Social determinant of health

it illustrates the categories of the social determinants and its role with sexual and reproductive health (it was prepared in 2016)

1. Dr. Lamiaa Gamal
Assistant lecturerof maternal and child health
Alexandria University

2. http://www.med.uottawa.ca/sim/data/Health_Determinants_e.htm

3. Determinants of health:
‘The range of personal, social, economic and
environmental factors that determine the
health status of individuals or populations.’
Source: WHO 1998. Health promotion glossary. Geneva:
WHO, p. 6.

4. Determinants of health:
‘Factors that influence health status and determine
health differentials or health inequalities.
They include, for example,
natural, biological factors, such as age, sex and
ethnicity;
behaviour and lifestyles, such as smoking, alcohol
consumption, diet and physical activity;
the physical and social environment, including
housing quality, the workplace and the wider urban
and rural environment; and access to health care’.
Source: WHO 2005. Health impact assessment (HIA): Glossary of terms
used. Geneva: WHO; citing Lalonde1974; Labonté1993.

5. They are sometimes referred to as
'the causes of the causes',
as it is recognized health is not simply about
behaviour or exposure to risk, but how social
and economic structures shape the health of
populations.

6. http://www.who.int/hia/evidence/doh/en/

10. http://www.cdc.gov/nchhstp/socialdeterminants/faq.html

11. The social determinants of health (SDH)
are the conditions in which people are born,
grow, work, live, and age, and the wider set of
forces and systems shaping the conditions of
daily life.
http://www.who.int/social_determinants/en/

12. These circumstances are shaped by the
distribution of money, power and resources
at global, national and local levels which are
themselves influenced by policy choices.
http://www.who.int/hrh/resources/Ebook1st
_meeting_report2015.pdf

13. These conditions influence a person’s
opportunity to be healthy, his/her risk of illness
and life expectancy.
Social inequities in health –the unfair and
avoidable differences in health status across
groups in society –are those that result from
the uneven distribution of social determinants.
http://www.euro.who.int/en/health-topics/health-determinants/social-determinants

14. http://healthier.scot/2016/03/10/time-for-a-fair-share/

15. The World Health Organization has identified 10
social determinants of health:
1)The social gradient
2)Stress
3)Early life
4)Social exclusion
5)Work
6)Unemployment
7)Social support
8)Addiction
9)Food
10)Transport
http://www.dhhs.tas.gov.au/wihpw/principles/determinants_of_health

16. http://www.publichealthbydesign.com/resources/

17. http://leadersandlegacies.com/2014/06/17/social-determinants-of-health-focus-being-
ignored-by-mainstream-media-despite-research-proven-evidence-of-its-importance/

18. The social gradient
▪Within countries, the evidence shows that in
general the lower an individual’s socioeconomic
position the worse their health.
▪There is a social gradient in health that runs
from top to bottom of the socioeconomic
spectrum.
▪This is a global phenomenon, seen in low,
middle and high incomecountries.
▪The social gradient in health means that health
inequities affect everyone.

19. •People further down the social ladder
usually run at least twice the risk of
serious illness and premature death as
those near the top.

20. Disadvantage has many forms and can be
absolute(e.g. not having access to
education or unemployment), or relative
(e.g. poorer education, insecure
employment).
https://ama.com.au/position-statement/social-determinants-health-and-prevention-
health-inequities-2007

22. under-five mortality rates for the 10-year period preceding the survey, by wealth
quintile, Egypt 2014
42
34
29
26
19
0
5
10
15
20
25
30
35
40
45
lowest second middle fourth highest
U5MR
U5MR

23. Stress
•Stressful circumstances, making people
feel worried, anxious, unable to cope, are
damaging to health and may lead to
premature death.

