Introduction The World Health Organization defines health as “a stateof complete physical, mental and social well-being and not merely the absenceof disease or infirmity” (WHO, 2006). Social determinants of health are shapedby access to health and social care services, the quality of these services,socio-economic status, education, social environmental conditions, and culture(Bambra et al., 2010; Graham, 2007). These determinants of health overlap overtime and structure health by social status creating health inequalities (Pegaet al., 2017).
Health inequalities result in behaviours that reflect individualswith different social positions are able to use their resources and handle theconditions they live in (Lundberg et al., 2015). Culture is a social determinant of health that impacts anindividual’s beliefs, behaviours, perceptions, diet, and attitudes towardspain, illness, and adversity. These aspects influence how people assess,communicate, and treat their health issues. Cultural influences compriseindividual, educational, socio-economic, and environmental that contribute toan individual’s health and health behaviours (Helman, 2007). Socio-economic factors influence health behaviours as theinequalities and differences in social and educational opportunities amongindividuals vary. This influence either benefits or limits access to healthservices aiding in prevention or treatment (Santelli et al., 2000).
Helman(2007) discusses that socio-economic factors are a leading cause of poorhealth. Lower socio-economic status may result in inadequate nutrition anddiet, poor living conditions, and a low level of education. Negative outcomesof these factors include higher levels of risk from violence, exposure toenvironmental dangers, and drug and alcohol abuse. Graham (2007) highlightsthat socio-economic factors shape people’s experiences of health risksthroughout the course of their lifetime. Social position inequalitiesinclude economic status and education, ethnicity, gender, and sexualorientation.This paper discusses the socio-cultural impacts on health through examples ofglobal cases of sexual health and the influences of an individual’s socialcontext, social position, and culture on sexual behaviours. SexualHealth Aggleton et al.
(2014) states that sexual health isclosely linked with how people live their lives as communities and asindividuals. WHO (2006) defines sexual health as “a state of physical,emotional, mental, and social well-being in relation to sexuality: it is notmerely the absence of disease…sexual health requires a positive and respectfulapproach to sexuality and sexual relationships, as well as the possibility ofhaving pleasurable and safe sexual experienced, free of coercion,discrimination and violence.” This includes the ability to obtain informationand education about sexual health, the right to communicate sexual desire,sexual satisfaction (Ruiz-Munoz et al., 2013), sexual equality, choice inpartners, sexual activities, and family planning (Metusela et al., 2017). Social position differences in sexual orientation andidentification, ethnicity, and gender can either work as protective factorstowards sexual health or can produce negative sexual health outcomes. Culturalinfluences vary from well-informed, quality health services to sexual stigma,lack of communication, and patriarchal dominated societies (Metusela et al.,2017).
According to Sathyanarayana Rao et al. (2012), the socialdeterminants of sexual health include laws and human rights, education, societyand culture, economics, and health systems. Sathyanarayana Rao et al. (2012)discusses the importance and influence of these factors in India, where sexualattitudes are conservative resulting in negative sexual health outcomes.
Promotingsexual health education in school, work, and community based settings candecrease stigma and increase communication. Cultural implications on sexualhealth discriminating against women and the LGBT communities should practicesexual equity to decrease sexual violence and adverse sexual health outcomes.Recognition of the burden that poverty has on sexual health including poorreproductive health, high-risk behaviours, and lack of service utilization arecrucial to obtaining overall sexual health equity. Health care providers shouldprovide good quality, accessible, and affordable sexual health care withoutdiscrimination. Socio-economicStatus Education provides health literacy,awareness of services, and opportunities in maintaining good health inpopulations. (Gillespie et al., 2007).
Bambra et al. (2010) discusses educationas a platform to acquire optimum health by accumulating prospects of betterjobs to become more financially stable. Economic stability will increase healthby ensuring good living conditions, quality food and nutrition, and socialinvolvement. Gillespie et al. (2007) provided anoverview of a collection of research investigating the relationship between therisk and prevalence of the sexually transmitted infection, HIV andsocio-economic status in different regions of Africa. Results varied withindifferent study objectives and different countries in Africa.
