Underrepresented groups in the United States carry a significant and disproportionate burden of specific diseases. For example, while African Americans make up only 12% of the U.S. population, this group accounted for 44% of all HIV/AIDS cases in the United States in 2010 (Kaiser Family Foundation, 2013). In 2010, Hispanics were 1.2 times (Office of Minority Health, 2012) more likely to be obese and almost 2 times (Office of Minority Health, 2013) more likely to be diagnosed with diabetes than their non-Hispanic white counterparts.
There has been much discussion about the type of effective interventions for promoting well-being and improving health outcomes in all Americans, especially for underrepresented groups. Medical social workers excel at providing direct services to individual patients. Given current efforts to shift the paradigm to population-centered interventions, social workers must modify their skills, broaden their perspective, and consider evidence-based interventions.
To prepare for this Assignment, select a public health issue of interest to you (e.g., obesity, diabetes, cancer, HIV/AIDS, mental health).
- Describe the specific underrepresented population(s) affected by the health issue you selected. Explain how this population is discriminately affected by the health issue you selected.
- Explain the primary determinants of the health issue. Then, explain how these determinants contribute to the disparities in care for the population.
- Explain what specific social work interventions you might implement to address this health issue, reduce or eliminate disparities, and improve health outcomes.
- Identify some challenges you may encounter when implementing the interventions. Then, explain the strategies you might employ to address these challenges.
- Explain the advocacy roles a medical social worker might play in addressing the disparities in health care for the health issues and population you selected.
- Cite your response using external scholarly resources.
Describe the specific underrepresented population(s) affected by the health issue you selected. Explain how this population is discriminately affected by the health issue you selected.
Explain the primary determinants of the health issue. Then, explain how these determinants contribute to the disparities in care for the population.
Explain what specific social work interventions you might implement to address this health issue, reduce or eliminate disparities, and improve health outcomes.
Identify some challenges you may encounter when implementing the interventions. Then, explain the strategies you might employ to address these challenges.
Explain the advocacy roles a medical social worker might play in addressing the disparities in health care for the health issues and population you selected.
Cite your response using external scholarly resources.
1
Eliminating Healthcare Disparities
Tolulope I. Moses
Master of Social Work, Walden University
SOCW-6204: Medical Social 1
Dr Kristie Abbs
October 2021
Eliminating Healthcare Disparities of Teenage
mental health Issues
Teenagers are the most affected when it comes to mental health challenges. The adolescence phase comes with extreme responsibilities, some which the teenager is not prepared to experience. The phase is a transition between childhood and adulthood and most of the young adults are confused about the path they should follow. For instance, the teenager is confused between clinging to the parents and breaking free to explore the new life stage. Some of the possible mental health challenges are depression and severe anxiety (Blakemore, 2019). An individual contracts the difficulty as a response to activities happening in their primary environment. Most parents attest experiencing difficulties in raising a child in the teenage phase. However, they fail to understand how transitioning to that level where they are experiencing body transformation is extremely confusing and they might contract mental challenges. Their emotional health has been discarded and no individual has expressed the required concerns.
Change is inevitable and it might bring positive and negative reactions. However, most adolescents perceive change as a negative face contracting mental health challenges. Suicide rates have increased in teenagers because of the challenges in trying to live through societal and individual pressure. Moreover, most of the adolescents affected by psychological disorders will be challenged during the adulthood level if it goes untreated or given the proper attention (Kazdin, 2019). The primary way they are affected by such disorders is growth in a negative environment. Children exposed to violence and other forms of abuse will transition in the teenage phase with mental challenges. They will try to incorporate what they have learned in their childhood thus become victims of circumstances. Parents and guardians are more focused on nurturing the physical health and ensure that their children are not constantly sick. However, the emotional and mental health is discarded thus most children face challenges in fighting unknown battles by the parents. The most common battle they experience is struggling to fit within an environment where they are considered different. Experiencing negative instances like discrimination and alienation from their peers will accelerate the damage in their mental health.
Determinants of Mental Health
Various determinants have accelerated the prevalence of mental health damage on adolescents. The first determinant is growth and development in a depressing environment. It is one topic which parents are not ready to discuss especially on how their nurturing style causes teenage mental disorders. The contemporary world parents are extremely busy to try and create a comfortable life for their children and in the process mess their mental health and leave the individual struggling for a lifetime (Levenson, 2017). A depressing environment is filled with physical and emotional abuse. Parental conflicts are inevitable but happening before children’s presence will affect their perception towards a peaceful home. Such an adolescent will develop communication problems when in the adult face since the primary way they have learned to express their thoughts is through anger and shouting or violence. Therefore, the teenage will go through that life level suffering through every type of disorder.
Additionally, the second determinant of the mental health in adolescents is increased peer pressure. Families have different social economic backgrounds and how people are raised. However, the concepts become apparent in the teenage phase where they have learned the gap between wealth and poverty (Sapiro & Ward, 2020). Adolescents raised from poverty struggle in trying to fit in with the extended community. The pressure results from lacking some of the luxurious items which will place them on the same scale levels as their age mates. Therefore, most of the teenagers will feel isolated because they have the minimum requirements which pass them as the present-day teenagers.
Mental disorders can be inherited suppose the parent lived through life without seeking consultation. Such parents and guardians will experience difficulties in bonding or forming healthy relationships with their children (Stephen, 2018). additionally, technology has become a weapon which promotes psychology disorders among adolescents. Parents expose their children to the social media platforms where they experience different forms of abuse. Cyber bullies target such naïve groups and negatively impact their lives through insults and unnecessary negativities. Lowering a teenager’s self-esteem while they are striving to accept the new changes and transitions will only facilitate increase in mental health challenges.
Social work interventions and Teenage Mental Health Challenges
The first implementation I will incorporate as a social worker is creating awareness regarding adolescent mental health challenges. Parents and the extended community need to be educated that not only physical health is significant when raising children. The primary benefit for creating awareness and educating the parents is that they will be more responsible for their children’s mental wellness. For instance, parents and guardians will ensure they provide more peaceful environment and develop excellent relationships with their children. It is the only way adolescents will strike conversations with the parents and express various challenges they experience in school and other places (Rogers & Pilgrim, 2021). Moreover, community awareness will ensure that all members unite to make mental health a priority. The best way is to educate them on the challenges faced during the adolescent phase and ensure that community members collaborate to help children have a smooth transition. Ignorance will be eradicated and will be focused on raising an emotional and mentally healthy generation.
Additionally, adolescents require the mental health education. The strategy is essential because most of such children have minimal knowledge on the condition. Educating them will ensure they understand all the psychological disorders with their signs and symptoms. Therefore, those affected with the disorder will ensure they approach the required organization to get help in the early stages (Blakemore, 2019). Furthermore, adolescents will ensure they form groups which support one another through the challenges experienced in the life level. The primary objective is to minimize the population suffering from the disorder due to parental and community negligence.
Learning institutions need to be part of the implemented programs which will help eliminate the challenges which cause mental health disorders. For instance, schools should develop a section in the curriculum where students are addressed about mental health challenges and how it can be eliminated (Kazdin, 2019). It means that the school administration should develop guidance and counseling officers where children can have adults to confide in regarding their psychology situation. The primary objective for implementing the multiple programs as a social worker is ensuring that children have minimal struggle with their mental health. They deserve to grow and develop in areas which support physical, emotional, and mental wellbeing.
Challenges and interventions.
The first challenge I may encounter when working to implement the interventions is language barriers. Social workers are dispensed to different locations and sometimes I might be sent to a community who has minimal understanding of the common language. It will be difficult to address the mental health challenges and explain the concepts (Levenson, 2017). Moreover, people within such places are not ready to trust a stranger and confide about their children. Therefore, I tend to struggle in convincing the community members about the significance of my services to ensure they nurture a mentally stable future generation. The primary solution for such a problem is ensuring that I find a translator understanding the common language and ensure they help me engage the community. The strategy is significant since it will help them in building trust and opening up about some of the psychological disorders witnessed and treatment approaches taken.
Additionally, another challenge experienced is the stigma and stereotypes created around psychological disorders. Most of the community members believe that children dispensing mental challenges have been cursed and should be excommunicated from society (Sapiro & Ward, 2020). The stereotype has been passed through generations and is extremely challenging to convince the community that most of the disorders are treatable with the best medication plans. Furthermore, it is challenging to convince the potential customers to use their resources and take their children for treatment. Parents believe they need to be tough to ensure that the teenagers grow and develop according to the harsh environment provided.
Social workers also experience financial constraints when moving through communities and creating adolescent mental health awareness. For instance, the social worker is required to develop posters and flyers to be distributed to the community members and help them comprehend the topic. However, it is pretty challenging because the activity is costly and the social worker will be hindered from delivering quality services (Stephen, 2018). The best solution for financial constraints is the government acknowledging the efforts made by social workers and ensuring they have received the much-needed support. The social workers are essential part of the community and should be given the required help for their services.
Advocacy roles a medical social worker in Teenage Mental Health Issue
The primary role of a social worker is to ensure that they help in diagnosing the mental health disorder. Social workers working in the mental health department have been trained to discern the psychological disorders and provide a diagnostic. After that, the social worker will recommend the best medical institution and health professional to offer high quality services. The social worker will reassure the patient to take on the treatment plan ensuring they stick on the recovery path (Rogers & Pilgrim, 2021). Additionally, the individual is obligated to provide follow up activities which will keep the patient busy and focused to reduce the disorder damage on their mental health. Social workers understand that mental health clients require constant attention thus ensure they provide quality services. The primary objective is ensuring that the client is placed in an excellent medical plan and supported throughout their recovery period.
The social worker is obligated to educate parents and guardians on their teenager’s condition. The major goal is to ensure that the adolescent receives full parental support and love to help them through the recovery period. Educating the family is essential since they will be taught on some of the triggers and how they should be avoided. For instance, if the patient’s psychological illness is caused by a violent and abusive environment, the family is educated on the significance of ensuring they maintain peace and serenity (Blakemore, 2019). The social worker and the family will collaborate in ensuring that they push the adolescent to taking their medication and attending all of the guidance and counseling therapy sessions. The social worker will ensure they have received medical attentions despite the financial constraints faced. They respond to all of the raised complaints and ensure that adolescents have an excellent growth and development surroundings thus minimizing psychological disorders cases.
References
Blakemore, S. J. (2019). Adolescence and mental health. The lancet, 393(10185), 2030-2031.
Kazdin, A. E. (2019). Annual research review: expanding mental health services through novel models of intervention delivery. Journal of Child Psychology and Psychiatry, 60(4), 455-472.
Levenson, J. (2017). Trauma-informed social work practice. Social Work, 62(2), 105-113.
Sapiro, B., & Ward, A. (2020). Marginalized youth, mental health, and connection with others: a review of the literature. Child and Adolescent Social Work Journal, 37(4), 343-357.
Stephan, U. (2018). Entrepreneurs’ mental health and well-being: A review and research agenda. Academy of Management Perspectives, 32(3), 290-322.
Rogers, A., & Pilgrim, D. (2021). A Sociology of Mental Health and Illness 6e. McGraw-Hill Education (UK).
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Journal of Gerontological Social Work
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Growing Health Disparities for Persons Who
Are Aging With Intellectual and Developmental
Disabilities: The Social Work Linchpin
Laura M. Robinson , Jason Dauenhauer , Kathleen M. Bishop & JoAnne
Baxter
To cite this article: Laura M. Robinson , Jason Dauenhauer , Kathleen M. Bishop & JoAnne Baxter
(2012) Growing Health Disparities for Persons Who Are Aging With Intellectual and Developmental
Disabilities: The Social Work Linchpin, Journal of Gerontological Social Work, 55:2,
175
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Journal of Gerontological Social Work, 55:175–190, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0163-4372 print/1540-4048 online
DOI: 10.1080/01634372.2011.644030
Growing Health Disparities for Persons
Who Are Aging With Intellectual and
Developmental Disabilities: The Social
Work Linchpin
LAURA M. ROBINSON
Department of Pediatrics, University of Rochester Medical Center, Rochester, NY,
USA
JASON DAUENHAUER
Department of Social Work, College at Brockport, State University of New York, Brockport, NY,
USA
KATHLEEN M. BISHOP
Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
JOANNE BAXTER
Easter Seals New York, Rochester, NY, USA
Similar to the general population, adults with intellectual and
developmental disabilities (IDD) are living into their 70s and
beyond. Health care disparities have been well-documented for this
vulnerable and underserved population. Social workers are often
responsible for assessment, coordination of care, and negotiation
of needed services for people with IDD. This article explores the
challenges facing social workers in meeting the growing health and
social needs of aging adults with IDD and their families. Trends in
Received 31 May 2011; accepted 21 November 2011.
Ms. Robinson’s, Dr. Bishop’s, and Dr. Dauenhauer’s efforts were supported by funds
from the Bureau of Health Professions (BHPr), Health Resources and Services Administration
(HRSA), Department of Health and Human Services (DHHS) under Geriatric Education
Centers Grant #D31HP08811. This information or content and conclusions are those of the
authors/speakers and should not be construed as the official position or policy of, nor
should any endorsements be inferred by the BHPr, HRSA, DHHS or the US Government. Ms.
Robinson’s and Dr. Bishop’s efforts were also supported by UCEDD Grant #90DD066102 from
the US Department of Health and Human Services, Administration on Developmental
Disabilities to the University of Rochester.
Address correspondence to Laura M. Robinson, M.P.H., Program in Aging and
Developmental Disabilities, University of Rochester Medical Center, 601 Elmwood Avenue,
Box 671, Rochester, NY 14642, USA. E-mail: LauraM_Robinson@urmc.rochester.edu
175
176 L. M. Robinson et al.
social work practice and gaps in education are discussed as they
relate to addressing and reducing current health disparities.
KEYWORDS social work, aging, intellectual disability
INTRODUCTION
Over 640,000 adults with intellectual and developmental disabilities (IDD)
over the age of 60 were identified in the United States in 2000; this number
is expected to double by 2030 (Heller, Janicki, Hammel, & Factor, 2002).
The increase in life expectancy can be attributed to improved medical
knowledge, access to health care, deinstitutionalization, and better living
conditions (Heller et al., 2002), and can be expected to continue.
Increased longevity has presented challenges for service providers who
work with people with IDD and their families. Health care practitioners
and community services providers often do not have sufficient knowledge
and skills to provide appropriate interventions for this unique aging popula-
tion due to lack of awareness, research, and formal education within health
professions training programs (Ansello, 1992; Fenton, Hood, Holder, May, &
Mouradian, 2003; Horwitz, Kerker, Owens, & Zigler, 2001; U.S. Public Health
Service, 2001; Wolff, Waldman, Milano, & Perlman, 2004).
Social workers play an important role in meeting the needs of those
who are aging with IDD. Specifically, social workers provide assessment,
intervention, and advocacy for people with IDD and their families. Although
these basic skills are taught within both undergraduate and graduate social
work programs, formal education specifically targeting the unique needs of
people who are aging with IDD is limited. Therefore, finding social workers
adept, or even familiar, in aging and IDD is rare. Thus, the purpose of this
article is to bring attention to the limited presence of social workers in the
IDD field, the lack of educational opportunities to support the current and
future social workers in this field, and the impact of these trends on health
disparities experienced by people who are aging with IDD.
