satisfy needs; and, on the other hand, to change
or cope with the environment. Health is,
therefore, seen as a resource for everyday life,
not the objective of living; it is a positive
concept emphasising social and personal
resources as well as physical capacities.
This holistic definition of health is reflected in the book Meeting the Health Needs of People Who Have a Learning Disability (Thompson and Pickering 2001) which contains chapters on self-concept, meaningful occupation and life transitions. It can be argued that unless we feel good about ourselves and have meaning in our lives, such as going to work, raising a family, learning new skills, visiting friends, helping others or pursuing hobbies and interests, we
Changing relationships for promoting health
Chapter
10 ill health (Leon and Walt 2001), and physical hazards, such as dampness, poor architectural design and danger- ous work practices, can cause disease and injury (Siegnal and Theorel 2006). Living in deprived neighbourhoods also increases the risk of ill health and mortality, regardless of the individual’s personal situation (Steptoe 2006; Wiles 2008). Much of the legislation passed by the Victo- rians improved people’s health by tackling problems at this level (Brunton 2004). Various factory, housing and sanitation Acts, for example, reduced the incidence of serious diseases, such as tuberculosis (TB) and typhoid, as well as improving the quality of people’s lives generally. Le Fanu (1999) claims that there was a 92% decline in TB before the introduction of curative drugs. Similar evi- dence has been put forward by McKeown (1984) who notes that many life threatening and disabling diseases, such as poliomyelitis and diphtheria, had radically declined before the introduction of inoculation. Naidoo and Wills (2008) conclude that medicine has had only a marginal influence on health and mortality rates, although Hubley and Copeman (2008) believe that the under- utilisation of health services, especially preventative serv- ices, is a contributing factor to the ill health of the poorer sectors of society.The outermost layer affecting our health concerns general socioeconomic, cultural and environmental con- ditions. This includes the economic state of the country, the level of employment, the tax system, the degree of environmental pollution and our attitudes, for example towards women, old people, ethnic minorities and disa- bled people. Increasingly, these factors have taken on an international dimension as globalisation accelerates (Pryke 2009). It is at this level that government can be particularly influential by implementing policy and passing legislation to bring about wide social change, for example seat belt legislation (Figure 10.3), banning smoking in public places and equality legislation, such as cannot be fully healthy. Having a sense of control over our
lives and being connected to the people around us are also important for health and well-being (Naidoo and Wills 2008; Wiles 2008).
There are many influences on all aspects of our health. Dahlgren and Whitehead (1995) depict these as layers piled on top of each other. At the bottom of the pile are biological factors over which we have limited, or no, control. These include our sex and age, and the genes we inherit from our parents. Many diseases become more common as we grow older (e.g. cancer and cardiovascular disease), some diseases are specific to men or women (e.g. prostate and ovarian cancer), while others are genetic or congenital in origin (e.g. cystic fibrosis and congenital heart disease). When the NHS was established in 1948 it concentrated on this biological layer. It was hoped that improvements in health would eliminate health inequali- ties but although the overall health of the population has gradually improved (mainly through improved living con- ditions) the gap between the social classes has widened (Asthana and Halliday 2006; Wiles 2008).
The second layer focusses on our personal behaviour. This includes whether or not we smoke cigarettes or eat too much, the amount of exercise we take and how well we attend to our health needs in the broadest sense. Most policy initiatives from government have focussed on this layer, where attempts have been made to change peoples’ behaviour in order to improve their health, for example anti-smoking campaigns (Jones 2000b; DH 2004; Wiles 2008). This emphasis on personal behaviour has, however, been criticised. Asthana and Halliday state that ‘…the government’s strategy suggests an implicit assumption that health inequalities can be reduced without changing overall levels of inequality’ (2006: 98). There is also a denial of the ways in which the social setting affects our behaviour and reduces our control.
The next layer concerns social and community influ- ences. The people around us, including family members, neighbours, colleagues and friends, can influence our health by giving meaning to our lives and providing assist- ance and support in times of illness, difficulty and stress. Conversely, these people can have a detrimental effect on our health by neglect, abuse or failing to take account of our needs. Organisations such as the church and self-help groups may also be important (Asthana and Halliday 2006). Berkman and Melchior (2004) point out that social networks provide opportunities for support, access, social engagement and economic advancement, allowing indi- viduals to participate in work, community and family life. Social networks can, however, also lead to discrimination, hostility and exclusion.
