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Advances in Social Sciences Research Journal – Vol. 8, No. 4
Publication Date: April 25, 2021
DOI:10.14738/assrj.84.10082.
Kotti, A. B., Cherif, A., & Elloumi, A. (2021). The Social Roots of Health Inequity in Tunisia: A Preliminary Study on the Social
Determinants of Health Inequity. Advances in Social Sciences Research Journal, 8(4). 576-593.
Services for Science and Education – United Kingdom
The Social Roots of Health Inequity in Tunisia: A Preliminary
Study on the Social Determinants of Health Inequity
Ahmed Bilel KOTTI
University of Sfax, Faculty of Arts and Humanities,
LARIDIAME Laboratory, University of Sfax, Tunisia
Aicha CHERIF
University of Sfax, Faculty of Arts and Humanities
LARIDIAME Laboratory, University of Sfax, Tunisia
Ali ELLOUMI
TEC Laboratory, Paris Descartes University,
France & LARIDIAME Laboratory, University of Sfax, Tunisia
ABSTRACT
Addressing the Social Determinants of Health is critical if we truly want to achieve
health equity. The World Health Organization’s Commission on the Social
Determinants of Health (2008) recognized the need to broaden the understanding
of these determinants among the general public to facilitate change in communities
and improve the overall health status. Using the data from the Tunisian Health
Examination Survey (2016), this quantitative preliminary study explored the state
of social inequity in health among the Tunisian population using a quantitative
statistical analysis that shed light on the relations between the SDHs (Age – gender
– SES – Geographical location – Area of residence – and Educational attainment) and
the self-rated health status. This preliminary study explored the current state of
health equity in Tunisia through exploring the hidden patterns of social identity
formation and power relation inside society. This preliminary study also pointed
out certain aspects of health inequity in Tunisia as well as the social factors and
determinants contributing to the status-quo. The findings of this preliminary study
could be the basis of an ambitious academic work that will explore the intersection
between SDHs and their impact on health outcomes in Tunisia that will be an asset
in the process of implementing health equity policies in the future.
Keywords: Social determinants of health, Health equity, Tunisia, Social factors, health
outcome, Socio-economic inequality, Regional disparities.
INTRODUCTION
The phenomenon of inequality has been widely observed by the field of social sciences since it
is at the heart of interests of this discipline. It would be improbable to find an aspect of human
social life that social inequality does not touch. That’s why Social scientists are committed to
rigorously examine different trends in which individuals are unequal (Kallenberg & Meyer,
2012).
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Kotti, A. B., Cherif, A., & Elloumi, A. (2021). The Social Roots of Health Inequity in Tunisia: A Preliminary Study on the Social Determinants of Health
Inequity. Advances in Social Sciences Research Journal, 8(4). 576-593.
URL: http://dx.doi.org/10.14738/assrj.84.10082
Research on the differences in health outcomes within populations and their social roots has a
long tradition dating back to the classic era of social sciences in the 19th century by different
pioneers. The social and economic origins of health inequity have been well-documented since
the industrial revolution in the 1840s, which led to a series of scientific studies, starting with
the work of Friedrich Engels that established a link between high mortality and poor living
conditions of the working class in England, and the thoughts of a pioneer researcher, Rudolf
Virchow that studied the relation between pandemics and epidemics in one hand, and economy
and poverty on the other hand. Later, the work of Salvador Allende that highlighted the impact
of social factors on health (Jayasinghe, 2015).
Nowadays, Despite the rapid development of medical technology and medicine that has greatly
improved the overall population state of health worldwide, Over the past decade, several
studies, mainly in underdeveloped countries and marginalized regions where the social gap is
more obvious, highlighted that the difference in the social gradient that affects the
socioeconomic status, has led to inequality in health (Schofield, 2007). People with higher
socioeconomic status can afford daily medical expenses, and the education they receive allows
them to understand the importance of health. Conversely, individuals in the lower socio- economic class may find themselves tight in a lifestyle cycle. They usually suffer from high rates
of harmful behaviors such as smoking, lack of exercise, and long-term consumption of junk food.
The existence of these behaviors makes it difficult to solve health problems that contribute to
health inequalities (Singh et al., 2017).
Several recent studies found correlations between vulnerability and social disadvantage along
with poor health status and low life expectancy (Irwin et al., 2006; Odekina, 2015), the data
from these studies is suggesting that the health equity gap is getting wider and wider despite
growing in wealth and technological advancement (Bonnefoy et al., 2007; Cox, 2016).
