Social inequalities and access to health: challenges for society and the nursing field / Las iniquidades sociales y el acceso a la salud: desafíos para la sociedad, desafíos para la enfermería

By Maggie Sullivan Moderator | 05 May, 2016

Social inequalities and access to health: challenges for society and the nursing field

By Regina Celia Fiorati, Ricardo Alexandre Arcêncio, Larissa Barros de Souza

Rev. Latino-Am. Enfermagem vol.24 Ribeirão Preto [Brazil] 2016
Published online: April 2016

Objective: to present a critical reflection upon the current and different interpretative models of the Social Determinants of Health and inequalities hindering access and the right to health.

Method: theoretical study using critical hermeneutics to acquire reconstructive understanding based on a dialectical relationship between the explanation and understanding of interpretative models of the social determinants of health and inequalities. Results: interpretative models concerning the topic under study are classified. Three generations of interpretative models of the social determinants of health were identified and historically contextualized. The third and current generation presents a historical synthesis of the previous generations, including: neo-materialist theory, psychosocial theory, the theory of social capital, cultural-behavioral theory and the life course theory.

Conclusion: From dialectical reflection and social criticism emerge a discussion concerning the complementarity of the models of the social determinants of health and the need for a more comprehensive conception of the determinants to guide inter-sector actions to eradicate inequalities that hinder access to health.
*Traduccion al espanol*

Las iniquidades sociales y el acceso a la salud: desafíos para la sociedad, desafíos para la enfermería

Objetivo: reflexionar críticamente sobre los diferentes modelos interpretativos actuales de los Determinantes Sociales de la Salud y las iniquidades que dificultan el acceso y el derecho a la salud.

Método: estudio teórico que utiliza el referencial teórico de la hermenéutica crítica para comprensión reconstructiva, a partir de una relación dialéctica entre la explicación y la comprensión de los modelos interpretativos de los determinantes sociales de la salud e iniquidades.

Resultados: iniciamos identificando las tres generaciones, históricamente contextualizadas, de los modelos interpretativos de los determinantes sociales de la salud; la tercera generación y la actual se muestran como la síntesis histórica de las anteriores, las que se dividen en los siguientes modelos: neomaterialista, teoría psicosocial, teoría del capital social, teoría cultural comportamentalista y teoría del curso de la vida.

Conclusión: se discute, a partir de una reflexión dialéctica y crítica-social, la complementariedad entre los modelos de determinantes sociales de la salud y la necesidad de concebir comprensivamente los determinantes, para orientar las acciones intersectoriales con el objetivo de erradicar las iniquidades que dificultan el acceso a la salud.



Ruth Staus Replied at 3:18 PM, 5 May 2016


Thank you for posting this excellent article that very much reflects the ideas from liberation theology -the need for a preferential option for the poor. There have been numerous nurses writing , for many years, about the need for nursing to start paying attention to the socio- political- economical- historical context in which disease is experienced. Drevdahl, Canales, & Shannon (2008, p.20) noted that the causes of health disparities "exist at much broader social, political, and economic levels, and therefore require much broader approaches if they are to be eliminated". Stevens (1992, p.186), noted that "without reframing nursing theory and include historical, cultural, and sociopolitical contexts...the interventions we devise seek only to change individual's attitudes and behaviors rather than alter the conditions that deter clients from receiving adequate healthcare".

I spent this past weekend at the Reimagining Social Medicine conference at the University of Minnesota. Our medical colleagues are actively teaching and talking about issues such as structural violence, neoliberalism, neocolonialism, Friere's Pedagogy of Oppression, liberation theology, etc. My family medicine colleagues have recently come out and publicly dedicated themselves to taking responsibility for poverty beyond just providing medical care. As a nursing faculty member I am having a great deal of difficulty getting support for teaching these ideas in our curriculum. I am wondering if my situation is unique?

