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What is Meant by the Term “Social Determinants of Health”

Describe what is meant by the term `social determinants of health’. Discuss the evidence of how work has an impact on health. Outline the implications for nursing practice. Introduction. This assignment aims to discuss the evidence of the impacts that can have on an individual’s health. Health has been defined as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (World Health Organisation – WHO, 1946). Therefore, health is viewed as a much broader concept in that it includes social wellbeing. It has long been recognized that social determinants can influence health. There are many social determinants of health, for example, food, stress, early life, transport, social gradient, unemployment, social support, addiction and social exclusion.

However, this assignment intends to discuss the evidence of the impact of work as a social determinant. Secondly, this assignment will explore Babbage, Taylorism and Fordism about the influence on the development of work. The discussion will also include how work within the UK has changed over the last 20 to 30 years. A description and evidence of the effects of paid and unpaid work and the boundaries between the two will also be illustrated. Lastly, the implications of work as a social determinant of health for nursing practice will be outlined.

Main body. Social Determinants of Health. Social determinants of health are the economic and social conditions under which individuals live, determining their health. WHO (1946) has identified ten different social determinants (stated in the introduction) of health that can all have an effect on a person’s physical and mental wellbeing. Identifying and researching social determinants of health have helped extend awareness and encourage action from healthcare workers and advocates. According to Drever and Whitehead (1997), in studies of social inequalities of health, the most frequently used indirect indicators of social and economic conditions are an individual’s occupation, education or income and how these factors influence their lifestyle and wellbeing.

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The Babbage Principle. Charles Babbage first introduced the Babbage principle in 1832. He pointed out that industrial work could be more profitable because it could employ less skilled, cheaper labour (Cooke 2008). Watson (2003) also stated that in purchasing a ‘whole’ task, the employer must pay the rate for the most skilled part of the task, whereas if the task is broken up, many parts of the task may be more cheaply obtained.

Taylorism and Fordism. Frederick Taylor first introduced a system of ‘scientific management’ in 1911. This involved task allocation work being sub-divided into smaller tasks. Tasks were expected to be completed within a certain amount of time. For example, attaching one bolt was expected to take 15.2 seconds. Taylor (1947) believed this was ‘the one best way’ as tasks would be completed quickly and efficiently, although this approach meant that workers were treated like machines and thus had no control over their work. Watson (2003) stated that Taylor regarded workers as ‘economic animals’ who would ‘allow managers to think of them.’

Braverman (1974) has argued that the influence of Taylorism has led to attempts to de-skill and routinize work across the labour force leading to work intensification. However, Fordism was developed by Henry Ford, which is a process that goes beyond Taylorism. Fordism is different because it is fundamentally a mass production process that includes employers as part of the market for its productions. This shows that Fordism recognizes the need to take an interest in their employer’s lives and not treat them as machines, meaning they may be more than just producers but could be consumers of the product as well (Watson 2003).

The connection between producing and consumption is stressed by Aglietta (1979), who points to Fordism’s recognition of the need to develop working-class ‘social consumption norms’ which stabilize the market for the products of mass production industries. How work has changed over the last 20 – 30 years. During the 1980s, the tertiary sector, consisting of services such as retailing, banking and leisure industries, greatly increased in size and importance. The growth of the service industry had many implications on the economy; one implied growth of white-collar jobs, which in turn resulted in a decline of manual work, and another implied that physical skills are now less important than interpersonal skills, which shifted the focus of dexterity within jobs such as shop and office work.

This growth and decrease in physical work increased job opportunities for women and is somewhat responsible for their increased participation in the labour market. (Cooke 2008) The boundaries between paid and unpaid work. Nicholls (2005) states that ‘work does not automatically suggest regular, full time or even paid employment. Part of the reason for this is that work has become a contested concept’. He implies that work has become a challenging idea because work can include non-paid work such as housework or being an un-paid carer and having an occupation for which one gets paid. However, due to the type of society we live in today, parents are now encouraged to pay for childcare instead of caring for their children themselves under schemes such as ‘welfare to work.’ (Mooney 2004).

