Assess social determinants of health

Household income matters for child health and has direct and indirect links with children’s outcomes, especially their social and emotional development. Income is related to cognitive development and educational attainment, which has long-term consequences for health inequalities as children grow into adults. Increased household income is also beneficial for adult mental health and wellbeing, in particular in reducing anxiety, stress and depression. Increased income broadens choices for education and employment, with likely further positive impacts on health. (The Scottish Health Observatory - income and employment)

Assessment and understanding of the person with type 1 diabetes’ financial and employment status allows a holistic person-centred approach to support and healthcare provision. It may be of benefit to signpost to welfare rights advisors and other information sources such as travel expenses, for example.

Health literacy means more than being able to access websites, read pamphlets and follow prescribed health-seeking behaviours. It describes the person's ability to critically judge information and use resources to make decisions about their health. By improving people’s access to understandable and trustworthy health information and their capacity to use it effectively, health literacy is critical to both empowering people to make decisions about personal health, and in enabling their engagement in collective health promotion action to address the determinants of health. (WHO - Health Promotion Glossary of Terms, 2021)

It is easy to underestimate people’s health literacy needs. This may be because those needs can be hidden or people are reluctant to admit that they haven’t understood information that has been explained. Everyone can be at risk of poor health literacy and you should not assume a person’s level of health literacy or their level of understanding. (The Health Literacy Place - health literacy techniques)

See the NHS Education for Scotland website The Health Literacy Place for resources, e-learning tools and techniques recommended for good health literacy practice.

• Good work can reduce the risk of premature mortality and morbidity
• Active Labour Market Programmes can improve the mental health of participants
• A large number of working-age people lack paid employment
• Not all work is good for health
• Work is not always a route out of poverty
• Employment opportunities are unevenly distributed
• Working conditions may affect people’s ability to self manage their diabetes; for example, shift patterns, inability to use devices, ability to take breaks and attend clinics and education courses.   

(The Scottish Public Health Observatory - income and employment)

The rising cost of living is causing more people to cut back, skip meals, seek assistance from food banks, and in extreme cases to go without food completely. There is evidence that compromising on food can have significant impact on both physical and mental health. Scottish Government has adopted a human rights approach to tackling food insecurity. The groups most likely to be most impacted by food insecurity are included within its Action Plan which aims to improve the response to financial hardship and reduce the need for emergency food parcels. (Scottish Government)

• People with no recourse to public funds (subject to immigration control)
• Younger people (under 25)
• Disabled people
• Minority ethnic households
• Single adult households
• Households with children
• Tenants
• Low income households

Housing has an important influence on health and wellbeing through several routes, including affordability, quality, fuel poverty and the role of housing as home within a community. Overcrowding is another important aspect of housing quality. Although improvements in housing in the 20th century reduced overcrowding, it remains an issue for many families. A significant proportion of households in Scotland struggle to afford fuel, putting them at risk of experiencing cold and damp housing, or conversely having to make difficult choices between heating and other vital expenditure. This is particularly the case for those with low incomes.

The costs of housing influence where people live, the size and quality of the home that they can afford, and how much money they have left, after housing costs, to support their health and wellbeing. Housing costs can negatively affect mental health through anxiety and stress associated with factors such as rent or mortgage payments or fuel bills. (The Scottish Public Health Observatory - housing)

Aspects of the physical environment that are important to health and wellbeing in 21st century Scotland cover both traditional environmental health issues (such as air, water, pollution) and those related to the social sphere (such as housing, neighbourhoods, safe areas). The benefits and the adverse influences that the environment can have are not fairly distributed across society, and the environment is part of the causal chain of health inequalities. (The Scottish Public Health Observatory - physical environment)

Early childhood development and the school years play a crucial role in determining future health, and are affected by a range of influences including biological factors and social, environmental, and economic conditions. Improvements and reductions in inequality in child development are possible through action across these influences, including health in pregnancy, family income and access to parental leave, early years education and surveillance and targeted intervention for developmental concerns. (Realistic Medicine Doing the right thing: Chief Medical Officer annual report 2022 to 2023)

There is increasing awareness that stressful events occurring in childhood, such as neglect, abuse, or having parents affected by domestic violence or alcohol and drug problems, are associated with lifelong impacts on health and wellbeing.

