www.mdm-scd.org

> The socio-cultural determinants of access to healthcare are:

• Representations of disease, the body and treatments. Popular beliefs about health, religious principles (banned foods, sexual interdictions...), etc.
• The language: the words used to speak of disease, the understanding of messages and their reinterpretation, and the introduction of new words that cannot be translated (e.g. asepsis)
• Society, groups and family members around the sick person: these figures play key roles in the healthcare pathways
• Competition in the offer of healthcare: medical pluralism
• The kinds of relationship between healthcare provider and patient
• New economic, social and political challenges generated by the projects.

Some examples of how Socio-Cultural Determinants can determine access to healthcare or impact on our programmes

Socio-cultural determinants of health are very diverse. These determinants have a cultural dimension in the representations of disease, the body and treatments. Some child health prevention messages take stands on “prohibited” foods: in some West African countries, for example, a pregnant woman is advised not to eat red meat to avoid a haemorrhage at birth, nor should she eat bananas to avoid “a soft baby”.  Similarly, in a Latin American programme, prescribed antibiotics were rarely taken because the medication, in killing the germs, locked the spirit of the disease inside the body. Familiarity with these disease representations has helped healthcare providers adapt their language whilst prescribing such treatments, thereby rendering the medicines acceptable.

The issue of language is obviously an important cultural determinant for access to healthcare. How many dialects can offer a translation for “asepsis”? Healthcare providers and patients are confronted every day with problems with the spoken word. Even if they use the same language, they may not have the same understanding of the words being used: for a healthcare provider, what does “I hurt on the outside but not on the inside” mean?

In addition to language issues, the quality of communication, the ability to listen and attitudes towards people, or the provider/patient relationship, is fundamental to the care process. This relationship doubtless influences the provider’s confidence and sense of efficiency.  A lack of knowledge concerning the perceptions of and wariness about therapeutic decisions (which can be totally rational from the point of view of the population under consideration) can create problems between the healthcare provider and the patient: a sick person only takes his treatment once a day instead of the three times prescribed because the doctor is unaware of the patient’s precarious living conditions and recommends that the medication be taken with meals. Another example: some women fear an obstetrical ultrasound scan as they believe it exposes their child to the evil eye.

These determinants to access to healthcare have a social dimension that is equally important. The outcome of therapeutic decisions is swayed by the patient’s individual motivation and resistance, but also family or social influences: a young mother will not change the diet of her child if it involves going against the edicts of her mother or mother-in-law. Even where elders do not directly oppose new ideas, certain courses of action may evoke fears of marginalisation: “what will my mother think if I take the free condom on offer?”  In society, some diseases are dealt with alone (STDs), others require joint action (fertility problems). Some diseases only require treatment; others are more stigmatising and risk exposing the patient’s identity.

Healthcare pathways

The representation of a disease and its causes influence the kind of health services used. Disease attributed to supernatural factors (convulsions, delirium, madness), the transgression of a taboo or a curse (sterility, abortion, breast cancer) are treated with traditional medicine.  How effective is modern medicine in appeasing the wrath of the spirits or refocusing vital energies?  How surprised should we be when a brand new health centre is under-utilised since it cannot respond to the population’s expectations?  The teams working in Haiti realised that the Hougan, the traditional healer, is an essential intermediary in their project. Indeed, it is he who determines if the patient’s disease is due to natural or spiritual causes. It is therefore he who directs the patient to one health system or another. Refusing to acknowledge his role means we cannot offer the best care.

Because health and social determinants, health and cultural determinants, health and sociocultural determinants, health and socio-cultural determinants, social determinants of health within cultural determinants of health, social determinants of access to healthcare, cultural determinants of access to healthcare, social determinants of access to care, cultural determinants of access to care, social determinants of access to health, cultural determinants of access to health are important Medecins du Monde (MDM, Doctors of the World) has launched the project "Sociocultural determinants and Access to Healthcare" that combines "social determinants and access to healthcare" and "cultural determinants and access to healthcare."

Model grid to question the local sociocultural environment (general questions to make a survey)