SEE ALSO addiction; evidence based; peer education; power; risk factors; sexual health; youth
A healthy school environment includes health education, health services, nutrition and food safety, physical education and counselling. The school implements policies and practices that respect an individual’s well-being and dignity and works with the local community to help it contribute to the health of the pupils (WHO, 1997).
School-aged children face a number of health risks associated with the social dimensions of their lives including substance abuse, teenage pregnancy, sexual health, suicide, bullying and depression. Public health professionals working with school children are also faced with a number of challenges for the effective planning and implementation of appropriate services including health education, screening, immunization, hygiene checks and the monitoring of national legislation and policy (Hubley, Copeman and Woodall, 2013).The health-promoting school is a public health approach that is used to reach children through specific settings including day-care centres and nurseries, child minders, pre, primary and secondary schools. A health-promoting school encompasses six components: (1) healthy school policies, (2) the school’s physical environment, (3) the school’s social environment, (4) individuals’ health skills and action competencies, (5) community links and (6) health services. Health-promoting schools are characterized as using a holistic model that engages with health and education officials, teachers, unions, students, parents, health providers and communities (Senior, 2012). There are a number of networks for health-promoting schools, such as the Schools for Health in Europe (SHE), focusing on making school health promotion an integral part of policy development and providing a platform for different stakeholders to interact.
Policies to address childhood obesity have become a national priority in many countries because diet at a young age can condition behaviours for healthy eating across the life span. School meals can contribute substantially to the diet of many children, especially those from low-socio economic families. From 2008, primary schools in England were required to comply with legislation specifying the frequency with which certain foods can be served in school meals. This legislation led to children who consume school lunches having a healthier mean nutrient profile than those who consume home-packed lunches, in particular for the most deprived school children (Spence et al., 2013). However, whether or not regulations influence long-term dietary choices, obesity or other health outcomes is unclear. Government policy may in fact be adding to the overweight and obesity burden of school children. For example, one study in the United Kingdom found that the promotion of fruit and vegetable consumption in schools was not displacing the intake of higher calorific foods in children. This finding does not support assumptions that have been made about the relation between fruit and vegetable consumption and healthy weight (Hender and Horne, 2012). Better understanding about the effectiveness and costs of regulatory interventions – for example, the implications of encouraging children to eat more fruit and vegetables – will help to direct government-led action to where it could help promote healthier lifestyles in schools.
Bullying among school children is increasingly being recognized as a worldwide social problem that can directly affect the health, well-being and educational development of school children. Bullying is a specific type of aggression that goes beyond normal peer pressure and conflict because the behaviour is intended to harm or disturb, occurs repeatedly over time and has an imbalance of power, with a more-powerful person or group attacking a less-powerful one. If bullying is done by a group, it can be called mobbing and the people being bullied are often called victims or targets of bullying. Bullying may be verbal, physical or psychological and may result because of an interaction from person-to-person or through channels such as social media (Besag, 1989). Cyberbullying is mostly experienced outside of the school environment but is still an aggressive act or behaviour that is carried out using an electronic means, repeatedly and over time against a victim who cannot easily defend himself or herself. Prevention strategies that are used for traditional bullying can also be extended to cyberbullying including school staff and high status peer support, online education, self-help groups, life skills and individual coping strategies (Slonje, Smith and Frisen, 2012).
Schools are seen as an important setting for the learning of health-related knowledge, attitudes and behaviours from an early age, for example, sex and relationships is a subject taught to focus on broader emotional, values and skills necessary for adolescents to help deal with this issue later in their lives (Naidoo and Wills, 2009). Many school health programmes work on the perspective that establishing healthy behaviours during childhood is more effective than trying to change unhealthy behaviours during adulthood. However, many strategies that have been used have relied upon educational methods that have imparted information in a didactic, one-directional manner, for example, through lectures, leaflets and the mass media. This ignores the influence that other factors, including complex social processes, peer pressure, structural inequalities, poverty and powerlessness, can have on children’s lives and health. It also ignores the need for children to have a supportive environment for their behaviour change, an environment that makes the healthy choice the easy choice, and provides infrastructural and social support.
