Determinants of health and reducing health inequity

Case scenario

Your regular patient, Meera, is looking at nicotine replacement therapy (NRT). You know she is a smoker and has attempted to quit several times unsuccessfully. This time she is considering NRT to assist, but is shocked at the price. You advise that if she sees her GP and engages with a smoking cessation support and counselling service (e.g. Quitline), she may be eligible for NRT subsidised by the Pharmaceutical Benefits Scheme. However, she is worried about the associated costs, as the GP practice no longer bulk-bills and the wait time to see a GP in your regional town is at least 4 weeks. She leaves empty-handed.

Introduction

Health can be defined in many ways and is influenced by context, culture and an individual’s belief systems. Traditionally pharmacists have used the disease or medical model as their working definition of health, where the major focus is on disease, ill health and deteriorating physical and mental function. Following a diagnosis, the disease is then treated with medicines and/or lifestyle changes.

Increasingly, pharmacists can be observed in their practice and local community to be key contributors to public health efforts, including health promotion, health prevention and health protection activities. In public health, health is defined as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.1

A compromise between these two definitions may be required to ensure pharmacists can contribute meaningfully to this broader definition of health.

Further, for some patients, health will include their physical, mental, social, emotional, cultural, spiritual and environmental health. Importantly, how each is prioritised may differ from person to person, and it is important that this is considered by pharmacists.

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Determinants of health

There are several factors that, in combination, determine the health outcomes of individuals and communities. These determinants of health include²:

• The social environment (e.g. family, friends and support networks)
• The economic environment (e.g. income and social status) 
• The physical environment (e.g. water and air quality, working conditions) 
• Cultural factors (e.g. beliefs of the community, customs, traditions) 
• Education level
• Health services (e.g. access and appropriate use) 
• The individual’s characteristics and behaviours (e.g. gender, genetics, diet, exercise). 

A person’s circumstances and environment, including where a person of the environment in which they live, their genetics, income and education level, and their relationships with friends and family have all been found to have considerable impacts on health.2 In contrast, factors commonly thought to be key determinants of health, such as access to and use of healthcare services, may in fact have less of an impact.²

The social determinants of health (SDH) are factors that concern the conditions in which people are born, grow, live, work and age.³ This includes the health system, and if and how people can access it. Importantly, this is shaped by the distribution of money, power and resources at global, national and local levels, which are also influenced by policy choices.^3,4 The SDH are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.³

There are several models that illustrate the determinants of health. The determinants of health model (Figure 1) produced by Barton and Grant⁵ includes the global ecosystem and climate change. The importance of these recent additions to the determinants of health model have been recognised by the pharmacy profession.^6,7

Determinants that impact Australians

The Australian Institute of Health and Welfare⁸ highlights six key determinants impacting Australians: socioeconomic position, early childhood, family relationships, social inclusion, employment and work, housing and homelessness.

Although Australia is a rich country by international standards, not all people within our population enjoy the health benefits this can offer. Australians who experience greater socioeconomic disadvantage are more likely to die earlier, and experience more disability and worse health overall.⁹

However, it is not just our income that is associated with our health. People who are unemployed, are blue collar rather than white collar workers, are of Aboriginal or Torres Strait Islander background, or are refugees or migrants experience poorer health outcomes.¹⁰ Australians who live in regional rather than urban areas also have a shorter life expectancy.^11,12

An increase in health inequities during and post COVID-19 led to calls for better-quality data on the determinants of health that impact Australians so that we can build back from the pandemic in a fairer way.¹

How determinants influence the health outcomes of Australians

It is not possible to discuss all six of these determinants in detail, however some examples are provided below.