Adverse childhood experiences (ACEs) occur across the population but are more common among children living in areas of higher deprivation. Poverty itself should be considered a form of childhood adversity given its close association with poorer long-term health, wellbeing, and life opportunities.(Realistic Medicine Doing the right thing: Chief Medical Officer annual report 2022 to 2023: Chapter 7)

In Scotland, national surveys have shown that the prevalence of hazardous, harmful or possibly dependent drinking behaviour was higher among those who reported one or more ACEs than those who reported no ACEs. Those who reported four or more ACEs were significantly more likely to be obese, current smokers and suffer from a limiting long-term condition, any cardiovascular disease and have not met physical activity guidance. (Scottish Health Survey 2019 - volume 1: main report)

By identifying a need in this area, people with type 1 diabetes and ACEs can be referred to psychology services or signposted to welfare rights advisors, housing advisors, social work and family support.

Materials to promote and implement trauma-informed practice from NHS Education for Scotland include a training plan for staff and key trauma training resources from the National Trauma Training Programme to meet the vision of: “A trauma-informed and responsive nation and workforce that is capable of recognising where people are affected by trauma and adversity, is able to respond in ways that prevent further harm and support recovery and can address inequalities and improve life chances.”

How we behave, our relationships, our gender and ethnic group, our education and work, the conditions and communities in which we live, and how we feel about ourselves are all elements of the social environment. These elements overlap and interact with elements of the physical environment to influence our health and impact on how long we live. There are also many links with other health determinants, for example different life circumstances, different population groups, health inequalities and much more.

When people are socially connected and have stable and supportive relationships they are more likely to make healthy choices and to have better mental and physical health outcomes. They are also better able to cope with hard times, stress, anxiety, and depression. (CDC - How Does Social Connectedness Affect Health?)

Social capital is a term used to describe the social connections that provide support (social networks, workplaces etc) and that are beneficial to the quality of life, health, safety, economy and wellbeing of individuals and the neighbourhoods in which they live. Such social connections promote a sense of individual and collective wellbeing as well as strengthening communities, offering a source of support and providing opportunities to meet others.

Loneliness and social isolation are increasingly recognised as significant public health matters with the potential to impact significantly on mental wellbeing. They can affect people of any age and in any circumstances, although key groups identified as being at increased risk include those with poor mental and physical health, those living in poverty, those with disabilities, those from lesbian, gay, bisexual, trans, queer, questioning and ace (LGBT+) or minority ethnic communities, carers and younger adults. (Scottish Health Survey – telephone survey – August/September 2020: main report)

Assessing the degree of social support a person with type 1 diabetes has may help guide the support provided by their healthcare team but also identify opportunities to share local and national networks and peer support from which they may benefit.

There are many things to consider when enabling a person to access health services with ease and equity. These include location, timing, remote or in person attendance, access to digital technology, ability to travel, income and health literacy. A holistic and patient-centred approach must be taken to allow equitable healthcare provision and support.

Healthcare services in Scotland are either accessed equally across social groups despite differences in need, or disproportionately by those whose needs are lower. There are many reasons for this, including:

• people not feeling worthy of using NHS resources
• barriers to getting appointments and accessing services
• loss of trust in services and providers
• cost, time, caring or employment barriers, and
• services being more stretched in areas with greater needs.

While this may suggest a need to target services to geographical areas of deprivation, such approaches can be stigmatising, and not all people affected by inequalities live in these areas. A better alternative is to apply 'proportionate universalism' whereby everyone has access, but with more service provision for populations with greater needs. NHS services can also link patients to other services such as welfare advice to support them with other needs.(Realistic Medicine Doing the right thing: Chief Medical Officer annual report 2022 to 2023: Chapter 3)

The term ‘social prescribing’ is used to describe a variety of approaches that link individuals to resources and services within local communities with the aim of improving mental and physical health and wellbeing. It encapsulates the concept that people’s health can be affected by socioeconomic factors, and that people who have access to social supports within their communities are healthier.

Social prescribing is an approach to help people manage their mental health. It is based on the rationale that supporting people to access and use non-medical sources of support can contribute to improved mental health. Social prescribing can reduce social isolation, increase resilience and confidence, giving individuals an increased sense of purpose and belonging to their communities. (Primary care services - mental health and wellbeing: resources - Social Prescribing Tools) It sits alongside the ‘House of Care’ model which is led by teams of professionals working with patients and their carers in the community, and can be effective in helping people to take more control over their health and to stay well.

Links to social prescribing resources

• ALISS (A Local Information System for Scotland)
• Third Sector Interfaces
• Volunteer Scotland
• National Physical Activity Pathway
• The Collective For Health and Wellbeing
• Health on the Shelf
• Citizens Advice Scotland
• Money Advice
• Befriending Networks
• Scottish Men’s Sheds Association
• Ethnic Minority Resilience Networks

Healthcare professionals may benefit from a poverty training course or reading further information about Adverse Childhood Experiences and trauma.