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Understanding social determinants of health seeking behaviours, providing a rational framework for health policy and systems development

  Babar T. Shaikh  ( Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Place; Liverpool, UK )
 

Abstract
The concept of studying health seeking behaviours has evolved with the course of time and has ultimately become a tool for understanding how people employ the health care systems in their respective socio-cultural, economic and demographic circumstances. All these behaviours actually define social position of health and provide a better understanding of the disease process. It is therefore imperative to study the impacts of all the determinants, such as ethnicity, education of the mother, gender of child, lifestyles, or economics of a community. All the same, biomedical knowledge alone cannot guarantee better health. Health practitioners, managers and policy makers ought to reflect on social determinants while delivering services, designing health promotion interventions and developing policies. To build a responsive health system, there is a strong need to understand the health seeking behaviours on the demand side and that is the only way to expect improved health outcomes. This paper trails the history of pledges and promises, from Alma Ata declaration to Millennium Development Goals, to consider the importance of social determinants for a healthy public policy and health system development.
Introduction
The determinants of health extend beyond health care and can be attributed to social and economic
determinants which most health systems have not been able to link with the health of their populations. The health issues are complex and necessitate systematic knowledge that goes well beyond the health sector to address them. The creation of this knowledge involves a number of social science disciplines working together with the medical professions. For instance, cost of medical care is a real concern to poor people throughout the world. Therefore, poverty and vulnerability of livelihood determines health status and vice versa. Ill health is a major contributor to poverty. However, there is little logical information about how people's livings are affected when an earning hand in a family suffers from a serious health problem, or about how family, community or other social networks help that family to cope up with the hard times.1 Also, what happens when a child falls sick or for that matter, what are the patterns of health care seeking of women in a specific society. Some risks have common social and behavioural determinants. Members of poor households in rural areas are the most likely to be undernourished, use unsafe water sources and be exposed to indoor smoke from solid fuels. Due to these epidemiological and social characteristics of risk factor exposure and hazard, policy-relevant analysis should include an assessment of the health benefits of simultaneous reductions in multiple risks.2 Health seeking behaviour is not merely dependent on individual's choice or circumstances; it depends largely upon the dynamics of
communities that influence over the well-being of the inhabitants.3 The concept of studying health seeking behaviours has evolved with the course of time and has ultimately become a tool for understanding how people employ with health care systems in their respective socio-cultural, economic and demographic circumstances. All these behaviours can be classified at various institutional levels: family, community, health care services and the state. One of the essential functions of public health is to use the applications of social and behavioural sciences for better understanding of the disease process.4 Social position of health thought has been studied taking socio-economic status as an indicator, but to measure inequalities only.5 It is therefore imperative to study the impacts of all these allied determinants, such as ethnicity, education of mother, gender of child, lifestyles, or economics of a community.6 Unfortunately, policy makers and health practitioners do not have enough time to reflect on social determinants while developing policies. All the same, biomedical knowledge alone cannot guarantee better health.

Introduction
The determinants of health extend beyond health care and can be attributed to social and economic
determinants which most health systems have not been able to link with the health of their populations. The health issues are complex and necessitate systematic knowledge that goes well beyond the health sector to address them. The creation of this knowledge involves a number of social science disciplines working together with the medical professions. For instance, cost of medical care is a real concern to poor people throughout the world. Therefore, poverty and vulnerability of livelihood determines health status and vice versa. Ill health is a major contributor to poverty. However, there is little logical information about how people's livings are affected when an earning hand in a family suffers from a serious health problem, or about how family, community or other social networks help that family to cope up with the hard times.1 Also, what happens when a child falls sick or for that matter, what are the patterns of health care seeking of women in a specific society. Some risks have common social and behavioural determinants. Members of poor households in rural areas are the most likely to be undernourished, use unsafe water sources and be exposed to indoor smoke from solid fuels. Due to these epidemiological and social characteristics of risk factor exposure and hazard, policy-relevant analysis should include an assessment of the health benefits of simultaneous reductions in multiple risks.2 Health seeking behaviour is not merely dependent on individual's choice or circumstances; it depends largely upon the dynamics of
communities that influence over the well-being of the inhabitants.3 The concept of studying health seeking behaviours has evolved with the course of time and has ultimately become a tool for understanding how people employ with health care systems in their respective socio-cultural, economic and demographic circumstances. All these behaviours can be classified at various institutional levels: family, community, health care services and the state. One of the essential functions of public health is to use the applications of social and behavioural sciences for better understanding of the disease process.4 Social position of health thought has been studied taking socio-economic status as an indicator, but to measure inequalities only.5 It is therefore imperative to study the impacts of all these allied determinants, such as ethnicity, education of mother, gender of child, lifestyles, or economics of a community.6 Unfortunately, policy makers and health practitioners do not have enough time to reflect on social determinants while developing policies. All the same, biomedical knowledge alone cannot guarantee better health.

