Socio-cultural Determinants of Health

Question 1

What are social determinants of Health?

Answer 1

They are economic and social conditions that influence the health of people and communities.These conditions are shaped by the amount of money, power, and resources that people have, all of which are influenced by policy choices.

Question 2

Social determinants of health affect factors that are related to health outcomes. The factors that are related to health outcomes include:

Answer 2

1. Early childhood development
2. Amount of Education
3. Ability to get and keep a job
4. Kind of work they do
5. Food security
6. Access to health services and quality of the health services
7. Housing status
8. Income
9. Discrimination and social support

Question 3

What are health inequities?

Answer 3

> These are avoidable inequalities in health between groups of people within countries and between countries.
The health inequities arise from inequalities within and between societies. Social and economic conditions and their effects on peoples lives determine their risk of illness and and it also determines the actions taken to prevent them from becoming ill or treat illness when it occurs.

Question 4

Explanation of the distributions of disease:

Answer 4

• Psychosocial approaches
• Social production of disease/political economy of health
• Eco-social and other emerging multi-level frameworks.
  # All represent theories which presume but cannot be reduced to mechanism–oriented theories of disease causation.

Question 5

The main social pathways and mechanisms through which social determinants affect peoples health can usefully be seen through three perspectives:

Answer 5

1. Social selection/social mobility
2. Social causation
3. Life course perspectives
   #These frameworks/directions and perspectives are complementary.

Question 6

How do differences in social position account for health inequities?

Answer 6

Diderichsen’s model of “the mechanisms of health inequality”.

Question 7

The mechanisms of health inequality stratify health outcomes:

Answer 7

Social contexts - which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions
> Social stratification - in turn, engenders differential exposure to health-damaging conditions
> Differential vulnerability - in terms of health conditions and material
resource availability.
#Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes per se.)

Question 8

Historical context of the Social Determinants in Health

Answer 8

• In 1948 the WHO constitution: acknowledgement of “impact of social and political conditions on health” and need for intersectoral to achieve health gains. 1950s- 1960s
• There was little regard for social contexts, strong focus on technology and disease- specific campaigns. 1978
• Then there was the Alma-Ata Declaration on Primary Health / Health for All. This declaration asserted the need to strengthen health equity by addressing social conditions through intersectoral programs 1980s
• Limited political will - Neoliberal governments in many European countries and the US with market-oriented reforms in health care - Structural Adjustment Programs for developing countries: reduced government’s social and public spending • At the same time: biomedical paradigm was challenged: Black Report (UK)8

Question 9

How is the World Health organization addressing social determinants of health?

Answer 9

• The World Health Organization (WHO) created the Commission on Social Determinants of Health to address social determinants of health. The Commission uses three principles to guide its work in eliminating health inequities for local communities and nations and throughout the world.

Question 10

The 3 WHO Principles:

Answer 10

1. Improve the conditions of daily life –> the circumstances in which people are born, grow, live, work, and age.
2. Tackle the inequitable distribution of power, money, and resources –> the structural drivers of those conditions of daily life –> globally, nationally, and locally.
3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

Question 11

Conceptual social determinants of health framework (CSDH)

Answer 11

• The commission a conceptual framework that describes relationships among individual and structural variables.
• The framework represents relationships among variables that are based on scientific studies or substantial evidence.
• The framework provides a point from which researchers can take action, such as creating targeted interventions, on social determinants of health.

Question 12

CSDH Framework

Answer 12

• Emphasis on the socioeconomic and political context and the structural determinants of health inequity.
• “Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market; the educational system political institutions and other cultural and societal values.
• Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies).
• In the CSDH framework, the structural mechanisms are those that interplay between context and socio-economic position: generating and reinforcing class divisions that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and policies of the socioeconomic and political context.

Question 13

Structural stratifiers and proxy indicators [stratification is to put into different groups]

Answer 13

1. Income
2. Education
3. Occupation
4. Social Class
5. Gender
6. Race/ethnicity.
   #Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities”

Question 14

Policy action on SDH:

Answer 14

Three broad approaches to reducing health inequities can be identified. These may be based on:

1. Targeted programmes for disadvantaged populations.
2. Closing health gaps between worse-off and better-off groups.
3. Addressing the social health gradient across the whole population.

Question 15

SDOH = social determinants of health

Answer 15

• Economic stability: Poverty, Employment, Food security and Housing stability
• Education: High school grad, Higher Edu, Language and Literacy, Early childhood Edu. and development.
• Social and community context: Social cohesion, Civic participation, Discrimination, and Incarceration [being in jail]
• Health and health care: Access to Health care, Access to primary care, and health literacy.
• Neighborhood and built environment : Access to healthy foods, Quality of housing, Crime&violence, Environmental conditions.

