Evidence for the Social
Determinants of Health in Australia
Even in the
world's wealthiest countries there are significant discrepancies in life
expectancies and health outcomes between groups in society. Research into the
correlation between health outcomes and factors such as education and income has
led to a growing understanding of the sensitivity of human health to the social
environment. Such factors, which include education, gender, power and the
conditions of employment, have become known as the social determinants of
It is argued in the World Health Organisation's
Commission on Social Determinants of Health's (CSDH) report
Closing the Gap in a Generation (WHO Report), that:
structural determinants and conditions of daily life constitute the social
determinants of health and are responsible for a major part of health
inequalities between and within countries.
health inequities is, for the Commission on Social Determinants of Health, an
ethical imperative...there is no necessary biological reason why there should
be a difference in [life expectancy at birth] of 20 years or more between
social groups in any given country. Change the social determinants of health
and there will be dramatic improvements in health equity.
the social determinants of health that are the genesis of many health problems,
the costs to government of providing healthcare can be reduced, and individuals
can enjoy better health outcomes. One recent Australian study found that by addressing
the social determinants of health in line with the recommendations of the WHO
Report (discussed in Chapter 3), then:
- 500 000 Australians could avoid suffering a chronic illness;
170 000 extra Australians could enter the workforce, generating
$8 billion in extra earnings;
- Annual savings of $4 billion in welfare support payments could be
60 000 fewer people would need to be admitted to hospital
annually, resulting in savings of $2.3 billion in hospital expenditure;
- 5.5 million fewer Medicare services would be needed each year,
resulting in annual savings of $273 million; and
- 5.3 million fewer Pharmaceutical Benefit Scheme scripts would
need to be filled each year, resulting in annual savings of $184.5 million each
determinants do not attempt to address the choices of specific individuals, but
the context in which personal choices are made. The committee heard that:
Often when people talk about social determinants they are
talking about preventative health – stopping people from smoking and having
poor diets or getting diabetes or HIV or whatever it happens to be. That is not
actually dealing with the social determinants of health. That is an element of
an approach and it is a very important element of an approach to dealing with health
outcomes and population health, but it is not the whole story.
I think that sometimes we fall into that trap of thinking
that, if you deal with prevention and get health promotion right, you solve
health outcomes. You do not. But all you are doing is stopping someone from
smoking or reducing obesity rates. You are not dealing with income, you are not
dealing with educational outcomes, you are not dealing with people's housing
situations, which as we know are the key things to sort out. Most of these other
health issues are not such an issue in the end anyway. As we all know, there is
higher prevalence of these types of diseases, illnesses and conditions in
people who have poor housing, low income, poor access to education who are born
in particular parts of the country.
Moore from the Public Health Association of Australia articulated the meaning
of 'social determinants':
Australians ought to get it, because it is just about a fair
go; it is just about common sense. Take as an example two people growing up in
different communities. One is from the North Shore of Sydney, who has
educational opportunities, is encouraged by their parents, has adequate food
and has parents who are not alcoholics. Compare that person to the extreme case
of somebody growing up in the community of Yuendumu, just out of Alice Springs,
where there are not the educational opportunities and encouragement. I have to
say they do have a lot of other things like family support and so forth; I am
not saying it is all negative. But their health outcomes would be very
provides an overview of the theory and evidence underpinning the argument that
social determinants of health are a major health problem that needs to be
addressed, with a particular focus on Australia. The following chapter will examine
the WHO Report.
The key social
determinants of health
determinants of health are interrelated. Although they are considered here in
isolation, in any one person's life several may be relevant. For example, a
single parent may have limited access to the labour market which may compel the
family to live in a poorer neighbourhood, enjoy fewer amenities and medical
services, and buy less-nutritious food. It also means that
the children may be more likely to do worse at school and later may themselves
have more trouble accessing the labour market, in turn resulting in a negative
impact on their health.
sections highlight a number of key areas of life and society in which the
social determinants of health play out. In particularly, early childhood
education, employment and income, and access to healthcare are discussed. These
three issues were highlighted to the committee as being among the most
important in improving the social determinants of health.
life and children
foundations of adult health have been shown to be laid before birth and in
early childhood. Underlining the inequalities in society that can begin to
impact on health from birth, the WHO Report argues:
from disadvantaged backgrounds are more likely to do poorly in school and
subsequently, as adults, are more likely to have lower incomes and higher
fertility rates and be less empowered to provide good health care, nutrition,
and stimulation to their own children, thus contributing to the
intergenerational transmission of disadvantage.
