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- 1. Enhancing the development, monitoring and control of Indigenous health policy through the integration of the psychosocial determinants & social wellbeing David Campbell Centre for Remote Health, Alice Springs Objective: To show how the integration of the psychosocial stressors with social wellbeing can enhance the application of SWB as a health policy tool I have no conflict of interest to disclose
- 2. Integration of social wellbeing with psychosocial stressors • SWB provides a reasonable indicator of future health and longevity, but limited in explaining causality: • limiting its application to health policy • The integration of the psychosocial stressors with social wellbeing is one way of overcoming this shortcoming • Stress is an important connector. With: • Psychosocial stressors affecting homeostasis, and • SWB status being a measure of the cognitive response to stress and homeostasis
- 3. Pathways from PSD stressors to psychosocial and pathological outcomes affecting SWB status Psychosocial response PSD Coping Stress Behavioural Endocrine Biomedical Chronic Stressors response response health risk disease Hormonal response leading to poor behavioural response Cognitive response SWB status Note: The broken line represents the effect of pre- and postnatal factors, such as poor kidney development, on future (mid-life) health. Based, in part, on Campbell (2013). The mitigation of chronic disease can be addressed anywhere along the continuum. Where best?
- 4. Psychosocial stressors likely to affect Indigenous peoples • Those stressors affecting other members of the Australian population including bad health choices: • Lack of exercise, poor diet, smoking, alcohol, drugs, personal and interpersonal violence; • Socioeconomic factors • A range of factors specific to invasion and colonisation: • Disenfranchisement from traditional country and traditional cultural practice - Violence
- 5. What does this imply for health policy, research practitioners and the training of health practitioners? • Integration of the psychosocial determinants with SWB can assist in: • Developing and monitoring policy responses • Enhancing our understanding of causality • Guidance in directing training of policy implementers and health practitioners to ‘what works’ in upstream psychosocial factors.
- 6. Some references Cummins RA, Eckersley R, Pallant J, Vam vugt J, and Misojon R. 2002. ‘Developing an national index of subjective wellbeing: The Australian Unity Wellbeing Index’, Social Indicators Research, 64: 159-190. Daniel, M.; Brown, A.; Garnggulpuy Dhurrkay, J.; Gargo, M.D.; O’Dea, K. 2006. ‘Mastery, perceived stress and health-related behaviour in northeast Arnhem Land: A cross-sectional study’, Int. J. Equity Health, 5: 5–10. Deeming C. 2013. ‘Addressing the social determinants of subjective wellbeing: the latest challenge for social policy’, Journal of Social Policy, 42(3): 541-565. Diener E, Chan MY. 2011. ‘Happy people live longer: Subjective well-being contributes to health and longevity’, Applied Psychology: Health and Wellbeing, 3(1): 1-43. Diener E. Inglehart R. and Tay L. 2012. ‘Theory and validity of life satisfaction scales’, Social Indicators Research, 112: 497-527. Lazarus R, and Folkman S. 1984. Psychological Stress and the Coping Process, Springer, New York. Stiglitz JE, Sen A, Fitoussi JP. 2009. Report by the Commission on the Measurement of Economic Performance and Social Progress, Paris. d.campbell@flinders.edu.au
Notas del editor
- Two approaches to measuring wellbeing are objective wellbeing and subjective wellbeing. Objective wellbeing is based on directly measurable variables such as income, housing, education, employment, and other quantifiable social and market based factors. Subjective Wellbeing, while influenced by bjective wellbeing variables, includes a wide range of non-quantifiable factors such as loss of control and a history of social disenfranchisement. Although both measures of Well Being are affected by genetic disposition, Social Wellbeing is affected by an additional range of non-quantifiable factors. Indeed, it is possible for Objective Wellbeing to be intramarginal, or even contradictory to Subjective Wellbeing. This is the case with the Aboriginal community in Utopia, north of Alice Springs. Which, on the basis of quantifiable social indicators, we would expect to have worse health outcomes than that observed for other Aboriginal communities in the Northern Territory. Yet, their life expectancy is closer to that of non-Indigenous Northern Territorians than that of other Northern Territorian Aboriginal communities. This difference between expected and actual outcomes being due to factors that are accounted for in SWB indicators but are not accounted for in OWB indicators.