A study analyzingeight countries in Sub-Saharan Africa found that individuals of high and lowsocio-economic status’ have increased risk of HIV. Wealthier individuals wereat risk due to residing in urban areas with high prevalence of HIV, the abilityto commute and mobilize for multiple sexual encounters, and having casualsexual partners, and tend to live longer through quality healthcare. Individualswith higher socio-economic positions have adequate knowledge of HIV, safetymethods, better education, and use contraception which reduces their risk ofinfection. Individuals with lower socio-economic status are at high risk of HIVas they are more susceptible to malnourishment, which can affect the immunesystem and increase the risk of HIV transmission from unsafe sex. Gender An increased socio-economic status can provide foodsecurity and greater living conditions. Poverty is a driving force for highrisk sexual behaviour that increases chances of individuals to acquire HIVinfection. Previous research shows thatsexual health inequality is highest among women with a lower socio-economicstatus (Elliot et al., 2013; Gillespie et al.
, 2007). A study found thatpopulations of women with low socio-economic status in South Africa, Botswana,and Swaziland are more susceptible to participate in high risk sexualbehaviours such as “transactional sex” to obtain food and resources for theirfamilies. Women with low socio-economic status in relationships have aneconomic dependency on their partners creating difficulties in negotiatingsafer and pleasurable sex for themselves (Gillespie et al., 2007). Ruiz-Munoz et al.
(2013) produced results from a studyfocusing on socio-economic factors, genders, and sexual behaviours related tosexual health among a sexually-active sample living in Spain. The studyrevealed that women with lower socio-economic positions are more likely toinvolve alcohol or drugs in sexual experiences. Their sexual behaviours andsexual satisfaction are mainly reflective of pressures from “socialreproduction and gender-based division of work”. Individuals with lowersocio-economic positions tend to suffer more sexual abuse and partake in andunsafe sexual activities. Socio-economic status also moderated the use ofcontraception. Participants with highersocioeconomic status had more control of family planning, access to resources,and greater awareness of their sexual health needs.
Influenceson Youth Research organized by Valle et al. (2005), revealedpatterns in sexual debut in teenagers in Oslo, Norway based on social positionand gender. The increased risks of early sexual debut for sexual health includesexually transmitted infections and teenage pregnancies. In this study socialclass for the teenagers was divided into levels based on their parents’occupation. For example, Social Class I included upper managerial occupations,while Social Class V included manual working class.
Valle et al. (2005) foundthat boys were at higher risk for early sexual debut in Social Class I.Findings among girls reflected traditional social power organisations wherethere was an increased risk for early sexual debut in girls from the manualworking class. These results reflect similar findings in studies with samplesin the UK and USA. Social levels and individual academic self-perceptions ofyouth influenced early sexual debut where teenagers with higher levels ofperceived social-acceptance increased opportunities for early sexualdebut. Research by Elliot et al. (2013) that administered sexualliteracy interventions to teenage students in Glasgow, showed that both maleand female students from lower socioeconomic groups reported having more sexualinteractions and intercourse than students from higher socioeconomic groups.Although these groups were participating in more sex, the results also revealedthat after the intervention, students from lower socioeconomic groups were lessknowledgeable about sexual health.
Interventions that included knowledge andaccess to services were most beneficial in changing behaviour in students withlower socio-economic positions students as they became aware of their resourcesand how to access them.Society and Culture Metusela et al. (2017) states that “sexual andreproductive health is shaped by socio-cultural factors which can act asbarriers to knowledge and influence access to healthcare”. Cultures worldwidedo not offer options of safe, supportive, free, and pleasurable sex for allmembers of their populations (IPPF, 2015). In a study interviewing migrant andrefugee women in Australia and Canada by Metusela et al. (2017), the sample ofwomen whose ethnicities included, Latina, Somali, Sudanese, Afghani, Iraqi,Tamil and Punjabi reported that their socio-cultural status and cultural norms,including stigma and religion, prevented sexual health knowledge and access tohealthcare. Major constraints included inadequate knowledge leading to manymisconceptions, lack of communication, coercive sex, and negative healthoutcomes.
An example from this study includes the cultural lack of opendiscussion about sex and sexual health. Misconceptions and lack of resources aboutsexual health led to risky sexual behaviours such not using contraception andavoiding cervical cancer screenings and HPV vaccinations as they “threatenedvirginity”. Discussion about sex was forbidden and considered “harming yourreligion”, so married women could not negotiate safe sex with their husbands andvirgins would not receive information about sex until their wedding day. Riskysexual behaviours were a results of lack of resources and information as wellas undependable advice from other women. A main cultural theme within thissample of women included avoiding medical services because they did not want toexpose their bodies to strangers. Therefore, concepts of menstruation andmenopause were perceived traditionally with shameful attitudes and inadequateunderstanding of reproductive systems. Education Education increases positive sexual health outcomesthrough knowledge and awareness of obtaining and maintaining good sexual healththrough positive behaviours.