24. Infections, diabetes, hypertension, heart attacks,
stroke, depression and aggression
Long term stress
Social & psychological circumstances
Continual anxiety, insecurity, low self esteem, social isolation,
and lack of control over work and home
https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/social-determinants-of-health-
and-nursing_a-summary-of-the-issues.pdf?la=en

25. Early life
with slow growth and low emotional
supportduring early childhood as key
factors contributing to poorer health later in
life,

26. ❑It is now well understood that the foundations of
adult health are laid down before birth and in
early childhood.
❑Slow growth and poor early experience become
biologically embedded during development.
❑They increase the lifetime risk of poor emotional
health and reduce physical cognitive and emotional
functioning into adulthood.
❑Poor experiences during pregnancy such as
nutritional deficiencies, maternal smoking, alcohol
and drug use, and inadequate prenatal care can
lead to poor fetal development, which is a risk in
itself forpoor health later in life
https://ama.com.au/position-statement/social-determinants-health-and-prevention-
health-inequities-2007

28. Social exclusion
❑Poverty(absolute and relative) has a major
impact on health and premature death.
❑Povertydenies people access to full
participation in the life of the community.
❑In the international context, those who are
homelesshave the highest rates of
premature death.

29. ❑Social exclusion also results from racism,
discrimination, stigmatization and unemployment.
❑The greater the length of time that people live in
disadvantaged circumstances the greater the risk
for ill-health, particularly cardiovascular disease.
❑As people move in and out of poverty during their
life, the prevalence of people who have
experienced social exclusion (and its negative
impact) is greaterthan the current incidence

30. Absolute
poverty
A lack of the
basic material
necessities of
life
Relative
poverty
Living on less
than 60% of the
national median
income.

31. Work
❑working conditions, as source of stress
and a direct cause of ill health in the
absence of adequate workplace health
protection measures,
❑Jobs that are demanding and where
employees have little control or decision
making in their employment are the most
detrimental to health.

32. ❑Improved work conditions will lead to a
healthier workforce, which will, in turn,
improve productivity and decrease
absenteeism.
❑Occupationis often used as a measure of
socio-economic status.
❑Those in 'blue collar' occupations have
poorer health status across almost all
indicators compared with those in
professional/managerial occupations

34. Unemployment
❑unemploymentas another source of stress
and a key factor that negatively impacts an
individual's place on the social ladder.
❑Job insecurityor very unsatisfactory
employment can be as harmful as
unemployment, with increasing effects on
mental health, heart disease, and the risk
factors for heart disease

36. Social support
❑Social support and social relations give
people emotional and practical resources as well
as a sense of mutual respect where people feel
loved and valued.
❑All these aspects have a protective effect on
health and provide a buffer against health
problems.
❑Without them people are likely to experience
less well-being, more depression, and higher
levels of disability from chronic diseases.

37. ❑At the societal level, social cohesion (the
quality of social relationships and the
existence of trust, mutual obligations and
respect in communities) helps to protect
people and their health.
❑Societies that have high levels of income
inequality tend to have lesssocial
cohesion and moreviolent crime

39. Addiction
❑addiction, with alcohol dependence, illicit
drug use and tobacco consumption all
pointing towards underlying social and
economic marginalization
❑These substances are a large drain on
people's incomes, reduce participation in
society, and are a large cause of ill-health
and premature death

40. Food
healthy food, with both over-and under-
nutritioncontributing to theoverall burden
of disease,

41. Agricultural production issues and
manufacturing
•Tobacco farming and its impact on heart disease, stroke,
certain cancers and chronic respiratory disease. Including
passive smoking and impact of fetal development.
Pesticide policies on tobacco crops require consideration.
•Changes in land use, soil quality, choice of crop, use of
agricultural labourand occupational health.
•Mechanisationof work previously done by hand, and
plantation agriculture.
•Fisheries–biotoxins, pollution, chemical use, wastewater,
processing, and occupational health
•Forestry–vector borne diseases, occupational health,
and food security.