Methods
This paper is based on a literature review of peer-reviewed literature on social science research, social determinants of health and its implications on health policy and system development. A search of peer-reviewed, indexed paper was done using PubMed. A combination of the keywords was used: social determinants, social science, public health, health outcome, health systems, health policy, health seeking behaviours, developing countries and Pakistan. Further to this, all health charters of World Health Organisation were consulted for providing the evidence on social determinants and their relation to health, research and policy. Moreover, to insert World Bank's perspective in this context, publications from Bank's library were also referred to, including one on Millennium Development goals.
World Health Organization's advocacy agenda
WHO and its member states advocated research into social determinants in all of the charters pertaining to health promotion. Beginning from Alma Ata declaration on strengthening primary health care, it was pledged that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.7 Then followed Ottawa Charter, proclaiming that improvement in health requires a secure foundation in the basic prerequisites such as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity.8 In Adelaide, all the member states recognized that in the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry and communications need to take into account health as an essential factor when formulating policy.9 Furthermore, Sundsvall statement on health in Sweden pointed out poverty and deprivation affecting millions of people who are living in extremely degraded environment which threatens their health.10 Another reaffirmation was witnessed in Jakarta where once again poverty, low status of women, civil and domestic violence was announced as the major threats to health.11 The Mexico statement on health research pledges to address the social determinants of health in all types of health systems and public health research endeavors, thereby increasing resources and leadership to accelerate the achievement of critical health related millennium development goals.12 Recently in Bangkok, it was asserted that the increasing inequalities within and between countries, new patterns of consumption and communication, commercialisation, environmental degradation and urbanization are some of the critical factors that influence health. Rapid and often adverse social change affects working conditions, learning environments, family patterns and the culture and social fabric of communities. Evolving patterns of health and demographic transitions have also contributed to change. Women and men are affected differently by these developments; the vulnerability of children and exclusion of marginalised, disabled and indigenous people have increased.13 Even the Millennium Development Goals are largely influenced by the broad social science agenda on development and health.14
Social determinants and Health seeking behaviour research: upshots and outcomes
The factors determining the behaviours may be seen in various contexts: physical, socio-economic, cultural and political.15 There is sample amount of literature and evidence available to justify the utmost significance of studying social determinants of health seeking behaviours for health promotion and disease prevention, improving medical care and health systems development. There is growing international interest in the choice of socioeconomic indicators for health research.5 In any health care system, policy-makers, health providers and the population at large can carry out performance assessment with the lens of social arrangements they have constructed to improve health. It invites reflection on the forces that shape performance and the actions that can improve the overall performance and responsiveness.16 Some of the multi-fold advantages of the research into social determinants would significantly contribute to better health service utilization, a rational policy and a responsive health system.
Ensuring appropriate health services utilization: In most of the developing countries, it is customary to see the yawning gaps in the health care system designed contrary to the community's norms and culture. Such are the societies where women having a subjugated position in the family, need to seek the permission of head of the household or the men in the family. to go to health services.17 Besides having technical knowledge of the diseases, contextual knowledge has to be acquired to understand people's perceptions leading to specific health seeking behaviours.18 To reverse the frightening high rates of infant and maternal mortality, changes will be required at the grass root level health services and to institutionalize these changes. Community involvement is yet another pre-requisite. People seek advice and purchase drugs from a variety of providers and quite often the boundaries between the public and private sectors are indistinct. Any reforms to revamp the role of primary care and primary health care can be successful only, if these are able to change public perceptions about health and health care services.19 Providing greater autonomy, confidentiality, dignity, quality and choice to the users will also lead to improved utilization of health services. Having understood such diverse behaviours of health care seeking and health service utilization, there is a great potential of transforming conservative communities into informed consumers of health services.
Working towards rational and evidence based health policy: From designing advocacy campaigns, lobbying for a policy shift and convincing donors to invest in priority areas, to implementing programmes dealing with health promotion and disease prevention; the behavioural, social and economical determinants of health ought to be taken into account.20,21 In low-income countries and transition economies, policymakers need to understand how to foster an enabling environment for health services to perform effectively and for that they need to extend their theoretical understanding of all the social determinants influencing health. More than often, medical research has dominated the policy formulation. Nonetheless, bridging the division between the social scientists, health system researchers, policymakers and the communities may provide opportunities for them to exchange ideas for designing a rational and evidence based policy. Civil society perspective through participatory action research can amplify the relevance of the research.22 Moreover, stakeholders from all relevant sectors must be allowed to contribute to the formulation of health-related national policies and the identification of research priorities.
Responsive health systems development: Responsiveness is not a measure of how the system responds to health needs, which shows up in health outcomes, but of how the system performs relative to non-health aspects, meeting or not meeting a population's expectations of how it should be treated by providers of prevention, care or non-personal services.16 More meticulous research furnishing information on how social forces affect health care seeking behaviours of individuals and families should be made available to improve health care and health systems. Institutional re-arrangements according to norms, values, and culturally sensitive traditions of the society are fundamental for good performance of the health care system.1 Decisions regarding interventions should depend on assessments of the local burden of disease, local health infrastructure and other social factors as well as on cost-effectiveness analyses.14 Hence, there is a strong need to understand the demand side to change user behaviour and that is the only way to expect improved health outcomes.23,24 International donors and technical agencies will have to support health systems development geared by research on social determinants of health. [(0)]

