The Socioeconomic Factors and Determinants of Global Sexual Health

Introduction

The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2006). Social determinants of health are shaped by 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 over time and structure health by social status creating health inequalities (Pega et al., 2017). Health inequalities result in behaviours that reflect individuals with different social positions are able to use their resources and handle the conditions they live in (Lundberg et al., 2015).

Culture is a social determinant of health that impacts an individual’s beliefs, behaviours, perceptions, diet, and attitudes towards pain, illness, and adversity. These aspects influence how people assess, communicate, and treat their health issues. Cultural influences comprise individual, educational, socio-economic, and environmental that contribute to an individual’s health and health behaviours (Helman, 2007).

Socio-economic factors influence health behaviours as the inequalities and differences in social and educational opportunities among individuals vary. This influence either benefits or limits access to health services aiding in prevention or treatment (Santelli et al., 2000). Helman (2007) discusses that socio-economic factors are a leading cause of poor health. Lower socio-economic status may result in inadequate nutrition and diet, poor living conditions, and a low level of education. Negative outcomes of these factors include higher levels of risk from violence, exposure to environmental dangers, and drug and alcohol abuse. Graham (2007) highlights that socio-economic factors shape people’s experiences of health risks throughout the course of their lifetime. Social position inequalities include economic status and education, ethnicity, gender, and sexual orientation. This paper discusses the socio-cultural impacts on health through examples of global cases of sexual health and the influences of an individual’s social context, social position, and culture on sexual behaviours.

Sexual Health

Aggleton et al. (2014) states that sexual health is closely linked with how people live their lives as communities and as individuals. WHO (2006) defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality: it is not merely the absence of disease…sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experienced, free of coercion, discrimination and violence.” This includes the ability to obtain information and education about sexual health, the right to communicate sexual desire, sexual satisfaction (Ruiz-Munoz et al., 2013), sexual equality, choice in partners, sexual activities, and family planning (Metusela et al., 2017).

Social position differences in sexual orientation and identification, ethnicity, and gender can either work as protective factors towards sexual health or can produce negative sexual health outcomes. Cultural influences 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 social determinants of sexual health include laws and human rights, education, society and culture, economics, and health systems. Sathyanarayana Rao et al. (2012) discusses the importance and influence of these factors in India, where sexual attitudes are conservative resulting in negative sexual health outcomes. Promoting sexual health education in school, work, and community based settings can decrease stigma and increase communication. Cultural implications on sexual health discriminating against women and the LGBT communities should practice sexual equity to decrease sexual violence and adverse sexual health outcomes. Recognition of the burden that poverty has on sexual health including poor reproductive health, high-risk behaviours, and lack of service utilization are crucial to obtaining overall sexual health equity. Health care providers should provide good quality, accessible, and affordable sexual health care without discrimination.

Socio-Economic Status

Education provides health literacy, awareness of services, and opportunities in maintaining good health in populations. (Gillespie et al., 2007). Bambra et al. (2010) discusses education as a platform to acquire optimum health by accumulating prospects of better jobs to become more financially stable. Economic stability will increase health by ensuring good living conditions, quality food and nutrition, and social involvement.

Gillespie et al. (2007) provided an overview of a collection of research investigating the relationship between the risk and prevalence of the sexually transmitted infection, HIV and socio-economic status in different regions of Africa. Results varied within different study objectives and different countries in Africa. A study analyzing eight countries in Sub-Saharan Africa found that individuals of high and low socio-economic status’ have increased risk of HIV. Wealthier individuals were at risk due to residing in urban areas with high prevalence of HIV, the ability to commute and mobilize for multiple sexual encounters, and having casual sexual partners, and tend to live longer through quality healthcare. Individuals with higher socio-economic positions have adequate knowledge of HIV, safety methods, better education, and use contraception which reduces their risk of infection. Individuals with lower socio-economic status are at high risk of HIV as they are more susceptible to malnourishment, which can affect the immune system and increase the risk of HIV transmission from unsafe sex.