However, although health differences are obvious and can be easily observed, these differences
cannot be solely attributed to biological, medical and genetic factors. The more we dig into the
depth of health inequalities, the more we realize that a lot of it is not only attributed to a
particular biological malfunction, it is beyond that, reaching the core of being human; a social
being (Benoit et al., 2009).
These observations led to a general acceptance in research and policy circles that health
inequalities are socially caused (Blas et al., 2008; Veenstra, 2013). These differences are
attributed to demographic and societal factors, universally and scientifically known as the
Social Determinants of Health (SDH) and academic research has made substantial progress in
understanding the SDH (Braveman & Gottlieb, 2014; Wilkinson & Marmot, 2003). Moreover, in
early 2008 the report of the World Health Organization commission on the social determinants
of health noted that the conditions in which people are born, live, work and age are the most
important determinant of one’s health status (CSDH, 2008; Satcher, 2010).
THE SOCIAL DETERMINANTS OF HEALTH
A Framework to Understand Health Differences
There is a noticeable increase in the literature production where SDH has received considerable
attention in the recent few years, which makes one think that it represents a new area of
academic research. However, the link between social factors and the impact on population
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Advances in Social Sciences Research Journal (ASSRJ) Vol. 8, Issue 4, April-2021
Services for Science and Education – United Kingdom
health has long been the subject of debate dating back to the 19th century with the recognition
of structural determinants of health in the early 1800’ with pioneer social scientists like
Virchow, Engels and later on McKeown (Braveman & Gottlieb, 2014; Islam, 2019).
Because of the relatively vast amount of literature produced in a small period of time, there was
a certain kind of confusion and ambiguities surrounding the subject, with tons of definitions,
conceptual frameworks and classifications. This confusion resulted in a growing need toward a
clear understanding of the concept, since SDH has a vital role in determining the overall health
status and its pivotal implication in the effort focusing on public health improvement by
different major stakeholders such as healthcare providers, policy makers and researchers
(Singh et al., 2017).
SDH is a very important concept to understand. Because of its impact on the health of
individuals and populations, in this section, we will be taking a look at what it is, how it impacts
health and a useful framework to understand it. Health is quite variable; it is very simple to
come up with such conclusion with a quick look around us. Health is variable not just between
individuals but also across different population groups. For example, in 2015 the life
expectancy of a child born in Sierra Leone was 50 years whereas in Australia it was 83 years
(United Nations Statistics Division, 2017), a difference of 33 years. However, these differences
exist even within countries. For example, in Australia the life expectancy of indigenous people
is about 10 years lower than that of non-indigenous people (Bonnefoy et al., 2007). Social status
is influencing health Within populations, individuals with higher income, a higher level of
education and a better occupation, are in a better shape and enjoy a longer life reaching a
maximum life expectancy. Health status can change as well, for example, studies of migrants
have shown that the type of diseases, health behaviors and risk factors are different in migrants
compared to those in their country of origin (Deaton, 2013).
So, why is there so much variability? To answer this question, we must understand the factors
that can influence health. It is well recognized in the literature that one's health is influenced
by a range of factors, called determinants of health, these include; who they are; individual
factors such as age, sex and genetic makeup, and also what they do; this includes their health
and lifestyle behaviors such as smoking, physical activity, alcohol use and diet. According to the
World Health Organization’s conceptualization of Health, it is also largely influenced by the
conditions in which people are born, grow, live, work and age, these include their social and
community networks, the socio economic, cultural and environmental conditions that people
live in as well as healthcare systems, these are collectively called the social determinants of
health. SDHs are ultimately shaped by the distribution of wealth, power and resources at an
international, national and local level, they have a marked influence on health inequities, which
are the unfair and avoidable health differences between different groups of people within
countries or between countries. There are many different SDH working across many levels and
with complex interactions between them (Solar & Irwin, 2010). In order to understand and
explain how these determinants influence and interact with each other to affect health and well- being, several models or frameworks have been proposed. According to the WHO’s framework,
the SDHs are defined as “the conditions in which people are born, grow, work, live, and age, and
the wider set of forces and systems shaping the conditions of daily life. These forces and systems
include economic policies and systems, development agendas, social norms, social policies and
political systems.” (CSDH, 2008).