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Social factors underpinning poor health and how they can be addressed in Hackney, London.

It is well-established that social factors – including education, economic participation and access to health services – have a considerable impact on a person's physical and mental health outcomes (World Health Organisation, 2015: np). Addressing these social factors underpins effective responses to poor health (World Health Organisation, 2015: np). This paper provides a critical overview of the social factors which contribute to poor health outcomes in one borough in London, England. It then discusses how these social factors can be addressed to improve health outcomes in this borough. The borough selected for analysis in this paper is Hackney.

Hackney is located in north London. The borough has a population of approximately 263,150 (Hackney Council, 2015a: p. 1). It is socio-culturally diverse, though the largest ethnic group, comprising 36.2% of the population, is 'White British' and the majority of people speak English (Hackney Council, 2015a: p. 1). Hackney is divided into 137 Lower Super Output Areas (LSOAs), each containing approximately 1,500 people (Hackney Council, 2014b: p. 1); these LSOAs allow for the close monitoring of population health and social data. Hackney consistently reports poor health outcomes in a variety of domains, and it is recognised that these health outcomes are underpinned by a complex interplay of social factors (Hackney Council, 2014b).

The first of the social factors contributing to poor health outcomes in Hackney to be explored in this paper is education. Education is an important social determinant of health because it enables people to be 'health literate' – that is, to access, understand and use health information to improve their health (Kilgour, Matthews, Christian, Shire, 2015: p. 487). Currently, the rate of educational attainment in Hackney is high, with the proportion of students obtaining GCSEs, approximately 58%, comparable with the national average (Hackney Council, 2014a: p. 18). However, Hackney has a history of educational disadvantage, and some LSOAs in Hackney are still considered to be in the top 20% of the most educationally-deprived in Britain (Hackney Council, 2014b: p. 9). Indeed, the number of adults in Hackney with no qualifications, approximately 9.1%, is higher than the national average (Hackney Council, 2015a: p. 3). As noted by Kilgour et al. (2015, p. 488), health literacy is directly correlated with positive health attitudes, behaviours and outcomes. Subsequently, the attainment of a lower standard of education – in the UK, particularly in the primary years – and, therefore, lower health literacy increases a person's risk of a range of negative health outcomes (Albert & Davia, 2011: p. 163).

In the UK, standard of education is directly linked to a person's level of economic participation, including their prospects for employment and level of income – all important social determinants of health (Borooah & Mangan, 2008: p. 351). Educational disadvantage in Hackney is closely related to economic disadvantage. Rates of unemployment in Hackney are 8.1%, compared with a national average of just 6.2%, and in Hackney another 3% of the population identify as unemployed job-seekers (Hackney Council, 2015a: p. 3). Hackney ranks within the top 10% of the most economically deprived boroughs nationally and, in terms of household income, 13% of its LSOAs rank in the top 5% of the most deprived nationally (Hackney Council, 2014c: p. 2).

Studies have found that, in the UK and elsewhere, unemployment and job insecurity are directly correlated with health in all domains, including physical health (Puig-Barrachina, Malmusi, Martenez & Benach, 2011: p. 459; Hergenrather, Zeglin & McGuire-Kuletz, 2015: p. 2). In the UK, there is a strong relationship between economic disadvantage and a lack of access to nutritionally-appropriate foods, and this underpins poor health outcomes (Hamer & Mishra, 2010: p. 491). Indeed, many people on low incomes in the UK consume cheap, easily-accessible 'fast food diets' characterised by a high intake of saturated fat, leading to higher rates of obesity in economically disadvantaged regions (Hamer & Mishra, 2010: p. 491; Estrade, Dick, Crawford, Jepson, Ellaway & McNeill, 2015: p. 793). In Hackney, approximately 23% of adults and 26% of children are overweight or obese; this is slightly below the national average; however Hackney Council still identifies obesity as a significant burden on the region's health system (Hackney Council, 2015b: p. 55; Hackney Council, 2015c: p. 67). It is well established that obesity significantly predisposes people to a range of poor health outcomes. Indeed, in Hackney the prevalence of obesity-related diseases such as cancer, diabetes mellitus, stroke, hypertension and cardiovascular disease are either comparable to or above London averages (Hackney Council, 2014f: p. 81-110).

Unemployment and lower disposable income also result in reduced access to appropriate housing, and this is another key social determinant of health. Hackney has a greater number of overcrowded households, including those lacking at least one bedroom, more temporary accommodation and higher levels of homelessness than other economically-comparable boroughs in London (Hackney Council, 2014d: p 6; Hackney Council, 2014e: p. 6). Adding to this problem is the fact that housing affordability in Hackney has declined significantly in the past five years (Hackney Council, 2014a: p. 20; Hackney Council, 2015a: p. 2). Access to appropriate housing can be considered a social determinant of health in the UK because it is correlated with mental health (Barratt, Green & Speed, 2015: p. 107; Lidell & Guinea, 2015: p. 191).

Though there are complexities in terms of drawing a direct causal relationship between socioeconomic disadvantage and mental illness, it is well-established that mental illness is a considerable problem for socioeconomically disadvantaged people in the UK (Mangalore, Knapp, Jenkins & 2007, p. 1037). Some LSOAs in Hackney have rates of serious mental illness, including schizophrenia and bipolar affective disorder, as high as 3% (Hackney Council, 2014e: p. 7). Hackney's young, transient and socio-culturally diverse population contributes to the high rates of mental illness in the borough (Hackney Council, 2014e: p. 5). In Hackney, socioeconomic disadvantage – and particularly unemployment and housing instability – is strongly correlated with psychiatric admission and suicide (Hackney Council, 2014e: p. 6). Poor mental health also has effects on physical health. As noted by Hackney Council (2014e: p. 60), a person with a mental health disorder in Hackney is more likely to experience comorbidities such as cancer, cardiovascular disease, diabetes mellitus and other systemic disorders.

