Health Determinants

INTRODUCTION: Health is mans greatest possession; good health is very essential to economic and technological development. And a healthy community is the infrastructure upon which an economically viable society is build. Good health is a prerequisite to human productivity and development. According to WHO community health refers to the health status of the members of the community, to the problems affecting their health, and to the totality of health care provided for the community.1 It is also known as community medicine a field concerned with the study of health and disease in human population. OBJECTIVES OF COMMUNITY HEALTH: a. Increasing the average span of human life. b. Decreasing the mortality rate, particularly IMR, MMR. c. Decreasing the morbidity rate. d. Increasing the physical, mental and social well-being of individual. e. Increasing the pace of adjustment of the individual to his environment. f. Providing total health care to enrich quality of life.1 Health is multifactoral. The factors which influence health lie both within the individual and externally in the society in which he or she lives. All factors/ health determinants can be classified under main 4 headings: - Human biology - lifestyles - environment - healthcare organizations HEALTH DETERMINANTS 1. Biological determinants The genetic make-up is unique in that it cannot be altered after conception. We often hear that, someone has inherited the strength of his fathers family. Certainly we inherit or physical structure, or skin texture and pigmentation and most likely our native intelligence through the genes received or parents.1 Also a number of disease are now to be of genetic origin, eg., chromosomal anomalies, errors of metabolism, mental retardation, some types of diabetes, etc. The state of general health therefore depends partly on the genetic constitution of man. Now a days, medical genetics offers hope for prevention and treatment of a wide spectrum of diseases. A vast field of knowledge has yet to be exploited. It plays a

particularly important role in genetic screening and gene therapy. Thus from the genetic stand-point, health may be defined as state of the individual which is based upon the absence from the genetic constitution of such genes as correspond to characters that take the form of serious defect and derangement and to the absence of any aberration in respect of the total amount of chromosome material in the karyotype or stated in positive terms, from the presence in the genetic constitution of the genes that correspond to the normal characterization and to the presence of a normal karyotype. A study on genetic determinants of health span and life span: progress and new opportunities reviewed three approaches to the genetic analysis of the biology and pathobiology of human aging. The first and so far the best-developed is the search for the biochemical genetic basis of varying susceptibilities to major geriatric disorders. These include a range of progeroid syndromes. Collectively, it told much about the genetics of health span. Given that the major risk factor for virtually all geriatric disorders is biological aging, they may also serve as markers for the study of intrinsic biological aging. The second approach seeks to identify allelic contributions to exceptionally long life spans. While linkage to a locus on Chromosome 4 has not been confirmed, association studies have revealed a number of significant polymorphisms that impact upon late-life diseases and life span. The third approach remains theoretical. It would require longitudinal studies of large numbers of middle-aged sib-pairs who are extremely discordant or concordant for their rates of decline in various physiological functions. Study concluded that there are great opportunities for research on the genetics of human aging, particularly given the huge fund of information on human biology and Patho biology, and the rapidly developing knowledge of the human genome. 2. Behavioral and socio-cultural conditions the term lifestyle is rather a diffuse concept often used to denote the way people live, reflecting a whole range of social values, attitudes and activities. It is composed of cultural and behavioral patterns and lifelong personal habits (smoking, alcoholism, etc.) that developed through process of socialization. So many diseases, now a days are associated with life style changes, like- coronary heart disease, obesity, lung cancer, drug addiction, etc. Though all life style factors are not harmful. There are many that actually promote health, like- adequate nutrition, enough sleep, sufficient physical activities etc. Still in developing countries like India, where traditional life styles still persists, risk of illness and death connected with lack of sanitation, poor nutrition, personal hygiene, elementary human habits, customs and cultural patterns.2

3. Environment Hippocrates, first related disease to environment, eg., climate, water, air, etc. Internal (each and every part, every tissue, organ and organ- system and their harmonious functioning within the system). External environment : Physical housing, water, air, light, noise, excreta disposal etc. Biological includes all living things (animals, rodents, plants etc. Even virus, bacteria etc.) Psycho-social refers to micro or personal environment (individual ways of living & life styles, at home, school, workplace, neighbor-hood etc.)1 Its an established fact that environment has a direct impact on the physical, mental and social wellbeing of those living in it. The environmental factors ranges from housing, water supply, psychosocial stress, family structure through social and economic support systems, to the organization of health and social welfare services in the community.2 As for example in many of the developing countries, the lack of pure water supply, defective sanitation and lack of effective measures to control communicable diseases is held responsible for the continuing prevalence of many health problems. Water born diseases like, cholera, typhoid, fever, hepatitis, diarrheal diseases etc, then, air born communicable diseases like, tuberculosis, diphtheria, whooping cough etc spreads due to overcrowding, poor hygiene etc.1 4. Socio economic conditions For the majority of the worlds people, health status is determined primarily by their level of socio-economic development, e.g., per capita income, education, nutrition, employment, housing, political system of the country etc. i. Economic status: it is the economic progress that has been the major factor in reducing morbidity, increasing life expectancy and improving the quality of life. It is also an important factor in seeking health care. And also be a contributory cause of illness like coronary heart disease, obesity, and diabetes in the upper socio-economic groups. The per capita GNP (gross national product) is the most widely accepted measure of general economic performance. ii. Education: a second major influencing health status is education. The world map of illiteracy closely coincides with the maps of poverty, malnutrition, ill health, high infant and child mortality rates. Kerala, a striking example of low infant mortality (14 compare to 71 for all India, 1999) due to its highest female literacy rate (87.86% compare to 54.16% for all India).