IDD, AGING, & HEALTH DISPARITIES
The Centers for Disease Control and Prevention (CDC) defines developmen-
tal disabilities (DD) as a diverse group of severe chronic conditions that
affects one or more major life activities, such as learning and mobility, as
well as independent living. The term intellectual disability (ID) falls under
the umbrella definition of a developmental disability and is used interna-
tionally to reference a significant cognitive impairment expected to last a
lifetime (CDC, 2011).
Health Disparities, IDD, and Social Work 177
Based on US Census data from July 2008, it is estimated that adults
over age 65 will grow to 20% of the population (71 million) by 2030 (US
Census Bureau, 2011). Of people over age 65, 42% of the civilian, noninstitu-
tionalized population has a disability (physical, cognitive or emotional) that
impacts the ability to function at home or work (US Census Bureau, 2011).
Unfortunately, national health surveillance data in the US for people with
IDD are lacking (CDC/National Center on Birth Defects and Developmental
Disabilities, 2009; Healthy People, 2010; US Department of Health and
Human Services [USDHHS], 2005; US Public Health Service, 2001). Data
collection for children with DD is inconsistent throughout the states with
different collection processes and even different criteria for diagnosis. After
school age and transition to adulthood, the collection of data is even more
challenging with little or no information on adults who are not part of for-
mal service systems (Shannon & Agorastou, 2006). Social workers are a
bridge between people and services. Without this information, it is difficult
to determine how many people have a diagnosed IDD, how many are over
age 65, what their health needs will be across the lifespan, and what impact
their lifelong disabilities and chronic conditions will have on the US health
care system, in particular Medicaid and Medicare spending. Understanding
the demographics of the community and different subpopulations will assist
social workers in advocating for needed services.
Genetics, attitude, environment, lifestyle, and the interaction of preexist-
ing lifelong disabilities affect a person’s overall aging experience (Machemer,
1994). Adults with IDD follow similar aging patterns as the general pop-
ulation, however with increased severity of a disability, a shortening of
life expectancy and/or reduction of quality of life are more likely (Heller,
Caldwell, & Factor, 2007). As they age, people with IDD are more likely
than the general population to experience cardiovascular disease, sen-
sory decline, functional decline, and increasing dependence on paid and
unpaid caregivers (Cooper, 1997; Evenhuis, Henderson, Beange, Lennox, &
Chicoine, 2000; Haveman et al., 2011; Janicki et al., 2002; Robinson
et al., 2010; van Schrojenstein Lantman-de Valk, Metsemakers, Haveman, &
Crebolder, 2000). The most common conditions experienced by people with
IDD are vision and hearing loss, musculoskeletal decline (e.g., osteoporosis,
osteoarthritis), gastro-intestinal conditions (e.g., constipation, reflux), and
hypertension. Factors contributing to these health issues include poor diets,
decreased physical activities and/or exercise routines, and side effects from
medications (Heller, McCubbin, Drum, & Peterson, 2011). People with dis-
abilities in the general population are more likely to report poor health
status than people without disabilities (Healthy People, 2010; Morbidity and
Mortality Weekly Report [MMWR], 2008). In conjunction with a lifelong dis-
ability, any additional health conditions significantly compromise the overall
health and functional status of aging adults with IDD (Henderson et al.,
2009).
178 L. M. Robinson et al.
Diagnostic overshadowing is a term utilized when psychosocial or other
health problems are not diagnosed due to a primary diagnosis of IDD
(Fisher, 2004; Jones, Howard, & Thornicroft, 2008; Jopp & Keys, 2001; Reiss,
Levitan, & Szyszko, 1982). Adults with IDD are known to have a higher risk
for a co-occurring mental illness, thus increasing the need for advocacy, ser-
vices, and supports that can be provided by a social worker (Chaplin, 2004).
The challenges of identifying and diagnosing a coexisting mental illness in
the IDD population include the difficulty in distinguishing depression from
physical illness or dementia, use of appropriate screening tools, commu-
nication challenges, differences in symptom presentation, and determining
which of the available services would best meet the needs of the individual
with a dual diagnosis (Bourus, 1999). Diagnostic overshadowing is a com-
mon problem in the IDD field and one that social workers can advocate to
prevent.
Medicaid is the primary form of health care insurance for adults with
IDD (Bachman, Tobias, Master, Scavron, & Tierney, 2008; Drainoni et al.,
2006; Havercamp, Scandlin, & Roth, 2004). Many health care providers
either do not accept Medicaid insurance or limit the number of patients
in their practices with Medicaid (Havercamp et al., 2004; Reichard, Sacco, &
Turnbull, 2004). As a result, anecdotal evidence suggests that individuals
with IDD often access care in clinic settings with long waits for appoint-
ments, see newly trained health care providers with limited experience
and exposure to people with IDD, and have limited access to after-hours
services (Agency for Healthcare Research and Quality, 2011). A lack of
sensitivity/experience with this population may result in negative attitudes
toward people with IDD from health care professionals who may struggle
with communicating at appropriate developmental levels (Ward, Nichols, &
Freedman, 2010).
Studies also indicate that adults with IDD are less likely to receive qual-
ity preventive health care (Kerr, Richards, & Glover, 1996; Lewis, Lewis,
Leake, King, & Lindemann, 2002). Studies by Horwitz, Kerker, Owens,
and Zigler (2000) and Lewis et al. (2002) identified limitations in spe-
cialty services including mental health care, ophthalmological care, dental
services, and preventive screenings for cancer. In another study utilizing
focus groups with parents/guardians, self advocates, and community sup-
port professionals, health care disparities in four areas were identified:
access, knowledge, communication and quality (Ward et. al., 2010). Ward
and colleagues (2010) stated that the limited amount of training available
and utilized by health care professionals perpetuates these disparities, and
thus continues to negatively impact the health of individuals with IDD. Social
workers, often as part of an interdisciplinary team, must also receive edu-
cation and training on the specific health needs of the IDD population to
support their role as the coordinator of appropriate health services.
Similar to general population trends, family members provide a major-
ity of informal long-term caregiving for aging adults with IDD (Family
Health Disparities, IDD, and Social Work 179
Caregiver Alliance, 2006; Thompson, 2004) in a home setting. Due to their
own advancing age and lack of supportive resources, family caregivers
of adults aging with IDD have significant health and social needs (Heller
et al., 2007). As these caregivers age, or are no longer able to care for
their adult child with IDD, planning for the future is critical (e.g., hous-
ing, financial, and related supports). Limited long-term support is evidenced
by waiting lists for residential or congregate care settings, which exist in
most states (Heller et al., 2002; Lakin, 1998). As the health care needs
surpass those that can be addressed at home, competition for placements
in long-term care facilities are expected to increase as both adults with
IDD and adults without IDD continue to live longer (Parish & Lutwick,
2005). The numbers of older adults that will need services will be at an
unprecedented high, thus competition for staff, residential facilities, pro-
grams, and other support services may limit what is available and who will
have access to these resources. Additional factors that will impact the qual-
ity of care for people with IDD include low wages for direct support staff,
high turnover rates, and lack of training on aging issues (Larson, Lakin, &
Bruininks, 1998; Mitchell & Braddock, 1994; Shakespeare, Iezzoni, & Groce,
2009).
Thus, access to health care for people with IDD that includes regu-
larly scheduled preventive services (e.g. mammograms, FOBT); meaningful
interaction with informed practitioners; and sufficient time for the discussion
of current symptoms, concerns, and/or management of chronic conditions
(other than the developmental disability) that is supported by a familiar fam-
ily member or staff person would likely begin to close the gap that exists
in the health status of adults with IDD compared to the general population.
It is clear that health disparities for people with IDD are significant and will
continue to grow unless these trends are addressed. Social work has a tra-
dition of helping to meet the needs of this population and can be integral
to bridging solutions. The following section provides an overview of current
social work practice and recent changes that are impacting service coordi-
nation in our home state of New York. New York State (NYS) is one of
48 states and DC that operate Home and Community-Based Services (HCBS)
Medicaid Waivers to support services to people with IDD (Kaiser, 2011).
NYS has one of the highest HCBS expenditures per person in the coun-
try, demonstrating a significant need for services (Kaiser, 2011). Despite this
high rate of spending for services, social workers are not integral to service
delivery in NYS.
CURRENT SOCIAL WORK PRACTICE
Social work is a discipline based upon a strengths-based model of assess-
ment and intervention. According to this model, all individuals have the
capacity for growth and change (Saleeby, 1996). Social workers use their
180 L. M. Robinson et al.
skills to assist disadvantaged populations in achieving social justice within a
variety of interconnected systems. A person is understood within the con-
text of his or her environment. As articulated by Russo-Gleicher (2008,
p. 131), the values of social work and the field of IDD coincide with
one another: “Social workers value rights, dignity, individual uniqueness,
self-determination, and client access to resources (National Association of
Social Workers, 1999). The field of DD values independence, inclusion,
individualization, and productivity (Aventi & Otis, 1994).”
People with IDD and their families are served by social work providers
in traditional DD service delivery systems and in social service agencies
(Parish & Lutwick, 2005). Social workers are most often responsible for
assessment and coordination of care and negotiation of needed services for
this population. Care coordination often includes linking families to needed
services including housing, health, transportation, education, recreation, and
day service programs. Social workers also provide counseling and advocate
for needed services and social/public policies that affect individuals with
IDD and their caregivers (Heller, et al., 2007; Parish & Lutwick, 2005).
In NYS, Medicaid Service Coordinators (MSCs) are the social work-
ers for people with IDD enrolled in the New York State Office for People
With Developmental Disabilities (NYSOPWDD) system. The role of the MSC
includes the provision of assessment, care planning, linkage and referral,
monitoring and follow up, and service documentation (NYSOPWDD, 2011).
These basic services are in line with the core social work skills. MSCs do
not need to have a bachelor’s degree in social work however, and expe-
rience working with people with IDD is either minimal or not required
(NYSOPWDD, 2011).
Requirements for MSC caseload size and the minimum number of face-
to-face contacts have changed effective October 1, 2010. These changes
increase the maximum caseload from 25 units to 40 units. There is a
weighting factor of 0.8 units for each individual with IDD that resides in
a residential program, thus the number of people on an MSC caseload could
exceed 40. Monthly face-to-face contacts with individuals with IDD had been
a requirement, and this service has changed to a minimum of 3 contacts per
year. An MSC is expected to provide services as needed and may have more
frequent contact if needed (NYSOPWDD, 2011). These minimum standards
for MSCs that include limited or no work experience with IDD, low edu-
cation requirements, higher caseloads, and decreased required face-to-face
contacts, could have a negative impact on the amount, type, and quality of
services people with IDD receive over their lifetime.
At a time when people with IDD, especially those who are aging, will
be requiring more time and expertise of the social work profession, these
systemic changes signal that service provision is going in the opposite direc-
tion that is needed to decrease the impact of health disparities and improve
care to meet needs of this very vulnerable population.
Health Disparities, IDD, and Social Work 181
SOCIAL WORK EDUCATION AND IDD
Increased education of future and current social work practitioners is essen-
tial to addressing the needs of individuals aging with IDD, their families,
and systems of care. This section describes both formal and continuing
social work education as it relates to IDD and the goal of eliminating health
disparities.
Formal Education
Over the past 15 years, significant progress has been made to infuse
gerontological content and foster gero-competencies within social work
curricula (Dauenhauer, Steitz, Aponte, & Fromm Faria, 2010; Ericson &
Tompkins, 2006; Fromm Faria, Dauenhauer, & Steitz, 2010; Scharlach,
Damron-Rodriguez, Robinson, & Feldman, 2000), but aging with IDD has
received little curricular attention. It is argued that practitioners are often
exposed to this group’s specialized needs in a direct practice situation
without any previous education (Kropf, 1996; Russo-Gleicher, 2007). Thus,
schools of social work have a responsibility to prepare future practitioners
with the skills necessary to meet the needs of this growing population.
Several studies report that schools of social work are not preparing
students for practice in the IDD field (DePoy & Miller, 1996; Kropf, 1996;
Russo-Gleicher, 2007). The most recent study by Laws, Parish, Scheyett, and
Egan (2010) reviewed online curricular documentation of the 50 top-ranked
schools of social work, as indicated by US News and World Report. Schools
included BSW, MSW, and doctoral programs. Findings revealed that 18%
(n = 9) of schools offered courses on IDD, and 6% (n = 3) offered concen-
trations in IDD. One surprising outcome was the fact that 58% (n = 28) had
one or more tenure-track faculty members with research experience in IDD.
The authors describe how this finding indicates schools have the capacity to
offer more education in this area, but are not doing so.
This paucity of DD courses translates to lack of exposure for students,
which, in turn, detracts from the adequacy of the training and education
provided to those students and reduces the quality of services provided
to people with DD. Furthermore, this lack of exposure to the DD field
minimizes the potential for students to discover a field of service that
sorely needs to expand and strengthen its workforce. (Laws et al., 2010,
p. 327)
Continuing Education
In the 1960s, University Centers for Excellence in Developmental Disabilities,
or UCEDDs (formerly University Affiliated Programs), were created through
182 L. M. Robinson et al.
legislation with the intent of educating community-based health care clini-
cians and service providers on IDD. Although most programs were founded
within pediatric departments, the need for a lifespan approach to education
and training has become obvious. Continuing education for social workers
and other clinicians in the field of DD on aging was not easily available in
the 1980s once the deinstitutionalization movement placed people with IDD
back in communities. One example of addressing this need in NYS was the
creation of the Program in Aging and Developmental Disabilities (PADD)
at the University of Rochester Strong Center for Developmental Disabilities,
one of three UCEDDs in NYS, in 1986. PADD was designed to provide pre-
and postservice training to interdisciplinary teams (including social work),
develop curricula for agency training, and provide supplemental resources
to enhance service delivery (e.g., statewide conferences, videos). PADD has
also collaborated on research related to health status and health trajectories
of adults with IDD who are aging (Davidson et al., 2008; Henderson et al.,
2008; Janicki et al., 2002; Robinson et al., 2010) to inform not only the med-
ical field but the staff, caregivers, and social workers who provide direct
services on a regular basis. In partnership with the Department of Social
Work at SUNY Brockport, PADD was part of a Developmental Disabilities
Certificate Program offered at SUNY Brockport in the early 1990s. However,
the program was discontinued due to low enrollment.
In the late 1990s, PADD partnered with the Finger Lakes Geriatric
Education Center (FLGEC), one of 50 geriatric education centers (GEC) in the
United States funded by the Health Resources and Services Administration.
The project included (a) rotating medical school Residents and Fellows
through geriatric assessment clinics for people with IDD; (b) Grand Rounds
presentations on IDD for current geriatricians and other health care practi-
tioners; and (c) training for nurses, clinicians, direct-care staff, caregivers,
and administrators of community agencies on aging with IDD, differen-
tial diagnosis, and environmental modifications. The FLGEC component on
geriatric education/training in IDD was highly successful over the last two
funding cycles. Although not social work specific in terms of its educational
target audience, the FLGEC initiatives attract a significant percentage of social
work providers from the across the region. At this time, the FLGEC is the
only funded GEC with an IDD focus, an indication of the continuing need
for more resources on aging with IDD.