Gender

An increased socio-economic status can provide food security and greater living conditions. Poverty is a driving force for high risk sexual behaviour that increases chances of individuals to acquire HIV infection. Previous research shows that sexual health inequality is highest among women with a lower socio-economic status (Elliot et al., 2013; Gillespie et al., 2007). A study found that populations of women with low socio-economic status in South Africa, Botswana, and Swaziland are more susceptible to participate in high risk sexual behaviours such as “transactional sex” to obtain food and resources for their families. Women with low socio-economic status in relationships have an economic dependency on their partners creating difficulties in negotiating safer and pleasurable sex for themselves (Gillespie et al., 2007).

Ruiz-Munoz et al. (2013) produced results from a study focusing on socio-economic factors, genders, and sexual behaviours related to sexual health among a sexually-active sample living in Spain. The study revealed that women with lower socio-economic positions are more likely to involve alcohol or drugs in sexual experiences. Their sexual behaviours and sexual satisfaction are mainly reflective of pressures from “social reproduction and gender-based division of work”. Individuals with lower socio-economic positions tend to suffer more sexual abuse and partake in and unsafe sexual activities. Socio-economic status also moderated the use of contraception. Participants with higher socioeconomic status had more control of family planning, access to resources, and greater awareness of their sexual health needs.

Influences on Youth

Research organized by Valle et al. (2005), revealed patterns in sexual debut in teenagers in Oslo, Norway based on social position and gender. The increased risks of early sexual debut for sexual health include sexually transmitted infections and teenage pregnancies. In this study social class 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) found that boys were at higher risk for early sexual debut in Social Class I. Findings among girls reflected traditional social power organisations where there was an increased risk for early sexual debut in girls from the manual working class. These results reflect similar findings in studies with samples in the UK and USA. Social levels and individual academic self-perceptions of youth influenced early sexual debut where teenagers with higher levels of perceived social-acceptance increased opportunities for early sexual debut.

Research by Elliot et al. (2013) that administered sexual literacy interventions to teenage students in Glasgow, showed that both male and female students from lower socioeconomic groups reported having more sexual interactions and intercourse than students from higher socioeconomic groups. Although these groups were participating in more sex, the results also revealed that after the intervention, students from lower socioeconomic groups were less knowledgeable about sexual health. Interventions that included knowledge and access to services were most beneficial in changing behaviour in students with lower socio-economic positions students as they became aware of their resources and how to access them.

Society and Culture

Metusela et al. (2017) states that “sexual and reproductive health is shaped by socio-cultural factors which can act as barriers to knowledge and influence access to healthcare”. Cultures worldwide do not offer options of safe, supportive, free, and pleasurable sex for all members of their populations (IPPF, 2015). In a study interviewing migrant and refugee women in Australia and Canada by Metusela et al. (2017), the sample of women 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 to healthcare. Major constraints included inadequate knowledge leading to many misconceptions, lack of communication, coercive sex, and negative health outcomes. An example from this study includes the cultural lack of open discussion about sex and sexual health. Misconceptions and lack of resources about sexual health led to risky sexual behaviours such not using contraception and avoiding cervical cancer screenings and HPV vaccinations as they “threatened virginity”. Discussion about sex was forbidden and considered “harming your religion”, so married women could not negotiate safe sex with their husbands and virgins would not receive information about sex until their wedding day. Risky sexual behaviours were a results of lack of resources and information as well as undependable advice from other women. A main cultural theme within this sample of women included avoiding medical services because they did not want to expose their bodies to strangers. Therefore, concepts of menstruation and menopause were perceived traditionally with shameful attitudes and inadequate understanding of reproductive systems.

Education

Education increases positive sexual health outcomes through knowledge and awareness of obtaining and maintaining good sexual health through positive behaviours. Sexual health education can decrease “stigma and discrimination” seen throughout different cultures (Sathyanarayana Rao et al., 2012).