42. •Livestock use –vector borne diseases, drug residues,
animal feed, waste, and food security.
•Sustainable farming including chemical and energy use,
biodiversity, organic production methods, and diversity of
foods produced.
•Fertilizer use –nitrate levels in food, pollution of
waterways, re-use of agricultural waste.
•Water–irrigation use and its impact on river/water-table
levels and production outputs.
•Pesticide usage and veterinary drugs–legal requirements,
best practice, consumer issues.
•Food packaging, preservation and safety, and avoidance of
long storage and travel.

43. Access to, and distribution of food
•Household food security –appropriate food being
available, with adequate access and being affordable
(location of markets, supermarkets and closure of
small suppliers creating food deserts in cities).
•Food supplies, including national and regional food
security, and regional production.
•National food security –able to provide adequate
nutrition within a country without relying heavily on
imported products
•Cold-chain reliability –the safety of transporting
products that deteriorate microbiologically in the
heat.

44. Dietary patterns, diversity of food
available and home production,
particularly:
•Fruit and vegetable consumption on reduced stroke,
heart disease and risk of certain cancers,
•Total, saturated and polyunsaturated fat, carbohydrates
and sugars consumptionon obesity, heart disease, stroke
and other vascular diseases.
•Alcohol consumption and impact on social effects related
to behaviour (traffic accidents, work/home accidents,
violence, social relations, unwanted pregnancy and STDs),
and toxic effects (all-cause mortality, alcoholism, certain
cancers, liver cirrhosis, psychosis, poisoning, gastritis,
stroke, fetal alcohol syndrome and others).
•Micronutrientssuch as iron, vitamin A, zinc and iodine and
their impact on deficiency syndromes.

45. Food safety and foodborne illness
hazards
•Microorganismssuch as salmonella, campylobacter, E.
coli O157, listeria, cholera.
•Virusessuch as hepatitis A, and parasitessuch as
trichomonosis in pigs and cattle.
•Naturally occuringtoxins such as mycotoxins, marine
biotoxinsand glycosides.
•Unconventional agents such as the agent causing
bovine spongiform encephalopathy (BSE, or "mad cow
disease"),
•Persistent organic pollutants such as dioxins and
PCBs. Metals such as lead and mercury.
•New foods developed from biotechnologysuch as
crops modified to resist pests, changes in animal
husbandry, antibiotic use and new food additives.

46. Transport
transport, in regard tothe adverse
effects of increasing road traffic
(accidents, pollution, stress,
decreased physical activity,
social isolation) and the benefits
of reliable public transportation
systems and environments
encouraging physical activity
(walking and cycling) and
stimulating social interaction.

47. Regular exercise protects against heart
disease and, by limiting obesity, reduces the
onset of diabetes.
Well planned urban environments, which
separate cyclists and pedestrians from car
traffic, increase the safety of cycling and
walking.

49. Evidence of health impact focus on:
•Accidentsbetween motor vehicles, bicycles
and pedestrians (particularly children and
young people).
•Pollutionfrom burning fossil fuels such as
particulates and ozone.
•Noisefrom transportation.
•Psychosocial effects such as severance of
communities by large roads and the
restriction of children’s movement.
•Climate change due to CO2 emission

50. Evidence of health impact focus on:
•Loss of land
•Improved physical activity from cycling
or walking
•Increased access to employment, shops
and support services
•Recreational uses of road spaces
•Contributesto economic development
•Vectorborne diseases
http://www.who.int/hia/evidence/doh/en/index2.html

51. Education
❑Generally, those with the lowest health status
also have loweducational and literacy levels.
❑Poor education means a person is less likely
to attain secure and well paidemployment
and this can lead to poverty and other
predictors of ill health.

53. Disability
This can include physical/mental/emotional
disabilities.
Those with disabilities are more likely to be
living in povertyand experiencing social
exclusionthan the general population.

54. Raceand culture
❑There are some differences in the burden of
disease between races that are determined by
genetics.
❑But the issue that has the greatest impact on
equity in health outcomes is racismwhether it is
at an individual level or institutionalised.

55. ❑Institutional racism refers to the ways in
which racist beliefs or values have been
built into the operations of social
institutions in such a way as to
discriminate against, control and oppress
various minority groups.
❑Racismcan affect diagnosis and
treatment and therefore health outcomes.

