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Universal Declaration of Human Rights

(Readings, notes and student online activities)

Learning Outcomes for Module 4

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Upon successful completion of this module, you should be able to:

Describe   and discuss health, human rights and social justice

Understand       the difference between equality and equity

Discuss     what is meant by ‘close the gap’

Describe   and discuss the determinants of health

Discuss     the ten social determinants of health as identified by the World         Health Organization (WHO)

Critically    analyse how history, loss of land, culture and racism act as         additional social determinants specific to Aboriginal and Torres   Strait Islander peoples

Module 4 is divided into five sections

Section 1: Human rights and social justice

Section 2: The Determinants of Health

Section 3:  The Social Determinants of Health

Section 4:  An Aboriginal definition of health – A ‘whole of life’ view

Section 5:  Social and cultural determinants of Aboriginal health

Please note: Aboriginal and Torres Strait Islander people should be aware that some of this content may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.

Readings for Module 4

This week’s readings listed below are incorporated into this document.

Department of Health (2013). National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023. Canberra: Australian Government.

Braveman, P. A. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129 (S2), 5-8.

Department of the Prime Minister and Cabinet (2017). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing. Canberra: Australian Government.

Department of Health (2017b). My Life My Lead  Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultation. Canberra: Australian Government.

Wilkinson, R. G., & Marmot, M. (Eds.). (2003). Social determinants of health: the solid facts . 2 nd Ed. World Health Organization.

N.B. These weekly readings are incorporated into the notes and activities in this module.  Complete the Module 4 student online activities. read the notes, review the PowerPoint slides and then attempt the online quiz.

Introduction

Student    Activity 1: Write and reflect.

What        do you think is meant by social justice?  What do you think is meant         by a ‘fair go’ in Australia?            In every country there are people who live long healthy lives and there are those that don’t.  There’s a gap or a gradient. Professor Sir Michael Marmot’s work has shown that the reasons for this health gap are far more that your cholesterol, blood pressure or whether you exercise every day.  Marmot has led the way in producing the evidence about the economy, education, culture, the organisation of work and many other factors – the social determinants of health.  In 2016 he completed four Boyer lectures in Sydney called Fair Australia, Social Justice and the Health Gap.

Lecture: Click on the link to listen to the first of the Boyer Lectures: Health Inequalities and the causes of the causes

A transcript of the lecture can be accessed  at the following link Transcript

Having listened to this lecture, you can then use this week’s notes and ‘Student online activities’ to explore how social and cultural determinants can impact the health and wellbeing of Aboriginal and Torres Strait Islander peopleand how these relate to humanrights.  An understanding of the relevant concepts will allow you to participate in discussions during the tutorials.

The relationships between health, human rights, social justice, equity and equality frame the discussions that occur throughout this unit.

Section 1:  Health, Human rights and Social Justice

Health is fundamental to everyone’s life.  “The right to the highest attainable standard of health” is promoted by the World Health Organization (WHO, 1948).

Article 25 of the Universal Declaration of Human Rights (United Nations, 1948) articulated the ‘right’ to health.  “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

All people have a right to be treated equally and fairly. Consequently, social justice is achieved when people have fair and equal access to a society’s resources and services along with freedom and choice in how to live their lives regardless of geographical area and cultural background. These values are reflected in our beliefs and attitudes of acceptance, equality, fairness, human rights and social justice.

The WHO (2015) suggest that:

“A human rights-based approach to health provides strategies and solutions to address and rectify inequalities, discriminatory practices and unjust power relations, which are often at the heart of inequitable health outcomes” (WHO Fact sheet N°323 December, 2015).

What responsibility does society have with regards to Aboriginal and Torres Strait Islander people and the unacceptable gaps that exist in multiple areas?

‘Justice’ means fairness in the way people are treated and is based on a human right.  ‘Social’ refers to ‘society’ which is made up of human beings.  Therefore, social justice equates to a fair society.  It means giving people a fair chance, a share or choice based on their human rights as determined by the United Nations Universal Declaration of Human Rights.  It is about making sure that all Australians, Aboriginal and Torres Strait Islander people and non-Indigenous people, have the choice about how they live and have the means to make those choices (Human Rights & Equal Opportunity Commission, 2003).

Figure 1: Tools for Social Innovators (Spark Policy Institute). Used under CC BY-NC 4.0.

The United Nations Declaration on the Rights of Indigenous Peoples (2007) frames the relationship between Aboriginal and Torres Strait Islander peoples’ right to self-determination and the right to health:

An    Aboriginal and Torres Strait Islander concept of health needs to be         adopted and the need for self-determination must be recognised as         fundamental, and that

The   many determinants impacting health, that are complex and interrelated in nature are recognised and acknowledged (see    Neumayer, 2016 pp 15).

A human rights-based approach recognises the systemic discrimination that negatively impacts the health of Aboriginal and Torres Strait Islander Australians and addresses Indigenous health in a way that acknowledges health inequalities and social determinants (WHO, 2015).

Some important definitions:

Equity relates to fairness, social justice and human rights. ‘Equity means justice; health equity is social justice in health’ (Braveman, et al., 2014).

Health equity “is the absence of systematic disparities in health (or in the major social determinants of health) (Braveman et al., 2003, p. 254). Health equity can be estimated through the comparison of health indicators and socio-economic determinants of health between differing social groups (WHO, 2012).

Health inequity can occur when there is unfair distribution of resources and support (e.g. lack of health professionals in remote areas, lack of culturally appropriate services).

Health disparities are ‘systematic’, plausibly avoidable health differences adversely affecting socially disadvantaged groups” (Braveman et al., 2011, p. 149).

Social disadvantage is unfavourable social, economic, or political conditions experienced by some groups of people based on their relative position in social hierarchies.

‘Health equity is the principle or goal that motivates efforts to eliminate disparities in health between groups of people who are economically or socially worse-off and their better-off counterparts – such as different racial/ethnic or socioeconomic groups or groups defined by disability status, sexual orientation, or gender identity’ (Braveman, 2014, p. 6).

If all individuals and/or groups were treated equally but outcomes were different then health inequity is present and needs to be addressed.

Health equality suggests that all people should have the same health outcome.

Health equity & health equality equity in relation to health refers to the processes used to achieve health equality. Diversity and differences between groups that have differing levels of social advantage/disadvantage means that there is a need for unequal inputs, resources and systems to ensure equitable outcomes. To achieve health equity, those who are disadvantaged within society need to receive extra resources to enable them to reach their full health potential. Where there are disparities in life chances and outcomes within and between Aboriginal and Torres Strait Islander populations and non-Indigenous Australians, additional resources and an enabling policy environment are key to closing those gaps (Braveman, et al. 2011; Holland, 2018).

Application to Practice

Primary health care (PHC) is a philosophy of care based on social justice.  It acts as an organising framework for health professionals that aims to address inequities in health, recognising that wellbeing is dependent on complex political, social, economic and environmental factors.  PHC is a pathway to achieving basic human rights, which is essentially social justice.

An understanding of health equity and health equality by nurses/midwives heightens their awareness of the right of people to receive a fair and equitable opportunity to achieve their full health potential irrespective of different levels of underlying social advantage or disadvantage.  This awareness of equity issues within their immediate and extended communities places all members of an inter-professional team in a position to advocate for more equitable outcomes.  PHC has a set of principles that guide nurse/midwives in helping people to create socially just, equitable conditions for good health (McMurray & Clendon, 2015).

Section 2:  The Determinants of Health

To gain an understanding of the factors associated with the ‘gap’ in health between Aboriginal and non-Aboriginal populations it is necessary to identify and critically analyse the complex interaction of the determinants of health.  A health determinant is ‘something that can influence health in a positive way (protective factor) or negative way (risk factor).’ (Australian Institute of Health and Welfare, 2016, p. xi). Health determinants include social, cultural, structural and environmental factors, as well as health behaviours.

The determinants of health include:

Biological determinants (genetics, sex, age, body weight, blood pressure,         glucose levels, cholesterol levels; birth weight).

Behavioural       determinants of health (e.g.  alcohol, tobacco and/or other drug         use, diet, lifestyle, unprotected sex).

Social determinants of health:  where the circumstances in which people are born, grow, live, work and age.  These factors have a significant impact on each person’s lifelong health and wellbeing (Australian Institute of Health and Welfare, 2016).

Cultural determinants of health:  the ‘protective’ factors, which support improved health outcomes include the protection and promotion of traditional knowledges, family and clan arrangements, and cultural and kinship practices valued as important to community cohesion and personal resilience (Brown, 2014).

Access to health services (e.g. access to quality health care and having or not having insurance is included in some descriptions of health determinants).

Figure 2: The determinants of health . (Dahlgren & Whitehead, 1991, p.9)

The Dahlgren and Whitehead (1991) model above.  Their model of health determinants is one of many models you will find.  This model is useful as it acknowledges the biological determinants and offers a useful framework through which relationships between individual lifestyle ‘choices’, social networks, working and living conditions and cultural, economic, political and environmental factors, globally, nationally and locally can be viewed. The different layers and factors can have positive and protective influences on our lives. They can also undermine health and wellbeing, both for individuals and communities.

Section 3  The Social Determinants of Health

A well-known definition is:

“the social determinants are functions of the circumstances in which people live, work and grow; largely shaped by the distribution of resources and power, these determinants are closely linked to and mediate exposure to environmental risk factors such as working conditions, housing, water and sanitation or healthy lifestyles” (WHO, 2016, p. 4).

Smoking, drinking alcohol, obesity, unhealthy patterns of eating and exercising are indeed causes of ill-health; but the real issue is the causes of the causes. ( Australian Institute of Health and Welfare, 2016, p. 129)

Student    Activity 2: Watch      the following introduction to the social determinants of health Chatham         Kent The social determinants of health – they affect us all and then listen to the six interventions that Sir Michael Marmot         suggests would reduce inequalities in health. American        Public Health Association:  Michael Marmot The social determinants         of health 

The original seminal work that identified the social determinants of health was Wilkinson & Marmot’s – The Social Determinants of health – The Solid Facts .

Wilkinson and Marmot identified ten social determinants of health (see below).  Many other frameworks have subsequently been developed; we will consider additional social and cultural determinants of health that are specific to Aboriginal and Torres Strait Islander people in a later section. Please note that Wilkinson and Marmot (2003) do not identify education as a specific social determinant but it is fundamental to them all.

