The Social Selection Perspective Health And Social Care Essay


A conceptual frame work is defined as a plan developed to explain the relation between two things; the problem and the underlying factor (Wolfson, 1994).

In other words, it is an introductory stage for a problem under study. In this age, health is viewed as a social factor which needs more social justice and not only as a physical phenomenon (Marmot, 2005).

Social background has a great impact on one’s health. Life expectancy for people in rich countries is very different from the life expectancy in poor countries. In addition, even within the same country, access to health services can be different, depending on the social class of the people concerned.

Health Equity, Health Inequalities and Health Inequity

Health equity is creating equal opportunities for all to have a healthy life regardless of ethnicity, religion, socio-economic status and anything that stands as a barrier to health. This is a major task that the public health sector needs to handle if public health is to be improved. Health inequalities, also known as health disparity, refer to the variations in health outcomes across a population, and are an indicator for assessing health equity and inequities. Health inequity is the difference in health status that arises from social injustice and unfairness. Discrimination is one factor that has a big effect on health inequities.

A grounded understanding of these concepts would enable strategic approaches that will reduce the impacts of health disparities and increase health equity thereby improving the population’s health. (Laura. K et al . 2008)

This essay aims to critically evaluate different approaches that have been adopted to create changes in the health of people, communities and organisations, in order to address the health inequity problem. This report will start from the WHO Report on CSDH, which will be reviewed, and then other approaches will be assessed regarding their effectiveness in reducing health inequities. Finally, we will compare these models with the WHO report.

Social determinants of health can be defined as any social or economic situation that can interfere with the individual or the community’s health (CSDH, 2008). There are certain aspects that highlight a person’s present health situation. Some of these factors are biology, health behaviour, psychology, and finally the social aspect.

Five major determinants of population health

Figure 1. Estimates of how each of the five major determinants influence population health. Tarlov, A.R.,(1999)

The first step toward achieving health equity can be achieved by focusing on the social determinants of health. In 2005, the WHO developed a frame work on social determinants of health, and the final report was published in 2008. The WHO report reviewed many models and theories, and finally three areas were selected.

The first model is the psychosocial model. This approach originates from a study done by Cassel. In the study it was noted that stress causes the neuro-endocrine system to be more susceptible to diseases, resulting in poor health (Jone and Cassel, 1976). This proves that people’s negative impressions about their personal lives are reflected in their health. The second model is the social construction of disease and a political economy of health. The consequences of low income, due to the lack of resources of the person concerned or the lack of funds for general communication are defined as structural reasons of health inequity (Kaplan, 1996).The third approach is the eco-social, in which Krieger developed new thinking relating the biological with the social in the determination of health (Krieger, 2005).

All models agree that social position is the essential determinant of health. Therefore, these three perspectives view social factors as the most important aspects in determining a population’s health (West, 1991).

The Social Selection Perspective

The basis of this perspective is that the lack of health of unhealthy individuals has a detrimental effect on the skills, and therefore on the achievements of the lower social classes. On the other hand, those who are healthy can achieve social mobility, and move up the social scale. This shows that people’s health determines where they are placed on the social scale (Illsley, 1955).

Many approaches have been studied in order to determine the effect of health on social grading. Blane and Manor believe that the influence of indirect selection is more than the influence of direct selection. Lifestyle during childhood can be considered as being indirect social selection. Poor lifestyle or social situation at any time during one’s life has a negative impact on one’s social grade and future health status (Illsley, 1955).

The Social Causation Perspective

Social causation is considered to be the leading cause of socioeconomic inequalities in health as shown by research. Usually it has an indirect impact on health with the inclusion of other factors such as behavioural factors and material factors (Link, 1998). Economic adversity or poor quality housing or work situations are aspects of material factors. In this approach, people who are more educated or in a higher social class have a better chance of protecting themselves and adopting a healthy lifestyle (Link, 1998).

In addition, behavioural factors are affected by some cultural practices. For example, smoking in some countries is more common among lower class people, while the opposite is the practice in other places in the world (Olson, et al, 2007).

The Life Course Perspective

Ben-Shlomo and Kuh (2002), mention two models for the life course perspective. The first is the biological programming or the critical periods’ model in which contact time plays an essential role in later life effects, whether it leads to chronic defects or not. Examples of this can be seen in diseases, such as hypertensive or coronary heart diseases. (Kuh and Ben-Shlomo, 1997).The second model is the collection of risk. In this approach, the early life condition has a great impact on the future life. For example, if a child lives in conditions of air pollution, this will affect his adult health condition (William, 2005)

Why the CSDH Framework?

It was necessary to develop a framework to assist in the answering of five important questions:

What is the difference between social determination of health in general and the social determination of inequities in health?

How do the social determinations of health lead to inequities in health, and how do they connect to each other?

