This was my first essay written during my Bachelor of Nursing degree.
Please note my writings are published for educational purposes only, all of my works have been submitted to Turnitin so please do not copy and paste or you will be flagged for plagiarism. My reference list is included at the bottom.
The feedback I received from my marker was:
“You have worked hard with your essay to produce a very good result. The presentation of your paper is good with minimal spelling and grammatical errors. Your list of references is really well done. Further work on clearly presenting ideas and integrating the evidence with your ideas will further improve your results. The case study section could have had the SDoH separated into paragraphs. Academic integrity and rigour take practice and time. I encourage you to use this essay as an opportunity to learn how to further improve your grade in the future.” and I received a Distinction for this essay.
The social determinants of health and an individual’s health narrative combine to form a core in understanding illness and the overall health of people. As health care professionals, nurses need to recognise the ways that the social determinants of health and an individual’s health narrative influence their health and behaviour to enable them to provide better care, promote healing, and foster improved health outcomes. This essay will analyse the importance of the social determinants of health as well as the relevance of health narratives to illness, health, and well-being; and discuss three social determinants of health specifically relevant to the case study presented as the essay topic.
2. What is a health narrative?
Hinyard & Kreuter (n.d.) state that health narratives have no single universally accepted definition. However, they do suggest that a narrative should be defined essentially as any comprehensive story with a clear beginning, middle and end that imparts knowledge regarding characters, scene and conflict, which fosters questions to be answered and conflicts to be settled and then to provide resolution. Using narratives and storytelling is the main way in which humans communicate and share information; and holds promise for applications of health behaviour (Hinyard & Kreuter, n.d.). Conventionally, health communication has been primarily based upon a more scientific approach, utilising experimental and empirical methods of determining illness (Hinyard & Kreuter, n.d.). Conversely, narrative information may include stories, historical accounts and subjective experiences, along with faith and religion, etc. and can promote better understanding of many issues which may be more personal to an individual such as social relationships, morality and personal values for example (Hinyard & Kreuter, n.d.). Getting to know a person through their narratives and stories imparts contextual information regarding characteristics of themselves as a person that individualises them (Hall & Powel, 2011). This makes narratives a way to define and understand a patient’s experiences that may also be culturally consistent as almost every culture has its place for storytelling (Hall & Powel, 2011). Narratives can enable a person to talk about past events and relate them to current symptoms, additionally providing information that is culturally relevant (Hall & Powel, 2011). Recounting one’s story can uncover a recalled timeline of happenings in a person’s life that can be used to provide a better level of care to an individual (Hall & Powel, 2011). To listen to a patient’s story and absolutely hear enables health care professionals to provide care in a manner that is more relevant to their patient’s beliefs and values and reaches further than just a physical diagnosis of illness (Colmenares, 2004). In doing so, narratives embody what is missing in medicine – a story of a person; highlighting an individual person and their story as opposed to just a seeing name on a chart (Colmenares, 2004). Finally, narratives may also be a way of attaining shared decision-making between health care providers and relatives of the patient, who may have been caregivers and can further contribute to the patient’s narrative and thereby enhance the quality of health outcomes for the patient (Frid, Öhlén, & Bergbom, 2000).
3. What are SDOH?
The Australia’s Health 2016 report by the Australian Institute of Health and Welfare quoted the World Health Organisation (WHO) definition of social determinants as “…the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces” (AIHW, 2016, p. 129), additionally expressing that these circumstances are crucial to determining good health versus ill health. Social determinants being the “causes of the causes” provide a foundation by which it can be determined how other factors also impact on a person’s overall health status. The AIHW identifies socioeconomic position, early life, social exclusion, social capital, employment and work, housing, and residential environment as the primary social determinants of health (AIHW, 2016). Observing the significance of social determinants of health on an individual’s well-being can aid health care workers to better understand their patients and be able to communicate more effectively with them regarding their health conditions and behaviour patterns, thereby improving health outcomes (ACOG, 2018). Conventional biomedical models of disease generally concentrate on hereditary and biological factors as well as personal health behaviour of individuals (ACOG, 2018). While genetics and lifestyle play a key role in shaping the overall health of individuals, the conditions in which people are born, work, live and play are just as important in shaping health outcomes (ACOG, 2018). How individual social determinants of health intertwine with each other to form a deeper knowledge of an individual’s health pattern is also an important factor to understand. For instance, Hankivsky & Christoffersen (2008) consider that focusing on an individual’s gender as a social determinant attached to women may overlook how such areas as economics, location, culture, and other elements may combine together with gender to shape health narratives. This is just one example among many. Understanding how social determinants of health may intertwine and interconnect with other social determinants of health may ultimately aid in the creation of more precise understanding of health issues and improvement of health policies (Hankivsky & Christoffersen, 2008).