The Social Gradient pp. 10-11

Fact: Life expectancy is shorter and most diseases are more common for people who are further down the social ladder in each society. Health policy must tackle the social and economic determinants of health.

Stress pp. 12-13

Fact: Stressful circumstances can make people feel worried, anxious and unable to cope, which is damaging to health and may lead to premature death.

Early life pp. 14-15

Fact: A good start in life requires support for mothers and young children: the health impact of early development and education lasts a lifetime.

Social exclusion pp. 16-17

Fact: Life is short where its quality is poor. Poverty, social exclusion and discrimination cause hardship and resentment, which can cost lives.

Work pp. 18-19

Fact: Stress in the workplace increases the risk of disease. People who have more control over their work have better health.

Unemployment pp. 20-21

Fact: Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death.

Social support pp. 22-23

Fact: Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

Addiction pp. 24-25

Fact: Individuals turn to alcohol, drugs and tobacco and may suffer from health consequences as a result, but the use of addictive substances is influenced by the wider social setting.

Food pp. 26-27

Fact: Because global market forces control the food supply, healthy food is a political issue.

Transport pp. 28-29

Fact: Healthy transport means less driving and more walking and cycling, backed up by better public transport systems.

Now that you have listened to the lecture, watched the YouTube introduction to the social determinants of health and identified ten social determinants as stated in ‘Solid Facts,’ you will understand that the social determinants of health impact us all.

The next section will focus on one of the social determinants of health, the social gradient. Health and illness are not equally distributed within the Australian population. There is a remarkably close link between where a person is on the socioeconomic ladder and their health – the higher the rank, the better the health (Marmot, 2015).  Therefore, inequalities in health appear in the form of a ‘social gradient of health’.

The Social Gradient in Health

Biological factors, access to health services and the choices people make (whether to smoke for example) impact health.  Conventional approaches to improving health have emphasised access to technical solutions – improved medical care, sanitation, and control of disease vectors; or behaviours – smoking, drinking, obesity, which are linked to diabetes, heart disease and cancer; but these approaches only go so far .  Health needs to be viewed within a broader societal context (Marmot, 2015).

There is good evidence that if people are disempowered, if they have little control over their lives, if they are socially isolated or unable to participate fully in society, then there are biological effects (Marmot, 2015).

The effects of the social gradient start from birth and persist throughout life, often extending to the next generation. It affects all countries, regardless of whether they are low, middle or high-income countries (Australian Institute of Health and Welfare 2016, p. 134).

Creating the conditions for people to lead flourishing lives, fostering self-empowerment in individuals and communities, is key to the reduction of health inequalities. As people move up and down the social gradient, so the risk of ill-health changes. What makes these health inequalities unjust is that there is compelling, new evidence from round the world that suggests people now know what to do to reduce them.  This evidence has the potential to radically change the way we think about health, and indeed the way society does (Marmot, 2015).

The WHO suggests that countries adopt a ‘whole-of-government’ approach to address the social determinants of health. Policies and interventions should be proposed from all sectors and levels of society; for example, transport and housing policies at the local level; environmental, educational, and social policies at the national level; and financial, trade, and agricultural policies at the global level (WHO, 2011).

Section 4:  Health: An Aboriginal Definition of Health  A Whole of Life view

Worldview is personal as well as collective – it is a cultural construction of a person’s/group’s current reality. The concept of ‘worldview’ is closely linked to culture – values, beliefs, philosophies, experiences and social structure.  These vary from group to group.

Before considering the social and cultural determinants of Aboriginal and Torres Strait Islander health, it is necessary to recall Aboriginal peoples’ holistic view of health and wellbeing (see Module 3 Student Online Activities).  This ‘whole-of-life view’, which is central to the Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013-2023 , health is defined as not just the physical wellbeing of a person but the social, emotional and cultural wellbeing of the whole community (Department of Health, 2013, p. 8).

As the following activity will show, this ‘whole-of-life’ view underlies the concept of ‘social and emotional wellbeing’ (SEWB). SEWB refers to the ability of individuals or communities to develop, live in harmony with others and the environment, and to affect change. SEWB is integral to the physical and mental health of Aboriginal and Torres Strait Islander peoples.

Student    Activity 3: Access the following link to National Strategic Framework for Aboriginal and Torres Strait Islander       Peoples Mental Health and Social and Emotional Wellbeing 2017-2023 . Read page 6 and answer the following questions:

How is social and emotional wellbeing foundational for physical and    mental health for Aboriginal and Torres Strait Islander peoples?

Review      the ‘domains’ of Model of Social and Emotional Wellbeing         developed by Gee, Dudgeon, Schultz, Hart and Kelly (2013).  What are the seven overlapping social and emotional domains?

The   domains act as sources of wellbeing and connection that support a         strong and positive Aboriginal and/or Torres Strait Islander identity, grounded within a collectivist perspective. They are     situated within historical, political and social determinants. 

Section 5  Social and Cultural Determinants of Aboriginal Health

Negative social and cultural determinants of health flowing from historical dispossession and colonisation can have a detrimental influence on Aboriginal and Torres Strait Islander health and society:

‘Social and emotional wellbeing can be affected by the social determinants of health including homelessness, education and unemployment and a broader range of problems resulting from grief and loss, trauma and abuse, violence, removal from family and cultural dislocation, substance misuse, racism, discrimination and social disadvantage.  It is Important that policy approaches recognise the legacy of intergenerational trauma on social and emotional wellbeing’ (Department of Health, 2013, p. 21).

The Aboriginal and Torres Strait Islander Health Performance Framework Report (AHMAC, 2017) offers a breakdown of determinants of health. It indicated that at least 34.4 per cent of the health gap for Aboriginal and Torres Strait Islander people is linked to social determinants. This rises to 53.2 per cent when combined with behavioural risk factors (see figure 1 below). (Risky behaviours are associated with social determinants).

Figure 1. Proportion of health gap between Aboriginal and non-Aboriginal peoples explained by social determinants of health 2011-13 (Australian Health Ministers’ Advisory Council, 2016, p. 24).

Student    Activity 4: Write and Reflect

The   social and cultural determinants of health affect us all?  Place       yourself on the social gradient and reflect on how social   positioning has impacted your life chances and health.  Is there a       fair go for all?

Access My         Life My Lead and answer the following frequently        asked question.

Q.     Why is it important to focus on social and cultural determinants of         health? 

Wilkinson & Marmot (2003) identify ten social determinants of health. These social determinants impact us all, but as we have seen from the Aboriginal models of health in previous tutorials, history, racism and the loss of land and loss of culture impact the health of Aboriginal and Torres Strait Islander people and act as additional social determinants of health (Lovett, 2014). Culture as a social determinant of health offers ‘protective’ factors which support improved health outcomes for Aboriginal people. These include connection to family and community, land and sea, culture and identity (Commonwealth of Australia, Department of Health, 2017).

“Aboriginal and Torres Strait Islander people and communities are diverse. This diversity includes distinct language, kinship and cultural traditions, religious beliefs, family responsibilities and personal histories and experiences. Importantly, this diversity also extends to the health needs of Aboriginal and Torres Strait Islander people and communities” (Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee, 2016, p. 6).

Culture as a Determinant of Health

Culture as a determinant of health encompasses the cultural factors that promote resilience, create and maintain a sense of identity and promote good mental and physical health and wellbeing for individuals, families and communities.  Culture as a determinant of health may not be as well understood as the social determinants of health, but there is convincing evidence emerging about the many ways that culture can support better health outcomes (Department of Health, 2017).

Evidence for the negative effects of social determinants of health is substantial; but how that evidence is portrayed; i.e., framed by negativity, deficiency and disempowerment (Forde et al. 2013) has come to be associated with what is known as a ‘deficits discourse’ or perspective in relation to Aboriginal and Torres Strait Islander people and their health;

By this we mean that by always describing the Aboriginal and Torres Strait Islander population as having poorer health outcomes, lower social economic status, lower educational attainment, longer term unemployment, welfare dependency and intergenerational disadvantage, etcetera, reinforces a deficits narrative and fails to acknowledge individual, family and community strengths that continue to flourish, despite 200 hundred plus years of colonisation. Perpetuating such a deficits discourse in relation to social and cultural determinants contributes to structural racism. The work of reframing this discourse is the responsibility of everyone in the health care system.

Connections to Culture and Country build Stronger Individual and Collective Wellbeing

“The cultural determinants of health originate from and promote a strength-based perspective. This approach acknowledges that stronger connections to culture and Country contribute to stronger individual and collective identities, a sense of self-esteem, resilience, and improved outcomes across the other determinants of health including education, economic stability and community safety” (Brown, 2014).

Exploring and articulating the cultural determinants of health acknowledges the extensive and well-established knowledge networks that exist within communities, the Aboriginal community-controlled health service movement, human rights and social justice sectors.

Social and emotional wellbeing resulting from strong cultural connections, cultural engagement and cultural knowledge are increasingly reported in the literature (Tighe et al. 2012; Dudgeon et al. 2012).

Student    activity 5: Write and reflect:  How does your culture    positively impact your health?

Access      the following link My Life My Lead and answer the following frequently asked question.

What        is meant by the cultural determinants of health? 

The cultural determinants of Aboriginal and Torres Strait Islander health include, but are not limited to:

Self-determination

Freedom   from discrimination

Individual and collective rights

Importance       and value of Aboriginal culture

Protection         from removal/relocation

Connection       to, custodianship and utilisation of country and traditional lands

Reclamation,     revitalisation, preservation and promotion of language and cultural     practices

Protection         and promotion of traditional knowledge and Aboriginal intellectual        property

Understanding of lore, law and traditional roles and responsibilities (Brown, nd;         cf Lovett, 2014).

A ‘social and cultural determinants’ approach recognises that there are many drivers of ill-health that lie outside the direct responsibility of the health sector and which therefore require a collaborative, inter-sectoral approach. There is an increasing body of evidence demonstrating that protection and promotion of traditional knowledge, family, culture and kinship contribute to community cohesion and personal resilience (Department of Health, 2017).

If change is to be achieved in the future, the following principles need to be adopted:

Strong connections to culture and family are vital for good health and wellbeing.

The best results are achieved through genuine partnerships with communities.

The impacts of trauma on poor health outcomes cannot be ignored.

Systemic racism and a lack of cultural capability, cultural safety and cultural

security remain barriers to health system access and this needs to be addressed.