56. The WHO Commission on Social
Determinants of Health (CSDH )
The WHO Commission on Social
Determinants of Health (CSDH), set up in
2005, identified the achievement of health
equity as the overarching goal in addressing
the social determinants of health.

57. Its final report'Closing the Gap
in a Generation' (2008) put
forward three key
recommendations, namely to “
1.to improve daily living
conditions,
2.to address the inequitable
distribution of power, money
and resources and
3.to measure and understand
the problem and assess the
impact of action".

58. In May 2009, the 62
nd
World Health Assembly
endorsed the CSDH report and requested
WHO to "convene a global event to discuss
renewed plans for addressing the alarming
trends of health inequitiesthrough
addressing social determinants of health".

59. ❑As a result, the 2011 Rio World
Conference on the Social Determinants of
Health was convened in October 2011 and
adopted the Rio Political Declaration on
Social Determinants of Health.
❑The declaration expressed political
support for priority actionon the social
determinants of health, affirming the right to
the enjoyment of the highest attainable
standard of health and stressing the
importance of intersectoral mechanisms
such as the Health in All Policies approach.

61. References
▪Global health of Europe:
http://www.globalhealtheurope.org/index.php/glossary-
71/institution/468-social-determinants-of-health-
▪Australian medical association:
https://ama.com.au/position-statement/social-determinants-
health-and-prevention-health-inequities-2007
▪Social determinant of health: the solid facts, 2
nd
edition.
http://www.euro.who.int/__data/assets/pdf_file/0005/98438/
e81384.pdf
▪http://www.med.uottawa.ca/sim/data/Health_Determinants_
e.htm

62. •Health impact assessment: glossary
http://www.who.int/hia/about/glos/en/
•Health promotion glossary.
http://www.who.int/healthpromotion/about/HPR%20Gloss
ary%201998.pdf
•http://www.who.int/hia/evidence/doh/en/
•http://www.cdc.gov/nchhstp/socialdeterminants/faq.html
•http://www.who.int/social_determinants/en/
•http://www.who.int/hrh/resources/Ebook1st_meeting_rep
ort2015.pdf
•http://www.euro.who.int/en/health-topics/health-
determinants/social-determinants
•http://www.dhhs.tas.gov.au/wihpw/principles/determinant
s_of_health

64. Reproductive health
Reproductive health implies that people
are able tohave a responsible, satisfying
and safe sex life and that they have the
capability to reproduce and the freedom to
decide if, when and how to do so. (ICPD,
1994)

65. Reproductive rights
Reproductive rights is the basic right of all
couples and individuals to decide freely and
responsibly the number, spacing and timing
of their children and to have the information
and means to do so and the right to attain the
highest standard of sexual and reproductive
health. (ICPD, 1994)

66. Sexual health
Sexual health is a state of physical, emotional,
mental and social wellbeing in relation to sexuality; it
is not merely the absence of disease, dysfunction or
infirmity.
Sexual health requires a positive and respectful
approach to sexuality and sexual relationships, as well
as the possibility of having pleasurable and safe
sexual experiences, free of coercion, discrimination
and violence.
For sexual health to be attained and maintained,
sexual rights of all persons must be respected,
protected and fulfilled. (FWCW, 1995)

67. Health promotion
Health promotion:
… not only embraces actions directed at
strengthening the skills and capabilities of
individuals, but also action directed towards
changing social, environmental and economic
conditions so as toalleviate their impact on public
and individual health.
Health promotion is the process of enabling people
to increase control over the determinants of health
and thereby improve their health (WHO, 1986).

68. Health inequity
Health inequity is defined as "inequalities in
health deemed to be unfair or to stem from
some form of injustice. The dimensions of
being avoidable or unnecessary have often
been added to this concept."

70. ❑Researchers have documented that large
families are more likely to become poor and
less likely to recover from poverty than smaller
family households.
❑large family size was associated with increased
risk of
-Maternal mortality and
-Less investment in children's education.

