Social determinants of health in poverty

The social determinants of health in poverty describe the factors that affect impoverished populations'

Social determinants of health in poverty reveal inequalities in health. Health is defined "as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do".^[6] Measurements of health take several forms including subjective health reports completed by individuals and surveys that measure physical impairment, vitality and well-being, diagnosis of serious chronic disease, and expected life longevity.^[1]

The

Social Determinants of Health have a huge impact on the lives of many individuals. It impacts their job likelihood, success, health, and future. For instance, those who come from lower socioeconomic status are more likely to develop health conditions such as cardiovascular disease. Some factors that affect these individuals and their health are food insecurity, financial stability, and healthcare access. Those who are from lower socioeconomic status backgrounds are likely to have adverse CVD outcomes when compared to higher-income populations who may also be benefiting from curative and preventative strategies.[8]

Social position

Poverty gradient and severity

Within the impoverished population exists a wide range of real income, from less than US$2 a day, to the United States

Socioeconomic status has long been related to health, those higher in the social hierarchy typically enjoy better health than do those below.[16] In a 2016 review of the county health rankings for all US counties published in the American Journal of Preventive Medicine, the authors found that socioeconomic factors were the highest weighted factor in determining health outcome, compared with health behaviors, clinical care and the physical environment.^[17]

With respect to

Prenatal care also plays a role in the health of women and their children, with excess infant mortality in impoverished populations and nations representing these differentials in health. According to Ward, poverty is the strongest predictor of insufficient prenatal care,^[15] which is caused by three factors that reduce access. These include socio-demographic factors (such as age, ethnicity, marital status, and education), systematic barriers, and barriers based on lack of knowledge, attitudes and life-styles.^[15] Several studies show the complex associations between poverty and education, employment, teen births, and the health of the mother and child. In 1985, The World Health Organization estimated that maternal mortality rates were 150 times higher in developing countries than developed nations.^[19] Furthermore, increased rates of postpartum depression were found in mothers belonging to low socioeconomic status.^[20]

Differential health for men

There also exist differentials in health with respect to men. In many post-transition countries, like the

Adolescent health has been proven to be influenced by both structural and proximal determinants, but structural determinants play the more significant role. Structural determinants such as national wealth, income inequality, and access to education have been found to affect adolescent health.[7] Additionally, proximal determinants such as school and household environments are influenced by stratification created by structural determinants, can also affect adolescent health. Access to education was determined to be the most influential structural determinant affecting adolescent health.Proximal determinants include household and community factors, such as household environment, familial relationships, peer relationships, access to adequate food, and opportunities for recreation and activity.^[7] The most influential proximal determinant has proven to be family affluence.^[21] Family affluence directly affects food security, which correlates with adolescent nutrition and health.^[22] Family affluence also influences participation in regular physical activity. While nutrition and physical activity promote physical well-being, both promote psychological health as well.^[21] Thus family affluence is correlated with reduced psychological stress during adolescence. Family affluence also affects access to healthcare services; however, in countries with universal healthcare systems, youth belonging to less-affluent households still display poorer health than adolescents from wealthier families.^[23] One study (that followed individuals from childhood to adulthood) showed that housing environment impacted mortality, with the main cause of death being the presence of pollutants in the house.^[24] Higher rates of chronic diseases^[25] such as obesity and diabetes, as well as cigarette smoking^[26] were found in adolescents aged 10–21 belonging to low socioeconomic status.^[25]

Infant health

Poverty during pregnancy has been reported to cause a wide range of disparities in newborns. Low maternal socioeconomic status has been correlated with low infant birth weight and preterm delivery,^[27] physical complications such as ectopic pregnancy, poorer infant physical condition, compromised immune system and increased susceptibility to illness, and prenatal infant death.^[28] Sixty percent of children born into poor families have at least one chronic disease.^[15] Infant mental complications include delayed cognitive development, poor academic performance, and behavioral problems.^[28] Poor women display greater rates of smoking,^[29] alcohol consumption, and engagement in risky behaviors.^[28] Such risk factors function as stressors that, in combination with social factors such as crowded and unhygienic living environments, financial difficulties, and unemployment, affect fetus health.^[28]