In addition to mental illness, poverty is strongly correlated with substance misuse in Hackney (Hackney Council, 2014d: p 6). Because it leads to a range of poor physical and mental health outcomes, substance misuse can itself be considered a poor health outcome. Substance misuse is a significant problem in Hackney; indeed, the rates of people claiming medical benefits for alcoholism and attending inpatient treatment programs for the misuse of drugs, particularly opiates, in Hackney is higher than the averages for both London and England (Hackney  Council, 2014d: p. 6). High-risk behaviours associated with substance misuse, such as binge drinking, and rates of hospital admission for substance misuse are higher in Hackney than in London generally (Hackney Council, 2014d: p. 7). Whilst the rate of death from substance misuse in Hackney is decreasing, it is still considerably higher than the national average and poses a significant cost to the health care system (Hackney Council, 2014d: pp. 6-7). Rates of smoking in Hackney, at around 25%, are also higher than national averages (Hackney Council, 2015b: pp. 47-50). It is well-established that smoking, as with substance misuse in general, predisposes people to a range of poor health outcomes; indeed, in Hackney there is a comparatively high prevalence of chronic obstructive pulmonary disease linked to smoking (Hackney Council, 2014f: p. 92).

There is one final reason why socioeconomic disadvantage may be considered a social determinant of health: both in the UK and elsewhere, socioeconomic disadvantage reduces a person's capacity to access health services (Hanratty, Zhang & Whitehead, 2007, p. 89). Whilst ease of access to health services in Hackney is unknown, 57% of adults using social care services in Hackney report having less access to these services than they would like (Hackney Council, 2014e: p. 6). Reduced access to health care services, including both primary (preventive) and tertiary (treatment) services, logically underpins poor health outcomes. 

As noted earlier in this paper, responding effectively to poor health outcomes involves addressing the social factors which underpin these outcomes (World Health Organisation, 2015: np). Because education is one of the key social health determinants and is directly related to many other determinants, including economic participation, addressing education must be a focus. Hackney Council's "Five Year Vision for Education" is centred on Hackney's schools, which are already performing at a standard above the national average (Hackney Council, 2012). There is a need to instead, target educational initiatives towards the considerable number of adults in Hackney who lack formal education. In the UK context, self-management education in particular has proven to be effective in improving health outcomes (Lorig, Holman & Halsted, 2003: p. 1).

In addition to education, improving economic participation is an important consideration in improving health outcomes in Hackney. Hackney Council (2010: p. 5) is critical of the effects of national unemployment welfare programs for people in Hackney, noting rising costs of living in Hackney, including increasing healthcare-associated costs, make welfare benefits appear more attractive than employment to some. Though it is beyond the scope of this paper, the benefits of national welfare reform on rates of economic participation and, subsequently, health should be considered. In the short-term, however, evidence suggests that 'welfare-to-work' programs – such as Hackney's "Pathways to Work" program, which supports the unemployed to become 'job-ready' – may be effective in increasing economic participation (Hackney Council, 2010: p. 5). In the UK, research indicates that such interventions are most effective when they are delivered in combination with physical and mental health services, thus conclusively breaking the cycle of poor health and economic participation (Hackney Council, 2010: p. 5; Ceolta-Smith, Salway, Tod, 2015: p. 254)

Addressing other issues underpinning the complex interplay between socioeconomic disadvantage and poor health outcomes is also important. As obesity underpins many poor health outcomes for people in Hackney, addressing obesity through exercise and nutrition interventions should be a focus. The proportion of people in Hackney taking part in structured physical activity programs is considerably higher than the national average, and this is encouraging (Hackney Council, 2014e: p. 65). However, providing safe spaces for exercise is an important consideration in socioeconomically disadvantaged regions; Hackney's "Strategy for Parks" (Hackney Council, 2008: p. 16) outlines a variety of ways in which this may be achieved. There are also multiple different strategies by which a population's nutritional status may be improved, however research suggests the most effective strategies in the UK context involve the provision of government-funded food vouchers and school meals (Attree, 2005: p. 67; Machell, 2015: p. 14). Hackney Council (2015c: p. 67) estimates that between 34% and 37% of children in Hackney are eligible for free school meals, and so this is a particularly important consideration in this context.

In addition to physical health, mental health should also be addressed. Hackney Council (2014d, 2014e) already provides a sophisticated range of services to support people with both mental illness and illness related to substance misuse. However, a number of UK studies highlight a strong correlation between property regeneration and improvements in participants' mental health (Curl, Kearns, Mason, Egan, Tannahill & Ellaway, 2015: p. 12; Egan, Lawson, Kearns, Conway & Neary, 2015: p. 101). Therefore, housing regeneration initiatives – particularly those targeting council housing, where the majority of socioeconomically disadvantaged people in Hackney reside – is another important consideration. Research suggests the best housing programs in the UK also address other health factors by ensuring effective water and waste infrastructure, damp and thermal insulation and appropriate social spaces are established (Stewart, 2005: p. 533).

Social factors – including education, economic participation and access to health services – have a considerable impact on a person's physical and mental health outcomes, and addressing these social factors underpins effective responses to poor health. This paper has provided a critical analysis of the social factors which contribute to poor health outcomes in the borough of Hackney. It has also discussed how these social factors can be addressed to effectively improve health outcomes for those in Hackney.

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