Report is unequivocal on the importance of Early Childhood Development (ECD):
science of ECD shows that brain development is highly sensitive to external
influences in early childhood, starting in utero, with lifelong effects. The
conditions to which children are exposed, including the quality of
relationships and language environment, literally 'sculpt' the developing
brain. Raising healthy children means stimulating their physical,
language/cognitive, and social/emotional development. Healthy development
during the early years provides the essential building blocks that enable
people to lead a flourishing life in many domains, including social, emotional,
cognitive, and physical well-being.
in foetal development are a risk for health in later life. For example, infants
with a birth weight less than 2.5 kilograms have almost seven times the chance
of developing diabetes in later life than infants born weighing in excess of
Insecure emotional attachment and poor stimulation as an infant can lead to
reduced readiness for school, low educational attainment, problem behaviour,
and the risk of social marginalisation in adulthood. Furthermore, the
development of good health-related habits such as eating sensibly, exercising
and not smoking, is associated with parental and peer group examples, as well
as with education.
ECD has great potential to reduce health inequalities; furthermore, it is an
investment likely to pay for itself many times over according to the WHO Report.
There are strong intergenerational effects evident in the health and education
outcomes of children. The level of education of the mother has been recognised
for the last two decades as a critical determinant of child health and
relation to the social determinants of health in Australia, Catholic Health
Australia CEO Martin Laverty cited early childhood experience as one of the
'best building blocks of income and social status', and argued that 'early
childhood development is one of the most crucial determinants that governments
and civic society organisations can invest in'.
Similarly, Professor Fran Baum highlighted for the committee that:
I think we are still clear that the best investment we can
make in terms of social determinants is giving every child a good start to
life. Of course, that starts in pregnancy, and there is more and more
information that there are a whole lot of things that happen when you are a
foetus that affect your chances in life subsequently.
In Australia, research has indicated that although all children benefit
from early childhood education, the benefits are most pronounced among vulnerable
There is consistent evidence showing the positive impact of
high-quality early education and care programs on young children's cognitive
and social outcomes and adjustment to school. Importantly, while vulnerable
children at risk of school failure seem to benefit most from high-quality early
childhood programs, there is also evidence of far-reaching academic and social
benefits for all children. Unfortunately...many of the most vulnerable children
do not participate in early childhood programs or they attend the lowest
quality programs. Similarly, children of working poor families are most often
exposed to poor-quality care.
income and work
and working conditions have a powerful effect on health equity. Work is cited
by the WHO as the key arena 'where many of the key influences on health are
The WHO report argues that 'people's economic opportunity and financial
security is primarily determined, or at least mediated, by the labour market.'
It goes on to note that when working conditions and access to the labour market
are good: '[T]hey can provide financial security, social status, personal
development, social relations and self-esteem, and protection from physical and
There are two key ways in which employment and health intersect: access to the
labour market, and the nature of the work undertaken.
clear negative health consequences for people unable to access the labour
market, or who are precariously engaged in paid employment. Unemployment
negatively impacts on the health of both the unemployed person and their
The health effects of unemployment have been linked to both its psychological
consequences and the financial problems it brings, especially debt. The health
effects of unemployment begin before a person actually loses their job; the
insecurity people first feel when their job is threatened is also detrimental
to health. Job insecurity has been linked to mental health (particularly
anxiety and depression), self-reported ill-health and heart disease.
heard that income inequalities not only impact individual health through
reducing access such things as services and education, but also provide a
metric for social inequality more broadly. The Tasmanian Social Determinants of
Health Advocacy Network argued that:
The greater the income inequality in a country, the greater
the health and social problems such as life expectancy, obesity, poor education
outcomes and so forth.
and organisation of the available work and workplaces can also impact on the
health of an individual. Having little control over one's work is particularly
strongly related to negative health outcomes. Similarly, receiving inadequate
rewards for the effort expended at work in the form of money, status and
self-esteem is associated with increased cardiovascular risk.
