How the Social Determinants of Health contribute to Health Inequity

between population groups in Australia

Introduction:

The World Health Organisation (WHO) defined health as a state of complete

physical, mental and social well-being and not merely the absence of disease or infirmity.
(1) This took into account non-medical factors that impact health, on an individual and
population level, which helped address the underlying issues of ill health. (2) This view
introduced a shift in thinking, where other determinants had just as much impact on health
as access to healthcare. Consequently, WHO defined these social determinants of health as
the conditions in which people are born, grow, live, work and age, and that are shaped by
the distribution of money, power and resources. (3) These social determinants are major
contributors to health inequity, the unfair and avoidable differences in health status between
population groups. (3)

In Australia, there are numerous cases of health inequity between populations,

primarily due to social determinants of health. (4) Social determinants of health can be
divided broadly into social, economic, cultural, and environmental factors. One important
factor from each category are discussed in detail here, with an affected Australian population
group used as a case study. Several general strategies are proposed to help reduce the health
inequity, and promote equity, which is the absence of avoidable or remediable differences
among groups of people. (5) Social justice can be thought of as an absence of differences in
health states between populations, where everyone has basic human rights and equal access to
the benefits of society. (6)

In implementing these models, discrimination between populations when addressing

the health inequity must be avoided for fairness to be achieved. (7) This means addressing
inequities between two populations should not negatively impact a third population.
Generally, the principles of social justice, fairness, and equity in the context of health are
highly interrelated, the discussion below aims to provide insight on how these principles are
violated for some Australian populations, and how the suggested strategies could help
achieve the aims of these principles.

Social Factor: Discrimination

Discrimination can be described as a type of stressful experience that negatively

impacts health. (8) It can also be described as the beliefs, behaviours, and practices that result
in avoidable and unfair inequities across population groups. (9) Discrimination has been
linked with increased risk of mental illness, due to increased stress and anxiety from the
experience. (4) In a survey of Indigenous Australians, those who reported experiencing the
most discrimination also recorded the highest psychological distress scores. (9) In addition,
70% of participants worried about friends or family experiencing discrimination, suggesting
that discrimination has much wider mental impact than on just the individual targeted. (9)
Discrimination may also erode the self-control of an individual, leading to indulgence in
unhealthy practises like alcohol abuse. (8) In addition, discrimination contributes to other
social determinants of health including unemployment, income, education, and housing. (4)
Overall, discrimination is a complex social issue that affects health outcomes, causing health
inequity between population groups. Hence, it is an important social determinant of health.
Population groups on the opposite end of discrimination stand to gain from this, this could be
the major racial demographics of Australia, where some might benefit from preferential
treatment when competing against discriminated groups.

The Indigenous people of Australia are a population group that face some of the most
discrimination. (9) In a recent report, 16% of participants reported being mistreated due to
their Indigenous status, of this cohort, 89% reported this occurred 2-3 times a week. (10)
Most common forms of discriminatory behaviour identified were from members of the
public, and at the workplace. (10) These stressors contribute to the health inequity between
Indigenous and non-Indigenous Australians, as non-Indigenous Australians are not exposed to
the adverse health effects of discrimination. It is also a violation of social justice as
Indigenous Australians are not able to function as normal members of society, which is a
human right. Discriminatory behaviour by the public can lead to physical injury, or increased
risk of mental illness from chronic stress. (4) Indigenous Australians who worry about being
discriminated against might avoid activities other Australians take for granted and become
socially isolated, contributing to adverse mental health. (4) Problems at work or less access to
employment can lead to unemployment or lack of income.

