In this essay the relation of low income, ill-health and childhood will be evaluated from the inequalities in health point of view. The first part of this essay will provide an overview of income as a one of the main reasons of health inequality. Then it will follow with analysis of income inequality, its related social and behavioural factors, and the role they play in relative poverty. Following this point it will discuss briefly Britain economic development for the past years and its effects in health inequality. Then, using different research data to illustrate how psycho-social factors affect health, a model of income and health through the life-course will be introduced and explained. Thereafter, studies in food purchasing behaviours will be used to evaluate whether unhealthy choices are irrational or situational. After having seen the behavioural side of low income inequalities and health, the essay will move to explain the social conditions that worsen the poorer people health in today’s society.
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The second part of the essay will be centred in the actual policies, frameworks, strategies and plans that the government and the health services are implementing to tackle income and health inequalities. However, as there are so many low income groups and their health problems are various, the essay will focus into children and families living in relative poverty. This decision is based on two factors: firstly the amount of literature found that highlights the importance to break the poverty cycle from birth. And secondly the relevance of the model of income and health explained in the first part of the essay. Initially, the recommendations the government has had for last 20 years will be explained, and the data about child poverty in Britain and Wales will be used to contrast their outcomes. Then the government plans to eradicate child poverty and its possibilities will be discussed, to review the unrealistic goals that were set initially. Following this, the plans of the National Health Service to approach to health inequalities and its social reasons will be viewed. Thereafter, the Welsh government initiatives will be discussed as the government is trying to reduce its child poverty statistics, as they are the highest in Britain. Finally, the essay will look into where the Nursing and Midwifery Council stands when nurses face problems that are not directly related to physical health, and also how the nurses’ role fits in the primary care multi-professional team.
Income and health are closely related. The poorer you are the more likely to have ill-health (Quick and Wilkinson 1991 and Benzeval et al 2001). However, low income and poverty are two different things. Low income is defined as lower than half of the average income (Acheson 1998), but poverty can be split in two types: absolute or relative (UN 1995). In developed countries, such as Britain, the relative poverty is measured by using factors that stops poorer classes sharing the social commodities with upper socioeconomic groups. Absolute poverty in Britain does not exist, as shelter, access to adequate water and food are available to everybody.
Lack of income, limited access to education, poor housing or homelessness are some factors of relative poverty which are directly related to health and social inequality (Barry and Yuill 2003). These authors also write that one of the groups most affected by relative poverty, and therefore more at risk of health inequality, is people in a low income and unemployed.
Despite the economic growth Britain has experienced in last years and although life expectancy and health services have improved, the relation between income and health inequality has broaden. Quick and Wilkinson (1991) point out this relation as a one of the misconception when tackling inequalities. They emphasise that the income distribution is more affluent in health rather than the countries’ wealth itself. Acheson (1998) also found similar figures and compared them in relation to the population with material disadvantages and poor health. Then using Townsend deprivation score he highlighted that there were a higher mortality rate and more self-reported illnesses in the population living in areas with higher scores. It is important to remark that people in higher score areas worked in worse paid jobs or were unemployed. Nevertheless, the Black Report (1977) and the Acheson Report (1998) agreed that this data should be considered carefully as there is not enough evidence to confirm or deny a relationship between the results and the casual relationship between low income and ill-health.
Acheson (1998) explains that income is one of the socio-economic determinants of health, along with education, employment, housing, safety and transport. People in low income groups tend to be less educated and work in unskilled jobs, live in areas with poor housing, reduced green spaces and unsafe. These factors broaden health inequalities. Margolis et al (1992) research showed that infants from lower socio-economic status in U.S.A. were more prone to suffer respiratory illnesses than those from higher statuses. Apparently this was partially attributed to environmentally factors such as smoking parents, housing or bottle feeding. Blow et al (2005) also found that children from low income families were more likely to smoke than those from higher income families. Moreover, if the mothers’ education level was included in the analysis the figures of smoking prevalence increased. In Richardson’s (2001) thematic discussion about smoking uses the level of depravation to show how in the affluent classes smoking has decreased and how in the more deprived areas of Britain smoking habits are prevalent over a period of time, increasing health inequality. These examples illustrate how low income, along with other socio-economic factors leads to a certain behaviours that are linked to the life-course health resources of the individual and his/her mechanisms or capabilities to prevent or cope with ill-health in the present and the future. This is a life-course perspective of health and income. Here Health Capital is the accumulation of physical and social health resources, and Income Potencial is the cumulated education, skills and learnt behaviours for the later working life (Benzeval et al 2000 see appendix 1).