Figure       4.  Priority areas to address the social and cultural determinants   of health (Department of Health, 2017b, p. 8)

Student    activity 6: Figure 4 above identifies priority areas to address Aboriginal and Torres Strait        Islander social determinants and cultural determinants of health.      List the 7 priority areas (illustrated above) that aim to address     the social determinants and cultural determinants of health.

Student    Activity 7: Write and reflect.

Having      read about social and cultural determinants of Aboriginal and Torres         Strait Islander health, in which of these priority areas do you        think you could have an impact in terms of reducing the gap in health outcomes between Aboriginal and non-Aboriginal people? 

Application to Health Promotion

When engaging in health promotion with Aboriginal and Torres Strait communities an understanding of the cultural determinants listed above and the need to work in partnership and collaboration with Aboriginal and Torres Strait Islander families and communities is vital.  When viewed through an Aboriginal ‘lens’, core values specifically identified for Aboriginal health promotion theory and practice include:

Aboriginal self-determination principles.

A holistic definition of health that acknowledges connection to land and spirit.

Community ownership and localised decision-making.

Recognition of the specific historical, social and cultural context of the community.

Student    Activity 8: This activity      will assist you to structure a critical reflection.  Your         first of two critical reflections is due in Week Five (see Learning   Guide for details).

Identify     an issue/topic in the Module 4 and critically reflect over it.  This is not for submission.  Use the       following sequence based on Gibbs Reflective Cycle to guide your    writing.

(Gibbs       1988)

The   issue you select may relate to one of those listed below or   something else that has caught your attention/effected how you think about Aboriginal and Torres strait islander people.  This may be     something current in the press?

The   following are some possible areas on which to base this week’s         reflection, but you need to decide which ones are relevant to you,         what has impacted you?

The   ‘causes of the causes’

Health,              human rights and social justice

Social                determinants of health

Cultural             determinants of health

Fill    in the next page

Description:

Feelings:

Critical     Evaluation:

Analysis   and conclusion: 

Useful guidelines to successful Aboriginal health promotion with regards to what does and doesn’t work are offered by Charles (2015) and Percival et al. (2016).

References

American Public Health Association. (2016, November 1). Michael Marmot and the Social Determinants of Health. [Video file]. Accessed on 27/2/19 at https://www.youtube.com/watch?v=BHYBHKma3x8

Australian Health Ministers’ Advisory Council (AHMAC) (2017). Aboriginal and Torres Strait Islander Health Performance Framework Report. Canberra: Australian Government. Accessed 19/2/19 from https://www.pmc.gov.au/sites/default/files/publications/2017-health-performance-framework-report_1.pdf

Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee (2016). Cultural Respect Framework 2016-2026 for Aboriginal and Torre Strait Islander Health.  A national approach to building a culturally respectful health services. Accessed on 27/2/19 from https://nacchocommunique.files.wordpress.com/2016/12/cultural_respect_framework_1december2016_1.pdf

Australian Institute of Health and Welfare (2016). Australias health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.  Accessed 27/2/19 from https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true

Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of epidemiology and community health 57 (4), 254-258.  Accessed 27/2/19 from http://jech.bmj.com/content/57/4/254.full

Braveman, P. A, Kumanyika, S., Fielding, J., Laveist, T., Borrell, L. N., Manderscheid, R., et al. (2011). Health disparities and health equity: the issue is justice. American Journal of Public Health, 101 (Suppl 1), S149-155.

Braveman, P. (2014).  What are health disparities and health equity? We need to be clear. Public Health Reports 129 .

Brown, N. (2014). Exploring Cultural Determinants of Health and Wellbeing. The Lowitja Institute – Cultural Determinants Roundtable, Melbourne 26 th November 2014, PowerPoint, online. Accessed 19/2/12 from https://www.lowitja.org.au/page/research/research-roundtable/cultural-determinants

Charles, J. (2015). An evaluation and comprehensive guide to successful Aboriginal health promotion. Australian Indigenous Health Bulletin, 16 (1). Accessed 10/3/18 from from http://healthbulletin.org.au/articles/an-evaluation-and-comprehensive-guide-to-successful-aboriginal-health-promotion

Chatham-Kent Public Health Unit. (2011, October 19). Chatham-Kent Social Determinants of Health Video . [Video file]. Accessed on 27/2/19 at https://www.youtube.com/watch?v=NyTni-vn93Y

Commission on Social Determinants of Health (2008). Closing the gap in a generation: Healthequity through action on the social determinants of health. Final Report on Social Determinants of Health . Geneva: World Health Organization, p. 43. Accessed  on 27/2/19 from http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

Dahlgren, G., & Whitehead, M. (1991). Policies and Strategies to Promote Equity in Health , World Health Organization, Copenhagen.

Declaration of Human Rights. (1948). Universal declaration of human rights. UN General Assembly . Accessed 16/2/19

http://www.verklaringwarenatuur.org/Downloads_files/Universal%20Declaration%20of%20Human%20Rights.pdf

Department of Health. (2013). National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Canberra: Australian Government. Accessed 27/2/19 from

www.health.gov.au/internet/main/publishing.nsf/Content/natsih-plan

Department of Health (2017a).  Frequently asked questions on My Life My Lead. Canberra: Australian Governmen t. Accessed 27/2/2019 http://health.gov.au/internet/main/publishing.nsf/Content/indigenous-faq-my-life-my-lead#4

Department of Health (2017b). My Life My Lead  Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations December 2017. Canberra: Australian Government. Accessed 27/2/19 from

http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-ipag-consultation

Department of the Prime Minister and Cabinet (2017c). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2017-2023. Canberra: Australian Government. Accessed on 27/2/19 from https://pmc.gov.au/sites/default/files/publications/mhsewb-framework_0.pdf

Dudgeon, P., Cox, K., D’Anna, D., Dunkley, C., Hams, K., Kelly, K., Scrine, C., & Walker, R. (2012) Hear our voices: community consultations for the development of an empowerment, healing and leadership program for Aboriginal people living in the Kimberley, Western Australia: final research report, Australian Indigenous Health Bulletin, 12 (3).

Forde, C., Bamblett, L., Lovett, R., Gorringe, S., & Fogarty, B. (2013). Discourse, deficit and identity: Aboriginality, the race paradigm, and the language of representation in contemporary Australia, Media International Australia 149 (1), 162-173.

Gibbs, G. (1988) Learning by doing: a guide to teaching and learning methods. [London]: FEU.

Gee, G., Dudgeon, P., Schultz, C., Hart, A., & Kelly, K.  (2014). Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective,’ in Dudgeon, P., Milroy, M. & Walker, R.(eds.), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice Revised Edition , Commonwealth of Australia, Canberra, 2014, p. 55. https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working-together-second-edition/wt-part-1-chapt-4-final.pdf

Holland, C. (2018). A ten year review: Closing the Gap Strategy and Recommendations for Reset. Sydney: Close the Gap Steering Committee. Accessed 27/2/19 from https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/publications/close-gap-10-year-review

Human Rights & Equal Opportunity Commission (2003).  Information Sheet – Social justice and human rights for Aboriginal and Torres Strait Islander peoples.  Accessed 27/2/19 from https://www.humanrights.gov.au/sites/default/files/content/social_justice/infosheet/infosheet_sj.pdf

Lovett, R. (2014). Socio-cultural determinants of Aboriginal and Torres Strait Islander health and wellbeing. The Lowitja Institute – Cultural Determinants Roundtable, Melbourne 26 th November 2014, PowerPoint, online.  Accessed 27/2/19 from https://www.lowitja.org.au/content/Document/PDF/Ray-Lovett.pdf

Marmot M. (2015). The Health Gap: The Challenge of an Unequal World. London:  Bloomsbury.

McMurray, A., & Clendon, J. (2015).  Community Health and Wellness 5.  Primary Healthcare in Practice.  Churchill Livingston.  Elsevier, Australia.

Percival, N., O’Donoghue, L., Lin, V., Tsey, K., & Bailie, R. S. (2016). Improving health promotion using quality improvement techniques in Australian Indigenous Primary Health Care. Frontiers in Public Health .  Accessed 27/2/19 from http://dx.doi.org/10.3389/fpubh.2016.00053

Tighe, J., & McKay, K. (2012). Alive and Kicking Goals! Preliminary findings from a Kimberley suicide prevention program. Advances in Mental Health , 10 (3), 240-245.

Wilkinson, R. G., & Marmot, M. (Eds.). (2003). Social determinants of health: the solid facts . 2 nd Ed. World Health Organization.  Accessed 27/2/19 from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

WHO (World Health Organization) (2011). Closing the gap: policy into practice on social determinants of health: discussion paper. Geneva: WHO.  Accessed 27/2/19 from http://www.who.int/sdhconference/Discussion-Paper-EN.pdf

WHO (World Health Organization) (2016 ). Preventing Disease through Healthy Environments. A global assessment of the burden of disease from environmental risks.

WHO (World Health Organization). (2003). Social Determinants of Health The Solid Facts. Denmark. WHO. Accessed 27/2/19 from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

(Readings, notes and student online activities)

Learning Outcomes for Module 4

Upon successful completion of this module, you should be able to:

Describe   and discuss health, human rights and social justice

Understand       the difference between equality and equity

Discuss     what is meant by ‘close the gap’

Describe   and discuss the determinants of health

Discuss     the ten social determinants of health as identified by the World         Health Organization (WHO)

Critically    analyse how history, loss of land, culture and racism act as         additional social determinants specific to Aboriginal and Torres   Strait Islander peoples

Module 4 is divided into five sections

Section 1: Human rights and social justice

Section 2: The Determinants of Health

Section 3:  The Social Determinants of Health

Section 4:  An Aboriginal definition of health – A ‘whole of life’ view

Section 5:  Social and cultural determinants of Aboriginal health

Please note: Aboriginal and Torres Strait Islander people should be aware that some of this content may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.

Readings for Module 4

This week’s readings listed below are incorporated into this document.

Department of Health (2013). National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023. Canberra: Australian Government.

Braveman, P. A. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129 (S2), 5-8.

Department of the Prime Minister and Cabinet (2017). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing. Canberra: Australian Government.

Department of Health (2017b). My Life My Lead  Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultation. Canberra: Australian Government.

Wilkinson, R. G., & Marmot, M. (Eds.). (2003). Social determinants of health: the solid facts . 2 nd Ed. World Health Organization.

N.B. These weekly readings are incorporated into the notes and activities in this module.  Complete the Module 4 student online activities. read the notes, review the PowerPoint slides and then attempt the online quiz.