Research by Elliott et al. (2013) administered sexual health education to groups of students in Glasgow, where different types of education included sexual health information, skills training, and access to health services. Results reflected that although knowledge is important for sexual health, awareness and access to services is beneficial for positive sexual behaviours. This experiment included topics that students had knowledge of prior to this experiment including negotiating safe sex, using condoms, and sexual risk of early pregnancy and infections.

Conversely, there are populations around the world that do not receive such information. In Metusela’s et al. (2017) study, results revealed that lack of exposure to information of sexual health throughout one’s lifecourse due to culture leads to risky sexual behaviour and negative health outcomes. Poor sexual health conditions may include forced and non-pleasurable sexual intercourse for at least one partner, infections, limited use of contraception, and abortions and unintentional pregnancies.

As sexual health education varies among cultures and societies, so does acceptance and exposure to homosexuality and sexual health for homosexuals. The unequal coverage of information and services are due to homosexuality being a sexual minority (Operario et al., 2015) In a study conducted by Roberts et al. (2004), focus groups were used to understand the social and cultural context of sexual health among young people in Mongolia. While many sexual health topics were presented in educational settings including condom demonstrations and sexually transmitted infections, homosexuality was a subject that teachers did not feel was appropriate to teach in class. Teachers and students believed that homosexuality is a foreign concept and teachers failed to consider that students in their classes may be homosexual.

Gender

Metusela’s et al. (2017) study discusses that culturally prescribed gender roles, in the study’s represented cultures, limit a women’s ability to control their sexual and reproductive life and needs. While knowledge of contraception may be present, family pressures to bear children restricts women from using it. Women in these cultures cannot contribute to decisions on family planning and often there are large amounts of pressure towards having children, especially males.

Research by Hall & Tanner (2016) assesses sexual health in black women attending university in the USA includes gender inequalities within “college hookup culture”. Hall & Tanner (2016) note that black women are impacted more by sexual victimization, negative sexual health outcomes, and sexual double standards. In a culture where having non-serious sexual relationships is commonly practiced, women are more likely to be discriminated by partaking in these relationships than men. Women also suffer higher risk of infection due to the inconsistent use of condoms, and low risk perception in these casual sexual relationships.

Roberts et al. (2004) discovered through focus groups that there is a division of sexual power between males and females in Ulaanbaatar, Mongolia. Participants of the focus groups believe that women should not be informed or experienced in sexual matters. Women should also never initiate sexual activities but are obliged to accept initiations from men. This prohibits women from avoiding coercive sex, obtaining condoms, and negotiating safe sex. Mongolian men were explained to “naturally know” about sex and were shamed for seeking information. This causes men to rely on friends for information which may not always be dependable. Unlike women, men gain good reputations by being sexually experienced.

Health Systems

It is important that health care systems are nonjudgmental and provide quality preventative, healing, and knowledge resources, confidentially to all patients (Sathyanarayana Rao, 2012). Currently, this does not apply across cultures and many health care systems discriminate based on sexual orientation, and have negative stigma of discussing sexual health (Santos et al., 2017; Metusela et al., 2017; IPPF, 2015). Health systems and health professionals cannot be highly successful unless populations have access to information, positive attitudes and values in their relationships, supportive communities, and are welcoming to skills and services (Aggleton et al., 2014).

Sexual Orientation

Sexual health systems typically provide limited sexual health resources for the homosexual community (Aggleton et al., 2014). Santos et al. (2017) discovered, during interviews with Latina women of lesbian, bisexual, and queer (LBQ) communities, that most doctor visits included providing information for heterosexual sexual health. Sexual health recommendations from health care providers for this sample was limited and the women often reported high risk sexual behaviour due to the lack of knowledge of safer sex with women. One participant stated that a doctor implied that regular screenings were not necessary because she did not participate in heterosexual sex. Health services are more familiar with risks and treatments associated with homosexual males than homosexual females. This study highlighted that an accumulation of minority status (gender, ethnic, and sexuality) instigates risky sexual behaviour as discrimination is high and one’s culture, social position, and sexuality do not receive unified support.

