Social and Behavioral Determinants of Health

Social and Behavioural Determinants of Health
Critical analysis paper
Task:
Throughout this course, you have been introduced to social and behavioural perspectives
as a means by which to understand public health issues. Acceptance of social and cultural
understandings of health encourages an emphasis upon social and cultural context in both
health research and interventions.
Your task is to review the Healthy City concept, selecting a specific case study either in
Australia or overseas and, reflecting on the course content, analyse and discuss how the
selected case study reflects the social and behavioural determinants of health.
What am I being asked to do?

  1. Using a ‘settings’ approach, critically review the theory underlying the Healthy City
    approach; and investigate and critique models, and interpretations of the concept.
  2. Select (justifying your selection) a Healthy City case study either in Australia or, if
    available, in your home country.
  3. Describe, analyse and discuss, in the light of your study through the semester, how your
    case study reflects the social and behavioural determinants of health.
    Ensure firstly, that you understand what we mean by a ‘settings’ approach. Secondly,
    understand the requirements and formalities of registering as a Healthy City. What does
    this imply or require, in terms of social and behavioural perspectives and the concept of the
    social model of health. To what extent does your selected case study truly reflect this
    model? Refer to your course and literature notes for further details. Here are some guiding
    questions that may help you develop your ideas:
    � Has there been a formal undertaking from key decision-makers in the community (eg,
    City Council) to become a Healthy City and what relevant strategies indicate that action
    has been taken to this end?
    � How does your case study illustrate the recognition of the individual, social and
    environmental determinants of health? (What social, economic and cultural factors or
    contexts are addressed in planning for/implementing a Healthy City?)
    �How has the community been engaged in developing, implementing or evaluating the
    Healthy City? (who is affected, what groups in the community?)
    �What types of strategies have been used to engage and consult with the community? Was
    it ALL the community? Were such strategies appropriate and realistic?

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 2

�To what extent are the community’s health issues socially constructed (eg, distribution of
infrastructure resources, green space)? How does your case study address such socially
constructed health inequities?
� To what extent has Healthy City policy making affected public beliefs, perceptions or
ways of representation of local health issues? or the ways healthcare services are provided?
� What evidence and documentation exists in the public arena to show that your Healthy
City case study is achieving its objectives? What processes of monitoring and evaluation
have taken place? do we know about the experiences and beliefs of people who have been
or are affected by local health issues? (What types of research methods and interventions
have been employed?)
Make sure you have a clear understanding of the concept and the practice of the “Healthy
City”. Conduct a literature search using library databases (eg Pubmed, Medline, Scopus)
to find literature and research that investigates and examines the Health City and related
aspects of the social model of health.
Identify and describe the relevant aspects of this literature and ensure that your analysis is
logical and not superficial. Identify areas of potential further investigation relating to
aspects of the social and behavioural determinants of health in your analysis.
Consider the strengths and weaknesses of the Healthy City approach, utilising the social
model of health to critique it: e.g. ask yourself to what extent is the social model of health
relevant to your selected city? Can the social model of health be usefully applied to the
Healthy City case study you have selected? Does it lead to highly complex interventions
that are hard to achieve? What role does the model allow for individual responsibility?
Summary
In your essay, you must:
Include critical analysis of relevant literature on the Healthy City focussing on the
application of the social model of health to your selected case study.
Review the Healthy City concept and draw conclusions on the strengths and limitations of
this approach in addressing the social determinants of health.
Organize your description, analysis and conclusions with clarity and logic in a well-written
and appropriately referenced -essay of up to 2000 words 20 references.
Social and Behavioral Determinant of Health: Critical Analysis
With each passing day, more and more people are being motivated into appreciating
healthcare and the general health setup in their localities. From research there appears to be a
deeper connection between the growth of businesses, government leadership and the level of