Ethnicity

Ethnicity can play an especially large part in determining health outcomes for impoverished minorities. Poverty can overpower race, but within poverty, race highly contributes to health outcomes.^[30] African Americans, even in some of the wealthiest cities in the United States, have lower life expectancy at birth than people in much poorer countries like China or India.^[30] In the United States, specifically for African American women, as of 2013 for every 100,000 births 43.5 black women would not survive compared to the 12.7 of white women^[31] According to studies, black individuals in South Africa have worse morbidity and mortality rates due to the limited access to social resources.^[30] Poverty is the chief cause of the endemic amounts of disease and hunger and malnutrition among this population.^[30] A disproportionate number of cases of the AIDS epidemic in North America are from American minorities, with 72% of women's AIDS cases among Hispanic or African-American women.^[15] Among those American minorities, African Americans comprise 12% of the American population yet, made up 45% of new HIV diagnoses. Blacks in American account for the highest proportion of those living with HIV and AIDS in America.^[32]

Farmer says the growing mortality differentials between whites and blacks must be attributed to class differentials-^[30] which includes recognizing race within impoverished populations. Recognition of race as a determining factor for poor health without recognizing poverty has misled individuals to believe race is the only factor.^[15] A 2001 study showed that even with health care insurance, many African Americans and Hispanics lacked a health care provider; the numbers doubled for those without insurance (uninsured: White 12.9%, Black 21.0%, Hispanics 34.3%). With both race and insurance status as obstacles, their health care access and their health declined.^[33]

Health differentials amongst races can also serve as determining factors for other facets of life, including income and marital status.^[15] AIDS-affected Hispanic women hold smaller salaries than average women, are part of poorer families, and are more likely to head households.^[15] According to one study, black teenage women living in dysfunctional homes were more likely to have serious health issues for themselves or children.^[15]

Redlining intentionally excluded black Americans from accumulating intergenerational wealth. The effects of this exclusion on black Americans' health continue to play out daily, generations later, in the same communities. This is evident currently in the disproportionate effects that COVID-19 has had on the same communities which the HOLC redlined in the 1930s. Research published in September 2020 overlaid maps of the highly affected COVID-19 areas with the HOLC maps, showing that those areas marked "risky" to lenders because they contained minority residents were the same neighborhoods most affected by COVID-19. The Centers for Disease Control (CDC) looks at inequities in the social determinants of health like concentrated poverty and healthcare access that are interrelated and influence health outcomes with regard to COVID-19 as well as quality of life in general for minority groups. The CDC points to discrimination within health care, education, criminal justice, housing, and finance, direct results of systematically subversive tactics like redlining which led to chronic and toxic stress that shaped social and economic factors for minority groups, increasing their risk for COVID-19. Healthcare access is similarly limited by factors like a lack of public transportation, child care, and communication and language barriers which result from the spatial and economic isolation of minority communities from redlining. Educational, income, and wealth gaps that result from this isolation mean that minority groups' limited access to the job market may force them to remain in fields that have a higher risk of exposure to the virus, without options to take time off. Finally, a direct result of redlining is the overcrowding of minority groups into neighborhoods that do not boast adequate housing to sustain burgeoning populations, leading to crowded conditions that make prevention strategies for COVID-19 nearly impossible to implement.^{[34][35][36][37][38][39][40]}

Education

Education plays an especially influential part in the lives of the impoverished. According to Mirowsky and Ross, education determines other factors of livelihood like occupation and income that determines income, which determines health outcomes.^[6] Education is a major social determinant of health, with educational attainment related to improved health outcomes, due to its effect on income, employment, and living conditions.^{[41][42][43][1]} Social resources, such as education, determine life expectancy and infant mortality, which measures health.^[44] Education has a lasting, continuous, and increasing effect on health.^[1] Education is a special determinant of health because it enables people toward self-direction, which leads them to seek goals such as health.^[1] Education helps the impoverished develop usable skills, abilities, and resources that help individuals reach goals, including bettering health.^[6] Parent's educational level is also important to health, which influences the health of children and the future population. Parent's education level also determines child health, survival, and their educational attainment (Caldwell, 1986; Cleland & Van Ginneken, 1988).^[1] "Children born to more educated mothers are less likely to die in infancy and more likely to have higher birth weights and be immunized.^[10] Studies in the United States suggest maternal education results in higher parity, greater use of prenatal care, and lower smoking rates, which positively affects child health.^[10] An increase in child schooling in Taiwan during the educational reform of 1968 reduced the infant morality rate by 11%, saving 1 infant per 1000 births.^[10]