The previous two examples underscore the limited opportunities for
future and current social work practitioners to acquire the skills and knowl-
edge to address the growing needs of the IDD population in NYS. In the
section to follow, key areas are outlined for which social workers are
well-positioned to address in conjunction with IDD-specific education and
training.
Health Disparities, IDD, and Social Work 183
THE SOCIAL WORKER’S ROLE IN MEETING
GROWING NEEDS
In addition to limited educational opportunities, there are currently no
requirements in NYS for social workers to complete continuing education
units to maintain certification or licensure. The absence of an ongoing edu-
cational requirement places additional responsibility on the social worker;
the social worker must take the initiative to research new populations and
identify local demographic trends to maintain a knowledge base that is rel-
evant to practice. There are several major areas in which social workers
could assist older individuals with IDD, as well as their caregivers. These
areas are described in the following paragraphs, with suggestions for social
work practice.
Health Care Advocacy
Given the access and health care disparities previously described, social
workers play an important role at local and systemic levels in the reduction
and elimination of these inequalities. Some areas in which social workers
can have a significant impact include (a) educating family caregivers to
become informed consumers of health care, advocates for health screenings,
and good observers/reporters of functional changes over time; (b) training
health care providers to enhance their understanding of the physical and
psychosocial needs of people with IDD; and (c) facilitating communication
between health care providers and people with IDD. In particular, social
workers may collaborate with primary care physicians, nutritionists, physical
therapists, and caregivers to develop strategies to assist with healthy lifestyle
changes for individuals with IDD (Sohler, Lubetkin, Levy, Soghomonian, &
Rimmerman, 2009) as overweight and obesity status are highly prevalent, as
well as increasing comorbidities with age (Robinson et al., 2010).
Care Coordination
As the lifespan of people with IDD continues to increase, more commu-
nity services will be utilized such as senior day programs, nursing homes,
and other long-term facilities that were designed for the general popula-
tion. The consumption of health care resources will also increase as older
adults with IDD manage their lifelong chronic conditions, in addition to
age-related chronic conditions. Social workers can play a key role in train-
ing family caregivers, direct care staff, and administrators in appropriate and
comprehensive assessments, as well as inclusive service provision to older
adults with IDD. Social workers can also develop coalitions of providers
184 L. M. Robinson et al.
to enhance communication across service systems (Parish & Lutwick, 2005)
and between specialty health care providers (Coughey et al., 2010). These
two traditional roles of social workers (training and advocacy) could con-
tribute to the reduction in health disparities experienced by older adults
with IDD.
End-of-Life Issues
As people with IDD are living longer, they will be experiencing end-of-life
issues as family members, friends, staff members, and other caregivers die.
They will also be faced with their own journey toward the end of life. Social
workers can tailor education, assessment, and intervention regarding aging,
grief counseling, bereavement services, and support groups to help individ-
uals with IDD cope with grief and loss issues (Bostford, 2000). Advanced
directives including health care proxies, Do Not Resuscitate orders, and burial
preferences should be discussed with family and the individual with IDD (to
the extent possible; Botsford, 2000). Social workers can promote and assist
with such planning and take on a leadership role to ensure that obstacles
to end-of-life care are addressed and supportive planning and interventions
are provided. Last, social workers will be able to assist families with access-
ing services at various entitlement and community service agencies to help
develop comprehensive future care planning that meets the needs of the
individual with IDD as well as the aging caregiver.
Educational Needs
Advocates have recommended several ways to improve educational oppor-
tunities provided by social work educators. First, undergraduate and
graduate programs need to provide coursework that includes IDD content
(Kropf, 1996; Laws et. al., 2010; Russo-Gleicher, 2007). Because many stu-
dents may not have the opportunity to complete an elective course, infusion
of IDD content into foundation courses such as diversity, human behavior
in the social environment, policy, and others is highly suggested. Models
that utilize an ecological perspective as proposed by Kropf (1996) call
for integrative infusion methods that do not require faculty expertise with
IDD. She provides ideas for using case studies, supplemental readings, and
assignments that would give students exposure to this population.
Russo-Gleicher (2007) emphasizes the necessity for IDD content in
human behavior courses where the life course perspective can be used to
highlight service needs at various life stages. Policy and practice courses
are also areas where IDD-specific knowledge and skills need be taught to
both undergraduate and graduate students. Ideally, social workers would
be included in the development of health and education programs as well
Health Disparities, IDD, and Social Work 185
as the creation and evaluation of evidence-based interventions that can be
offered through an internship or practicum. Beyond coursework, Laws and
colleagues (2010) encouraged social work educators to partner with IDD
service providers and UCEDDs to help identify social work-related training
needs. These partnerships may lead to field practicum sites and opportuni-
ties for collaborative research further enhancing student opportunities with
this population.
Research Needs
Current research in medical homes and care coordination models focus on
children with chronic conditions and/or special health care needs (Coughey
et al., 2010). These models could be expanded to include older adults with
IDD whose comorbidities increase with age (Haveman et al., 2011; Robinson
et al., 2010). Although nurses are the primary coordinator in most care coor-
dination and medical home models (Boyd et al., 2009; Chiverton, Lindley,
Tortoretti, & Plum, 2007; Wegner et al., 2008), the expertise of social work-
ers in connecting, referring, and maintaining relationships could easily be
applied to a model with older adults with IDD. Coughey and colleagues
(2010) provided evidence that a medical home/care coordination model can
be successful when staff members other than nurses are responsible for
coordination. More research needs to be done to provide evidence-based
support of the creation of medical homes coordinated by social workers,
especially for aging populations and adults with IDD.
CONCLUSIONS
Social workers are uniquely poised to bridge the aging services network,
social services network, and US health care system to coordinate and
improve care for one of the most vulnerable populations. The increasing
longevity and multiple chronic needs of people with IDD provide the incen-
tive for social work programs to expand formal coursework and continuing
education on the IDD population. Advocacy is needed within and beyond
human services agencies to reposition social workers as the care coordina-
tion experts, and research is needed to determine best health care practices
in meeting the myriad biopsychosocial needs of people with IDD who are
aging. Rising health care costs and the burden on Medicaid and Medicare
provide the financial incentive to find the most cost-effective means of pro-
viding care to this dual-eligible population. Social workers can be the catalyst
for change through training/education, advocacy, and identification of needs
on all levels (i.e., individual, community, state) to create and sustain the
valuable and necessary partnerships to reduce the health care disparities
experienced by people who are aging with IDD.
186 L. M. Robinson et al.
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Making the Invisible Visible: Are Health Social
Workers Addressing the Social Determinants of
Health?
Shelley L. Craig PhD LCSW , Raluca Bejan MSW & Barbara Muskat PhD RSW
To cite this article: Shelley L. Craig PhD LCSW , Raluca Bejan MSW & Barbara Muskat PhD RSW
(2013) Making the Invisible Visible: Are Health Social Workers Addressing the Social Determinant
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Social Work in Health Care, 52:311–331, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981389.2013.764379
Making the Invisible Visible: Are Health
Social Workers Addressing the Social
Determinants of Health?
SHELLEY L. CRAIG, PhD, LCSW and RALUCA BEJAN, MSW
Factor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, Ontario, Canada
BARBARA MUSKAT, PhD, RSW
The Hospital for Sick Children, Toronto, Ontario, Canada
This study explored the ways in which health social workers (HSW)
address the social determinants of health (SDH) within their social
work practice. Social workers ( n = 54) employed at major hospitals
across Toronto had many years of practice in health care ( M =
11 years; SD = 10.32) and indicated that SDH were a top priority
in their daily work; with 98% intentionally intervening with at least
one and 91% attending to three or more. Health care services were
most often addressed (92%), followed by housing (72%), disability
(79%), income (72%), and employment security (70%). Few HSW
were tackling racism, Aboriginal status, gender, or social exclusion
in their daily practice.
KEYWORDS hospital social work, social work, social determi-
nants of health, medical social work, health and social care
Received June 19, 2012; accepted January 1, 2013.
We are grateful to the inspired social workers from Toronto Western Hospital, The
Hospital for Sick Children, St. Michaels Hospital, Centre for Addiction and Mental Health,
University Health Network, and the Ontario Association of Social Workers for sharing their
time and insight with us.
Address correspondence to Shelley L. Craig, PhD, LCSW, Assistant Professor, University
of Toronto, Factor-Inwentash Faculty of Social Work, 246 Bloor Street W., Toronto, Ontario,
M5S 1A1, Canada. E-mail: shelley.craig@utoronto.ca
311
312 S. L. Craig et al.
INTRODUCTION
The social determinants of health (SDH) have been defined as the “causes
of the causes” (Marmot, 2007, p. 1153), the environmental, social, politi-
cal, cultural, and economic factors (Baum, Begin, Houweling, & Taylor,
2009), adverse social conditions (Fisher & Baum, 2010), or social inequalities
(Daniels, Kennedy, & Kawachi, 1999) that influence individuals’ health status
(Kosny, 1999). These SDH mirror fundamental social hierarchical structures
(Marmot, 2007), and affect the degree of health and illness experienced by
members of various socioeconomic groups (Halfon, Larson, & Russ, 2010;
Raphael et al., 2006). Social determinants, rather than a genetic predispo-
sition or personal health choices (Marmot & Wilkinson, 2003), have been
found to be the primary correlates of health (Commission on the Social
Determinants of Health [CDSH], 2008). Although all societies are stratified
along social axis of differentiation, such as ethnicity, race, gender or occupa-
tion, health disparities mainly result from the unequal distribution of power,
privilege, and resources among various groups (Marmot, 2007). A signifi-
cant body of multidisciplinary and international literature has determined
that many health and mental health issues are rooted in preventable social
inequalities such as poverty, inadequate housing, food insecurity, and social
exclusion (Berkman & Kawachi, 2000; Raphael, 2008a; Rosenberg, 2008),
themes familiar to social workers.
The social causes of ill health have been recognized since the 1980s, fol-
lowing the public release of the Black Report and the Health Divide (Raphael,
2004). Starting points for future research studies, these reports explored the
relation between social class and health. The Black Report was the first to
link material deprivation with health differences, as particularly defined by
mortality and morbidity rates (Fein, 1995; Raphael, 2004; Smith, Bartley, &
Blane, 1990). The materialist-structuralist perspective approach highlighted
in the report (Marmot, 2001; Marmot, Kogevinas, & Elston, 1987), identified
societal structures’ impact on health (Fein, 1995; Feinstein, 1993; Smith et al.,
1990) and proposed long-term policy recommendations to better address
health inequalities (Marmot, 2001). Later research studies constructed fur-
ther knowledge regarding the social causes of health disparities (Fein, 1995;
Phillimore, Beattie, & Townsend, 1994), mainly framed in terms of mate-
rial resources (Feinstein, 1993), as distal causes of disease (Link & Phelan,
1995). By 1995, the link between socioeconomic status (SES) and health out-
comes has been well established (Dahl, 1994; Feinstein, 1993). Ten years
after the Black Report, the awareness of health inequalities (Whitehead,
Evandrou, Haglund, & Diderichsen, 1997) and mortality differences across
class divisions has increased (Smith et al., 1990).
The SDH paradigm is grounded in values of social justice, human rights,
and equality (Bywaters, McLeod, & Napier, 2010). It goes well beyond the
bio-medical and behavioral approaches (Watt, 2007), traditionally ingrained
Applying SDH to Social Work Practice 313
within the public health discourse (Cameron, Mathers, & Parry, 2006) and
entails a holistic view of praxis (Nayar, 2007), as a foundational basis of
health (Buijs & Olson, 2001). It further defines the social, cultural, and polit-
ical contextual circumstances (Hankivsky & Christoffersen, 2008; Heinonen,
Metteri, & Leach, 2009; Irwin & Scali, 2007) as proxies for opportunities and
resources influencing health outcomes (Frohlich, Ross, & Richmond, 2006)
and suggests that physical as well as mental health and well being, are con-
ditions embedded in social experiences (Heinonen et al., 2009). Thus, the
SDH framework provides a mechanism to understand multilevel policy and
practice interventions designed to improve health (Raphael, 2008a).
Health Social Work and the Social Determinants of Health
A SDH perspective fits well with social work’s fundamental values of social
justice and also with the ecological model emphasizing a broad context
of individual functioning (Kasperski, Power, & VanderBent, 2005). The
International Federation of Social Work (IFSW) has stated that health is both
a human rights and social justice issue (Karban, 2010), yet most of the exis-
tent literature is focused on policy directives and fails to adequately address
the relevance for social workers in direct practice. HSWs bring a holistic
perspective to health care, by incorporating a full range of psychological,
social, and emotional factors (Rachman, 1995) and by focusing on the social
effects of illness rather than on the illness in itself (Volland, 1996). They are
educated to consider the social context more so than any other profession
(Lymbery, 2006), with a particular focus on the on the ecological perspective,
which suggests that individuals function within larger systems (Claiborne &
Vandenburgh, 2001), and a biopsychosocial approach, which emphasizes
the person in the environment (Berkman, 1996; Cowles & Lefcowitz, 1992).
Therefore, HSWs are considered to be closer to service users (Herod &
Lymbery, 2008), provide a continuum of care coordination and support
for their clients (Keefe, Geron, & Enguidanos, 2009), and identify many
more patient psychosocial problems than professionals from other disci-
plines (Mizrahi & Abramson, 2000). Their presence in health care settings
has been associated with fewer emergency visits, less hospital admissions,
and reduced lengths of patient stay (Keefe et al., 2009). It has been suggested
that other health care professionals would not be able to adequately address
these issues, if HSWs were to be withdrawn from medical multidisciplinary
teams (Herod & Lymbery, 2008). Although scholarly work has emphasized
the need for research related to SDH for many years (Baum et al., 2009;
Raphael, 2008) and the need for HSWs to concentrate on social inequalities
(Rosenberg, 2008), there has been a lack of practice-based research about
how HSWs are addressing these issues. This pilot study aims to understand
the relevance of this conceptual framework to social work by exploring those
SDH currently attended to by HSWs within their daily work.
314 S. L. Craig et al.
The Social Determinants of Health
SDH definitions have been inconsistently reported in the literature
(Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006), as they dually
refer to the social factors determining health, but also to the processes
and mechanisms contributing to their unequal distribution (Graham, 2004).
Without a SDH universal typology in place, scholarly work has inconsis-
tently been reporting on a variety of health influences (Buijs & Olson, 2001;
Courtwright, 2008) including: SES (income, education, employment, working
conditions), personal health practices, coping skills, healthy child develop-
ment, physical environments, social support networks (Buijs & Olson, 2001),
Aboriginal status, geographical locations (Frohlich et al., 2006), chronic stres-
sors, racism, or the medicalized stigmatization of disease (Courtwright, 2008).
Using Public Health Agency of Canada’s categorization of SDH (PHAC, 2004),
this article reports on those SDH most frequently cited within the litera-
ture and loosely organizes them into several domains of social stratification:
(1) SES: income and its distribution; unemployment and employment secu-
rity; education, employment, and working conditions; early life; (2) social
supports: housing, social safety net, food security; (3) diversity and equity:
gender, racism, Aboriginal status, disability status, social exclusion; and
(4) health care services. Although this article is not intended to provide
an exhaustive review of the SDH (see Rosenberg, 2008 for a comprehensive
review), each of these categories is briefly described below to contextualize
the pilot study.
