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- Redante Castro
There are many factors that interfere with health equity and the ability of the patients to get their healthcare needs met. Whether people are healthy or not, is determined by their circumstances and environment. There are challenges that a patient and healthcare providers encounters in securing and providing health services. These social determinants of health, such as income, education, transportation, housing, and race or ethnicity, have powerful influence on a patient’s life long before they arrive at a hospital or clinic.
According to literature, persistent social exclusion and inequities in wealth distribution and in access and use of services are reflected in health outcomes. Social exclusions and inequity are obstacles to human development. It poses barriers to poverty reduction strategies. It hinders social unity and improved health conditions of the populations. Social exclusion and inequity are further compounded by racial and gender discrimination. There are health disadvantages due to differences between segments of populations or between societies. There are health gaps arising from the differences between the worse-off and everyone else. Lastly, there are health gradients relating to differences across spectrum of the population. Studies have shown that the poorest of the poor have the worst health. This is also a global phenomenon, seen in low, middle, and high income countries. Within countries, studies showed that a person with low socioeconomic position has worse health- this is the social gradient of health. The poorest have the highest mortality rates. Improvements in income and education has a positive effect on health. One’s occupation is also relevant to health in terms of workplace risks exposure and its role in positioning the person along a society’s hierarchy. There is also demographic transition to consider that affects health, i.e., increasing life expectancy, increasing number of youths, growing number of elderly persons in the population, increased migration, and rapid urban growth. Population distribution and population age structure are crucial determinants of social, economic, and health-related services. For example, people in poverty are likely to be exposed to higher level of stress, economic uncertainty, and unhealthy conditions than their wealthier countrymen.
It was recognized by some policymakers and stakeholders that the population’s health cannot be sustained by focusing solely on the financing and distribution of medical services. A more comprehensive and integrated strategies are necessary to foster health in all policies. An approach that integrate considerations of health, well-being, and equity in the development, implementation, and evaluation of policies and services. Determinants of health are being acknowledged and incorporated into health reform processes and policy changes are made. Examples of these policy changes are: regulation of alcohol and tobacco products, the expansion of healthier transportation systems (bicycle paths, pedestrian-friendly roads, and pathways), improvement in air and water quality, expansion of primary health care services, and improvements in nutrition programs. This new focus has helped divert the emphasis away from individual lifestyles and from a focus on disease towards broader determinants and actions that created a big impact on population health. However, it is probably fair to say that all community issues are political to some degree. For example, if a factory is poisoning town water system with its effluent and poisonous waste, local officials are faced with the choice of not dealing with the actual cause of the problem, i.e., the dumping of waste and endangering citizen’s health, or addressing the dumping and endangering citizen’s job. Differences of political opinion can have enormous consequences in the health of the community.
Health is not merely the absence of illness or infirmity. It is the embodiment of physical, mental, social, emotional and spiritual wellbeing (World Health organization, 2007). Spiritual wellbeing involves one’s religious belief. Religious belief is essentially personal and private matter over which the individual should exercise control and choice. It is of value to understand the relative importance of religious beliefs and practices in protecting and promoting the health of the people of religious faith and the need to protect their rights to practice this belief free from discrimination. There is an abundant evidence in literature that religiousness can generate multitude benefits in health outcomes. For people of faith, their religion and belief system may influence individual health-promoting practices, for example encouraging abstinence from alcohol or not eating pork. They may also influence social environments. Strong social support and participation have been found to be associated with better health/ longer life and may be offered by some religious communities. To people of faith, prayer is very important while seeking healthcare or undergoing procedures, a prayer of support and encouragement when unfavorable result was received. There are some religious group that blood and blood products are not to be part of any treatment. For some religious groups, contraceptives, abortion and anti-life practices are against their belief system. With these in mind, alternative ways are to be sought to promote the health and wellbeing of the individual without compromising their belief system.
Values are criteria that people use to evaluate actions, people and events. What is important to a person may not be important to someone else. Each individual holds numerous values with varying degrees of importance. Values are motivational construct. They refer to the desirable goals people strive to attain. People have different health care value system. There are three ways people will view their health: how they became ill, what made them ill, and how they believed they can be cured. Example, people from the East (China) would value acupuncture for pain management option. This in turn will cause health care providers to look at health treatment plan to accommodate those needs. Among Asian cultures, maintain family harmony is an important value. The interests and honor of the family are more important than those of individual family members. Older family members are respected, and their authority is often unquestioned. Therefore, due to respect for authority, disagreement with treatment recommendation by the health team is avoided. (McLaughlin, L. & Braun, K. 1998).
Ethnic discrimination and exclusion affects all aspects of the individual’s life, including those related to health. Studies show that indigenous working people has low income, low educational level, poor access to healthcare, and has high mortality rate. Health screening, diagnosis, and treatment inequities within and between communities of different race, ethnicity and socioeconomic background are evident. Poverty barriers are linked to lack of primary care physicians, geographical barriers to care, competing survival priorities, comorbidities, inadequate health insurance, lack of information and knowledge, risk –promoting lifestyles, provider-and system-level factors, perceived susceptibility to disease, cultural beliefs and attitudes. Social exclusion can be the result of prejudice, which results in different access to health care, education, or other services.
