Social factors are major determinants of health outcomes with significant differences in life expectancy and experience of disability according to social class, gender, ethnicity, and education. Cultural factors also influence health, for example, the ways that people respond to certain symptoms and cues or the practices of daily life and ritual beliefs about health and illness. As a public health practitioner, you need to reflect on the role of social and cultural factors in the distribution of disease and determinants, the delivery of interventions, and the way that different groups can participate in public health research and practice. Where the people most affected by a health problem are disadvantaged with little social and political power, it's particularly important that you include participatory approaches to ensure appropriate and effective public health responses. In this lecture, you will look at examples of the importance of social and cultural factors and then explore these in more detail in relating readings and activities. This will help you when you're designing a participatory approach for a public health challenge, which is part of your assessment. Let's start by thinking about what we mean by social and cultural. Broadly speaking, social refers to the way that societies are organized, the structures and relationships between people and groups. You may remember that the World Health Organisation defines the social determinants of health as the conditions in which people are born, grow, live, work and age. WHO goes on to say that these circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. In practice, social factors that affect health outcomes include class, status, or caste gender, ethnicity, sexual orientation, or identity, disability, geographic location, education, and occupation. For the purposes of public health, social factors relate to both the interactions between people and groups and the distribution of power between individuals and groups. Culture is more difficult to define. One study by a group of American anthropologists in the 1950s found a 164 different definitions. If you want to know more, you should probably be studying anthropology, which is the study of human societies and cultures and their development. In this specialization, we can use a dictionary definition which is that culture refers to the customs and beliefs, art, way of life and social organization of a particular country or a group. As a shorthand, I tend to think of social factors which those which are shaped by power and relationships. Cultural factors are those that define how we live within that society. Social, cultural, and political factors all affect health in a range of ways and understanding how they affect individuals and communities is important if you are designing health research and public health interventions. However, as a public health professional, you can't expect to know everything about these varied influences. And that's one of the reasons why participatory approaches are so important. They help us to learn through working directly with affected communities. So let's think about a couple of examples together and then you can read about others and discuss them with your peers. The first example comes from work on sexually transmitted infections, my own clinical specialty. Reducing the impact of STI involves a range of activities, including basic health promotion to encourage safer sexual behavior. But also ensuring that infections are diagnosed and treated as soon as possible. That's dependent on what people do when they think they might have an STI. Think about your own community. What do you and people like you do if they're worried about their sexual health? In the UK, there is a network of public clinics and services where anyone can get a check-up for free. This system has been in place for over 100 years, but not everybody wants to go to a special sexual health clinic. Others ask friends or go online for advice or a test or they may just do nothing and hope that any symptoms or worries will go away. These decisions will reflect social factors. Men and women act differently. Younger people and migrants may avoid clinics through fear that their parents or the authorities might be informed even though the services are actually confidential. Cultural factors are also influential. These may affect beliefs about what might be helpful. In the 1990s, I was working with the World Health Organisation on AIDS prevention indicators focusing on low income countries. Prompt diagnosis and treatment of STI was one of the indicators we were testing and that led us to explore the role of health seeking behavior. We found that there wasn't a lot of research in the biomedical literature but local practitioners and anthropologists were able to describe the wide range of responses. For example, work in Sub-Saharan Africa showed that people with STD symptoms often presented to traditional healers rather than western or allopathic medical providers. This was based in part on the availability and accessibility of these providers but also on beliefs about the cause, and therefore the appropriate management of sexually transmitted infections. And this is not just relevant to STI. What people do when they may be ill is deeply rooted in what they learn in families and social groups influenced by beliefs, experience, and availability of different options. These are therefore important, cultural, social, and political factors. A second brief example, type 2 diabetes is a growing problem globally linked to changing diet and lifestyles. if people are found to be at increased risk or to have early diabetes, this can often be controlled or even reversed by weight loss, exercise, and dietary changes. But these lifestyles are deeply embedded in social and cultural factors. Generic interventions, which stress a particular diet and exercise routine, may not be seen as relevant, appropriate, or achievable for some people. In London, the prevalence of type 2 diabetes is high in people of South Asian Heritage, many of whom have poor outcomes as a result. A research project in South London used an ethnographic approach to explore some of the challenges. They identified some key issues including a normalization of diabetes because it was so common, a culture of denial with people believing it was inevitable and beyond their control, and difficulties in changing diet. Because food habits were so deeply ingrained in communities and in particular, in relation to cultural identity. These brief examples show some of the connections between social and cultural factors in health. Participatory approaches are based on the need to take this into account in public health practice and recognizing that the best way to do this is to involve the communities directly in the work throughout. If these factors are minimized or ignored, at best, programs risk missing key factors, which will affect impact particularly on those with fewest resources, and at worst will alienate communities and be counterproductive [MUSIC]