SOCIOECONOMIC STATUS
Although social SES, as defined by social SES empirical measures, such
as occupation, income and education (Fein, 1995), has often been at
the center of analyses on health disparities (Marmot et al., 1987), the
SDH approach also includes the hierarchized dynamics of social positions
(Bartley, Blane, & Smith, 1998). A social gradient (Marmot, 2003), as a rel-
ative position in social hierarchy (Marmot, 2001; Marmot et al., 1987) was
deemed to affect health (Marmot, 2003) and to translate into differential
health outcomes (Marmot, 2001, 2003; Marmot et al., 1991). Social gradi-
ent’s effect on health (Daniels et al., 1999; MacDonald, 2006) has been
explained via a cultural behavioral model (Irwin & Scali, 2007) that iden-
tifies chronic stress (Bywaters et al., 2010), links stressors to their contexts
(Schulz et al., 2002), and associates the differential distribution of health
behaviors and living standards (Graham, 2004) with hierarchical social posi-
tions (Frohlich et al., 2006; Irwin & Scali, 2007). Although intersectional
SDH perspectives (Hankivsky & Christoffersen, 2008) do not presume the
importance of ethnicity, gender, and other singular categorical positionali-
ties (Graham, 2004; Hankivsky & Christoffersen, 2008), health disparities are
Applying SDH to Social Work Practice 315
related to the inequitable distribution of social and cultural capital among
economically variant groups (Frohlich et al., 2006). Overall, SES factors are
markers for position in society (Marmot, 2003). Those in a lower economic
strata are more likely to experience adverse health outcomes (Rahkonen,
Laaksonen, Martikainen, Roos, & Lahelma, 2006; Marmot, 2007; Wilson,
2009), higher rates of mortality and morbidity (Auger, Zang, & Daniel, 2009;
Isaacs & Schroeder, 2004), and frequent use of health care services (Barnett,
Coyle, & Kearns, 2000); yet individuals’ health depends on context specific
stressors: physiological, psychological, or behavioral (Fiscella & Williams,
2004; Schulz et al., 2002).
Income inequality at the neighborhood level and socially differentiated
material resources have been found to unequally influence the distribution of
health outcomes (Irwin & Scali, 2007; Watt, 2007; Whiteside, 2004) and health
care (Kilbourne et al., 2006) at the societal, environmental, behavioral, and
disease levels (Graham, 2004).
Unemployment and employment insecurity have been associated with
poor physical health and well-being (Bambra & Eikemo, 2009; Kalil, Ziol-
Guest, Hawkley, & Cacioppo, 2010), chronic disease (Safaei, 2008), psycho-
logical distress (D’Souza et al., 2005; Puig-Barrachina, Malmusi, Martenez, &
Benach, 2011; Virtanen, Vahtera, Kivimaki, Pentti, & Ferrie, 2002), poor self-
reported health (Bambra & Eikemo, 2009; Burgard, Brand, & House, 2009),
higher rates of medical visits (D’Souza et al., 2005), and decreased medical
coverage (Kendall, Rose, & Kim, 2009).
Lower educational levels have also been linked to adverse health out-
comes in later life (Albert & Davia, 2011; Goldman & Smith, 2002; Stafford,
Nazroo, Popay, & Whitehead, 2008), including shorter life expectancies,
even after controlling for SES and economic resources (Baker, Leon, Smith
Greenaway, Collins, & Movit, 2011). The link between education and health
(Marmot, 2003) may be mediated through health behaviors (Daniels et al.,
1999), literacy levels (Reading & Wien, 2009), income (Fiscella & Williams,
2004), and labor participation (Fiscella & Williams, 2004).
Poor working conditions (Daniels et al., 1999; Kaikkonen, Rahkonen,
Lallukka, & Lahelma, 2009), such as precarious or temporary, employment
(Burgard et al., 2009; Kim, Kim, Park, & Kawachi, 2008), occupational sta-
tus (Clougherty, Souza, & Cullen, 2010), work-related stress (Holmgren,
Dahlin-Ivanoff, Bjorkelund, & Hensing, 2009; Vanroelen, Levecque, Moors, &
Louckx, 2010), longer working hours (Artazcoz, Cortes, Escriba-Aguir,
Cascant, & Villegas, 2009), high level of work–life conflicts (McNamara,
Bohle, & Quinlan, 2011), and a lack of job control (Rahkonen et al., 2006),
have been associated with adverse health outcomes (Clougherty et al., 2010),
including poor self-rated physical (Holmgren et al., 2009; Kim et al., 2008)
and mental health (Artazcoz et al., 2009).
From a life course epidemiological perspective (Kuh, Ben-Shlomo,
Lynch, Hallqvist, & Power, 2003), children’s development is dependent on
316 S. L. Craig et al.
their environments (Daniels et al., 1999; Marmot, 2007). The exposure to risk
factors during early life (Johnson & Schoeni, 2007) has been found to impact
health (McGowan & Szyf, 2010; Melchior, Moffitt, Milne, Poulton, & Caspi,
2007; O’Rand & Hamil-Luker, 2005), throughout all life stages (Marmot, 2007;
Reading & Wien, 2009).
SOCIAL SUPPORTS
Social supports such as housing, food security, and a social safety net have
been shown to be health predictors. Poor housing, defined as unaffordable
(Pollack, Griffin, & Lynch, 2010) or unstable (Kushel, Gupta, Gee, & Haas,
2006) is related to poor self-rated health, higher rates of acute health care
use (Kushel et al., 2006), chronic health conditions (Pollack et al., 2010),
and non-adherence to health care regimes (Pollack et al., 2010). In turn,
improvements in housing conditions have been linked to better self reported
levels of physical and mental health, along with lower rates of health services
use (Thomson, Petticrew, & Morrison, 2001).
Food insecurity, which generally refers to one’s inability to afford suffi-
cient food for an active and healthy life (Seligman, Laraia, & Kushel, 2010),
has been associated with high rates of acute health services utilization
and low rates of access to care (Kushel et al., 2006), as well as adverse
physical (Seligman et al., 2010) and mental health outcomes (Stuff et al.,
2004).
Social safety networks, as the universal social protection benefits and
programs intended to support health, including welfare and unemployment
insurance, various social services or health care (Iatridis, 2000) are associated
with better population health (Malmberg-Heimonem, 2010; Marmot et al.,
2008).
DIVERSITY AND EQUITY
Social exclusion further entrenches inequalities in health (Gray, 2003) and
can include aspects of diversity such as disability, gender, and racial discrim-
ination. The association between social marginalization and poor health has
been related to levels of chronic stress factors (Fiscella & Williams, 2004).
Fair or poor health (Havercamp, Scandlin, & Roth, 2004) has been more
commonly reported by those with disabilities and developmental disabili-
ties compared to non-disabled adults. Gender differences are also found.
For example, adult women are more likely to be hospitalized for depres-
sive disorder and men are more likely to report bipolar disorder (Savoie,
Morettin, Green, & Kazanjian, 2004). Racial discrimination has also been
associated with poor or fair self-rated health, lower physical functioning,
and higher rates of cardiovascular disease (Harris et al., 2006; Keefe, 2010),
Applying SDH to Social Work Practice 317
and lifetime illness (Kwate, Valdimarsdottir, Guevarra, & Bovbjerg, 2003).
Finally, a number of chronic physical (Larson, Gillies, Howard, & Coffin,
2007) and mental health (Reading & Wien, 2009) conditions are more preva-
lent among Aboriginal individuals than the general population (Anand et al.,
2001; Reading & Wien, 2009).
HEALTH CARE SERVICES
The health care system has been considered a social determinant in itself,
given it mediates access to all other social determinants (Marmot et al., 2008).
Availability and access to health services has been found to significantly
reduce people’s mortality (Bloom, 2001). A systematic review on the associ-
ation between health insurance and health status documented poorer general
health and higher mortality rates for medically uninsured U.S. residents,
in comparison with those insured (Hadley, 2003). Uninsured individuals
have also been found to report many more unmet health needs (Ayanian,
Weissman, Schneider, Ginsburg, & Zaslavsky, 2000), use fewer preventive
services (Sudano & Baker, 2002), and experience cost barriers in seeing a
physician (Ayanian et al., 2000), resulting in increased use of emergency
rooms for primary care (CIHI, 2012).
METHODS
Sample
Toronto, the largest city in Canada, was chosen for this study, as it con-
tains multiple major hospitals employing many HSWs. A self-report survey
collected information from hospital-based social workers about the nature
of their daily work. Participants (N = 65) were recruited through contact
with social work practice leaders in hospitals who distributed an informa-
tional flyer to social workers in seven settings. These included hospitals
serving adults, children, patients with medical and mental health issues, and
encompassed staff who work with a broad variety of medical conditions.
Study participants represented a range of professional and demographic
backgrounds. Their average age was 43.07 (SD = 14.02) and ranged from
22 to 65 years. Participants identified as female (87%) or male (13%), and
as heterosexual (91%) or sexual minority (9%). Race and ethnicity included
Caucasian (75%); Asian (12%); mixed (9%); Aboriginal (2%); African (2%),
and the highest level of education indicated as MSW (83%) followed by
BSW (13%) and PhD/DSW (2%). Table 1 presents the demographics of the
sample.
Participants reported being engaged in many years of social work prac-
tice (M = 14 years; SD = 12.7), specifically in health care settings (M =
11 years; SD = 10.32), ranging, on both dimensions, from less than 1 year
318 S. L. Craig et al.
TABLE 1 Summary of Participants’ Demographic Characteristics
Number Percent
Age group (n = 52)
15–24 3 5.8
25–44 27 51.9
45–64 18 34.6
65–74 4 7.7
Gender (n = 54)
Female 47 87
Male 7 13
Race/Ethnicity (n = 51)
Caucasian/White European 36 70.6
South Asian 6 11.8
Mixed Background 4 7.8
East Asian 3 5.9
Aboriginal 1 2.0
African American 1 2.0
Sexual orientation (n = 54)
Heterosexual 50 92.6
Queer 2 3.7
Gay 1 1.9
Other 1 1.9
Education (n = 54)
MSW 45 83.3
BSW 7 13.0
PhD/DSW 1 1.9
Other 1 1.9
Years as a social worker (n = 54)
Less than 1 year 4 7.4
1–5 years 15 27.8
6–10 years 7 13.0
11–20 years 12 22.2
Over 20 years 16 29.6
Years in health care settings (n = 53)
Less than 1 year 6 11.3
1–5 years 18 34.0
6–10 years 8 15.1
11–20 years 10 18.9
Over 20 years 11 20.8
Not every participant answered each question and therefore, the actual number (n) is
reported for clarification purposes.
to over 20 years of experience. Their job titles included social worker (66%),
professional practice leader (10%), advanced practice clinician (9%), coun-
selor (9%), and case manager (6%). Chronic care, rehabilitation, emergency
care, outpatient counseling, oncology, and heart units were the participants’
reported workplace settings. In terms of job duties, they conducted assess-
ments (61%), advocacy work (42%), counseling (35%), case management
(33%), and research (9%).
Applying SDH to Social Work Practice 319
Measures
Participants provided basic demographic information (age, race, gender
identity, sexual orientation, educational degree), job details (number of years
in social work practice, number of years in a health care setting), job title, job
duties and overall job satisfaction, ranging from very dissatisfied to very sat-
isfied. Public Health Agency of Canada’s explanation of the SDH (PHAC,
2004) was used to capture the key constructs. The final list was gener-
ated in collaboration with two HSWs. The 12-item measure included health
care services, housing, income and its distribution, social exclusion, gen-
der, unemployment and employment security, aboriginal status, early life,
disability status, education, employment and working conditions, and food
security. Participants were asked to identify whether or not they addressed
each of the SDH through their daily hospital work practice (yes/no). The
term addressing was operationalized to include HSWs role specific efforts in
reducing the impact of social factors and underlying social processes associ-
ated with health disparities on their clients, during the assessment, planning,
intervention, or referral stages. Data was collected by a two-person team,
one who is a member of a social work faculty and the other who is a social
work leader in a hospital. Respondents were instructed to complete the sur-
vey anonymously. The study was approved by the research ethics board at
the principal investigator’s university. Using SPSS 19.0, quantitative analy-
sis of the data, including descriptive statistics, correlations, and Chi-square
analyses, was conducted.
RESULTS
Findings indicate that SDH were a priority for the participants, with 98
%
intervening with at least one and 91% attending to three or more of the
SDH. HSWs defined intervention activities as the provision of assistance by
directly acquiring services for patients, educating them about resources or
advocating with the medical team for consideration of the relevant SDH in
their care. On average, HSWs in health care settings have been addressing
7 out of the 14 SDH surveyed. Table 2 illustrates the range and frequencies of
social work involvement with SDH in their daily practice. Health care services
were reported to receive the greatest attention, (92%), followed by housing
(72%), disability status (79%), income and its distribution (72%) and unem-
ployment and employment security (70%). A further 60% of medical HSWs
were addressing factors related to the social safety net, 57% were attending
to those related to employment and working conditions, while others were
addressing food security (47%) and education (47%). On the lower end,
many participants did not report attending to several SDH, including early
life (79%), Aboriginal status (68%), racism (68%) gender (66%), and social
T
A
B
L
E
2
F
re
q
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e
n
ci
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s
o
f
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e
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SD
H
an
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u
ar
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A
n
al
y
se
s
So
ci
o
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co
n
o
m
ic
st
at
u
s
(S
E
S)
SD
H
%
In
co
m
e
an
d
it
s
d
is
tr
ib
u
ti
o
n
U
n
e
m
p
lo
y
m
e
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t
an
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m
p
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m
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t
in
se
cu
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ty
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d
u
ca
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o
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m
p
lo
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m
e
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t
an
d
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rk
i
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g
co
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d
it
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s
E
ar
ly
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fe
In
co
m
e
an
d
it
s
D
is
tr
ib
u
ti
o
n
7
2
–
p
< .0
1
∗∗
p
=
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1
p
=
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6
p
=
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1
U
n
e
m
p
lo
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m
e
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E
m
p
lo
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m
e
n
t
In
se
cu
ri
ty
7
0
p
<
.0
1
∗∗
–
p
=
.1
3
p
=
.0
6
p
=
.3
3
E
d
u
ca
ti
o
n
4
7
p
=
.2
1
p
=
.1
3
–
p
<
.0
1
∗∗
p
<
.0
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∗∗
E
m
p
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e
n
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an
d
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o
rk
in
g
C
o
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d
it
io
n
s
5
7
p
=
.3
6
p
=
.0
6
p
<
.0
1
∗∗
–
p
<
.0
1
∗∗
E
ar
ly
Li
fe
2
1
p
=
.1
1
p
=
.3
3
p
<
.0
1
∗∗
p
< .0 1 ∗∗
–
So
ci
al
Su
p
p
o
rt
SD
H
%
H
o
u
si
n
g
F
o
o
d
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cu
ri
ty
So
ci
al
Sa
fe
ty
N
e
t
–
–
H
o
u
si
n
g
7
2
–
p
<
.0
1
∗∗
p
<
.0
1
∗∗
–
–
F
o
o
d
Se
cu
ri
ty
4
7
p
<
.0
1
∗∗
–
p
<
.0
1
∗∗
–
–
So
ci
al
Sa
fe
ty
N
e
t
6
0
p
<
.0
1
∗∗
p
<
.0
1
∗∗
–
–
–
D
iv
e
rs
it
y
an
d
E
q
u
it
y
SD
H
%
G
e
n
d
e
r
R
ac
is
m
A
b
o
ri
g
in
al
St
at
u
s
D
is
ab
il
it
y
St
at
u
s
So
ci
al
E
x
cl
u
si
o
n
G
e
n
d
e
r
3
4
–
p
<
.0
1
∗∗
p
<
.0
1
∗∗
p
=
.8
5
p
< .0 1 ∗∗ R ac is m
3
2
p
<
.0
1
∗∗
–
p
<
.0
1
∗∗
p
=
.7
0
p
< .0 1 ∗∗ A b o ri g in al St at u s 3 2 p < .0 1 ∗∗ p < .0 1 ∗∗ – p = .7
3
p
< .0 1 ∗∗ D is ab il it y St at u s
7
9
p
=
.8
5
p
=
.7
0
p
=
.7
3
–
p
=
.9
0
So
ci
al
E
x
cl
u
si
o
n
4
7
p
<
.0
1
∗∗
p
<
.0
1
∗∗
p
<
.0
1
∗∗
p
=
.9
0
–
A
st
e
ri
sk
s
(∗
∗ )
in
d
ic
at
e
si
g
n
ifi
ca
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ce
at
th
e
.0
1
le
v
e
l
(p
< .1
).
