Social Determinants of Health

Introduction

Research shows that coronary heart disease (CHD) is preventable and that the

prevalence of heart disease (including heart attack and angina) in South Australia (SA) is

currently higher than in urban areas (O’Connor and Wellenius, 2012 and Clark, Eckert, et

al 2007). This paper will explain heart health in rural SA and examine patterns within this

population. Furthermore, an explanation of the social determinants of health (SDH) in

relation to rural heart health will be offered.

A public health intervention will be proposed which will utilise the principles of

The Ottawa Charter for Health Promotion (WHO, 1986) to encourage physical activity

(PA) in rural populations. Community members will be invited to attend sporting clubs

using a SDH model (WHO, 2003). The concept of the social gradient of health will be

addressed by encouraging other sectors to become involved with this intervention such as

local government, sporting clubs, fitness groups, local education facilities and volunteers

in service organizations.

Heart health in rural South Australia

According to the World Health Organisation (WHO, 2012) heart attacks are

avoidable. They can be prevented by addressing risk factors such as reducing the use of

tobacco, eating a healthy diet and by increasing physical activity (PA). In South Australia

(SA) research shows that in 2010, 23 % of deaths were as a result of cardiovascular

disease (AIHW, 2015). The Heart Foundation (Heart Foundation, 2014) maintains that,

unless current trends are not addressed, life expectancy is likely to fall in the next

generation. Rural populations are very much at risk of poorer health outcomes as shown

in research by Dixon and Welch (2000). Clark, Eckert et al. (2007) concur with this view

and discuss heart disease and chronic heart failure in rural locations in Australia. Further

to this, The Heart Foundation’s Mary Barry notes that Australians who live outside urban

areas are at “significantly greater risk of the nation’s biggest killer, cardiovascular disease”

(Heart Foundation, 2014, accessed online 14 February 2015).

How does SDH impact on this data?

The social determinants of health (SDH) are extensively described in The Solid

Facts (WHO, 2003), and include ten themes to explain differences in health outcomes: the

social gradient, stress, early life, social exclusion, work, unemployment, social support,

addiction, food and transport. This comprehensive publication encourages all countries to

make structural and policy changes at all levels of government. Moreover, it encourages

accountability by public and private sector agencies to address these determinants to

improve population health. As Rose (in Marmot, 2005) points out, an examination of the

‘causes of the causes’ is required in order to address health inequities.

Dixon and Welch (2000, p. 254) note “the health status of rural people is inferior”.

Their research examines poorer health outcomes using a social determinants of health

(SDH) framework. Burnley (in Dixon and Welch, 2000) states that studies show that the

incidence of health disease is higher for people living in small rural towns and better for

people living in the coastal areas. Additionally the data shows that men in particular had

poorer health outcomes. Dixon and Welch (2000) discuss this occurrence and question if

the poorer outcomes could be as a result of inadequate health services in rural towns.

O’Connor and Wellenius (2012) examined the prevalence of diabetes and coronary health

disease in USA and noted that risk factors such as poverty, obesity and the use of tobacco

products may contribute to the higher prevalence of heart disease in rural communities.

For populations living away from major urban centres, access to health services may be

limited. The cost of travel to major towns to access health services can be prohibitive

resulting people not attending hospitals for support or education regarding their health

problems. In addition, social exclusion has been shown to lead to poorer health outcomes

(WHO, 2003). As noted in The Solid Facts (WHO, 2003), the longer people spend

excluded from their community the greater their risk of developing chronic disease,

“particularly cardiovascular disease” (WHO, The Solid Facts, p.16).

Physical activity in rural areas – a pilot program

The Ottawa Charter for Health Promotion framework (WHO, 1986) will be used to

advocate for free physical activity programs in rural SA. According to WHO (2003)

public health interventions that reduce social exclusion at a community level, as well as at

an individual level, are required in order to reduce inequities and promote better health

outcomes. Increasing daily physical activity has been shown to improve health outcomes

and encourage social connectedness in communities (Brownson, Housemann, et al., 2000).

Jackson, Howes, et al, (2005) agree with this notion and note that not only has physical

activity been shown to have benefits to physical health but can also lead to improvements

in mental health and personal development.

A pilot program is proposed which will encourage people living in rural SA to

attend local sporting clubs on a regular basis that will improve general fitness levels and

encourage social connections.

The ‘come and try’ events will be piloted in a major rural town initially and then

rolled out across South Australia. Funding and support will be sourced from local

governments, local businesses (cycling/sporting shops, local major employers, farming

machinery companies, mining companies) as well as local service organisations (Rotary,

Probus). The location of the events will be the local primary school or the area high

school. The equipment will be either at the school or funded by local service clubs. The

program will initially be simple and will be developed in consultation with community

leaders and local community groups. Suggestions of activities to ‘come and try’ may lead

to sports such as soccer, netball, cricket being offered. However, some non-traditional

activities may be offered such as tai chi, yoga, fencing, etc. An offer of 6 free sessions

may also be of interest and keep people attending for at least six weeks. Family

memberships could be funded to get the whole family involved. Media advertising will

be necessary – with local community radio stations becoming popular there may be an

opportunity to seek free publicity. E-mentoring has been suggested as a method of

supporting public health campaigns (McNab, 2009) and could prove successful in this

instance. People could be mentored and supported online or via social media to encourage

attendance and offer support – this could be facilitated by trained volunteers (thus

developing their skills).

The social gradient of health

According to The Solid Facts (WHO, 2003. p. 10) people who live “further down

the social ladder usually run twice the risk of serious illness and premature death as those

near the top”. Physical activity has been shown to reduce the social gradient in some

instances (Vyncke, De Clercq, et al. 2013). The rural physical activity pilot project will

address the social gradient of health by offering a six week ‘come and try’ sporting

activity to rural populations for free, thus reducing the cost for individuals. Funds to cover

fees and equipment will be sourced from local businesses, local service groups and

through sponsorship. Volunteers (local community members) will be recruited and trained

consequently enhancing skills in the community. In addition, this experience may benefit

those who are unemployed as they will gain valuable skills that could lead to entry into the

paid workforce. In order to attend the sessions, some individuals may require assistance

with transport which is poor in rural areas. Volunteers may be called to assist with

transport, but to address the overall problem of rural transport community members will

be encouraged to advocate for improvements in bus timetabling and better routing

systems. Social exclusion is an important SDH and will be addressed by the rural physical

activity program by encouraging people to be involved in the sporting clubs. By attending

the come and try sessions, it would be hoped that people feel more comfortable joining

social events and thus reduce social exclusion.

Conclusion

The prevalence of heart disease in rural Australia poses a major problem for public

health practitioners. This paper examines how a social determinants of health framework

could be used to address this issue, and the notion of the social gradient of health was

explored. In addition, the principles of The Ottawa Charter for Health Promotion (WHO,

1986) have been considered.

A ‘come and try’ pilot program is proposed which will encourage community

members to attend a free 6-week trial at a local sporting club. Transport will be provided

by volunteers with funding provided by a collaborative group comprising local businesses,

local government and local education authorities. Costs will be kept to a minimum by

having the support of trained volunteers who will run the classes. This will also enhance

the skill set of the volunteers and may lead to employment. Social exclusion will be

addressed by reducing the barriers to becoming involved in the community (reduction of

costs, improved transport). Effective and efficient community engagement will enhance

this proposed pilot program and ensure success for the final roll-out across South

Australia.

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