Socioeconomic status is an important determinant of health with indicators including educational attainment, income or occupation level often used to understand a person’s socioeconomic position.⁸

As highlighted internationally, every step up the socioeconomic ladder is associated with improvements in health outcomes for Australians.⁸

A circular relationship exists between wealth and health, with poor health being both the result of, and a contributor to, a lower socioeconomic position.⁸

Social connectedness and the degree to which individuals form close bonds with others has been linked in some studies to lower morbidity and increased life expectancy.¹² The mechanisms through which strong social networks improve physical and mental health may include the provision of practical and emotional help and support as well as assistance with finding work and coping with economic and material hardship.⁸ Recent studies have shown that social connectedness may reduce potentially preventable hospital readmissions.¹

Homelessness and overcrowding can have a negative impact on an individual’s physical and mental health.⁸ Additionally, poor-quality housing has been directly associated with poor physical and mental health.¹⁶

As with socioeconomic position, the relationship between homelessness and health is circular, with poor health being both the result of and a contributor to homelessness.¹⁷

The people at greatest risk of living in poor-quality housing in Australia are young people, Aboriginal and Torres Strait Islander peoples, people with long-term health conditions or disability, people living in low-income housing, and people who are unemployed or underemployed.⁸

How determinants create inequities in Australia

Social determinants of health, including income level and socioeconomic position, are largely responsible for the systematic differences in health status that occur between different groups of people. Where these systematic differences in health status exist but could be avoided by ‘reasonable policy action’, there is health inequity.18 A reduction of health inequities, between and within countries, is a social justice issue that requires urgent attention.¹⁸

Addressing inequity is central to effective public health action. The words ‘inequality’ and ‘inequity’ are often used interchangeably; however, they mean very different things.. Health inequities are avoidable and unfair, and addressing them is about making sure that everyone gets access to the same opportunities to be healthy.

Strategies to reduce inequities

The social determinants require a focus on policies, organisations and social structure to reduce health inequities.^19,20

The World Health Organization (WHO) defines public health as “the art and
science of preventing disease, prolonging life and promoting health through the
organised efforts of society”.²¹ The overall vision is to promote greater health and wellbeing in a sustainable way, while strengthening integrated public health services and reducing inequity. To achieve this, the public health approach involves working with other sectors (e.g. education) to address the wider determinants of health, and with health professionals. Primary healthcare professionals, including pharmacists, can play a key role in preventing illness and promoting health, as outlined in the Alma-Ata Declaration.²¹

Global strategies that have been implemented to address inequity and support effective health promotion and health prevention efforts include the Ottawa Charter,²² Sustainable Development Goals,²³ Health in All Policies²⁴ and the Universal Health Coverage²⁵ approach.

In Australia, one example of a strategy which aims to address inequity is the Closing the Gap agenda. This partnership places Aboriginal and Torres Strait Islander peoples at the table as shared decision-makers.²⁶

How pharmacists can reduce inequities

The accessibility of the healthcare sector is an important determinant of health. Health services such as pharmacy provide a key resource capable of improving health in an equitable manner.

It is important for pharmacists and other health professionals to recognise the health sector’s propensity to generate health inequity and act to redress these wherever possible. This includes strengthening its role in working with other sectors of government (e.g. education, justice) to identify and act upon the deep-rooted causes of poor and inequitable health.4 This is referred to as a Health in All Policies approach.²

Given their accessibility and regular and repeated interactions, pharmacists are in a unique position to see firsthand how the social, economic and environmental determinants influence each of their patient’s health.²⁷ As pharmacists are usually embedded within their community themselves, they are trusted and known, which gives them the opportunity to support and develop health promotion and prevention initiatives that are tailored to address the needs of their patients and the wider community.

Breaking down the determinants of health into some of their broad categories makes it possible to see why it is so important for pharmacists to understand them, and how some pharmacists are responding in their routine practice.

Social determinants of health

Although people’s living and working conditions vary, trends exist in some communities. Pharmacists can become attuned to the trends and needs in their local community and tailor the health services they provide to ensure they are accessible to those who need them most.

Pharmacists are well placed to address local trends as they have the clinical and communication skills required and, when working in community pharmacies, provide a centralised contact point. This is one simple approach that uses existing resources to address inequities that may exist within some communities.