Introduction

Student    Activity 1: Write and reflect.

What        do you think is meant by social justice?  What do you think is meant         by a ‘fair go’ in Australia?            In every country there are people who live long healthy lives and there are those that don’t.  There’s a gap or a gradient. Professor Sir Michael Marmot’s work has shown that the reasons for this health gap are far more that your cholesterol, blood pressure or whether you exercise every day.  Marmot has led the way in producing the evidence about the economy, education, culture, the organisation of work and many other factors – the social determinants of health.  In 2016 he completed four Boyer lectures in Sydney called Fair Australia, Social Justice and the Health Gap.

Lecture: Click on the link to listen to the first of the Boyer Lectures: Health Inequalities and the causes of the causes

A transcript of the lecture can be accessed  at the following link Transcript

Having listened to this lecture, you can then use this week’s notes and ‘Student online activities’ to explore how social and cultural determinants can impact the health and wellbeing of Aboriginal and Torres Strait Islander peopleand how these relate to humanrights.  An understanding of the relevant concepts will allow you to participate in discussions during the tutorials.

The relationships between health, human rights, social justice, equity and equality frame the discussions that occur throughout this unit.

Section 1:  Health, Human rights and Social Justice

Health is fundamental to everyone’s life.  “The right to the highest attainable standard of health” is promoted by the World Health Organization (WHO, 1948).

Article 25 of the Universal Declaration of Human Rights (United Nations, 1948) articulated the ‘right’ to health.  “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

All people have a right to be treated equally and fairly. Consequently, social justice is achieved when people have fair and equal access to a society’s resources and services along with freedom and choice in how to live their lives regardless of geographical area and cultural background. These values are reflected in our beliefs and attitudes of acceptance, equality, fairness, human rights and social justice.

The WHO (2015) suggest that:

“A human rights-based approach to health provides strategies and solutions to address and rectify inequalities, discriminatory practices and unjust power relations, which are often at the heart of inequitable health outcomes” (WHO Fact sheet N°323 December, 2015).

What responsibility does society have with regards to Aboriginal and Torres Strait Islander people and the unacceptable gaps that exist in multiple areas?

‘Justice’ means fairness in the way people are treated and is based on a human right.  ‘Social’ refers to ‘society’ which is made up of human beings.  Therefore, social justice equates to a fair society.  It means giving people a fair chance, a share or choice based on their human rights as determined by the United Nations Universal Declaration of Human Rights.  It is about making sure that all Australians, Aboriginal and Torres Strait Islander people and non-Indigenous people, have the choice about how they live and have the means to make those choices (Human Rights & Equal Opportunity Commission, 2003).

Figure 1: Tools for Social Innovators (Spark Policy Institute). Used under CC BY-NC 4.0.

The United Nations Declaration on the Rights of Indigenous Peoples (2007) frames the relationship between Aboriginal and Torres Strait Islander peoples’ right to self-determination and the right to health:

An    Aboriginal and Torres Strait Islander concept of health needs to be         adopted and the need for self-determination must be recognised as         fundamental, and that

The   many determinants impacting health, that are complex and interrelated in nature are recognised and acknowledged (see    Neumayer, 2016 pp 15).

A human rights-based approach recognises the systemic discrimination that negatively impacts the health of Aboriginal and Torres Strait Islander Australians and addresses Indigenous health in a way that acknowledges health inequalities and social determinants (WHO, 2015).

Some important definitions:

Equity relates to fairness, social justice and human rights. ‘Equity means justice; health equity is social justice in health’ (Braveman, et al., 2014).

Health equity “is the absence of systematic disparities in health (or in the major social determinants of health) (Braveman et al., 2003, p. 254). Health equity can be estimated through the comparison of health indicators and socio-economic determinants of health between differing social groups (WHO, 2012).

Health inequity can occur when there is unfair distribution of resources and support (e.g. lack of health professionals in remote areas, lack of culturally appropriate services).

Health disparities are ‘systematic’, plausibly avoidable health differences adversely affecting socially disadvantaged groups” (Braveman et al., 2011, p. 149).

Social disadvantage is unfavourable social, economic, or political conditions experienced by some groups of people based on their relative position in social hierarchies.

‘Health equity is the principle or goal that motivates efforts to eliminate disparities in health between groups of people who are economically or socially worse-off and their better-off counterparts – such as different racial/ethnic or socioeconomic groups or groups defined by disability status, sexual orientation, or gender identity’ (Braveman, 2014, p. 6).

If all individuals and/or groups were treated equally but outcomes were different then health inequity is present and needs to be addressed.

Health equality suggests that all people should have the same health outcome.

Health equity & health equality equity in relation to health refers to the processes used to achieve health equality. Diversity and differences between groups that have differing levels of social advantage/disadvantage means that there is a need for unequal inputs, resources and systems to ensure equitable outcomes. To achieve health equity, those who are disadvantaged within society need to receive extra resources to enable them to reach their full health potential. Where there are disparities in life chances and outcomes within and between Aboriginal and Torres Strait Islander populations and non-Indigenous Australians, additional resources and an enabling policy environment are key to closing those gaps (Braveman, et al. 2011; Holland, 2018).

Application to Practice

Primary health care (PHC) is a philosophy of care based on social justice.  It acts as an organising framework for health professionals that aims to address inequities in health, recognising that wellbeing is dependent on complex political, social, economic and environmental factors.  PHC is a pathway to achieving basic human rights, which is essentially social justice.

An understanding of health equity and health equality by nurses/midwives heightens their awareness of the right of people to receive a fair and equitable opportunity to achieve their full health potential irrespective of different levels of underlying social advantage or disadvantage.  This awareness of equity issues within their immediate and extended communities places all members of an inter-professional team in a position to advocate for more equitable outcomes.  PHC has a set of principles that guide nurse/midwives in helping people to create socially just, equitable conditions for good health (McMurray & Clendon, 2015).

Section 2:  The Determinants of Health

To gain an understanding of the factors associated with the ‘gap’ in health between Aboriginal and non-Aboriginal populations it is necessary to identify and critically analyse the complex interaction of the determinants of health.  A health determinant is ‘something that can influence health in a positive way (protective factor) or negative way (risk factor).’ (Australian Institute of Health and Welfare, 2016, p. xi). Health determinants include social, cultural, structural and environmental factors, as well as health behaviours.

The determinants of health include:

Biological determinants (genetics, sex, age, body weight, blood pressure,         glucose levels, cholesterol levels; birth weight).

Behavioural       determinants of health (e.g.  alcohol, tobacco and/or other drug         use, diet, lifestyle, unprotected sex).

Social determinants of health:  where the circumstances in which people are born, grow, live, work and age.  These factors have a significant impact on each person’s lifelong health and wellbeing (Australian Institute of Health and Welfare, 2016).

Cultural determinants of health:  the ‘protective’ factors, which support improved health outcomes include the protection and promotion of traditional knowledges, family and clan arrangements, and cultural and kinship practices valued as important to community cohesion and personal resilience (Brown, 2014).

Access to health services (e.g. access to quality health care and having or not having insurance is included in some descriptions of health determinants).

Figure 2: The determinants of health . (Dahlgren & Whitehead, 1991, p.9)

The Dahlgren and Whitehead (1991) model above.  Their model of health determinants is one of many models you will find.  This model is useful as it acknowledges the biological determinants and offers a useful framework through which relationships between individual lifestyle ‘choices’, social networks, working and living conditions and cultural, economic, political and environmental factors, globally, nationally and locally can be viewed. The different layers and factors can have positive and protective influences on our lives. They can also undermine health and wellbeing, both for individuals and communities.

Section 3  The Social Determinants of Health

A well-known definition is:

“the social determinants are functions of the circumstances in which people live, work and grow; largely shaped by the distribution of resources and power, these determinants are closely linked to and mediate exposure to environmental risk factors such as working conditions, housing, water and sanitation or healthy lifestyles” (WHO, 2016, p. 4).

Smoking, drinking alcohol, obesity, unhealthy patterns of eating and exercising are indeed causes of ill-health; but the real issue is the causes of the causes. ( Australian Institute of Health and Welfare, 2016, p. 129)

Student    Activity 2: Watch      the following introduction to the social determinants of health Chatham         Kent The social determinants of health – they affect us all and then listen to the six interventions that Sir Michael Marmot         suggests would reduce inequalities in health. American        Public Health Association:  Michael Marmot The social determinants         of health 

The original seminal work that identified the social determinants of health was Wilkinson & Marmot’s – The Social Determinants of health – The Solid Facts .

Wilkinson and Marmot identified ten social determinants of health (see below).  Many other frameworks have subsequently been developed; we will consider additional social and cultural determinants of health that are specific to Aboriginal and Torres Strait Islander people in a later section. Please note that Wilkinson and Marmot (2003) do not identify education as a specific social determinant but it is fundamental to them all.

The Social Gradient pp. 10-11

Fact: Life expectancy is shorter and most diseases are more common for people who are further down the social ladder in each society. Health policy must tackle the social and economic determinants of health.

Stress pp. 12-13

Fact: Stressful circumstances can make people feel worried, anxious and unable to cope, which is damaging to health and may lead to premature death.

Early life pp. 14-15

Fact: A good start in life requires support for mothers and young children: the health impact of early development and education lasts a lifetime.

Social exclusion pp. 16-17

Fact: Life is short where its quality is poor. Poverty, social exclusion and discrimination cause hardship and resentment, which can cost lives.

Work pp. 18-19

Fact: Stress in the workplace increases the risk of disease. People who have more control over their work have better health.

Unemployment pp. 20-21

Fact: Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death.

Social support pp. 22-23

Fact: Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

Addiction pp. 24-25

Fact: Individuals turn to alcohol, drugs and tobacco and may suffer from health consequences as a result, but the use of addictive substances is influenced by the wider social setting.

Food pp. 26-27

Fact: Because global market forces control the food supply, healthy food is a political issue.

Transport pp. 28-29

Fact: Healthy transport means less driving and more walking and cycling, backed up by better public transport systems.

Now that you have listened to the lecture, watched the YouTube introduction to the social determinants of health and identified ten social determinants as stated in ‘Solid Facts,’ you will understand that the social determinants of health impact us all.

The next section will focus on one of the social determinants of health, the social gradient. Health and illness are not equally distributed within the Australian population. There is a remarkably close link between where a person is on the socioeconomic ladder and their health – the higher the rank, the better the health (Marmot, 2015).  Therefore, inequalities in health appear in the form of a ‘social gradient of health’.

