Social Determinants

1. Social Determinants Presentation at the Provincial Consultation on “Expanding the MDG Agenda” Lahore. August 31, 2005 Narjis Rizvi Community Health Sciences Dept. Aga Khan University. Karachi.

2. Outline of Presentation • Why Social Determinants-Rationale • Approaches to understand Social determinants • Analysis of case study,a ‘webbing exercise’ (highlights the web of causation) • Focusing on data (conventional) • Community assessment -- An example from the field • Linking the three approaches

3. Why Social Determinants-Rationale Women's health is influenced by determinants including: participation and influence in society, economic and social security, secure and favourable conditions during girlhood and adolescence, healthy occupational and living environments, health and medical care that actively promote good health, effective protection against communicable diseases, safe sexuality and good reproductive health, increased awareness of healthy lifestyles, good eating habits and safe food, and healthy stress-coping mechanisms. http://www.euro.who.int/socialdeterminants/gender/20050711

4. Approaches to understand Social determinants • Analysis of case study, a ‘webbing exercise’ (highlights the web of causation) • Focusing on data (conventional) • Community assessment --An example from the field

5. Analysis of Case Study, through a ‘webbing exercise’ Highlights the web of causation

6. Analysis of Case Study -Maternal Death • Immediate cause • High fever • Bleeding • Low economic status • Drought • No work opportunity • High parity-9th pregnancy • Distance from health center • Women’s social status-Mother-in-law was uncertain • Early age at marriage-13 years • Frequent illnesses-Upset stomachs • Unsafe water • Less food • Work load • Lack of Ante-natal care • Lack of Family planning • Untrained birth attendant • Lack of female staff at health facility

7. Focusing on data (conventional) Based on Data….

8. Economic statusPoverty and Mortality

9. Causes of Death http://ucatlas.ucsc.edu/cause.php

12. Analysis of Existing Data • Low economic status • Illiteracy • Malnutrition • Rural residence • Early marriage • High parity • Lack of access to health care And many more depending upon the specific location

13. Community assessment -- An example from the field From Community’s perspective….

14. UC Khuhra Justice demands that we know the reason … Households with illnesses Difference ? Households without illnesses

15. 14 priorities listed at Khuhra 1.Health Awareness 2.Poverty 3.No Drainage 4.Hospital not available 5.No road 6.Education 7.No timely treatment 8.Mosquito spray 9.Tribal conflict 10.Cleanliness at home 11.Health facility is far 12.No vaccination 13.Women’s treatment is delayed 14.Gender inequality

16. Linking the Three ApproachesFramework of Analysis

17. Common Themes • All three approaches • Economic Status • Lack of Access to Health Facility • At least two approaches • Sanitation • Education

18. Gaps • Data is ignoring (Community is more concerned) • Roads • Gender inequity • Tribal conflict • Awareness about health • Cleanliness at homes • And so on……..

19. Gaps • Community is not concerned (Data is focusing more on) • Early age at marriage • Frequent Illnesses • Unsafe water • Nutrition • Workload • Lack of Pregnancy care • Lack of female staff • And so on…….

20. What can we now conclude about Social Determinants ?

21. Determinants of Health Agent Host Environment

22. We conclude that To understand and determine Social Determinants, one approach would not be enough one has to understand and determine Social Determinants from all approaches so as to address health holistically and Design intervention which are, though focused, but effective

23. If only community approach is used which fails to recognize.. Relationship between parity, pregnancy care and health; both its immediate effects as well as impact; on not only the woman but the whole family and the population. Family planning and mother and child care services would not bring about fertility reduction and improvement in women’s health Until these services incorporate strategies for behaviour modification and attitudinal change so that society instead of giving value to high parity, gives worth to woman’s life and health.

24. If only conventional approach is used which fails to recognize Access to health care is not only affected by economic reasons, but non-financial barriers such as Tribal conflict, law and order situation, non-availability of female health provider etc. also restrain health seeking. We cannot go to the health center after dusk. Insufficient sanctioned posts for trained nurses 162 health facilities sampled had no female staff; 53 percent of the Dispensary had no female staff

25. If conventional approach is used which fails to recognize Gender gaps, and Strategies do not address practical as well as strategic gender needs and are not cross-cutting • Interventions are mainly focusing on women’s maternal role • “Iron supplementation to pregnant women” Unable to fill about 60 percent of the sanctioned posts for women health care provider (15) and 4 percent attrition rate of female health workers (16)

26. Thank you

27. Why did Zubaida Died? (A case study for analysis of maternal death.) • On the day of Zubaida’s death, her husband was not in the village. He had gone to town to look for a job, as there was no work on the land because of the drought. In and around his village, even the bigger farmers depended on the rain, hence there was no work opportunity even on the bigger farm. His own piece of land was barely enough to provide for the basic needs of his and his two brothers’ families. His youngest brother was a truck driver, and was mostly away; and the other brother had tuberculosis and was unable to do hard, manual work. Being the eldest brother, he felt a great responsibility for the welfare of the larger family, and was determined to find a job no matter how long it takes. He knew that Zubaida had not been feeling well, but thought that she was now an old hand at child-birth, and that with his mother and the dai being in the village, everything would be all right.

