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The medical profession must understand and addresses the social influences on the lives of people with disability in order to improve the health, wellbeing and lives of people with disability.
Social determinants of health (SDoH), the social model of disability, and the recommendations made in the recent Disability Royal Commission are linked together when considering the health outcomes of people with disability. The links lie with the influence of social circumstances on both health and disability.
Factors such as education, employment, income, housing, health care access, transport and social support are considered SDoH. SDoH also encompass the broader set of forces that shape conditions of daily life, such as governing policies and associated procedures. For people with disability, the negative consequences of poor SDoH are often multifactorial, and can be amplified when compared to people without disability. The connection between poor SDoH consequences and people with disability demonstrates the value of considering the social model of disability.
The social model of disability views societal barriers, rather than individual impairments, as a limit to full participation in society for people with disability. The model recognises that attitudes, practices and systems can act as barriers for people with disability to fulfil their rights as equal members of the community.
The impact on health outcomes
The Disability Royal Commission made several SDoH related recommendations. The recommendations were aimed at improving social factors like education, employment, housing, health care access, community support, and transport for people with disability. These SDoH are interconnected with health and quality of life. Therefore, addressing these socially influenced determinants of health in medical care is crucial for creating a more inclusive and just society that improves the health and wellbeing of people with disability, particularly considering that one in six Australians have a disability, and report worse health. As an example, poor housing is related to worse health outcomes, and the negative impact of housing on health is amplified for people with disability.
The negative effects of suboptimal SDoH on health outcomes can also be seen in the Australian Institute of Health and Welfare report, “Indicators of socio-economic inequalities in cardiovascular disease, diabetes and chronic kidney disease”. The report highlights how Australians with the poorest SDoH have the highest prevalence of these chronic diseases. For example, the prevalence of type 2 diabetes among male and female Australians living in lower socio-economic areas was 1.70 and 2.07 times higher, respectively, than those living in the highest socio-economic areas. Relatedly, the report also outlines a “social gradient” associated with chronic disease. The social gradient describes a direct association with a person’s socio-economic status and the impact this has on chronic disease incidence and prevalence, that is, the better a person’s SDoH, the better their health outcomes, and conversely, the poorer their life circumstances, the worse their health.
Socio-ecological models of health
Social and medical models of health are not mutually exclusive. It is usual practice in clinical care to consider people’s social circumstances. Unfortunately though, this interventional requirement is not formalised enough in the medical model. On the contrary, a model that incorporates social influences on a person’s life, is the socio-ecological model of health. In addition to the social influences, the socio-ecological model of health incorporates both the individual modifiable factors like lifestyle and behaviour; and non-modifiable factors such as age and gender.
When doctors acknowledge the social determinants of a health condition, and account for the socio-ecological model of health, the “causes of the causes” can be addressed. This, in turn, increases the likelihood of improved self-management, early intervention, and prevention. Addressing SDoH in clinical care underpins the sustained improvement of health outcomes, health equity, and generational prevention of unhealthy lifestyles, or more appropriately termed, suboptimal life circumstances.
Combining health care provision based on a “medical model” with a “socio-ecological” view of health may require a paradigm shift when providing care for people with disability.
Doctors can make an impact by making small but effective changes to current practice. Possible inclusions could be:
- SDoH screening for people with disability: SDoH screening specific to people with disability could include factors such as accessible housing and supported living arrangements, accessible transport, social support, and employment opportunities for people with disability.
- Disability-specific social prescribing: Social prescribing that incorporates specific services for people with disability, such as disability-specific sporting clubs and accessible community activities.
- Referral to disability specialist services: This could include allied health, community health and other disability-specific supports.
- Engagement with disability organisations: This could assist with the understanding of the specific needs and support required for people with disability.
- Advocacy for inclusive policies: This could include policies that address SDoH and disability inclusion.
- Data collection on disability and SDoH: Collect data to create data-driven activity on the impact of social determinants of health, specifically for people with disability. This data could then be used to inform practice and policy, and conduct research to identify effective interventions.
The primary purpose of the Disability Royal Commission was to reduce violence, abuse, neglect and exploitation of people with disability. The more the medical profession understands and addresses the social influences on the lives of people with disability, in clinical practice and systematically, this purpose is more likely to be achieved, and the ethos of the social model of disability can be upheld. This way, holistic health care provision could be further enhanced, which would ultimately improve the health, wellbeing, and lives of people with disability.
Amanda Frier is a dietitian with a PhD on the social determinants of health, and is the manager of CheckUP Australia’s Access for All program. She has a neurological disability so has first-hand understanding of the impact of SDoH on people with disability.
Assistant Professor Dinesh Palipana OAM is a doctor with a spinal cord injury at the Gold Coast University and Beaudesert hospitals, a lawyer, Senior Lecturer at Griffith University, and Assistant Professor at Bond University.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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