How Might Socioeconomic Factors Hinder Patients In Implementing Medical Guidance And Reducing Lifestyle Risks?

Implementing medical guidance should be a primary factor in reducing lifestyle risks. When this is prevented due to patients not receiving the guidance or not wanting to implement it into their lives as they don’t believe it is worth it, there become problems later in life for patients. Educational achievement especially in literacy, debt and family context are all socioeconomic factors which I will discuss in this essay, with several life style risks also being address. These risks primarily are alcohol consumption and child obesity along with others.

Socioeconomic status (SES) is a large factor in the health outcomes of an individual as a consequence of alcohol consumption, which is a large lifestyle risk factor for many. The reasons for this discrepancy between higher SES individuals and lower SES individuals are complex and not linked to the amount of alcohol consumed. In many studies higher SES individuals consumed more or similar quantities of alcohol compared to their lower SES counterparts. However individuals from of a lower SES still faced disproportionately more health problems. These findings also linked negative health outcomes, particularly within lower SES groups, with other factors such as racial and ethnic minorities and homeless individuals. (Ref. 1)

The literature on the health impacts of alcohol is vast, with serious short and long term impacts of alcohol consumption. Short term primary effects of acute intoxication include decreased reaction time, perception and motor skills. These have secondary short term effects which include increased risk for traffic accidents, suicide, falls, drowning, and interpersonal violence. The long term effects can include medical conditions such as cancer, CV disease and liver cirrhosis, alongside serious psychiatric disorders like depression and alcohol use disorder (AUD). (Ref. 2) Therefore if there is any socioeconomic impact on alcohol consumption which may cause these health impacts, it would be serious.

There are many different elements of SES, for this essay I am including educational level, income/economic factors, employment status, and housing status, with the alcohol related outcomes are each of these factors.

Impact of low educational achievement - Study based evidence

Specifically when looking at lower educational achievement, especially in men, there is an increased risk of reporting negative alcohol consequences. This seems to regardless of drinking quantities and drinking patterns (Ref. 3). One reason for this increased reporting of negative consequences may be due to the increased exposure of these lower SES individuals to chronic stress which can accumulate over their life time (Ref. 4). This increased stress may be a risk factors for substance abuse and addition (Ref. 5). These substance addictions could come in the form of alcohol addition but may also take the form of other recreational drugs, which would have negative health outcomes. This may explain one reason why individuals with the same alcohol consumption may have differing outcomes, as some of these outcomes are actually secondary effects of alcohol due to increased rates of drug addiction.

The results show the link between worse health outcomes for lower SES individuals is greater in lower income countries (Ref. 3), especially for men in these lower income countries. There are several different factors which may cause this, but one would be that there may be less financial support to allow them to access health care in lower income countries (Ref. 6). So for any health consequence they may have, they are more unlikely to see a health care professional about it. So therefore rather than seeing a health care professional about a health problem they may have, they leave it until it becomes a more serious and potentially less treatable illness. In contrast those of a higher educational attainment SES may have the same health problems as a result of alcohol but may have the financial means to see a health care professional who can treat this illness before it becomes more serious, resulting in better long term health for these individuals.

Specific to lower educational achievement, there may be a reduction in the ability to understand health messaging or guidance related to alcohol. This may lead them to have a poorer use of health care services (Ref. 7) and if they are unable to understand medical guidance they will not be able to implement it into their lives.

Impact of debt - Study based evidence

There is a clear association between personal and unsecured debt and health outcomes for individuals. (Ref. 8) Some of these health outcomes include mental health disorders, suicide attempts or completion, problem drinking and drug dependence. This clearly suggests there is a link between people with a lower SES having increased lifestyle risk factors related specifically to alcohol. So this may differ from some of the other studies which concluded in many situations alcohol consumption is higher or comparative in higher SES individuals. This difference can be explained due to the unrepresentative data used, as this study only focuses on individuals who have personal unsecured debt, not just anyone in with a lower SES.

One reason debt may lead to these negative health outcomes is due to the increased stress placed on households who are in debt (Ref. 10). They may no longer have the security of knowledge that they will be able to feed their children next month or pay the bills for heating or other essentials.

