Policy

Policy is a set of principles, guidelines, frameworks and actions that are intended to set standards for the behaviour of individuals, groups and populations and essentially, to solve problems (Knill & Tosun, 2020). Policies exist at government level, but all companies and organisations will have their own sets of policies that may have a positive impact on the workforce (Timms et al., 2015). Policies address problems within societies by providing a platform that aims to keep the public safe and from a health perspective, by preventing or reducing diseases or conditions that impact economically and on quality of life (QoL) (Eyler, 2016). For example, Davies, (2015) recognised that incontinence was a prevalent issue impacting negatively on individuals QoL and on society in terms of the economic impact on health services. They proposed that policies should be commissioned to provide educational programmes and physiotherapy services to address these matters. Thus when a policy is established, it demonstrates an intention which can increase resources and funding in order to solve a societal issue.

What is healthy public policy?

Healthy public policy (HPP) is policy which is not specifically designed for health but ultimately has a positive impact on health (Carey et al., 2014). It is concerned with the social and environmental issues that impact on health and places an important focus on the social determinants of health (Bryant et al., 2019). The health in all policies initiative is an example of HPP which was designed so that health is addressed in all policies and sectors, including business and politics, local and national government, that is, that the impacts of a given policy on health are considered in every policy at every level (Guglielmin et al., 2018).

Examples of healthy public policy include those targeting obesity. It is said that obesity is caused by the environment in which people live which is influenced by issues such as poor access to space for physical activity, high costs of healthy food and marketing of unhealthy foods (Marmot, 2015). A recent policy, gear for change: a bold vision for cycling and walking, aims to increase active travel and proposes to invest in infrastructure that supports active travel as well as making changes to the highway code which will make it safer for the public to do so (Hirst & Dempsey, 2020). By addressing healthy public policy, it allows questions to be raised regarding the efficacy of siloed approaches to policy that focus on the individual behaviour, many of which are ineffective (Raine et al., 2014), to a focus on the wider issues that are impacting on health. Ultimately, HPP allows for the creation of environments that are conducive to the health of all (Raphael, 2015).

Policy Formulation

Policy formulation refers to the process by which an idea or a problem is transformed into an action or set of actions and the outcomes which it produces. The process of policy formulation is dynamic; there is a process, but it is not typically followed in a linear or cyclical fashion. Policy formulation begins with establishing a problem and setting an agenda to solve it. The agenda is then implemented and evaluated, and the policy may be adapted if necessary (Hansson-Forman et al., 2021).

In theory, policies must be evidence based or at least informed by evidence and in health policy, epidemiological studies provide a basis for new policies to arise (Bhattacharya, 2013; Bowman et al., 2012; Smith, 2013).  Policy can also be informed by the experiences of political leaders such as the current United Kingdom (UK) Prime Minister Boris Johnson who invested £100 million in weight loss services due to the impact his weight had on the severity of his COVID-19 illness. Moreover, policy can be informed by external pressures from lay people who lobby for new policies such as seen in the gradual changes being made to domestic violence policies and laws which have the power to improve health (Crozier & Jarman-Howe, 2020; Gill & Theriault, 2005; UK Parliament, 2022).

There does appear to be a gap however, between identifying an issue through research, and forming policies or actions (Bowman et al., 2012; Kitson & Straus, 2010). This gap appears to occur due to the unrelatedness of researchers and policy makers but is potentially addressed with the use of a framework (Field et al., 2014; Smith, 2013). The framework identified that policy decision makers or all those who have a stake in actions, must become involved from the earliest stages of research through a process of co-production in order for the policy process to be successful (Smith, 2013).

Policies and power

A welfare state implements economic support such as for public pensions, healthcare and unemployment support. Welfare states are present in all developed capitalist nations to which the UK is one. The balance of equity within a nation may be dependent on the type of welfare state to which it belongs. The UK is considered a liberalist welfare state that prioritises the economic market and pro-business political parties. This has the effect of de-prioritising citizen economies and social security which increases health inequalities. In contrast, nations such as Sweden, Finland and Norway belong to a social democratic welfare state that prioritises equality, independent of employment status and as such, these countries have a higher level of health equality (Bryant et al., 2019).