D
as
h
e
s
(–
)
in
d
ic
at
e
th
at
:
(a
)
n
o
o
th
e
r
SD
H
ar
e
se
lf
-r
e
p
o
rt
e
d
w
it
h
in
th
e
ca
te
g
o
ri
ca
l
ax
e
s
o
r
(b
)
th
e
an
al
y
si
s
is
n
o
t
fe
as
ib
le
w
it
h
in
e
ac
h
SD
H
.
320
Applying SDH to Social Work Practice 321
exclusion (53%). To understand whether job factors were associated with
particular SDH, chi-square analyses were conducted between the number of
years in social work practice, job satisfaction and respectively, each singular
and the total number of addressed SDH. For all determinants, no statistically
significant differences occurred with respect to participants’ experience or
job satisfaction.
As seen in Table 2, chi square analyses were conducted to examine
the relationships between those SDH addressed by participants in their daily
practice. Statistically significant correlations (p < .1) were observed between
income inequality and unemployment and employment insecurity, early life
and education, and early life and working conditions. In contrast, signifi-
cantly higher percentages were reported within the social supports category.
Those participants addressing housing were also more likely to address food
security and social safety net factors. However, within the diversity and
equity domain, with the exception of disability status, statistically significant
associations (p < .1) were observed among all other determinants, including
gender, racism, social exclusion, and Aboriginal status.
DISCUSSION
This study provided valuable information about the work of HSWs, partic-
ularly regarding: (1) the relationship of employment and social supports
constructs to the SDH and (2) the most influential SDH addressed in
their daily practice. The lack of significant correlations between SDH and
participants’ employment measures indicated that, regardless of their job sat-
isfaction or professional experience, social workers are dealing with many
SDH frequently and concurrently. Although many SDH are addressed by hos-
pital HSWs in their daily practice, efforts solely directed toward disparities
related to diversity and equity, such as racism, Aboriginal status, gender, and
social exclusion, do not take the majority of their time. Further, participants’
self-reported inability to intervene with each one of these determinants was
significantly associated with the lack of action on those within the same
domain. For instance, if racism was not addressed, the other equity and
diversity issues such as Aboriginal status, gender, and social exclusion were
also not likely to be a focus.
There are several explanations for why HSWs report the least amount
of attention to diversity and equity related SDH. First, it is plausible that,
the very same medical settings per se, had contributed to HSWs choice of
attended SDH. Since prior research findings (Craig & Muskatt, 2013) sug-
gested that HSWs roles within urban hospitals often resembled the figurative
work aspects of firefighter, broker, and glue, it is likely that they are focused
on proximal concerns, such as health care utilization, rather than on distal
and more complex issues such as racism and gender. These findings might
322 S. L. Craig et al.
also suggest that HSWs are focused on meeting immediate micro-level needs,
with less available time to take on added macro issues.
Second, the medical model’s dominance within the health care settings
(Baum et al., 2009; Niederdeppe, Bu, Borah, Kindig, & Robert, 2008), which
is often criticized for failing to consider the impact of wider environments on
individual health outcomes (Raphael, Curry-Stevens, & Bryant, 2008), could
potentially impact practitioners’ focus on individual treatments over inter-
ventions addressing macro social determinants of health. The perspective
that an individual bears sole responsibility for health (Kosny, 1999), which
links adverse health outcomes with biomedical markers, erroneous personal
choice, and risky behaviors (Raphael et al., 2008). In such cases, health
promotion efforts become targeted toward changing such unsafe individual
behaviors (Baum et al., 2009) and less attention is ultimately paid to the
societal context and its influence on health inequities. It is hard to know if
a study’s participants have been attending to the health service utilization as
the main determinant of health, simply because they are employed in health
care settings or merely because they share the general public belief that
“medical care is the primary determinant of health” (Niederdeppe et al., 2008,
p. 492). Practitioners’ responses could also be reflective of the overall “pub-
lic health gaze” (Raphael, 2008, p. 15), which has not adequately developed
concrete social policies to address the numerous forms of marginalization
impeding on individuals’ health (Baum et al., 2009; Raphael, 2008) and to
shape the quality of SDHs (Raphael, 2006). HSWs’ direct practice occurs in
settings shaped by complex political environments and social work funding
often requires direct services such as discharge, mental health, or behavioral
challenges, hence efforts related to the distal SDH may be further challenging
in these environments.
IMPLICATIONS FOR SOCIAL WORK PRACTICE
By increasing the visibility of singular and relational SDH aspects that are
attended to by HSWs in their daily work, this study aims to assist them in
efforts to better understand and address the socially created inequalities in
health (Bywaters et al., 2010), both at the population and individual lev-
els (Graham, 2004). At a policy level, medical HSWs could strengthen their
advocacy efforts (Bywaters et al., 2010) and augment the public health dis-
course focused on health outcomes (Graham, 2004), through the support of
employment, fiscal, or housing policies and programs, aimed at reducing dis-
parities that impact health (Graham, 2004). Further, this study identifies that
the mutually reinforced (Frohlich et al., 2006) and intersecting (Hankivsky &
Christoffersen, 2008) SDH, at both, micro and macro levels of practice are
important areas for HSW to address.
Applying SDH to Social Work Practice 323
At the direct level of practice, HSWs are trained to attend to the diversity
of circumstances influencing individuals’ physical and mental health and
well-being (Heinonen, Metteri, & Leach, 2009). Therefore, although most
health promotion workers tend to address SDH symptoms rather than the
determinants in themselves (Whiteside, 2004), HSWs have the potential to
go beyond such efforts to better facilitate the development and implemen-
tation of interventions addressing the social factors and social processes
producing health disparities. HSWs can use the SDH framework to address
health disparities outside their institutional sphere (Courtwright, 2008) and
promote the SDH paradigm within their vast range of assessment, planning
and intervention related activities. At a practice level, this could translate in
directly supporting clients’ health by facilitating their access to health knowl-
edge and education resources (Frohlich et al., 2006), providing them with
tangible SDH information, connecting them with appropriate referral ser-
vices, countering disease stigmatization (Courtwright, 2008), intervening in
discrimination within health care, addressing biases related to race and lan-
guage differences (Nguyen, Ho, & Williams, 2011), promoting social support
(Schulz et al., 2002), and developing programs and interventions that could
diminish the impact of contextual stressors on health and reduce subsequent
health disparities.
This study’s limitations must be considered when interpreting the results.
Our sample was relatively small and homogenous, with the majority of par-
ticipants identifying as Caucasian and therefore, it might not be entirely
representative of all HSWs or hospital environments. It is important for future
SDH research to investigate how the concepts of race, gender, and other
social categories operate as social processes within research settings, even
more so than participants’ independent variables (Cole, 2008). Moreover,
data is based on participant self-report, which may contribute to reporting
biases. Despite such limitations, this study adds to the existent scholarly
knowledge as it relates to hospital HSWs’ practice of addressing the vast
range of SDH within their daily work.
Further research should create a more complex measure of SDH and
detail the specific types of interventions used to address each SDH, have
a larger and more diverse sample that compares the impact on SDH across
other disciplines, and include participants’ feedback about how SDH informs
their practice in health care settings. Finally, HSWs should consider the
ways in which they impact the SDH in their daily practice, as professional
expectations continue to focus on service efficiency and best practices, and
strive to demonstrate their efforts as effective and positive influences on vul-
nerable patients’ outcomes (Judd & Sheffield, 2010). Partnerships between
community and university based researchers using a practice-based research
approach, such as those employed in this study, can assist HSWs to identify
their roles, functions, and overall value to the health system.
324 S. L. Craig et al.
CONCLUSION
In sum, participants did address many SDH in their health care prac-
tice; however, they focused more on proximal SDH, such as access to
health care services and housing and less on the complex distal ones,
such as social exclusion. This approach may be suitable for the types of
roles they are hired to fill. It has been advanced that health services are
both causes and solutions to health disparities (Kilbourne et al., 2006).
Improving population health requires a vision of social justice (Krieger,
2001) and therefore there is potential for social work to work toward equal-
ity in health care (Whiteside, 2004). Health inequalities are located at the
heart of social work (Bywaters et al., 2010), and this article hopes to add
to a critical knowledge base by discussing how social work practitioners
are addressing the SDH. It will be difficult for social workers to achieve
goals for a just society until consideration of SDH implications becomes a
priority.
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Volland, P. (1996). Social work practice in health care: Looking to the future with a
different lens. Social Work in Health Care, 24(1), 35–51.
Watt, R.G. (2007). From victim blaming to upstream action: Tackling the social
determinants of oral health inequalities. Community Dentistry and Oral
Epidemiology, 35(1), 1–11.
Applying SDH to Social Work Practice 331
Whitehead, M., Evandrou, M., Haglund, B., & Diderichsen, F. (1997). As the health
divide widens in Sweden and Britain, what’s happening to access to care? British
Medical Journal, 315, 1006–1009.
Whiteside, M. (2004). The challenge of interdisciplinary collaboration in addressing
the social determinants. Australian Social Work, 57 (4), 381–393.
Wilson, J. (2009). Not so special after all? Daniels and the social determinants of
health. Journal of Medical Ethics, 35(1), 3–6.
The Contribution of Social Work and
Social Interventions Across the Life
Course to the Reduction of Health
Inequalities: A New Agenda for Social
Work Education?
Esther Coren, Wendy Iredale, Deborah Rutter &
Paul Bywaters
Inequalities in health and well-being are wide and widening and reflect the disadvantaged
circumstances in which many people live. Users of personal social services in many cases
already experience disadvantaged health and well-being. Social work has established
experience of working with marginalised groups, and may play a role in promoting
individual and community health and well-being. The value base for social work includes
a focus on social justice, which may directly impact on the social determinants of health.
Using four examples of social interventions across the life span, this paper considers the
role that social work can play in improving the health and well-being of disadvantaged
people across the life course, and the implications of this for evidence based social work
practice and education.
Keywords: Inequalities; Health and Well-being; Interventions; Evidence; Social Work;
Education
Since the 1990s, a preoccupation with risk and its management has become central to
social interventions (Bornat and Bytheway, 2010), detracting from a more holistic
approach to social work practice and education (France et al., 2010). Macdonald
ISSN 0261-5479 print/1470-1227 online q 2011 Taylor & Francis
DOI: 10.1080/02615479.2011.586556
Correspondence to: Esther Coren, Department of Social Work, Community and Mental Health/Centre for Research in
Children, Families and Communities, Canterbury Christ Church University, North Holmes Road, Canterbury CT1 1QU,
UK. Email: esther.coren@canterbury.ac.uk
Esther Coren, Canterbury Christ Church University, UK; Wendy Iredale, Sheffield Hallam University, UK; Deborah
Rutter, Social Care Institute for Excellence, UK; Paul Bywaters, Coventry University, UK.
Social Work Education
Vol. 30, No. 6, September 2011, pp. 594–609
and Macdonald (2010) suggest that social work concentrates too heavily on low-
probability, high-cost outcomes. Thus, social care efforts would be better placed in
identifying those whose welfare is seriously compromised and seeking to address the
underlying causes, rather than minimising unquantifiable risks (Gordon and Gibbons,
1998). The key challenge for social workers is to address underlying threats to well-
being that may develop into risk. Thus, social work education optimally needs more
focus on the range of interacting factors which contribute to an individual’s health,
well-being and resources, where there may be no obvious risk of immediate harm but
where well-being and quality of life is threatened.
One way in which social work and social interventions might impact on the
underlying causes that lead to risk is to address factors which underlie inequalities in
health and well-being: the social determinants of health [Commission on the Social
Determinants of Health (CSDH), 2008]. Despite continuing overall improvements in
life expectancy, inequalities in UK health outcomes, for example, are wide and
widening (Boyle et al., 2009), reflecting international patterns. Differences in average
life expectancy between the most and least disadvantaged UK local areas increased
from 9 to 11 years for men over the decade to 2001 (CSDH, 2008). Crucially, however,
inequalities do not impact only on the most disadvantaged, but are reflected in a
gradient across the population: ‘Put simply, the higher one’s social position, the better
one’s health is likely to be’ (Marmot, 2010, p. 4), and this association is a global
phenomenon (CSDH, 2008). Social services are mainly delivered to people with social
and health disadvantages, a large proportion of whom are already ill and/or disabled.
Social work has established experience of working with marginalised groups, and may
play an important role in promoting individual and community health and well-
being. Social work values include a focus on social justice, human rights and
empowerment which may directly impact on the social determinants of health
(Bywaters, 2009). By interrogating the role that social work can play in the health and
well-being of disadvantaged people across the life course, important evidence-based
recommendations for social work education can be developed.
The social determinants of health—‘the circumstances in which people grow, live,
work, and age, (and how they are) shaped by political, social, and economic forces’—
impact on health status throughout the life span (Marmot, 2010, Preface). These
determinants reflect the conditions of social life which contribute to social inequality
and well-being: access to material resources and services, locality factors, education,
training and employment, and individual factors such as access to social capital and
the confidence or esteem to benefit from opportunities. Many users of personal social
services have a lifetime history of such disadvantaged circumstances (McLeod and
Bywaters, 2000; CSDH, 2008) and this may be central to their involvement with
personal social services.
Implicit within this complex understanding of health, and disadvantages in health
and well-being, is the acknowledgement that health cannot be reduced to physical
pathology. According to the WHO (1948), health is not only the absence of disease,
but a state of complete physical, mental and social well-being. Our focus is therefore
Social Work Education 595
the social determinants and physical, mental and social outcomes of a healthy life, and
how these might be influenced by social interventions.