71. ❑Unwanted pregnancy was positively correlated
with health risks of
-Unsafe abortion.
❑Short birth intervals were found to negatively
influence child survival, and early pregnancy was
associated with lifelong risk of morbidities.
❑On a global scale, women living in low-and
middle-incomecountries experience higherlevels
of morbidity and mortality attributed to sexual and
reproductive health than do women living in
wealthier countries.

72. ❑Many developing countries continue to struggle with
high rates of population growth.
❑While fertility rates in less-developed countries are
declining, they remain almost double(at 2.9 versus
1.6 births per woman) the rates that are
experienced by women in more-developed
countries.
❑Excluding China, the average number of births per
woman rises to 3.4in developing countries and
more than five births among women living in the
least-developed countries.

73. ❑The average number of induced abortions a
woman experiences in her lifetime is
approximately the same regardless of
whether she lives in a developed or
developing country.
❑The likelihood of her dying from an unsafe
abortion, however, is almost exclusively
dependent on where she lives, with almost
all mortality attributable to unsafe abortion
occurring in developing countries.
❑The risk of dying from an unsafe abortion is
exceptionally high in sub-Saharan Africa.

74. ❑A woman living in sub-Saharan Africa is 15
times more likely to die from an unsafe
abortion than is a woman living in Latin
America, and 75 times more likely than is
a woman living in a developed country.
❑Young women in developing countries are
most at risk, with almost half of all
mortality attributable to unsafe abortion
occurring among women less than 25
years of age.

75. ❑The Revised Global Burden of Disease
(GBD) 2002 Estimates indicate that over
90% of the global disability-adjusted
life years (DALY) caused by sexually
transmitted infections (STIs), excluding
HIV, are experienced in low-and middle-
income countries and over 50% of the
global burdenis suffered by women in
low-income countries.

76. ❑Researchers estimate that 8%–12% of couples
worldwide will experience infertilityat some point
during their reproductive years.
❑Yet, a considerably higher level of infertility was
found among couples living in developing
countries.
❑Based on data from Demographic and Health
Surveys (DHS), investigators estimated that one in
fourever-married women of reproductive age will
experience infertility at some point in her life time.
❑Infection from unsafe abortion and
prolonged exposure to STIare
commonly known causes of infertility.

77. ❑Human papillomavirus (HPV) transmitted though
sexual contact is estimated to cause
-100% of cases of cervical cancer,
-90% of anal cancer, and
-40% of cancers of the external genitalia.
❑Of the total estimated HPV-attributable cancers,
94% affect womenand 80%are in developing
countries.
❑In Latin America, the Caribbean, and Eastern
Europe, cervical cancer contributes more to years
of life lost (YLL) thantuberculosis, maternal
conditions, or acquired immunodeficiency
syndrome (AIDS).

78. Women in low-income countries, such as
the Gambia, Uganda, and Zimbabwe, had
lower 5-year survival rates (25%) when
compared to women from higher-income
countries such as China, Hong Kong Special
Administrative Region (Hong Kong SAR),
the Republic of Korea, and Singapore (more
than 65%5-year survival rate).

79. ❑Adolescentsliving in poverty are
particularly vulnerable and evidence from
developing countries suggests that an
adolescent from a poor household is from
1.7 to 4 times more likely to give birth
than a young woman from the wealthiest
household.

80. ❑By examining the disparities in health
outcomes and the determinants that create
these gaps,
-public health programmes can better organize
services to reach the most disadvantaged,
-advocate for social development to have a positive
impact on health, and
-play a key role in promoting progress towards a
more equitable society.
❑In recognition of observed disparities in health and
the importance of social context in predicting
health outcomes, the World Health Organization
established the Commission on Social
Determinants of Health (CSDH).