Health in schools is generally applied as targeted interventions, such as for sun-protection or healthy eating, rather than aiming for a holistic school organizational change. This may be because in order to integrate the health-promoting model into the structure and systems of a school requires substantial support from staff, senior management and health and education authorities over a long time frame. This overlaps with the issue of the evidence of health outcomes in schools and the complexities that this covers requiring improved research and evaluation methods to measure these outcomes and to produce evidence that can better inform policy and practice (Simovska, 2012).
KEY TEXTS
•Blair, M. et al. (2010) Child Public Health (Oxford: Oxford University Press)
•Simovska, V. (2012) ‘Processes and Outcomes in School Health Promotion: Engaging with the Evidence Discourse’, Editorial. Health Education, 112 (3)
•Thurtle, V. and Wright, J. (2008) Promoting the Health of School Aged Children (London: Quay Books)
SEE ALSO health; lesbian, gay, bisexual and transgender; Maternal, Newborn and Child Health; men’s health; prostitution; schools; women’s health; youth
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality and not merely the absence of disease, dysfunction or infirmity (WHO, 2006b).
The interpretation of sexual health is associated with sexual thoughts, feelings, identities and behaviours and the impact they have on well-being. 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 (WHO, 2006b).
Sexual health is closely linked to reproductive health. Reproductive health implies that people are able to have a responsible, satisfying and safe-sex life but that they also have the capability to reproduce and the freedom to decide if, when and how often to do so (WHO, 2010b). Implicit in this is the right to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation. It also implies the right of access to appropriate health care services that enable women to go safely through pregnancy and childbirth (WHO, 2010b).
Sexual health issues include unwanted pregnancies, sexually transmitted infections and the physical and emotional effects of abusive relationships. Being sexually healthy involves having a positive sense of self, emotional well-being, strong relationships and being able to take control of personal safer sex needs (WHO, 2006b). The ability of men and women to achieve sexual health also depends on their access to good-quality information about sex and sexuality, about the risks they face and their vulnerability to the adverse consequences of sexual activity and access to health care.
Worldwide, 40% of all pregnancies are unintended and unsafe abortion accounts for 13% of maternal deaths, being highest in countries where women do not have access to safe abortion services and to proper care to treat complications (Malarcher, Olson and Hearst, 2010). Unintended pregnancy is strongly influenced by access to, and the use of, effective contraception and by exposure to unwanted sex through, for example, child marriage and sexual violence. Addressing unintended pregnancy and improving pregnancy outcome require interventions specifically designed to achieve equity in the availability of all related health services, especially targeting disadvantaged women. Such efforts are most effective when combined with improving education for women, effective health care and the access to skilled birth attendance (Malarcher, Olson and Hearst, 2010).
The male latex condom is the main method used to protect both men and women from sexually transmitted diseases and women from unintended pregnancies. It is important, therefore, that condoms are readily available, either free or at low cost, and that information is provided to help overcome social and personal obstacles to their use. Public health interventions on condom use have focused on whether a condom was simply used or not. Thailand’s efforts to de-stigmatize condoms and its targeted condom promotion for sex workers and their clients dramatically reduced HIV infections in these populations and helped reduce the spread of the epidemic to the general population (UNAIDS, 2004). The continued delivery of public health programmes to promote condom use is necessary because a perception of low-risk and a sense of complacency can lead to unprotected sex through reduced or non-consistent condom use. For example, in order to be effective against pregnancy and the transmission of infections a condom must be put on prior to any intimate skin contact. Evidence from young people in the United Kingdom indicates three forms of ‘unsafe protected sex’ that fail to minimize or eliminate the risk of pregnancy and/or STI transmission during sexual encounters: (1) condom failure, (2) condoms used for ejaculation only and (3) condoms used after limited unprotected penetration (Graham et al., 2011). Promotion of correct and consistent condom use within reproductive health and family planning services is essential to reduce sexual health issues.
Sexual health cannot be achieved and maintained without also respecting and protecting human rights related to sexual health (sexual rights) and mental health related to sexual health. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health with respect for the rights of others and within a framework of protection against discrimination (WHO, 2006).The learning of health-related knowledge, attitudes and behaviours in regard to sexual health begin at school age. Sex education in schools is now called ‘sex and relationships’ in an attempt to move away from a medical model focus on biology to a focus on broader emotional, values and life skills necessary for adolescents to deal with this issue in their lives (Naidoo and Wills, 2009).