Dobson et al (1994) research data on food purchasing and eating is used by Barry and Yuill (2003) to discuss diet and nutrition behaviours within low income families. They argue that bad choices of food sometimes are a rational response to an irrational situation. For example mothers would shop food that their children would eat, such as crisps or sweets which are known to be unhealthy. Moreover budgeting, which is directly conditioned by income, education and transport (Dibsdall et al 2002), and lack of knowledge about healthy eating were discussed to show how other behaviour factors affected unhealthy diet choices. Acheson (1998) also mention that mothers purchase smaller amounts of food in order to avoid its consumption before it is necessary or it is wasted. He also pointed out that when there is shortage of money the mothers themselves would go by without food leading to a poor nutritional intake affecting their health. This decision appears to be irrational but here again income is conditioning a choice that affects short and long term health.
Certain behaviours do not only come down to be the irrational response to income inequalities and its health related issues. Moreover there are social factors that affect decisions related to psycho-social health. New societies are built with barriers to people that cannot afford the necessary things or to participate in normal social activities (Quick and Wilkinson 1991). For example, not being able to have friends around at home to dine or play with, buying inappropriate cloths or cloths that are an embarrassment to wear, or not having the resources to visit their relatives. Theses social inequalities deteriorate poor people’s relationships and networking, driving them to a life style that might be more prone to stress or deprivation, these factors leads to related psycho-social inducted health problems.
Another social factor affecting the community health is cohesion. Various authors have recalled life expectancy data from the war years in order to highlight how health improved despite the devastating situation (Quick and Wilkinson 1991 or Barry and Yuill 2003). It is thought that during war time a camaraderie feeling emerged and jointly with a more rationalized food supplied provoked an increase in the life expectancy across all classes, being more prominent in lower classes as a result of a more equal distribution of resources. Contradictorily, today’s society is driven by individual achievements, goals and appearance, becoming more fragmented and increasing the health inequalities between poorer and richer individuals. It can be said that societies in which there are feelings of belonging, security, safety and support are more likely to be healthier, despite relative materialistic or economic factors (Wilkinson 1996). This means that egalitarian societies have a better psycho-social health, resulting in happier individuals with a lower stress and deprivation levels.
Social policies, their implementation and the nurse
Following the above discussion where it was said that low income is a persistent issue when analysing health inequalities, two questions have emerged: What does the government do to tackle low income inequalities? and Which role multi-professional health teams have when finding, diagnosing or treating illnesses derived or triggered by this social inequality?
The Black Report (1977) at first found that the Britain nation’s health had improved in general terms but its inequalities between the classes had widened, consequently it recommended setting the following objectives: creation and improvement of policies in relation to childhood, people on a cumulative ill-health and deprivation, and proactive approaches to prevention of ill-health. Later the Acheson Report (1998) found similar results as the Black Report (1977) and recognized poverty as the base of health inequalities. Therefore the report gave recommendations to increase welfare benefits and pensions, to prioritize polices to reduce income inequality for women expecting to give birth, single mothers and young children, and to help to seek advice and information to those unaware of their entitlement to welfare benefits.
Despite all the recommendations encouraged in both reports, statistics still show that Britain has for long time suffered from a high percentage of child poverty. More specifically, the figures showed that in Wales 13% of children live in severe poverty and 19% in households with a low income (Crowley and Winckler 2008). It is obvious that reducing income inequalities in families and children will improve their life-course health and their opportunities to break the circle of poverty.
It is important to see what the British government is doing to improve the situation and whether is doing any good or not. The government has increased benefits for families out of work, it has also increased working tax credits and in-work benefits for families and it has created more employment initiatives. Figures show that the government target is met when increasing parents’ employment status to reduce child poverty. However, there is a tendency to measure low income before housing expenses making difficult to contrast the data between earnings and poverty. The in-work benefits strategy has not taken into account the increasing cost of living, therefore low income families eventually will find themselves in the same situation (Evans and Scarborough 2006). Despite the reduction of child poverty, the government’s target to eliminate it in 2020 looks unrealistic, consequently it is now set to a reduction of 5% or lower in order to become one of the lowest in Europe.
