Social determinants of health in poverty

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 World Health Organization defines the social determinants of health as "the conditions in which people are born, grow, live, work and age" ,^[7] conditions that are determined by the distribution of money, power, and resources at global, national, and local levels.^[7] There are two main determinants of health: structural and proximal determinants. Structural determinants include societal divisions between social, economic, and political contexts, and lead to differences in power, status, and privilege within society. Proximal determinants are immediate factors present in daily life such as family and household relationships, peer and work relationships, and educational environments.^[7] Proximal determinants are influenced by the social stratification caused by structural determinants. Social determinants of health include early child development, globalization, health systems, measurement and evidence, urbanization, employment conditions, social exclusion, public health conditions, and women and gender equality.^[1] Different exposures and vulnerabilities to disease and injury determined by social, occupational, and physical environments and conditions, result in more or less vulnerability to poor health.^[1]

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 cardiovascular outcomes when compared to higher-income populations who may also be benefiting from curative and preventative strategies.^[8]

Within the impoverished population exists a wide range of real income, from less than US$2 a day, to the United States poverty threshold,^[1] which is $22,350 in a year for a family of four.^[9] Within impoverished populations, being relatively versus absolutely impoverished can determine health outcomes, in their severity and type of ailment. The poorest of all, globally, are the least healthy.^[1] Those in the lowest economic distribution of health, marginalized and excluded, and countries whose historical exploitation and inequality in global institutions of power and policy-making, have the worst health outcomes.^[1] As such, two broad categories distinguish between relative severity of poverty. Absolute poverty is the severe deprivation of basic human needs such as food, safe drinking water and shelter, and is used as a minimum standard below which no one should fall regardless of where they live. It is measured in relation to the 'poverty line' or the lowest amount of money needed to sustain human life.^[2] Relative poverty is "the inability to afford the goods, services, and activities needed to fully participate in a given society."^[2] Relative poverty still results in bad health outcomes because of the diminished agency of the impoverished.^[10]

Certain personal, household factors, such as living conditions, are more or less unstable in the lives of the impoverished and represent the determining factors for health amongst the poverty gradient.^[11] These factors prove challenging to individuals in poverty and are responsible for health deficits amongst the general impoverished population.^[11] Having sufficient access to a minimum amount of food that is nutritious and sanitary plays an important part in building health and reducing disease transmission.^[11] Access to sufficient amounts of quality water for drinking, bathing, and food preparation determines health and exposure to disease.^[11] Clothing that provides appropriate climatic protection and resources to wash clothes and bedding appropriately to prevent irritation, rashes, and parasitic life are also important to health.^[11]Housing, including size, quality, ventilation, crowding, sanitation, and separation, prove paramount in determining health and spread of disease.^[11] Availability of fuel for adequate sterilizing of eating utensils and food and the preservation of food proves necessary to promote health.^[11] Transportation, which provides access to medical care, shopping, and employment, proves absolutely essential.^[11] Hygienic and preventative care, including soap and insecticides, and vitamins and contraceptives, are necessary for maintaining health.^[11] Differential access to these life essentials depending on ability to afford with a given income results in differential health.^{[citation needed]}

Gender can determine health inequity in general health and particular diseases, and is especially magnified in poverty. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women.^{[12][13][14][5]} The health gap between the impoverished and other populations will only be closed if the lives of women are improved and gender inequalities are solved. Therefore, gender empowerment is key in achieving fair distribution of health.^[1] The rate at which girls and women die relative to men is higher in low- and middle-income countries than in high-income countries.^{[citation needed]}

"Globally, girls missing at birth and deaths from excess female mortality after birth add up to 6 million women a year, 3.9 million below the age of 60. Of the 6 million, one-fifth is never born, one-tenth dies in early childhood, one- fifth in the reproductive years, and two-fifths at older ages. Excess female deaths have persisted and even increased in countries immensely affected by the HIV/AIDS epidemic, like South Africa. In South Africa, excess female mortality between 10 and 50 years of age rose from close to zero to 74,000 deaths per year in 2008. In impoverished populations, there are pronounced differences in the types of illnesses and injuries men and women contract. According to Ward, poor women have more heart disease, diabetes, cancer, and infant mortality. Poor women also have significant comorbidity, or existence of two ailments, such as psychiatric disorders with psychoactive substance use. They are also at greater risk for contracting endemic conditions like tuberculosis, diabetes, and heart disease. Women of low socioeconomic status in urban areas are more liable to contract sexually transmitted diseases and have unplanned pregnancies. Global studies demonstrate that risk for contracting cervical cancer, exclusive to women, increases as socioeconomic status decreases."^[10]