Physical and psychological health at work are important factors contributing to
an individuals' overall health outcomes. It is increasingly recognised that
maintaining a healthy work-life balance is important for health and overall
The clearest outcome of exclusion from the labour market is a lack of
money. The committee heard that 'income is probably in everybody's top three'
social determinants of health.
The impacts of low income on health can be seen through statistics provided by
the Australian Social Inclusion Board that indicate that 33 per cent of people
in the lowest income quintile reported fair or poor health compared with just
6.5 per cent of those in the highest income quintile.
Research by the Australian Council of Social Services provides an insight into
the number of low income families in Australia, finding that:
In 2010, after taking account of household costs, an
estimated 2 265 000 people or 12.8% of all people, including 575 000 children
(17.3% of all children), lived in households below the most austere poverty
line used in international research. This is set at 50% of the median (middle)
disposable income for all Australian households...A less austere but still low
poverty line, that is used to define poverty in Britain, Ireland and the
European Union, is 60% of the median income....When this higher poverty line
is used, 3 705 000 people including 869 000 children, were found to be living
in poverty. This represented 20.9% of all people and 26.1% of children.
relative deprivation and social exclusion have a major impact on health and
premature death. Absolute poverty – a lack of basic material necessities of
life – continues to exist even in wealthy countries. Relative poverty means
being much poorer than most people in society and is often defined as living on
less than 60% of the national median income.
Relative poverty can deny people access to decent housing, education, transport
and other factors vital to full participation in life. The stresses of living
in poverty are particularly harmful during pregnancy, to babies, children and
to old people.
living wage throughout a person's life course was also highlighted by the WHO
Report as essential for positive health outcomes. A living wage takes into
account the current cost of living, and is regularly updated based on health
needs such as adequate nutritious food, shelter and social participation.
The WHO Report highlights the benefits of a strong system of social
with more generous social protection systems tend to have better population
health outcomes, at least across high-income countries for which evidence is
available...countries with higher coverage and greater generosity of pensions and
sickness, unemployment and work accident insurance (taken together) have a
higher [life expectancy at birth].
The committee received evidence that addressing income and employment
disadvantage results in better health outcomes in the Australian context. A
recent study conducted in the Northern Territory found that lifting
socio-economic index scores for family income and education/occupation by two
quintile categories for low socio-economic indigenous groups was sufficient to
overcome the excess hospital utilisation among the Aboriginal population
compared with the non-Aboriginal population in the Northern Territory.
healthcare system itself is an important social determinant of health that is
influenced by and has influence over other social determinants. Australia currently
has a universal healthcare system. However, it is well documented that some
areas of Australia, and some social groups, are better serviced by health
infrastructure than other areas. The NSW Council of Social Services reported
Structural barriers in Australia's health system inhibit
equitable access to health care and cause or compound health inequalities.
These include health care costs and user fees, unavailability of timely,
quality services, and low health literacy. For instance, more than a quarter of
people (26.4%) report financial barriers to seeing a dentist, and nearly one in
ten people (8.7%) delayed or did not see a GP due to cost. Australians in the
most disadvantaged areas have lower rates of dental services, optometry
services, and ambulatory mental health services.
the WHO Report, universal coverage means that everyone within a country
can access the same range of goods and services according to needs regardless
of their level of income or social status.
The National Health and Hospitals Reform Commission has highlighted
inequalities in healthcare in Australia including gaps in dental, public
hospital and mental health services.
People living in rural locations with minimal access to healthcare report
poorer health outcomes and lower life expectancies than people living in major
The Australian Institute of Health and Welfare's Health Workforce
2025 reported that:
living in regional, rural and remote areas exhibit:
- 20 percent
higher self-reported rates of fair or poor health;
- 10 percent
higher levels of mortality;
- 20 percent
higher rates of injury and disability;
- 10-70 percent
higher rates of perinatal death.
access to most healthcare is subsidised through Medicare to ensure access for
all people to medical treatment, assess to certain areas of healthcare appears
to remain constrained by income with Professor Friel noting:
We see this already in Australia – for a given level of need,
socio-economically advantaged women are more likely to use specialist medical,
allied health, alternative health and dental services than less advantaged
As can be
seen from the above examples, the provision of healthcare services, and access
to them, are social determinants of health.