It is also a question about the role of the National Health Service (NHS) when reducing health related issues in low income families. The NHS in 2000 presented “The NHS plan” (Department of Health (DoH) 2000), which actually recognizes the importance of tackling inequalities from birth, using different programs. For example, neonatal and antenatal screening, to promote programs such as “Sure Start” to reduce children poverty (in Wales known as “Cymorth”), and to introduce and support initiatives for a better nutrition through campaigns like giving free fruit in nursery/schools, “five-a-day” and working with the Food Standards Agency. In order to progress towards these changes liaising between agencies, social services and a variety of care professionals is a key factor. Hence there is a need to review the role of the care staff and its traditional structure, as well as the past relations between NHS and social services. These altogether have denied the clients’ right to be treated in a holistic way, which is to solve physical, emotional and psycho-social issues under the same umbrella. For example, in many cases there have been clients lost in the system and never had the standards of care that they are entitle to, which is unacceptable and completely disagrees with the nursing code of practice. A part of the NHS plan is the “one-stop-care” model which is adopted by the NHS in partnership with other local authorities. This model gives children with complex needs and/or long-term health problems a wider assessment of their psycho-social and physical needs. Therefore they receive a better health planning. It also allows more disadvantaged families and their children to have an access specialized treatments locally. It also will try to provide help to youngsters through adulthood, as well as supporting young couples with parenting issues and giving mothers more support and information (DoH (2004) Children’s NSF).
It is also relevant to talk about the Welsh Assembly Government (WAG) plans and policies in relation to these inequalities. The WAG in 2005 proposed its plan to halve child poverty by 2010. Therefore in 2006 it was launched the strategy “A Fair Future for Our Children” which targets were set to reduce child poverty through the improvement and promotion of education, employment and public services (WAG 2006). This strategy partly linked with the ongoing “Communities First” project that had been running since 2001. This project tackles more deprived and disadvantaged communities throughout Wales. “Communities First” aims to address community issues by learning and working in partnership with local authorities and associations. It also has engaged local residents in taking decision, in developing a role in their community, and it has empowered people to change and maintain a better lifestyle (WAG 2007). This social strategy encourages communities become stronger and safer, creating a healthier society for next generations (Wilkinson 1996). The WAG tries to bring these strategies alongside with the health sector by promoting multi-professional team work to avoid gaps in care and to reduce health inequalities in low income population. For example, WAG funds the scheme “Better Advise: Better Health” in primary care. This allows GP’s to refer families with children in need of benefits advice and social services to professional services such as Citizen Advise Bureau. It is important to remark that this initiative is also aimed to everyone.
Finally, the NMC code of practice (2008) acknowledges the duty and responsibility to advocate for the clients, regarding health and social care, information and support. In most of the cases nurses are at the frontline of care in wards and within the primary care multi-professional teams. They know more the patients needs and their daily living activities than other multi-professional team members, therefore picking up earlier signs of ill-health, psycho-social problems or poverty is easier. Observation and problem solving are two essential skills in nursing profession. These are key elements to assess patients’ individual needs and to have a pro-active approach to social and physical health. These skills are easily transferable to work alongside social policies and framework that tackle poverty and social exclusion within the low income groups. For example, as part of a routine assessment or a visit, a nurse can detect indicators of relative poverty in families and children. These indicators might be related to income, childcare, education, unemployment or housing. Once they are found, for example if they are regarding income, the nurse either could give advice to the client about the welfare benefits his/her family is entitled and how to claim them, or refer the client to the social services team (Hoskins and Carter 2000).
The essay has summarised and explained the different social and behavioural factors that influence inequalities in income and its subsequence health problems. It has also discussed a psycho-social perspective of health and income during the live-course. Therefore the importance of learning good health behaviours and coping mechanisms from birth has been explained in order to have a better future health when becoming an adult. In relation to this the essay has also shown the NHS plans to reduce health inequalities by creating more easy reachable services for families and by promoting health campaigns targeting children and youngsters.
Moreover, as it was explained, there are also social factors adhered to ill-health. By reviewing nowadays problems faced by society, the essay discussed the local authorities polices to improve their communities, and highlighted their future repercussion in health improvement.
Through the presentation and analysis of the more relevant reports that have been published in Britain during the last 30 years, the actual social strategies and their implementation in health have been reviewed and analyzed, in order to highlight the importance of partnership between agencies when tackling inequalities.
The last part of the essay has put together the work of different government institutions and their plans to reduce inequalities, in the social and health context. Using this discussion the nurse role has been looked as a part of the multi-professional team, and it is important to conclude that despite social problems might be overlooked as apart of the medical side of nursing, it has been shown through the essay that ill-health is the product of a wide range of factors. As a part of a professional body with a code of practice, nurses should not underestimate or dismiss the implementation of social policies and the liaison within agencies, as it is in their duty to provide the best of care for their patients.
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