Society and context

TANYA MARCHANT: In this step, we will examine the influence of society and context on the health of women and children through the lifecycle, particularly the empowerment of girls and women. This is a very complex topic to cover. Nonetheless, important examples were raised throughout the course that are worth noting here in this step. The importance of country context is central, especially when thinking about transferability of health care solutions from one place to another. For example, what is the breakdown of populations living in urban and rural areas? What type of infrastructure does the country have? Who gets educated? What are the laws and policies? How does the health system function? Context includes leadership also.

There are many examples of change being driven by the ambition of a small number of individuals in a given setting. Also within this broad heading come inequities in health, who they happen to, and what their mechanisms are. And then there is the need for empowerment in society, especially of women and girls, and the need for more accountability.

So again, just working through our lifecycle structure, the issues highlighted here are going to represent just a fraction of the facets of society context in adolescent health, but they’re a start. The first is empowerment to make choices. An obvious example of this is empowerment to make the sexual choices that young people want to, to be able to access the contraception that they need, both to prevent pregnancy, but also to prevent infection.

We’ve heard that in some societies, the dynamics between adolescents and providers of contraceptive services are dysfunctional because of fear that young people may have about castigation for being engaged in sexual activity and because of the biases that providers hold, which will almost inevitably reflect the feelings held in their society. Voice and social acceptance are closely intertwined. Still thinking about examples from this course, we heard from Peter Piot that the world is currently failing to prevent an estimated 100,000 new HIV infections in adolescents each year, the majority of them girls. And in many cases, these girls are not infected by boys of their age, but by older men.

Sadly, this phenomenon is exacerbated by social denial about the problem so that even when a girl voices her problems, she’s not readily heard. We see that this denial even extends to provision of the protective tool she might carry, condoms. And still today, girls who carry condoms can experience raised eyebrows and name calling. And finally, socioeconomic factors are amongst the most important determinants of risk that an adolescent will face. This is true for the girl who is infected with HIV by an older man and is also true of young people who experience violence and injuries. More conversation about these issues will help to raise awareness and hopefully reduce the negative impacts that society can have on the health of young people.

In the ‘Reproductive health: every birth wanted’ week of the course, we heard that the majority of countries in the world have prohibitive laws around induced abortion. And access to safe abortion continues to be deeply affected by political, religious, and cultural issues, often to the detriment of the health of the woman and her own individual human rights. Cicely Marston asked, why is it that even where contraceptive methods are widely available, we do not always observe increases in uptake? She talked about how societies have an understanding of when it is inappropriate or undesirable to restrict fertility and how in many societies, it is family members and husbands, not women themselves, who are perceived to have the authority to make fertility choices.

We also heard about the problem of side effects arising from some contraceptive methods– for example, weight gain or bleeding. But society and health workers who are part of society, often not taking these issues seriously, giving the impression instead that women should put up with these side effects as an inevitable part of life. These issues are deeply embedded in society and very complex to address. But again, part of the answer will likely lie in increasing empowerment and voice of girls and the social acceptance of their rights to health and choice.

The topic of vulnerability is not restricted to the domain of maternal health, but has importance across the lifecycle. Socioeconomic disadvantage can accumulate from conception through childhood and into adulthood. As we heard from Oona Campbell, in maternal health, there are several mechanisms that can lead to this situation, such as the more vulnerable women not knowing about the benefits of seeking medical care, traditional attitudes that restrict women’s movement, lack of transportation from remote areas, cultural or language barriers between women and health staff, or inability to afford fees for medical care. Possible solutions to reducing the risk that vulnerability poses have been discussed, but experience shows us that the solutions are not one size fits all.

What works in one country context may not be applicable in another, because of the health system structure, how far the population lives from services, and what the quality of those services are, but also for reasons beyond the health system– for example, the road infrastructure, the terrain, and how urban or rural the population is. An important issue is to increase accountability for maternal health. It must become unacceptable everywhere for women to die while giving birth, and better, more transparent and publicly available data can be part of that solution.

The newborn experiences the same inequities as her mother, for the most part. Babies born to the most vulnerable mothers are the most likely to be born without skilled attendants at birth and to experience multiple mechanisms throughout the lifecycle that hinder surviving and thriving. But like the mother, we need to move towards a world that does not expect a newborn baby to die so that cultures that have historically experienced high neonatal mortality– and as a consequence delayed the naming of their baby until beyond the period of highest risk, or that prohibit health workers from visiting the home of the newborn for fear of bringing negative events with them– can begin to feel more confident about the survival of their newborns.

An enormous challenge here, as for other stages, is the importance of context. Strategies that have been observed to have a high impact on neonatal mortality in some settings– for example, the lifesaving effect of health care counselling provided by community health volunteers in southeast Asia– have failed to be effectively transferred to other contexts. It is imperative that we continue to try to understand what drives change and how to harness it in every setting of the world. We’ve observed that inequities persist even for child health where the greatest achievements have been made. And these inequities, again, are linked into the changing distribution of populations between urban and rural settings.

But as more countries move towards a context where children are expected to survive to their fifth birthday, more inter-sectoral integration for child development will be needed, from nutrition, to education, to play and building safe environments, which will rely on different communities within society coming together and working in a new way. Society and context are large and complex topics, and here, we’ve only highlighted key features that have been raised by contributors across the course. But clearly, women, children, and adolescents live within country contexts and strategies to improve their health must take account of these. The empowerment of women and girls is one clear step that can be taken along that pathway.