Conceptualising, understanding and developing practices in relation to social determinants
Our discussions with the PHC workers suggest that the term “social determinants” incorporates a heterogeneous group of factors that differ in terms of scale (global, national, regional, local), the extent to which they are contested and the extent to which PHC services can respond directly to address them. Acting on these complexities requires reflection from the workers and managers in regard to how their own work practices are able to take account of and, in some cases, act to mitigate the impact of these determinants. Practice was shaped significantly by the context of the organisation and the broader health system. These organisational environments, in the main, operated to restrict the agency of workers with respect to SDH; below we examine their accounts within this context.
Understanding
Respondents discussed how they understood SDH and the impact they perceived them having on the populations they worked with. Most responses indicated that they recognised the importance of SDH as shown by this comment:
… and the structures that support health and wellbeing. Whether that is safe roads, safe environments, no disadvantage, no great pockets of poverty so that people do have access to a good quality education system and all the stuff that is supportive of good health. (Regional Health Executive)
Often the workers linked statements about SDH to their detailed understanding of the community in which they worked as this nurse noted:
Well what we know of course in this specific area is we’re one of the lowest socio economic areas in Australia, let alone in South Australia, and so we are aware transport, lack of cars, funding is a huge thing. We’re on the fourth generation of unemployment. (Nurse, Service A)
Most statements about SDH were cast in light of the heavy burden of disadvantage experienced in the communities served. This was most acute in the Aboriginal services.
Our clients have multiple issues. It could be financial, it could be housing, education, and all that can contribute to bad health in ways where if you don’t have a proper income, you're not getting proper food. I mean just not being educated, you're not going to know how to read signs, maybe not go into services because you can't even talk to the receptionist. (Worker, Service D)
Most staff at all the services were aware that problems with SDH translates into illnesses and so the populations they serve have a high burden of illness;
We’ve just got the highest social determinants of ill health … And I guess our contribution is seeing people that don’t necessarily access other services. Each client we see has got multiple illnesses, from younger people to old people, who just really show a burden of ill health from early age to later age. (Medical Officer, Service B)
Workers showed a clear understanding of the limits that adverse social conditions placed on the ability of the people they worked with:
People will say “I’m skipping meals because I’ve run out of money” or “I’m eating the cheap sausages because they’re cheap rather than having a piece of steak”, stuff like that. So a real connection to their money and the kind of food you eat. Also lots of clients are female and they have young children and so their children come first. So they’ll say “Yeah I buy all this fruit at the beginning of the week and my children eat it, which I want them to do and so I won’t eat the fruit” (Lifestyle Advisor, Service A)
Through these comments workers were clearly indicating the limited agency their clients were able to exert in the face of the structural constraints of unemployment and poverty, including the last comment from a worker whose main remit was to promote healthy behaviours. They provide very explicit pictures of the ways in which a life lived in poverty makes it hard to make healthy choices. The material circumstances of life were also linked to mental health as in this example:
Housing is a major issue. Often you can’t start unlocking the client’s depression if the home environment is not - and the social determinants of health is a really big issue in that respect, it’s just massive. (Manager, Congress)
A minority of staff, typically younger and less experienced showed less awareness of the work of their service in responding to SDH. For example:
There is work that’s being done here, not particularly with me but I don’t quite know the extent of that. But I know the counsellors and the social workers have roles to find people housing and help people with those sorts of things; writing letters for people, but I don’t know the extent of those things. (Worker, Service A)
Most of the staff showed a good understanding of the ways in which SDH affected the communities they worked with and saw that they made their work more complicated and challenging. The interviews suggested the staff were generally reflexive about the social and economic constraints on people’s lives and the impact that these constraints have on their health and also on the ability of PHC services to fully respond to the issues people have to deal with.
Developing practices to respond to SDH
Respondents commonly emphasised using a holistic approach in which the circumstances of people’s lives were central to how they were treated by the services.
