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Introduction to some of the challenges

Dr Cliona Ni Challaigh talks through some of the challenges of working with vulnerable patients and how these can occur.
Hi, everybody. My name’s Clíona Ní Cheallaigh. I’m an infectious disease and inclusion health doctor in Dublin, in Ireland, and a clinical academic. And I want to talk to you a little bit about some challenging situations that we can face as clinicians, and what is underlying those situations, and how and why we can address them. I’m going to start with a story that I think will ring bells with many of you. And so this one stands out in my memory because it was particularly challenging, a young woman, younger than myself. She was in her 30s when I was looking after her last year. She used drugs. She injected heroin.
And she came in with a staphylococcus aureus endovascular infection of her femoral artery. She was very unwell and she was at a high risk of complications and death, and she needed inpatient care for admission and surgery. So already complicated in terms of the medical presentation and the type of treatment that she needed, this was compounded by the fact that this lady was quite challenging to manage on a ward. And she tended to become upset very easily. She would get very angry with the nurses and doctors and other staff on the ward. She cursed and was quite volatile in her behaviour, and she often refused to have the treatment or the scans or whatever it was that we suggested for her.
So at least once a day I would get a call from somewhere that this lady had been, whether it was radiology department or the ward or something, and just, staff were really at the end of their tether trying to deal with her. And as a clinician, I was then left in a very difficult situation. I’m trying to balance the patient’s needs for inpatient hospital care and trying to manage her behaviour in a setting in which staff and other patients were really struggling to deal with her behaviour. And I think that this is a situation that probably is familiar to many of you.
And I’d like to talk a little bit about what was underlying that particular scenario, what kind of societal and psychological factors were contributing to it, and also to give you some ideas of how we can deal with similar situations.
So the first important concept that I want to highlight is that poverty is bad for you. And I think we all see that every day, but we don’t necessarily think about it in our roles as clinicians. But if we look at a very hard end point like how likely you are to die at any given age, which is what the standardised mortality ratio is, we can see that you’re twice as likely to die at any given age if you live in a poor part of the UK compared to a richer part. And that’s not unique to the UK. That would be the same over many, many rich countries.
When I talk about this with students or other clinicians, I think the first thing that comes to people’s minds are behavioural factors like smoking, obesity, alcohol, and drug use. And there can be a lot of judgement associated with the increase of those behaviours in poorer areas and a sort of thought that well, those people should just stop smoking and stop drinking and pull themselves together.
And we can take that a little bit more further in the discussion, but I think it’s important to note that if you correct for all those behavioural variables, it only corrects about a third of the difference between rich and poor in terms of health, and 2/3 of the effect that poverty has in causing ill health is not understood.
And that’s known as the Slope Index of Inequality. And there are a lot of amazing people who work on this area, who research on it, including Michael Marmot and Richard Wilkinson, and if you’re interested in this area I would encourage you to read more about it. I think as a clinician it’s a really important thing to understand, because it’s driving a lot of the ill health that we deal with.
What I’m really interested in though is what I would conceptualise as the very deep end of poverty, and that is the poverty and social exclusion experienced by people who are really on the margins of society. And that at the moment is typified by homelessness and prison, injecting drug use. Those are all people who really struggle to engage in education, engage in occupation, engage in housing and all those other things that we would see as being critical parts of participation in our society. And I think it’s important to note that these aren’t separate events that happen separately to separate people. People who usually have experience of one of more of these experiences.
So people who are homeless frequently will have spent time in prison, frequently may inject drugs or have other significant substance use disorders. And so really what they are, those experiences are different facets of a common experience. And other groups that also have this experience and aren’t mentioned in this particular paper would include
members of the travelling community: Roma gipsies, Aboriginal communities in Australia, First Nations in Canada, and Native Americans and Black communities to some degree in the US, so communities that are disproportionately burdened by a lot of adversity. And what we can see if we recognise these as being a common experience, a common pathway, and pool studies that have been done on people with these different experiences together and then look at the effect on their health, we see that social exclusion, which is the term that describes that experience, is associated with a dramatic increase in the risk of death, for example.
So men who are socially excluded have a standardised mortality ratio that’s eight-fold higher than that of the more affluent, and in women it’s 12 times higher. So really if you think about poverty being a gradual slope in the waters, the water is getting deeper and deeper and then you hit a point where the water just, the bottom falls out under you and you’re in very deep water. Or another way to think of it is that you have this slope of increasing ill health and then you hit a cliff. So we’re seeing effects that are similar to poverty really magnified many-fold over.
And the lady that I described at the start of this talk was homeless, had been in prison, was an injecting drug user, and had exchanged sex for money or drugs. So she had had many of those experiences that characterise social exclusion and definitely would be socially excluded.
So we know that social exclusion makes you more likely to die. It also greatly increases your risk of having certain diseases, and particularly psychiatric disease and infection. And you can see, for us infectious diseases doctors, this is one of the reasons why we tend to deal with quite a high proportion of socially excluded people amongst our patients.
Unsurprisingly– I’m a hospital doctor. That’s my world. And need for acute unscheduled hospitalisation is very much driven by two things, by ageing and multiple morbidity, and by poverty and social exclusion. And you can see here data that we’ve generated in Dublin showing about a tenfold increase in acute unscheduled hospital care in people who are homeless. So it’s not a coincidence that many of your patients will be socially excluded, because social exclusion is making them unwell, and making them unwell to the point where they require hospital care.

In this video, Cliona Ni Challaigh introduces some of the challenges that can be faced by both patients and healthcare professionals when a vulnerable patient is seeking health care.

Cliona talks about social exclusion and how this can inform or cause some of the behaviours you might encounter. She explains how significantly poverty affects health, as anybody at any age is twice as likely to die if they are in poverty. Rectifying other socially excluded behaviours such as drug use, alcohol use and smoking is likely to only correct a third of the difference that poverty causes.

Patients in the deep end of poverty (those who are homeless, in prison or inject drugs) often simultaneously experience multiple situations which lead to difficulties in finding housing or jobs. Men who are socially excluded have an 8-fold standard mortality rate and women have an 11-fold standard mortality rate. This magnification of mortality risk due to social exclusion is termed the cliff of inequality.

A personal experience of caring for a socially excluded patient highlights other challenges clinicians may face including difficulty communicating, volatile behaviour, verbal abuse and refusal of scans and treatment.

Cliona highlights some of the challenges faced by clinicians due to socially excluded patients. The following steps look further into the social determinants of health including poverty and homelessness.

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Infection Prevention for Vulnerable Patients

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