2d. Social Support and Social Exclusion   

The last set of health determinants I’ll be covering in this module concerns the importance of inclusion, both at the interpersonal level, through a network of caring supportive friends, loved ones, and neighbours, and at the broader societal level.¹

Individual and Community Relationships

Interpersonal connectedness, which is more commonly known as social support, has been shown to be related to health behaviours. This association was first widely observed and reported by the Alameda County study, a longitudinal cohort study of residents of Alameda County, California.² The following figure depicts data from the Alameda County study examining the distribution of four health behaviours (smoking, alcohol abuse, physical inactivity, and poor diet), according to level of connectedness or belonging that people felt with their community. As you can see, the more connected people felt with their community, the lower the probability that they engaged in three or more health-risk behaviours. This relationship was true for both men and women.³ 

Societal Enablers and Barriers

More recently, the concept of connectedness has broadened beyond individual and community relationships to focus on societal enablers and barriers. Social exclusion refers to specific groups being denied the opportunity to fully participate in society. In Canada, Indigenous people, people of colour, recent immigrants, women, and people with disabilities are especially vulnerable to social exclusion.¹

Galabuzi identifies four components of social exclusion:⁴

1. Denial of participation in civil affairs arises from legal sanctions and other institutional mechanisms. Laws and regulations prevent non-status residents or immigrants from full participation in society. Systemic forms of discrimination based on race, gender, ethnicity, or disability status excludes people. For example, New Canadians are frequently unable to practice their professions due to regulations and procedures barring their participation.^{1, 4}
2. Denial of social goods such as health care, education, housing, and language services is common. Groups socially excluded in Canada earn lower incomes and are more likely to lack affordable housing and experience difficulty accessing health and social services.^{1, 4}
3. Exclusion from social production refers to barriers to participation in social and cultural activities (e.g., organized sports). A key barrier is the lack of financial resources to enable involvement.^{1, 4}
4. Economic exclusion is present when individuals cannot access economic resources and opportunities such as participation in paid work.^{1, 4}

The presence of social exclusion and its impact upon health is illustrated dramatically in a mapping exercise using data from the United Way of Greater Toronto and the Institute for Clinical Evaluative Sciences. Figure 2 depicts maps of neighbourhoods in the City of Toronto that detail the varying concentrations of poverty, diabetes, and visible minorities in these neighbourhoods. As you can see, the degree of association among poverty rates, prevalence of diabetes, and concentration of visible minorities is quite remarkable.

 

 

By now, some of you may be feeling a little overwhelmed as to what can be done to promote the health of populations and reduce health inequities arising from the SDH. Well, don’t be discouraged! The next few modules focus on some of the key interventions used by population health practitioners to achieve these goals.