iii. Occupation: unemployment usually show higher incidence of ill health and death, also cause psychological and social damage.2 5. Health services the term health and family welfare services cover a wide spectrum of personal and community services of treatment of disease, prevention of illness and promotion of health. The purpose of health services is to improve the health status of population. For example, immunization of children can influence the incidence/prevalence of particular disease. Provision of safe water can prevent mortality and morbidity from water born diseases. Proper care of pregnant women and children would contribute to the reduction of maternal and child morbidity and mortality. To be effective, the health services must reach the social periphery, equitably distributed, accessible at a cost the country and community can afford and acceptable (primary health care). 6. Aging of the population By the year 2020, the world will have more than one billion people aged 60 and over and more than two-thirds of them living in developing countries. Along with increased aged population, prevalence of chronic diseases and disabilities accompanying the aging process and deserve special attention. 7. Gender Special consideration should be given on womens health covering nutrition, reproductive health, the health consequences of violence, aging, lifestyle related conditions and the occupational environment. It has brought about an increased awareness among policy-makers of womens health issues and encourages their inclusion in all development plans as a priority. 8. Other factors Other contributions to the health of population derive from systems outside the formal health care system like food and agriculture, education, industry, social, rural welfare etc. This would include employment opportunities, increased wages, prepaid medical programmes, family support system. An article from internet suggests few health determinants based on evidences. Providing a comprehensive review of the evidence base is not simple. It needs to draw on the best available evidence that from reviews and research papers, and including qualitative and quantitative evidence. However, there are examples where the best available evidence has been documented.

These are presented below: Transport Food and Agriculture Housing Waste Energy Industry Urbanization Water Radiation Nutrition and health Transport Evidence of health impact focus on: i. Accidents between motor vehicles, bicycles and pedestrians (particularly children and young people). ii. Pollution from burning fossil fuels such as particulates and ozone. iii. Noise from transportation. iv. Psychosocial effects such as severance of communities by large roads and the restriction of childrens movement. v. Climate change due to CO2 emission vi. Loss of land vii. Improved physical activity from cycling or walking viii. Increased access to employment, shops and support services ix. Recreational uses of road spaces x. Contributes to economic development Food and Agriculture Agricultural production issues and manufacturing: i. Tobacco farming and its impact on heart disease, stroke, certain cancers and chronic respiratory disease. Including passive smoking and impact of foetal development. Pesticide policies on tobacco crops require consideration. ii. Changes in land use, soil quality, choice of crop, use of agricultural labour and occupational health. iii. Mechanization of work previously done by hand, and plantation agriculture. iv. Fisheries bio toxins, pollution, chemical use, waste water, processing, and occupational health v. Forestry vector borne diseases, occupational health, and food security. vi. Livestock use vector borne diseases, drug residues, animal feed, waste, and food security.