Summary

Policies exist for the health and safety of the populations they serve. The formulation of policies is complex and not always derived from the best evidence available at the time. This can change but requires the coming together of all stakeholders, researchers and government bodies. Policies are driven largely by those in the highest power but every person within society has the ability to influence and change policy to create a better society for all.

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Social determinants of health (SDOH) are the factors that fall outside of biological or genetic, that impact upon health (Bambra et al., 2010). They are the also the driving force of health inequalities (Lynch, 2017). SDOH account for one third of premature deaths in the United Kingdom (Lacobucci, 2019). Social determinants of health include: position within the social hierarchy, income, level of education, living and working conditions, access to healthcare, social isolation, adverse childhood experiences, race and gender. Health inequalities happen when subgroups of the population have a less equal chance of being healthy due to the SDOH. Health is impacted by where someone is born, where they grow up, where they live and the conditions in which they work and grow old (Marmot, 2015). Health inequalities are avoidable. It is possible to reduce health gaps by addressing the underlying, wider determinants that are causing ill health rather than targeting individual symptoms. The drivers for this change are social policy that filters down through healthcare structures.

To demonstrate the SDOH, illustrated, is the example of a 15 year old girl. Kerri was raised in care after losing her mother and experiencing abuse and neglect from her father. She became pregnant at 15, never finished school and had 3 children by 18. At home, the father was an alcoholic and violent. He also has experienced physical abuse at the hands of his father. In danger, the family moved to a new town, cutting contact with family. Kerri made attempts to gain employment, but each time was faced with a conundrum: it was more financially viable to remain unemployed and receive benefits than it was to work and pay for childcare. The family often lived in poverty, in unsafe areas which prompted several house moves. When Kerri did work, it was in a low paid and low skilled environment where bullying was experienced. Kerri’s children moved out of the family home at a young age and did not pursue ongoing education. These issues demonstrate the social determinants of health.

This live scenario evidences the complex interplay between the social determinants of health. All combined, these factors are mutually reinforcing and have a far reaching, negative impact upon health (Lovell & Bibby, 2018). The mother and children were in a low socioeconomic position. Health and life expectancy can be seen on a gradient from the lowest to the highest within the social hierarchy (Marmot, 2017a). The lowest on the social gradient have poorer health and health improves for each increased stage of the gradient. They were also victims of adverse childhood experiences (ACEs). Children who have experienced trauma such as domestic violence, alcoholism, divorce or death, are more likely to experience low mental wellbeing and ACEs correlate with heart disease and cancer. More respiratory and gastrointestinal disturbances are also seen in the adulthood of children who have had ACEs (Bellis et al., 2014). They are also more likely to adopt health offensive behaviours and are less likely to engage in health improvement behaviours (Bartley, 2017).

Lifestyle factors such as smoking, drinking excessive alcohol, poor diet and lack of physical activity are all causes of non-communicable diseases such as heart disease, obesity, type 2 diabetes and some cancers (Arena et al., 2016). Poor lifestyle factors are more prevalent in people in low socioeconomic positions and ACEs (Bellis et al., 2014; Lakshman et al., 2011). At first glance, this suggests that health issues within these populations are behavioural and is it the individual behaviours that must be targeted (Crinson, 2009). These behaviours, however, can be a way of seeking relief for those in dire circumstances (Baum & Fisher, 2014) and may also be culturally adopted (Kriznik et al., 2018). Marmot (2015), argues however, that poor lifestyle behaviours are adopted due to the conditions that people live in as opposed to the free choices one is able to make.

Sufficient opportunity must first exist in order for people to adopt healthy behaviours. (Lovell & Bibby, 2018). For example, Kerri would be unlikely to leave the house for a daily run when it was unsafe to be outside. She would also be unlikely to exercise due to lack of social support and time (Marmot, 2015). With time being and money being an issue, the gym and healthy food may not at the top of the priority list (Lovell & Bibby, 2018). Additionally, education may not be at the top of the priority list for a family who is struggling to survive. Education, however, impacts upon life chances (Braveman et al., 2011).