The Social Gradient in Health

Biological factors, access to health services and the choices people make (whether to smoke for example) impact health.  Conventional approaches to improving health have emphasised access to technical solutions – improved medical care, sanitation, and control of disease vectors; or behaviours – smoking, drinking, obesity, which are linked to diabetes, heart disease and cancer; but these approaches only go so far .  Health needs to be viewed within a broader societal context (Marmot, 2015).

There is good evidence that if people are disempowered, if they have little control over their lives, if they are socially isolated or unable to participate fully in society, then there are biological effects (Marmot, 2015).

The effects of the social gradient start from birth and persist throughout life, often extending to the next generation. It affects all countries, regardless of whether they are low, middle or high-income countries (Australian Institute of Health and Welfare 2016, p. 134).

Creating the conditions for people to lead flourishing lives, fostering self-empowerment in individuals and communities, is key to the reduction of health inequalities. As people move up and down the social gradient, so the risk of ill-health changes. What makes these health inequalities unjust is that there is compelling, new evidence from round the world that suggests people now know what to do to reduce them.  This evidence has the potential to radically change the way we think about health, and indeed the way society does (Marmot, 2015).

The WHO suggests that countries adopt a ‘whole-of-government’ approach to address the social determinants of health. Policies and interventions should be proposed from all sectors and levels of society; for example, transport and housing policies at the local level; environmental, educational, and social policies at the national level; and financial, trade, and agricultural policies at the global level (WHO, 2011).

Section 4:  Health: An Aboriginal Definition of Health  A Whole of Life view

Worldview is personal as well as collective – it is a cultural construction of a person’s/group’s current reality. The concept of ‘worldview’ is closely linked to culture – values, beliefs, philosophies, experiences and social structure.  These vary from group to group.

Before considering the social and cultural determinants of Aboriginal and Torres Strait Islander health, it is necessary to recall Aboriginal peoples’ holistic view of health and wellbeing (see Module 3 Student Online Activities).  This ‘whole-of-life view’, which is central to the Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013-2023 , health is defined as not just the physical wellbeing of a person but the social, emotional and cultural wellbeing of the whole community (Department of Health, 2013, p. 8).

As the following activity will show, this ‘whole-of-life’ view underlies the concept of ‘social and emotional wellbeing’ (SEWB). SEWB refers to the ability of individuals or communities to develop, live in harmony with others and the environment, and to affect change. SEWB is integral to the physical and mental health of Aboriginal and Torres Strait Islander peoples.

Student    Activity 3: Access the following link to National Strategic Framework for Aboriginal and Torres Strait Islander       Peoples Mental Health and Social and Emotional Wellbeing 2017-2023 . Read page 6 and answer the following questions:

How is social and emotional wellbeing foundational for physical and    mental health for Aboriginal and Torres Strait Islander peoples?

Review      the ‘domains’ of Model of Social and Emotional Wellbeing         developed by Gee, Dudgeon, Schultz, Hart and Kelly (2013).  What are the seven overlapping social and emotional domains?

The   domains act as sources of wellbeing and connection that support a         strong and positive Aboriginal and/or Torres Strait Islander identity, grounded within a collectivist perspective. They are     situated within historical, political and social determinants. 

Section 5  Social and Cultural Determinants of Aboriginal Health

Negative social and cultural determinants of health flowing from historical dispossession and colonisation can have a detrimental influence on Aboriginal and Torres Strait Islander health and society:

‘Social and emotional wellbeing can be affected by the social determinants of health including homelessness, education and unemployment and a broader range of problems resulting from grief and loss, trauma and abuse, violence, removal from family and cultural dislocation, substance misuse, racism, discrimination and social disadvantage.  It is Important that policy approaches recognise the legacy of intergenerational trauma on social and emotional wellbeing’ (Department of Health, 2013, p. 21).

The Aboriginal and Torres Strait Islander Health Performance Framework Report (AHMAC, 2017) offers a breakdown of determinants of health. It indicated that at least 34.4 per cent of the health gap for Aboriginal and Torres Strait Islander people is linked to social determinants. This rises to 53.2 per cent when combined with behavioural risk factors (see figure 1 below). (Risky behaviours are associated with social determinants).

Figure 1. Proportion of health gap between Aboriginal and non-Aboriginal peoples explained by social determinants of health 2011-13 (Australian Health Ministers’ Advisory Council, 2016, p. 24).

Student    Activity 4: Write and Reflect

The   social and cultural determinants of health affect us all?  Place       yourself on the social gradient and reflect on how social   positioning has impacted your life chances and health.  Is there a       fair go for all?

Access My         Life My Lead and answer the following frequently        asked question.

Q.     Why is it important to focus on social and cultural determinants of         health? 

Wilkinson & Marmot (2003) identify ten social determinants of health. These social determinants impact us all, but as we have seen from the Aboriginal models of health in previous tutorials, history, racism and the loss of land and loss of culture impact the health of Aboriginal and Torres Strait Islander people and act as additional social determinants of health (Lovett, 2014). Culture as a social determinant of health offers ‘protective’ factors which support improved health outcomes for Aboriginal people. These include connection to family and community, land and sea, culture and identity (Commonwealth of Australia, Department of Health, 2017).

“Aboriginal and Torres Strait Islander people and communities are diverse. This diversity includes distinct language, kinship and cultural traditions, religious beliefs, family responsibilities and personal histories and experiences. Importantly, this diversity also extends to the health needs of Aboriginal and Torres Strait Islander people and communities” (Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee, 2016, p. 6).

Culture as a Determinant of Health

Culture as a determinant of health encompasses the cultural factors that promote resilience, create and maintain a sense of identity and promote good mental and physical health and wellbeing for individuals, families and communities.  Culture as a determinant of health may not be as well understood as the social determinants of health, but there is convincing evidence emerging about the many ways that culture can support better health outcomes (Department of Health, 2017).

Evidence for the negative effects of social determinants of health is substantial; but how that evidence is portrayed; i.e., framed by negativity, deficiency and disempowerment (Forde et al. 2013) has come to be associated with what is known as a ‘deficits discourse’ or perspective in relation to Aboriginal and Torres Strait Islander people and their health;

By this we mean that by always describing the Aboriginal and Torres Strait Islander population as having poorer health outcomes, lower social economic status, lower educational attainment, longer term unemployment, welfare dependency and intergenerational disadvantage, etcetera, reinforces a deficits narrative and fails to acknowledge individual, family and community strengths that continue to flourish, despite 200 hundred plus years of colonisation. Perpetuating such a deficits discourse in relation to social and cultural determinants contributes to structural racism. The work of reframing this discourse is the responsibility of everyone in the health care system.

Connections to Culture and Country build Stronger Individual and Collective Wellbeing

“The cultural determinants of health originate from and promote a strength-based perspective. This approach acknowledges that stronger connections to culture and Country contribute to stronger individual and collective identities, a sense of self-esteem, resilience, and improved outcomes across the other determinants of health including education, economic stability and community safety” (Brown, 2014).

Exploring and articulating the cultural determinants of health acknowledges the extensive and well-established knowledge networks that exist within communities, the Aboriginal community-controlled health service movement, human rights and social justice sectors.

Social and emotional wellbeing resulting from strong cultural connections, cultural engagement and cultural knowledge are increasingly reported in the literature (Tighe et al. 2012; Dudgeon et al. 2012).

Student    activity 5: Write and reflect:  How does your culture    positively impact your health?

Access      the following link My Life My Lead and answer the following frequently asked question.

What        is meant by the cultural determinants of health? 

The cultural determinants of Aboriginal and Torres Strait Islander health include, but are not limited to:

Self-determination

Freedom   from discrimination

Individual and collective rights

Importance       and value of Aboriginal culture

Protection         from removal/relocation

Connection       to, custodianship and utilisation of country and traditional lands

Reclamation,     revitalisation, preservation and promotion of language and cultural     practices

Protection         and promotion of traditional knowledge and Aboriginal intellectual        property

Understanding of lore, law and traditional roles and responsibilities (Brown, nd;         cf Lovett, 2014).

A ‘social and cultural determinants’ approach recognises that there are many drivers of ill-health that lie outside the direct responsibility of the health sector and which therefore require a collaborative, inter-sectoral approach. There is an increasing body of evidence demonstrating that protection and promotion of traditional knowledge, family, culture and kinship contribute to community cohesion and personal resilience (Department of Health, 2017).

If change is to be achieved in the future, the following principles need to be adopted:

Strong connections to culture and family are vital for good health and wellbeing.

The best results are achieved through genuine partnerships with communities.

The impacts of trauma on poor health outcomes cannot be ignored.

Systemic racism and a lack of cultural capability, cultural safety and cultural

security remain barriers to health system access and this needs to be addressed.

Figure       4.  Priority areas to address the social and cultural determinants   of health (Department of Health, 2017b, p. 8)

Student    activity 6: Figure 4 above identifies priority areas to address Aboriginal and Torres Strait        Islander social determinants and cultural determinants of health.      List the 7 priority areas (illustrated above) that aim to address     the social determinants and cultural determinants of health.

Student    Activity 7: Write and reflect.

Having      read about social and cultural determinants of Aboriginal and Torres         Strait Islander health, in which of these priority areas do you        think you could have an impact in terms of reducing the gap in health outcomes between Aboriginal and non-Aboriginal people? 

Application to Health Promotion

When engaging in health promotion with Aboriginal and Torres Strait communities an understanding of the cultural determinants listed above and the need to work in partnership and collaboration with Aboriginal and Torres Strait Islander families and communities is vital.  When viewed through an Aboriginal ‘lens’, core values specifically identified for Aboriginal health promotion theory and practice include:

Aboriginal self-determination principles.

A holistic definition of health that acknowledges connection to land and spirit.

Community ownership and localised decision-making.

Recognition of the specific historical, social and cultural context of the community.

Student    Activity 8: This activity      will assist you to structure a critical reflection.  Your         first of two critical reflections is due in Week Five (see Learning   Guide for details).

Identify     an issue/topic in the Module 4 and critically reflect over it.  This is not for submission.  Use the       following sequence based on Gibbs Reflective Cycle to guide your    writing.

(Gibbs       1988)

The   issue you select may relate to one of those listed below or   something else that has caught your attention/effected how you think about Aboriginal and Torres strait islander people.  This may be     something current in the press?