Sexual health education can decrease “stigma anddiscrimination” seen throughout different cultures (Sathyanarayana Rao et al.,2012). Research by Elliott et al.
(2013) administered sexualhealth education to groups of students in Glasgow, where different types ofeducation included sexual health information, skills training, and access tohealth services. Results reflected that although knowledge is important forsexual health, awareness and access to services is beneficial for positive sexualbehaviours. This experiment included topics that students had knowledge ofprior to this experiment including negotiating safe sex, using condoms, andsexual risk of early pregnancy and infections. Conversely, there are populations around the world thatdo not receive such information. In Metusela’s et al.
(2017) study, resultsrevealed that lack of exposure to information of sexual health throughout one’slifecourse due to culture leads to risky sexual behaviour and negative healthoutcomes. Poor sexual health conditions may include forced and non-pleasurablesexual intercourse for at least one partner, infections, limited use ofcontraception, and abortions and unintentional pregnancies. As sexual health education varies among cultures andsocieties, so does acceptance and exposure to homosexuality and sexual healthfor homosexuals. The unequal coverage of information and services are due tohomosexuality being a sexual minority (Operario et al., 2015) In a studyconducted by Roberts et al.
(2004), focus groups were used to understand thesocial and cultural context of sexual health among young people in Mongolia.While many sexual health topics were presented in educational settingsincluding condom demonstrations and sexually transmitted infections, homosexualitywas a subject that teachers did not feel was appropriate to teach in class.Teachers and students believed that homosexuality is a foreign concept andteachers failed to consider that students in their classes may be homosexual.
Gender Metusela’s et al. (2017) study discusses that culturallyprescribed gender roles, in the study’s represented cultures, limit a women’sability to control their sexual and reproductive life and needs. Whileknowledge of contraception may be present, family pressures to bear childrenrestricts women from using it.
Women in these cultures cannot contribute todecisions on family planning and often there are large amounts of pressuretowards having children, especially males. Research by Hall & Tanner (2016) assesses sexualhealth in black women attending university in the USA includes genderinequalities within “college hookup culture”. Hall & Tanner (2016) notethat black women are impacted more by sexual victimization, negative sexualhealth outcomes, and sexual double standards. In a culture where havingnon-serious sexual relationships is commonly practiced, women are more likelyto be discriminated by partaking in these relationships than men. Women alsosuffer higher risk of infection due to the inconsistent use of condoms, and lowrisk perception in these casual sexual relationships. Roberts et al.
(2004) discovered through focus groupsthat there is a division of sexual power between males and females inUlaanbaatar, Mongolia. Participants of the focus groups believe that womenshould not be informed or experienced in sexual matters. Women should alsonever initiate sexual activities but are obliged to accept initiations frommen. This prohibits women from avoiding coercive sex, obtaining condoms, and negotiatingsafe sex.
Mongolian men were explained to “naturally know” about sex and wereshamed for seeking information. This causes men to rely on friends forinformation which may not always be dependable. Unlike women, men gain good reputationsby being sexually experienced. HealthSystems It is important that health care systems arenonjudgmental and provide quality preventative, healing, and knowledgeresources, confidentially to all patients (Sathyanarayana Rao, 2012).
Currently, this does not apply across cultures and many health care systemsdiscriminate based on sexual orientation, and have negative stigma ofdiscussing sexual health (Santos et al., 2017; Metusela et al., 2017; IPPF,2015). Health systems and health professionals cannot be highly successfulunless populations have access to information, positive attitudes and values intheir relationships, supportive communities, and are welcoming to skills andservices (Aggleton et al., 2014). SexualOrientation Sexual health systems typically provide limited sexualhealth resources for the homosexual community (Aggleton et al., 2014).