Conclusion
A coalition between clinical researchers, social scientists, health care providers and technicians is indispensable to accelerate the efforts to create evidence based knowledge.25 An in-depth research and its appropriate use would be imperative to visualize the real picture, the habits and practices of the people of the developing world and more challenging would be translating the research into policy and action.26,27 Therefore, investing in health with the right understanding, the right approach and the right plan should be the point of advocacy.28 Given the pluralistic and intricate panorama of the health care delivery system in most of the developing countries, it is essential for researchers to logically plan and design their research to develop understanding of the health seeking behaviour of the populations and the factors behind health service utilization trends. Health seeking behaviour is a complex phenomenon and its appreciation could be very intriguing and informative for designing a rational policy.29 This change in paradigm embodies an opportunity for action on social determinants and to formulate healthy public policies as opposed to policies concerned with mere delivery of health care services.30 Health systems research must aim to build appropriate structures for health care, to influence the delivery of efficient, sustainable and effective health services and to provide more opportunities for information and participation for the end users.

Social determinants and Health seeking behaviour research: upshots and outcomes
The factors determining the behaviours may be seen in various contexts: physical, socio-economic, cultural and political.15 There is ample amount of literature and evidence available to justify the utmost significance of studying social determinants of health seeking behaviours for health promotion and disease prevention, improving medical care and health systems development. There is growing international interest in the choice of socioeconomic indicators for health research.5 In any health care system, policy-makers, health providers and the population at large can carry out performance assessment with the lens of social arrangements they have constructed to improve health. It invites reflection on the forces that shape performance and the actions that can improve the overall performance and responsiveness.16 Some of the multi-fold advantages of the research into social determinants would significantly contribute to better health service utilization, a rational policy and a responsive health system.