Claudia Lefko Replied at 6:01 PM, 5 May 2016

Dear Ruth: Amen. I am not a nurse, I am educator working in partnership (from the US) with two pediatric oncologists in Baghdad. There is a serious cancer problem in Iraq, although all we can testify to is the cancer load at Children's Welfare Teaching Hospital in Medical CIty Baghdad. And, Iraq is a ruin, surely an LMIC but worse than that, a country that has been embroiled in catastrophic national and international conflicts for four decades. Everything, including much of the population that remains in the country, is warn down, damaged and/or broken. We have just written an article citing what appear to be new avenues for health advocacy in Iraq, including the strengthening of language and conventions that define health as a human right, and bundles the rights as dependent on one another. The overall state of "health" in Iraq is abysmal, as one would expect in a war/post war zone. And cancer has been a growing problem for the last twenty years. Somehow, if the health community--individuals and institutions-- was more actively involved in promoting the idea/concept of social determinants, we might see the beginning of the end of the wars that continue to steal peoples' health, not just in Iraq, but in many many other countries too numerous to mention. And, then I would expect (I am not a doctor or a nurse!) we would see an improvement in overall global health and in specific diseases such as cancer. I dream on.

There was an article published in the Lancet a few years ago, The Political Origins of Health Inequity: Prospects for Change, Lancet 2014; 383: 630–67 which boldly argued for health as the major determinant of policy decisions at every level of policy making and government. I am heartened by this conversation, even without reading the article Maggie posted. I am off to read it now! Claudia

Maggie Sullivan Moderator Replied at 10:10 AM, 16 May 2016

Ruth and Claudia - thank you so much for your thoughtful replies. I know this article has a very academic bent and is not the most accessible reading material, but it's underpinnings are vital. Ruth, to clarify, do you mean that your nurse faculty colleagues are not supportive of integrating topics such as structural violence, Friere's Pedagogy of Oppression, liberation theology, etc into the nursing curriculum? Or do you more mean that nurse faculty aren't publicly dedicating themselves to taking responsibility for poverty beyond the provision of medical care? Again, thank you so much for this conversation. I had always hoped that nursing education would be at the forefront of human rights and social justice.
*Traducción al español*
Ruth y Claudia - muchísimas gracias por sus comentarios pensativos. Entiendo que este articulo esta escrito en una manera muy académica, y por un lado no parece muy accesible, pero el asunto del mensaje es demasiado importante. Ruth, para clarificar, quiere decir que sus colegas de la escuela de enfermería no apoyan la integración en el currículo de las temas de violencia estructural, pedagogía de los oprimidos definido por Paulo Freire (enlace abajo), teología de la liberación (enlace abajo)? O quiere decir que sus colegas de la escuela de enfermería no están dedicándose ellas mismas a tomar la responsabilidad para la pobreza, fuera de brindar atención medica, aunque los médicos si lo están haciendo? De nuevo, muchas gracias por sus contribuciones. Siempre quisiera saber que la educación de enfermeras estaría en la frontera de los derechos humanos y justicia social.

*les pido disculpas por mi español escrito

Attached resources:

Ruth Staus Replied at 1:18 PM, 16 May 2016


I am experiencing both issues- integrating these important ideas that are very closely aligned with the theoretical and historical underpinnings of nursing and the idea that we as nurses need to publicly dedicate ourselves to eradicating the conditions that produce poor health. The more people attempt to silence me, however, the more dedicated I become to speaking truth to power. I have been providing primary care to the poor and disenfranchised in my community for 30 years with little in the way of support. I have invited my students to come with me on this very difficult journey. I continue on because the work is critical and I am hoping for the day when I have worked my way out of a job....


Elizabeth Glaser Moderator Emeritus Replied at 1:22 PM, 16 May 2016

I can understand why it might be difficult to integrate these ideas into some nursing and medical schools. Pedagogy of the Oppressed is not an easy read , particularly if one has not been exposed to broader topics in human rights, liberation theology, and principles of sustainable development . In addition, some with more conservative political and economic leanings may equate his ideas with socialism or communism and reject his overall thesis.