The   following are some possible areas on which to base this week’s         reflection, but you need to decide which ones are relevant to you,         what has impacted you?

The   ‘causes of the causes’

Health,              human rights and social justice

Social                determinants of health

Cultural             determinants of health

Fill    in the next page

Description:

Feelings:

Critical     Evaluation:

Analysis   and conclusion: 

Useful guidelines to successful Aboriginal health promotion with regards to what does and doesn’t work are offered by Charles (2015) and Percival et al. (2016).

References

American Public Health Association. (2016, November 1). Michael Marmot and the Social Determinants of Health. [Video file]. Accessed on 27/2/19 at https://www.youtube.com/watch?v=BHYBHKma3x8

Australian Health Ministers’ Advisory Council (AHMAC) (2017). Aboriginal and Torres Strait Islander Health Performance Framework Report. Canberra: Australian Government. Accessed 19/2/19 from https://www.pmc.gov.au/sites/default/files/publications/2017-health-performance-framework-report_1.pdf

Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee (2016). Cultural Respect Framework 2016-2026 for Aboriginal and Torre Strait Islander Health.  A national approach to building a culturally respectful health services. Accessed on 27/2/19 from https://nacchocommunique.files.wordpress.com/2016/12/cultural_respect_framework_1december2016_1.pdf

Australian Institute of Health and Welfare (2016). Australias health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.  Accessed 27/2/19 from https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true

Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of epidemiology and community health 57 (4), 254-258.  Accessed 27/2/19 from http://jech.bmj.com/content/57/4/254.full

Braveman, P. A, Kumanyika, S., Fielding, J., Laveist, T., Borrell, L. N., Manderscheid, R., et al. (2011). Health disparities and health equity: the issue is justice. American Journal of Public Health, 101 (Suppl 1), S149-155.

Braveman, P. (2014).  What are health disparities and health equity? We need to be clear. Public Health Reports 129 .

Brown, N. (2014). Exploring Cultural Determinants of Health and Wellbeing. The Lowitja Institute – Cultural Determinants Roundtable, Melbourne 26 th November 2014, PowerPoint, online. Accessed 19/2/12 from https://www.lowitja.org.au/page/research/research-roundtable/cultural-determinants

Charles, J. (2015). An evaluation and comprehensive guide to successful Aboriginal health promotion. Australian Indigenous Health Bulletin, 16 (1). Accessed 10/3/18 from from http://healthbulletin.org.au/articles/an-evaluation-and-comprehensive-guide-to-successful-aboriginal-health-promotion

Chatham-Kent Public Health Unit. (2011, October 19). Chatham-Kent Social Determinants of Health Video . [Video file]. Accessed on 27/2/19 at https://www.youtube.com/watch?v=NyTni-vn93Y

Commission on Social Determinants of Health (2008). Closing the gap in a generation: Healthequity through action on the social determinants of health. Final Report on Social Determinants of Health . Geneva: World Health Organization, p. 43. Accessed  on 27/2/19 from http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

Dahlgren, G., & Whitehead, M. (1991). Policies and Strategies to Promote Equity in Health , World Health Organization, Copenhagen.

Declaration of Human Rights. (1948). Universal declaration of human rights. UN General Assembly . Accessed 16/2/19

http://www.verklaringwarenatuur.org/Downloads_files/Universal%20Declaration%20of%20Human%20Rights.pdf

Department of Health. (2013). National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Canberra: Australian Government. Accessed 27/2/19 from

www.health.gov.au/internet/main/publishing.nsf/Content/natsih-plan

Department of Health (2017a).  Frequently asked questions on My Life My Lead. Canberra: Australian Governmen t. Accessed 27/2/2019 http://health.gov.au/internet/main/publishing.nsf/Content/indigenous-faq-my-life-my-lead#4

Department of Health (2017b). My Life My Lead  Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations December 2017. Canberra: Australian Government. Accessed 27/2/19 from

http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-ipag-consultation

Department of the Prime Minister and Cabinet (2017c). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2017-2023. Canberra: Australian Government. Accessed on 27/2/19 from https://pmc.gov.au/sites/default/files/publications/mhsewb-framework_0.pdf

Dudgeon, P., Cox, K., D’Anna, D., Dunkley, C., Hams, K., Kelly, K., Scrine, C., & Walker, R. (2012) Hear our voices: community consultations for the development of an empowerment, healing and leadership program for Aboriginal people living in the Kimberley, Western Australia: final research report, Australian Indigenous Health Bulletin, 12 (3).

Forde, C., Bamblett, L., Lovett, R., Gorringe, S., & Fogarty, B. (2013). Discourse, deficit and identity: Aboriginality, the race paradigm, and the language of representation in contemporary Australia, Media International Australia 149 (1), 162-173.

Gibbs, G. (1988) Learning by doing: a guide to teaching and learning methods. [London]: FEU.

Gee, G., Dudgeon, P., Schultz, C., Hart, A., & Kelly, K.  (2014). Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective,’ in Dudgeon, P., Milroy, M. & Walker, R.(eds.), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice Revised Edition , Commonwealth of Australia, Canberra, 2014, p. 55. https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working-together-second-edition/wt-part-1-chapt-4-final.pdf

Holland, C. (2018). A ten year review: Closing the Gap Strategy and Recommendations for Reset. Sydney: Close the Gap Steering Committee. Accessed 27/2/19 from https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/publications/close-gap-10-year-review

Human Rights & Equal Opportunity Commission (2003).  Information Sheet – Social justice and human rights for Aboriginal and Torres Strait Islander peoples.  Accessed 27/2/19 from https://www.humanrights.gov.au/sites/default/files/content/social_justice/infosheet/infosheet_sj.pdf

Lovett, R. (2014). Socio-cultural determinants of Aboriginal and Torres Strait Islander health and wellbeing. The Lowitja Institute – Cultural Determinants Roundtable, Melbourne 26 th November 2014, PowerPoint, online.  Accessed 27/2/19 from https://www.lowitja.org.au/content/Document/PDF/Ray-Lovett.pdf

Marmot M. (2015). The Health Gap: The Challenge of an Unequal World. London:  Bloomsbury.

McMurray, A., & Clendon, J. (2015).  Community Health and Wellness 5.  Primary Healthcare in Practice.  Churchill Livingston.  Elsevier, Australia.

Percival, N., O’Donoghue, L., Lin, V., Tsey, K., & Bailie, R. S. (2016). Improving health promotion using quality improvement techniques in Australian Indigenous Primary Health Care. Frontiers in Public Health .  Accessed 27/2/19 from http://dx.doi.org/10.3389/fpubh.2016.00053

Tighe, J., & McKay, K. (2012). Alive and Kicking Goals! Preliminary findings from a Kimberley suicide prevention program. Advances in Mental Health , 10 (3), 240-245.

Wilkinson, R. G., & Marmot, M. (Eds.). (2003). Social determinants of health: the solid facts . 2 nd Ed. World Health Organization.  Accessed 27/2/19 from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

WHO (World Health Organization) (2011). Closing the gap: policy into practice on social determinants of health: discussion paper. Geneva: WHO.  Accessed 27/2/19 from http://www.who.int/sdhconference/Discussion-Paper-EN.pdf

WHO (World Health Organization) (2016 ). Preventing Disease through Healthy Environments. A global assessment of the burden of disease from environmental risks.

WHO (World Health Organization). (2003). Social Determinants of Health The Solid Facts. Denmark. WHO. Accessed 27/2/19 from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

WHO (2015) Fact sheet N°323.  Accessed 27/2/19 http://www.who.int/mediacentre/factsheets/fs323/en/

(Readings, notes and student online activities)

Learning Outcomes for Module 4

Upon successful completion of this module, you should be able to:

Describe   and discuss health, human rights and social justice

Understand       the difference between equality and equity

Discuss     what is meant by ‘close the gap’

Describe   and discuss the determinants of health

Discuss     the ten social determinants of health as identified by the World         Health Organization (WHO)

Critically    analyse how history, loss of land, culture and racism act as         additional social determinants specific to Aboriginal and Torres   Strait Islander peoples

Module 4 is divided into five sections

Section 1: Human rights and social justice

Section 2: The Determinants of Health

Section 3:  The Social Determinants of Health

Section 4:  An Aboriginal definition of health – A ‘whole of life’ view

Section 5:  Social and cultural determinants of Aboriginal health

Please note: Aboriginal and Torres Strait Islander people should be aware that some of this content may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.

Readings for Module 4

This week’s readings listed below are incorporated into this document.

Department of Health (2013). National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023. Canberra: Australian Government.

Braveman, P. A. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129 (S2), 5-8.

Department of the Prime Minister and Cabinet (2017). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing. Canberra: Australian Government.

Department of Health (2017b). My Life My Lead  Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultation. Canberra: Australian Government.

Wilkinson, R. G., & Marmot, M. (Eds.). (2003). Social determinants of health: the solid facts . 2 nd Ed. World Health Organization.

N.B. These weekly readings are incorporated into the notes and activities in this module.  Complete the Module 4 student online activities. read the notes, review the PowerPoint slides and then attempt the online quiz.

Introduction

Student    Activity 1: Write and reflect.

What        do you think is meant by social justice?  What do you think is meant         by a ‘fair go’ in Australia?            In every country there are people who live long healthy lives and there are those that don’t.  There’s a gap or a gradient. Professor Sir Michael Marmot’s work has shown that the reasons for this health gap are far more that your cholesterol, blood pressure or whether you exercise every day.  Marmot has led the way in producing the evidence about the economy, education, culture, the organisation of work and many other factors – the social determinants of health.  In 2016 he completed four Boyer lectures in Sydney called Fair Australia, Social Justice and the Health Gap.

Lecture: Click on the link to listen to the first of the Boyer Lectures: Health Inequalities and the causes of the causes

A transcript of the lecture can be accessed  at the following link Transcript

Having listened to this lecture, you can then use this week’s notes and ‘Student online activities’ to explore how social and cultural determinants can impact the health and wellbeing of Aboriginal and Torres Strait Islander peopleand how these relate to humanrights.  An understanding of the relevant concepts will allow you to participate in discussions during the tutorials.

The relationships between health, human rights, social justice, equity and equality frame the discussions that occur throughout this unit.

Section 1:  Health, Human rights and Social Justice

Health is fundamental to everyone’s life.  “The right to the highest attainable standard of health” is promoted by the World Health Organization (WHO, 1948).

