Allostatic load: single parents, stress-related health issues, and social care.
I have felt vulnerable and lacking in one way or another. I have often felt powerless to change the situation. (Canadian single parent)
Variations in socioeconomic position that account for a population's overall health may be improved with comprehensive health care and health promotion aimed at individual lifestyle choices and behavior, but this will not equalize those health inequalities over the life course for everyone. The social work profession must invest in social care plans for populations and their stress-related health issues. To truly promote social care within and for a population of vulnerable individuals, social workers must advocate for plans that anticipate stress-related health issues and that precede--not follow--illness. It is essential to view a population, such as single parents, and its health not only with respect to physiologic responses, but also to encapsulate the social conditions and experiences from which these physiologic responses materialize (Allsworth, 2001).
Single parents' lives are composed of social conditions and experiences that can culminate in states of chronic stress. To anticipate and meet single parents' health needs effectively with respect to chronic stress states, an ongoing holistic social care plan is essential. The construct of social care in the social work profession should incorporate the knowledge of a population health perspective (PHP) and the biological framework of allostatic load (AL) to better understand and ameliorate single parents' stress-related health issues. Social care with a focus on alleviating health risks and health conditions over the life course will promote social justice. This article entreats social work practitioners to experience a mental shift in the reconceptualization of social care that includes PHP and AL, try to enhance their understanding of the PHP theoretical and AL biological frameworks, and stimulate further inquiry and investigation of these frameworks.
In this article, I introduce a reconceptualization of social care with five descriptive elements: (1) PHP; (2) stress and coping; (3) allostasis and AL; (4) socioeconomic status (SES), health, and single parents; and (5) social care in a Canadian context. Although this article represents a Canadian perspective on health and social care, the literature that this article draws on is of value to other social workers' understanding of overall health, well-being, and social care for all societies.
POPULATION HEALTH PERSPECTIVE
According to Health Canada (1998), the government department with responsibility for national public health, a PHP is a way of looking at, understanding, and acting on the underlying causes of health and illness. Health Canada stated that the overall goal of a population health approach is to "maintain and improve the health of the entire population and to reduce inequities in health between population groups" (p. 1). According to Singer (2003), health is conceptualized as people's capacity to manage or not manage life's challenges and changes. This definition of health resonates with the idea that every individual should have the capacity to pursue personal growth and goals and acquire skills and education. A global conceptualization of health must include the range of social, economic, and physical environmental factors that contribute to everyone's health.
Although the definition of health continues to evolve, several important attributes of a PHP have been identified. A PHP provides a conceptual framework from which one can identify factors such as stress and coping that influence health, analyze them, and assess their relative importance in determining health. It includes decisions from evidence gathered about multiple health factors and their interactions and their possible contribution to population health. Population health suggests that evidence-based knowledge garnered from research concerning what factors determine health and how is applicable to the social production of health.
Factors and conditions that research has shown to influence health status are collectively known as determinants of health. These determinants do not evolve in isolation but interact in a complex web, mediating and influencing one another. Laing (2004) suggested that there are five basic categories of health determinants: (1) human biology (including risk factors such as age and gender as well as physiological and pathological manifestations such as stress, personality, and blood pressure); (2) lifestyle and behavior (including factors such as coping, diet, exercise, and smoking); (3) society (including factors such as economic issues, support, education, and unemployment); (4) environment (including such factors as food, housing, and water); and (5) health care (including factors such as accessibility [service provision and information services], comprehensiveness [need identification], and universality [efficacy and effectiveness]).
Population health is understandable from these five basic categories and their factors or entry points. All factors are a valid place to begin when considering health and possible interventions for improving health. McEwen and Wingfield (2003) maintained that the use of basic biologic frameworks in human society is necessary to "conceptualize and measure the cumulative impact of socioeconomic status, working and living environments, lifestyle, health-related behaviors and stressful life experiences on physical and mental health in populations" (p. 2). AL represents a basic biologic framework in human society (McEwen & Wingfield).