Much unpaid work nowadays is carried out by women (Cooke 2008). The 2003 Census findings showed that over 5 million people within England alone cared for a relative or friend. The majority of these people were older women caring for their ill husbands. The census findings also established that approximately 15,000 children under 18 were also caring for an ill family member. How does employment affect health? Lack of control over work conditions and hazardous and repetitive tasks can result in a negative employment experience, hurting health (Marmot et al. 1991, Pantry 1995), leading to low self-esteem and employment insecurity (Heaney et al. 1994).

Positive work experiences include skill development (Hackman and Lawler 1971), autonomy (Kohn and Schooler 1973), and a sense of belonging to a significant group of colleagues (House et al. 1998). Differences between the positive and negative work experiences are known to have different physical and psychological effects on an individual employer. The negative effects that can have an impact on an individual’s health are discussed below. Evidence of the impact work can have on an individual’s health. Substantial evidence demonstrates how work can hurt an individual’s physical and mental health. For example, Karasek’s job strain model (1979) and Miers’s (2003) study emotional and physiological factors and CHD.

Evidence of the impact work can have on health includes the connection between stress and different diseases, particularly coronary heart disease, type 2 diabetes and some mental health illnesses that stress is known to have a link to. All these links are discussed below. In addition, Karasek’s job strain model (1979) and the effect reward imbalance model, Marmot et al. (1999) demonstrate how negative health effects within the workplace can impact health. Karasek’s job strain model, also known as the demand-control model, states that the stressors of work can be caused by a high level of psychological demands, such as working fast and not having enough time to get everything done combined with a low level of decision making and low control in meeting the demands that had been made. Karasek and Theorell (1990) noted that learning might contribute to a worker’s possibility of applying control over the work situation.

Marmot et al. (1999) state that the effort-reward imbalance model is associated with recurrent options of contributing and performing within a workplace setting and, in turn, being rewarded and feeling a sense of belonging to a significant group, for example, work colleagues. Marmot et al. found six studies that reported findings relevant to his model. The Whitehall II studies (Bosma et al. 1998) and a German blue-collar manual work-study (Siegrist et al. 1990) found a risk of CHD among those who reported effort-reward imbalance compared to those who did not report chronic work stress. Overall, the Whitehall II study reported that both Karesak’s demand-control model and the effort-reward balance model were separately related to CHD outcomes.

Repetitive Strain Injury. Cannan (1999) explains the reported incidence of repetitive strain injury (RSI) in Britain has risen dramatically. Evidence from a Department of Employment workplace found survey found that musculoskeletal problems accounted for 550,000 lost working days in 1990. Kihilji and Smithson (1994) found that this figure had doubled since 1983. RSI incidences can be linked to the increase in mechanical tasks within the workplace, which are known to link to upper limb disorders.

Coronary Heart Disease. There are many physical risk factors related to Coronary Heart Disease (CHD), such as high cholesterol, smoking and high blood pressure. Still, more recent research has found evidence linking workplace stress and CHD. Recent workplace changes in developed society show a greater demand for physiological and emotional factors; for example, more jobs now demand interpersonal skills (Miers 2003). This can cause a great deal of psychological stress to an individual. Recently there has also been an increase in part-time jobs, unemployment and job instability (Marmot et al.). This can also have an effect on a person’s physiological health, which in turn increases stress within the workplace.

Sokejima and Kagamimori (1998) examined the extent to which working hours affect the risk of Myocardial infarction (MI) through a case-control study of men aged between 30 and 69 in Japan. Japan is known for very long working hours but low levels of morbidity and mortality caused by CHD (Uehata 1991). The study demonstrated that the risk of a MI was increased not only by long working hours but also shorter than average working hours. Sokejima and Kagamimori noted that the risk of an MI might be increased by shortened hours and unemployment. Still, a biological explanation of changing activities within the autonomic nervous system was given for long working hours to explain how this can increase stress, thus eliciting an acute MI.

