WHAT ARE SOCIAL DETERMINANTS OF HEALTH AND DEVELOPMENT?

“Social determinants” refer to broader social factors, such as income inequality or

social exclusion that lead to or influence health and development outcomes. In
Section 4 of this chapter, for instance, a development worker in Mexico tells of
realizing that one of the major causes of malnutrition in the area where he was
working was not that there simply wasn’t enough food. Sharecropping farmers were
able to grow enough to feed their families, but had to borrow seed from the
landowner to plant their crops. The terms of the loan were that, for every liter of
maize borrowed at planting time, three liters had to be repaid from the harvest. With
this high interest rate, peasants went deeper and deeper into debt, and had to use
more of their crop each year to pay the landowner. Without power, group solidarity,
and influence, the farmers were unable to create conditions that assured the health
and well-being of their families.

There is a great deal of research on the social determinants of health. Most of

it points to three overarching factors:

Income inequality. Once a country has reached the point of development where most
deaths come not from infectious diseases (tuberculosis, dysentery, cholera, malaria,
flu, pneumonia, etc.), but from chronic diseases (heart disease, diabetes, cancer),
the economic and social equality within the society is a greater determinant of death
rates and average lifespan than the country’s position with regard to others. The
United States, for instance, lags behind Japan, Sweden, Canada, and many other
less affluent countries in the life expectancy of its citizens. The difference seems to
be the size of the gap between the most and least affluent segments of the society.

Social connectedness. Many studies indicate that “belonging” – whether to a large

extended family, a network of friends, a social or volunteer organization, or a faith
community – is related to longer life and better health, as well as to community
participation.

Sense of personal or collective efficacy. This refers to people’s sense of control over
their lives. People with a higher sense or stronger history of efficacy tend to live
longer, maintain better health, and participate more vigorously in civic life.
COMMUNITY CASE STUDIES IN TOURISM

Research, Practice and Ethical Action Through application of theoretical

frameworks, concepts and models, communication and reflection, community case
studies in tourism bring together theory and practice. Moreover, this dialogic
conversation between theory and practice can induce actions by both researchers
and community members that unleash tourism’s world-making capacity. Both Tribe
(2004) and Jamal (2004) have argued for closer alignment between tourism
knowledge generated by research and practical action. Tribe (2002) builds upon
Schon’s (1983) reflective practitioner, arguing for a ‘knowing–in-tourism-
ethicalaction’ wherein ‘reflection and action are integrated where people act for the
good of tourism societies’ (p. 322). Jamal (2004) argues that Tribe’s argumentation
does not go far enough, and that, while action is good, further examination of the
ethics underpinning research is needed. Building upon Tribe’s work, and drawing
from classical philosophy of Aristotle, Jamal argues that researchers must address
what Aristotle called the ‘good life’ – a research life characterized by acting virtuously
for the good of the community.

These authors provide important justifications for valuing practical, engaged

community research that facilitates ethical action. Adding to this, we advocate that
the dialogic sense-making that takes place in community case studies when
researchers and community members engage in communication and reflection
results in Mode 2 knowledge production (i.e., context and problem driven inquiry
wherein both the researcher and the researched contribute to the production of
knowledge) (Nowotny, 2003). This sense making and ethical action approach can
result in the researcher defining the problem and researching in consultation with the
community (rather than independently of it). Unanticipated insights, derived through
the co-production of local knowledge, can help to generate solutions and joint
actions. Bodorkós and Pataki (2009), for example, adopted a participatory action
research approach to ‘learn about the possibilities for bottom-up regional
sustainability planning in a planning culture dominated by top-down institutional
arrangements’ in economically disadvantaged regions in Hungary. Ecotourism
emerged as a possible action identified by stakeholders. Reflecting on the value of
this community based research the authors observed that it involved a different
problem-structuring process: [It] takes a lot of time and effort; indeed, the mutual
learning process is time-consuming. Researchers are necessarily required to spend
a great deal of time listening to the local inhabitants, striving to become familiar with
their priorities, problems, and visions. As compared to one-shot research processes
typically applied in mainstream research, community-based research can create a
better learning environment through providing more flexibility and being more
responsive to local ideas. (p. 1130)
Challenges in public health facilities and services: evidence from a
geographically isolated and disadvantaged area in the Philippines

Abstract

Background

The study describes the conditions of public health sector in the Island Municipality
of Jomalig, Quezon Province in Luzon, Philippines. Located at the far north-eastern
side of the Quezon Province, Jomalig Island can be reached through a motor boat at
around 4-5 hours (or more depending on the sea condition). Given the geographical
disadvantage, challenges in economic and social services in the island are apparent.
That includes deficiencies in basic public utility services such as water and
electricity. The paper showcases a needs assessment on public health facilities and
services in a far-flung municipality in the Philippines. This study examines the
challenges in public health aspirations in a location considered to be a
geographically isolated and disadvantaged area (GIDA).