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 3

infrastructure in a given city. The most prevalent of the social factors is education among
recreational facilities which combatively improve the wellbeing of people’s social and cultural
practices. On the same note, cities are ruled by the settings approach which sets standards, limits
and regulations for the classification of healthy cities. With the healthy city status, arises fame,
and association with affluence among analysts using the settings approaches. All these initiatives
are aimed at bettering human lives both at work place and in their areas of residence.
In classifying healthy cities, the settings approach determines the initiation of long term
social development policies such as those dictated by the World Health Organization (WHO)
with regard to international development standards that priorities the growth and consequent
development of health agendas (Tain-Tsair, 2006). The ideas are further supported by law
makers in the respective cities. As a result the locals are made to internalize the settings approach
as recommended and with persistent reviewing of social and cultural policies, local strategies are
established in order to promote protection of health and sustain the development of existing
health programs (Casting’s & Springett, 2007). A summative form of a settings approach entails
basic features which encourage participation of communities and city residents, creation of
empowerment programs to educate the locals, encourage equity in resource distribution and
above all seek partnership among government organs offering various social amenities such as
hospitals, health facilities and recreational facilities.
Despite the criticality involved in ranking healthy cities using the setting approach, it is
prudent to acknowledge the fact that cities are different in all aspects ranging from infrastructure
to academic empowerment and awareness. With this in mind, healthy cities are not dependent
upon theories depicting their current state of infrastructural development rather such cities are

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 4

graded upon their holistic model encouraging the collective commitment towards refining the
cities environs and readiness to strike a connection between social, cultural, political and
economic arenas (Niyi, 2013). As such, theories on ranking of healthy cities is dependent on the
aims of the city governance to create a healthy supportive environment, need to improve the
quality of life through healthcare and social amenities, provision of basic hygiene needs and
sanitation and enhanced access to healthcare (Leeuw, 2012).
The city of interest in this paper is the Noarlunga City which initiated the Healthy Cities
Noarlunga initiative which was run as a start-up program for 18 years spanning between 1987
and 2005 (Lindsey, et al, 2013). The initiative was promulgated by the World Health
Organizations desire to institutionalize social and behavioral determinants into the lives of
people hence it begun initiatives to trigger positive lifestyle change among city inhabitants and
later on spread to towns and centers (Wang, et al, 2013). The Noarlunga Initiative has been
applauded for being sustainable since in spite of its being a pilot project, it quickly gained self-
sustainability which has made the city more admirable than it was in the years preceding the

  1. The Healthy City Noarlunga (HCN) initiatives success has been attributed to the fact that
    the locals have continuously supported local service providers and the local government and
    because of the commitment, the program has been sustainable for a long time. Among other
    factors that have influenced the success of Noarlunga City has been the willingness to ensure
    sustainability of the program, inspired leaders, vision by social health workers, selection of a
    holistic model that has been adaptive to the local conditions of the city, striking a balance
    between competing economic and social demands, active community involvement and lastly the
    city has been linked to research institutions and local education service providers (Kavanagh et
    al, 2012).

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 5

Basing on the setting approach, it is undeniable that the social model of health has proved
applicable in the explanation of Noarlunga as a suitable Healthy City (Holden, et al, 2013). This
is because its instruments of social control are currently driven by the need to reform the city’s
social and behavioral determinants in such a way that all the locals, residents, and tourists to the
city will enjoy the benefits accruing from controlled populations, improved citizens health,
affordable health insurance costs, healthy eating habits and lifestyles among people, and social
amenities and infrastructure that second the ideas encompassed in the Healthy Cities Noarlunga
Initiative (Smith, et al, 2012). Also, there are other factors such as better coordinated social
programs designated to help chronically ill patients, application of technology and automation of
medical databases and data on social programs, creation of parks, recreational facilities as well as
walk able communities aimed at the fulfillment of social and behavioral determinants of health
as stipulated by the WHO.
The sustainability of the Healthy Cities Noarlunga Initiative is manifested in the local’s
willingness to support the program which has been helpful in shaping the social and behavioral
lives of the residents. Inspirational leadership by the local government, social workers and
medical practitioners has helped in the success of the HCN program (Pluye et al, 2009).
Evidence illustrating the success of the Noarlunga City has been implicit in narratives made by
the World Health Organization in its attempts to strengthen loopholes that could have been
identified in its pilot program introduced by the Healthy Cities Noarlunga initiative. This is
because the WHO introduced the healthy cities programs motivated by the need to
institutionalize the Health promotion Charter that was made at Ottawa in the United States
(Leger, 2005). Among the startup projects fully supported by the World Health Organization in
Europe was the Healthy Cities Noarlunga initiative dubbed as the WHO’s European Healthy