How do we evaluate which SDH are the most important to address?

How do we determine specific intervention plans and strategies?

The Commission on Social Determinants of Health (CSDH), (2008).

There are two types of power; one is "the power to" which can be reached when the willing action creates change. The second is "the power over", when the authorized people decide or force other people’s behaviour.

Any decrease in health equity needs a more equal sharing of the power to and the power over to assist in the development of the lower class. The deprived communities and those in power should work together politically to bring about action on the social determinants of health. (McCarthy, 1994). According to Hannah Arendt, in order for the power to be lasting and visible, it should be group power.

The Application of the Diderichsen Model to the CSDH

In the Diderichsen Model, social location plays an important role in the process of health inequity. The process works in different methods of classifying health impacts. Firstly, the social contexts which allocate people to different social grades by developing social classification. Secondly, the social stratification whereby the state of people’s health and their access to material resources develop a degree of difference in exposure to health risk.

Finally, there is a different influence on the present and future health condition of the vulnerable group (Evans, 2001)

The Final Form of the CSDH Conceptual Frame work

This frame work focuses on the socio-economic and political context and also the structural determinants of health inequity. This framework provides answers to the origin of health inequities. It comes from the structural determinants and contexts which comprise the social determinants of health inequities.

Firstly, contexts mean all the social and political processes that produce, arrange and maintain social hierarchies. Examples of these contexts are the traditional, cultural, political process and the labour market. The welfare state is the most essential contextual factor in maintaining social hierarchies. There is about a 20% infant mortality rate difference between countries related to the presence or absence of the welfare system in a country. Also there is a 10% difference in birth weight among countries, which is explained by the same reason.

The structural determinant factors are:

1. Income:

Income has an effect on health in different aspects. It assists in better access to the health services, in buying good quality food, increases self-esteem and confidence, and finally better health choices, which later on in life affect health status (Krieger, et al, 1997).


Many studies support the role of education in improving the health state of the person.

Education has a great effect on determining income. It provides better access to health education programs and screening tests, such as breast cancer screen tests. In addition, it secures well organized and high standard medical care (Bartel and Ann, 1987).

3. Gender:

Being a woman or a girl in many countries is associated with discrimination. Cultures in different societies encourage the unfair treatment of women through early forced marriage or female genital mutilation (Foster, 1999)

4. Social class:

The social class of a person has a great impact on his or her health and rights. It explains why some people have to make big efforts for less payment, especially in the case of manual workers, where the manager works less and gets more money (Muntaner, et al, 1999)

5. Race: This is a social phenomenon and not a biological phenomenon. It refers to a group of people sharing the same family ancestral, skin colour and culture. Different races have different social positions. For example in the USA, black Americans have a lower life expectancy than white people (UNDP, 2005).

6. Occupation:

People can be classified into four categories depending on their occupation. Labourers with wages, petty bourgeois (self-employed), small employers, which means the person has 2 to 9 employees, and capitalists, those with a larger business with more than ten employees. Occupation can affect health in different ways, as it controls income. Also it can be related to toxic risks in some occupations. It also affects better health care. Finally, it can cause stress in some occupations (Marmot, et al, 1995). In addition, structural determinants can be controlled by other factors such as the intermediary social element.

Some of these categories are the material situation. This includes housing, which has a great impact on health. Galobard and other researchers identify many issues in housing. These issues were neglected before, such as heating, the location of the bathroom and the availability of clean water (Graham, 2004).

The Psychosocial Condition:

Stress is a leading cause of many diseases. There are different forms of stress .The person in a social position can create stress. Stress can come from work or debt .According to Wilkinson, The differences in the economic state create differences in the social class. As a result, people suffer from low self-esteem and stress. All the above feelings have a negative effect on the general health of the population (Wilkinson, 1996)

Behavioural and biological factors

The kinds of lifestyles people adopt create differences in their health and this falls under behavioural factors. Genetic factors, sex and age are included in the biological factors. Each of these factors affects health through different mechanisms. In the case of those consuming fatty diets, it will cause atherosclerosis, and put the person in risk of developing myocardial infarction. On the other hand, stress will lead to disruptions in the hormonal systems, which predispose the individual to the risk of developing high blood pressure (Marmot and Rose, 1978).

The health system, as an intermediary determinant of health

The CSDH framework was different from other frameworks in considering the health system as an intermediary factor. The health system has an important role to play in assessing the impact of the illness on how people live, preventing the deterioration of the social class due to their health state, and motivating people with chronic illness to work.