Methods

The study made use of key informant interviews (KIIs) among health professionals
and village health workers in the island. Aside from the KIIs, the study included the
World Health Organization’s (WHO) tracer checklist on general readiness. The
checklist was administered but in interview style. The participants were the public
health staff in the island. The researcher was able to interview the health
professionals (nurses and a midwife) manning the main public health facility in the
island municipality while in the case of the other villages, health volunteers or the
Barangay Health Worker (BHWs) were interviewed.

Results

There are deficiencies in facilities, offered services and health staff. Deficiencies are
seen too based on the domains under the WHO Tracer Checklist. Mortality and
morbidity rates were not at alarming rate though reports of hypertension and
diarrhea are common. The relatively “complete” health services are only available at
the island’s main health center yet unfortunately, some people who seek treatment
and health care could not visit due to distance and the accompanying expenditures.
Other factors affecting health status of the population include the reliance to “faith
healers” (quack doctors or Albularyos) and the delay of parental reports of their
health condition and the condition of their children, both of which result to the
“escalation” of illness. Among others, challenges and aspirations of the island’s
public health sector include electric supply, better budgetary allocation for their
facilities, and equipment and additional training for the barangay (village) health
workers.
Conclusions

Enduring the underfinanced and undermanned health facilities, the island’s

population also suffers the consequences on overall health owing to limited
movements and communication due to the geographical characteristics of the
municipality. Emergency boats per village, health education campaign that focuses
on eliminating open defecation and reliance on quack doctors, stand-by generators
for the health centers, and radio communication system are strongly recommended
to mitigate the negative impacts of living within GIDA communities

Connecting communities to primary care: a qualitative study on the roles,

motivations and lived experiences of community health workers in the
Philippines

Abstract

Background

Community health workers (CHWs) are an important cadre of the primary health
care (PHC) workforce in many low- and middle-income countries (LMICs). The
Philippines was an early adopter of the CHW model for the delivery of PHC,
launching the Barangay (village) Health Worker (BHW) programme in the early
1980s, yet little is known about the factors that motivate and sustain BHWs’ largely
voluntary involvement. This study aims to address this gap by examining the lived
experiences and roles of BHWs in urban and rural sites in the Philippines.

Methods

This cross-sectional qualitative study draws on 23 semi-structured interviews held

with BHWs from barangays in Valenzuela City (urban) and Quezon province (rural).
A mixed inductive/ deductive approach was taken to generate themes, which were
interpreted according to a theoretical framework of community mobilization to
understand how characteristics of the social context in which the BHW programmer
operates act as facilitators or barriers for community members to volunteer as
BHWs.

Results

Interviewees identified a range of motivating factors to seek and sustain their BHW
roles, including a variety of financial and non-financial incentives, gaining technical
knowledge and skill, improving the health and wellbeing of community members, and
increasing one’s social position. Furthermore, ensuring BHWs have adequate
support and resources (e.g. allowances, medicine stocks) to execute their duties,
and can contribute to decisions on their role in delivering community health services
could increase both community participation and the overall impact of the BHW
programmed.
Conclusions

These findings underscore the importance of the symbolic, material and relational
factors that influence community members to participate in CHW programmers. The
lessons drawn could help to improve the impact and sustainability of similar
programmers in other parts of the Philippines and that are currently being developed
or strengthened in other LMICs.

Methods

This study was conducted as part of the Responsive and Equitable Health Systems-
Partnership on Non-Communicable Disease (RESPOND) project, which uses
longitudinal mixed-methods to better understand health system barriers to care for
hypertension as a tracer condition for non-communicable diseases (NCD) in the
Philippines ]. The study was conducted in purposefully selected urban barangays in
the City of Valenzuela and rural barangays in Quezon province, and data for this
analysis was collected via semi-structured interviews with BHWs as part of the
facilities assessment component of the RESPOND project.