"Fig. 2.1 shows variation between countries in infant mortality from just over 20/1000 live births in Colombia to just over 120 in Mozambique. It also shows inequities within countries – an infant's chances of survival are closely related to her mother's education. In Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births; the infant mortality rate of babies born to mothers with at least secondary education is under 40/1000.All countries included in Fig. 2.1 show the survival disadvantage of children born to women with no education."^[1] Mortality inequalities are produced and reproduced by policies that promotes structural violence for those who are already vulnerable to poverty,^[45] while reinforcing the paradigm and the ontological order of power hierarchy.^[46] Hence, the political engagement of an individual and their communities play an important factor in determining their access to health care. The Commission on the Social Determinants of Health discusses that explicit commitment to action through multidisciplinary public policies are required for better access to healthcare.^[47] One of the recommended action is to expand knowledge and empower the participation of broad segment of society.^[48] A manifestation of such action is the mobilization of the population that has been historically oppressed and to raise question about the systemic issues affecting their life.^[49] According to WHO, civic participation does not just better physical health, but also mental health status, and overall life quality.^[49] History exhibits that when the masses become politically aware of the problems around them, they are more empowered to find their own voice and revolt against systemic inequalities to take control of their lives and improve healthcare accessibility and affordability.^[50] On the contrary, nations that do not empower its citizens to be politically educated have way worse health outcomes than nations whose citizens are politically engaged.^[51] For instance, there has been a surge in mortality differentials and unwavering decline in health benefits coverage, especially among for the population living under poverty line. As stated in Global Health Promotion, over the last 10 years there has been a steady loss of health coverage for 1 million people every year.^[51] Losing health coverage means that an individual could no longer seek affordable treatment or access healthcare, so their health quality would eventually deteriorate. However, if the citizens were to raise their concerns collective to the government, they would have been able to address this systemic factor and subsequently improve their health outcomes.

Occupation

Impoverished workers are more likely to hold part-time jobs, move in and out of work, be migrant workers, or experience stress associated with being unemployed and searching unsuccessfully for unemployment, which all in turn affects health outcomes.^[1] According to the World Health Organization, employment and working conditions greatly affect health equity (Kivimaki et al., 2003).^[1] This occurs because poor employment conditions exposes individuals to health hazards, which are more likely for low-status jobs.^[1] Evidence confirms that high job demand, low control, and low rewards for effort in these low status jobs are risk factors for mental and physical health problems, such as a 50% excess risk of heart disease (Stansfeld & Candy, 2006).^[1] The growing power of massive, conglomerate global corporations and institutions to set labor policy and standards agendas has disempowered workers, unions, and the job-seeking by subjecting these individuals to health-damaging working conditions. (EMCONET, 2007).^[1] In high- income countries, there has been a growth in job insecurity and precarious employment arrangements (such as informal work, temporary work, part-time work, and piecework), job losses, and a weakening of regulatory protections. Informal work can threaten health through its precarious job instability, lack of regulation to protect working conditions and occupational health and safety.^[1] Evidence from the WHO suggests mortality is greater among temporary workers than permanent workers. (Kivimaki et al., 2003).^[1] Since most of the global workforce operates under the informal economy, particularly low- and middle-income countries,^[1] impoverished populations are greatly affected by these factors.

Migration status

Migrants have a variety of physical and mental health needs, shaped by their background, the host country’s entry and integration policies, and their living and working conditions.^[52] Refugees and migrants remain among the most vulnerable members of society and may be faced with inadequate or restricted access to health services.^[52] Xenophobia, discrimination, and working conditions may further affect their mental health disproportionally.^[52] Comparison of a poor but mainly non-migrant population in rural Uganda with disadvantaged migrant population in urban South-Africa and urban Sweden found lower self-reported frequency of physical activity and lower social support and self-efficacy in the urban migrant samples.^[53]