28. Why did Zubaida Died? • This was Zubaida’s 9th pregnancy, or was it the 10th or 11th, Zubaida was not sure herself. She had high fever all night, but she did not tell her husband how miserable she felt. She had served him tea before he left for the town, and then had laid down herself. She had started to bleed since early morning, but hoped that if she lay down for a while it would be all right. Her mother-in-law went and fetched the dai from the neighboring village, but by the time she came, Zubaida could barely speak or listen to anybody. The dai advised that Zubaida be taken to the health center that was 3 km away, but the mother-in-law was uncertain. She thought that perhaps they should wait for one of her sons to return to the village. In the meantime, the dai decided to see whether the doctor at the health centre would come to the village. It took the dai nearly one hour before she reached the health centre; but it was a futile visit. The doctor refused to go to the village. Disappointed, the dai returned to the village, but by then Zubaida had died.

29. Why did Zubaida Died? • Zubaida was 23 years old. She had been married for 10 years, and had 6 children -- the youngest being 1 year old. Two of her children had died within 2 years of their birth; and all the others were malnourished, including herself. ‘How can we be healthy’, she had once said to a visitor in the village, ‘when whatever little we eat barely stays in us…. All of us have upset stomachs …’, and she had laughed at this. • ‘You tell us that we should have clean water, and proper food…. But where are we supposed to get it ?…’, she had continued. • Zubaida and her children had to carry water from a nearby water pond, from which the animals too had their fill. Besides carrying water, Zubaida also had to fetch fire wood, and also fodder for the 6 goats that the family owned. Besides, there were the usual tasks of cooking , washing, etc., that were part of her role as a woman in her village.

30. Why did Zubaida Died? • Since her last pregnancy, Zubaida had developed some problems that just would not go away. She often had fever, and it would be accompanied by a sever burning in her reproductive tract. The dai would give her some medicine whenever she told her about the burning, and also advised her to see the doctor. The advise she ignored , as this meant going into the town, since the nearby health centre did not have a female staff. ‘Such ailments are part of being a woman’, Zubaida used to tell the visitor who talked to her, and other village women, about family planning and better nutrition for women.

31. The Scientific approach • Education • Studies have proved a critical link between education level and economic growth and hence on the status in the society. • Studies have also proved the role of education particularly female education on child mortality , morbidity, household economy, family planning use etc. and overall health of the family.

32. The Scientific approach-Education • Households with more education enjoy better health, both for adults and for children. United Nations. The world's women: trends and statistics. New York: UN, 1995. • Women with even a few years of schooling have more self confidence; they assume responsibility, communicate more with their husbands, and may have a higher status in the family, giving them more say in health decisions. World Bank. World development report 1993—investing in health. New York: Oxford University Press, 1993.

33. The Scientific approach-Nutrition • The social causation hypothesis relates health to structural factors such as working environment or behavioural factors such as diet. • An estimated 450 million adult women in developing countries are stunted as a result of childhood protein-energy malnutrition.

34. The Scientific approach-Investment in Health • In the developing world, women use health services less than men. World Health Organisation. Women's health: improve our health, improve the world. Geneva: WHO, 1995. • Often health services are insensitive to the cultural needs of women: in many Middle Eastern countries, for example, most doctors are men, despite a strong belief that women should not be seen after puberty by men who are not relatives. World Bank. World development report 1993—investing in health. New York: Oxford University Press, 1993. • In some places, services are narrowly centred around women in their reproductive roles. World Health Organisation. Creating common ground in Asia. Geneva: WHO, 1994.

35. Households with illnesses Difference ? Households without illnesses Men Women Total 61 72 133 19 32 51 Data synthesis 15 6 21 12 Conducted by men only 4

36. Justice & Health Justice Environment Socio-economic Health Systems Health Overcoming disparities: Household; Village; UC, Taluka, District Overcoming disparities: Health Facilities; related services.

37. Framework of Analysis

38. Framework of Analysis11.Health facility is far13.Women’s treatment is delayed

39. Framework of Analysis

40. Framework of Analysis