Editorial

Recognising the impact of social exclusion: The need for advocacy and activism in health care

Debra Jackson
Professor, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney (UTS), Broadway NSW

Deborah C Saltman
Department of General Practice, University of Sydney, Sydney NSW

PP: 057 - 059

Article Text

Social exclusion has been identified as an issue of concern in Australia and internationally, and describes the inability to fully engage in society because of social characteristics that reduce opportunities for successful social engagement (Ferguson, 2008; Saunders, Naidoo, & Griffiths, 2008). It has been linked with a range of health and social outcomes, including disconnectedness, violence, drug and alcohol use, depression, stress and reduced perception of life as meaningful (Hardiman & Lapeyre, 2004; Mao et al., 2009; Morgan, Burns, Fitzpatrick, Pinfold, & Priebe, 2007; Saunders et al., 2008; Stillman et al., 2009), and is associated with multiple factors including family breakdown, unemployment, social security dependence, educational disadvantage and loss of identity (Hardiman & Lapeyre, 2004).

The very nature of social exclusion means that individuals can sometimes choose to remain elusive for various reasons such as fear of stigma and negative judgement. However, even people who are socially marginalised and excluded will seek out community- based health and support services, and in any working day, primary health care workers (PHCWs) encounter people who are socially excluded through isolation, stigmatisation, marginalisation, lack of voice, invisibility, distress, or lack of resources to improve their situations. Thus, PHCWs should be well positioned to establish trust and develop familiarity with those who are socially excluded.

This vital workforce faces challenges associated with dealing with 'new' and perplexing health and social problems associated with exclusion or the outcomes arising from social exclusion. To borrow a military metaphor, the primary care workforce forms the 'front line' in managing complex and sometimes confronting health and social issues that may not yet have been adequately resourced. In an exploration of the experiences of general practitioners in providing care to gay and HIV positive men with problematic crystal methamphetamine use, the need to ensure adequate resourcing and support for the health workforce was identified (Saltman, Newman, Mao, Kippax, & Kidd, 2008). Furthermore, some reluctance on the part of the acute care sector and referral services to accept participation in the care of these complex patients was noted, meaning that despite lack of resourcing, the full responsibility for care remained within the primary care sector (Saltman et al., 2008).

Another consequence of social exclusion is violence. Violence is strongly associated with social exclusion (Hardiman & Lapeyre, 2004). It is pervasive in community health settings and a known hazard. Though often framed as being essentially an interpersonal matter, violence has effects that go far beyond the direct protagonists, to the wider family, community and therapeutic contexts (Carmody, 2006; Jackson & McMurray, 2006; Luck, Jackson, & Usher, 2008). In a study that sought to explore the effects of witnessing community violence on women's anxiety and depressive symptomology, findings revealed that being a bystander to such violence was associated with an increase in clinically significant symptoms (Clark et al., 2008). This is concerning, not only when considering the prevalence of violence in many communities, but also when the focus of care in some primary health care settings is the management of one problem only at a time, as is the growing trend in UK general practice. Furthermore, it raises questions about the possible deleterious health effects of witnessing violence on the health workforce, given the well-documented and unacceptably high levels of violence and abuse encountered by health workers (Luck et al., 2008; Miedema, Easley, Fortin, Hamilton, & Tatemichi, 2009). Despite quite extensive research interrogation, these co-morbid aspects of violence are poorly understood and relatively unexplored.

Another arena of unrecognised violence is that of young people toward their mothers. Though it has received far less attention than other forms of family violence, extant research suggests it is a deeply distressing and isolating feature of life for those women that experience it (Jackson, 2003). Under-reporting has meant that women who experienced violence were faced with the double jeopardy of violence and social exclusion - not only silenced, but also isolated and unable to access services that could assist them because of guilt, shame and the belief they were alone in experiencing this form of violence (Edenborough, Jackson, Mannix, & Wilkes, 2008; Jackson, 2003).

In primary health care, clinicians walk with people on some of their most intimate and difficult life journeys. Therefore these health workers are strategically placed to ensure that the advocacy and activism required to secure a sustainably safer and more just society for all people is supported in the most fundamental of clinical settings. We believe that real action is required to help ameliorate the health risks associated with social exclusion. People affected by social exclusion may lack the voice, the skills or the stamina to raise issues and advocate for themselves, and because PHCWs have access to and intimate knowledge of the issues faced by such individuals and groups, are in a position to raise concerns and advocate on their behalf.

The importance of advocacy, increased accessibility, and consumer voice in developing and sustaining community-based health services is highlighted in the HIV literature (Mao et al., 2009) as is the need to target services for groups identified as vulnerable, either through lack of access, or their membership of stigmatised, marginalised or high risk groups (Kidd, Watts, & Saltman, 2008). These strategies should be extrapolated beyond this community to reduce discrimination of all forms. These are essential steps in improving health and addressing the health inequity faced by marginalised groups (Mao et al., 2009).

Mitigating against any action is the recognition that the primary health care environment comprises a large and disparate workforce, consisting of various health professional groups catering to diverse and complex community needs. Conversely, this workforce has potentially enormous collective political power. In improving equity for the socially excluded and marginalised in the community there is a need for activism and advocacy to:

• Increase awareness of the health ramifications of social exclusion;
• Transform the social and institutional forces that perpetuate social exclusion and health inequity;
• Facilitate the creation of strategies to enhance opportunities for social integration for all people;
• Promote the health needs of marginalised and vulnerable people and groups when allocating resources;
• Create opportunities for children in disadvantaged social groups to participate equally with peers;
• Promote equality for people and groups affected by discrimination;
• Reorient the provision of care by educating and reimbursing clinicians to recognise social inclusion and support activities beyond prevention and health promotion; and,
• Identify and implement strategies to ensure the sustainability of the primary health care workforce that they may continue to advocate for the excluded, marginalised and vulnerable members of the community.

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