Some strategies that can be implemented in practice to improve healthcare access include:

• Telehealth services²⁸
• Professional pharmacy services (e.g. blood pressure checks, risk assessment for chronic conditions, weight loss consultations, wound care, sleep apnoea assessment)
• Medicine reviews
• Translation services (e.g. Translating and Interpreting Service (TIS) – a free interpreting service available 24 hours a day, every day of the year for pharmacies)
• Provision of National Diabetes Services Scheme Supplies.
  Medicine delivery.

Additionally, pharmacies can apply for grants that are available in the communit (e.g. Primary Health Network grants) to fund the provision of services through their pharmacy to increase access to healthcare (e.g. the provision of after-hours home- based palliative care medicine).²⁹

Economic determinants of health

The cost of health services is an important barrier to patient’s accessing healthcare. There are several things that can be done to ensure patients are receiving the best value care, many of which are already routine practice for pharmacists. These include:

• Checking for concession/healthcare cards
• Checking for Closing the Gap eligibility and directing patients to their doctor to get registered if they are not already
• Checking for National Diabetes Services Scheme eligibility and supporting eligible patients to register for the program
• Advising patients of the Pharmaceutical Benefits Scheme safety net and assisting them to track their prescription expenditure
• Advising patients of the availability of a less expensive brand of a less expensive brand of medicine or a medicine that doesn’t have a brand price premium where relevant
• Implementation of state government-funded services (e.g. free nicotine replacement therapy).

If further support is required there are services available such as the Centrelink pharmaceutical allowance.³⁰

It is important to consider how the economic determinants may impact on your patient’s daily health decisions and how we might be able to provide health promotion and health prevention education activities in the pharmacy designed to make healthy choices the easier choices (e.g. pharmacy walking groups, diet advice and cancer screening services).

Environmental determinants of health

The environment in which people live, including the natural and built environment, impacts health outcomes. Environmental determinants can include the forces associated with our natural environment, for example floods and bushfires. Pharmacists working in communities devastated by floods know firsthand the impact this has to the health of their community. For many, this environmental determinant has had a negative flow-on effect to social and economic determinants. Examples of the impact of our built environment include the density of junk food advertising on buildings and buses (contributing to obesity) and the lack of green spaces (contributing to rising rates of mental ill health).^31,32

Many pharmacists already recognise that the environment has a direct impact on the health of their patients, and that as a society we may be damaging the environment and creating damaging environments (e.g. obesogenic environments). In addition, pharmacists are becoming increasingly aware of the health sector’s carbon footprint and taking steps to measure and reduce their footprint.^6,7 Given their position of trust, pharmacists can become key advocates for positive change in their local community. Pharmacists can also consider the impact that medicines, the disposal of packaging, disposal of medicines and the transportation of stock is having on the environment and what practices they can introduce to reduce their carbon footprint.

These can include:

• advising patients of the availability of inhalers that contribute less to carbon footprint, where appropriate (e.g. dry powder inhalers rather than pressurised metered dose inhalers)³³
• reducing excessive use of short-term reliever inhalers by supporting patients to optimise asthma control³³
• minimising the impact of medicine disposal on the environment (e.g through promotion of the Return of Unwanted Medicines (RUM) project)
• use of an eFax
• medicines blister pack recycling
• Use of environmentally friendly consumables (e.g. biodegradable opioid pharmacotherapy cups).

Cultural determinants of health

For many people, cultural and spiritual beliefs are tightly interwoven with their sense of country and place.^26,34 Understanding the diversity of cultures in your local community can help to ensure services are tailored to cultural preferences and care is provided in a culturally safe manner. The Professional Practice Standards require pharmacists to determine the specific health needs, including cultural needs, of the patient and/or community, to ensure their services are adaptable and responsive.

Further information on the provision of culturally safe care to Aboriginal and Torres Strait Islander peoples is available in the Pharmaceutical Society of Australia Guidelines for pharmacists supporting Aboriginal and Torres Strait Islander peoples with medicines management.³⁵

Conclusion

Determinants of health can unfairly impact the health of Australians and create health inequities. While many communities and individuals within communities are impacted by their determinants of health, pharmacist awareness of their existence and how they impact the health outcomes of Australians can help lead to the development of solutions to redress the inequity.