The social gradient
There is a
relationship between people's social circumstances and economic wellbeing, and
their health, referred to as the social gradient. As explained by Professor
Friel, one of the of the WHO Report's authors: 'As one moves down the
socio-economic ladder the risk of shorter lives and higher levels of disease
risk factors increases.'
Researchers have labelled this the social gradient of health.
The social gradient is not confined to relatively poor countries. Recent research
undertaken in Australia has borne out this trend:
The NATSEM report that Catholic Health Australia commissioned
indicated that a person in the lowest socioeconomic group in Australia can
expect to die on average some three years earlier than someone in the highest
socioeconomic group. That report also indicated that a person in the lowest
socioeconomic group can expect to have twice the prevalence of chronic illness
during their life than someone in the highest socioeconomic group.
Evidence for a social gradient of health was not confined to one problem
or group, with one study finding that:
Socioeconomic differences were found in all the health
indicators studied, and were evidence for both men and women and for both age
grounds. Health of Australians of working age was found to be associated with
socio-economic disadvantage, irrespective of how socio-economic status or
health was measured...Household income, level of education, household employment,
housing tenure and social connectedness all matter when it comes to health.
Health outcomes are heavily impacted by the context in which people
work, live, and play:
One of the quite critical issues that comes up around social
determinants is the balance between people's personal responsibilities in relation
to health and what is socially determined and drives their health. If it were
simply up to individuals then you would have no social gradient, basically; you
would not be able to see that in your data. It would not matter if somebody
were in the top quintile rather than the bottom quintile.
In other words, without a social gradient of health, a wealthy person
would be equally as likely as a poor person to be obese or to experience a
range of other health problems. The available evidence indicates however that
this is not the case, and it is deduced from this that something other than
each individual's decisions must be influencing health outcomes.
Areas of health showing a strong social gradient are broad including
heart disease, diabetes, asthma, mental health conditions and obesity.
The underlying objective in social determinants of health theory is to level
the social gradient so that health outcomes are not determined by one's place
in the economic hierarchy of society, and to improve health by targeting
structural factors that can lead to harm.
A crucial social
determinant of health, according to the WHO Report, is ensuring that people
have access to quality education throughout their lives. 
the environment into which they are born can play a decisive role in their later
scholastic achievements. The socio-economic position of a child's parents has
been shown to play a significant role in educational outcomes. This holds true in
developed countries with universal education such as Australia. As explained by
macroeconomist Joann Wilkie:
earning parents may be able to purchase or produce better 'inputs' for their
children's development. Low-income earning parents cannot offer their children
the same quantity or quality of inputs. Studies have shown that children from
low-income backgrounds are more likely to have lower educational attainment and
earnings in adulthood than those from high-income households.
Evidence from the United States of America demonstrates the impact of
education on the social gradient of health:
Reports in 2005 revealed the mortality rate was 206.3 per
100,000 for adults aged 25 to 64 years with little education beyond high
school, but was twice as great (477.6 per 100,000) for those with only a high
school education and 3 times as great (650.4 per 100,000) for those less
Evidence from the Australian Bureau of Statistics highlighted the positive
impact education can have on Indigenous health, finding that:
In 2008, 59 per cent of Aboriginal and Torres Strait Islander
people aged 15–34 years who had completed Year 12 reported excellent/very good
health compared with 49 per cent of those who had left school early (Year 9 or
For Australia more broadly, data presented by the Department of Health
and Ageing (Department) showed clearly that long-term health risk factors such
as obesity, diabetes, hypertension and arthritis are higher for early school
leavers than those that go on to complete Year 12.
Similarly, the Health Lies in Wealth report found that: 'Early high
school leavers...are 10 to 20 per cent less likely to report being in good health
than those with a tertiary education.'
importance of education continues throughout a person's life. Access to
education enables people to changing jobs or retrain when they are not in work.
Education is a major contributor to intergenerational social mobility as
individuals who are more highly educated typically receive higher remuneration
and the health benefits that brings.
Report emphasized that all people need social protection throughout their lives
from infancy and childhood, throughout their working years and in old age,
providing surety in times of disability, injury or loss of work.