Ensuring appropriate health services utilization: In most of the developing countries, it is customary to see the yawning gaps in the health care system designed contrary to the community's norms and culture. Such are the societies where women having a subjugated position in the family, need to seek the permission of head of the household or the men in the family. to go to health services.17 Besides having technical knowledge of the diseases, contextual knowledge has to be acquired to understand people's perceptions leading to specific health seeking behaviours.18 To reverse the frightening high rates of infant and maternal mortality, changes will be required at the grass root level health services and to institutionalize these changes. Community involvement is yet another pre-requisite. People seek advice and purchase drugs from a variety of providers and quite often the boundaries between the public and private sectors are indistinct. Any reforms to revamp the role of primary care and primary health care can be successful only, if these are able to change public perceptions about health and health care services.19. Providing greater autonomy, confidentiality, dignity, quality and choice to the users will also lead to improved utilization of health services. Having understood such diverse behaviours of health care seeking and health service utilization, there is a great potential of transforming conservative communities into informed consumers of health services.
Working towards rational and evidence based health policy: From designing advocacy campaigns, lobbying for a policy shift and convincing donors to invest in priority areas, to implementing programmes dealing with health promotion and disease prevention; the behavioural, social and economical determinants of health ought to be taken into account.20,21 In low-income countries and transition economies, policymakers need to understand how to foster an enabling environment for health services to perform effectively and for that they need to extend their theoretical understanding of all the social determinants influencing health. More than often, medical research has dominated the policy formulation. Nonetheless, bridging the division between the social scientists, health system researchers, policymakers and the communities may provide opportunities for them to exchange ideas for designing a rational and evidence based policy. Civil society perspective through participatory action research can amplify the relevance of the research.22 Moreover, stakeholders from all relevant sectors must be allowed to contribute to the formulation of health-related national policies and the identification of research priorities.
Responsive health systems development: Responsiveness is not a measure of how the system responds to health needs, which shows up in health outcomes, but of how the system performs relative to non-health aspects, meeting or not meeting a population's expectations of how it should be treated by providers of prevention, care or non-personal services.16[())] More meticulous research furnishing information on how social forces affect health care seeking behaviours of individuals and families should be made available to improve health care and health systems. Institutional re-arrangements according to norms, values, and culturally sensitive traditions of the society are fundamental for good performance of the health care system.1 Decisions regarding interventions should depend on assessments of the local burden of disease, local health infrastructure and other social factors as well as on cost-effectiveness analyses.14 Hence, there is a strong need to understand the demand side to change user behaviour and that is the only way to expect improved health outcomes.23,24 International donors and technical agencies will have to support health systems development geared by research on social determinants of health.


World Health Organization's advocacy agenda
WHO and its member states advocated research into social determinants in all of the charters pertaining to health promotion. Beginning from Alma Ata declaration on strengthening primary health care, it was pledged that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.7 Then followed Ottawa Charter, proclaiming that improvement in health requires a secure foundation in the basic prerequisites such as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity.8 In Adelaide, all the member states recognized that in the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry and communications need to take into account health as an essential factor when formulating policy.9 Furthermore, Sundsvall statement on health in Sweden pointed out poverty and deprivation affecting millions of people who are living in extremely degraded environment which threatens their health.10 Another reaffirmation was witnessed in Jakarta where once again poverty, low status of women, civil and domestic violence was announced as the major threats to health.11 The Mexico statement on health research pledges to address the social determinants of health in all types of health systems and public health research endeavors, thereby increasing resources and leadership to accelerate the achievement of critical health related millennium development goals.12 Recently in Bangkok, it was asserted that the increasing inequalities within and between countries, new patterns of consumption and communication, commercialisation, environmental degradation and urbanization are some of the critical factors that influence health. Rapid and often adverse social change affects working conditions, learning environments, family patterns and the culture and social fabric of communities. Evolving patterns of health and demographic transitions have also contributed to change. Women and men are affected differently by these developments; the vulnerability of children and exclusion of marginalised, disabled and indigenous people have increased.13 Even the Millennium Development Goals are largely influenced by the broad social science agenda on development and health.14

Acknowledgment
This work has been done as part of an ongoing PhD programme under the supervision of Dr David Haran PhD at Liverpool School of Tropical Medicine, University of Liverpool, UK and Dr Juanita Hatcher at Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
Conflict of Interest: None