Similar findings of inadequate homosexual health discrimination were reflected in a study conducted by Aegnor et al. (2016), where health services were examined among male and female homosexuals in the USA. Results included differences in recommendations of screenings and treatments based on sexual orientation rather than individual patient risk. This may be a result of poor communication between patients and health care providers, a health care providers lack of training on non-heterosexual sexual health, and the perceptions of sexual health risk of the health care provider and the patient.

Interventions

Aggleton et al. (2014) highlights different health promotion strategies focusing on topics associated with intervention success. The examples of health promotion underline that interventions are significantly shaped by context and cultural beliefs for outcomes and participant experiences. Approaches and interventions do not acquire the same achievements across different countries, as each country, ethnicity, and culture has different sexual health needs. The paper focused on the topics of changing sexual practices and cultures and innovation in sexuality, education, and service provision.

Changing sexual practices and cultures refer to creating interventions that are appropriate and address problems specific to that culture. In a study conducted in Malawi (Jaganath et al., 2014, cited in Aggleton et al., 2014, p.548), researchers analysed a programme called “This is my Story” including a 5-week course encouraging community dialogue, empowering community members living with HIV, increasing community understanding, and breaking down barriers. Participants reported feedback of this intervention where the community was increasingly supportive, there was less stigma about those with HIV, and an understanding that there is a possibility of full life with HIV.

Innovation in sexuality, education, and service provisions refers to the importance of a populations social structure and culture when providing sexual. A health facilities and services. Interventions should differ based on values, religious principles, attitudes and presence of human rights, and cultural traditions. A programme administered in a population in Kenya (Maticka-Tyndale et al., 2014, cited in Aggleton et al., 2014, p.549) involved role modelling, behaviour practice, and interactive interventions for students involving safe sexual health. The results of the students’ knowledge increased self-value when demonstrating sexual restraint, condom use, and acceptance of people with HIV. While defining HIV was not discussed in depth, student’s knowledge and behaviour was impacted based on what was relevant to them. This study was replicated throughout Kenya, and teacher effectiveness increased as they became more experienced with the programme. An example of a study conducted in South Africa, aimed to promote healthy sexual experiences for all genders (De Palma and Francis, 2014, cited in Aggleton et al., 2014, p.550). This programme clarified that education should not disempower women in society and teachers should not continue to include discrimination and stero-typing in lessons. An example including lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities conducted in Canada, focuses on the discriminations encountered by these sexual minorities (Knight et al., 2014, Aggleton et al., 2014, p. 550). Clinicial experiences and services are intensifying health inequalities, as social and cultural norms reinforce the assumption of an entirely heterosexual community.

Health is described as an outcome and a determinant of people’s social position and social conditions. Health increases in individuals with favourable social positions and declines with individuals with disadvantaged social positions. The determinants of health and inequalities within socio-economic status, ethnicity, gender, and sexual orientation work together to regulate health and sexual health similarly. This paper uses sexual health and sexual behaviour as an illustrative example of how social context, social position, and culture can influence an individual’s health. Sexual health is an interlinking health issues that connects to most health matters people experience.

Organizations and researchers aim to extend sexual health among greater populations through education, cultural perspectives, behaviours, and interventions. Health promotion and changes in behaviour are significant components to achieving positive sexual health outcomes; however, reducing poverty can also help close the health inequality gap. Cultural shifts toward positive perceptions of minorities are capable of restraining discrimination and lowering inequalities for all health needs. Cultural encouragement in policy, human rights, public health developments, and educational systems supporting positive sexual health are required for successful and global change. The global examples provided establish that sexual health needs are not generalizable across all cultures and societies. Inequalities of social position across cultures require appropriate and specific alterations, values, and services to achieve global health.