Broad-based programmes that involve the integration of sexual health services with reproductive health services and broader systems of provision are essential to promote sexual health effectively. The use of targeted interventions, for example, to reach men, the poor and vulnerable, is also a significant aspect of effective sexual health services.
KEY TEXTS
•Malarcher, S., Olson, L. and Hearst, N. (2010) ‘Unintended Pregnancy and Pregnancy Outcome: Equity and Social Determinants’ in E. Blas and A. Kurup (eds), Equity, Social Determinants and Public Health Programmes (Geneva: World Health Organization), Chapter 10
•WHO (2006b) ‘Defining Sexual Health: Report of a Technical Consultation on Sexual Health’, 28–31 January 2002 (Geneva: World Health Organization)
•WHO (2010b) ‘Developing Sexual Health Programmes’. Department of Reproductive Health and Research. WHO/RHR/HRP/10.22 (Geneva: World Health Organization)
SEE ALSO empowerment; Health in All Policies; inequalities agenda; policy change; power; risk factors
The social determinants of health are the conditions in which people are born, grow, live, work and age; circumstances that are shaped by the distribution of money, power and resources and which are themselves influenced by policy choices (WHO, 2008).
The health of the poor and the marked health inequities between people and between countries are caused by the unequal distribution of power, income and services. The inequalities that this creates in everyday living include unequal access to health care and education, conditions of work and the limited opportunities of leading a healthy life. This unequal distribution is the result of a combination of poor social policies, unfair economic arrangements and unjust governance. People who have, for example, high-risk lifestyles or who have poor living conditions are typically more influenced by economic and political policies, suffer greater health inequalities and consequently have more disease, premature death and less well-being (Wilkinson and Marmot, 2003).
The Commission on Social Determinants of Health (CSDH) was established in 2005 to provide advice on how to reduce health inequalities and its final report contained three overarching recommendations (WHO, 2008): (1) tackle the inequitable distribution of power, money and resources; (2) measure and understand the problem and assess the impact of action; and (3) improve daily living conditions.
The specific conditions that relate to the social determinants of health include:
The social gradient: Life expectancy is shorter for people further down the social ladder and who are likely to experience twice as much disease and ill health as those nearer the top in society;
Stress: People who are worried, anxious and unable to psychologically cope suffer from stress that over long periods of time can damage their health. Stress can result from many different circumstances in a person’s life but the lower people are in the social gradient the more common are these problems;
Early life: Slow physical growth and poor emotional support can result in a lifetime of poor health and a reduced psychological functioning in adulthood. Poor foetal development, linked to, for example, stress, addiction and poor prenatal care, is a risk for health in later life;
Social exclusion: Poverty, discrimination and racism can all contribute to social exclusion. These processes all prevent people from participating in health and education services, are psychologically damaging and can lead to illness and premature death;
Work: Whilst having a job is generally healthier than not having a job, stress in the workplace increases the risk of ill health. This is more pronounced when people have little opportunity to use their skills and have low decision-making authority;
Unemployment: Job security increases health, unemployment or the insecurity of losing one’s job, causes more illness and premature death. The health effects of unemployment are linked to psychological factors such as anxiety brought on by problems of debt;
Social support: Having friends, good social relationships and supportive networks can improve health. People have better health when they feel cared for, loved and valued. Conversely, people who do not have these factors in their lives suffer from poorer health and premature death;
Addiction: Alcohol dependence, illicit drug use and smoking are not only markers of social and economic disadvantage but are also important factors in worsening health;
Food: A good diet and an adequate supply of food are important to health and well-being. A poor diet can cause malnutrition and a variety of deficiencies that can contribute to, for example, cancer and diabetes. Poor diet is often associated with people who are lower on the social gradient and can also lead to obesity;
Transport: The reliance on mechanized transport has resulted in people taking less exercise, increased fatal accidents and pollution. Other forms of transport such as cycling and walking increase the level of exercise and help people to reduce obesity and diseases such as diabetes and strokes (Wilkinson and Marmot, 2003).