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 6

Cities Program. The Noarlunga initiative together with Illawarra and Canberra were likewise
funded by the Australian government. Specifically, Noarlunga is a suburb of Adelaide which is
the capital city of South Australia (Cooke & Baum, 2005).
Three years into the project, Noarlunga’s social model of health was evaluated by
national analysts of social and behavioral change initiatives and it was a success owing to the
support derived from the locals, government agencies and Non-Governmental Organizations.
With the realization that the program would accrue more benefits than it had been thought of,
Noarlunga integrated a new hospital in support of its health care service in the year 1991
(Seymour & Ashton, 2008). More funds were pumped into the project by well-wishers. The
funds were used to employ a project manager, administrators, community representatives, senior
staff and administrative costs incurred by follow-up committees. A slogan was also enacted to
strengthen the need for a ‘Healthier Noarlunga’. Up to this level the Healthy Cities Noarlunga
initiative was earmarked as an achievement after it had positively gone through the three
pertinent stages of project development; starting, organizing and acting. Later on in 1991, the
HCN was incorporated as a Non-Governmental Organization after withdrawal of dedicated
financiers. The initiative was made to depend on contributions and profits ploughed back from
its local healthcare facilities (Nagata, et al, 2013). To motivate active participation by the locals,
most of the community members were infused into the management board and committee.
In the 1990’s and the preceding years, three major projects were ongoing. The projects
were Noarlunga towards a safe community (NTSC), Onkaparinga Collaborative Approach for
the Prevention of Domestic Violence and Noarlunga Community Action on Drugs. During the
same time, the HCN initiative was gaining much acceptance from local university specifically in

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 7

the Public Health Department (Baum, 2012). In support of the program, the university
incorporated training programs while at the same time the curriculum was rescheduled to offer
post-graduate courses with special emphasis on Healthy cities. This implies the beliefs that the
HCN program had inculcated into the residents of Noarlunga city.
According to reports made by the WHO regarding the progress of Healthy Cities, it was
appreciated that evaluation of projects progress is an issue of major concern. The Healthy Cities
Noarlunga initiative is by itself complex by design and mode of execution. This aspect further
complicates the process of project evaluation since there are several interlinked factors that
dictate the interaction between community mobility, local politics, local agencies as well as
foreign agencies (Judge & Bauld, 2011). All this dimensions have to be put into consideration.
Likewise it is empirically proven that Healthy City initiatives cannot be directly equated to
health outcomes or social and behavioral change. With relation to the HCN project, it can be said
to be a success because it has been sustainable in the sense that the project has been in existence
since 1987 to present and currently there local communities, politicians and service providers
have shown support for the project through involvement in committees, conducting, evaluating
and analyzing periodic reports.
Similarly, the HCN project has influenced transformation of organizational cultures
which have become inclined to focusing on promotion of health and capacity building. The two
elements have been identified to be important in steering sustainability. It is further
acknowledgeable that in a period spanning between 1987 and 2013, the Healthy City Noarlunga
initiative has successfully completed 25 social and behavioral health projects in the field of
safety, environmental conservation, drug use and service access as well as school based

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 8

developments (Otgaar, et al, 2011). Analyzing documented sources of information on the
Healthier Cities Noarlunga initiative identified that the word sustainability is more preferred to
success because project management is a continuous development which makes it’s a tiresome
processes coupled with evaluations and constant reviews. The advantages accrued from the HCN
initiative have been associated with a lasting transformation of people’s lives especially in the
communities where the community members have admitted that their social and behavioral
characteristics have been transformed for the better under the drug use projects as well as the
domestic violence project.
Both local and foreign agencies have shown a preference for working with the Healthier
Cities Noarlunga because the city has institutionalized the basic concepts associated with such
initiatives. This has been advantageous in shaping cultures and social ways of lives. Health wise,
it has been identified that Noarlunga which is currently a home to millions of people has been
rated by Almanac 2012 as being among the most inhabitable cities in the world (Lynch, 2011).
This fact cements earlier advantages associated with the Healthier Cities initiatives as promoted
by the WHO. Equally commercial health insurance expenditure has been identified being 30%
lower than the national Medicare insurance while real expenditure on Medicare for Noarlunga is
22% below the Australian national average. Other advantages have been associated with
improvement of general healthcare provision through increased healthcare facilities and the local
authorities continuous involvement in removing of potential hazards from residential areas, city
cleanup programs as well as cleaning up of estuaries has facilitated participation in local
activities such as swimming (Riley, et al, 2012). Social functions have been known to foster the
growth of social networks, and enhanced social support which is healthy to the body.