We don’t just look at the medical model, we look at the whole person. Not just their medical problems, but social, economical, environmental, all those things that affect people, like education, income. So we don’t just focus on one little thing, we try and just see the whole person and the whole picture, not just a small part of it. (Aboriginal Health Worker, Congress)
A similar picture was presented by a member of SHine SA:
I think if you went and talked to someone in our clinic out at [suburb], then they would be saying holistically there are a whole lot more problems, issues, when they see a client. Other things impact a whole lot more on their sexual health and their general health, like their drug and alcohol use, or their homelessness, or being in prison when we run the clinic at the prison (Nurse, SHine SA)
Some also noted that adverse social determinants can make intervention very difficult:
You can’t do therapeutic counselling with someone who has no home or has got the bills piled up and can’t pay the bills. (Counsellor, Service C)
For others it was about constantly keeping in mind the limitations people faced in their lives and, where possible, linking them in to services that may help them:
So while it might not be that we’re actively involved necessarily in being able to influence those social determinants of health directly ourselves, often it is about linking people in with services who could assist them with that and then working with those services. (Psychologist, Service C)
All of the services offered group activities. These included groups for people with a particular illness such as diabetes or depression, those defined by a social issue such as domestic violence, or with risk factors such as exercise or eating behaviours. These groups were generally designed with an appreciation of the limits people have on their lives and in some cases challenged social stereotypes as this nurse noted:
The Dads’ group looks at social change about the role of the father. It encourages fathers to fight against the stereotypes of what is a father, and to encourage [them] to be more involved. (Nurse, Service C)
Another example is the statewide program Community Foodies[52] which involves local residents in a peer education and support program to promote healthy eating based on a longstanding concern with access to low cost, healthy food.
More than a place to deliver services
The services were more than a place in which health professionals see individuals. They were also conceived of as community spaces and, to a varying degree among the services, places which were also the site of community action. This openness to community also signifies an understanding of the importance of community connectedness as itself a SDH. The importance of space has been noted in a previous study of community health centres [53] which noted how space can “permeate into social relationships, experiences of health and identity and connections to a sense of community” (p. 1874). This appears to remain true in our study sites. This was shown most forcefully in the case of a men’s service within Congress which was seen as a safe and welcoming space and one which could provide social support:
So you can come in and have a yarn with your mates and have a shower and wash your clothes, just chill out for a while. A lot of men actually like to come in here because they said there’s no humbug here. So if they’re living in an area where there’s lots of drinking, they can’t sleep and that sort of stuff so it’s just a hassle free place. We don’t get in anyone’s face and they just come and take it easy and do what you have to do. (Manager, Congress)
This manager highlights the importance of making the men feel comfortable as a first step to them using PHC services. SHine SA were also aware of the importance of creating a welcoming space which could be used for community activities:
The office at [suburb], for example, has a resource library and coffee and internet café. So the view is, it’s a drop in centre. And also if consumer groups, community groups want to use the premises for other meetings and things like that, all of those offices are available to that. (Board member, SHine SA)
Service C reached out to people with mental illness who lived in local boarding houses by creating a community garden, which encouraged these clients to feel comfortable with the service and see the staff as approachable as well as a place where people could form friendships and networks:
It is such a great way to get people involved in something and essentially they are contributing to something that they see changes over time - growing plants and vegetables. But they are also socialising, they are also interacting with health professionals, like myself. (Worker, Service C)
Service D used their centre to hold lunches, which once again enabled people to make social connections and become familiar with services, as one of their workers explained:
…. It’s an opportunity for us to promote our health professionals in this area as well so that the community can put faces to names…. So Housing comes down here so they can put a face to their names or their workers there, all the other non-government organisations come down (Aboriginal Health Worker, Service D)
These examples indicate how PHC service staff see their role as going beyond the provision of services to one in which they create welcoming spaces in which people feel comfortable and provide opportunities for social connection, itself an important SDH and link them to other (non-health) services and programs. In this way they were increasing opportunities for clients to use services and especially clients who faced barriers to using services for cultural, gendered or other social reasons.