These are social norms of acceptance of particular behaviors or practices. Culture influences how people define illness or wellness, how they understand the causes of illness or wellness, and whom they access to improve their health. Greater support from families, friends and communities is linked to better health. Culture-customs and traditions, and the beliefs of the family, practices and behaviors, and community all affect health and even the outcomes of intervention. Example: smoking, or even alcohol abuse, may be accepted part of the culture of a community. In that case, many more people will adopt it than in a community where those practices are considered health risks.
Some people think that health is not having any disease or illness, something that one feels. A paper from a conference of international health experts in 2011 sees health as the ability to adapt and to self-manage (Jocelyn Lowinger 2014).Medical News Today (2014) claims that most people accept that there are two aspects of health, physical and mental health. Most people relates physical health to good body health because of regular physical activity (exercise), good nutrition, and adequate rest. To some people, physical health involves structural health and chemical health. Structural health is associated with one’s height/weight ratio, body mass index, resting heart rate, and recovery time after exercise. Chemical health suggests that there are no toxic chemicals in one’s body and that there is a balance of nutrients needed by the body. Mental health on the other hand refers to people’s cognitive and emotional well-being. People have always found it easier to explain what mental illness is, rather than mental illness. Most people agree that mental health is the absence of mental illness. Mental health, to some people includes the ability to enjoy life, the ability to bounce back from adversities, the ability to achieve balance, to be flexible and adapt, the ability to feel safe and secure and making the best of what you have. Some views health as reflecting lifestyle, including a moral dimension and emotional well-being (MacInnes & Milburn: 1994). Healthy behavior as not smoking, good diet, exercising, and not drinking alcohol to excess, a positive approach to life. Elderly people concepts of health were identified as the absence of disease, as a dimension of strength, weakness and exhaustion and health as a functional fitness. (Williams, R. (1983)”Concepts of Health: an analysis of Lay Logic”. Sociology 17:185-204).
Illness results from negative attitudes, arising from a conflict between the individual and society-lifestyles in its widest sense. Ideas about causes of disease tend to emphasize biological rather than behavioral factors. Some of the agents of disease cited by working class women included infection, hereditary factors and environmental factors. The causes of disease are very much outside the control of the individual. Studies have also shown that people’s ideas about disease causation and vulnerability from illness are also influenced by biomedicine, example, and germ theory. However, people tend to take on beliefs which tend to fit with their lay understandings. (Calnan, M. (1987) Health and Illness: the Lay perspective. London: Tavistock). (Blaxter, M (1983) “The Causes of Disease: Women Talking”, Social Science and Medicine, 16:43-52). On the other hand, non-Western people views illness into two main systems according to anthropologists- personalistic and naturalistic. Personalistic system views illness to be caused by the active and purposeful intervention of an agent that may be: a supernatural being such as a deity or a god, a non-human being such as a ghost, ancestor, or evil spirit, or a human being such as a witch or a sorcerer. In this system, the sick person is a victim, the object of punishment directed specifically against him, for reasons that concerns him alone. In naturalistic system, illness is explained in impersonal, systemic terms. There is a concept of balance and equilibrium. Health prevails when elements in the body – heat, cold, the humors, etc. are in balance appropriate to the age and condition of the individual in his natural and social environment. (Foster, G. & Anderson, B. (1978) Medical Anthropology New York: Jon Wiley). There are also beliefs or superstition that people believes as causative factor of illnesses.
An understanding of people’s ideas about health maintenance and disease prevention is crucial to the success of health education and health promotion programs. One’s health beliefs may contribute to the knowledge of informal health care-how people manage their own health and whether they choose biomedical health services.
Public attitudes towards health professionals and their authority as medical experts are changing. The days of blind trust in a doctor “who knows best” is history. Social and cultural processes that have encouraged change in interpersonal trust relations have stimulated changes in institutional trust. Beliefs about the limits of medical expertise together with concerns about the effectiveness of professional regulatory systems to ensure high standards of clinical care, magnified by the media coverage of medical errors and examples of medical incompetence, have eroded trust in health care organizations, in the medical professions in general, and in the health system as a whole. The lower level of institutional trust and the emergence of more informed and potentially demanding patients who are aware that expert knowledge may be contested and who may actively seek further opinions poses challenges for both governments and the medical professions and raises the question of whether trust is still relevant and necessary to the provision of medical care in the 21st century. (Trust relations in health care – new agenda/The European Journal of Public Health 2006)
There should be policies to improve health in early life, such as equal opportunity of access to education, good nutrition, health education; access to health and preventive care facilities and access to adequate social and economic resources. Legislations to help protect minority and vulnerable groups from discrimination and social exclusion should be implemented. Government should intervene to reduce poverty and social exclusion at both individual and neighborhood levels. There should be policy regarding improvement in conditions of work and employees involvement in decision making process. For individuals who turn to drugs, alcohol and tobacco use – there should be a policy that aims to address the patterns of social deprivation in which the problems are rooted. Effective drug policy must be supported by the broad framework of social and economic policy.
Countries, such as New Zealand can develop health policy changes in assembling and promoting effective, evidence based practices, place health equity as a shared goal across governments and other sectors of society, build a sustainable global movement and to turn public health knowledge into political action. Governments should recognize that welfare programs need to address both psychosocial and material needs.
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