According to Benzeval, Judge and Whitehead, the health system impacts in three main ways in the reduction of the inequity gap. The summary of it is that health services are meant to enable equal allocation of resources and effective response, depending on the need of the areas and the social group, whilst also creating a platform for strategic and effective interventions and policies at all national levels (Wilkinson, 1996)

Social cohesion / social capital

The concept of social capital and cohesion occupy an important position in explaining the SDH. Three approaches illustrate the social capital concept; communitarian approaches, network approaches and resource distribution approaches. In the communitarian approach social capital is viewed as a psychosocial mechanism, defined by Putnam (2000) as,

" features of social organization, such as networks, norms and social trust, that facilitate coordination and cooperation for mutual benefit."

Social capital is related to both the structural and intermediary factors. The social capital approach considers the function of the state in promoting health.( Ferguson, K. 2006).

The recommendation of the WHO report

As a result of social diversity and its effect on the health system, the WHO

recommended the policy action to fight inequities in health care due to social diversity in three ways

.1-Developing programmes focusing on the disadvantages in the community.

2-Narrowing the gap between the different social classes.

3-Addressing care to all the population.(Braveman P.1998).

The policy frame work from Stronks et al. and Diderichsen can assist the policymaker to highlight the level of intervention which is required and the starting point for the action.

Among the approaches of the policy action recommended by the CSDH three were highlighted.

1-Particular mechanism in tackling the structural and intermediary determinants (Context).

2- Intersectoral action

3- Social participation and empowerment.

The most important lesson learned from CSDH is that there should be consideration given to the structural determinants and programmes to tackle it, which should be developed .and not only focus on the intermediary determinants.

In order to face the structural and intermediary determinants intersectoral policy approaches are needed, which aim to protect the low and disadvantaged group and decrease the inequities. (Solar and Irwin, 2010, p. 8).

Other approaches reduce health inequity

Other public and private institutions and scholars recommend different approaches to reduce inequities in health and wellbeing.

Other approaches which complement the CSDH framework include social movement, targeting disadvantaged and vulnerable populations, a self-care or lifestyle approach, community-based health insurance, and the concept of healthy lifespan

Social movement

Social movement play an important role in addressing health inequities through increasing the awareness about social issues and unfair distribution of material resources.

The approach started during the Industrial Revolution. It aims to prevent the development of critical illness, change health care policy and lessen or remove inequalities in health and wellbeing. Moreover, social movement encourages public action through actively encouraging organizational changes to target disadvantaged populations. (English, 2012, p. 18; Raphael, 2009, p. 374).

Whitehead and Dahlgren

Mention three models in reducing health inequity. Targeting the poor people only,

This approach focus mostly on targeting the disadvantaged population. So the poor people can assess the service as a result this will narrow the gap.

Lifestyle approach

Health Promotion

Health promotion is defined as the art and science of assisting people to fight for the best possible health by directing them to obtain a healthy life style. This means that they can reach their optimal health in respect of their complete physical, social, emotional and spiritual wellbeing, and not just the absence of disease or deformity (Michael 2009)

Both public health and health promotion can help individuals, families and the whole community in improving their health by decreasing the risk of diseases and helping to cope with chronic illnesses. For those programmes to succeed, people need to consider and select their health behaviour in the light of their background and environment.

In this connection, there were two types of theory proposed. In the explanatory theory, the focus is on the nature of the problem and the possible solution. The other theory is the action theory or the change theory. In this theory, the focus is the development of the plan or the intervention.

The health promotion theory originates from either the behavioural or the social sciences. But good knowledge in the epidemiology and physical sciences are required for the application.

Many psychosocial theories are proposed to help in changing health behaviour. This theory can be classified into two categories: social cognition models and stage models. The cognition models are divided into a group of theories explaining the beliefs and attitudes. Some of these theories are,

1. Social Cognition Models

This model is considered as being the root for health behaviour intervention. Behaviour is affected by many factors. some of which are social, cultural and personality elements. The model assumption is that there is a continuous relation between the population and their environment. The model gives the alternative response and reaction. People can learn from others actions and not only from their own experience.

This is an example of the circumstances in which the theory can be applied. A first time mother who is interested in breast feeding but has just started working. If a group is established, they can persuade the manager to provide a room with a refrigerator. This can solve the problem. At the same time, her self esteem and confidence that she can work will increase. Bandura, A, (1986).

The Health Belief Model

In 1974, social psychologist researchers developed this model. The group was assessing the reasons for people not using vaccinations and screen facilities. It worked from four centres, two related to action, while the other two were related to a particular disease. Perceived susceptibility, perceived severity, perceived benefits, and perceived barriers were all noted. For example some people believe that you can get high blood pressure even if you are a symptomatic.( Perceived Susceptibility )

Hypertension can contribute to complications such as stroke and heart attack. (Perceived Severity).

The treatment reduced the risk and prevented complications.( Perceived Benefits)

In some cases, the side effect from the treatment can be developed.(perceived barriers)

Physical and environmental situation can encourage people to take acton.( Cues to Action)

Different demographic, sociopsychological, structural variables that interfere health related behaviour by effecting the person perception. (Other Variables)

The belief that successfully carrying out the behaviour leads to the desired outcomes.( Self-Efficacy).