Higher levels of education are associated with improved health literacy and, in turn, higher levels of positive health management. Although domestic violence occurs at all stages of the social gradient, it is more concentrated in less educated, socially deprived areas. Education level can result in female empowerment: women who are well educated are more likely to seek help earlier. (Michael Marmot, 2017b). Education is also linked with better rates of employment and higher levels of income. Greater income would enable the family to acquire housing in a safer area. Deprived areas are typically more built up so have more light and noise pollution which can impact sleep as well as fear of inherent dangers (Davies & Pearson-Stuttard, 2020). Research by (Bambra et al., 2010) showed that urban regeneration has the potential to improve health but only if the social issues within the area are also addressed.Therefore, housing quality is impacted by income (Braveman et al., 2011). With more money, people may be able to move to a safer area that has access to green space for exercise and where it is safe to do so. Education, therefore, impacts upon socioeconomic position.

Position in the social hierarchy has an independent effect on health (Bambra & Schrecker, 2014). Those who are lower in the social hierarchy in all areas, experience poorer health outcomes. The mother was unable to work. Unemployment impacts health on multiple levels. It increases psychosocial stress and risk of poverty which increases the risk of malnutrition (Marmot, 2017b). Psychosocial stress increases the risk of cardiovascular disease (Marmot et al., 2013).The stress also impacts upon children’s socio-emotional behaviour which can impact upon engagement within education settings and perpetuate more social isolation (Marmot, 2017b). Social isolation negatively impacts upon health (Haslam et al., 2018). It correlates with increased risk of heart disease and strokes (Lovell & Bibby, 2018). However, being in employment but in low skilled, unsupported, emotionally toxic work, with lack of autonomy and control also impacts upon health (Marmot & Brunner, 2005). This makes clear, the need for social interventions in order to improve overall health.

Healthcare provision is largely biomedical. For example, if someone visited the general practitioner’s office for depression, they are likely to be prescribed anti-depressants – medicine. Medicine will not solve the underlying social issues the individual is facing. This is changing. It is being recognised that people need non-medical interventions and social prescribing, whilst it has been around since the 1980’s, has more recently caught the attention of the National Health Service (NHS) and was included within the 5 year plan in 2014 (National Health Service, 2019). Social prescribing provides help to patients who are experiencing social difficulties. As those social difficulties can result in poor health, the aim is to increase social health with a view of improving overall health (South et al., 2008).  Social prescribing has been driven by policy (Kilgarriff-Foster & O’Cathain, 2015).

Policy drives healthcare. Policy is a set of laws, frameworks and guidelines, set to achieve particular goals (British Ecological Society, 2017). Prior to the war, inequalities were largely accepted (Crinson, 2009). After World War II a need for social justice was highlighted and this drove the inception of the NHS in 1948, for the purpose of improving health and reducing social differences in health. Whilst general health improved and life expectancy increased (Dorling, 2013), health inequalities also continued to increase; the dominant governmental belief at the time was that it was due to individual behaviours (Crinson, 2009). However, Marmot et al. (1978) found that individual behaviours explained only a portion of the rates of mortality in the civil service workers who were studied and this lead to the commission of the black report by the Labour government (McIntosh Gray, 1982). The black report provided compelling evidence of health inequalities. This coincided Margaret Thatcher coming into power for the Conservative government and the report was subsequently ignored in favour of pushing the individual behaviour narrative (Crinson, 2009). What is demonstrated here, is that policy is unstable and healthcare provision is controlled by political agendas. Regardless of whether or not a policy is working, politicians hold the trump card.

Labour came back into power in 1997 and commissioned the Acheson report which served as an update to the black report and corroborated the original findings (Crinson, 2009). The initial evasion of this undeniable data is responsible for the public health policies that are directed at improving individual behaviour. It has been shown however, that health promotion, is unlikely to drive health improvements in low socioeconomic position populations (Baum & Fisher, 2014).  Over time, changing governments also saw the cancellation of policies such as the Sure Start program (Melhuish et al., 2008) which was evidenced to improve the social problems and life chances for children in low socioeconomic groups. The National service framework for children, young people and maternity services which aimed to intervene and provide additional care to children who were exposed to domestic violence, was abolished due to an organisational change within the NHS (Department of Health, 2004).