Article 25 of the Universal Declaration of Human Rights (United Nations, 1948) articulated the ‘right’ to health.  “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

All people have a right to be treated equally and fairly. Consequently, social justice is achieved when people have fair and equal access to a society’s resources and services along with freedom and choice in how to live their lives regardless of geographical area and cultural background. These values are reflected in our beliefs and attitudes of acceptance, equality, fairness, human rights and social justice.

The WHO (2015) suggest that:

“A human rights-based approach to health provides strategies and solutions to address and rectify inequalities, discriminatory practices and unjust power relations, which are often at the heart of inequitable health outcomes” (WHO Fact sheet N°323 December, 2015).

What responsibility does society have with regards to Aboriginal and Torres Strait Islander people and the unacceptable gaps that exist in multiple areas?

‘Justice’ means fairness in the way people are treated and is based on a human right.  ‘Social’ refers to ‘society’ which is made up of human beings.  Therefore, social justice equates to a fair society.  It means giving people a fair chance, a share or choice based on their human rights as determined by the United Nations Universal Declaration of Human Rights.  It is about making sure that all Australians, Aboriginal and Torres Strait Islander people and non-Indigenous people, have the choice about how they live and have the means to make those choices (Human Rights & Equal Opportunity Commission, 2003).

Figure 1: Tools for Social Innovators (Spark Policy Institute). Used under CC BY-NC 4.0.

The United Nations Declaration on the Rights of Indigenous Peoples (2007) frames the relationship between Aboriginal and Torres Strait Islander peoples’ right to self-determination and the right to health:

An    Aboriginal and Torres Strait Islander concept of health needs to be         adopted and the need for self-determination must be recognised as         fundamental, and that

The   many determinants impacting health, that are complex and interrelated in nature are recognised and acknowledged (see    Neumayer, 2016 pp 15).

A human rights-based approach recognises the systemic discrimination that negatively impacts the health of Aboriginal and Torres Strait Islander Australians and addresses Indigenous health in a way that acknowledges health inequalities and social determinants (WHO, 2015).

Some important definitions:

Equity relates to fairness, social justice and human rights. ‘Equity means justice; health equity is social justice in health’ (Braveman, et al., 2014).

Health equity “is the absence of systematic disparities in health (or in the major social determinants of health) (Braveman et al., 2003, p. 254). Health equity can be estimated through the comparison of health indicators and socio-economic determinants of health between differing social groups (WHO, 2012).

Health inequity can occur when there is unfair distribution of resources and support (e.g. lack of health professionals in remote areas, lack of culturally appropriate services).

Health disparities are ‘systematic’, plausibly avoidable health differences adversely affecting socially disadvantaged groups” (Braveman et al., 2011, p. 149).

Social disadvantage is unfavourable social, economic, or political conditions experienced by some groups of people based on their relative position in social hierarchies.

‘Health equity is the principle or goal that motivates efforts to eliminate disparities in health between groups of people who are economically or socially worse-off and their better-off counterparts – such as different racial/ethnic or socioeconomic groups or groups defined by disability status, sexual orientation, or gender identity’ (Braveman, 2014, p. 6).

If all individuals and/or groups were treated equally but outcomes were different then health inequity is present and needs to be addressed.

Health equality suggests that all people should have the same health outcome.

Health equity & health equality equity in relation to health refers to the processes used to achieve health equality. Diversity and differences between groups that have differing levels of social advantage/disadvantage means that there is a need for unequal inputs, resources and systems to ensure equitable outcomes. To achieve health equity, those who are disadvantaged within society need to receive extra resources to enable them to reach their full health potential. Where there are disparities in life chances and outcomes within and between Aboriginal and Torres Strait Islander populations and non-Indigenous Australians, additional resources and an enabling policy environment are key to closing those gaps (Braveman, et al. 2011; Holland, 2018).

Application to Practice

Primary health care (PHC) is a philosophy of care based on social justice.  It acts as an organising framework for health professionals that aims to address inequities in health, recognising that wellbeing is dependent on complex political, social, economic and environmental factors.  PHC is a pathway to achieving basic human rights, which is essentially social justice.

An understanding of health equity and health equality by nurses/midwives heightens their awareness of the right of people to receive a fair and equitable opportunity to achieve their full health potential irrespective of different levels of underlying social advantage or disadvantage.  This awareness of equity issues within their immediate and extended communities places all members of an inter-professional team in a position to advocate for more equitable outcomes.  PHC has a set of principles that guide nurse/midwives in helping people to create socially just, equitable conditions for good health (McMurray & Clendon, 2015).

Section 2:  The Determinants of Health

To gain an understanding of the factors associated with the ‘gap’ in health between Aboriginal and non-Aboriginal populations it is necessary to identify and critically analyse the complex interaction of the determinants of health.  A health determinant is ‘something that can influence health in a positive way (protective factor) or negative way (risk factor).’ (Australian Institute of Health and Welfare, 2016, p. xi). Health determinants include social, cultural, structural and environmental factors, as well as health behaviours.

The determinants of health include:

Biological determinants (genetics, sex, age, body weight, blood pressure,         glucose levels, cholesterol levels; birth weight).

Behavioural       determinants of health (e.g.  alcohol, tobacco and/or other drug         use, diet, lifestyle, unprotected sex).

Social determinants of health:  where the circumstances in which people are born, grow, live, work and age.  These factors have a significant impact on each person’s lifelong health and wellbeing (Australian Institute of Health and Welfare, 2016).

Cultural determinants of health:  the ‘protective’ factors, which support improved health outcomes include the protection and promotion of traditional knowledges, family and clan arrangements, and cultural and kinship practices valued as important to community cohesion and personal resilience (Brown, 2014).

Access to health services (e.g. access to quality health care and having or not having insurance is included in some descriptions of health determinants).

Figure 2: The determinants of health . (Dahlgren & Whitehead, 1991, p.9)

The Dahlgren and Whitehead (1991) model above.  Their model of health determinants is one of many models you will find.  This model is useful as it acknowledges the biological determinants and offers a useful framework through which relationships between individual lifestyle ‘choices’, social networks, working and living conditions and cultural, economic, political and environmental factors, globally, nationally and locally can be viewed. The different layers and factors can have positive and protective influences on our lives. They can also undermine health and wellbeing, both for individuals and communities.

Section 3  The Social Determinants of Health

A well-known definition is:

“the social determinants are functions of the circumstances in which people live, work and grow; largely shaped by the distribution of resources and power, these determinants are closely linked to and mediate exposure to environmental risk factors such as working conditions, housing, water and sanitation or healthy lifestyles” (WHO, 2016, p. 4).

Smoking, drinking alcohol, obesity, unhealthy patterns of eating and exercising are indeed causes of ill-health; but the real issue is the causes of the causes. ( Australian Institute of Health and Welfare, 2016, p. 129)

Student    Activity 2: Watch      the following introduction to the social determinants of health Chatham         Kent The social determinants of health – they affect us all and then listen to the six interventions that Sir Michael Marmot         suggests would reduce inequalities in health. American        Public Health Association:  Michael Marmot The social determinants         of health 

The original seminal work that identified the social determinants of health was Wilkinson & Marmot’s – The Social Determinants of health – The Solid Facts .

Wilkinson and Marmot identified ten social determinants of health (see below).  Many other frameworks have subsequently been developed; we will consider additional social and cultural determinants of health that are specific to Aboriginal and Torres Strait Islander people in a later section. Please note that Wilkinson and Marmot (2003) do not identify education as a specific social determinant but it is fundamental to them all.

The Social Gradient pp. 10-11

Fact: Life expectancy is shorter and most diseases are more common for people who are further down the social ladder in each society. Health policy must tackle the social and economic determinants of health.

Stress pp. 12-13

Fact: Stressful circumstances can make people feel worried, anxious and unable to cope, which is damaging to health and may lead to premature death.

Early life pp. 14-15

Fact: A good start in life requires support for mothers and young children: the health impact of early development and education lasts a lifetime.

Social exclusion pp. 16-17

Fact: Life is short where its quality is poor. Poverty, social exclusion and discrimination cause hardship and resentment, which can cost lives.

Work pp. 18-19

Fact: Stress in the workplace increases the risk of disease. People who have more control over their work have better health.

Unemployment pp. 20-21

Fact: Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death.

Social support pp. 22-23

Fact: Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

Addiction pp. 24-25

Fact: Individuals turn to alcohol, drugs and tobacco and may suffer from health consequences as a result, but the use of addictive substances is influenced by the wider social setting.

Food pp. 26-27

Fact: Because global market forces control the food supply, healthy food is a political issue.

Transport pp. 28-29

Fact: Healthy transport means less driving and more walking and cycling, backed up by better public transport systems.

Now that you have listened to the lecture, watched the YouTube introduction to the social determinants of health and identified ten social determinants as stated in ‘Solid Facts,’ you will understand that the social determinants of health impact us all.

The next section will focus on one of the social determinants of health, the social gradient. Health and illness are not equally distributed within the Australian population. There is a remarkably close link between where a person is on the socioeconomic ladder and their health – the higher the rank, the better the health (Marmot, 2015).  Therefore, inequalities in health appear in the form of a ‘social gradient of health’.

The Social Gradient in Health

Biological factors, access to health services and the choices people make (whether to smoke for example) impact health.  Conventional approaches to improving health have emphasised access to technical solutions – improved medical care, sanitation, and control of disease vectors; or behaviours – smoking, drinking, obesity, which are linked to diabetes, heart disease and cancer; but these approaches only go so far .  Health needs to be viewed within a broader societal context (Marmot, 2015).

There is good evidence that if people are disempowered, if they have little control over their lives, if they are socially isolated or unable to participate fully in society, then there are biological effects (Marmot, 2015).

The effects of the social gradient start from birth and persist throughout life, often extending to the next generation. It affects all countries, regardless of whether they are low, middle or high-income countries (Australian Institute of Health and Welfare 2016, p. 134).

Creating the conditions for people to lead flourishing lives, fostering self-empowerment in individuals and communities, is key to the reduction of health inequalities. As people move up and down the social gradient, so the risk of ill-health changes. What makes these health inequalities unjust is that there is compelling, new evidence from round the world that suggests people now know what to do to reduce them.  This evidence has the potential to radically change the way we think about health, and indeed the way society does (Marmot, 2015).