Poor health and well-being should be seen in terms of cumulative disadvantages
across the life course (Bywaters, 2007) and the effects of early disadvantage on health
and well-being may only be apparent in later life. For example, children and young
people who have experienced abuse or neglect, who are disabled, or in local authority
care, and their parents, are among those most likely to die prematurely as a result of
poor health and unhealthy lifestyles (Davey-Smith, 2003). The health disadvantage of
people with mental illnesses, who have learning disabilities or are disabled, or who are
addicted to drugs or alcohol, is exacerbated because these circumstances create
barriers to economic, environmental and social success, and because their physical
health needs may be neglected (Michael and Richardson, 2008). As the Marmot
Review (2010) argues, investment during the early years of life may be the most
important priority for reducing health inequalities within a generation.
This paper discusses evidence that social work can contribute to reducing health
disadvantage across the life course. Based on a preliminary synthesis of selected
published research—a SCIE research briefing (Coren et al., 2010)—we demonstrate
how social work and social care can impact on factors that contribute to health
disadvantage and how these findings might inform social work education. We use the
framework provided by the UK General Social Care Council’s Codes of Practice for
Social Care Workers (2010) to highlight the correspondence between social work
practice and values and the promotion of health and well-being.
Review of Literature
The literature below illustrates the impact of social care and social work-led
interventions on health. No studies were found which attempted to show that
inequalities in health across the population as a whole were reduced. Therefore the
studies reported were included because they evidenced attempts to improve the health
of service users, through impact upon the social determinants of health.
Four examples of social interventions across the life span were identified: early
years programmes, kinship care for children in out-of-home care, parenting
programmes for parents with learning disabilities and extra care housing for older
people. The literature included was international research on interventions in the
developed world published in English. For further details on search methods please see
SCIE (2009).
Findings
The UK General Social Care Council Codes of Practice (2010) for social care workers
and employers in the UK describe expected standards of conduct and practice. We
use these in the absence of a more international code of practice. However, the
International Federation of Social Workers (2010) has as its priorities ‘social justice,
human rights and social development through the development of social work, best
596 E. Coren et al.
practices and international cooperation between social workers and their professional
organisations’, consistent with the UK codes.
The codes state that social workers must:
. protect the rights and promote the interests of service users and carers;
. strive to establish and maintain the trust and confidence of service users and carers;
. promote the independence of service users while protecting them as far as possible
from danger or harm;
. respect the rights of service users whilst seeking to ensure that their behaviour does
not harm themselves or other people;
. uphold public trust and confidence in social care services; and
. be accountable for the quality of their work and take responsibility for maintaining
and improving their knowledge and skills.
We use these six key obligations as a framework for reporting evidence of the actual or
potential impact of social work and social care on health disadvantage. Evidence is
presented according to the four intervention types discussed above, with a table
presented for each code, separated into findings and recommendations for practice
development as supported in the literature.
Protect the Rights and Promote the Interests of Service Users and Carers
The research discussed in Table 1 suggests that by protecting the rights and promoting
the interests of service users and carers, social care workers may impact on the social
determinants of health across the life course.
Strive to Establish and Maintain the Trust and Confidence of Service Users and Carers
If service users are to benefit from services, they must have trust and confidence in
services and staff. This may be particularly important for service users from minority
or marginalised groups (see Table 2).
Promote the Independence of Service Users while Protecting Them as Far as Possible from
Danger or Harm
The research discussed in Table 3 suggests that social care-led interventions can impact
on determinants of health by promoting independence, skills, competencies and
resilience across the life course.
Respect the Rights of Service Users whilst Seeking to Ensure that Their Behaviour Does
Not Harm Themselves or Other People
The research discussed in Table 4 suggests that social work values, including the
promotion of social justice and individual rights, are consistent with reducing the risk
of harm to self and others arising from disadvantaged life circumstances.
Social Work Education 597
T
a
b
le
1
P
ro
te
ct
th
e
R
ig
h
ts
an
d
P
ro
m
o
te
th
e
In
te
re
st
s
o
f
S
er
v
ic
e
U
se
rs
an
d
C
ar
er
s
E
ar
ly
ye
ar
s
(E
Y
)
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
(
L
D
)
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
E
ar
ly
ye
ar
s
(E
Y
)
in
v
es
tm
en
t
‘v
it
al
’
to
re
d
u
ce
h
ea
lt
h
in
eq
u
al
it
ie
s
(M
ar
m
o
t
R
ev
ie
w
,
2
0
1
0
).
E
Y
p
ro
g
ra
m
m
es
im
p
ro
ve
m
at
er
n
al
an
d
ch
il
d
h
ea
lt
h
.
S
u
re
S
ta
rt
im
p
ro
v
ed
o
u
tc
o
m
es
(b
re
as
t
fe
ed
in
g
,
b
ab
y
m
as
sa
g
e,
im
p
ro
v
ed
ch
il
d
co
n
fi
–
d
en
ce
)
(N
o
rt
h
ro
p
et
a
l.
,
2
0
0
8
).
S
u
re
S
ta
rt
h
o
m
e
v
is
it
s
im
p
ro
v
ed
fa
m
il
y
h
ea
lt
h
an
d
p
ar
en
ta
l
co
n
fi
d
en
ce
(N
E
S
S
,
2
0
0
1
,
2
0
0
6
).
P
ar
en
ts
w
it
h
L
D
m
ay
n
o
t
re
ac
h
lo
ca
l
se
rv
ic
e
th
re
sh
o
ld
s,
an
d
o
n
ly
co
m
e
to
se
rv
ic
es
’
at
te
n
ti
o
n
if
ch
il
d
re
n
p
er
ce
iv
ed
as
in
n
ee
d
/a
t
ri
sk
(W
ar
d
an
d
T
ar
le
to
n
,
2
0
0
7
).
S
u
re
S
ta
rt
ch
il
d
re
n
h
ad
im
p
ro
v
ed
le
ar
n
in
g
sk
il
ls
/a
tt
it
u
d
es
;
b
et
te
r
so
ci
al
d
ev
el
o
p
m
en
t
(O
fs
te
d
,
2
0
0
9
).
A
d
u
lt
s
w
h
o
re
ce
iv
ed
p
re
-s
ch
o
o
l
p
ro
g
ra
m
m
e
ac
h
ie
v
ed
h
ig
h
er
ac
ad
em
ic
sc
o
re
s
(C
am
p
b
el
l
et
a
l.
,
2
0
0
2
;
H
il
l
et
a
l.
,
2
0
0
3
;
M
el
h
u
is
h
an
d
O
ffi
ce
,
2
0
0
4
;
B
lo
k
et
a
l.
,
2
0
0
5
).
S
u
re
S
ta
rt
in
cr
ea
se
d
co
n
fi
d
en
ce
,
p
ar
en
ti
n
g
sk
il
ls
,
ch
il
d
–
p
ar
en
t
b
o
n
d
s,
so
ci
al
ca
p
it
al
an
d
em
p
o
w
–
er
m
en
t
(N
E
S
S
R
es
ea
rc
h
T
ea
m
,
2
0
0
1
,
2
0
0
6
,
2
0
0
8
;
B
ag
le
y
an
d
A
ck
er
le
y,
2
0
0
6
;
A
n
n
in
g
et
a
l.
,
2
0
0
7
;
A
ll
en
,
2
0
0
8
).
F
in
d
in
gs
:
F
o
r
yo
u
n
g
p
eo
p
le
in
o
u
t
o
f
h
o
m
e
ca
re
,
k
in
sh
ip
ca
re
m
ay
p
ro
m
o
te
b
et
te
r
em
o
ti
o
n
al
/m
en
ta
l
h
ea
lt
h
o
u
tc
o
m
es
co
m
p
ar
ed
to
o
th
er
fo
rm
s
o
f
ca
re
(F
ar
m
er
,
2
0
0
9
;
W
in
o
k
u
r
et
a
l.
,
2
0
0
9
).
S
te
in
(2
0
0
9
)
su
g
g
es
ts
th
at
p
la
ce
–
m
en
t
st
ab
il
it
y
fo
r
ch
il
d
re
n
ag
ed
1
1
þ
is
ce
n
tr
al
to
w
el
l-
b
ei
n
g
,
sc
h
o
o
l
sa
ti
sf
ac
ti
o
n
an
d
g
en
er
al
h
ap
p
in
es
s:
k
in
sh
ip
ca
re
as
so
ci
at
ed
w
it
h
g
re
at
er
p
la
ce
m
en
t
st
ab
il
it
y.
F
in
d
in
gs
:
W
o
m
en
w
it
h
L
D
h
av
e
le
ss
ac
ce
ss
to
m
at
er
n
it
y
ca
re
ch
o
ic
es
(C
am
p
io
n
,
1
9
9
6
).
P
ar
en
ts
w
it
h
L
D
m
ay
ex
p
er
i-
en
ce
d
if
fi
cu
lt
ie
s
ac
ce
ss
in
g
re
so
u
rc
es
(T
ag
g
an
d
K
en
n
y,
2
0
0
6
).
F
in
d
in
gs
:
S
o
ci
al
ca
re
m
ay
im
p
ac
t
o
n
h
ea
lt
h
o
u
tc
o
m
es
b
y
im
p
ro
v
in
g
li
v
in
g
co
n
d
it
io
n
s.
E
x
tr
a
ca
re
h
o
u
s-
in
g
(
E
C
H
)
m
ay
o
ff
er
b
et
te
r
q
u
al
it
y
o
f
li
fe
th
an
el
se
w
h
er
e
(C
ro
u
ch
er
et
a
l.
,
2
0
0
6
;
B
ro
o
k
er
an
d
W
o
o
le
y,
2
0
0
6
).
E
C
H
fo
u
n
d
to
re
d
u
ce
re
si
d
en
ts
’
h
o
sp
it
al
st
ay
s
an
d
se
v
er
it
y
o
f
d
ia
g
n
o
se
d
m
en
ta
l
il
ln
es
se
s
(C
ro
u
–
ch
er
,
2
0
0
7
;
B
ro
o
k
er
et
a
l.
,
2
0
0
9
).
T
en
an
ts
w
h
o
en
g
ag
ed
w
it
h
co
m
–
m
u
n
it
y
ac
ti
v
it
ie
s
in
E
C
H
fo
u
n
d
li
fe
m
o
re
st
im
u
la
ti
n
g
(E
v
an
s
an
d
V
al
–
le
ll
y,
2
0
0
7
;
E
v
an
s,
2
0
0
8
).
L
es
s
k
n
o
w
n
ab
o
u
t
m
ee
ti
n
g
n
ee
d
s
o
f
sp
ec
ifi
c
g
ro
u
p
s,
e.
g
.
th
o
se
w
it
h
se
n
so
ry
im
p
ai
rm
en
ts
/d
em
en
ti
a
(B
er
n
ar
d
et
a
l.
,2
0
0
7
;
D
u
tt
o
n
,2
0
0
9
).
598 E. Coren et al.
T
a
b
le
2
S
tr
iv
e
to
E
st
ab
li
sh
an
d
M
ai
n
ta
in
T
ru
st
an
d
C
o
n
fi
d
en
ce
o
f
S
er
v
ic
e
U
se
rs
an
d
C
ar
er
s
E
ar
ly
ye
ar
s
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
P
ar
en
ts
o
f
d
is
ab
le
d
ch
il
d
re
n
m
ay
fi
n
d
ac
ce
ss
in
g
S
u
re
S
ta
rt
d
if
fi
cu
lt
(P
in
n
ey
,
2
0
0
7
).
M
ai
n
ly
m
o
th
er
s
as
m
en
m
ay
fe
el
u
n
co
m
fo
rt
ab
le
(P
ea
r-
so
n
an
d
T
h
u
rs
to
n
,
2
0
0
6
).
F
in
d
in
gs
:
K
in
sh
ip
ca
re
rs
o
ft
en
p
ai
d
fa
r
le
ss
th
an
n
o
n
-k
in
sh
ip
fo
st
er
ca
re
rs
an
d
o
ff
er
ed
m
in
im
al
su
p
p
o
rt
;
le
v
el
/-
ty
p
e
o
f
su
p
p
o
rt
fo
r
k
in
sh
ip
ca
re
p
la
ce
m
en
ts
v
ar
ie
s
g
eo
g
ra
p
h
ic
al
ly
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
F
in
d
in
gs
:
D
es
p
it
e
p
o
li
cy
,
p
ar
en
ts
w
it
h
L
D
fe
el
ju
d
g
ed
b
y
p
ro
fe
ss
io
n
al
s
n
o
t
su
p
p
o
rt
ed
(O
ls
en
an
d
W
at
es
,
2
0
0
3
;
T
ag
g
an
d
K
en
n
y,
2
0
0
6
)
an
d
fe
ar
re
m
o
v
al
o
f
ch
il
d
re
n
.
P
ar
en
ts
o
ft
en
so
ci
al
ly
ex
cl
u
d
ed
an
d
m
ay
d
ep
en
d
o
n
st
at
u
to
ry
ag
en
ci
es
fo
r
su
p
p
o
rt
(M
cG
ra
w
et
a
l.
,
2
0
0
2
).
T
o
av
o
id
la
b
el
li
n
g
as
‘i
n
n
ee
d
’,
p
ar
en
ts
m
ay
re
je
ct
n
o
t
se
ek
h
el
p
(W
ar
d
an
d
T
ar
le
to
n
,
2
0
0
7
).
F
in
d
in
gs
:
S
u
p
p
o
rt
v
ar
ie
s
b
et
w
ee
n
p
ro
v
id
er
s.
D
if
fe
re
n
ce
s
in
sc
h
em
e
su
cc
es
s
m
ay
d
ep
en
d
o
n
ru
ra
l/
u
rb
an
lo
ca
ti
o
n
(E
as
te
rb
ro
o
k
an
d
V
al
le
ll
y,
2
0
0
8
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
C
re
at
in
g
st
af
f
te
am
s
fr
o
m
v
ar
ie
d
so
ci
al
g
ro
u
p
s
an
d
st
ri
v
in
g
to
re
ac
h
al
l
el
ig
ib
le
fa
m
il
ie
s
re
q
u
ir
es
im
p
ro
v
ed
in
te
r-
ag
en
cy
w
o
rk
in
g
(N
E
S
S
,
2
0
0
5
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
G
re
at
er
eq
u
it
y
in
su
p
p
o
rt
re
q
u
ir
ed
to
im
p
ro
v
e
k
in
co
n
fi
d
en
ce
to
ta
k
e
o
n
fo
st
er
ca
re
an
d
av
o
id
fi
n
an
ci
al
h
ar
d
sh
ip
.
R
ec
o
m
m
en
d
a
ti
o
n
s:
T
o
p
ro
m
o
te
co
n
–
fi
d
en
ce
,
se
rv
ic
e
fo
cu
s
sh
o
u
ld
ac
ti
v
el
y
sh
if
t
fr
o
m
ju
d
g
em
en
t
to
su
p
p
o
rt
.
R
ec
o
m
m
en
d
a
ti
o
n
s:
O
ld
er
p
eo
p
le
’s
ca
re
sh
o
u
ld
n
o
t
b
e
g
eo
g
ra
p
h
ic
al
ly
d
ep
en
d
en
t;
ac
ce
ss
to
so
ci
al
/l
ei
su
re
fa
ci
li
ti
es
m
ay
b
e
es
p
ec
ia
ll
y
im
p
o
rt
an
t
in
ru
ra
l
ar
ea
s
(A
ll
ar
d
ic
e,
2
0
0
5
).