Advocating for access to services
Staff described how they were able to act as advocates for individuals and assist them in gaining access to housing, social security benefits, legal advice, or helping women to leave violent situation. For Service D the support role reflected the history of violent situations distrust between Aboriginal people and state organisations and was expressed by a worker who saw their role as “advocating and supporting clients and building relationships to break down barriers such as distrust of government services.” A worker at Congress noted the importance of advocacy to other services for their clients when they said:
A lot of the work that we do relies on the relationships we have with other agencies. If we have good relationships with them then we often are then able to shape the way that our clients and families can access the services that they’ve got. (Social Worker, Congress)
PHC services were playing a crucial role in joining up the services that are available but which for a range of cultural, social and other reasons were hard for people to access.
Advocates for policy change
The PHC services advocated for policy change relating to SDH. The most striking examples uncovered in our study were from the two services with independent boards of management. Congress reported a campaign to increase the unit price of alcohol so that very cheap liquor was unavailable. There had been some success in this and staff reported that there had been a reduction in violent assaults and homicides as a result [54]. Most of their advocacy effort was through a People’s Alcohol Action Coalition with one of Congress’ medical practitioners often acting as a media spokesperson. Congress was also involved in advocacy on achieving suitable and affordable housing for Aboriginal people in Alice Springs where many live in “town camps” with inadequate housing and infrastructure. Congress also advocated to the Federal government for comprehensive PHC and the need for Aboriginal controlled health services, to maintain a focus on health promotion and disease prevention including work on SDH. The overall pattern of advocacy at Congress was described by one of the managers:
[Advocacy] means that we’re getting the policy environment focused on what we are saying is going to work for Aboriginal people. So it’s about using our capacity and our ability to shape the way in which government decides around health policy or education, any of the health systems, and anything to do with broader social determinants. (Manager, Congress)
SHine SA also has a clear commitment to advocacy and directly sees this work linked to SDH issues as explained by a manager:
SHine does a lot of trying to convince other organisations at a national level that we need a national sexual health strategy. We need to do some work around what are the costs of continuing with no intervention around unplanned teenage pregnancy … the cost is actually to those young women who have low levels of health literacy, access to services, who probably have been a child of a single parent who hasn’t worked for 25 years. I mean that’s the social determinant stuff that we need to address. That’s the only way we will change some of the issues. (Manager, SHine SA)
The organisation had been involved in a high profile campaign to deliver a well-researched sexual health program in schools, which was based on training teachers to teach issues of sexuality and respectful relationships which are important SDH [55]. Opposition from some politicians and religious figures meant the program has often been in the news and staff from the centre had been vocal defenders of the program and its benefits to the health of young people [55]. A further example of advocacy was that the organisation lobbied members of parliament when a bill was proposed that would have raised the age at which young people could access medical treatment without their parents’ consent.
Our study also indicated that PHC workers face barriers in undertaking advocacy. Most significantly, the state-managed services noted the conflict between advocacy and their role as public servants. As a worker at Service B noted:
If we were advocating for community against something that the government had decided, well then that wouldn’t go down too well. (PHC Worker, Service B)
Time was noted as a further constraint and especially in terms of the high demand and long waiting lists for services to individuals. Policy advocacy was seen to result from community development work and the state managed services noted that whereas their services had employed several such workers in the past, these positions were being replaced by roles that concerned direct services to individuals. As one worker at Service A said that “limits the advocacy with community that we can do”. The best examples of advocacy we found came from the NGOs in our study and the notion that advocacy was a more acceptable activity for them was borne out by one worker at Service C who noted that when she had previously worked in an NGO advocacy was encouraged and her role had more flexibility and support for community and advocacy work.