82. Current use of family planning methods by
Wealth Quintile in Egypt 2014
54.2 54.3
58 58.1 59.3
10
20
30
40
50
60
70
80
90
100
lowestsecondmiddlefourthhighest
current use any modern method %
current use any modern
method %

83. Within the health
system
Quality of care
•provider attitudes and
practices
political and financial
support for sexual and
reproductive health
services and products
Beyond the clinic
walls
examines the
relationship between
social conditions of
vulnerability (e.g.
poverty, migration, and
social exclusion),
institutions(e.g.
schools), behaviours
(e.g. sexual violence or
coercion) and sexual
and reproductive health.

84. Promote or discourage:how providers can
influence service use
❑The quality of any health system is
determined by a complex array of
interconnecting factors:
▪infrastructure,
▪guidelines and standards,
▪supplies and drugs,
▪record-keeping, and
▪personnel.

85. The term 'providers' refers togovernment
doctors and nurses, private practitioners,
community-based distributors, midwives and
nurse auxiliaries, pharmacists, and the
assistants to all these.

86. •As professionals who deal directly with the
public, providers have considerable power in
determining how policies and guidelines are
implemented.
Power routines Barriers

87. psychosocial
and financial
hurdles
humiliating
treatment by
providers at the
facility
acute shame if
privacy is not
ensured or if the
provider is of the
opposite
sex
Others may be
seeking services
secretly
low-literate people,
or those with
limited access to
the media or the
Internet
those who lack
resources
Those who are
more socially
marginalized
Fears about the
potential side-
effects

88. ❑In view of providers’ power and influence on
clients, policy-makers and programme
managers have been interested in making
provider behaviour more ‘client-oriented’,
with more consideration given to clients’
rights to safe, respectful, and comprehensive
SRH services

89. Provider behaviours affecting
access
A 15-country study estimated that clinic-
related factors accounted for 7%–27% of
client discontinuation of contraception after
one year, but the authors were unable to
estimate how many people were discouraged
from initiating use.

90. ❑In Peru, researchers calculated that
contraceptive prevalence would increase
by 16%–23% if all women were given
high-quality care.
❑A study from Zimbabwe, found that greater
access to contraception could halvethe
number of repeat abortions after twelve
months

91. six types of “medical barriers” that can lead
providers to deny family planning services:
-outdated contraindications,
-eligibility restrictions,
-process hurdles,
-limits on who can provide services,
-provider bias, and regulation.

92. Medical barriers are defined as “practices,
derived at least partly from a medical
rationale, that result in a scientifically
unjustifiable impediment to, or denial of,
contraception”

93. Administrative barriers, such as providers’
refusal to offer services on certain days or to
demand unauthorized fees for services, are
difficult to quantify because providers
generally do not engage in these practices
when they are being observed, and records of
denials are not kept.

94. Despite the measurement difficulties,
numerous studies have documented that
people are being denied contraceptives on
the grounds that they are not eligible for
services due to age, marital status, or
parity, even though most national guidelines
have removed these restrictions.

95. ❑A study in Kenya and Zambia found that
only 55%–67% of nurse-midwives agreed
that “a school girlwho is sexually active
should be allowed to use contraceptives”
❑In China, 40%of providers did not approve
of government provision of contraceptive
services to young people, and
approximately 75%felt these services should
not be extended to high-school students.

96. ❑In Indonesia, a retrospective study of 1945
women estimated that if choice had not
been denied, 91.1%of women would still
be users after one year rather than the
actual rate of 82.5%
❑In a study in Kenya, researchers estimated
that 78%of non-menstruatingclients
(35% of all potential new clients) were sent
away without contraceptive services.

97. ❑In general, the literature indicates that
providers seem more inclined to deny
contraception to young, unmarried or
nulliparous women. When it comes to
abortion, however, regulatory or legal
restrictions routinely lead providers to
deny services to all women.

102. Socio-economic disadvantage is both a cause
and an outcomeof poor sexual and
reproductive health (WHO, 2010).
Socio-economic disadvantage can be
indicated by low income, poor levels of
educational attainment, employment in
relatively unskilled occupations, and high
unemployment.

