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Despite the importance of medical care itself, public health is becoming increasingly aware of, and vigilant in addressing, the social and economic conditions that predispose the public to poor health in the first place (Wilkinson, & Marmot, 2003). The identified sensitivity of human health to the broader social environment has given rise to the proposed 10 social determinants of health (SDoH) (AIHW, 2016). These include social gradient, stress, early life, social exclusion, working conditions, unemployment, social support, addiction, food and transport (Wilkinson, & Marmot, 2003). Their importance lies in the potential development of public policy frameworks, targeting each determinant and facilitating the overcoming of socioeconomic barriers to achieve improved health outcomes (AIHW, 2016). Accordingly, the following report aims to outline the influence of two SDoH, stress and addiction, among the young adult (YA) population (18-25 years). The implications of the SDoH on providing care as a physiotherapist will also be discussed and evaluated at both the individual and broader community levels.
Stress is a term encompassing various forms and can stem from multiple aspects of individuals’ lives. It refers to the influence of factors such as perceived demand from an individual’s environment, a response to a threatening situation and external stressors including life events, relationships and work (Bovier et al., 2004). Generally, stress induces long-term health effects, such as constant release of stress hormones, raised heart rate and blood pressure and diverting blood away from many physiological processes vital to health-maintenance (Wilkinson, & Marmot, 2003).
More specifically, YAs have been identified as susceptible and likely to experience stress during the transitionary phase from school to either tertiary education or directly to the workforce (Zunhammer et al., 2014). Pascoe et al. (2019) highlighted that across 77 countries, 66% and 59% of tertiary students reported feeling stressed regarding poor examination results and difficulty of upcoming tests, respectively. This prevalence among university students is especially relevant when considering that 59% of Australian school leavers enrol in tertiary study (ABS, 2019). For the 29% of Australian school leavers entering the workforce, stress also arises as a significant health risk factor (ABS, 2019). Sawang and Newton (2018) interviewed 18 young Australian workers, uncovering that stress emerges in YAs’ working lives most commonly due to perceived incompetence damaging self-esteem, interpersonal conflict and belittlement from older colleagues.
The implications of stress on YAs are vast and significant throughout the social, mental and physical domains of their lives (Sawang & Newton, 2018). Stress is undoubtably associated with mental health; in particular anxiety and depression have proven to be eventual by-products of high stress levels (Pascoe et al., 2019). Accordingly, Pascoe et al. (2019) documented that academic-related stress in university students has led to 35% and 30% of tertiary students experiencing anxiety and depression, respectively. The repercussions of this are clear in the findings that examination performance is hindered in students dealing with stress, anxiety and depression, resulting in a vicious circle as poor results further impact students’ mental health (Pascoe et al., 2019).
From a physical health perspective, research conducted by Zunhammer et al. (2013) reinforced the presence of a spike in stress, anxiety and depression in students surrounding examinations. Alarmingly, students commonly reported stress-related symptoms such as nausea, diarrhea, loss of appetite and gastro-intestinal pain leading up to and during examination periods (Zunhammer et al., 2013). Furthermore, Zunhammer at al., (2013) revealed that students are prone to suffering from insomnia during examination periods, according to the identified half-hour average decrease in daily sleep. The reported decreases in sleep time was attributed to cognitive mechanisms such as hyperarousal and rumination occurring in response to examination stress (Zunhammer at al., 2013). Sexual health is also influenced by stress, as Dimou et al. (2013) discovered that increased levels of stress in YAs strongly correlated with unsafe sexual practices, decreased testosterone levels in males and menstrual cycle disturbances in females.
Clearly, academic and work-related stress serve as threats to the health of YAs, both psychosocially and physically. In response to this, interventions must be sought and implemented to reduce the impact of stress in YAs. For instance, a study examining the relationship between stress and sexual health in YAs involved the administering of twice-daily, evidence-based guided relaxation over a period of eight weeks; proving effective in reducing stress and subsequently improving sexual health (Dimou et al., 2013).
Circumstances involving an individual presenting with cravings, impaired self-control and development of tolerance and withdrawal symptoms, resembles addiction associated with an aspect of their life (Thomée et al., 2011). Addictions commonly arise as they may offer an escape from adversities and external stressors; and are pertinent to the lives and health of many YAs (Wilkinson & Marmot, 2003). The debilitating short and long-term impacts of addiction on quality of life are undeniable, exacerbated by its tendency to overlap, interconnecting various addiction types (Wilkinson & Marmot, 2003).
Mobile phone and social media dependence among YAs is considered a form of addiction, with research identifying corresponding symptoms of withdrawal, separation anxiety and impaired self-control in young Australian adults (Lyvers et al., 2018). Its prevalence is certainly widespread as an estimated 32% of young Australian adults spend at least two hours on social media daily (Lyvers et al., 2018). Additionally, studies have revealed an increasing relationship between mobile phone dependence and level of education as university students displayed greater symptom levels, further proving the prevalence of social media addiction in YAs (Oviedo-Trespalacios et al., 2019).