The Report noted that: 'Generous universal protection systems are associated
with better population health, including lower excess mortality among the old
and lower mortality levels among socially disadvantaged groups.'
obstacle in improving society-wide health outcomes is intergenerational
Children born to parents from lower socioeconomic backgrounds are more likely
to do poorly at school,
more likely to be unemployed, and more likely to have poor health. Adequate
social protection systems can prevent intergenerational poverty and prevent
temporary unemployment from becoming entrenched unemployment.
has already canvassed the negative health impacts that can be caused by
poverty. Recent research indicates that those most likely to be impoverished
are reliant on social security payments: unemployed households, single adults
over 65 years of age, and households whose main income is social security.
The committee heard that unemployment allowances in Australia had not been
increased in real terms for over two decades, and that now 'over 50 per cent of
people living on [Newstart] are living below the poverty line.'
The New South Wales Council of Social Services expressed concern that the
current levels of income support are insufficient to keep people out of poverty,
and therefore out of poor health:
The [Councils of Social Services] have serious concerns about
the inadequacy and inequality of unemployment and income support payments. We
believe that it is everyone's right to have access to paid work, and when
looking for paid work, to have income support to live with dignity. Yet our
social security system is failing to provide people with this basic guarantee, plunging
people into poverty.
While it is
important to have sufficient social supports in place to protect people
throughout the life cycle, it is also necessary to ensure that there are steps
in place to move people from the welfare system to employment. It was pointed
out to the committee that in the case of Tasmania, the number of people in
receipt of government aid has not changed in a long time, and it is necessary
to establish pathways to assist people into employment:
We do have to find better ways of getting the third of the
population who are on income support payments back into the workforce, back
into participating in life. For those who have disabilities, et cetera, that
does not mean that they are not able to be engaged in work or in social
activities. It is important for us to start to look at that more closely and
how we can shift that. That 30 per cent figure has not changed in a long, long
time and I think it is something we definitely have to look at as well.
factors: food, addiction, stress
Lifestyle factors that can cause poor heath such as diet, alcohol and
tobacco use are often deemed to be, and responded to, as individual factors
that should be addressed through individual behavioural change. Professor Friel
highlighted for the committee the correlation of environmental factors – in
this case social status – on individual health outcomes, explaining:
The systematic evolution and continuation of the uneven
distribution of obesity, tobacco and alcohol use suggests that there is
something about the broader society that is affecting people's ability to
pursue healthy behaviour, increasingly so with decreasing social status.
The social determinants approach shifts the focus – and thereby the
necessary solution – from the individual to the context.
It was noted by the Northern Territory Department of Health that many of
the 'lifestyle' risk factors are exacerbated by other social determinants of
Many of the modifiable risk factors that influence the
development of chronic conditions such as smoking, consumption of excess
alcohol, poor diet and limited physical activity are linked to the [social
determinants of health], and are exacerbated by other [social determinants of
health] such as level of income, limited education and unemployment which are
risk factors for chronic conditions in their own right.
A good diet
is central to health and well-being. Social and economic conditions result in a
social gradient in diet quality that contributes to health inequalities. Food
insecurity is not typically considered a problem for countries such as
Australia, however levels of food insecurity have been found to impact
between 5–10 per cent of the population.
Excess intake (also a form of malnutrition) contributes to cardiovascular
disease, diabetes, cancer, degenerative eye diseases, obesity and dental
caries. The main difference between social classes is the source of the
nutrients, with poor demographics tending to substitute cheaper processed food
for fresh food. People on low incomes, such as young families, the elderly and
unemployed are least able to eat well and are therefore most at risk.
One explanation for this trend is provided by the WHO Report:
liberalisation – opening many more countries to the international market –
combined with continuing food subsidies has increased the availability,
affordability, and attractiveness of less healthy foodstuffs, and transnational
food companies have flooded the global market with cheap-to-produce,
energy-dense, nutrient-empty foods.
psychological circumstances can cause long-term stress which is harmful to
human health. Continuing anxiety, insecurity, low self-esteem, social isolation
and lack of control over home and work life have powerful effects on health.
