Social Determinants of Health
Health inequality is a well-documented global issue requiring collaboration among government and nongovernment entities to improve human living conditions, early childhood education, and employment opportunities that create upward mobility for people living in poverty. Families living in poverty often live in overcrowded housing and have high levels of stress, substance misuse, and domestic violence. Reducing or eliminating social inequalities can improve global health.
A health determinant is based on five factors that include biology or genetics, behaviors, social and physical environments, and health services. Biology or genetics cannot be altered; however, the remaining four factors are pertinent to improve the health status of humanity. The relationship between the social determinants of health and health determinants is widely recognized. Therefore, improving health must focus on resolving social and personal responsibility.
Categories of Homeless People
Children and Adolescents
Runaway or throwaway children and adolescents enter the foster-care system that is riddled with chronic and complex issues focused on funding, legal matters, inappropriate placement, and insufficient case management. Many of these children leave the foster-care system and become homeless. More than 3 million children were placed in protective services in 2001, and more than 900,000 were victims of abuse. Young people are vulnerable and easily persuaded to use drugs and are led into prostitution by pimps and drug dealers who may physically or sexually assault the homeless youth. Homeless youth develop a deep-rooted mistrust of adults and society, are resistant to change, and are at risk for early morbidity and mortality. The complexity of living with trauma can cause young people to become depressed, angry, or aggressive because of frequent encounters with the legal system. About 5000 young people (10–24 years of age) living on the streets die from suicide (13%) or homicide (16%).
Pregnant female adolescents present a different constellation of risk factors. They may suffer with poor nutrition, stress, depression, and substance misuse, which result in 35% to 70% of miscarriages. The infant may or may not have a relationship with his or her mother, which can have lifelong implications. A study of young homeless mothers found that only half of the mothers were able to help with caring for their children, and up to one fifth of the mothers never see their children because of mental health concerns.
Single homeless adults who have experienced foster care, unstable parenting, housing, or a lack of support enter adulthood without housing. Many are undereducated and live with mental illness and or substance misuse. The primary cause for homelessness in single adults is related to misusing substances, which often brings them in contact with the legal system. Arrests, incarceration, and a history of felony charges often prevent them from accessing public housing.
Social inequality perpetuates the cycle of poverty and homelessness that causes chaotic family living, stress, depression, substance misuse, unemployment, and indifference to improving their health. The cost of health care is a financial burden for families with lower incomes because they are uninsured or underinsured. Uninsured and underinsured families delay seeking health care because of high out-of-pocket expenditures. Rural families and individuals seeking financial, physical, or emotional stability are moving to inner cities or urban life in the hope of improving their lifestyle. However, transitioning to urban living may cause a family to move in with other family members, known as doubling up. Doubling up creates a different set of health risk factors, including stress, alcohol, tobacco, illicit drug use, and physical, emotional, or sexual abuse. Strengthening and empowering parenting skills can be supportive to encourage and nurture all members of the family, as well as prevent homelessness.
Patient and Family Assessment
Therapeutic communication is vital to develop a trusting relationship with a homeless patient or family because of society and health care professionals’ attitudes toward mentally ill and homeless people. Motivational interviewing helps identify the needs and desires of the patient and helps to identify the stage of readiness to change health behaviors. Providers allowing patients to share their stories can explore the history of homelessness, victimization, education, and work history. Patients’ freely expressing their thoughts and feeling helps to identify intellectual disabilities, developmental delays, and concerns with cognition. Moreover, determining the cultural or ethnic background is vital because of differences in perception of health and recognizing differences in metabolism.
Homeless people suffer a variety of acute and chronic illnesses that require medications and treatments; however, their lack insurance or money does not allow adherence to treatment plans. Furthermore, their health status is dependent on living conditions, consumption of food and water, and sexual behaviors. Screening for communicable (tuberculosis, sexually transmitted infections) and noncommunicable (obesity, heart disease, diabetes) disease is vital while the patient is in the clinic because of transportation issues around getting to the clinic.
Living on the streets or in a shelter requires homeless people to be vigilant about their personal safety and securing their belongings. Consequently, many homeless people are sleep deprived because of fear of being victimized. Sleep deprivation, stress, and loss of family or community support lead to depression, and with a lack of coping strategies, people may turn to alcohol or street drugs to cope with their stressors.
Data collected in the health assessment require the physician assistant to apply critical thinking regarding the physical examination and the plan of care. For example, will the physical examination be a head-to-toe examination that is clothed versus unclothed? How will the patient manage his or her health issue while living on the street without money or insurance to pay for additional treatments or medications? Does the patient indicate a readiness to take action toward improving his or her health status?
John and Suzie were happily married with two boys, 9 and 11 years of age. One afternoon, John’s employer said his son-in-law would replace John as the groundskeeper. John began to drink more heavily since the loss of his job. The loss of income was a challenge for the family to keep up with their living expenses. Eight months later, John was diagnosed with esophageal cancer. The loss of John’s income and health insurance created a burden caused by out-of-pocket expenses from their savings. The family moved in with John’s parents, who had a smaller house in a low-income neighborhood, and Suzie found a part-time job.
After John’s surgery, Suzie arranged for home health care instead of a lengthy stay in the hospital. Suzie’s long hours of caring for John began to present problems with parenting. John’s cancer returned within 18 months of surgery and treatment. Suzie was unable to keep up with her job and caring for John around the clock. Exhaustion prevented much interaction with her sons, who were depressed and angry. John’s parents added tension between Suzie and John because they both began to drink heavily. One day, the oldest son came home from school 4 hours late. Enraged, Suzie beat him with a broom while the youngest son and grandparents watched. The grandfather condemned the boy for upsetting his mother. The next morning, both boys were gone. Suzie notified the police, but the boys were not found. A month later, Suzie quit her job to care for John. Without an income or insurance, John’s parents asked them to move out. Suzie refused to move out of the house. After John’s death, Suzie was forced to move out and had did not have a place to live. Presently, the two boys have been placed in a juvenile detention center because of theft of property.
What social determinants might have influenced the family?
What did health care providers overlook when caring for John and his family?
Identify primary, secondary, and tertiary psychosocial and medical interventions to help each family member.
How could health care empower and strengthen the family unit?