Furthermore, alcohol consumption has been identified as another widespread addiction carrying significant health implications throughout the YA population (Mewton et al., 2011). McKenzie et al. (2011) reported that 19% of YAs in Australia were diagnosed with an alcohol use disorder (AUD), with approximately 60% of this subset consuming at least five standard drinks, on average, once each week. The predisposition of YAs to alcohol addiction presents itself due to their newfound financial and social independence encountered as they leave school and begin working or studying full-time (McKenzie et al., 2011). Moreover, McKenzie et al., (2011) discovered an association between depression and anxiety experienced as a teenager, and AUD diagnosis as a YA. It was found that AUD prevalence in those who experienced more than two waves of moderate to severe adolescent depression and anxiety symptoms (27%) greatly exceeded those who experienced few symptoms (17%), establishing the crucial link between stress, poor mental health and alcohol addiction (McKenzie et al., 2011).
As a consequence of widespread alcohol and social media addiction, YAs are evidently more susceptible to poor mental and physical health outcomes (Mewton et al., 2011). Mobile phone dependence was shown in multiple studies to both trigger and amplify symptoms of anxiety, depression and insomnia in YAs (Thomée et al., 2011). Similarly, 60% of YAs diagnosed with an AUD were also diagnosed with at least one mental health disorder and 8% reported suicidal thoughts, behaviours or attempts (Mewton et al., 2011). In addition, long-term physical health implications such as cancer, dementia and liver disease, along with the short-term risks including traffic accidents, unsafe sex and violence, substantiate the threat posed by alcohol to YAs (Mewton et al., 2011).
Combined, the works of Lyvers et al., (2018) and Mewton et al., (2011) established a connection between mobile phone and alcohol addictions in YAs as long-term predictors of illicit substance addiction. These findings were attributed to congruencies in the criteria commonly met for each addiction; including rash impulsivity and narcissism, along with the fact that YAs diagnosed with an AUD were 15 times more likely to have an illicit drug addiction (Lyvers et al., 2018; Mewton et al., 2011). Accordingly, it is absolutely pivotal that health professionals consider interventions combatting impulsive behaviour, anxiety and depression during adolescence in order to prevent mobile phone, alcohol and drug addictions in YAs (Lyvers et al., 2018).
The SDoH are embedded in health promotion strategies as they directly influence the prevalence of health inequity; the avoidable, systemic differences in health status across socioeconomic groups (Paz, 2012). Health promotion is a concept unpinning the Ottawa Charter, a framework encompassing the advocation, enablement and mediation of people to gain control over the improvement of their health (Fry & Zask, 2017). It aims to achieve this across five key action areas; developing personal skills, strengthening community action, creating supportive environments, building healthy public policy and reorientating health services (Fry & Zask, 2017). In doing so, the Ottawa Charter widens the scope of public health beyond individual behaviours and risk factors to also consider the socioeconomic factors influencing health outcomes across populations (Fish & Moffatt, 2014). Accordingly, physiotherapists are able to effectively ensure positive health outcomes across populations by utilising health promotion strategies, as outlined by the Ottawa Charter, at both individual and community levels.
The Ottawa Charter describes downstream health promotion strategies as those that target the immediate health needs of individuals, while seeking to increase equitable access to health and social services (Fish & Moffatt, 2014). This constitutes the basis of physiotherapy, involving the use of physical approaches that aim to restore, maintain and promote physical, social and psychological well-being (Boakye et al., 2018). As a physiotherapist, it is imperative to investigate the socioeconomic factors contributing to patients’ health outcomes in order to ensure that the treatment, as well as implemented maintenance and prevention strategies, are suitable and sustainable (Bezner, 2015).
Developing personal skills and reorientating health services are two key action areas, as addressed by the Ottawa Charter, applicable to physiotherapists when considering SDoH in their provision of care (Fry & Zask, 2017). For example, a patient’s unemployment status may be attributed to an injury sustained due to suboptimal working conditions, such as strenuous manual labour or extensive sedentary periods (Yasobant & Mohanty, 2017). A physiotherapist can then intervene using rehabilitation to return the individual to work and implement prevention strategies addressing the original cause. Furthermore, the implementation of home physiotherapy services can eliminate the barrier often posed by transport and social gradient to individuals who are logistically or financially unable to travel to a primary health care setting (Paz, 2012). On another note, compliance to physiotherapy treatment and rehabilitation is largely determined by an individual’s exposure to social support. If a lack of social support for an individual is identified, motivational interviewing can be employed by physiotherapists to increase a patient’s motivation to improve health behaviours (Bezner, 2015).
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- Samuel Lehmann (Author), 2020, Social Determinants of Health Impacting Young Adults aged 18 to 25. Stress and Addiction, Munich, GRIN Verlag, https://www.grin.com/document/903760