The WHO suggests that countries adopt a ‘whole-of-government’ approach to address the social determinants of health. Policies and interventions should be proposed from all sectors and levels of society; for example, transport and housing policies at the local level; environmental, educational, and social policies at the national level; and financial, trade, and agricultural policies at the global level (WHO, 2011).

Section 4:  Health: An Aboriginal Definition of Health  A Whole of Life view

Worldview is personal as well as collective – it is a cultural construction of a person’s/group’s current reality. The concept of ‘worldview’ is closely linked to culture – values, beliefs, philosophies, experiences and social structure.  These vary from group to group.

Before considering the social and cultural determinants of Aboriginal and Torres Strait Islander health, it is necessary to recall Aboriginal peoples’ holistic view of health and wellbeing (see Module 3 Student Online Activities).  This ‘whole-of-life view’, which is central to the Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013-2023 , health is defined as not just the physical wellbeing of a person but the social, emotional and cultural wellbeing of the whole community (Department of Health, 2013, p. 8).

As the following activity will show, this ‘whole-of-life’ view underlies the concept of ‘social and emotional wellbeing’ (SEWB). SEWB refers to the ability of individuals or communities to develop, live in harmony with others and the environment, and to affect change. SEWB is integral to the physical and mental health of Aboriginal and Torres Strait Islander peoples.

Student    Activity 3: Access the following link to National Strategic Framework for Aboriginal and Torres Strait Islander       Peoples Mental Health and Social and Emotional Wellbeing 2017-2023 . Read page 6 and answer the following questions:

How is social and emotional wellbeing foundational for physical and    mental health for Aboriginal and Torres Strait Islander peoples?

Review      the ‘domains’ of Model of Social and Emotional Wellbeing         developed by Gee, Dudgeon, Schultz, Hart and Kelly (2013).  What are the seven overlapping social and emotional domains?

The   domains act as sources of wellbeing and connection that support a         strong and positive Aboriginal and/or Torres Strait Islander identity, grounded within a collectivist perspective. They are     situated within historical, political and social determinants. 

Section 5  Social and Cultural Determinants of Aboriginal Health

Negative social and cultural determinants of health flowing from historical dispossession and colonisation can have a detrimental influence on Aboriginal and Torres Strait Islander health and society:

‘Social and emotional wellbeing can be affected by the social determinants of health including homelessness, education and unemployment and a broader range of problems resulting from grief and loss, trauma and abuse, violence, removal from family and cultural dislocation, substance misuse, racism, discrimination and social disadvantage.  It is Important that policy approaches recognise the legacy of intergenerational trauma on social and emotional wellbeing’ (Department of Health, 2013, p. 21).

The Aboriginal and Torres Strait Islander Health Performance Framework Report (AHMAC, 2017) offers a breakdown of determinants of health. It indicated that at least 34.4 per cent of the health gap for Aboriginal and Torres Strait Islander people is linked to social determinants. This rises to 53.2 per cent when combined with behavioural risk factors (see figure 1 below). (Risky behaviours are associated with social determinants).

Figure 1. Proportion of health gap between Aboriginal and non-Aboriginal peoples explained by social determinants of health 2011-13 (Australian Health Ministers’ Advisory Council, 2016, p. 24).

Student    Activity 4: Write and Reflect

The   social and cultural determinants of health affect us all?  Place       yourself on the social gradient and reflect on how social   positioning has impacted your life chances and health.  Is there a       fair go for all?

Access My         Life My Lead and answer the following frequently        asked question.

Q.     Why is it important to focus on social and cultural determinants of         health? 

Wilkinson & Marmot (2003) identify ten social determinants of health. These social determinants impact us all, but as we have seen from the Aboriginal models of health in previous tutorials, history, racism and the loss of land and loss of culture impact the health of Aboriginal and Torres Strait Islander people and act as additional social determinants of health (Lovett, 2014). Culture as a social determinant of health offers ‘protective’ factors which support improved health outcomes for Aboriginal people. These include connection to family and community, land and sea, culture and identity (Commonwealth of Australia, Department of Health, 2017).

“Aboriginal and Torres Strait Islander people and communities are diverse. This diversity includes distinct language, kinship and cultural traditions, religious beliefs, family responsibilities and personal histories and experiences. Importantly, this diversity also extends to the health needs of Aboriginal and Torres Strait Islander people and communities” (Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee, 2016, p. 6).

Culture as a Determinant of Health

Culture as a determinant of health encompasses the cultural factors that promote resilience, create and maintain a sense of identity and promote good mental and physical health and wellbeing for individuals, families and communities.  Culture as a determinant of health may not be as well understood as the social determinants of health, but there is convincing evidence emerging about the many ways that culture can support better health outcomes (Department of Health, 2017).

Evidence for the negative effects of social determinants of health is substantial; but how that evidence is portrayed; i.e., framed by negativity, deficiency and disempowerment (Forde et al. 2013) has come to be associated with what is known as a ‘deficits discourse’ or perspective in relation to Aboriginal and Torres Strait Islander people and their health;

By this we mean that by always describing the Aboriginal and Torres Strait Islander population as having poorer health outcomes, lower social economic status, lower educational attainment, longer term unemployment, welfare dependency and intergenerational disadvantage, etcetera, reinforces a deficits narrative and fails to acknowledge individual, family and community strengths that continue to flourish, despite 200 hundred plus years of colonisation. Perpetuating such a deficits discourse in relation to social and cultural determinants contributes to structural racism. The work of reframing this discourse is the responsibility of everyone in the health care system.

Connections to Culture and Country build Stronger Individual and Collective Wellbeing

“The cultural determinants of health originate from and promote a strength-based perspective. This approach acknowledges that stronger connections to culture and Country contribute to stronger individual and collective identities, a sense of self-esteem, resilience, and improved outcomes across the other determinants of health including education, economic stability and community safety” (Brown, 2014).

Exploring and articulating the cultural determinants of health acknowledges the extensive and well-established knowledge networks that exist within communities, the Aboriginal community-controlled health service movement, human rights and social justice sectors.

Social and emotional wellbeing resulting from strong cultural connections, cultural engagement and cultural knowledge are increasingly reported in the literature (Tighe et al. 2012; Dudgeon et al. 2012).

Student    activity 5: Write and reflect:  How does your culture    positively impact your health?

Access      the following link My Life My Lead and answer the following frequently asked question.

What        is meant by the cultural determinants of health? 

The cultural determinants of Aboriginal and Torres Strait Islander health include, but are not limited to:

Self-determination

Freedom   from discrimination

Individual and collective rights

Importance       and value of Aboriginal culture

Protection         from removal/relocation

Connection       to, custodianship and utilisation of country and traditional lands

Reclamation,     revitalisation, preservation and promotion of language and cultural     practices

Protection         and promotion of traditional knowledge and Aboriginal intellectual        property

Understanding of lore, law and traditional roles and responsibilities (Brown, nd;         cf Lovett, 2014).

A ‘social and cultural determinants’ approach recognises that there are many drivers of ill-health that lie outside the direct responsibility of the health sector and which therefore require a collaborative, inter-sectoral approach. There is an increasing body of evidence demonstrating that protection and promotion of traditional knowledge, family, culture and kinship contribute to community cohesion and personal resilience (Department of Health, 2017).

If change is to be achieved in the future, the following principles need to be adopted:

Strong connections to culture and family are vital for good health and wellbeing.

The best results are achieved through genuine partnerships with communities.

The impacts of trauma on poor health outcomes cannot be ignored.

Systemic racism and a lack of cultural capability, cultural safety and cultural

security remain barriers to health system access and this needs to be addressed.

Figure       4.  Priority areas to address the social and cultural determinants   of health (Department of Health, 2017b, p. 8)

Student    activity 6: Figure 4 above identifies priority areas to address Aboriginal and Torres Strait        Islander social determinants and cultural determinants of health.      List the 7 priority areas (illustrated above) that aim to address     the social determinants and cultural determinants of health.

Student    Activity 7: Write and reflect.

Having      read about social and cultural determinants of Aboriginal and Torres         Strait Islander health, in which of these priority areas do you        think you could have an impact in terms of reducing the gap in health outcomes between Aboriginal and non-Aboriginal people? 

Application to Health Promotion

When engaging in health promotion with Aboriginal and Torres Strait communities an understanding of the cultural determinants listed above and the need to work in partnership and collaboration with Aboriginal and Torres Strait Islander families and communities is vital.  When viewed through an Aboriginal ‘lens’, core values specifically identified for Aboriginal health promotion theory and practice include:

Aboriginal self-determination principles.

A holistic definition of health that acknowledges connection to land and spirit.

Community ownership and localised decision-making.

Recognition of the specific historical, social and cultural context of the community.

Student    Activity 8: This activity      will assist you to structure a critical reflection.  Your         first of two critical reflections is due in Week Five (see Learning   Guide for details).

Identify     an issue/topic in the Module 4 and critically reflect over it.  This is not for submission.  Use the       following sequence based on Gibbs Reflective Cycle to guide your    writing.

(Gibbs       1988)

The   issue you select may relate to one of those listed below or   something else that has caught your attention/effected how you think about Aboriginal and Torres strait islander people.  This may be     something current in the press?

The   following are some possible areas on which to base this week’s         reflection, but you need to decide which ones are relevant to you,         what has impacted you?

The   ‘causes of the causes’

Health,              human rights and social justice

Social                determinants of health

Cultural             determinants of health

Fill    in the next page

Description:

Feelings:

Critical     Evaluation:

Analysis   and conclusion: 

Useful guidelines to successful Aboriginal health promotion with regards to what does and doesn’t work are offered by Charles (2015) and Percival et al. (2016).

References

American Public Health Association. (2016, November 1). Michael Marmot and the Social Determinants of Health. [Video file]. Accessed on 27/2/19 at https://www.youtube.com/watch?v=BHYBHKma3x8

Australian Health Ministers’ Advisory Council (AHMAC) (2017). Aboriginal and Torres Strait Islander Health Performance Framework Report. Canberra: Australian Government. Accessed 19/2/19 from https://www.pmc.gov.au/sites/default/files/publications/2017-health-performance-framework-report_1.pdf

Australian Health Ministers’ Advisory Council’s National Aboriginal and Torres Strait Islander Health Standing Committee (2016). Cultural Respect Framework 2016-2026 for Aboriginal and Torre Strait Islander Health.  A national approach to building a culturally respectful health services. Accessed on 27/2/19 from https://nacchocommunique.files.wordpress.com/2016/12/cultural_respect_framework_1december2016_1.pdf

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