Type II Diabetes. A study published by the British Medical Journal (2003) has shown a link between type II diabetes (non-insulin-dependent diabetes) and stress in the workplace. Researchers observed the association between workplace stress and metabolic syndrome in 10,308 British civil servants aged 35 and 55. The study took place over a period of 14 years. Work stress was measured on four different occasions throughout the 14 years. Researchers found a dose-response relationship between exposure to job stress and metabolic syndrome, even after accounting for other risk factors such as social position and health-damaging behaviour.

Men with chronic work stress were nearly twice as likely to develop the syndrome as those with no exposure to work stress. A possible explanation for the findings is that long-standing exposure to stress at work may affect the nervous system, also stated by Marmot et al. Chronic stress may also reduce biological resilience, disturbing the body’s homeostasis, thus causing an imbalance of the body’s systems.

Unemployment and Health. Stress within the workplace has been shown to ill affect an individual’s health, but unemployment can also affect a person’s mental and physical health. Many different research studies have established a link between unemployment and physical ill-health (Morris et al. 1994, Bartley et al. 1996, Nylen et al. 2001) and psychological ill-health (Warr and Jackson 1987, Montgomery et al. 1999) amongst both men and women who are out of work. Poor physical effects in men aged 33 who had experienced unemployment were more likely to have lower body weight, smoke and have a drinking problem (Bartley et al. 1999.) Psychological effects of unemployment identified include anxiety, low self-esteem, and depression and more likely to self-harm and/or commit suicide (Moser et al. 1984 and Bartley 1994)

Conclusion. Summary. This assignment has defined social determinants of health and how their recognition has helped healthcare workers extend their understanding of how they can all influence an individual’s health in different ways and how negative affects of one or more social determinants can greatly influence the onset of an illness. The main body of the assignment discussed how the Babbage Principle, Taylorism, and Fordism have all influenced the development of work from industrialization to the tertiary sector. The boundaries of unpaid work and employment were also outlined, and statistics from the 2003 census were given to show the increase of unpaid carers, particularly women in England.

Secondly, the assignment discussed important evidence relating to the physical and psychological effects of stress in the workplace. This included models by Karasek and Marmot et al., which both showed a link between stress, ill-health and a connection to CHD. A study by the British Medical Journal also showed a link between type II diabetes and chronic stress in the workplace. Research has also concluded that unemployment plays a large part in the onset of stress, illness and disease.

Some research has found a link between unemployment, particularly among males and high risks of suicide. All the evidence found illustrates that both stresses within the workplace and stress caused due to unemployment can have a serious number of negative effects on an individual’s health, which in turn can result n the onset of illness or disease and/or psychological factors which can result in several issues for an individual, such as low self-esteem, anxiety, depression and even suicide.

Implications for Nursing Practice. The consequential problems due to chronic stress in the workplace have been recognized, and some solutions have been made to endeavour the problem. However, most social determinants have various implications for nursing; according to Gordon et al. (1999), the NHS has two interlinked responsibilities about health inequalities. Firstly, to provide equitable access to effective healthcare about the individual’s needs; secondly, to work in partnership with other agencies to tackle the broader determinants of health. They also pointed out that in terms of equity, the observations of the NHS should be to contribute towards reducing inequalities in health status, achieve equality of access to health services about need, and finally achieve equality of treatment and intervention outcomes.

A document published by the Canadian Nursing Association (CNA) also pointed out that individual nursing practices have a lot of input when addressing problems associated with social determinants of health. For example, within an individual practice, nurses could ask questions when assessing to see if there is a link between their patient’s illness and stress at work and understand the impacts of different social determinants on a patient’s health. It has also been suggested that nurses are u to date with what services are available to their patients within their area of residence and help them make a link with social determinants and help them understand the common health issues associated with them.

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[Accessed 09/12/08]

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