Contextual Factors that can Diminish or Exacerbate Health Inequities

From this model, please identify and discuss four contextual factors including cultural differences relevant to your problem, and note how each either diminishes or exacerbates the problem you are seeking to address. Your overall response should be 4–5 double-spaced pages, excluding references. Your analysis of the impact of each factor should be supported with evidence from the scholarly literature (at least one peer-reviewed source per factor) and properly cited both within the body of your paper and the reference list appearing at the end.
Length: 4-5 pages, double-spaced (excluding cover-page and reference list).
Format: APA format is required for this assignment.
1.2 Globalization and social determinants of health: Mapping the linkages Diderichsen, Evans and Whitehead (2001, p. 14) propose a framework that identifies “four main mechanisms – social stratification, differential exposure, differential susceptibility, and differential consequences – that play a role in generating health inequities.” Globalization can affect health outcomes through each of these mechanisms. Their model contributed numerous insights to the organizing framework adopted by the Commission on Social Determinants of Health (Solar & Irwin, 2007), and has been further modified for purposes of the GKN (Figure 1; see Appendix 1 for a more complex rendering of this model and the key research questions that guided the work of the GKN). Crucially in terms of the study of globalization, for Diderichsen et al. the social context “encompasses those central engines in society that generate and distribute power, wealth, and risks” – engines that increasingly operate on a global scale (p. 16). A stylized illustration, necessarily oversimplified but supported by evidence cited later in this Report, serves to illustrate the model’s relevance. Import liberalization may reduce the incomes of workers in sectors serving the domestic market, or shift them into the informal economy, thereby affecting social stratification, differential exposure (e.g. as workers are exposed to new hazards) and differential vulnerability (e.g. as income loss means adequate nutrition or essential health care become harder to afford, or in the extreme cases in which women are driven to reliance on “survival sex” (Wojcicki & Malala, 2001; Wojcicki, 2002). Increased vulnerability may also magnify the negative consequences of ill health by reducing the resources available to households to pay for health care or absorb earnings losses, increasing the chance of falling into ‘poverty traps’ (hence the feedback loop to social stratification). Import liberalization may also reduce tariffs revenues (and therefore funds available for public expenditures on income support or health care) in advance of any offsetting increases from income and consumption taxes. In countries with high levels of external debt, the need to conserve funds for repaying external creditors, perhaps by initiating or increasing user fees for health and education, may create a further constraint; at the same time, scarcity of resources Figure 1: Globalization and social determinants of health Source: Modified from Diderichsen, Evans & Whitehead, 2001. Final Report to the Commission on Social Determinants of Health 19 for health systems increases the attractiveness of ‘vertical,’ disease-specific external funding mechanisms. (The rationale for including health systems as a separate element of the diagram now becomes apparent.) Conversely, if import liberalization is matched by improved access to export markets, new employment opportunities may be created for specific groups, such as women working in export processing zones, who are thereby empowered to escape patriarchal social structures (social stratification) and reduce their economic vulnerability. As Commission Chair Sir Michael Marmot has pointed out, “The further upstream we go in our search for causes,” and globalization is the quintessential upstream variable, the greater the need to rely on “observational evidence and judgment in formulating policies to reduce inequalities in health” (Marmot, 2000, p. 308). Much of the evidence reviewed by the GKN does not directly link globalization to health outcomes. Rather, it describes pathways linking globalizations with social stratification, differential exposure or vulnerability, differential consequences or health systems: elements that are already established as “causes of the causes” of health inequalities (Rose, 1985; Marmot, 2005). If globalization creates inequalities in these more distal causes, then at the very least defensible grounds exist to assume that increased health inequalities are a result.4 An illustrative application of this approach is provided by De Vogli & Birbeck (2005), who identified five multi-step pathways that lead from globalization to increased vulnerability to HIV infection among women and children: currency devaluations, privatization, financial and trade liberalization, implementation of user charges for health services and implementation of user charges for education. The first two pathways operate by way of reducing women’s access to basic needs, either because of rising prices or reduced opportunities for waged employment. The third operates by way of increasing migration to urban areas, which simultaneously may reduce women’s access to basic needs and increase their exposure to risky consensual sex. The fourth pathway (health user fees) reduces both women’s and youth’s access to HIV-related services, and the fifth (education user fees) increases vulnerability to risky consensual sex, commercial sex and sexual abuse by reducing access to education. The authors examined each of these pathways through a review of available studies examining the linkages, concluding that adjustment policies may inadvertently produce conditions facilitating the exposure of women and children to HIV/AIDS. Their conclusions are supported by those reached by the Commission for Africa (2005), which considered some of the domestic austerity programmes arising from structural adjustment (see section 3.1.3) as important causal factors in the rapid rise of AIDS in Africa; and by field research that convincingly links economic restructuring with the insecurities that render certain populations, especially of women, more vulnerable to HIV infection (Schoepf, 1998; Schoepf et al., 2000; Mill & Anarfi, 2002; Schoepf, 2002; Schoepf, 2004). The variation in HIV prevalence across African countries indicates that other factors are important, as well. These include variations in how rapidly nations accepted the existence of the pandemic, the causative role of HIV and the need for scaled up programmes of prevention and treatment; differences in male circumcision rates (Beyrer, 2007); and cultural differences in the patterning of sexual relationships, specifically considering the role of multiple concurrent partnerships in HIV prevalence (Halperin & Epstein, 2004). National policies and social norms still matter; our point here is simply that globalization also matters, and is increasingly a conditioning and constraining influence on both.
Source: World Health Organization, Globalization Knowledge Network (2007). Towards health-equitable globalization: Rights, regulation and redistribution; Final report to the Commission on Social Determinants of Health.