Social determinants of health

The World Health Organization defines the Social Determinants of Health (SDH or SDOH) as the conditions in which “people are born, grow, work, live, and age and the interactions of forces that shape the conditions of one’s daily life” [1]. Social determinants of health primarily fall into 3 categories as defined by the Commission on Social Determinants of Health under WHO. The first category is structural factors which refer to those that generate stratification and social class divisions in the society and are primarily influenced by the political and socioeconomic context of a given community. Examples of structural factors are Income, Education, Occupation, Social Class, Gender, Race/ethnicity. The second category is intermediary factors including broader factors such as material circumstances (such as housing and neighborhood quality), psychosocial circumstances (such as social support, and stressful living circumstance, behavioral and biological factors (such as nutrition and physical activity) [2].

In the past 20 years, various discussions and interventions focusing on the social determinants of health have emerged globally. Specifically, a large amount of research has focused on the importance of social determinants of health in early childhood to predict health outcomes in adulthood [3,4,5]. In addition, many studies have focused on the importance of SDOH to predict health outcomes in adulthood, especially among women. Prior research has found social support, socioeconomic position, ethnicity, and nature of their country’s health system were among the most essential factors in predicting women’s health outcomes [6, 7]. Social support is defined as, interpersonal transactions that involve emotional concern, instrumental aid, information, or appraisal [8]. However, the impact of social determinants on rural maternal health has not been as thoroughly researched.

This study focuses on the determinants that prevent women from participating in a health intervention program focused on improving their chances of a successful pregnancy and delivering a healthy child. These social and personal determinants can reveal the beliefs, characteristics, and thought processes that enable or limit women in making decisions related to their own health. Many social determinants for not participating in such healthy behaviors have been suggested including personal causes, such as concerns about privacy and time, and widely held beliefs, such as lack of trust in researchers and confusion about the goals of the study [9, 10].

From a statistical standpoint, low participation rates can lead to sampling bias when a significant number of people refuse to join a study. As a result, the sample may not accurately represent the desired population and can lead to non-response bias and a decrease in the statistical accuracy of the study.

The initiative

Healthy Life Trajectories Initiative (HeLTI) is an international research collaboration between the Canadian Institutes of Health Research, the Department of Biotechnology (India), Medical Research Council (South Africa), and the National Natural Science Foundation (China), in collaboration with the World Health Organization. The study focuses on 4 linked cohorts that will assess the effects of interventions to lower the risk factors for noncommunicable disease (NCD) and promote early childhood development [11].

The Indian cohort is supervised by the Vivekananda Memorial Hospital (VMH) and focuses on rural women living in 2 sub-districts located near the Southern Indian city of Mysore: Heggadadevanakote (HD) Kote and Saragur. The intervention features 10 personalized educational modules that are delivered to local women by community health workers. The community health care workers are women from the aforementioned 2 sub-districts that are trained and paid by VMH to deploy modules directly to the women, and collect biospecimens and other clinical data (detailed below). The educational modules focused on maintaining a diverse diet, normal body weight, and an adequate intake of micronutrients before and during pregnancy, and the benefits of breastfeeding postnatally, and were delivered throughout the conception and pregnancy process. Depending on the group that the women were randomly assigned to, women will be delivered these modules prenatally or during pregnancy at monthly intervals. Women also participated in group parenting programs run by community health workers trained in cognitive behavioral therapy with the aim to encourage discussion to address perinatal depression and improve child development [11].

The study requires voluntary participation from the women who are expected to provide information about the health status and SDOH of both themselves and their families. This information will be collected by community health workers and will involve regular contact sessions by these health workers to disseminate the above-mentioned modules in the women’s homes.

It is envisioned that the results of this study will encourage women to participate in improving health outcomes and adopt clinically beneficial maternal health practices to support the development of both mothers and children. In order to monitor the improvement of health outcomes and practices, the community health workers also collect clinical data through biospecimens and data such as weight, height, and body composition at monthly intervals to monitor changes throughout the delivery of the educational modules [11].


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