Maria Minerva P. Calimag
Sep 2017 DOI 10.35460/2546-1621.2017-0033
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.")
-Constitution of the World Health Organization
The terms "health inequities," "health disparities," and "health inequalities" reflect the magnitude of differences in health outcomes existing in populations unless we address the underlying causes of disease and ill health. In the Philippines, Kalusugang Pangkalahatan (KP) or Universal Health Care (UHC) is the health reform agenda of the Aquino administration which has been implemented by the Department of Health (DOH) since 2011. Rather than moving toward a system of universal access to medical care however, the access to and quality of clinical services is being turned over increasingly to the insurance industry leading to the commodification of healthcare. Patients are now “clients” and clinical services are “product lines.” The present administration of President Duterte is implementing the "All for Health, Health for All" agenda. Through community-oriented patient care, advocacy, research, and training the next generation of physicians will strive to improve our nation's state of public health, social justice, and health equality, hence the need to establish a research agenda for discussions in social medicine (1).
A roundtable discussion on the role of researchers in achieving Kalusugang Pangkalahatan (KP) or Universal Healthcare, conducted during the 7th Philippine National Health Research System (PNHRS) Week on August 7, 2013 at Laoag City, showed that although most of the participants are familiar on KP, a good number are still unaware of what it is about and what it hopes to achieve.
Health is a complex phenomenon, and can be approached from many angles. Over recent decades, international health agendas have tended to oscillate between two poles of a spectrum: i.e., approaches that focus on the curative and rehabilitative dimensions of health that rely on technology-based medical health interventions, and approaches that emphasize the preventive and promotive dimensions of health and public health interventions that requires an understanding of health as a social phenomenon linked to a broader social justice agenda. The systematic study of social medicine that looks at the relationships between society, disease, and medicine and the forms of medical practice derived from it began in earnest in the early nineteenth century. Researches focused on a social model of health, later revived by the 1978 Alma-Ata Declaration on Primary Health Care (2) and the ensuing Health for All Movement, which reasserted the need to strengthen health equity by addressing social conditions through intersectoral policy and programs.
Social medicine emphasizes the way social theory can be used to analyze urgent issues in contemporary health. Over time, the term “social medicine” took on a kaleidoscope of meanings as it is adapted by different societies of diverse culture and contingent on existing social conditions. Nonetheless, certain common principles underlie the term (3) i.e.,
1. social and economic conditions profoundly affect health, disease and the practice of medicine;
2. population health is a matter of social concern; and
3. promotion of health in society should be through both individual and social means.
Prior literature investigating the relationship of social support, health literacy, and health care demand is scarce, and little research has been done into the determinants of individuals' health care utilization. Traditionally, medical anthropologists have displayed an interest in the role of socio-cultural factors in health and illness. In the setting of a globalizing world however, physicians in the field must be equipped with the knowledge to interact with individuals of different cultural and social backgrounds. They should be able to extensively examine how illness is conceptualized in various culture. Cross-cultural work can help researchers test their theories and assumptions in different cultural environments, a much-needed skill in a globalizing world. As culture plays an important role in the social determinants of health, there is a need to distinctly characterize the Filipino patients' context in order to address critical issues in the prevention and treatment of disease and poor health, as well as social, economic, and cultural factors in the delivery of health services that impact on health outcomes in the Philippines.
The Commission on Social Determinants of Health (CSDH) of the World Health Organization has purposely adopted a broad initial definition of the social determinants of health (SDH) that encompasses the full set of social characteristics within which living takes place...the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life (4). The United States Centers for Disease Control defines social determinants of health as "life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life".
Traditionally, the preclinical medical curriculum has left huge gaps in medically relevant, but “unscientific,” topics. Specifically, social factors such as economics, politics, race, and other issues related to healthcare disparities are often minimally addressed. Social medicine as a research agenda will focus on current issues in medical ethics, health literacy, health economics, health policy and various other topics dealing with health and disease from a socio-economic perspective.