Living and working conditions comprise the next layer of influence. It is well known, for instance, that the type of house in which we live and our environment at work can affect our health. Work pressure or noisy neighbours
2008). This is because of a range of factors that were summed up by Tudor Hart (1971) in his notion of the ‘inverse care’ law.
the Sex Discrimination Act (1975), the Disability Discrim- ination Act (1995) and the Human Rights Act (1998).
It is clear that these levels all interact and influence each other. If the economic state of the country is favourable, for example, people are likely to have more disposable income which may improve their health by allowing them to buy good quality food and housing of a better standard, engage in leisure pursuits, give their children more oppor- tunities and enjoy relaxing holidays to reduce stress. Simi- larly, if a person is attempting to give up drugs, success is more likely if community support is strong and if govern- ment is willing to act by establishing and financing supportive policies.
Despite the various influences on our health, the evi- dence suggests overwhelmingly that broad social factors concerning housing, income, educational level, employ- ment and social integration are more important than our individual behaviour or medical practice and advances (Ewles and Simmett 2003). People of the lowest socioeco- nomic status are at far higher risk, not only of physical illness and early death, but also of accidents, premature births, mental illness and suicide. Smith and Goldblatt (2004) report that of the 66 major causes of death, 62 are more prevalent in the lowest two social classes. It is also the case that men in professional occupations live, on average, seven years longer than men in manual occupa- tions and that the children of manual workers are twice as likely to die before the age of 15 years than the children of professional workers (Naidoo and Wills 2008). In addition, Hargreaves (2007) reports that in 2002–4 infant mortality was 19% higher among manual workers than professional workers, and that the gap had steadily widened. Wiles states that ‘…across the lifespan there are inequalities in people’s health that follow from their eco- nomic position. Poor people are more likely to be in poor health and to die at an earlier age’ (2008: 52).
It is important to realise, however, that the health status of a country does not equate to its wealth, but rather to how fairly the wealth is distributed (Eberstadt and Satel 2004). Asthana and Halliday (2006) note that longevity rises in societies which are more equal and socially cohe- sive, especially when infectious diseases have been con- trolled. They contend that psychosocial stress is related to feelings of relative disadvantage and subordinate status which, in turn, can lead to physical and mental ill health.
It can be disconcerting for healthcare professionals to realise that there is no obvious correlation between health- care and health status in any population; indeed, the health service has sometimes been referred to as an ‘ill health’ service as it tends to respond when the damage has been done. This is not to imply, however, that inequalities in health and healthcare facilities should be tolerated. Healthcare should be distributed fairly and in accordance with need. There is evidence, for example, that the uptake of preventative services, such as birth control and screen- ing, is low among poor people (Hubley and Copeman
Definition
Disability can be defined from an individual model or a social model. The individual model is dominant and assumes that the difficulties faced by disabled people are a direct result of their individual impairments or lack or loss of functioning. The social model of disability recognises the social origin of disability in a society geared by, and for, non-disabled people. The disadvantages and restrictions, often referred to as barriers, permeate every aspect of the physical and social environment. Disability can, therefore, be defined as a form of social oppression.
The inverse care law
The inverse care law states that those who are most at risk of acquiring illness and disease are least likely to receive medical and social services. This is because of a wide variety of factors relating to social inequalities and the availability of services.
In this section of the chapter we will examine two central models of disability – the individual model and the social model – to illustrate the ways in which underlying ideas and concepts can shape physiotherapy practice and wider medical and social policy. A model can be defined as a conceptual framework for understanding causal relation- ships. It usually lies within the framework of a broader
People with low incomes find it harder to access health- care services because of social isolation and lack of facili- ties, such as a car. It is also the case that the areas in which they live tend to have poor facilities and that health profes- sionals tend to give them less time and attention than people who are perceived to be culturally similar to them- selves (Naidoo and Wills 2008).
There are still many people in the UK who do not fully benefit from the facilities of the NHS. People from ethnic minorities are not well served (Atkin et al 2004) nor are people with learning difficulties (Mencap 2004; DH 2009). As noted in the section on culture, this is a result of a variety of factors, including poor and inadequate communication, racism, disablism and lack of cultural sensitivity.