Health of poor women is impacted by gender inequalities through discriminating distribution of household goods, domestic violence, lack of agency, and unfair distribution of work, leisure, and opportunities between each gender.^[1] The way in which resources such as income, nourishment, and emotional support are traded in the household influences women's psychosocial health, nutrition, wellness, access to healthcare services, and threat of violence.^[11] The exchange of these elements in a home mediates in the impacts of geographical, cultural, and household patterns that result in inequality in health status and outcomes.^[11] Health-related behaviors, access and use of healthcare, stress, and psychosocial resources like social ties, coping, and spirituality all serve as factors that mediate health inequality.^[11] Household discrimination causes missing girls at birth, and the persistence of discrimination and poor service delivery perpetuates high female mortality.^[10]

Socioeconomic status has long been related to health, those higher in the social hierarchy typically enjoy better health than do those below.^[15] With respect to socioeconomic factors, poor institutions of public health and services can cause worse health in women.^[10] Components of the geopolitical system that spawn gender and economic inequality, such as history of a nation, geography, policy, services, legal rights, organizations, institutions, and social structures, are all determinants of women's health in poverty.^[3] These structures, like socio-demographic status and culture, norms and sanctions, shape women's productive role in the workplace and reproductive role in the household, which determines health.^[3] Women's social capital, gender roles, psychological stress, social resources, healthcare, and behavior form the social, economic, and cultural effects on health outcomes.^[3] Also, women facing financial difficulty are more likely to report chronic conditions of health,^[16] which occurs often in the lives of the impoverished. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women.^{[12][13][14][5]}

In India, differences in socioeconomic status and resulting financial disempowerment for women explain the poorer health and lower healthcare utilization noted among older women compared to men.^[5] Psycho-social factors also contribute to differences in reported health.^[5] First, women might report higher levels of health problems as a result of differential exposure or reduced access to material and social factors that foster health and well-being^[17][5] Second, women might report higher health problems because of differential vulnerability to material, behavioral, and psychosocial factors that foster health.^[14][5]

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,^[18] 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.^[18] 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]

There also exist differentials in health with respect to men. In many post-transition countries, like the Russian Federation, excess female mortality is not a problem, but rather there has been an increase in mortality risks for men.^[10] Evidence suggests that excess male mortality correlates with behavior considered socially acceptable among men, including smoking, binge drinking, and risky activities.^[10] According to Moss, "Women are more likely to experience role strain and overload that occur when familial responsibilities are combined with occupation-related stress."^[3]

Social determinants can have differential effects on health outcomes based on age group.

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]

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.^[18] 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 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.^[18] 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.^[18] 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.^[18] AIDS-affected Hispanic women hold smaller salaries than average women, are part of poorer families, and are more likely to head households.^[18] According to one study, black teenage women living in dysfunctional homes were more likely to have serious health issues for themselves or children.^[18]

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]}

Relatedly, maintenance of good health through the utilization of proper healthcare resources can be quite costly and therefore unaffordable to certain populations. According to the Healthy People 2030, people with steady employment are less likely to live in poverty and more likely to be healthy, however, many people struggle with finding and keeping a job.^[41] Social needs, environmental factors and barriers to accessing health care that are unaddressed could lead to worse health outcomes for people with lower incomes.^[42][43] Additionally, residents of impoverished communities are at increased risk for mental illness, chronic disease, higher mortality, and lower life expectancy.^[44]

Housing is another critical aspect of economics as a social determinant of health. In a 2020 housing study in which millions of court records on renter evictions were analyzed, the evidence on racial and gender demographics were dramatic.^[45] Black and Latino tenants experienced significantly higher eviction rates than their white counterparts. And housing instability plays a critical role in health outcomes: when families have to spend a disproportionately high percentage of income (30% or more) on housing, there are insufficient funds remaining for essentials such as healthy foods, consistent health care, and medications.^[46] Racial disparities in eviction rates correspond to negative health outcomes, including depression.^[47]

Food security—meaning consistent availability and affordability of food that promotes well-being and prevents disease—is another important social determinant of health linked to economics.^[48] Food insecurity increases in neighborhoods where access to healthy food is limited because of travel distance to supermarkets and lack of transportation.^[49] Families living in poverty struggle with consistent access to sufficient healthy food, and suffer negative health outcomes as a result; food insecurity has been demonstrated to correlate with many health issues, including chronic disease and obesity.^[50]

As one's job or career is a primary conduit for both financial and social capital, work is an important, yet under represented, factor in health inequities research and prevention efforts.^[51] There are many ways that a job can affect one's health, such as the job's physical demands, exposure to hazards, mechanisms of employment, compensation and benefits, and availability of health and safety programs. In addition, those who are in steady jobs are less likely to face poverty and its implications and more likely to have access to health care.^{[51][52][53][54][55]}

Education plays an especially influential part in the lives of the impoverished. 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.^{[56][57][58][1]} Social resources, such as education, determine life expectancy and infant mortality, which measures health.^[59] 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]

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.

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.^[60] Refugees and migrants remain among the most vulnerable members of society and may be faced with inadequate or restricted access to health services.^[60] Xenophobia, discrimination, and working conditions may further affect their mental health disproportionally.^[60] 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.^[61]