Such psychological risks accumulate over life and increase the chances of a person
suffering from poor health.
dependence, illicit drug use and cigarette smoking are all closely associated
markers of social and economic disadvantage. All three are a significant drain
on the financial resources of poorer people and a large cause of health
problems and premature death.
In Australia, for example, areas of relative disadvantage such as regional
areas show significantly higher rates of alcohol and tobacco use than wealthier
and design of urban environments has a major impact on health equity through
its influence on behaviour and safety.
The WHO Report notes that:
people live affects their health and chances of leading flourishing lives.
Communities and neighbourhoods that ensure access to basic goods, that are
socially cohesive, that are designed to promote good physical and psychological
well-being, and that are protective of the natural environment are essential
for health equity.
For the first
time in human history more people live in urban than rural areas.
The impact of the growing urbanisation on human health will be determined, in
many ways, by the decisions regarding how urban areas are developed and
maintained. Improvements over the last 50 years in mortality and morbidity in
highly urbanised countries such as Japan, the Netherlands, Singapore and Sweden
highlight that modern cities can be healthy environments. The above examples also
point towards the importance of supportive political structures, appropriately
applied financial resources, and social policies that underpin the equitable
provision of conditions and services.
The kind of
neighbourhood an individual lives in also impacts on their exposure to crime –
which tends to concentrate in specific areas, and availability of and access to
appropriate housing and transport.
Evidence provided from the Australian Council of Social Services highlighted
the impact of income on access to services, noting: 'that there was virtually
nowhere in the capital cities that people living on social payments could
afford to rent in the private rental market.'
is evidence that urban environments can be places of health, there are also
threats to human health. One of the greatest emerging health issues among
wealthy countries is obesity, a problem particularly prevalent among socially
disadvantaged groups in many cities throughout the world.
The WHO Report argues:
activity is strongly influenced by the design of cities through the density of
residences, the mix of land uses, the degree to which streets are connected and
the ability to walk from place to place, and the provision of and access to
local public facilities and spaces for recreation and play. Each of these plus
the increasingly reliance on cars is an important influence on shifts towards
physical inactivity in high- and middle-income countries.
policy can play a key role in combating sedentary lifestyles by reducing
reliance on cars and increasing the number of people who walk, cycle and use
public transport. Not only does walking and cycling improve an individual's
health, it reduces the cost to society of road deaths and injuries, has a lower
environmental impact, and increases social interactions. Urban areas that
depend on car use isolate the young and the old.
The WHO Report highlights the 'vicious cycle' of growing car dependence,
land-use change to facilitate car use, and increased inconvenience of
non-motorised transport modes leading to even more car use.
The report goes on to call for the prioritisation of walking and cycling over
car use in order to address some of the health impacts of existing urban
A person's inclusion
in society and control over their destiny are each important for social development
and health. Having the freedom to participate in economic, social, political,
and cultural relationships has been shown to have intrinsic value.
Social exclusion may result from unemployment, discrimination, stigmatisation
and other reasons. Poverty and social exclusion also increase the risks of
divorce and separation, disability, illness, and addiction. People who live in,
or have recently left institutions such as prisons, psychiatric homes and
orphanages are particularly vulnerable. The greater the length of time that
people live in disadvantaged circumstances, the more likely they are to suffer
from a range of health problems.
included in the society in which one lives is vital to the material,
psychological, and political aspects of inclusion that underpin social
well-being and equitable health. As noted by the WHO Report:
equity depends vitally on the empowerment of individuals and groups to
represent their needs and interests strongly and effectively and, in doing so,
to challenge and change the unfair and steeply graded distribution of social
resources to which all men and women, as citizens, have equal claims and
support and good social relations make an important contribution to health.
Belonging to a social network of communication and mutual obligation makes
people feel cared for, loved, esteemed and valued. Supportive relationships may
also encourage healthier behavioural patterns. High levels of social cohesion,
defined as the quality of social relationships and the existence of trust,
mutual obligation and respect in communities, also help protect a person's
involves improving access to education, reducing insecurity and unemployment,
improving housing standards, and increasing the opportunities for social engagement
available for all citizens. Addressing the discrepancies of health outcomes
resulting from the prevailing social determinants means addressing the causes
of those social determinants. The following chapters discuss areas of possible
government action to address the social determinants of health in Australia.
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