STRESS AND COPING
The basic biological framework of AL incorporates the concepts of stress (human biology category of health determinants) and coping (lifestyle and behavior category of health determinants). Acute stressors and major life events create vulnerability to illness. Many demands or stressors, both physical (for example, infection, inflammation, or trauma) and psychosocial (for example, humiliation, anxiety, or fear), can create stress in individuals (Allsworth, 2001). Lazarus and Folkman (1984) defined stress as a relationship between a "person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being" (p. 21) and coping as the "constantly changing cognitive and behavioral efforts to manage specific external and internal demands that are appraised as taxing or exceeding the resources of the person" (p. 21).
Stress and coping represent a relationship or state between an internal system and an external response. The body's attempt to maintain a stable internal state, or balance, during the ongoing coping responses to environmental demands placed on it is called homeostasis. The body is constantly adjusting to reach an internal balance. Any stress, mental or somatic, within the environment, such as material deprivation, presents a challenge to homeostasis. Behaviorally, responses to stress include the flight-or-fight response. In people, a behavioral response to stress could involve health-related behaviors such as overeating, alcohol consumption, and smoking.
ALLOSTASIS AND AL
Allostasis was suggested as an alternative to homeostasis when Sterling and Eyer (1988) proposed a new way of thinking about the regulation of physiologic processes in relation to stress and the flight-or-fight response. According to McEwen and Wingfield (2003), allostasis is a process that achieves stability through change (environment and life history change) and that supports homeostasis (stability of physiological systems such as body temperature and glucose levels that maintain life). In other words, the body maintains equilibrium through never-ending alterations in its physiologic processes as it faces various challenges. This equilibrium or allostasis evolves through an intricate relationship between the body and the brain.
In allostasis, stability does not refer to physiologic systems, as it does in homeostasis, but to the adequate functioning of the individual. When the health of an individual is examined, mediators, such as glucocorticosteroids, associated with allostasis have protective effects in the short term but can have damaging effects over longer time frames. If there are many adverse life events, these damaging effects of glucocorticosteroids can then lead to AL.
Some authors (for example, Allsworth, 2001; Crimmins, Johnston, Hayward, & Seeman, 2003; McEwen & Wingfield, 2003; Seeman, McEwen, Rowe, & Singer, 2001) have suggested that the concept of AL is "a measure of the cumulative physiological burden exacted on the body through attempts to adapt to life's demands" (Seeman et al., p. 4770). These demands include responses to chronic stress or to stress-related changes in health behavior. "When the adaptive responses to [physical, environmental, and psychosocial] challenges lie [chronically] outside normal parameters, [biologic] wear and tear on regulatory systems occurs and AL accumulates" (Seeman et al., p. 4770). This physiologic deregulation over the long term predisposes people to conditions such as impaired immunity and obesity.
McEwen (2002) believed that several elements connected to stress hormones are necessary for AL to accumulate. Individual characteristics, such as genetics, previous experience and development, and physical and social conditions, influence the brain and its perception of a stressor and the resultant physiologic response. Perceived stress also affects behavioral responses (flight or fight) and personal behaviors such as eating, smoking, exercise, and sexual behavior. These behavioral responses or coping mechanisms affect the body's physiologic response to challenges in its social, economic, and physical environments. The accumulative AL wear and tear on the body as it tries to adjust to various challenges is irreversible.
AL can result when economic factors such as underemployment or unemployment act as a source of challenge in acquiring basic necessities like food and shelter (McEwen & Wingfield, 2003). High glucocorticosteroid levels can increase the appetite, leading to stress-induced overeating. If a social and economic challenge such as unemployment becomes a chronic condition, then a longer-lasting allostatic state ensues with severely deregulated glucocorticosteroid secretion, a state of persistently elevated food consumption, an increase in insulin resistance, and increased disposition of fat. Sometimes glucocorticosteroid secretion may be permanently increased due to low SES interacting with disability, poor housing and working conditions, noise, and danger from crime (McEwen &Wingfield). Glucocorticosteroid levels are one of the measurable biological parameters within AL.