Discrimination against Indigenous Australians is deeply ingrained in a societal and

institutional level, manifesting in social exclusion, racist attacks, and inequitable
opportunities for work. (9) Intervening at institutional levels are thus necessary to effectively
address this issue. Anti-discriminatory policies should be bolstered with strategies to promote
respect for different ethnicities. Policies should avoid attacks or laying blame on other
population groups, so as to avoid violation of the fairness principle. Education to institutions
and the general public should complement these strategies and ultimately aim to lessen the
discrimination Indigenous Australians face. The Victorian Localities Embracing and

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Accepting Diversity (LEAD) program is an example of a multi-strategy program designed to
combat discrimination. (11) With a focus on prevention, several intervention resources were
implemented. This included the Workplace Diversity and Anti-Discrimination Assessment
Tool, designed to review current practices and policies within the institution, and facilitate
better cultural diversity and addressment of any discrimination. (11)

Economic Factor: Income

Income levels are an important social determinant of health. (4) Poverty, or a lack of
access to income, can be linked to adverse health outcomes through multiple factors.
Healthier foods might be neglected in favour of unhealthy, often cheaper alternatives. (4)
Rent consideration might force individuals to live in unsanitary conditions, exposing them to
increased risk of illness. (12) Less access to education can mean food and medical illiteracy,
as well as diminished employment prospects, exacerbating the lack of disposable income
those in poverty have. (12) Stress, anxiety, and social exclusion have been shown to
accompany the experience of living in poverty. (9) These factors contribute to the health
inequity between impoverished population groups and non-impoverished groups.

Several population groups in Australia have been identified as at risk of living in

poverty. The highest incidence came from the unemployed population, as they do not have a
stable access to income. (12) Other groups of note at risk include: people with disabilities,
and the Indigenous population. (12) From the ACOSS report, 72% of these people in poverty
reported suffering from financial stress. (12) They engaged in activities such as skipping
meals, selling possessions, and not heating the room, which contributed to stress and adverse
health outcomes. (12) Poverty can be a long-term sentence, with many experiencing it for
most of their lives, creating a sizable population with a significant inequity in health
outcomes. On the flip-side, those who enjoy a large disposable income generally enjoy high
social status and enjoy numerous benefits within society. (4) They are thus enhanced by the
social determinant.

Poverty between population groups can also be addressed directly through several
policies. Ensuring government policies that bridge the income gap are properly enforced and
targeted is essential for fairness, meaning there is no discrimination between impoverished
groups in the policy. In the context of welfare payments, proper enforcement means having
procedures, such as rigorous income tests, in place to ensure only the people in need of
welfare benefits are receiving them, as opposed to opportunistic individuals. Proper targeting

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of the policy means only the desired demographic can claim the benefit legally. A poorly
targeted policy has loose guidelines that allow individuals to claim benefits legally, but may
not be the policies intended demographic. Put into practice, proper enforcement and targeting
could make progress in ensuring populations with insufficient income have enough financial
help to bridge the health inequity between impoverished and non-impoverished groups.

Cultural Factor: Loss of culture

Culture can be defined as the dynamic collection of thoughts and meanings that are
shared and transmitted from one generation to another. (13) This manifests in the values,
practices, and social interactions of the given culture. (13) It is a foundation for identity and
self-worth, and its erosion can adversely affect health and wellbeing. (14) Different cultures
can be thought of as population groups, and when there is subjugation of cultural expression
or breakdown in cultural communication, adverse health outcomes can result. Thus, culture
can be thought of as a social determinant of health.

The refugee population in Australia face several cultural factors that have adverse
effects on their health. Refugees experience a loss of culture from the migration process. (14)
Living in a different country where they are a minority means that their way of living and
expressing themselves culturally are no longer right. Religious and spiritual expression can
lead to prosecution, in particular for Muslim communities, since the September 11 attacks.
(15) A lack of established cultural communities and support networks in a foreign country can
promote social isolation and exacerbate other factors such as discrimination. (4) This lack of
social participation is linked with physical and mental health consequences. (4) The majority
of refugees do not speak English fluently, hence language is a major obstacle that can
adversely affect health. (13) Problems with verbal communication can lead to
misunderstandings and bad outcomes in simple interactions, such as out in public, or when
dealing with welfare and housing staff. (4) This can lead to avoidance of social interaction
and institutional services, which might be essential to their health and wellbeing. Hence,
these cultural factors contribute to bad health outcomes, and a health inequity between non-
refugee and refugee population groups. Population groups that stand to gain or be enhanced
by this discrimination include ones with a hatred or fear of the affected group, they might
derive perverse satisfaction from seeing the culture repressed.

