Precarity and the Social Determinants of Health – exploring theory and research agendas for social science and academic primary care

Problem

The term precariat is increasingly used to describe an emergent disenfranchised social class who suffer economic and social insecurity and marginalisation, especially in relation to income. While this phenomena has been debated and theorised in terms of politics, sociology, economics, globalisation and social justice, little attention has been paid to the health impacts of this particular state of extreme marginalisation and how primary care might mitigate the lived experiences of precarity. New collaborations and research agendas are needed to explore this topic and help inform policy and practice.

Approach

In order to generate new ways of thinking about and researching precarity and primary health care, we draw on our combined experiences of qualitative health research – drawing on projects about regeneration, homelessness, food banks, and Universal Credit – and reflect upon how health, precarity and insecurity are perceived by the practitioners and vulnerable populations we have spoken to. We focus on the ways in which encounters with primary care and health needs feature in precarious trajectories and experiences.

Findings

We propose a theoretical and pragmatic focus on precarity around the Social Determinants of Health. The growing body of people who endure the ‘temporary’ and ‘emergency’ in perpetuity find themselves in substandard ‘temporary’ housing, employed on a casual basis, the subject of benefit sanctions, and the (often unwilling) recipients of ‘emergency’ food and shelter for extended periods. Such an existence is characterised by external locus of control, lack of agency, repeated and sometimes hostile interactions with state agencies, intermittent reliance on third sector assistance with meeting basic needs, a lack of social capital and the need for advocacy; in combination these processes can be summarised as undermining a sense of citizenship and engagement in local communities and national structures This, in combination with the commodification of incapacity in welfare regimes and the recent spate of reforms challenging it, generate a specific set of health challenges. Anxiety, depression, disincentivising self-care and health seeking behaviours, isolation, obesity, smoking and reluctance to seek help from state agencies and/or primary care were all spoken about in relation to the lived experiences of precarity. Building on these themes in peoples’ experiences we also suggest particular ‘pathways’ by which primary care could address these challenges. Further, we identify research questions and avenues for theoretical development.

Consequences

Primary care providers, local authorities and the third sector are increasingly tasked with responding to the health and social impacts of precarity, insecurity and marginalisation. Understanding the lived experiences of precarity and the specific health needs that arise from them is key to both informing research agendas and challenging the problematizing of vulnerable populations. Exploring precarity around the social determinants of health is one way of reimagining contemporary health inequalities.