Research themes and topics will include:
1. Health issues related to different age groups include: infants and children (the politics of abortion, bonding and latch-on at birth, cerebral palsy, malnutrition, violence at home, cancer in children, etc.); adolescents (teenage pregnancy, cyber addiction, drug addiction, etc.); elderly (polypharmacy, Alzheimer's disease, coping behaviors to declining health, elderly neglect and abuse, etc.);
2. Health issues related to culture/ethnic/special groups: health literacy among different ethnic groups; health-related practices among different ethnic groups, ethnopharmacologic practices in different areas of the Philippines, race/ethnicity and unequal treatment, healthcare for people with disabilities, coping issues among cancer patients and their families;
3. Health issues related to people in special areas: industrial health, correctional health, seafarer health, migration health, health issues among Business Process Outsourcing (BPO) personnel, health among informal settlers, health among patients in drug rehabilitation centers, health among patients in mental health institutions;
4. Gender and sex-related health issues: cancer in women, transgender diseases, HIV;
5. Health system related issues: the practice of social medicine in the Philippines, the impact of Philippine Health Insurance (PHILHEALTH) policies in the delivery of healthcare, health literacy of Filipinos, community-based alternative health clinics, the ethics of stem cell research, legalizing marijuana and drug policy formulation in the Philippines, laws that impact on health, i.e., deaths related to gun violence, motorcycle-related health issues, the impact of social media in health, etc.;
6. Lifestyle-related health issues: diabetes, hypertension, obesity, etc;
7. Health issues related to environmental and climate change: medical waste disposal, health effects of pollution, health impact of mining, road accidents, etc.
Moreover, many public health community advocates (5) have since challenged the overzealous reliance on randomized controlled trials (RCTs) in research (6). The RCTs’ strict inclusion and exclusion criteria, well-controlled, and narrow interventions, such as in comparing a new drug or procedure against a standard drug or procedure, is clearly limited by the non-generalizability of research data. Increasingly, however, public health interventions, which are at the core of studies in social medicine acknowledge the multifactorial and multifaceted spectrum of many health interventions and outcomes, and thus the need for more sophisticated, multidimensional, community-based designs. Moreover, RCTs have limited capacity to assess such comprehensive aspects of quality (7) as well as performance measurement.(8)
Developing theory-informed implementation interventions based on robust theoretical frameworks (9), such as the Theory of Change (10) and Syndemic Theory (11); the use of anthropological and sociological tools for data collection (Delphi technique, focus group dynamics, semi-structured interviews) to hybrid models combining several traditional approaches; and varied mixed-model analysis such as Q Methodology, conjoint analysis, structural equation modeling and social network analysis, are necessary if we are to understand the effectiveness of complex community interventions.
Client participation that highlights the values of trust and choices of patients, families and even of communities, are critical prerequisites for successful program design and evaluation when viewed from the population perspective. Such patient-centered approaches, however, is inconsistent with the “randomized and blinded” methodology of RCTs. Community interventions require research designs commensurate with their complexity. The article in this maiden issue of the JMUST, entitled, “Patient perception of medical student engagement in community-based outreach activities during Community Health Clerkship: a Q-methodology study” by Calimag and Calimag, utilizing Q-methodology, a mixed-methods study design best illustrates this point.
Finally, a broad initial definition of social determinants of health is important in order that multiple and varied avenues of investigation may be foreshadowed. Embracing the concept of SDH, whereby not all factors have equal importance, requires an understanding of the causal hierarchies that encompasses the field. Much of the researches that will be undertaken under this Research Interest Group (RIG) should be concerned with clarifying these crucial distinctions and making explicit the relationships between the underlying determinants of population-based health inequities and the more immediate determinants of individual health.
- Anderson M, Smith L, Sidel VW. What is social medicine? Mon Rev. 56(8):27–34.
- World Health Organization. Declaration of Alma-Ata, Alma-Ata, USSR [Internet]. International Conference on Primary Health Care 6-12 September 1978. 1978 [cited 2017 Feb 12]. Available from: http://www.who.int.
- Social Medicine Portal [Internet]. [cited 2017 Feb 12]. Available from: http://www.socialmedicine.org/students.html
- Fisher J. A Framework for Educating Health Professionals to Address the Social Determinants of Health. [Internet]. Institute of Medicine. 2016 [cited 2017 Feb 12]. Available from: http://whoeducationguidelines.org
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