Finally , if we consider the ideas in Pedagogy to be valid for situations in other countries, then we must also consider the situation in the US where there is a widening chasm between the haves and have nots with decreasing social mobility leading to the prospect of people living in poverty with no prospect of ever improving their life: Friere's ahistoric existence. It is easy to consider other countries through Friere's lens but very difficult to turn it on ourselves , yet if we are to be serious in teaching and understanding Friere and others, then we have to do so.

Claudia Lefko Replied at 9:02 PM, 16 May 2016

This discussion is happening at an interesting point in my own work with two pediatric oncologists in Baghdad. As some people may remember, we are working to develop an education/training project for pediatric oncology nurses for this unit at Children's Welfare Teaching Hospital in Medical City Baghdad, the largest cancer facility in the Middle East by the number of patients they serve. Only about 25% of the nurses have a college degree. Their lack of strong English skills, and the enormous gap in their experiences working in a poorly-functioning hospital makes it difficult to take advantage of international training opportunities. And, on some level we are struggling to imagine how to develop and adapt a curriculum that will be successful given their personal and professional struggles living and working in Baghdad, a city in a near-constant state of chaos.

First, as a team --I am a educator/acitivst in the US/they are Iraqi doctors-- we are trying to co- construct knowledge that will help us launch the project. We are trying to look at and to understand the problem and the challenge both in the context of Bagdad and of the medical system as it is today and as it has been over the last 40 years and from an transcultural educational perspective, understanding how people learn in general and how learning will be best facilitated in this particular context. I have put out a call on this list for ideas, but we have not had much of a response, in part I imagine because Iraq is a unique situation. Every situation is unique of course, and the challenges are particular to the situation. And in part because people in similar situations are simply too busy with their own challenges.

I have not read Friere in a long time, but as an educator what I think is important is that we understand that everyone has capacity and the potential to learn, the potential to take responsibility to learn what they need and want to know in order to live and to work to their satisfaction. Sometimes children/youth or adults "learn" this in traditional school or through schooling, other times the the formal systems don't speak to their needs or is unavailable or unaffordable and it is difficult to find support/facilitation or a kind of scaffolding to support learning outside of the traditional system. In our situation, disrupted culture and schools and schooling at every level have left a huge gap so that hospitals and clinics are struggling to find and to keep qualified nurses and doctors. Without going into it in detail, our approach will be to involve nurses directly, working with doctors and internationals in the process of developing the education/training project.

Obviously, nurses and doctors cannot "solve" poverty or make up for a lack of education, but by recognizing the overall impact of poverty and lack of education on their patients and on certain communities, by developing holistic programs for patients in those communities, they/we begin to address the problem. It is the Social Determinants of Health; improving health, helps improve everything...outlook and overall capacity. The patients are more able to take advantage of education and training, of work opportunities. If opportunities are not available, perhaps they have the energy and increased confidence to develop it, to find partners to help them develop it in their community.

Iraq and Syria and the Middle East face enormous problems; how can we deliver or provide healthcare without taking into consideration decades of war and the impact on people ? We cannot/will not necessarily stop the wars with good health care training and delivery but it seems we must keep the context front and center as we develop education and training programs and deliver care. This is a necessity for us as we are directly in the situation. Maybe our work and our thinking will not help you Ruth, as you seemed tuned in to the same channel. I feel the same frustration however, as we reach out for help…how do you move people --students or those already in the profession--interested in medicine to take on such huge issues as poverty, lack of education and war.

Monique Germain Moderator Replied at 12:23 PM, 30 May 2016

This is great research and it shows the greater role the nurse can play in the rehabilitation process of such clients. I also think that nurses need to work in a health system environment that fosters flexibility and advocacy to reduce these social determinants. It is even more poignant when it happens in industrialized countries between well to do and not so well to do neighborhoods. Nurses do have to capacity to bring change. It is the consciousness raising that nurses need to develop so they can take action.
Thanks, Maggie, for making such research available.

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