Empirical evidence (Kubansky, Kawachi, & Sparrow, 1999; Schnorpfeil et al., 2002; Seeman et al., 2001) has supported the concept of AL as a measure of cumulative biological burden in the investigation of health risk over the life course. Further study, particularly studies that pursue longitudinal data on AL measures, is necessary to continue to challenge the traditional approach of using individual biological parameters as indicators of health risk over the life course.
SES, HEALTH, AND SINGLE PARENTS
It has been observed that the higher one's SES, the better one's health (Hayes & Dunn, 1998; MacIntyre, 1997; Marmot &Wilkinson, 1999; Wilkinson, 2005). SES and health point to the productivity and well-being of not only individuals but populations. SES is the most significant risk factor for health and well-being (Syme, 2000).To develop more effective programs to promote health, more attention must be paid to the environmental contexts in which people live, not just to individual lifestyle and behaviors (Syme).
Annandale and Hunt (2000) believed that the concept of SES pulls together several aspects of an individual's life under one umbrella in an attempt to represent a holistic entity. SES thus encapsulates measurable components such as income and skill (education) levels to represent a person's social and economic position or status in society.
Societies involve complex social structures that are mediated through SES. There is much variation between and within populations: People experience great diversity in their lives and work conditions, their access to needed resources, their range of personal choices, their life course challenges, and their physiologic responses to those challenges. Gradients of health along the socioeconomic continuum are connected to a number of risk factors such as age, gender, heredity, marital status, and geography. These risk factors are differentially distributed in societies and may have a cumulative influence on behavioral and physiological AL. Risk behaviors such as smoking, overeating, and consumption of alcohol are intricately linked with risk factors and social conditions.
The relationship between SES and health is implicated in disease in most of the body's systems: digestive, genitourinary, respiratory, circulatory, nervous, blood, and endocrine (Syme, 2000). Chronic stress, which is linked to various biological parameters from SES and other social processes, culminates over time. Abdominal obesity, measured by waist-hip ratio, is a stress-linked parameter orAL and varies with SES (Evans, 2003; Gorin & Lewis, 2004; McEwen & Wingfield, 2003). Brindley and Rolland (1989) suggested that this type of obesity is linked to cardiovascular disease and Type 2 diabetes.
Does stress account for SES effects on health? Several authors (Baum, Garofalo, & Yali, 1999; McEwen, 2002; Raphael, 2002) have suggested that stressful and unstable living and working challenges can accompany low SES. McEwen asserted that if glucocorticosteroid secretion becomes chronically and differentially elevated (that is, an individual experiences chronic stress while coping with material deprivation), along with imbalances in other mediators, poor health outcomes are inevitable.
The literature states that single mothers generally have poorer mental and somatic health than mothers in two-parent families (Byrne et al., 1998; Kahn, Wise, Kennedy, & Kawachi, 2000; Perez & Beaudet, 1999). Peterson and Friel (2001) suggested that single mothers of low SES experience depressive symptoms and feelings of hopelessness and powerlessness. Poor mental health in single-parent families with young children is associated with persistent poverty and is concentrated in populations receiving social assistance (Browne et al., 1997). Poor physical health in single parents of low SES is more prevalent than in single parents of high SES (Artazcoz, Borrel, Benach, Cortes, & Rohlfs, 2004). According to the literature, single parents are more vulnerable to poor health outcomes over the life course than the rest of the population because of income and skill inequities (Lahelma, Arber, Kivela, & Roos, 2002).
SOCIAL CARE IN A CANADIAN CONTEXT
The population of single parents in Canada (more than 1 million) is vulnerable (Kapsalis & Tourigny, 2002). The most pervasive factors for the single-parent population are low income and being female (Phipps, 2003). Kapsalis and Tourigny defined Canadian single parents as those who do not have a partner, live with at least one child younger than age 18, and are the main income recipient of the economic family. Kapsalis and Tourigny stated that in Canada single parents, of which 93 percent are mothers, have the highest incidence of low income of any family type and also the highest rate (68 percent) of receiving social assistance. More than one-quarter million single parents in Canada do not have a grade 12 education, with 70,000 having less than a grade 9 education (Galarneau, 2005).The Toronto Social Services Survey (2003) concluded that Canadian single parents struggle with material deprivation and mental and physical health issues because of complex social and economic needs. According to Sauve (2004), one in three Canadian single parents will experience chronic stress due to economic marginalization and exclusion.