vii. Sustainable farming including chemical and energy use, biodiversity, organic production methods, and diversity of foods produced. viii. Fertilizer use nitrate levels in food, pollution of waterways, re-use of agricultural waste. ix. Water irrigation use and its impact on river/water-table levels and production outputs. x. Pesticide usage and veterinary drugs legal requirements, best practice, consumer issues. xi. Food packaging, preservation and safety, and avoidance of long storage and travel. Access to, and distribution of food i. Household food security appropriate food being available, with adequate access and being affordable (location of markets, supermarkets and closure of small suppliers creating food deserts in cities). ii. Food supplies, including national and regional food security, and regional production. iii. National food security able to provide adequate nutrition within a country without relying heavily on imported products iv. Cold-chain reliability the safety of transporting products that deteriorate microbiologically in the heat. v. Dietary patterns, diversity of food available and home production, particularly: vi. Fruit and vegetable consumption on reduced stroke, heart disease and risk of certain cancers, vii. Total, saturated and polyunsaturated fat, carbohydrates and sugars consumption on obesity, heart disease, stroke and other vascular diseases. viii. Alcohol consumption and impact on social effects related to behavior (traffic accidents, work/home accidents, violence, social relations, unwanted pregnancy and STDs), and toxic effects (all-cause mortality, alcoholism, certain cancers, liver cirrhosis, psychosis, poisoning, gastritis, stroke, foetal alcohol syndrome and others). ix. Micronutrients such as iron, vitamin A, zinc and iodine and their impact on deficiency syndromes. Food safety and food borne illness hazards i. Food and water are the major sources of exposure to both chemical and biological hazards. They impose a substantial health risk to consumers and economic burdens on individuals, communities and nations. ii. Microorganisms such as salmonella, campylobacter, E. coli O157, listeria, cholera. iii. Viruses such as hepatitis A, and parasites such as trichomonosis in pigs and cattle. iv. Naturally occurring toxins such as mycotoxins, marine biotoxins and glycosides. v. Unconventional agents such as the agent causing bovine spongiform encephalopathy (BSE, or mad cow disease"), vi. Persistent organic pollutants such as dioxins and PCBs. Metals such as lead and

mercury. vii. New foods developed from biotechnology such as crops modified to resist pests, changes in animal husbandry, antibiotic use and new food additives. Housing Evidence of health impacts focus on: i. Improvements in housing and improved mental health and general health ii. The possibility of improved housing leading to rent rises, impacting negatively on health. iii. Movement of original tenants after housing improvement and therefore not benefiting from the improvements. iv. Housing tenure, outdoor temperature, indoor air quality, dampness, housing design, rent subsidies, relocation, allergens and dust mites, home accident prevention, and fire prevention. v. Homelessness. Waste Evidence of health impacts focuses on environmental and social determinants related to: i. the transmission of agents of infectious disease from human and animal excreta (sanitation, hygiene and water-related); ii. Exposure to toxic chemicals in human and animal excreta; and in industrial wastes discharged into the environment; iii. Environmental degradation, direct and indirect impacts on health; iv. Exposure to radioactive wastes; v. exposure to health-care wastes; vi. Exposure to solid wastes and involvement in informal waste recycling; and vii. Breeding of disease vectors. Energy Evidence of health impacts focus on health hazards such as: i. Fossil fuels ii. Biomass fuels iii. Hydropower and their impact on vector borne diseases, and pollution iv. Electricity generation and transmission v. Nuclear power vi. Other energy sources vii. Occupational health effects of energy workers viii. Impacts on ecosystems, agriculture, forests, fisheries and building materials ix. Noise x. Visual impact xi. Global warming

Industry Evidence of health impacts focus on industrial sectors such as: i. Asbestos and manmade fibres ii. Basic chemicals iii. Cement, glass and ceramics iv. Electronics v. Iron and steel vi. Manufacture of rubber and plastic products vii. Metal products viii. Mining ix. Pesticides, paints and pharmaceuticals x. Petroleum products xi. Pulp and paper xii. Service industries xiii. Textiles and leather xiv. Wood and furniture. Urbanization Evidence of health impacts focus on topics such as: i. Urban housing problems ii. City environment and non-communicable diseases iii. Communicable diseases iv. Road trauma v. Psychosocial disorders vi. Sustainable urban development vii. Urban wastes viii. Health services A study on Urban as a Determinant of Health suggests cities are the predominant mode of living, and the growth in cities is related to the expansion of areas that have concentrated disadvantage. The foreseeable trend is for rising inequities across a wide range of social and health dimensions. Although qualitatively different, this trend exists in both the developed and developing worlds. Improving the health of people in slums will require new analytic frameworks. The social-determinants approach emphasizes the role of factors that operate at multiple levels, including global, national, municipal, and neighborhood levels, in shaping health. This approach suggests that improving living conditions in such areas as housing, employment, education, equality, quality of living environment, social support, and health services is central to improving the health of urban populations. While social determinant and multilevel perspectives are not uniquely urban, they are transformed when viewed through the characteristics of cities such as size, density, diversity, and complexity. Ameliorating the immediate living conditions in

the cities in which people live offers the greatest promise for reducing morbidity, mortality, and disparities in health and for improving quality of life and well being.3 REFERENCES: 1. Basavanthappa B.T. Community Health Nursing. Bangalore: jaypee brothers; 1999. 2. Park K. Preventive and Social Medicine. 18th ed. Jabalpur: Banarasidas Bhanot; 2005. 3. Vlahof D, Freudenberg N, Proielli F, Ompad D, Quinn A, Nandi V, Galea S. Urban as a Determinant of health. J Urban Health 2007; 84(1): 16-26. 4. Martin, Burgman A, Barzilai N. PLoS Genet 2007; 3(70): 125.