Introduction al., 2010; Graham, 2007). These determinants of

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).

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            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 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.