Socioeconomic and political context

Location

Nation-state/geographical region

Which particular nation an impoverished person lives in deeply affects health outcomes. This can be attributed to governmental, environmental, geographical, and cultural factors. Using life expectancy as a measure of health indicates a difference between countries in likeliness of living to a certain age. Where people are born dramatically impacts their life chances. High-income countries like Japan or Sweden have a life expectancy of 80 years, Brazil-72, India-63.^[15] The WHO cites that for rich countries, only 56 (Iceland) to 107 (US) of 1000 adults between 15 and 60 years old will die each year, while Western and Central African countries have adult mortality rates exceeding 300 and 400 of every 1000. The rates are even higher in African nations in the AIDS epidemic, such as Zimbabwe where 772 of 1000 adults die each year (WHO 2010).^[10] Also, the type of health condition varies by countries for populations in poverty. Over 80% of cardiovascular disease deaths, that totaled 17.5 million people globally in 2005, occur in low- and middle-income countries.^[1] According to the WHO,13500 people die from smoking every day, and soon it will become the leading cause of death in developing countries, just as in high income countries. (Mathers & Loncar, 2005).^[1]

Infant and

• Obesity: Obesity is a paramount problem, especially among the poor and socially disadvantaged, in cities worldwide, according to the WHO (Hawkes et al., 2007;^{[full citation needed]} Friel, Chopra & Satcher, 2007).^{[full citation needed][1]} The increased amount of obesity can be contributed to the nutrition transition that describes how people are now increasingly turning to high-fat, sugar, and salt food sources because of their availability and price.^[1] This food transition has fueled the obesity epidemic. This nutrition transition tends to start in cities because of "greater availability, accessibility, and acceptability of bulk purchases, convenience foods, and 'supersized' portions" (Dixon et al., 2007).^{[full citation needed][1]} Physical activity and exercise is strongly determined by the design of cities, including density of homes, heterogeneous land uses, the extent to which streets and sidewalks connect, the walkability, and the provision of and access to local public accommodations and parks for recreation and play.^[1] These factors, along with increasing reliance on cars, results in the shift of the population toward physical inactivity, which damages health (Friel, Chopra & Satcher, 2007).^{[full citation needed][1]}
• Crime: Violence and crime are major urban health challenges. Worldwide, 90% of the 1.6 million annual violent deaths occur in low and middle income counties (WHO, 2002).^{[full citation needed][1]} A large number of deaths and injuries occur because of crime, which affects health.^[1]
• Traffic: Individuals in ghettos and urban areas are the most affected by traffic injuries and vehicle-created air pollution, which causes 800,000 annual deaths due to air pollution, and 1.2 million from traffic accidents. (Roberts & Meddings, 2007;^{[full citation needed]} Prüss- Üstün & Corvalán, 2006).^{[full citation needed][1]} This results in greater health risks, like death,^[1] for impoverished populations in cities.
• Mental illness: Living in a ghetto increases the likelihood of developing a mental illness, especially in children. People in this environment are less likely to receive effective mental health services. Children exposed to ongoing poverty, present in a ghetto, present a high level of depression, anxiety, social withdrawal, peer conflict and aggression.^{[55][full citation needed]} Mental health symptoms are increased in the ghetto due to exposure to community crime, gang induced violence, neighborhood drug infestations, and substandard housing conditions.^{[56][full citation needed]}
• Other: In the United States, HIV is more prevalent in cities along the east coast, with prevalence among African-American women in cities 5 to 15 times higher than for women in all areas of that state.^[15] "Inner-city women are the most likely of all in the United States to birth dead or extremely sick babies, partially because the massive erosion of prenatal care availability in their area.^[15] Slums, made up exclusively of extremely poor populations, provide a particularly strong threat for poor health. Child mortality in the slums of Nairobi, which 60% of the population inhabits, is 2.5 times greater than in other areas of the city.^[1] In the slums of Manila, 39% of children have TB, which is twice the national average.^[1] The term 'housing instability' describes a condition in which people have been or will be homeless in the future. People facing such instability have poorer health care access and more acute health problems than the rest of the population.^[57] A city populations grew and rents rose, those receiving Section 9 housing vouchers could no longer afford the rising rents and were forced to move away.^[58]

Rural

Living in a rural community, whether in the United States, or around the globe, reduces access to medical services,

The social environment that impoverished people dwell in is often a precursor to the quality of their health outcomes. Without equitable access to basic social needs, it is difficult to have a quality standard of health while under a significant financial burden. The Commission of Social Determinants of Health, created in 2015 by the World Health Organization, was a pioneer in the push for more focus on "creating better social conditions for health, particularly among the most vulnerable people".