Implications for Health Belief Model

This model is the best one to select .When the focus is on behaviour motivation, the model convinces the public in making healthy decisions.

The HBM can be used for social and economic conditions .For example, to increase the self esteem after weight loss, or to save money by stopping smoking, or in order to reach better health education on sexual risk behaviour.

Limitations for Health Belief Model

The model as a psychological model neglects the other environmental and financial factors that affect behaviour. It does not consider the impact of the social norms and peer pressure on the mechanism of the decision taken, especially in HIV patient conditions.( M H Becker Ed, 1974).

The Protection Motivation Theory

The Protection Motivation Theory was developed by Rogers in 1975 to explain the panic appeal and the way people deal with it. In 1983, Roger expanded the theory. Before Roger, Richard Lazarus, who was interested in assessing people’s reaction to stressful situations, created the basis of the theory, and mentioned that people have different feelings and vulnerability. The theory was used when evaluating people’s reactions to different health issues. Also it was used in discussing their different responses to the subject (Maddux, and Rogers, 1983).

The Protection Motivation Theory proposes that the intention to protect a person depends upon four factors:

1) The perceived severity of a threatened event

2) The perceived probability of the occurrence, or vulnerability

3) The efficacy of the recommended preventive behavior

4) The perceived self-efficacy

1-The theory has been used as a framework in decreasing alcohol consumption. (Stainback & Rogers, 1983)

2-The theory has been used to encourage the adaptation of healthy life styles and exercise. (Stanley & Maddux, 1986),

3-The theory has increased the awareness, and therefore the prevention of sexual transmitted diseases. (Van der Velde & Van der Pligt, 1991).

The Theory of Reasoned Action/Planned Behavior

It is representing of social-psychological approach to explain and assuming the determinants of health-behavior. In this theory the behavior is affected by intention.

Where the intention is affected by three variables

Subjective norms, attitudes, and self-efficacy.

The subjective norms engage the personal belief of the other assumption on his or her ability to perform the behavior.Example of that whether or not somebody is intention to cut down the sweet in his diet. What her kids opinion if she cut down the sweet could determent her behavior.In TRA two kinds of behavior consider .The behavioural belief and the normative belief. Bandura, A., (1986).

From the (TRA) the person performs in reducing the risk behavior related to his belief. The level in which healthy behavior reduce the risk.

The implication of the TRA

The theory widely used in diverse health-related behaviors like weight lost, HIV risk behavior and alcohol consumption.

Community engagement

Recently, great effort has been put into engaging the community in improving public health through the community engagement programme. Future prevention intervention depends on communities. They will take the lead in assessing their requirements and priorities.

The model widely used in campaigning for many health issues.

The programme encourages the public to adopt healthy life styles.

Community engagement can be defined as the mechanism of working cooperation

This is possible with a group of people who are joined by their location, their interest in the subject or their common experience of the same situation, to enable them to face issues affecting their well-being" (CDC, 1997, p.9)

Effective community engagement can be reached by arranging some activities and programmes identifying different aspects of the community issues, such as needs, resources and strengths. The result should then reflect the community view and expectations.

The cycle of engagement

Principle one: a clear statement about the reason and aim of the engagement.

Principle two: full knowledge about the related community.

Principle three: building relationships with the community in general.

Principle four: respect for community self determination.

Principle five: developing change with the assistance of the community.

Principle six: Considering the community diversity.

Principle seven: Creating sources to decide and act on the community’s health.

Principle eight: Allowing control intervention into the community, being ready for changes.

Principle nine: documenting the long term activities.


Human behaviour changes play an important role in preventing and maintaining a state of health. In addition, they assist in reducing the morbidity and mortality rate combined with health associated behaviour. The health behaviour change model was developed in order to assist people in coping with chronic illness, to motivate healthy life style adaptations and reduce health risk behaviour such as smoking.

But the health behaviour model itself can fail in many aspects. Firstly the participants must choose the project, which they probably will not. That will lead to a narrowing of the intervention and the real underlying cause of the problem not being addressed. Always there is a risk of increasing the health inequality because of neglecting the dignity of the participants.

On the other hand, the World Health Organisation report on the social determination of health had great value .The report critically highlighted important causes of health inequalities. It also suggested practical intervention to tackle the inequalities. (WHO, 2006).

Some factors like the education, gender, income and the health system itself are among the social determinants of health locally and internationally. The environmental and social factors are the basic determinants. The government and the entire community sector should share the goal. In holding up

Countries need to change their health polices through developing effective medical base models and intervention. The greatest effort is needed to take and transform public knowledge into political action.( Marmot, 2005)