Nonetheless, policy is responsible for substantial improvements in population health. Fiscal policy or tax on tobacco, alcohol and sugar has shown to be successful. By increasing tax by ten per cent  it induced four percent of smokers, largely from low social position groups, to quit (Chaloupka & Powell, 2018; Thomson et al., 2018). However, the tobacco industry seeks to undermine this effort by promoting cheaper ways to smoke such as ‘roll your own’ so policy needs to go further to address this (Hiscock et al., 2018).  Via social prescribing, smokers have access to healthier activities that may honour the relief they seek from smoking ,by obtaining additional social support (Kilgarriff-Foster & O’Cathain, 2015).

Creating policy that supports these issues is more conducive to health and a healthier society creates a more fruitful economy (Lovell & Bibby, 2018). Woolf (2019) argues that investments made in education and housing will do more for life expectancy than care provided by health services. Domestic violence is not caused by policy makers, but policy can be produced to address the cascade of social determinants that drive the health inequalities that keep generations in a vicious cycle of poor health (Bellis et al., 2014; Gill & Theriault, 2005; Department of Health, 2015). It is in the interest of policy makers to address these issues. Lovell & Bibby, (2018) argue that good health is the basic right of everyone in society. It is the moral obligation of the state to provide this. If governments, rather than pushing their own agendas would take heed of the data and provide continuity in the policies written to reduce inequalities, then it is a possibility that the health gaps and social gradient would reduce in a timelier fashion.

There are a multitude social issues that have a negative impact upon health. These issues drive inequalities but if the SDOH and health inequalities are addressed, it would benefit the economy as a whole, as well as reducing the costs to healthcare services. Ultimately, the life expectancy of Kerri and her children, according to the social gradient, will be lower. Currently, they have a higher probability of spending more time in their lives with illness, disease or disability. People are generally aware of the risks of smoking, drinking and poor diet so individualistic policies that target behaviours ignore the wider determinants of health. (Baum & Fisher, 2014). Change needs to come from the top to create a fairer society. Policy must address the underlying determinants, the deeper causes of these behaviours, alongside or even ahead of behaviour change, in order for change to be effective. Good health starts with political and organisational continuity of the policies that have proven fruitful in addressing the issues. Social determinants of health and health inequalities are likely to always exist, but if the gradient is tackled it would go a long way to reducing these issues, to the benefit of society as a whole.

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Chronic illness affects up to a quarter of people in the United Kingdom (The King’s Fund, n.d.) and many of those illnesses are invisible, including such diseases as many cancers, heart disease, HIV, AIDs, diabetes, ME/CFS and fibromyalgia and mental illness (Bassler, 2009; Kundrat & Nussbaum, 2003; Link & Phelan, 2014). One may experience symptoms that significantly alter their daily life and chronic long-term illnesses produce a series of complex psychological issues that further impact living with the disease (Marks et al., 2018). The person may lose their identity or sense of self and future aspirations, they may become subject to stigmatisation either directly or as a result of unconscious bias which in turn can affect every aspect of their lives, including access to healthcare. Improving one’s self efficacy may be a solution to the psychological impacts one faces when diagnosed with a chronic illness but in order for any of these factors to be improved upon, there must be an equal effort via societal structures in healthcare, workplaces and educational facilities, in order to support the individual with their ongoing needs. This in turn can produce better overall health outcomes and better support the individual.

A new diagnosis or experiencing debilitating symptoms of a chronic illness can threaten an individual’s identity (Marks et al., 2018). A person has a number of identities, including their self-identify which refers to who the individual is, their place in the world, their likes, dislikes and the activities they enjoy (He et al., 2019). An individual’s identity is also made up of their future plans and aspirations, their biography and the illness may leave the individual feeling like they no longer have a future or a place in the world.