Impact of increasing drinking trajectory - Study based evidence

There are studies which conclude that among Finnish men and women those with a steady high or increasing drinking trajectory were at an increased risk of experiencing health and economic disadvantages. This is concerning as it would suggest a downward spiral caused initially by the consumption of alcohol and ends with these individuals in a worse economic situation which we understand increases the chance of severe health impacts of this alcohol consumption. (Ref. 10)

This study is also concerned about the impact of an increased risk of future alcohol abuse for individuals who already have unhealthy drinking habits. As expected there is a large correlation between those who drink heavily at 16 and 22 and those who also drink unhealthily at 32 and 42. This identifies an important aspect of health risks associated with alcohol, as drinking alcohol is rarely a habit that is given up completely. So if an individual begins drinking at a young age such as 16, they not only have the direct negative mental health (Ref. 11) and physical health (Ref. 12) impacts of drinking at an earlier age, but they also have the increased risk of drinking alcohol later in life, which may bring further negative health outcomes.

To take this further, the children born into families in which the abuse of alcohol is present has a large impact on the health of children within this household, primarily increasing their risks of developing many different health risk factors later in life. These include abusing alcohol or other drugs themselves, engaging in violent and delinquent behaviour, being physically abused, performing poorly in school and developing mental health problems. (Ref. 13)

Impact of social family context on child obesity - Study based evidence

Social factors such as family context has a significant impact on risk factors for childhood obesity and obesity in children is often continued into adulthood with excess adiposity frequently being more severe in adults who were obese as children. In adulthood the health consequences are well established and include increased risk of hypertension, heart disease and type 2 diabetes mellitus. So it is fair to conclude obesity in children is a significant lifestyle risk (Ref. 14). Therefore in the next section of my essay I will particularly focus on the impact of social family context on the weight of children. The social family context is defined in this essay and wider literature as the relationships within the inner family, so for children this is predominately their parents or primary carers, and the actions these family members take which would impact health. In this part of my essay I will discuss the impacts routines and restrictions set up by family members on the health outcome on the child. I will also briefly discuss the impact of chaos within a household on health outcomes.

The primary environment (the inner family unit) is suggested to be the largest factor which impacts child obesity (Ref. 15). The primary environment here being defined as being family context, citing also that other environmental factors such as school, neighbourhood and community also had a smaller but significant impact on child obesity. In many cases, the secondary factors are linked to the primary factors as some parents will get a choice on which school or neighbourhood their child grows in up, and how their community forms based upon which clubs they are signed up for.

Family organisation impacts the health care of children growing up in the home. In general within house holds that are more structured, for example, with a set sleep routine meal routine and screen time and screen time limitation, had a significant reduction in child weight (aged 2-12) (Ref. 15). In this study across age ranges, 100% of studies (8 out of 8 studies) found significant association between sleep routines and child weight, 63% of studies (10 out of 16) found significant relations between meal routines and child weight and 82% of studies (9 out of 11) found significant relations between TV or screen time limitations and child weight.

Sleep routines

Setting a sleep routine is a prominent characteristic in a structured family, and has wide ranging benefits. Sleep routines, especially in infants is associated with longer and less variability in the sleep of the individual (Ref. 16). There is also a link between going to sleep early and the quality of sleep for the individual, which will also be linked to a structured family unit which would encourage an earlier initiation of the sleep routine. This is important for the health the infant as there is this association between sleep deprivation and increased weight gain and obesity levels (Ref. 17). At this point in development weight gain and obesity levels are not perfect but are very useful indicators of overall health as obesity will be more likely to last into adulthood in which case it will have large widespread implications. Therefore having a method to increase sleep by implementing a sleep routine in this instance, would allow for a positive outcome in weight but would also in education due to the dynamic role it plays in brain development. Infants have the ability to learn new information while asleep which is something adults can’t do but is another benefit of increased sleep. Education in infants has direction impacts of the social connections made, for example speech development and memory. These things will therefore have a secondary impact on the social context of health. (Ref. 18)

Screen time restrictions

Excessive use of screen time, a factor reduced by screen time limitations in a structured household, has a negative impact on health in children. Specifically associated with increased adiposity, cardiorespiratory fitness, depression and mental health, diet and quality of life, lower academic achievement, sleep, and lower levels of physical activity. (Ref.19). So therefore by limiting this screen time there is a reduced risk of these factors developing into serious health risks. Often the main reason for these risks being associated with screen time usage is due to the sedimentary nature of screen time. As the increased availability and quality of media consumption and video games, allows them to replace other hobbies which would otherwise take place at this time. For example rather than walking as a family in the evening when there is free time, which has health benefits (Ref. 20), children with unrestricted screen time usage, will be more likely to spend this same time sedentary inside.

