1. Social determinants of health are those factors that strongly dictate the health of an individual, they are the social, economic, physical and environmental living conditions that contribute either positively or negatively to an individual’s health outcome (Marmot and Wilkinson, 2006). Inequalities in health outcomes in a country and between countries create health inequities (Baum, 2015). Health inequities are consistent with the socio-economic status (SES), supported by the underlying risks of material, behavioral and psychosocial factors (Baum, 2015). They are built on- and persist through wealth inequalities and are avoidable (Commission on Social Determinants of Health, 2008). There is a linear interrelationship between a person’s SES and health status, Marmot and Wilkinson (2006) suggest that there is a strong link between the health and social gradients. Better health is experienced by those with higher social standing.
2. The film Poor Kids UK, aired by BBC One UK in 2011 follows several children living in poverty. Discussed below is one of the children, a boy named Sam, aged twelve. He lives with his sixteen years old sister, Kayleigh and father in Leicester, United Kingdom. His mother left when Sam was only two years old. His father has been unemployed for a prolonged period, as is approximately a third of the population in that part of Leicester (Poor Kids, 2011). He is existing on an income equivalent to less than $150 per week, with which he needs to feed and dress two children and pay bills. They are frequently without electricity, gas and often go without meals. Sam’s father cannot afford a school uniform, and Sam is forced to wear trousers that are too small and his sister’s school blouses, as a result Sam is bullied at school. Sam and his sister appear acutely aware of their desperate situation and are showing signs of stress and depression, as is the father. The father suffered a non-fatal heart attack (BBC News, 2011). Sam’s sister admitted to attempting suicide in the past.
As discussed in the Solid Facts (Wilkinson and Marmot 2003) poor economic and social circumstances have a detrimental effect on health throughout one’s life. Three social determinants of health impacting on Sam’s health are unemployment, social exclusion and stress. The second and last determinant are a direct result of the first and all are interrelated (Turrell and Kavanagh, 2004). Job security improves the health of an individual and the opposite, poor health, occurs where there is job insecurity. Unemployment causes ill health through mental problems (Wilkinson and Marmot, 2003, p.21). Sam’s father being unemployed is causing anxiety and stress in all family members (Poor Kids, 2016). Poor job prospects, uncertainty about when he will have a job again and the current financial stresses due to being unemployed are an accumulative psychological strain on all. These chronic stressors do not only affect mental health but have a real impact on the physical health of an individual. Prolonged stress can cause unwanted physical conditions, such as high blood pressure, stroke, heart attack, diabetes and infections due to the constant strain on the body’s stress response system. (Wilkinson and Marmot, 2003 p.13). Indeed, Sam’s father did suffer a heart attack, possibly due to prolonged stress.
As mentioned earlier, lack of control over one’s life due to relative poverty, owing to financial uncertainty, is damaging to the health of an individual. Sam’s father cannot afford a new school uniform and Sam has no choice but to wear his sister’s hand-me-downs. Sam is lacking in basic needs (Mack, 2016) and feels stigmatized and socially isolated (Poor Kids, 2016). The social exclusion due to stigmatization and relative poverty (Saunders, 1996) experienced by Sam and 3.6 million children, or one in four living in the United Kingdom (McGuinness, 2016) is especially harmful (Wilkinson and Marmot, 2003). Exclusion from social life and not being treated equally has a long lasting and accumulative effect and increases the risk of premature death (Wilkinson and Marmot, 2003 p.16). With prolonged unemployment, Sam and his family will face continuous exposure to the psychosocial risks, hence accumulating the risk of decreased mental health and physical health and facing increased the risk of premature death (Wilkinson and Marmot, 2013 p.13). It is evident from the above and other research (Marmot of and Wilkinson; 2005, Turell and Kavenagh, 2004; Baum, 2015) that the social determinants of health are all interrelated from upstream factors, through to midstream and downstream factors. Addressing the factors upstream will have the greatest impact.
3. Turrell and Kavanagh’s (2004, p. 392) key policy strategies are actions aimed at reducing the social gradient by means of targeting the three main and interrelated areas as described in their framework of socioeconomic health determinants (Turrell and Kavanagh, 2004 p. 397). Namely, the upstream, midstream and downstream factors, which influence the social determinants (Turrell and Kavanagh (2004).
Upstream factors are at work on a macro level and entail factors such as governmental strategies and policies (1), as well as physical and environmental factors (living and working conditions (2). Midstream factors are the psychosocial factors which influence an individual’s health indirectly. Addressing these factors by empowering communities and individuals to strengthen ties and reduce isolation, will in turn decrease behavioural risk factors that are detrimental to health (3,4,5). Finally, downstream factors or, micro factors, are the physiological systems (6). Addressing these downstream factors requires easily accessible, affordable and available universal health care (Turrells and Kavanagh, 2004, pp.397-398). Medical care is of the utmost importance, however optimum well-being cannot be gained unless the root causes upstream are addressed (Labonté and Schrecker, 2007).
Physiologic systems (downstream) have incurred detrimental stresses due to prolonged poor health behaviour and adverse psychosocial factors (midstream). Ultimately poor outcomes downstream are a consequence of the upstream factors (global forces and governments policies) and the determinants of health inequalities. Although being the hardest to achieve, addressing upstream factors at a macro level (Turrell and Kavanagh, 2004 pp. 392 -396) through assessment of effectiveness of existing policies and introduction of new economic and social policies, will have a widespread effect on the population and is the most effective way of reducing health inequities. Implementing government policies will encourage wealth distribution. The knock-on effect of this will positively adjust both the midstream and downstream factors and ultimately reduce the health inequities in a population. However, some broader factors such as globalization (Global Policy Forum, 2017) and rise of powerful transnational companies (TNCs) can impair national and local policy. It is, therefore, essential that there are in place global (health) policies.
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Briefing to the Minister
Reducing unemployment within a community by improving the economic environment through the support of local commercial investment.
Purpose:
The purpose of this briefing note is to present recommendations for improvement to the economic environment within a community.
Background:
Unemployment causes financial complication and has an almost immediate adverse effect on an individual’s health, it causes physical and psychological problems (Wilkinson and Marmon, 2003) in those affected by unemployment (the individual, spouse, children).
Current situation:
Many studies show that health inequalities in early life translates into increased health risk factors in adulthood (Turrell and Kavanagh, 2004) causing further issues downstream. Using an entry point upstream for the implementation of an intervention strategy has the greatest scope of reducing unemployment within a community and reducing health risk factors later in life. This can only be achieved by the provision of jobs to take people out of poverty (Bell and Rubin, 2007). To have a stable economic environment, a community requires commercial investment which can provide the community with job opportunities. The presence of successful businesses is a protective factor for the health of the community and the individual and will attract further business developments (Bell and Rubin, 2007) shaping a dynamic economic environment, increasing collective wealth (Bell and Rubin, 2007), ultimately leading to a healthier community.
Options:
Earmarking public funds to set up a regional-funding method to boost the local economy and create sustainable jobs, similarly to the UK Government’s Region Growth Fund (Gov.UK, 2012). The fund would leverage input by the private sector in a 5:1 ratio (Gov.UK, 2012). For every five dollars of private investment, the fund would invest one dollar. The RGF in the United Kingdom has successfully attracted numerous projects (Gov.UK) in this manner in North Eastern England and created thousands of jobs (1)
To identify skill shortages and to develop, in collaboration with local stakeholders (midstream) and new and existing businesses, tailored re-training for the unemployed within a community (2).
Recommendation:
Option 1, as it has been proven to be successful in other location.