Nations that have more generous social protection systems have better population health (Lundberg et al., 2007).[1] More generous family policies correlate with lower infant mortality.^[1] Nations that offered higher coverage and reimbursement for pensions and sickness, unemployment, and employment accident insurance have a higher LEB (Lundberg et al., 2007), as well as countries with more liberal pensions have less senior mortality. (Lundberg et al., 2007)^[1]

Access to Healthcare

The health care system represents a social determinant of health as well as it influences other determining factors. People's access to health care, their experiences there, and the benefits they gain are closely related to other social determinants of health like income, gender, education, ethnicity, occupation, and more.^[1] For poor people, systematic barriers in the social structure are formidable, especially financing.^[15] Medicaid and maternity coverage structures have complex and time-consuming registration processes, along with long waits and unsure eligibility.^[15] A study of the Emergency Department found that the majority of patients presenting with mental illness were those on Medical (20.4%) and Medicare (31.5%), whereas only 12.4% of privately insured patients presented with mental illness. California has expanded its eligibility of Medi-Cal under federal law to cover as many people as possible.^[67] Inequalities in health are also determined by these socioeconomic and cultural factors.^[1] Health care is inequitably distributed globally, with pronounced inequality for the poor in low- and middle-income countries.^[1] One study demonstrated that doctors treat poor populations differently, showing that disadvantaged patients are less likely to receive the recommended diabetic treatments and are more likely to undergo hospitalization due to the complications of diabetes (Agency for Health Care Research and Quality, 2003).^[1] According to the WHO, healthcare systems can most improve health equality when institutions are organized to provide universal coverage, where everyone receives the same quality healthcare regardless of ability to pay, as well as a Primary Healthcare system rather than emergency center assistance.^[1]

These structural problems result in worse healthcare and therefore worse health outcomes for impoverished populations. Health care costs can pose absolutely serious threats to impoverished populations, especially in countries without proper social provisions. According to US HHS, "In 2009, children 6–17 years of age were more likely to be uninsured than younger children, and children with a family income below 200% of the poverty level were more likely to be uninsured than children in higher-income families."^[44] In elderly populations, individuals below 400% of the poverty line were between 3 and 5 times more likely to lack insurance.^[44] Children below 200% of the poverty line were also less likely to have insurance than wealthier families.^[44] Also, in 2009 in the US, 20% of adults (ages 18–64) below 200% of the poverty line did not receive their necessary drugs because of cost, compared to only 4% of those above 400% of the poverty line.^[44] Increasing healthcare costs (including higher premiums) imposed a burden on consumers.^[68] In 2010, President Obama introduced the Patient Protection and Affordable Care Act (ACA), expanding health care to many that lacked coverage. The U.S. had the highest rate of uninsured people, and the highest health care costs, of all industrialized nations at the time. The ACA helped 20 million Americans get coverage and decreased the rates of uninsured from 16% in 2010 to 8.6% in 2016. The ACA brought coverage to people who had had downgrades in Employee Insurance programs, by providing a health insurance marketplace, giving them access to private insurance plans along with income-based government subsidies.^[69] This can be seen in other nations, where in Asia, payments for healthcare pushed almost 3% of the population of 11 countries below 1 US$ per day.^[1] However, under the current U.S. administration, there have been shifts in how federal funding is allocated to social service programs. Although, initiatives like the National Prevention Council have been established to address prevention, there have also been some drawbacks. Because of this political shift, entities that address the social determinants of health in poverty, like social service programs, are threatened under these new policies. These policies reallocate funding away from public social service programs, causing resources that promote prevention and public health to be limited.^[66] The problem most present with state provisioned resources like public social service programs that aim to alleviate health disparities are the ever changing political spheres that either propel or block communities from access to effective health care resources and interventions. Despite the strength of political influences, it has been shown that, globally, shifting attention to addressing social needs like healthcare access has dramatically affected the health of impoverished communities.^[70]

Societal psychological influences

In impoverished communities, different

Underlying social structures that propagate and perpetuate poverty and suffering- structural violence- majorly determine health outcomes of impoverished populations. Poor and unequal living conditions result from deeper structural conditions, including "poor social policies and programs, unfair economic arrangements, and bad politics,"^[1] that determine the way societies are organized. The structure of the global system causes inequality and systematically higher death rates, which is caused by inequity in distribution of opportunities and resources, which is termed structural violence.^[60]

Definition

Wikiversity has learning resources about Eliminating poverty

• Diseases of poverty
• Food Justice Movement
• Socioeconomic status and mental health
• Transit desert
• Transport divide
• Environmental racism
• Environmental Racism in the United States

References