Data collection and management

A senior in-country, bilingual, social scientist researcher led the data collection and
supervised two in-country, bilingual, trained research assistants (one male, one
female) with relevant experience and backgrounds in communication and public
health in administering semi-structured interviews in pairs in Filipino. A total of 23
BHWs were purposefully recruited, 13 from Valenzuela City and 10 from Quezon
province, to maximize diversity of experience in terms of length of service, education
and age, across the participating barangays. All BHWs in the study sites were
women and those agreeing to participate in the study varied in age from 35 to 75
years. All but one were married. Their lengths of service ranged from 1 to 38 years,
with 8 possessing 11 or more years of experience. Two participants reported
recently returning to their duties following periods undertaking parental and
household duties. The educational background of participants ranged from primary
school to undergraduate degree. None received formal training as a health
professional prior to starting their roles as BHWs.

The interview guide focused on their motivations for becoming a BHW, their day-to-
day experiences of developing their role and responsibilities in the community, and
their understanding of hypertension (Supplementary File 1). As BHWs in RESPOND
project communities were engaged in the sampling of the household survey
component, they were approached directly and oriented to the nature of the BHW
study. Written informed consent was acquired from those who wished to participate,
and interviews with each were arranged and conducted by the two research
assistants in Filipino as the mutually shared language. Because all interviewees
were women, it was considered important to include a female and male interviewer
who could work flexibly to minimize response bias. Interviews were conducted and
audio recorded in a secure place selected by participants between September 2018
and October 2019, lasting 30–60 min. After 15 interviews, data saturation was
reached and subsequent interviews were conducted to ensure no new data was
generated and to maximize sampling diversity.

Following each interview, written notes were reviewed jointly by the research
assistants and BHWs to ensure accurate representation and interpretation. The two
research assistants transcribed each interview recording verbatim in Filipino, and the
fidelity transcriptions was assessed by the senior researcher against the recording.
Anonymised transcripts were produced by removing all personal identifiers and
attributes, and participants were assigned a pseudonym, which have been applied
throughout this report. Research notes and signed consent forms were stored in
locked cabinets accessible only to the research team. All digital audio recordings,
digitised research notes, and original and anonymised transcript files were stored
separately on secure, encrypted and password protected servers or laptops. All non-
anonymised research material (e.g. audio recordings, original transcripts, notes) will
be destroyed at project end, while consent forms and anonymised transcripts will be
kept securely for 7 years thereafter.

Data analysis and rigour

Verbatim transcriptions in Filipino were analyzed using NVivo 12 software. The

senior social scientist led the open reading of the Filipino transcripts and several
rounds of coding using a thematic approach with the research assistants. The
coding frame emerged, in part, inductively through multiple, iterative readings of the
interview transcripts, but was also informed from our a priori interest in motivations
and experiences of BHWs, drawing on Campbell and Cornish’s approach to
examining how a “health enabling social environment” affects community
mobilization and participation . After several rounds of coding, analytical memos of
emerging and recurring themes were shared with the broader research team, who
have expertise in primary health care, health system strengthening in LMICs and the
local context, to conduct interpretation and contextualization via regular discussions
in English, ensuring the relevance and transferability of the results both locally and
globally. This also included critical assessments of the findings’ plausibility,
consistency with other research of findings, and in light of researchers’ own biases,
preconceptions, preferences, and dynamic with the respondent (i.e. researchers
were health professionals and/or staff of well-known universities) to ensure validity.
Key themes, supporting quotations and statements included in memos (and
subsequently in the manuscript) were extracted from interview transcripts and
translated to English by the bilingual research assistants; and the quality of
translations was assessed by bilingual senior researchers by checking and
rechecking transcripts against the translated interpretations.

Informed consent and ethical approval

Ethical approval for the research was obtained from the local research ethics board
of the University of the Philippines Manila Panel 1. We obtained written informed
consent from BHWs prior to the interview, ensuring that their anonymity, privacy and
confidentiality would be maintained. BHWs were advised of their right to withdraw
their participation at any time, although none of the participating BHWs did so.

Results

In this section, we summaries the lived experiences of community members who

volunteer as BHWs in our urban and rural study locations. We also describe the
salient themes from these accounts that relate to factors that influenced their initial
motivation to volunteer and that determine their continuing involvement.