In
v
o
lv
in
g
m
in
o
ri
ty
st
af
f
in
d
es
ig
n
in
g
se
rv
ic
es
m
ay
p
ro
m
o
te
m
in
o
ri
ty
g
ro
u
p
s’
ac
ce
ss
(C
ra
ig
,
2
0
0
7
).
Social Work Education 599
T
a
b
le
3
P
ro
m
o
te
In
d
ep
en
d
en
ce
o
f
S
er
v
ic
e
U
se
rs
w
h
il
e
P
ro
te
ct
in
g
T
h
em
as
F
ar
as
P
o
ss
ib
le
fr
o
m
D
an
g
er
o
r
H
ar
m
E
ar
ly
ye
ar
s
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
E
v
al
u
at
io
n
li
te
ra
tu
re
su
p
–
p
o
rt
s
co
m
m
u
n
it
y
d
ev
el
o
p
m
en
t
as
‘a
d
d
ed
v
al
u
e’
.
S
u
p
p
o
rt
iv
e
p
ar
tn
er
–
sh
ip
s,
so
ci
al
an
d
lo
ca
l
co
m
m
u
n
it
y
n
et
w
o
rk
s
ca
n
b
e
p
ro
te
ct
iv
e
an
d
h
el
p
p
ar
en
ts
w
it
h
ch
il
d
-r
ea
ri
n
g
(C
o
w
le
y,
1
9
9
9
).
E
v
id
en
ce
o
f
in
cr
ea
se
d
‘c
o
m
m
u
n
it
y
sp
ir
it
’
w
it
h
S
u
re
S
ta
rt
p
ar
en
ts
w
o
rk
–
in
g
to
g
et
h
er
to
im
p
ro
v
e
lo
ca
l
co
m
m
u
n
it
ie
s
(N
E
S
S
,
2
0
0
1
).
L
o
ca
l
v
ar
ia
ti
o
n
in
d
eg
re
e
to
w
h
ic
h
p
ar
en
ts
’
m
u
tu
al
su
p
p
o
rt
an
d
v
o
lu
n
–
te
er
in
g
g
en
er
at
ed
co
m
m
u
n
it
y
em
p
o
w
er
m
en
t
(N
E
S
S
,
2
0
0
1
).
F
in
d
in
gs
:
K
in
sh
ip
ca
re
rs
ap
p
ea
r
fi
n
an
ci
al
ly
d
is
ad
v
an
ta
g
ed
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
U
n
d
er
-r
es
o
u
r-
ci
n
g
m
ay
ex
ac
er
b
at
e
h
ea
lt
h
in
eq
u
al
–
it
ie
s:
w
it
h
o
u
t
ad
eq
u
at
e
su
p
p
o
rt
,
k
in
sh
ip
ca
re
rs
(o
ft
en
g
ra
n
d
p
ar
en
ts
)
an
d
yo
u
n
g
p
eo
p
le
h
av
e
in
cr
ea
se
d
ri
sk
o
f
d
is
ad
v
an
ta
g
ed
h
ea
lt
h
/w
el
l-
b
ei
n
g
o
u
tc
o
m
es
.
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
F
in
d
in
gs
:
P
ar
en
ts
w
it
h
L
D
m
ay
d
ev
el
o
p
in
d
ep
en
d
en
ce
th
ro
u
g
h
sk
il
ls
tr
ai
n
in
g
(S
h
ee
ri
n
,
1
9
9
8
;
T
ag
g
an
d
K
en
n
y,
2
0
0
6
).
In
d
ic
at
io
n
s
th
at
p
ar
–
en
ti
n
g
sk
il
ls
ca
n
im
p
ro
v
e
th
ro
u
g
h
se
lf
-i
n
st
ru
ct
io
n
al
p
ic
to
ri
al
ch
il
d
-c
ar
e
ca
rd
s
(F
el
d
m
an
et
a
l.
,
1
9
9
7
;
F
el
d
m
an
an
d
C
as
e,
1
9
9
9
);
n
u
tr
it
io
n
an
d
fe
ed
in
g
tr
ai
n
in
g
(F
el
d
m
an
et
a
l.
,
1
9
9
7
);
g
ro
u
p
le
ar
n
in
g
(H
ei
n
z
an
d
G
ra
n
t,
2
0
0
3
),
an
d
h
o
m
e-
b
as
ed
tr
ai
n
in
g
(L
le
w
el
ly
n
an
d
M
cC
o
n
n
el
l,
2
0
0
2
;
M
il
d
o
n
et
a
l.
,
2
0
0
8
;
W
ad
e
et
a
l.
,
2
0
0
8
).
P
ar
en
ts
w
it
h
L
D
m
ay
h
av
e
fe
w
su
p
p
o
rt
iv
e
fr
ie
n
d
s/
n
ei
g
h
b
o
u
rs
re
la
ti
o
n
sh
ip
s
(L
le
w
el
ly
n
,
2
0
0
2
).
F
in
d
in
gs
:
E
x
tr
a
ca
re
h
o
u
si
n
g
m
ay
in
cr
ea
se
fe
el
in
g
s
o
f
sa
fe
ty
an
d
p
ro
te
ct
io
n
w
h
il
st
m
ai
n
ta
in
in
g
in
d
e-
p
en
d
en
ce
,
o
ff
er
in
g
so
ci
al
,
re
c-
re
at
io
n
al
an
d
m
ed
ic
al
p
ro
v
is
io
n
s
‘i
n
–
h
o
u
se
’,
im
p
ro
v
in
g
sa
fe
ty
an
d
se
n
se
o
f
co
m
m
u
n
it
y.
T
h
u
s,
re
ti
re
m
en
t
v
il
la
g
es
ca
n
im
p
ro
v
e
b
o
th
in
d
ep
en
d
en
ce
an
d
se
cu
ri
ty
(B
er
n
ar
d
et
a
l.
,
2
0
0
7
;
C
ro
u
ch
er
,
2
0
0
7
;
B
ro
o
k
er
et
a
l.
,
2
0
0
9
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
R
es
ea
rc
h
sh
o
u
ld
as
se
ss
th
e
ro
le
o
f
p
ro
ce
ss
fa
ct
o
rs
,
e.
g
.
st
y
le
o
r
m
an
ag
em
en
t
o
f
se
rv
ic
e
d
el
iv
er
y,
in
ac
h
ie
v
in
g
su
ch
o
u
tc
o
m
es
,
to
en
ab
le
se
rv
ic
e
d
ev
el
o
p
m
en
t
to
o
p
ti
m
iz
e
p
o
te
n
ti
al
.
600 E. Coren et al.
T
a
b
le
4
R
es
p
ec
t
th
e
R
ig
h
ts
o
f
S
er
v
ic
e
U
se
rs
w
h
il
st
S
ee
k
in
g
to
E
n
su
re
th
at
T
h
ei
r
B
eh
av
io
u
r
D
o
es
N
o
t
H
ar
m
T
h
em
se
lv
es
o
r
O
th
er
P
eo
p
le
E
ar
ly
ye
ar
s
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
E
Y
ca
re
m
ay
n
o
t
re
ac
h
g
ro
u
p
s
m
o
st
at
ri
sk
:
m
o
st
v
u
ln
er
ab
le
m
ay
b
e
h
ar
d
es
t
to
re
ac
h
(B
ar
lo
w
et
a
l.
,
2
0
0
5
).
F
in
d
in
gs
:
K
in
sh
ip
ca
re
rs
d
is
ad
v
an
–
ta
g
ed
co
m
p
ar
ed
to
o
th
er
s,
in
cl
u
d
in
g
li
m
it
at
io
n
s
to
fr
ee
d
o
m
fo
r
ch
il
d
re
n
/-
ca
re
rs
;
is
su
es
fo
r
o
ld
er
ca
re
rs
co
p
in
g
w
it
h
b
eh
av
io
u
r
o
f
yo
u
n
g
p
eo
p
le
;
la
ck
o
f
ag
en
cy
su
p
p
o
rt
;
o
v
er
cr
o
w
d
in
g
;
ca
re
r
il
l
h
ea
lt
h
;
le
ss
th
o
ro
u
g
h
as
se
ss
–
m
en
ts
th
an
fo
r
n
o
n
-f
am
il
ia
l
ca
re
rs
;
le
ss
st
ri
ct
m
o
n
it
o
ri
n
g
,
lo
w
er
re
u
n
ifi
–
ca
ti
o
n
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
F
in
d
in
gs
:
P
ar
en
ts
m
ay
la
ck
sk
il
ls
/-
k
n
o
w
le
d
g
e
re
:
se
x
ed
u
ca
ti
o
n
,
ch
il
d
h
ea
lt
h
,
sa
fe
ty
an
d
d
ev
el
o
p
m
en
t
(C
am
p
io
n
,
1
9
9
6
;
Ja
m
es
,
2
0
0
4
)
so
m
ay
en
g
ag
e
in
b
eh
av
io
u
r
w
h
ic
h
co
u
ld
im
p
ac
t
o
n
p
ar
en
t/
ch
il
d
.
P
ar
en
ts
ca
n
im
p
ro
v
e
ch
il
d
ca
re
an
d
sa
fe
ty
th
ro
u
g
h
au
d
io
v
is
u
al
se
lf
–
in
st
ru
ct
io
n
al
h
an
d
b
o
o
k
s
(F
el
d
m
an
et
a
l.
,1
9
9
7
;F
el
d
m
an
an
d
C
as
e,
1
9
9
9
)
o
r
h
o
m
e-
b
as
ed
in
te
rv
en
ti
o
n
s
(L
le
–
w
el
ly
n
et
a
l.
,
2
0
0
3
).
P
ar
en
ti
n
g
p
ro
g
ra
m
m
es
m
ay
o
n
ly
b
e
o
ff
er
ed
in
ex
tr
em
e
ca
se
s
w
h
er
e
ch
il
d
re
n
ar
e
at
ri
sk
(S
h
ee
ri
n
,
1
9
9
8
).
F
in
d
in
gs
:
E
C
H
re
si
d
en
ts
m
ay
ex
p
er
ie
n
ce
lo
w
er
h
ea
lt
h
ri
sk
s
th
an
th
o
se
el
se
w
h
er
e,
e.
g
.
V
al
le
ll
y
et
a
l.
(2
0
0
6
)
fo
u
n
d
th
at
re
si
d
en
ts
h
av
e
m
o
st
h
ea
lt
h
ca
re
n
ee
d
s
m
et
in
–
h
o
u
se
,
w
it
h
m
o
re
o
p
p
o
rt
u
n
it
y
to
ac
ce
ss
G
P
h
o
m
e
v
is
it
s/
p
re
ve
n
ti
v
e
se
rv
ic
es
,
e.
g
.
p
h
y
si
o
th
er
ap
is
ts
o
r
ch
ir
o
p
o
d
is
ts
.
R
ec
o
m
m
en
d
a
ti
o
n
s:
C
re
at
in
g
a
te
am
fr
o
m
a
d
iv
er
se
p
o
p
u
la
ti
o
n
,
an
d
st
ri
v
in
g
to
re
ac
h
al
l
el
ig
ib
le
fa
m
il
ie
s
re
q
u
ir
es
m
o
re
ef
fe
ct
iv
e
in
te
r-
ag
en
cy
w
o
rk
in
g
(N
E
S
S
,
2
0
0
6
).
‘H
ar
d
to
re
ac
h
’
g
ro
u
p
s,
e.
g
.
m
in
o
ri
ty
et
h
n
ic
co
m
m
u
n
it
ie
s,
d
is
ab
le
d
p
eo
p
le
an
d
ca
re
g
iv
er
s,
p
eo
p
le
w
it
h
le
ar
n
in
g
d
if
fi
cu
lt
ie
s,
y
o
u
n
g
m
o
th
er
s
an
d
n
ew
se
rv
ic
e
u
se
rs
m
o
re
li
k
el
y
to
en
g
ag
e
if
th
ey
re
ce
iv
e
h
o
m
e
v
is
it
s
(N
E
S
S
,
2
0
0
6
;
P
ea
rs
o
n
an
d
T
h
u
rs
to
n
,
2
0
0
6
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
C
h
al
le
n
g
e
is
to
su
p
p
o
rt
k
in
sh
ip
p
la
ce
m
en
ts
,
re
d
u
ci
n
g
ri
sk
fa
ct
o
rs
to
en
ab
le
o
p
p
o
rt
u
n
it
ie
s
th
at
eq
u
ip
ch
il
d
re
n
fo
r
su
cc
es
sf
u
l
fu
tu
re
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
S
er
v
ic
es
sh
o
u
ld
p
ro
v
id
e
p
re
ve
n
ta
ti
v
e
ca
re
,
su
p
p
o
rt
–
in
g
p
ar
en
ts
w
h
er
e
ch
il
d
re
n
n
o
t
id
en
ti
fi
ed
as
‘a
t
ri
sk
’
(S
h
ee
ri
n
,
1
9
9
8
).
M
u
lt
i-
ag
en
cy
co
ll
ab
o
ra
ti
o
n
o
p
ti
m
al
(S
h
ee
ri
n
,
1
9
9
8
;
T
y
m
ch
u
k
,
1
9
9
9
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
E
C
H
m
u
st
b
al
–
an
ce
q
u
al
it
y
o
f
li
fe
w
it
h
ri
sk
m
an
ag
em
en
t.
O
ve
rc
au
ti
o
u
s
ap
p
ro
ac
h
es
ca
n
li
m
it
o
p
p
o
rt
u
n
it
ie
s
fo
r
so
ci
al
in
te
ra
ct
io
n
,
p
ar
ti
cu
la
rl
y
fo
r
re
si
d
en
ts
w
it
h
im
p
ai
re
d
m
o
b
il
it
y
(E
v
an
s
an
d
V
al
le
ll
y,
2
0
0
7
).
Social Work Education 601
Uphold Public Trust and Confidence in Social Care Services
The research discussed in Table 5 suggests that social care work can improve outcomes
for, and protect, marginalised and vulnerable groups, which is consistent with the
public expectation of social welfare.
Be Accountable for the Quality of Their Work and Take Responsibility for Maintaining
and Improving Their Knowledge and Skills
Social work and social care workers are expected to be accountable for improving
knowledge and skills, which requires access to best possible evidence. However, there
are gaps in the literature that suggest more evidence is needed to understand the
potential impact of social work on health inequalities. Table 6 outlines some gaps in
literature identified by this overview.
Discussion
The Marmot Review of health inequalities policy in England (Marmot, 2010, p. 159)
states that adult social care, ‘makes a significant contribution to health and to health
inequalities’, while also emphasising the importance of children’s services to health.
The Review asserts that access to holistic social care services is a health inequalities
issue and that sustained, adequate funding, ‘the greater integration of health and social
care, and joint action on health inequalities’ is required to underpin this. However, it
cannot be assumed that well intentioned preventive action which benefits some groups
within the population will necessarily reduce inequalities in health (Capewell and
Graham, 2010) and so evidence is needed of the impact of social interventions on the
distribution of health outcomes. The aims of this paper were to pilot a review of such
evidence and consider the implications for social work and social care education,
research, and practice. The UK General Social Care Council’s Codes of Practice for
Social Care Workers (2010) was adopted as a framework for reporting reviews covering
four examples of social work and social care practice across the life course.