Question 16

SOCIAL DETERMINANTS OF HEALTH IN SOUTH AFRICA

Answer 16

• SA is faced with Tuberculosis, HIV, and AIDS; high levels of maternal and child mortality and other communicable diseases; injuries; and non-communicable diseases, or NCDs that is (all) linked to poverty and deprivation.
• In 2011, NCDs alone accounted for 34.4% of years of life lost.
• It is only recently that there has been a greater recognition of the role of inter-sectoral action in tackling some of the health challenges facing SA (27).
• Key emphasis in the first phase of the National Health Insurance (NHI) reforms in SA is on ensuring that not only curative, but also preventive and promotive primary health services, which engage other relevant sectors, are dramatically improved.
• No clear strategy that addresses health inequalities bearing in mind the contributions of different sectors to health inequality in the country.
• This puts SA in a situation where there is a need for evidence to inform strategies for collaborative inter-sectoral action to redress existing health inequalities.

Question 17

CULTURE as a social determinant in South Africa

Answer 17

• South Africa is a multicultural society with a multitude of traditions and customs affecting the way we live, the way we relate to each other, and the way we bring up children.
• There are extensive ethnic differences, urban-rural differences, class differences, age group differences and gender differences.
• However, cultural trends are extremely difficult to assess as these complex social characteristics are much more difficult to measure than, for example, socio-economic characteristics.
• In addition, health related behaviours are sometimes portrayed as cultural in order to mask their political-economic origins.

Question 18

SOCIAL COHENSION as a social determinant

Answer 18

• A review of social determinants of health by Rispel et al.observed that the South African discourse on health determinants focuses on poverty, marginalization and disadvantage. The review explored marginalisation, which results from social exclusion for a variety of characteristics.
• Disease itself can result in exclusion, and illustrated it with cases of people with HIV or AIDS who have been excluded by their own family.
• The mid-term report noted that according to survey data, Africans seem the least networked, when compared to other population groups.
• The report highlights the fact that although it is often assumed that Africans have a better sense of community, they belong to networks of meagre resources.
• According to the review of macro-social trends, crime can be considered both a cause and an effect of social cohesion.

Question 19

UNEMPLOYMENT as a social determinant

Answer 19

• Unemployment levels in South Africa rose until about 2003, reaching levels of about 30%
• Unemployment is particularly high among the young, the unskilled and Africans.
• There is a current skills shortage in the economy and that concurrently, unemployment among the unskilled is high.36
• Informal work provides little respite. Aside from income, unemployment has health consequences resulting from psycho-social factors, and high risk behaviors related to unemployment such as binge drinking and substance abuse.

Question 20

EDUCATION as a social determinant

Answer 20

• Less than a third of the adult population has a matric or higher qualification.
• In 2007, 10% of the population aged 20 years and above had no education compared with 19% in 1996 .
• This trend is probably a consequence of changes in access to the education system since 1994.
• According to the 2003 SADHS, about 95% of the younger adult population of South Africa is able to read, however, the proportion decreased with age.

Question 21

Proposed interventions to address the social determinants of health, South African National Development Plan 2030

Answer 21

• Develop and expand the existing child-survival programmes.
• Collaborate across sectors to ensure that the design of other sectoral policies take impact on health into account.
• Promote healthy diet and physical activity, particularly in the school setting.

Question 22

Evaluating how NDP [national development plan]promotes a social-determinant approach

Answer 22

• NDP aims to eliminate poverty and reduce inequality by 2030.
• Their vision is to raise living standard of all South Africans to a minimum level. It was developed by National Planning commission. They see national development as a non-linear process requiring a multi-dimensional framework. Combination of increasing employment, higher incomes through productivity growth, a social wage and good quality public services. They want to create a virtuous cycle of growth and development.

Question 23

Evaluating how the Primary health care Re-engineering Strategy promotes a social-determinant approach

Answer 23

• A 4 stream approach to PHC re-engineering has been adopted by the National Department of Health (NDoH) . The four streams are:
  1. A system of community outreach referred to as Ward-based Outreach Teams (WBOTs)
  2. School health teams
  3. District Clinical Specialist Teams (focused on maternal and child health)
  4. Contracting of private general practitioners for clinical care.
  #Of all the four streams, the WBOTs and School Health Teams are best placed to begin addressing the social determinants of health.