Social Identity Theory (SIT) states that as part of groups, one’s identity is linked to the groups they are part of and can be linked to their status within their communities, social groups, workplace, friends and family roles (Marks et al., 2018; Tajfel & Turner, 2019). According to SIT, group conformity is important, and the individual may no longer be able to conform to their current groups due to restrictions imposed by the illness. Social connection has a strong impact on longevity, showing the huge threat one faces in this instance (Haslam, 2018).

This loss of one’s self, social groups and family roles can conjure a concoction of emotions such as helplessness, resentment and denial (Pranka, 2018) and the individual has a decision to make in this scenario: attempt to continue or find a way to maintain their current identity along with the illness (Pranka, 2018) or revise their identity, engage in biographical work which will help them to forge a different path for the future (Querol , et al., 2020), and accept the illness as part of their identity which can result in health improvements or be health protective (Ortis et al., 2018).

Conversely, if a change in identity is not accepted by the individual, they may attempt to assert control over their identity and control the parts of themselves that others see, leading them to conceal the illness (Aujoulat et al., 2008). This in turn, may force the individual into social isolation and also may prevent them from accessing the healthcare and social support they need (Quinn et al., 2017). Having strong social bonds is health protective and if the individual is limiting themselves from that social help and support, further psychological issues may ensue, including anxiety and depression (Haslam et al., 2018).

Forming new social identities or joining new groups can encourage post traumatic growth and help the individual to work towards overcoming the psychological impact of the illness trauma (Kelly et al., 2012; Zeligman et al., 2018). However, symptoms may make it difficult to join new groups due to the constraints of their illness (Marks et al., 2018). Additionally, there are risks in exposing their illness and building a new identity around it. Many chronic illnesses are stigmatised and by accepting and forming an identity around the illness, the individual exposes themselves to the risk of discrimination and thus the individual finds themselves in a vicious cycle, torn between the need to gain support but risking their wellbeing and life chances through that exposure (Link & Phelan, 2001).

To be stigmatised, is to be judged by an aspect of one’s self that deviates from what is considered in society, to be normal (Baxter, 2010) and chronic illness becomes stigmatised when there is a belief that because of the illness, the person is less, tainted or less able (Stuber et al., 2008). Discrimination via a stigmatised illness is woven into every crevice of society from the media, healthcare, to employment, educational facilities and social groups (Marks et al. 2018).

Stigmatisation is oppressive and subjugates the individuals experiencing it, resulting in discrimination; guilt and shame when the individual internalises the stigma; reduced healthcare; reduced employment opportunities; social exclusion and can even result in emotional and physical abuse (Kadianaki, 2014; Link & Phelan, 2014; Marks et al., 2018). For example, in healthcare, Friedberg et al., (2008) conducted a study to explore what medical students believed about chronic fatigue syndrome. Whilst the symptoms of the illness are very real and often disabling (Lacerda et al., 2019), terms such as ‘lazy’ and ‘made up’ were used. Some of this knowledge was obtained from the media which has historically stigmatised the illness but also from the very doctors they were learning from as it has been shown that even in healthcare, stigmatisation is likely to occur and this can then impact upon the care that the patient receives (Marks et al., 2018). If the individual feels they may be disbelieved by a GP it could result in the patient feeling unsupported which may result in avoidance of seeking help altogether. (Åsbring & Närvänen, 2002).

In coping, some, underplay the effect of their illness, some deny it altogether. Some however, challenge the stigma, using it as a platform for personal transformation and raising awareness, fighting against the stigmatising labels that are imposed on them (Link & Phelan, 2014; Marks et al., 2018).

There are, however, groups who may be more or less psychologically sensitive to stigma. Those who have been raised to believe the world is fair may be less sensitive than those who do not believe the world is fair, such as those from a low socioeconomic background (Haslam et al., 2018). However, individuals with a high status may be more sensitive to stigma due to the very real fear of losing their status, due to the stigmatisation attached to the illness (Scheepers et al., 2009). Those who are sensitive to stigma may experience a higher perception of discrimination where it may not exist which can cause significant psychological stress (Earnshaw & Quinn, 2012).