103. ❑There are two levels at which socio-economic
disadvantage operates as a determinant of sexual and
reproductive health.
❑One is the macro level, which identifies the economic
systems and structures that impact on the sexual and
reproductive health of population groups.
❑At a macro level the amount of government funding
allocated to health, education, housing, transport, childcare
and income support impacts upon the level of
socioeconomic disadvantage in the community, and
exacerbates the underlying drivers that compromise sexual
and reproductive health (WHO, 2010).
❑For example, governments’ replacing state-funded services
with user-pays services has had a significant impact on
people’s access to, and choices about, sexual and
reproductive healthcare

104. ❑Disadvantage also operates at a micro level,
which identifies the association between an
individual’s socio-economic status and their sexual
and reproductive health.
❑A micro level analysis explores how low socio-
economic status ‘…limits access to material and
psychosocial resources and affects individuals’
ability to exercise autonomy and decision-making’,
both of which are essential for optimal sexual and
reproductive health.
❑Socio-economic disadvantage can affect men and
women’s ability to access health services,
contraception, abortion and timely screening and
treatment for sexually transmitted infections
(WHO, 2010).

105. A micro level analysis also reveals that
women from socio-economic disadvantaged
households are less likely to use preventive
and curative sexual and reproductive health
services than women from wealthier
households, including antenatal care and
preventive screening (WHO, 2010).

109. Genderrefers to the socially constructed
roles, obligations, behaviours and attributes
assigned to men and women as a result of
their sex; while gender norms refer to the
social and cultural meanings associated with
masculinity and femininity.

110. For example, the cultural ideology of
masculinity and what it means to be a ‘man’
sees young menencouraged to actively
engage in sexual activity to prove their virility
, while for girlsit is considered appropriate
for sex to take place within the confines of a
monogamous, committed relationship.

111. ❑Gender-based power inequities lead to
social pressures and constraints through
which women, particularly young women,
negotiate sexual encounters, which impact
directly on their ability to negotiate and
make decisions about safe sexual
practices.
❑The social construction of masculinity and
traditional gender norms play a major role
in influencing the behaviour of men who
perpetrate violence

112. The way that men perform masculinity often
remains invisible in sexual and reproductive
health discourse.
For example, criminological, sociological
and public health approaches to the sex
industryfocus primarily on women’s
involvement in sex work and their sexual
health, while little attention has been paid to
men who buy sexual services

113. Despite an official recognition at the
International Conference on Population and
Development (1994) that men and boys
play a ‘crucial’ role in sexual and
reproductive health promotion, there are still
limited interventions designed to transform
the behaviours of men and boys and redress
the negative social norms associated with
masculinity.

115. Cultural norms include beliefs, behaviours,
customs, traditions, rituals, dress, and
language of a society or group of people.
In keeping with other social determinants of
health, cultural norms can promote or
undermine sexual and reproductive health.

116. ▪Heterosexism
▪Disability
▪Pornography & sexual assault
▪Indigenous women and high fertility

118. ❑Child marriage, adolescent pregnancy,
HIV and GBV all undermine girls’ access
to education
❑A significant proportion of girls become
pregnant during the time that they should
be in school: About 19%of girls in the
developing world become pregnant before
age 18, and about 3%become pregnant
before age 15

119. •Girls with no education are three times
more likely to marry before age 18 than
those with secondary or higher education
•A study in Bangladesh found that for each
additional year of delay in marriage, a girl
will gain an average of 0.22 additional
years of schooling, and the probability she
is literate will rise by 5.6%

120. References
•http://www.who.int/reproductivehealth/publicatio
ns/social_science/9789241599528/en/
•http://www.globalequality.org/storage/documents
/pdf/sida%20study%20of%20poverty%20and%2
0sexuality.pdf
•http://whwest.org.au/resource/social-
determinants-of-sexual-and-reproductive-health-
report-2011/
•http://www.unfoundation.org/what-we-
do/campaigns-and-initiatives/universal-access-
project/briefing-cards-srhr.pdf