Empowering these refugees through applying social justice, by helping them express
their culture, which is their right as human beings, would help promote physical and mental

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wellbeing. (4) This can include revitalisation of cultural expression, such as dance, song, and
festivals. (13) This can be achieved through concerted efforts of the refugees, government,
and community as a whole. (13) Policies aimed at promoting fairness and cultural
understanding, would facilitate better communication and less discrimination between
cultures. An example would be social service staff being trained to recognise and understand
the hardships that the refugees might have faced in their home country. Their behaviours to
refugees suffering from alcohol abuse might be different if they suspected it was to escape
memories of torture.

Environmental Factor: Access to safe drinking water

Access to safe drinking water is widely regarded as fundamental and a human right.
(4) Contamination of water means increased risk of exposure to harmful microbes such as
Escherichia Coli and Giardia Lamblia, and possible toxic chemical exposure, leading to
adverse health effects for the population, including diarrhoea, vomiting, and gastrointestinal
illness. (16) In Tasmania, over one third of the supply of drinking water is considered unsafe
by national guidelines. (16) This places several populations, the majority of which are rural,
at severe risk of illness from unsafe drinking water, which can be viewed as a violation of
social justice. (4)

Two factors have contributed to the disparity in access to safe drinking water between
rural and non-rural Tasmanian populations. Firstly, a study identified that the lack of adequate
or existing water supply infrastructure was a major hindrance to compliance with national
guidelines. (16) It was noted that the state lacked the resources needed to build the required
pipes and treatment facilities necessary to achieve safe drinking water standards in rural
Tasmania. (16) Secondly, was the effects of industry, like forestry, on rural water supplies.
(16) The spraying of herbicide Atrazine on Tasmanian forestry plantations is commonplace,
and the chemical detected in water supplies. (16) Atrazine is controversial due to its debated
carcinogenic properties. (17) Chemical contaminations such as these are further exacerbated
by inadequate water testing regimes, which are not mandatory in Tasmania. (16) No
jurisdiction on forestry and agricultural activity has been highlighted as a big risk to water
supply. (16) These two factors contribute to the elevated risks of microbial and chemical
contamination of water in rural areas, leading to health inequity between rural and non-rural
population groups. Groups that are enhanced by this disparity are the forestry and agricultural
industries and stakeholders, who benefit from maintaining the current status quo.

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 To address these issues, there would be need for greater funding by the state and
federal government, in order to address the lack of adequate water supply infrastructure. On
the household level, solutions can include installation of in-filter systems to provide safe
drinking water. Increased control over other industries that might jeopardise water supplies
can help prevention chemical contamination. More rigorous enforcement of water testing
regimes could help improve detection of contamination. Overall, a more integrated and
comprehensive approach must be taken to address the unsafe water supply in Tasmania. A
representative balance of government, industry, land-owners, and community members must
all be given a voice in deciding how the water supply should be managed. This helps reduce
the risk of discrimination between different rural populations, where some may benefit from
increased allocation of resources at the expense of others. When these issues are addressed,
the health inequity between rural and non-rural populations would be reduced.

Conclusion:

The social determinants of health: Discrimination, Income, Loss of Culture, and

access to safe drinking water were discussed, on how they led to adverse health outcomes for
several Australian population groups. This was than linked to health inequity between groups.
The concepts of equity, social justice, and fairness were explored in the context of how they
were violated within the current population health framework. Finally, it was discussed how
they can be applied through strategies to reduce health inequity between Australian
population groups caused by the social determinants of health.

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