Four broad conclusions can be drawn from these reviews.
Firstly, there is currently little or no conclusive evidence at the population level of
the impact of social work or social care interventions on health inequalities, because
such research hardly exists. Although this may be partially due to methodological and
resourcing difficulties, we suspect it is largely due to a lack of focus on this aspect of
practice. We therefore had to draw inferences from studies of the health impact
of interventions targeted at disadvantaged populations, or consider the impact of
interventions on aspects of the social determinants of health. The development of an
epidemiological approach within social work and social care research could be
valuable.
Secondly, the reviews have demonstrated the relevance of social work and social care
interventions for promoting physical and mental health, preventing illness and helping
people to build and maintain independence and life skills that improve outcomes
602 E. Coren et al.
T
a
b
le
5
U
p
h
o
ld
P
u
b
li
c
T
ru
st
an
d
C
o
n
fi
d
en
ce
in
S
o
ci
al
C
ar
e
S
er
v
ic
es
E
ar
ly
ye
ar
s
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
F
am
il
ie
s’
en
g
ag
em
en
t
w
it
h
S
u
re
S
ta
rt
n
eg
at
iv
el
y
as
so
ci
at
ed
w
it
h
d
is
ad
v
an
ta
g
e
an
d
ri
sk
,
i.
e.
u
n
d
er
–
re
p
re
se
n
ta
ti
o
n
o
f
te
en
p
ar
en
ts
,
lo
n
e
p
ar
en
ts
an
d
u
n
em
p
lo
ye
d
(S
ir
aj
–
B
la
tc
h
fo
rd
an
d
S
ir
aj
-B
la
tc
h
fo
rd
,
2
0
0
9
).
Id
en
ti
fi
ed
b
ar
ri
er
s
to
u
p
ta
k
e
w
er
e:
tr
an
sp
o
rt
,
co
st
,
la
n
g
u
ag
e
an
d
in
ac
cu
ra
te
p
er
ce
p
ti
o
n
(e
.g
.
th
in
k
in
g
S
u
re
S
ta
rt
w
as
ju
st
fo
r
‘d
is
ad
v
an
ta
g
ed
p
eo
p
le
’;
C
o
e
et
a
l.
,
2
0
0
8
).
F
in
d
in
gs
:
R
es
ea
rc
h
sh
o
w
s
k
in
sh
ip
ca
re
to
b
e
b
en
efi
ci
al
,
b
u
t
ca
re
rs
m
ay
b
e
in
h
ib
it
ed
d
u
e
to
fi
n
an
ci
al
h
ar
d
–
sh
ip
an
d
la
ck
o
f
ag
en
cy
su
p
p
o
rt
(A
ld
g
at
e
an
d
M
cI
n
to
sh
,
2
0
0
6
).
F
in
d
in
gs
:
D
es
p
it
e
h
ig
h
ra
te
s
o
f
ch
il
d
re
m
o
v
al
fr
o
m
L
D
p
ar
en
ts
,
in
v
es
tm
en
t
in
to
p
ro
m
o
te
ef
fe
ct
iv
e
p
ar
en
ti
n
g
lo
w
(B
o
o
th
an
d
B
o
o
th
,
1
9
9
9
).
E
n
v
ir
o
n
–
m
en
ta
l
fa
ct
o
rs
,
e.
g
.
p
o
v
er
ty
,
la
ck
o
f
su
p
p
o
rt
to
u
n
d
er
st
an
d
ea
rl
y
d
ev
el
–
o
p
m
en
t
n
ee
d
s,
d
is
ad
v
an
ta
g
e
p
ar
en
ts
w
it
h
L
D
(T
ag
g
an
d
K
en
n
y,
2
0
0
6
).
F
in
d
in
gs
:
D
aw
so
n
et
a
l.
(2
0
0
6
)
fo
u
n
d
th
at
th
e
m
o
st
in
fl
u
en
ti
al
fa
ct
o
r
p
ro
m
o
ti
n
g
d
ev
el
o
p
m
en
t
o
f
E
C
H
w
as
g
o
o
d
p
ar
tn
er
sh
ip
s
b
et
w
ee
n
so
ci
al
se
rv
ic
es
,
h
o
u
si
n
g
d
ep
ar
tm
en
ts
an
d
o
ld
er
p
eo
p
le
.
R
ec
o
m
m
en
d
a
ti
o
n
s:
Im
p
li
ca
ti
o
n
s
fo
r
p
ro
m
o
ti
o
n
,
fu
n
d
in
g
an
d
st
af
fi
n
g
(s
ee
ea
rl
ie
r
se
ct
io
n
s)
R
ec
o
m
m
en
d
a
ti
o
n
s:
K
in
sh
ip
ca
re
rs
n
ee
d
st
ro
n
g
er
su
p
p
o
rt
an
d
fu
n
d
in
g
to
en
ab
le
b
et
te
r
o
p
p
o
rt
u
n
it
y
fo
r
p
la
ce
m
en
t
st
ab
il
it
y
(B
ro
ad
,
2
0
0
7
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
A
d
v
o
ca
cy
al
o
n
e
w
il
l
n
o
t
re
li
ev
e
p
re
ss
u
re
s
th
at
u
n
d
er
–
m
in
e
p
ar
en
ts
’
co
p
in
g
(T
ag
g
an
d
K
en
n
y,
2
0
0
6
).
P
re
su
m
p
ti
o
n
o
f
in
co
m
p
et
en
ce
b
y
p
ro
fe
ss
io
n
al
s,
in
cl
u
d
in
g
fi
x
ed
id
ea
s
ab
o
u
t
o
p
ti
o
n
s
fo
r
ch
il
d
re
n
;
te
n
si
o
n
b
et
w
ee
n
p
o
li
–
ci
n
g
an
d
en
ab
li
n
g
ro
le
s;
se
rv
ic
es
d
e-
sk
il
li
n
g
p
ar
en
ts
b
y
ta
k
in
g
o
v
er
re
sp
o
n
si
b
il
it
ie
s;
b
la
m
in
g
v
ic
ti
m
s
ra
th
er
th
an
ad
d
re
ss
in
g
d
efi
ci
en
ci
es
in
sy
st
em
;
la
ck
o
f
tr
u
st
;
an
d
se
rv
ic
es
o
ff
er
in
g
co
n
fl
ic
ti
n
g
ad
v
ic
e
(B
o
o
th
an
d
B
o
o
th
,
1
9
9
9
;
W
ar
d
an
d
T
ar
le
to
n
,
2
0
0
7
).
R
ec
o
m
m
en
d
a
ti
o
n
s:
P
la
n
n
in
g
,
d
es
ig
n
an
d
m
an
ag
em
en
t
o
f
E
C
H
,
sh
o
u
ld
p
ri
o
ri
ti
se
so
ci
al
w
el
l-
b
ei
n
g
o
f
re
si
–
d
en
ts
(E
v
an
s
an
d
V
al
le
ll
y,
2
0
0
7
).
S
ta
ff
tr
ai
n
in
g
/r
em
u
n
er
at
io
n
is
k
ey
to
d
ev
el
o
p
in
g
in
te
g
ra
te
d
,
re
sp
o
n
si
v
e
se
rv
ic
es
,
es
p
ec
ia
ll
y
w
h
er
e
n
ee
d
s
ar
e
d
iv
er
se
(A
ll
ar
d
ic
e,
2
0
0
5
).
Social Work Education 603
T
a
b
le
6
B
e
A
cc
o
u
n
ta
b
le
fo
r
th
e
Q
u
al
it
y
o
f
T
h
ei
r
W
o
rk
an
d
T
ak
e
R
es
p
o
n
si
b
il
it
y
fo
r
M
ai
n
ta
in
in
g
an
d
Im
p
ro
v
in
g
T
h
ei
r
K
n
o
w
le
d
g
e
an
d
S
k
il
ls
E
ar
ly
ye
ar
s
K
in
sh
ip
ca
re
P
ar
en
ts
w
it
h
le
ar
n
in
g
d
is
ab
il
it
ie
s
O
ld
er
ad
u
lt
s
F
in
d
in
gs
:
T
o
re
d
u
ce
in
eq
u
al
it
y
o
f
ac
ce
ss
,
m
o
re
sh
o
u
ld
b
e
d
o
n
e
to
ad
d
re
ss
b
ar
ri
er
s
to
ac
ce
ss
in
g
se
rv
ic
es
.
V
ar
ia
ti
o
n
in
se
rv
ic
e
u
se
b
y
d
if
fe
re
n
t
m
in
o
ri
ty
g
ro
u
p
s,
g
en
d
er
s,
d
is
ab
il
it
ie
s
an
d
re
g
io
n
al
v
ar
ia
ti
o
n
s
n
ee
d
fu
rt
h
er
ex
p
lo
ra
ti
o
n
.
S
o
ci
al
w
o
rk
er
s
m
ay
p
la
y
a
ro
le
in
im
p
ro
v
in
g
ac
ce
ss
to
se
rv
ic
es
b
y
d
is
ad
v
an
ta
g
ed
fa
m
il
ie
s.
F
in
d
in
gs
:
R
es
ea
rc
h
su
g
g
es
ts
so
ci
al
w
o
rk
er
s
co
u
ld
re
d
u
ce
in
eq
u
al
it
y
b
y
ad
v
o
ca
ti
n
g
fo
r
eq
u
al
it
y
o
f
su
p
p
o
rt
b
et
w
ee
n
k
in
an
d
n
o
n
-k
in
fo
st
er
ca
re
rs
.
L
it
er
at
u
re
o
n
k
in
sh
ip
ca
re
fo
cu
se
s
o
n
b
eh
av
io
u
r
an
d
p
la
ce
m
en
t
st
ab
il
it
y
ra
th
er
th
an
h
ea
lt
h
an
d
w
el
l-
b
ei
n
g
.
E
v
al
u
at
io
n
s
n
ee
d
ed
o
f
h
ea
lt
h
/w
el
l-
b
ei
n
g
o
u
tc
o
m
es
fo
r
yo
u
n
g
p
eo
p
le
an
d
k
in
sh
ip
ca
re
rs
co
m
p
ar
ed
to
st
an
d
ar
d
fo
st
er
ca
re
.
F
in
d
in
gs
:
E
v
id
en
ce
sh
o
w
s
th
at
in
te
r-
v
en
ti
o
n
s
fo
r
p
ar
en
ts
w
it
h
L
D
m
ay
im
p
ro
ve
p
ar
en
ti
n
g
sk
il
ls
an
d
p
ro
–
m
o
te
p
ar
en
ti
n
g
b
y
p
ar
en
ts
.
B
u
t,
in
te
rv
en
ti
o
n
s
ca
n
n
o
t
ad
d
re
ss
st
ru
c-
tu
ra
l
is
su
es
:
p
o
v
er
ty
,
so
ci
al
is
o
la
ti
o
n
an
d
p
o
o
r
se
rv
ic
e
p
ro
v
is
io
n
th
at
m
ay
p
re
v
en
t
p
ar
en
ts
w
it
h
L
D
ac
h
ie
v
in
g
eq
u
al
ca
re
.
R
es
ea
rc
h
as
se
ss
ed
d
o
es
n
o
t
ad
d
re
ss
re
g
io
n
al
v
ar
ia
ti
o
n
.
P
ra
c-
ti
ti
o
n
er
s
m
an
ag
e
d
u
al
ro
le
s:
su
p
–
p
o
rt
in
g
p
ar
en
ts
an
d
m
o
n
it
o
ri
n
g
p
ar
en
ti
n
g
ca
p
ac
it
y.
R
es
ea
rc
h
n
ee
d
ed
to
ad
d
re
ss
in
cl
u
si
o
n
in
d
if
fe
re
n
t
re
g
io
n
s
o
r
am
o
n
g
g
ro
u
p
s
th
at
m
ay
b
e
fu
rt
h
er
m
ar
g
in
al
is
ed
d
u
e
to
,
e.
g
.
et
h
n
ic
it
y,
re
li
g
io
n
,
p
h
y
si
ca
l
o
r
se
n
–
so
ry
d
is
ab
il
it
y.
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604 E. Coren et al.
related to the social determinants of health. These examples reinforce the general
assertions of the Marmot Review (Marmot, 2010) that social care services contribute
to healthier outcomes for disadvantaged people.
Thirdly, the reviews highlight the potential damage which may arise when social
work or social care interventions do not adequately address the health dimensions of
people’s lives, including social determinants of health, such as housing, income and
life skills. Failure to reach potential beneficiaries of services (fathers, or minority ethnic
parents, for example), or to provide parallel support to kinship and non-kinship
carers, exacerbates the unfair distribution of health and other life chances. The limited
evidence which could be found which evaluated social care interventions aimed
directly at service users’ health is another marker of a lack of attention being paid to
this in current practice and research.
Fourthly, to alter this requires greater focus in social work and social care education
on the centrality of social aspects of physical and mental health in service users’ lives.
Three models for integrating teaching on health inequalities in social work education
have been outlined in a recent digest of the Social Work and Social Policy Subject
Centre of the Higher Education Academy (SWAP) in England (Bywaters et al., 2009):
. Permeation: spreading learning about health inequalities throughout the curriculum
in college and practice settings;
. Focused health modules: teaching about health in a discrete module or modules,
taking a health inequalities perspective; and
. Interprofessional modules: teaching about health inequalities as a core element in
interprofessional modules.
Such a shift in research, practice and education requires a policy context which current
trends in England make less likely. The social care sector is not resourced to address the
core social determinants of health and well-being; in particular, incomes, housing, and
aspects of access to opportunities. For example, programmes aimed at supporting
parents cannot compensate for low incomes and environmental deficiencies.
Unsupported kinship carers, often elderly and on low incomes, do not have the
same level of material support as their paid counterparts, and the continuity, stability
and attachment they can offer may therefore be compromised. Reduced budgets and
increased caseloads within professional social work have discouraged involvement in
debt counselling, community engagement and other social determinants of healthy
living. Moreover, the current UK coalition government’s economic policies herald
substantial cuts in local authority finances and health care funding, as well as
approaches to social policy which emphasise greater targeting [for example, in
Children’s Centres (HM Treasury, 2010)]. These policies are unlikely to support social
workers to consider the structural risk factors in service users’ lives, or to encourage
population based interventions, despite evidence of potential cost savings in the longer
term (Aked et al., 2009). However, social work education and practice should continue
to use its unique perspective to highlight the failures of policy which sustain
inequalities in health outcomes, with particular effect within marginalised groups.
Social Work Education 605
The sector should promote service delivery approaches that reduce inequalities and
advocate for individuals and populations caught in lifelong cycles of disadvantage.
Recognising health as a central dimension in service users’ lives and health disadvantage
as a universal focus for social work intervention is the key starting point.
Acknowledgements
This paper is based on work funded and commissioned by the Social Care Institute for
Excellence (Coren et al., 2010). The views expressed in this paper reflect the individual
views of the authors rather than those of the SCIE. The work also received institutional
support from Canterbury Christ Church University. The authors gratefully
acknowledge assistance from Manuela Thomae of Canterbury Christ Church
University at the final draft stage.
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