The Equality Act (2010) exists to protect those not just with disabilities but also with any ‘impairment’ or alteration to the ability to manage daily activities, physically or mentally, from the stigmas that exist. However, whilst policies do exist, there is no escaping from unconscious bias. Unconscious bias is a strong relative to stigmatisation because even though laws are in place for equality, the very nature of unconscious bias is that it is outside of conscious awareness.

Stenhoff (2015) describes how educating those within the medical industry using the biopsychosocial model of illness may help medical practitioners to be more understanding of stigmatised chronic illnesses. These positive attitudes may create less stigma and create better physical and mental health outcomes (Nyblade et al., 2019). There is a potential solution in helping a patient to cope with the stigmas that exist. Helping a patient to improve their self-efficacy may help to reduce their fears and disclose the stigmatised illness, (Mittal et al., 2012) achieving peer and social support, asking for the flexibility and adaptations they need in order to work or be educated because with high self-efficacy, the person will have the belief that they can overcome these challenging obstacles and obtain the support they need.

Self-efficacy (SE) is the belief that one has, in the ability to achieve what they set out to achieve and the confidence in knowing they can overcome a range of life challenges (Bandura, 1977). In chronic illness an individual is presented with a range of challenges, including: having to adapt lifestyle factors such as work, home life including roles, and changing or adopting new health behaviours in order to effectively manage the illness (Wilski et al., 2020). When faced with a diagnosis or symptoms of a chronic illness, an individual with high SE will have the belief that the action they take will be positive and will see it not as a threat to one’s life but as an opportunity for growth (Zeligman et al., 2018). An example of someone with high SE, is someone who becomes self-employed in order to be provided with the flexibility a standard workplace cannot provide (Beatty, 2012), the individual has found a solution to overcome the obstacle.

SE can be measured and it can be improved upon (Schwarzer & Warner, 2013). The general self-efficacy scale is used to measure SE which is positive because if an individual presents with low SE, improving SE has been linked with a range of health improvements such as improved illness perception, depression and anxiety, decreased pain and fatigue and improved quality of life (Schwarzer & Warner 2013).

SE is improved via four domains and in chronic illness these relate to: mastery of tasks related to management and/or improvement of the illness (Bonsaksen, Solveig & Lerdal, 2015), witnessing others with similar illnesses who have successfully achievement of health improvement via management of the illness (Bonsaksen, Lerdal, & Fagermoen, 2012), verbal persuasion from healthcare professionals who are able to successfully counsel the individual to adopt the required management and self-care (Aujolat et al., 2008) and reduction of stress and management of positive emotions related to the illness (Bandura 2010). The effects of low SE may result in maladaptive coping behaviours. (Korpershoek et al., 2011).

However, whilst there are clear benefits to improving SE and SE transformation is possible, there are external factors when it comes to improving SE. An SE improvement program will amount to little if social systems are not in place to support the individual. In one example, Beatty (2012) found that whilst up to one-fifth of employees have a chronic illness, just half of those had disclosed their illness. The problem is that whilst policies exist to protect those with chronic illness, many of those policies do not reflect the specific needs and the flexibility required by those with chronic illnesses. If could be said that the individuals who do not disclose the illness, have low SE but if supportive systems are not in place, it can hinder efforts to create self-efficacy in the first place.

There are a multitude of psychological factors that impact upon an individual who is faced with chronic illness. Self-efficacy is one therapeutic asset that can assist with buffering the impact of the identity and stigmatisation issues discussed but it can also have a negative psychological impact if it is low. Stigmatisation exists throughout society and whilst it can have a profoundly negative impact on an individual, it can also be area for personal growth if the individual is able to stand up to it. When faced with chronic illness and the life changes it entails, one can lose their sense of identity, personal and social but one way this can be resolved is by accepting the illness and forming new identities. The overarching issue is that society has a large part to play in improvements relating to these issues, starting with educating those in healthcare and workplaces about the needs of those in the chronic illness population, uncovering and diminishing unconscious bias and re-writing policies to account for the needs of those with chronic illness. This in turn will improve the life chances for those with chronic illness and bring about more social acceptance overall.

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