Limits to action
While staff generally showed a considerable awareness of SDH and were able to point to the action they undertook, they also were aware of the limitations on their ability to take action. These limitations were partly about the limited extent of any health sector response to SDH and partly about the constraints placed on action by particular policies or practices within the health sector. The former point was made by a number of respondents and articulated by one of the staff at Service C:
I don’t know that we do a huge lot on the social determinants of health. I think we’re looking at symptoms, more than causes actually. It’s probably on a higher level than we are, like having someone at the top in health speaking to somebody at the top of transport and speaking to somebody at the top of housing … I think that’s probably a higher kind of level than I’m ever likely to operate at. (Worker, Service C)
This worker was alluding to the South Australian initiative on Health in All Policies which has been adopted since 2007 [56]. This initiative has been driven by the Public Health Division of the State health department and does not work with the PHC services. Views on the limits placed on action on SDH within the health sector reflect the politics of the health sector at the time of our study. The PHC services that were funded and managed by the State government had undergone significant reorganisation over the five years preceding the research. This reorganisation had seen a shift from separate boards of management (and independent voice) to direct management through regional health structures. This was perceived to have come with a shift in the policy priorities in health so that there was less emphasis on a broad range of social health issues and much more emphasis on chronic disease management and prevention using behavioural models. A regional manager articulated this shift as a concern:
We would actually be focusing more broadly on social determinants and a more integrated whole of life approach rather than what we are having to do at the moment which is pulling back very much to chronic disease. (Regional Health Executive)
The impact of the tighter focus in departmental priorities was noted by a number of respondents including this one:
I think at the moment we’re becoming more clinically focused because of what the department requires, and so our ability to do that kind of social action, really grassroots community development is very limited (PHC Worker, Service B)
Some staff indicated unhappiness about the shift in priorities. The more selective approaches were reported as giving little room to respond to broader social determinants. As one regional manager noted:
I mean, part of the health reform is to address the demand, hospital demand, basically. And so I think that that driving factor around chronic disease and hospital avoidance has really been a major focus, which means that we’ve not kept our eye on the ball of that broader context… (Regional Health Executive)
This picture of service priorities for government managed services is strikingly different to that of the 1990s [57] when South Australian PHC services aimed, in addition to providing treatment to individuals, to “also reach out to change their social, political and economic environments'' (p. 162) as a means of improving the health and wellbeing of that community. Congress managers reported that health programs funded by the Commonwealth government were often vertical programs and that they were constantly having to adapt their more comprehensive orientation to these funding requirements:
As a comprehensive primary health care service we think that what they should be doing is funding comprehensive primary health care rather than vertical programs. … And the way that the government is rolling out the large investment at the moment is pretty much in vertical programs (Medical Officer, Congress)
The result of this shift in priorities meant that the idea of a comprehensive approach to PHC had moved from one that was broadly accepted by the health department to one where the workers advocating for the approach felt unsupported and unable to do community development work that had once been acceptable. Thus the changing policy environment had created a dilemmatic space which many of the workers found hard to navigate.
A further crucial factor which mitigated against the services undertaking action on SDH was the balance reported by respondents between concentrating on peoples’ immediate need as opposed to taking action on underlying determinants. Immediate clinical needs usually won out. The dilemma and the stress caused by this tension was well summarised by one manager:
I think we’ve got to try and get a balance within our clinical services around how do we just get ourselves out of the treatment regime? This is stuff that I agonise about continuously. How do we get a balance? How do we take that preventative approach? We’re still seeing people who come through our services that have scabies. We’ve got to be able to have the capacity and the vision I think to go and work at a preventative level because it’s total preventable. 80% of what we see is totally preventable. How do you get the balance between that, knowing that, and moving beyond just clinical treatment? (Manager, Congress)
Another factor that respondents were very much aware of was that, while there were some limited actions that the services could take to address SDH, they were quite powerless in the face of many of the broader determinants apart from being able to become advocates. Thus one worker noted:
I think a lot of that happens where we try and be part of networks or projects that try and advocate for that change, but often in the grand scheme of things we have very little control over those things (PHC Worker, Service B)
In a similar vein one of the SHine SA workers noted
And it just appals me that we go on concentrating on diseases when we’ve got Big Mac on every corner. It’s such a powerful lobby and nobody tackles that. We’ve spent the last probably 40 years recognising and beginning to fight the cigarettes lobby and it’s just sad that when we talk about community health, we don’t talk about where the food is and who’s getting it and why it’s actually cheaper to go to McDonalds. (Worker, SHine SA)
The sense of impotence in the face of often overwhelmingly difficult social circumstances was a common theme in the Congress interviews with the following comment typical:
One of the things that makes my heart sink is to see some of these clients who are young, intelligent, have so much potential and drive themselves, and so much inner strength, and yet are in such awful social circumstances from pressures within their families, or lack of housing, or lack of educational opportunity, that are absolutely trapped (Medical Officer, Congress)