Meal Routines

Meal routines which are defined by parents within the nucleus of a family unit often are behaviours which persist throughout a child’s life, so introducing a positive routine early is important and helps reduce weight gain and reduces the risk of mental health problems later in life. Factors which make a good meal routine include having a high frequency of shared family meals, especially at breakfast, and having the parents show a good example in the foods they eat and the priority they give to making time for shared family meals. Another factors which improves meal routines is switching off the TV at meals which embellishes the idea that restriction to screen time can have positive impacts. (Ref. 21)

Having looked at characteristics of a well structured household, I will now discuss the negative social health impacts that chaos within a family context has on a child’s health. Chaos is conceptualized as crowded housing, noisy, disorganized, unpredictable settings for child development (Ref. 22). There is an association between chaos in the family and worse child health outcomes even when controlling for other factors such as economic status and family structure.

There are many different factors which can cause negative physical and mental health issues which are related to overcrowding, for example, privacy, security and community resources, and many of these are amplified in effect for children. Children are particularly vulnerable in the family household due to their reliance on home to be a place where they can practice skills, build close relationships with adults (parents) and sleep. So losing the ability to do these things is the reason crowding has a negative impact on health (Ref. 23).

Health impacts of economic instability - Patient led evidence

From primary source evidence collected during time in a GP surgery, I have seen the impacts of a sudden change in economic stability on lifestyle risk factors. The patient found himself in debt due to many confounding issues, not least the end to a significant relationship. This left him without a place to live, and without the means to find a new property. As a result, he resorted to sofa surfing trying to pay whatever rent he could to the friends who were allowing him to stay in their houses. This lead to many different negative health outcomes, which appeared most in the deterioration of his mental health, partly due to debt stress and partly due to the undermining of his confidence due to the breakup with his partner. This was the reason he arranged an appointment with his GP. He needed time off work due to stress and depression, which was given to him by his GP, however this understandably did not solve any of his health problems. From this poor economic situation 3 major lifestyle risk factors emerged: a lack of suitable housing an increased uptake of drugs and alcohol and an inability to work leading to a feeling of unworthiness.

Suitable housing

The lack of suitable housing leading to ‘sofa surfing’ has a negative impact on many areas of health, both mentally and physically (Ref. 24). One reason for the negative impact it would have on mental health would be an increased feeling you were being a burden on the people you were living with, and this is a feeling the man I heard from felt. There would also be a negative impact due to the lack of your own personal space, if you are living in the living room of a friend, there is a significant reduction in privacy. Negative physical health impacts may include a reduced quality of sleep due to lack of proper bedding, and there is clear literature suggesting sleep is a large risk factor for health (Ref. 25).

Substance abuse

Both alcohol and drugs can lead to a vicious downward spiral when paired with debt, as seen with this man. To cope with the stress that comes with debt as presented earlier in this essay, he would drink excess amounts of alcohol and get high from drugs. However, buying these substances, especially drugs, lead him into more debt, with different individuals who he described as ‘the people you don’t want to owe money to’. It was clear he was weary of these people supplying him with drugs, and even had to ask the friends he was staying with to pay off his debt for the drugs. This would therefore bring him more stress leading him to more substance abuse in an attempt to get away from the stress. All while not bringing him any closer to paying off his debt which was one of the main causes of the original stress. To add to this he understood these were bad coping strategies but the addictive nature of these substances made it difficult for him to stop. This therefore added to his mental health problems and a feeling of inadequacy for not being able to stop taking these drugs despite wanting to. Alongside the negative mental health impacts of taking drugs and drinking alcohol, there are many negative serious health impacts of these things.

Inability to work

The third major factor was his inability to work his job due to stress and depression. As a result of this some of the positive results of working are lost. These include the social element of work, the exercise this man got from working, and finally the natural feeling of worth that comes with finishing a job properly and feeling like you are a needed member of the team. The loss of this final impact of working seemed like it played a large impact in the continued worsening in the man’s mental health. He no longer had a purpose to any of his days, and felt like he went to sleep having completed no worth while tasks. This is a common feeling for those who are used to working a full time job and then are no longer able to for whatever reason, and led to suicidal thoughts for this man. However it is important to understand the complexity of mental illnesses such as depression. The risks of sending him back to work in a state in which he was uncomfortable, may have led to even worse mental health outcomes. This would especially be the case if he tried to go back to work prematurely and clearly wasn’t able to function there so had to leave again.