Key points

• Health can mean different things to different people: health can include physical, mental, social, emotional, cultural, spiritual and environmental health.
• An individual’s health can be influenced by social, economic, environmental and cultural factors beyond their control.
• Pharmacists are trusted members of the community who understand firsthand which determinants are influencing the health of their patients and their local community.
• Pharmacists can combine their knowledge of their community and their clinical and communication skills to deliver tailored services to those who need them most.

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References

1. World Health Organization. Interim commission (1948) official records of the World Health Organization No. 2: Summary report on proceedings, minutes and final acts of the International Health Conference Held in New York From 19 June to 22 July 1946. Geneva: WHO.
2. World Health Organization. Determinants of Health. 2017. At: www.who.int/news-room/questions-and-answers/item/determinants-of-health
3. World Health Organization Commission on social determinants of health. Closing the gap in a generation: health equity through action on the social determinants of health. 2008. At: www.who.int/publications/i/item/WHO-IER-CSDH-08.1
4. Baum F, Bégin M, Houweling T, et al. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health 2009;99(11):1967–74. At: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2008.154856
5. Barton H, Grant M. A health map for the local human habitat. R Soc Health J 2006;126(6):252–53.
6. Gahbauer A, Gruenberg K, Forrester C, et al. Climate care is health care: a call for collaborative pharmacy action. J Am Coll Clin Pharm 2021;4:631–38. At: https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1002/jac5.1412
7. Roy C. The pharmacist’s role in climate change: a call to action. Can Pharm J (Ott) 2021; 154(2):74–5. At: www.ncbi.nlm.nih.gov/pmc/articles/PMC8020277/
8. Australian Institute of Health and Welfare. Social Determinants of Health. 2022. At: www.aihw.gov.au/reports/australias-health/social-determinants-of-health
9. Australian Institute of Health and Welfare. Health across socioeconomic groups. 2022. At: www.aihw.gov.au/reports/australias-health/health-across-socioeconomic-groups
10. Australian Institute of Health and Welfare. 2012. The health of Australia’s males: a focus on five population groups. Cat. no. PHE 160. Canberra: AIHW. At: www.aihw.gov.au/getmedia/a18e3efa-20de-432b-8e0b-65eaf7b4f706/13506.pdf.aspx?inline=true
11. Hanlon P, Carlisle S, Lyon A, et al. 2012. The Future Public Health. Maidenhead: McGraw-Hill Education; 2012.
12. Baum F. People’s health and the social determinants of health. Health Promot J Austr 2018; 29:8–9. At: https://onlinelibrary.wiley.com/doi/full/10.1002/hpja.49
13. Flavel J, McKee M, Freeman T, et al. The need for improved Australian data on social determinants of health inequities. Med J Aust 2022;216: 388-391. At: https://doi.org/10.5694/mja2.51495
14. Australian Institute of Health and Welfare. Australia’s Health 2016: 4.1 Social Determinants of Health. Cat. No. AUS 199. Canberra: AIHW; 2016. At: www.aihw.gov.au/getmedia/11ada76c-0572-4d01-93f4-d96ac6008a95/ah16-4-1-social-determinants-health.pdf.aspx
15. Ridge A, Peterson GM, Kitsos AR, et al. Potentially preventable hospitalisations in rural community-dwelling patients. Intern Med J 2021;53(2):228–35. At: https://onlinelibrary.wiley.com/doi/10.1111/imj.15545
16. Baker E, Lester LH, Bentley R, et al. Poor housing quality: prevalence and health effects. J Prev Interv Community 2016;44:219–32.
17. Australian Institute of Health and Welfare. Health of people experiencing homelessness. 2021. At: www.aihw.gov.au/reports/australias-health/health-of-people-experiencing-homelessness
18. Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet Public Health 2008;372(9650):1661–9. At: www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61690-6/fulltext
19. McCormack L, Thomas V, Lewis M, et al. Improving low health literacy and patient engagement: a social ecological approach. Patient Educ Couns 2017;100(1):8–13. At: https://pubmed.ncbi.nlm.nih.gov/27475265/
20. Baum F, Harris L. Equity and the social determinants of health: editorial. Health Promot J Austr 2006;17(3):163–5. At: https://search.informit.org/doi/pdf/10.3316/informit.452918300177222
21. Nutbeam D. Health promotion glossary. Geneva, World Health Organization, 1998.
22. World Health Organization. The Ottawa charter for health promotion. Geneva: WHO;1986. At: www.who.int/healthpromotion/conferences/previous/ottawa/en/index.html
23. United Nations Department of Economic and Social Affairs Sustainable Development. Sustainable development goals. At: https://sdgs.un.org/goals
24. Kickbusch I, Williams C, Lawless A. Making the most of open windows: establishing health in all policies in South Australia. Int J Health Serv 2014;44(1):185–94. At: https://pubmed.ncbi.nlm.nih.gov/24684091/
25. World Health Organization. Universal health coverage. At: www.who.int/health-topics/universal-health-coverage#tab=tab_1
26. Lowitja Institute. Transforming power: Voices for generational change close the gap campaign report 2022. 2022. At: www.lowitja.org.au/content/Document/Lowitja-Publishing/ClosetheGapReport_2022.pdf
27. Osae SP, Chastain DB, Young HN. Pharmacist role in addressing health disparities – Part 2: strategies to move toward health equity. JACCP 2022;5(5):541–50.
28. Livet M, Levitt JM, Lee A, et al. The pharmacist as a public health resource: expanding telepharmacy services to address social determinants of health during the COVID-19 pandemic. Explor Res Clin Soc Pharm 2021;2:1000032. At: https://pubmed.ncbi.nlm.nih.gov/35481124/
29. Capital Health Network. Annual Report 2020–21: After hours home-based palliative care medication. At: www.chnact.org.au/chn-annual-report-2020-21/care-across-the-continuum/after-hours-home-based-palliative-care-medication/
30. Services Australia. Pharmaceutical allowance. 2021. At: www.servicesaustralia.gov.au/pharmaceutical-allowance
31. Australian Institute of Health and Welfare. Built environment and health. 2022. At: www.aihw.gov.au/reports/australias-health/built-environment-and-health
32. Barton J, Rogerson M. The importance of greenspace for mental health. BJPsych Int 2017; 14(4):79–81. At: www.ncbi.nlm.nih.gov/pmc/articles/PMC5663018/
33. Pharmaceutical Society of Australia. Environmental sustainability: position statement. Canberra: PSA; 2022. At: https://my.psa.org.au/s/article/Environmental-Sustainability
34. Kingsley J, Munro-Harrison E, Jenkins A, et al. Here we are part of a living culture: understanding the cultural determinants of health in Aboriginal gathering places in Victoria, Australia. Health Place 2018;54:210–20.
35. Pharmaceutical Society of Australia. Guideline for pharmacists supporting Aboriginal and Torres Strait Islander Peoples with medicines management. Canberra: PSA; 2022. At: www.psa.org.au/wp-content/uploads/2022/07/Guidelines-for-pharmacists-supporting-Aboriginal-and-Torres-Strait-Islander-peoples-with-Medicines-Management.pdf

Our authors

Rosie Nash (she/her) BPharm (Hons), Grad Cert (Research), PhD, MPS is a pharmacist and senior lecturer in public health, and is Australia’s foremost researcher in children’s health literacy. She co-founded HealthLit4Kids and established the UTAS Health Literacy & Equity Research Unit.

Madeline Spencer (she/her) BPharm (Hons), PhD candidate is a pharmacist and PhD candidate at the School of Medicine, UTAS. Her research focuses on how health literacy mediators could aid in the provision of health literacy education to primary school children.