social inclusion & health care...social determinants of health: the solid facts. 2nd ed....

2018-1-EL01-KA202-047907 ©️ Martin Persson & Thomas Nilsen

Social inclusion & Health CareDr. Martin Persson & Mr. Thomas Nilsen


Learning objectives

• What is social exclusion

• What is socially marginalised groups

• Understand the frequency of social exclusion and poverty in Europe

• Explain how social determinants of health in relation to health care functions

• Understand the impact of mental health

• Understand the impact of health literacy


Social Exclusion

• In small groups for 5 minuets discuss what is the definition of social exclusion?


Social Exclusion

The state of disadvantage faced by particular groups who are felt to be removed from

mainstream society, and who cannot fully participate in normal life

Piachaud D, Bennett F, Nazroo J, Popay J. Report of task group 9: socialinclusion and social mobility. In: Task group submission to the marmotreview; 2009. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.472.3665&rep=rep1&type=pdf.


“analysis of social exclusion can broaden the discussion of wellbeing by

considering dimensions beyond income poverty ... Being poor can lead to

exclusion, but exclusion is more than just being poor, it is about participation”

Atkinson AB. Poverty in Europe. Oxford: Wiley-Blackwell; 1998.


Social Exclusion and Poverty

• European Union introduced the terms in the early 1990s in the agenda

• 2010 – the European Year for Combating Poverty and Social Exclusion.

The World Bank. Social Exclusion and the EU’s Social Inclusion Agenda: Paper Prepared for the EU8 Social Inclusion Study The

World Bank. 2007. http://siteresources.worldbank.org/INTECONEVAL/Resources/SocialExclusionReviewDraft.pdf. Accessed 15

Jan 2017.

Peace R. Social exclusion: a concept in need of definition? Soc Policy J N Z. 2001;16:17–36.

Daly M. Social Exclusion as Concept and Policy Tempate in the European Union: Center for European Studies Working Paper

Series #135: Minda de Gunzburg Center for European Studies Harvard University. 2006. https://ces.

fas.harvard.edu/uploads/files/Working-Papers-Archives/CES_WP135.pdf. Accessed 12 Aug 2017.


Social Exclusion and Health

• Social exclusion is often mentioned as one of the social determinants of health.

• Paramount to address this process of exclusion in health care settings, especially for socially marginalised groups

Shaw M, Dorling D, Smith GD. Poverty, social exclusion, and minorities. In: Marmot M, Wilkinson R, editors. Social determinants of health.

2nd ed. Oxford: Oxford University Press; 2005. p. 196–223.

Wilkinson R, Marmot MG, editors. Social determinants of health: the solid facts. 2nd ed. Copenhagen: World Health Organization Regional

Office for Europe; 2003.


Socially marginalised groups

• Who are they? • Talk in pairs for 5 minutes


Socially marginalised groups• people who experience

homelessness

• people who are problem drug users

• people who engage in sex work

• Gypsies and Travellers

• people with disabilities

• people who are unemployed

• people with mental health problems,

• women and children

• older people,

• rural dwellers,

• people leaving institutions

• single parent families

• people who are migrants and refugees

Gill P, MacLeod U, Lester H, Hegenbarth A. Improving Access to Health Care for Gypsies and Travellers, Homeless People and Sex Workers:

Royal College of General Practitioners Clinical Innovation and Research Centre. 2013

Cabinet Office Social Exclusion Task Force & Department of Health. Inclusion Health Evidence Pack: Cabinet Office Social Exclusion Task Force

and Department of Health. 2010.

Department of Health. Inclusion Health: Improving Primary Care for Socially Excluded People: Department of Health. 2010

The World Bank. Social Exclusion and the EU’s Social Inclusion Agenda: Paper Prepared for the EU8 Social Inclusion Study The World Bank.

2007.


What creates the Socially marginalised groups?


How health inequalities arise• poor housing

• unsafe neighbourhoods

• early drop out from school and training

• insecure income

• inadequate financial protection at times of need

• poor service access

• limited employment opportunities

• poor working conditions

• inadequate legal protection against discriminatory practices on the basis of gender, ethnicity and sexuality.

World Health Organization. Evidence and resources to act on health inequities, social determinants and meet

the SDGs. 2019


Estimate the percentage contribution of the following factors to health outcomes:

Clinical care

%?

Individual behaviour

%?

Socioeconomic factors

%?

Physical environment

%?

Health outcomes


https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model?componentType=category&componentId=2

https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model?componentType=category&componentId=2


Social determinants of health in relation to health care


What are they?

• The social determinants of health are the conditions in which people are born, grow, live, work and age.

• These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

http://www.who.int/social_determinants/sdh_definition/en/


Social determinantsIncome and social status – higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.