- While subjective wellbeing has been shown to be a reasonable indicator of future health and length of life, researchers, such as Diener, identify it as being only partly integrated with those explanative variables affecting health and longer term outcomes. This limits the application of Subjective Wellbeing in the development and control of health policy. It would be useful, therefore, to identify those causative agents affecting variation in health outcomes and Subjective Wellbeing status. The integration of the Psychosocial Determinants of Health with Subjective Wellbeing is proposed as a means to meeting this shortfall. The Psychosocial Determinants of Health consist of a range of stressors that trigger adaptive responses to the maintenance of homeostasis. Excessive stress and inappropriate adaptive response can disrupt homeostasis, and increase the risk of chronic disease. At the same time stress levels affect the cognitive assessment of Subjective Wellbeing status. That is, the response to stress forms a cognitive/psychological link between Psychosocial Stressors and Subjective Wellbeing status. The objective, then, is to show how the integration of the Psychosocial Determinants of Health with Subjective Wellbeing can enhance the application of Subjective Wellbeing in the development and monitoring of Indigenous health policy.
- Slide 3 provides a simplified representation of the relationship between PS stressors and likely psychosocial and biological response with consequent cognitive recognition and SWB status. Health improving interventions can be applied at any stage along this continuum, although resources have been concentrated on the treatment of chronic disease, with some response to educating people as to the health risks of bad behavioural choices. Interventions directed at correcting bad behavioural choices still miss the primary causative agent of stress. As with the Whitehall studies of the British Public Service, which showed psychological response to stressors, such as loss of personal control, has twice the impact of bad health choices. Recent studies by Damien and others, in Canada and Australia, confirm these results for Indigenous peoples. Stress occurs as a result of an individual’s perceived mismatch between the stressors placed on them the resources needed to cope. Biological adaptive compensatory responses to stressors are activated within the homeostasis system whenever a stressor exceeds a severity or temporal threshold. Excessive stress and inappropriate adaptive responses can disrupt homeostasis, and increase the risk chronic disease and decreasing Subjective Wellbeing status. Disenfranchised and disadvantaged peoples are more likely to suffer stressors and to have less capacity to adjust or cope. Indeed, the argument is made that it can be economically rational for people in these circumstances to make bad health choices. That is, addressing bad behavioural choices is closing the barn door after the horse has bolted. I am suggesting, therefore, that addressing the psychosocial stressors and capacity to cope, provides the means to close the stable door before that horse has bolted. It is proposed that the integration of Psychosocial stressors with Subjective Wellbeing, could enhance policy development and enhance the means of monitoring and control of research and health interventions.
- Integration of the Psychosocial Determinants with Subjective Wellbeing can assist us to: - develop and monitor policy responses; - enhancing our understanding of causality; - align health interventions to address upstream or distal causative factors; and - provide guidance in the direction undertaken in training health practitioners. Stressors result from multiple emotional and physical sources that vary with duration and acuteness. Individual vulnerability and consequent discomfort can differ according to genetic makeup, personal disposition and individual circumstance. PS stressors include social disenfranchisement, poor living conditions such as diet, crowded housing noisy surrounds, and the lack of mastery or control. The Australian Bureau of Statistics reported Aboriginal and Torres Strait Islander people to be 1.4 times more likely to experience stressors and more likely to suffer co-stressors. Although some might argue such difference is because Aboriginal and Torres Strait Islander peoples are prone to the same Psychosocial stressors as others, plus a range of additional stressors relating to their indigeneity – in particular, the consequences of invasion and the cultural and property disenfranchisement of ongoing colonisation.
- What does this imply for research, health policy and the training of health practitioners? Integration of the psychosocial determinants with SWB can assist us in: - developing and monitor policy responses: enhancing our understanding of causality; - alignment of health interventions to address upstream/distal causative factors; and - the training of health practitioners in addressing these upstream/distal factors; as, for example by connecting with culture. The New Zealand example of training Maori people to develop and provide culturally based medical and educational services