Synthesising Perspectives: Case Studies for Action

Session outcomes

• Understand the strengths and weakness of Dahlgren and Whitehead model of determinants of health

• Understand how different strategies can be used to tackle health problems by focusing on case studies

Determinants of HealthDahlgren and Whitehead 1991

Key strengths of the rainbow model

• Relatively simple to conceptualise• Demonstrates the interconnectness of the

layers in shaping health • Demonstrates how individual choice is a

relatively small determinant of health • Provides a tool to examines complex

causal pathways and how they may determine health inequity

• Acknowledges the necessity for multi-layer action to address health

Case study Malaria basics and context

• Globally malaria causes an estimated two million deaths and 300 million diagnoses annually (Walley, Webber & Collins, 2010).

• There are four types of malaria which can infect humans and the potentially most deadly of these is Plasmodium Falciparum which is carried by a mosquito vector.

• Being bitten by an infected mosquito can cause the transmission of the parasite from the saliva glands of the mosquito to the human bloodstream.

• The liver where multiplication of the parasites takes place. These are released into the bloodstream and produce toxins which cause the physical symptoms of infection – high temperature, headaches and pain (Walley, Webber & Collins, 2010).

The determinants of malaria

Poverty and socioeconomic disadvantage are directly linked to malaria, for example, being able to afford treatment .

Water storage and control of vector breeding sites are significant for the management of malaria.

The influence of other people on using preventive measures and seeking help are important.

Access to quick and effective treatment (of lack of) is a key determinant of outcomes once a person is infected with malaria.

Age is an important factor. For example, children are more vulnerable to malaria

Individual behaviours such as using an insecticide treated bednet are significant in the prevention of malaria.

Addressing malaria

• Primary prevention approaches Development of vaccinations to protect against exposure of Plasmodium sp.Spraying of households and environments to destroy mosquitos to prevent transmission of Plasmodium sp. Use of insecticides and covering skins to avoid being bitten by mosquitos

Addressing malaria

• Lifestyle and behavioural approachesCompliance and adherence to preventative behaviours such as using insecticide treated nets (ITNs)Understanding the nature of transmission of malaria and its associated vector. Lay beliefs about the causes and prevention startegies of malaria are important in shaping behaviour.

Addressing malaria

• Changing the social and economic environmentSubsidising or providing free ITNs

Removing stagnant pools of water near dwellings would prevent reproduction of mosquitos which need water to breed.

Addressing malaria

• Policy initiatives Eradication of malaria requires political will to reduce the poor socio-economic circumstances in which people live. For improved access and usage of ITNs political action is required. Action on climate change is needed to prevent wider distribution of infected mosquitos to more temperate areas of the world.

Case study cervical cancer• Approximately half a million women develop cervical cancer every year, and

almost half of those diagnosed die as a result (WHO 2010b). • Cervical cancer accounts for 1 in 10 cancers diagnosed in women worldwide

(Cancer Research UK, 2010) and causes the greatest problems in low-income countries in which health care resources are limited (Bosch et al (1995).

• Furthermore, in the UK, approximately 55 women are diagnosed with cervical cancer every week (Cancer Research UK, 2010).

• Finally, in the UK, around two thirds of women survive the disease for five years or more with survival rates being much higher in women diagnosed at a younger age. Women diagnosed under 40 years of age have survival rates of more than 85% (Cancer Research UK, 2010). Despite these survival rates, women diagnosed with this type of cancer die younger than in most other cases of cancer (Currin et al 2009)

• Cervical cancer is caused by particular strains of use a sexually transmitted virus Human Papilloma Virus (HPV).

The determinants of cervical cancer

Access to quick and effective treatment (of lack of) is a key determinant of outcomes once a woman is diagnosed with cervical.

Age is an important factor. For example, delaying the age of first intercourse is important in reducing the risk of cervical cancer.

Individual behaviours such as not smoking are important in reducing the risk of cervical cancer.

Poverty and socioeconomic disadvantage are directly linked to cervical cancer for example, the ability to negotiate safe sex is affected by societal position.

Effective screening programmes are successful at early detection and are a significant determinant of outcomes.

Addressing cervical cancer

• Primary prevention approachesDevelopment of Human Papilloma Virus (HPV) vaccination programme will protect young women against the causative agent of cervical cancer.Screening programmes (both Pap smears and HPV swabs) can be used to detect at risk young women to have preventive treatment.

Addressing cervical cancer

• Lifestyle and behavioural approachesDelaying the age of first sexual intercourse Using barrier methods such as condoms will prevent against transmission of HPV.Compliance and adherence to both vaccination and screening programmes. Education about the risks of HPV via schools SRE programmes,Caution needed here not to victim blame individuals

Addressing cervical cancer

• Changing the social and economic environmentLinks between social position and cervical cancer can be found (Currin, 2009).Changing the culture of sexual behaviour in which partners can negotiate safer sex is the goal of changing to social environment. Changing the stigma associated with HPV may aid fuller discussion about cervical cancer.

Addressing cervical cancer

• PolicyEvidence that more liberal approaches such as those in Holland will lead to reduction in unsafe sexual behaviour.Stronger commitment to lifeskills approaches to SRE.Commitment to resourcing vaccination and screening for HPV.

Case study: neighbourhoods as a setting for health

• There is a strong relationship between health and place • A ‘settings approach’ to health promotion came from Ottawa Charter for

health promotion stating that “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love” (WHO, 1986 p 6).

• It was proposed that health promotion activities take place in settings and their associated systems to improve overall health. Investments in health are made in social systems for which health is not their primary remit (Dooris, 2004).

• Neighbourhoods provide a major setting in which people live and work and can be thought of as a location in which a raft of health promotion strategies can be applied.

• Naidoo and Wills, (2009) suggest that neighbourhoods are a key setting for health promotion because physical and social environments interact with other service provision such as health care, welfare services, important hubs like a pubs, shops, post offices, community centre and churches.

Determinants of neighbourhoods

Trust or conflict Antisocial behaviour

Safety

Individual factors by definition in this case study are of less importance except that collectively they make up a community profile of ages and genders which will govern the needs of the neighbourhood.

Accessibility and distance of health care services

Type of housing and design of estates & streets

Transport: cars, public transport & road building exercise levels

Pollution: air and water quality

Physical environment quality: green spaces or dirty littered places

Active thriving local economy for jobs

School provision league tables

Family networks & interactions

Local food production &distribution

Critiques of rainbow model• The framework tends to be more descriptive rather

than analytical about the relationships between different influences on health.

• The model, as it stands, neglects global, political and historical determinants of health.

• As a model to depict the determinants of health, rather than health inequalities the distinction between the social factors influencing health and the social processes determining inequality can easily become confused.

• Determinants of health resulting from the lifespan are also not considered in the model with any great effect.

Summary Barton and Grant (2006)