The final report of the Commission on Social Determinants of Health did not make a strong political statement by naming the perpetrators of social injustice or by stating the actions necessary to deal with them. Instead it presented the evidence of the ‘causes of the causes’ and recommended more and better research (Laverack, 2012). This has been criticized as not going far enough and in not providing the evidence of effective reforms and interventions to act on and solve health inequalities (Potvin, 2009).
KEY TEXTS
•Marmot, M. and Wilkinson, R. G. (2005) Social Determinants of Health (Oxford: Oxford University Press)
•Wilkinson, R. G. and Marmot, M. (eds) (2003) Social Determinants of Health: The Solid Facts. 2nd edn (Copenhagen, Denmark: WHO Regional Office for Europe)
•World Health Organization (2008) ‘Closing the Gap in a Generation. Commission on Social Determinants of Health’. Final Report (Geneva: World Health Organization). Available at www.who.int/social_determinants. Accessed 6 May 2014
SEE ALSO activism; participation; peer education; reformers; volunteerism
Social entrepreneurship is the process of pursuing innovative solutions to social problems by drawing upon appropriate thinking in all aspects of the business and non-profit sectors (Dees, 2001).
Social entrepreneurship can include innovative not-for-profit ventures, social business ventures, such as for-profit community development banks, and organizations mixing not-for-profit and for-profit elements, such as homeless shelters. What distinguishes social entrepreneurs from socially responsible businesses and philanthropists is their aim to create and sustain social value. Social entrepreneurs value profit but they also value the positive return that their activities give to society in regard to social, cultural and environmental goals (Dees, 2001). Social entrepreneurship uses the disciplines and practices of the corporate world to tackle social problems. A distinction can be made in the different definitions between an individualistic focus on exceptional social entrepreneur leaders compared to others working within teams, networks and movements for social change (Abu-Saifan, 2012).
Homelessness describes people without a place to live and who are unable to acquire and maintain regular, safe, secure and adequate housing or lack an adequate night-time residence (Thomson, Petticrew Morrison 2001). Homeless people suffer from higher levels of physical and mental illnesses and often present to health care services in situations of personal crisis. The Big Issue was launched in 1991 by two social entrepreneurs, John Bird and Gordon Roddick, in response to the growing number of rough sleepers on the streets of London. The philosophy behind the Big Issue was in helping homeless people to help themselves and to offer a legitimate alternative to begging, by selling newspapers to individuals. The Big Issue is now one of the UK’s leading social businesses and continues to offer homeless people the opportunity to earn a legitimate income. The entrepreneurial organization is made up of a limited company which produces and distributes a magazine to a network of street vendors and a charity which addresses the issues that contribute to homelessness. The organization supports over 2900 homeless people across the United Kingdom and the street paper is read by over 670,000 people every week in the United Kingdom. The Big Issue has helped to challenge and shape public perceptions of homelessness and has worked with over 10,000 individuals supporting them to address issues on health, housing and employment. Street papers have begun to effect social change on a global scale by forming the International Network of Street Papers with members in 28 countries, and their combined annual circulation exceeds 24 million copies and has begun initiating global anti-poverty campaigns via its Global Street News Service (Mathieu, 2007; Big Issue, 2014).
Microfinance is a form of financial lending for entrepreneurs and small businesses lacking access to mainstream and related support services. The two main mechanisms for the delivery of this type of financial service are: (1) relationship-based banking for individual entrepreneurs and small businesses; and (2) group-based models, where several entrepreneurs come together to apply for loans and other services as a group. Microcredit is one aspect of microfinance and is the provision of credit services to clients who cannot secure small loans from elsewhere (Bornstein and Davis, 2010). Microfinance and social entrepreneurism have been used to improve health across populations – for example, women in Bangladeshi communities became more empowered through micro-financing with the help of the Grameen Bank. The loans were small and intended to give women more control over decisions regarding their income generation and health. The success of the loans was attributed to the solidarity of small community organizations, social support and the financial advantage offered by the scheme. By the beginning of 2005, the bank had loaned over USD 4.7 billion and by 2006 it had more than 2100 branches in the country (Papa, Singhal and Papa, 2006). Due to the broad range of services that are offered microfinance projects can be difficult to assess in terms of their overall impact and the evidence of using this form of support to poor communities is mixed (Bornstein and Davis, 2010).
