HIV in Canada: A primer for service providers

The Social Determinants of Health and Structural Interventions

Key Points

  • The social determinants of health are the range of social, economic and environmental factors that determine the health status of individuals or populations.
  • Social determinants of health play a role in HIV infection and the ability of people with HIV to seek treatment, care and support.
  • Structural approaches to HIV prevention seek to change the social, economic, political and environmental factors that have an impact on resilience and vulnerability to HIV.
  • Structural interventions should be part of a comprehensive prevention package.

The determinants of health are the range of social, economic and environmental factors that determine the health status of individuals or populations. The determinants of health as defined by the Public Health Agency of Canada include the following: income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender and culture.

Many factors in our society, including poverty, physical and sexual abuse, lack of education, homelessness, stigma, addiction, violence, untreated mental health problems, lack of employment opportunities, powerlessness, lack of choice, lack of legal resident status and lack of social support, play a role in HIV infection and the ability of people living with HIV to seek treatment, care and support. For example, poverty can lead to powerlessness in relationships and can have a negative impact on one’s self-esteem and sense of belonging in the community. All of this can have an impact on one’s judgement or can reduce one’s ability to protect oneself from HIV.

The understanding that physical, social, cultural, organizational, community, economic, legal and policy factors within our environments can impede or facilitate HIV prevention efforts has led to an interest in structural approaches to HIV prevention. Structural interventions seek to change the context that contributes to an individual’s resilience, vulnerability and risk. They include policies or programs that aim to change the conditions in which people live or community responses that bring about social or political change. These approaches address factors that affect the individual’s behaviour, in contrast with behavioural approaches, which attempt to change the behaviour. Structural approaches to HIV prevention must be complemented by other prevention programming, including interventions to influence individual behaviour, to achieve an effective and continued reduction in HIV risk and vulnerability.

Examples of structural HIV prevention initiatives include the following:

  • creation of a policy and legal environment that allows for needle exchange programs and safer consumption sites
  • implementation of anti-stigma measures that reduce discrimination against people with HIV and vulnerable groups
  • implementation of gender equality initiatives, including programs to enhance women’s education and economic independence and laws to combat sexual violence
  • implementation of stable housing initiatives for injection drug users
  • encouragement and funding for the active involvement of affected communities in developing and promoting HIV prevention interventions

Before structural interventions are implemented in a particular community, the social, economic, political and environmental facilitators and barriers to HIV risk within that context must be analyzed. Existing programs that have been successful elsewhere should then be reviewed for possible adaptation and adoption in the community of interest.

Many structural features that affect HIV vulnerability are difficult to change because they are deeply entrenched in the social, economic and political fabric of society; therefore, addressing these factors is viewed as a long-term initiative within broader economic and social development. Challenges in assessing the effectiveness of structural interventions have meant that limited evidence has been gathered on the effectiveness of structural approaches to HIV prevention. Most structural interventions involve large-scale elements that cannot be easily controlled by experimental or quasi-experimental research designs. There is a need for new research strategies to assess the impact of these interventions to create a foundation of knowledge on structural interventions.

Resources

What are the Social Determinants of Health? – National Collaborating Centres for Public Health

Social Determinants of Health: The Canadian  facts

Sources

  1. Leading together: Canada takes action on HIV/AIDS. 2013. Available from: http://www.leadingtogether.ca/
  2. Gupta GR, Parkhurst JO, Ogden JA, et al. Structural approaches to HIV prevention. The Lancet. 2008;372(9640):764–75.
  3. Public Health Agency of Canada [PHAC]. What determines health? Ottawa: PHAC; 2003. Available from: http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php