An ongoing holistic social care plan that focuses on health and well-being for all single parents in Canada must incorporate multiple strategies at different intensities and in different combinations to accommodate single parents' diverse needs throughout the fife course ("Testimony of David Butler," 2002). Some single parents may move in and out of poverty; some may experience better health when they work as full-time care providers in the home. Findings from the Toronto Social Services Survey (2003) of single parents on Ontario Works (a social assistance program) found that a social care plan must include services to address client obstacles, provide employment preparation programming, offer job transition and retention supports, and make employment viable.
Examples of services within such a social care plan (Toronto Social Services Survey, 2003) would include the following: overcoming obstacles (access to affordable housing and protected neighborhoods, access to integrated physical and recreational activities, access to counseling for mental health or depression); employment preparation (skills training and development, Canadian work experience opportunities); job transition and retention (food security, affordable and quality day care, transportation, drug coverage of over-the-counter cold and pain remedies, peer mentoring, allowance for work apparel); and viable employment (supportive benefits to include nonstandard jobs such as shift, weekend, or on-call jobs; tax relief for working poor people; wage supplements).
The Single Parent Employment Support Program (SESP, 2002) in Newfoundland and Labrador is an example of a Canadian research initiative that combined mental health counseling, peer support, day care, transportation, allowance for work apparel, skills training and development, work experience, and wage supplements. Single parents who participated in SESP reported improved health and well-being. The SESP initiative suggests that the development of long-term social care plans that focus on alleviating health risks and health conditions can be instrumental in promoting the health and well-being of the single-parent population.
ENHANCING SOCIAL WORK THEORY AND PRACTICE
Both the ecosystem approach (Germain & Gitterman, 1996) and the biopsychosocial perspective (Moniz & Gorin, 2003) are used in the social work profession to understand the interrelationships between people and their physical and social environments. These perspectives provide insights into how individuals interact, grow, and adapt to others and to their environments. These perspectives allow an orientation to practice (social care) that will assist people with adapting to or improving their environments. A PHP and the biological framework of AL have begun to demonstrate their potential to conceptualize and measure the cumulative effect of SES, working and living environments, lifestyle, health-related behaviors, and stressful life experiences on physical and mental health in populations.
Social workers who incorporate the knowledge of PHP and the biological framework of AL into their conceptualization of social care will not only deepen their understanding of individual health but also recognize the crucial link between sociostructural conditions and population health. The health-damaging effects of unequal social and economic conditions (gap between the rich and the poor) are not just limited to single parents but affect the health of all people. Social care can maximize population health, reduce the "health gap," and reduce health inequalities, both specifically and generally through poverty alleviation, inequality reduction, and equity enhancement (other than effectiveness and cost-effectiveness) that would have a major effect on the health outcomes of all citizens (Graham, Fitzmaurice, Bell, & Cairns, 2004).
Both PHP and AL encapsulate a definition of health that states that every individual should have the capacity to pursue personal growth and goals and acquire skills and education. Social care that focuses on enhancing everyone's capacity through alleviation of health risks and health conditions over the life course will promote social justice. Indeed, social justice will prevail when social workers' advocacy results in social care that maximizes everyone's health and well-being.
Original manuscript received September 7, 2004
Final revision received August 1, 2005
Accepted January 10, 2006
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Randy L. Johner, MSW, RSW, is a doctoral candidate and lecturer, Faculty of Social Work, University of Regina, 3737 Wascana Parkway, Regina, Saskatchewan S4S OA2, Canada; e-mail : email@example.com.
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|Author:||Johner, Randy L.|
|Publication:||Health and Social Work|
|Date:||May 1, 2007|
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