KEY TEXTS
•Bornstein, D. and Davis, S. (2010) Social Entrepreneurship: What Everyone Needs to Know (USA: Oxford University Press)
•Dees, G. (2001) ‘The Meaning of Social Entrepreneurship’. Center for Advancement of Social Entrepreneurship (Duke Fuqua School of Business: Durham, NC). Available at http://www.caseatduke.org/ Accessed 25 February 2014
•Ridley-Duff, R. and Bull, M. (2011) Understanding Social Entrepreneurship: Theory and Practice (London: Sage)
SEE ALSO activism; advocacy; epidemiology; power; reformers; risk communication; sexual health; volunteerism; women’s health
A social movement can be defined as a sustained and organized public effort targeting those in authority, using both conventional and unconventional strategies to achieve its goals (Tilly and Lesley, 2012).
What makes a movement different from other forms of social mobilization, such as pressure groups and advocacy groups, is an ability to go beyond the influence of its membership. A social movement is able to maintain an ideology irrespective of membership, function and organizational structure. To do this, the movement must have deep social roots and strong social networks (Laverack, 2013a).
Health social movements challenge state, institutional and other forms of authority to give the public more of a voice in health policy and regulation (Brown and Zavestoski, 2004). Health social movements are an important point of social interaction concerning the rights of people to access health services, personal experiences of illness, disease, disability and health inequality based on race, class, gender and sexuality.
Health social movements overlap in terms of their purpose and tactics but can be broadly categorized into three types (Brown et al., 2004):
1.Health access movements that seek equitable access to health care services, for example, through national health care reforms and an extension of health insurance to non-insured sectors of the population;
2.Embodied health movements concern people who want to address personal experiences of disease, illness and disability through a challenge of the scientific evidence and the recognition of their ideas. It can include people directly affected by a condition or those who feel they are an at risk group, for example, the HIV/AIDS movement;
3.Constituency-based health movements concern health inequalities when the evidence shows an oversight or disproportionate outcome, for example, the human rights movement.
The growing awareness of evidence that has become available through, for example, the internet, has led to people challenging government health policy. This has been coupled by the negative publicity received, for example, about experimentation with contraceptives, radiation and immunization, that has created a heightened level of distrust by the public. People have discovered that they can apply significant pressure to have an influence on health policy, especially at a collective level (Brown and Zavestoski, 2004).
The environmental breast cancer movement in the United States is an example of the efforts of women who were concerned with both access to health care services and to addressing health inequalities. Maren Klawiter (2004) discusses the experiences of women with breast cancer in the 1970s in the San Francisco Bay Area who endured isolation and power inequalities structured around the doctor–patient relationship. The movement was created to identify with those at risk from or affected by breast cancer and provided many women with the emotional support they needed to be able to move forward collectively to address a personal issue. Using the lessons that they had brought with them they pressed for expanded clinical trials, compassionate access to new drugs and greater government funding. The movement used tactics such as engaging in legal action, support to new research, creative media campaigns and influencing the policy process (Brown and Zavestoski, 2004). Twenty years later a new regime of breast cancer had emerged influenced by the efforts of the environmental breast cancer movement. Women had access to user-friendly cancer centres, patient education workshops, support groups, a choice of medical alternatives and a role as part of the health care team that delivered the cancer treatment. Essentially, breast cancer had become politicized and reframed as a feminist issue and an environmental disease.
The involvement in a social movement can result in marked differences in capacity between members and non-members. For example, for those living with HIV/AIDS, members of movements had better coping skills and preferences, knowledge of HIV-treatment and social network integration. The involvement in a movement had helped people to enhance their ability as individuals to make informed choices about personal health care and different treatment regimes (Brashers et al., 2002).
Social movements are important because they provide the opportunity for individuals to have greater influence by engaging in a broader participant and resource base. This allows people to engage in social interaction and political action through collective tactics such as lobbying, protesting, demonstrating and petitioning to influence government policy.
KEY TEXTS
•Brown, P. and Zavestoski, S. (2004) ‘Social Movements in Health: An Introduction’, Sociology of Health and Illness, 26 (6): pp. 679–694
•Staggenborg, S. (2010) Social Movements (Oxford: Oxford University Press)
•Tilly, C. and Lesley, J. (2012) Social Movements, 1768–2012 (Boulder, CO: Paradigm Press)