Education – low education levels are linked with poor health, more stress and lower self-confidence

Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions.World Health Organization. Health in all policies: training manual. 2015: ISBN 978 92 4 150798 1


Social determinantsSocial support networks – greater support from families, friends and communities is linked to better health. Culture –customs and traditions, and the beliefs of the family and community – all affect health.

Genetics – inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking and how we deal with life’s stresses and challenges all affect health.

Health services – access and use of services that prevent and treat disease influence health.

Gender – men and women suffer from different types of diseases at different ages.World Health Organization. Health in all policies: training manual. 2015: ISBN 978 92 4 150798 1


What are they?

• The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

http://www.who.int/social_determinants/sdh_definition/en/


Health inequities are avoidable inequalities in health between groups of people within countries and

between countries.


Outcomes associated with social determinants



the SDGs. 2019


Health disadvantages across generations


the SDGs. 2019


Intergenerational transfer

• a person is born into a family with shorter period educated parents, the possibility to be low educated themselves is 34.2 %

• a person born into a family with longer educated parents, the possibility to be low educated is just 3.4 %


the SDGs. 2019


Some facts• There is a strong association between under five

mortality rate and deprivation and children who live in relative poverty report lower cognitive development scores by age 7.

• In the teenage years lower family affluence is associated with lower health and educational scores among teenagers who report higher feelings of isolation, lower self-esteem, and greater stress levels.


the SDGs. 2019


Some facts• In some countries there is a gap of up to 12 years in

life expectancy between those with the most and those with the least material security (income, housing, and employment) and the mortality gap for men is higher than for women.

• Every year more than 100 000 deaths occur in the WHO European Region as a result of inadequate housing conditions, many of which could be prevented.


the SDGs. 2019

http://www.euro.who.int/__data/assets/pdf_file/0006/367188/eceh-eng.pdf?ua=1

http://www.euro.who.int/__data/assets/pdf_file/0006/367188/eceh-eng.pdf?ua=1


Discuss in pairs

• What questions can you ask to find out if your patient belongs to socially marginalised group?


Variables for Social Determinants of Health • It is important for health care professionals to be

aware of those variables


Socioeconomic status

• Therefore, when health care professionals address the psychological care of an individual with visible differences it is crucial at the same time to collect some basic variables.


Socioeconomic status

• These basic variables should at a minimum include the “big 3”

1. Family income,

2. Parental educational attainment,

3. Parental occupational status


Mental Health & Social determinants

• In pairs – discuss if you think mental health problems are influenced by social determinants• State why or why not?


http://www.euro.who.int/__data/assets/pdf_file/0005/383891/adolescent-mh-fs-eng.pdf?ua=1


Mental health facts• In all countries, most mental health problems are more

prevalent among those who are most deprived.

• Depression and anxiety are more common in the most poor and vulnerable in society.

• Socioeconomic status (SES) impacts on children life satisfaction. Four surveys of over 700,000 children across 14 years consistently finds children with the lowest SES are more likely to be at the bottom of the life satisfaction scale.

http://www.euro.who.int/__data/assets/pdf_file/0004/194107/63wd11e_MentalHealth-3.pdf?ua=1

World Health Organization. Evidence and resources to act on health inequities, social determinants and meet the SDGs. 2019

https://www.unicef-irc.org/publications/pdf/RC13_eng.pdf

http://www.euro.who.int/__data/assets/pdf_file/0004/194107/63wd11e_MentalHealth-3.pdf?ua=1

https://www.unicef-irc.org/publications/pdf/RC13_eng.pdf


World Health Organization. Evidence and resources to act on health inequities, social determinants and meet the SDGs. 2019


Hewlett, E. and V. Moran (2014), Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care,

OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/9789264208445-en.

https://doi.org/10.1787/9789264208445-en


Mental Health & Social determinants

• In pairs – discuss how do you identify and address mental health problems in your current work setting?


EU High Level Group of Experts on Literacy. Executive Summary, September 2012Luxembourg: Publications Office of the European Union. ISBN 978-92-79-25499-4


“Health literacy refers to people’s knowledge, motivation and competence to access, understand, appraise and apply health information in order to make judgments and take decisions about health care, disease prevention and health promotion to maintain or improve quality of life throughout their lives”

Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H (2012). Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health 12(80): 1-13. doi:10.1186/1471-2458-12-80.


“Survey results from Europe and north America show that around half of all patients cannot understand basic health care information, which indicates that health literacy is not simply a minority problem.”

Expert Panel on effective ways of investing in Health (EXPH), Report on Access to Health Services in the European Union, 3 May 2016


Discuss in pairs

• How does health illiteracy influence you work?

• What can you do to help those patients?

social inclusion & health care...social determinants of health: the solid facts. 2nd ed....

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