Elia, 2007). Genetic influences on the development and maturation of the sensory systems, and hormonal influences on emotional behaviour, contribute to the process of socialisation. Both genetic and cultural factors influence the development of social behaviour and prosocial behaviour. A child's capacity to interact with parents, teachers and siblings, as well as the influence of cultural and religious institutions, plays a major role in socialisation.

The changing views of prosocial behaviour can be seen in emerging literature. Extensive studies into moral development in the 1920s (Anon, 1928) led to an incorrect conclusion that the prosocial behaviour of school-age children was situation-specific and not influenced by moral behaviours such as generosity. In the 1980s, studies on delinquency and violence showed that these antisocial behaviours had their roots in parental rejection. A focus on injustice suffered by women, minority ethnic groups and the disabled, leading to positive action programmes, was a major theme during 1969–89. In the 1970s, a consolidation of ideas from developmental and social psychologists resulted in a greater understanding of social learning and related cognitive processes (Eisenberg, 1989).

The well-being of children

Many childcare policies are aimed at supporting children in health and social care, day care, and education, and approaches to the care and custody of young children are based on adverse effects of early life separation (from his/her mother) on the child's mental well-being and subsequent emotional development. These negative views of separation are informed by the work of Bowlby (1977...

Table of contents

• Coverpage
• Title page
• Copyright
• Dedication
• Contents
• List of tables and figures
• Notes on contributors
• Acknowledgements
• Preface
• Part One: Life chances
• Part Two: Lifestyle challenges
• Part Three: Social and community networks
• Part Four: Employment and housing
• Part Five: Supporting people at the edge of the community
• Part Six: The socio-political environment
• Conclusion Adrian Bonner