References
1. Institute of Development Studies. Mobilizing social science research to improve health. IDS Policy Briefing. Issue 23. Sussex. 2005.
2. World Bank. Global burden of disease and risk factors. Washington DC, 2006.
3. MacKian S. A review of health seeking behaviour: problems and prospects. Internal concept paper. Health Systems Development Programme, London School of Hygiene and Tropical Medicine. London. 2001.
4. Pommier J. Quelles sont les fonctions essentielles de la santé publique? Revue de littérature. Société Française de Santé Publique. Nancy. 2005.
5. Craig P, Forbes J. Social position and health: are old and new occupational classifications interchangeable? J Biosoc Sci 2005; 37:89-106.
6. Caldwell JC, Caldwell P. What have we learnt about the cultural, social and behavioural determinants of health? From Selected Readings to the first Health Transition Workshop. Health Transit Rev 1991; 1: 3-19.
7. World Health Organization. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata. 1978.
8. World Health Organization. The Ottawa Charter for Health Promotion. First International Conference on Health Promotion. Ottawa. 1986.
9. World Health Organization. Adelaide Recommendations on Healthy Public Policy. The Second International Conference on Health Promotion. Adelaide. 1988.
10. World Health Organization. Sundsvall Statement on Supportive Environments for Health. The Third International Conference on Health Promotion. Sundsvall. 1991.
11. World Health Organization. Jakarta Declaration on Leading Health Promotion into the 21st Century. The Fourth International Conference on Health Promotion: New Players for a New Era- Leading Health Promotion into the 21st Century. Jakarta. 1997.
12. World Health Organization. Mexico Ministerial Statement for the Promotion of Health. The Fifth Global Conference on Health Promotion. Health Promotion: Bridging the Equity Gap. Mexico City. 2000.
13. World Health Organization. The Bangkok Charter for Health Promotion in a globalized world. The Sixth Global Conference on Health Promotion. Bangkok. 2005.
14. World Bank. The millennium development goals for health: rising to the challenges. Washington DC. 2004.
15. Kroeger A.  Anthropological and socio-medical health care research in developing countries. Soc Sci & Med 1983; 17: 147-61.
16. World Health Organization. The World Health Report 2000. Health Systems: Improving Performance. Geneva. 2000.
17. Tinker AG. Improving women's health in Pakistan. Health, nutrition and population working paper series. Human Development Network. World Bank. 1998.
18. World Bank. Disease control priorities in developing countries. 2nd ed. Washingtion DC. 2006.
19. Moynihan R. Using health research in policy and practice. Case studies from nine countries. Academy Health; Milbank Memorial Fund. New York 2004.
20. Shaikh BT, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health (Oxf) 2004; 27: 49-54.
21. Gruskin S, Tarantola D. Health and human rights. In: Detels R, McEwen J, Beaghehole R, Tanaka H, editors. Oxford Textbook of Public Health. 4th ed. New York: Oxford University Press 2002.
22. Sanders D, Labonte R, Baum F, Chopra M. Making research matter: a civil society perspective on health research. Bull World Health Organ 2004; 82: 757-63.
23. Rogler LH, Cortes DE. Help seeking pathways: a unifying concept in mental health care. Am J Psychiatry 1993; 150: 554-61.
24. Standing H. Understanding the 'demand side' in service delivery: Definitions, frameworks and tools from the health sector. DFID Health Systems Resource Centre. London. 2004.
25. World Health Organization. The World Health Report 2004. Changing history. Geneva. 2004.
26. Nishtar S. The gateway paper: Health system in Pakistan - a way forward. Pakistan's Health Policy Forum. Heartfile, Islamabad 2006.
27. Shaikh BT, Kadir MM, Hatcher J. Health care and public health in South Asia. Public Health 2006; 120: 142-4.
28. World Bank. World Development Report 1993. Investing in Health. Oxford University Press. New York 1993.
29. Mackian S, Bedri N, Lovel H. Up the garden path and over the edge: where might health-seeking behaviour take us? Health Policy Plann 2004; 19: 137-46.
30. World Health Organization. Action on the social determinants of health: learning from previous experiences. Background paper prepared for the Commission on Social Determinants of Health. Geneva. 2005.

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SIUT SYMPOSIUM DECEMBER 2015

Sindh Institute of Urology and Transplantation (SIUT), Karachi will celebrate 40 years of its services by holding an International Symposium on Recent Advances in Urology, Nephrology, GI Hepatology, Paediatrics, Transplantation & Bioethics from 8th to 12th December, 2015.Social and economic aspects of health care especially in a developing country will also be included.
Important Dates: Last date for Abstract submission:31st July 2015
Last Date for early registration: 30. September, 2015



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