To conclude this section about this patient, it is important to recognise how all these social and economic factors are interlinked with the negative lifestyle risk factors. The importance of not just trying to improve one area is also shown in the attempt to elevate stress due to work. Although giving someone a note from the doctors for 2 weeks off work may be better than forcing them into work for these two weeks, there must be more support offered and taken up by the patient to help in other areas of his life. For example taking up talking therapy rather than turning to substances to help cope with stress.

Negative health impacts of low literacy ability - Patient led evidence

Another piece of primary source evidence from a GP surgery suggests there is a negative impact of lack of literacy ability of the outcomes of mental and physical health. It also shows how social cultural factors prevent individuals implementing medical advice.

Using a child as a translator

There was a Lithuanian women who spoke very little English, so came into the GP surgery with her 12 year old daughter as a translator. Already having a member of the family as a translator could present itself as a problem as there could be a power dynamic between the mother and daughter with the daughter potentially not allowing for her mothers opinion to be expressed fully to the doctor. This wouldn’t be the usual outcome but it may happen. It may also be the case that the 12 year old’s vocabulary isn’t accomplished enough in one of the two languages used to translate a medical conversation between the mother and doctor. This would potentially bring into question informed consent if the risks for a procedure couldn’t be properly communicated to the mother.

Another impact of using a 12 year old daughter as a translator is that they would hear any medical issue the mother wanted to discuss with the doctor. This could mean that the mother would restrict the amount of information she would disclose with the doctor in order to protect her daughter from hearing about certain medical issues. This could be especially relevant in the case of mental health issues, as parents rarely disclose mental health problems to their children immediately. Also it may be the case for sexual health concerns which the mother may feel is not appropriate for a 12 year old to be exposed to. As a result of these things, there is a reduced chance optimal medical guidance can be provided to the mother, as she won’t be able to fully inform the doctor of some medical issues.

Cultural factors

Cultural factors also played a significant role in the treatment of the rash in which the mother was presenting to the doctor. She had had to checked out by a doctor in Lithuania before moving to the UK, however after this she attended the GPs again to have it looked at by a doctor in the NHS. The diagnosis given by the doctor in the NHS contradicted the diagnosis of the Lithuanian doctor leading to the doctor in the NHS prescribing different medication to that of the Lithuanian doctor. For a period the patient did take this new medication, however due to bad communication some of the side effects of the new medication weren’t explained, and she stopped taking the new medication due a feeling that these negative side effects weren’t being cancelled out by the positive impacts of the medication. Therefore she went back to the medication prescribed by the Lithuanian doctor. To explain this change, it is important to understand that trust must be built up and there was a general lack of trust from the patient in the NHS, partially due to it being a more unknown organisation in comparison to the health care system in Lithuania. So in order to ensure this patient implements the correct and updated medical advice given by the NHS doctors it is important to try and built this trust back. This is more difficult given she didn’t speak English so the reassuring was via her daughter. It was also difficult for the doctor to fully address her concerns as he didn’t fully understand the social culture she was used to.

As a result of this social language cultural barrier, this patient didn’t take the correct medicine for several months, which may have meant a low risk disease became worse. There is also a negative impact on the daughter who was missing a morning of school to bring her mother to the doctors, again highlighting how different factors impact each other. If the daughter missed school on a regular basis to help her mother carry out basic things, there will be a negative impact on her social and educational progress (Ref. 26).

Conclusion

In this essay I have discussed the impacts of lower SES on alcohol outcomes, suggesting that the difference in health outcomes run much deeper than just the quantity of alcohol consumed by different groups. Rather other factors such as stress, can extenuate negative health outcomes due to alcohol. I have also discussed the role of a chaotic home as a risk factors for childhood obesity, with 3 main markers for this being meal and bedtime routines, along side restrictions to screen time. I also discussed patient accounts of the impacts of debt on many other areas of physical but more importantly mental health. Finally, I discussed the importance of literacy skills and the negative side effects of using your child as a translator, along with the importance of trust in the NHS in ensuring medical guidance in implemented by all.

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