Santoset al. (2017) discovered, during interviews with Latina women of lesbian, bisexual,and queer (LBQ) communities, that most doctor visits included providinginformation for heterosexual sexual health. Sexual health recommendations fromhealth care providers for this sample was limited and the women often reportedhigh risk sexual behaviour due to the lack of knowledge of safer sex withwomen. One participant stated that a doctor implied that regular screeningswere not necessary because she did not participate in heterosexual sex. Healthservices are more familiar withrisks and treatments associated with homosexual males than homosexual females. Thisstudy highlighted that an accumulation of minority status (gender, ethnic, andsexuality) instigates risky sexual behaviour as discrimination is high andone’s culture, social position, and sexuality do not receive unifiedsupport. Similar findings of inadequate homosexual healthdiscrimination were reflected in a study conducted by Aegnor et al.
(2016),where health services were examined among male and female homosexuals in theUSA. Results included differences in recommendations of screenings andtreatments based on sexual orientation rather than individual patient risk.This may be a result of poor communication between patients and health careproviders, a health care providers lack of training on non-heterosexual sexualhealth, and the perceptions of sexual health risk of the health care providerand the patient. Interventions Aggleton et al. (2014) highlights different healthpromotion strategies focusing on topics associated with intervention success.The examples of health promotion underline that interventions are significantlyshaped by context and cultural beliefs for outcomes and participantexperiences. Approaches and interventions do not acquire the same achievementsacross different countries, as each country, ethnicity, and culture hasdifferent sexual health needs. The paper focused on the topics of changingsexual practices and cultures and innovation in sexuality, education, andservice provision.
Changing sexual practices and cultures refer to creatinginterventions that are appropriate and address problems specific to thatculture. In a study conducted in Malawi (Jaganath et al., 2014, cited inAggleton et al., 2014, p.548), researchers analysed a programme called “This ismy Story” including a 5-week course encouraging community dialogue, empoweringcommunity members living with HIV, increasing community understanding, andbreaking down barriers. Participants reported feedback of this interventionwhere the community was increasingly supportive, there was less stigma aboutthose with HIV, and an understanding that there is a possibility of full lifewith HIV.
Innovation in sexuality, education, and serviceprovisions refers to the importance of a populations social structure andculture when providing sexual health facilities and services. Interventionsshould differ based on values, religious principles, attitudes and presence ofhuman rights, and cultural traditions. A programme administered in a populationin Kenya (Maticka-Tyndale et al., 2014, cited in Aggleton et al., 2014, p.549)involved role modelling, behaviour practice, and interactive interventions forstudents involving safe sexual health. The results of the students’ knowledgeincreased self-value when demonstrating sexual restraint, condom use, andacceptance of people with HIV.
While defining HIV was not discussed in depth,student’s knowledge and behaviour was impacted based on what was relevant tothem. This study was replicated throughout Kenya, and teacher effectivenessincreased as they became more experienced with the programme. An example of astudy conducted in South Africa, aimed to promote healthy sexual experiencesfor all genders (De Palma and Francis, 2014, cited in Aggleton et al., 2014,p.
550). This programme clarified that education should not disempower women insociety and teachers should not continue to include discrimination andstero-typing in lessons. An example including lesbian, gay, bisexual, transgender,and queer (LGBTQ) communities conducted in Canada, focuses on thediscriminations encountered by these sexual minorities (Knight et al., 2014,Aggleton et al.
, 2014, p. 550). Clinicial experiences and services areintensifying health inequalities, as social and cultural norms reinforce the assumptionof an entirely heterosexual community. Health is described as an outcome and a determinant ofpeople’s social position and social conditions. Health increases in individualswith favourable social positions and declines with individuals withdisadvantaged social positions. The determinants of health and inequalitieswithin socio-economic status, ethnicity, gender, and sexual orientation worktogether to regulate health and sexual health similarly. This paper uses sexualhealth and sexual behaviour as an illustrative example of how social context,social position, and culture can influence an individual’s health. Sexualhealth is an interlinking health issues that connects to most health matterspeople experience.
Organizations and researchers aim to extend sexual healthamong greater populations through education, cultural perspectives, behaviours,and interventions. Health promotion and changes in behaviour are significantcomponents to achieving positive sexual health outcomes; however, reducingpoverty can also help close the health inequality gap. Cultural shifts towardpositive perceptions of minorities are capable of restraining discriminationand lowering inequalities for all health needs. Cultural encouragement in policy, human rights, public healthdevelopments, and educational systems supporting positive sexual health arerequired for successful and global change. The global examples providedestablish that sexual health needs are not generalizable across all culturesand societies.
Inequalities of social position across cultures requireappropriate and specific alterations, values, and services to achieve globalhealth.