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 9

The main disadvantage with the Healthier Cities Noarlunga initiative is its possible
detachment to the stimulation of health outcomes. This observation is supported by the fact that
most the success or impact of community motivated initiatives on the local communities is hard
to measure and ascertain. Unlike charities, such community based projects lack straightforward
causal paths thus it inhibits stakeholders from soliciting for funds from agencies and national
governments (Judge & Bauld, 2011). The truth is that the HCN initiative has had a long term
change in social and behavioral improvements. Despite the opinionated views that might be
opposed to the reality on the existence and possible transformative impacts that have so far been
accrued from Healthier Cities across the world, the Healthier City trend which started as pilot
projects introduced by World Health Organizations in developed countries in Europe and
America, Healthier Cities concepts have reached the grassroots levels (O’Neill & Simard, 2006).
The ideas have diffused not only to cities but also to individuals conqueringly changing their
view on Healthier Cities. As a result sooner or later, all cities around the world will be marveling
at the social and behavioral improvements brought about by Healthier Cities Initiatives.

SOCIAL AND BEHAVIORAL DETERMINANT OF HEALTH 10

References

Baum, F. (2012). The New Public Health (3 rd Ed.). Melbourne: Oxford University Press.
Casting’s, C. & Springett, J. (2007). Towards a framework for the evaluation of health related
policies in cities. Adelaide: Wakefield Press.
Cooke, R.. & Baum, F. (2005). Two Healthy Cities in South Australia. Adelaide: Wakefield
Press.
Holden, K. B., Xanthos, C., & Treadwell, H. M. (2013). Social Determinants of Health Among
African American Men. San Francisco: Jossey-Bass.
Judge, K., & Bauld, L. (2011). Strong theory, flexible methods: Evaluating complex community
based initiatives (2 nd Ed.). Amsterdam: critical Public Health.
Kavanagh, A., Daly, J., & Jolley, D. (2012). Research methods, evidence and public health,
Australian and New Zealand, Journal of Public Health.
Leeuw, E. (2012). Do Healthy Cities Work? A Logic of Method for Assessing Impact and
Outcome of Healthy Cities. (Report). Journal Of Urban Health, (2), 217.
Leger, L. (2005). Questioning sustainability in health promotion projects and programs.
Wyoming: Health Promotion International.
Lindsey, M., Chambers, K., Pohle, C., Beall, P., & Lucksted, A. (2013). Understanding the
Behavioral Determinants of Mental Health Service Use by Urban, Under-Resourced
Black Youth: Adolescent and Caregiver Perspectives. Journal Of Child & Family
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Lynch, F. R. (2011). One Nation under AARP: The Fight over Medicare, Social Security, and
America’s Future. California: University of California Press.
Nagata, J. M., Hernández-Ramos, I., Kurup, A., Albrecht, D., Vivas-Torrealba, C., & Franco-
Paredes, C. (2013). Social determinants of health and seasonal influenza vaccination in
adults ⩾65 years: a systematic review of qualitative and quantitative data. BMC Public
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Niyi, A. (2013). The Healthy Cities Approach – reflections on a framework for innovating global
health. Bull World Health Organ.
O’Neill, M., & Simard, P. (2006). Choosing indicators to evaluate Healthy Cities Project: A
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Otgaar, A. J., Berg, L., & Klijs, J. (2011). Towards Healthy Cities: Comparing Conditions for
Change. Farnham: Ashgate Pub.
Pluye, P., Potvin, L., Denis, J., & Pelletier, J. (2009). Program sustainability focus on
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Riley, E. D., Neilands, T. B., Moore, K., Cohen, J., Bangsberg, D. R., & Havlir, D. (2012).
Social, Structural and Behavioral Determinants of Overall Health Status in a Cohort of
Homeless and Unstably Housed HIV-Infected Men. Plos ONE, 7(4), 1-7.
Seymour, H., & Ashton, J. (2008). The New Public Health. Wyoming: Open University Press.
Smith, L. R., Fisher, J. D., Cunningham, C. O., & Amico, K. (2012). Understanding the
Behavioral Determinants of Retention in HIV Care: A Qualitative Evaluation of a

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Situated Information, Motivation, Behavioral Skills Model of Care Initiation and
Maintenance. AIDS Patient Care & STDs, 26(6), 344-355.
Tain-Tsair, H. (2006). Building and Implementing Healthy City Concepts in Tainan City.  (5),
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Health Information Seeking among Chinese Adults in Hong Kong. Plos ONE, 8(8), 1-7.

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