4. Case Study
Amy was born in China and migrated to Australia, where she learnt how to speak English and obtained employment. Ill health caused her to lose her job, and her husband also lost his job creating financial hardship for the family as they were only eligible for a small payment through Centrelink. Suffering from depression and diagnosed with a mental illness, Amy found it stressful trying to obtain employment under the conditions imposed by Centrelink. A cultural and language barrier added to her troubles as her lack of understanding and of being understood created additional medical issues. The introduction of a support facilitator with a similar background to Amy helped her to obtain a better health outcome for her situation (National Mental Health Commission, 2016). The three main social determinants of health that appear to have shaped Amy’s health experience the most are culture and early life, unemployment, and stress. The case study reports that Amy migrated from China, undertaking an English course to obtain employment. As there is no further mention of an Australian education, it can be reasonably assumed for the purpose of this essay that Amy was a young adult and perhaps even married at the time of her migration. In traditional Chinese culture, mental illness and seeking treatment of mental illness is rarely spoken about, with studies showing that Chinese natives who migrate to other countries are also represented amongst sufferers that do not report symptoms or seek help for a mental condition (Liang, Gong, Wen, Guan, Li, Yin & Wang, 2012). Societal norms in China typically look upon being lower on the spectrum in regard to socioeconomic status, social recognition and cultural status as something to be ashamed of (Liang et al, 2012); therefore, as a child having grown up within this culture Amy is likely to have a negative association with the concept of seeking help for her depression. Having lost her job due to ill health, as well as her husband also losing his job placed the family into financial hardship with little help from Centrelink. Crowe & Butterworth (2016) undertook a study and discussed the effects of unemployment and underemployment on mental health, discovering that financial hardship, social support and a feeling of personal control were all meaningful determinants of the connection between depression and unemployment. They further suggest that mental wellbeing is improved by both clear and implied benefits of being employed, which indicates that Amy’s loss of employment and the resulting financial hardship is likely to have increased her levels of depression. The AIHW (2016) also highlights the psychosocial stress effect on mental and physical wellbeing resulting from unemployment, further adding that people in ethnic minority groups are among those whose rates of unemployment are generally higher. Schneiderman, Ironson, & Siegel (2005) state that while stressors can affect mood, sense of wellbeing, health and behaviour, when the sources of the stress are unrelenting the effects long term can be particularly damaging to mental and physical health. The links between disease and stress are additionally influenced by an individual’s vulnerability biologically, coping behaviours that have been learnt and social resources (Schneiderman, Ironson, & Siegel, 2005). Amy’s life has involved many factors that have contributed enormously to her stress levels, including job loss, financial deprivation, depression, a diagnosis of bi polar disorder, being excluded by her peers, and her difficulties with her health provider interactions. These factors have revealed several social determinants of health that have contributed to shaping Amy’s health experience with cultural and early life, unemployment, and stress among the highest contributing causes.
Amy’s case study shows the importance of ascertaining and understanding an individual’s health narrative to determine the social determinants that affect that person’s overall health. Upon reflection it became apparent that the social determinants of cultural background and early life experience, unemployment, and stress were deeply integrated into Amy’s health narrative and needed to be addressed to improve her health outcomes. Therefore, it is necessary to prioritise listening to and understanding an individual’s health narrative and identifying social determinants intertwined within their story in order to provide the best care possible within the capabilities of the health care provider’s role.
Australian Institute of Health and Welfare (AIHW). (2016). Australia’s health 2016. Retrieved from https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/summary
Colmenares, C. (2004). Stories we could tell: a look into narrative medicine. Retrieved from https://www.mc.vanderbilt.edu/reporter/index.html?ID=3221
Crowe L, & Butterworth P. (2016). The role of financial hardship, mastery and social support in the association between employment status and depression: results from an Australian longitudinal cohort study. doi: 10.1136/bmjopen-2015-009834
Frid, I., Öhlén, J., & Bergbom, I. (2000). On the use of narratives in nursing research. Journal of advanced nursing, 32(3), 695-703. doi:10.1046/j.1365-2648.2000.01530.x
Hall, J. M. & Powell, J. (2011). Understanding the Person through Narrative. Nursing Research and Practice, 2011(293837), 1-10. https://doi.org/10.1155/2011/293837
Hankivsky, O., & Christoffersen, A. (2008). Intersectionality and the determinants of health: a Canadian perspective. Critical Public Health, 18(3), 271-283. doi:10.1080/09581590802294296
Hinyard, L., & Kreuter, M. (n.d.). Using Narrative Communication as a Tool for Health Behavior Change: A Conceptual, Theoretical, and Empirical Overview. Health education & behavior., 34(5), 777–792. doi:10.1177/1090198106291963
Liang, Y., Gong, Y.-H., Wen, X.-P., Guan, C.-P., Li, M.-C., Yin, P., & Wang, Z.-Q. (2012). Social Determinants of Health and Depression: A Preliminary Investigation from Rural China. PLoS ONE, 7(1), e30553. http://doi.org/10.1371/journal.pone.0030553
National Mental Health Commission. (2016). 2016 National report on mental health and suicide prevention: Patient stories. Retrieved from http://www.mentalhealthcommission.gov.au/our-reports/our-national-report-cards/2016-report/personal-stories.aspx
Schneiderman, N., Ironson, G., & Siegel, S. D. (2005). STRESS AND HEALTH: Psychological, behavioral, and biological determinants. Annual Review of Clinical Psychology, 1, 607-628. Retrieved from http://ezproxy.scu.edu.au/login?url=https://search-proquest-com.ezproxy.scu.edu.au/docview/213147168?accountid=16926
The American College of Obstetricians and Gynecologists (ACOG). (2018). Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care. Retrieved from https://m.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Importance-of-Social-Determinants-of-Health-and-Cultural-Awareness-in-the-Delivery-of-Reproductive