Case report
Muhammad Ahmed Abdullah1, Babar Tasneem Shaikh1, Nargis Yousuf Sattar2, Syed Mujahid Gillani3, Ameer Sikander Ahmed3 and Waleed Qaisar Shaikh4
1Health Services Academy, Islamabad (Correspondence to Babar Shaikh:
Abstract
Background: Poverty is both a cause and a consequence of poor health, and the scarcity of resources limits access to essential health care services.
Aim: To highlight the implications on health of the often-neglected social determinants.
Methods: We examined the experiences of Shahida Parveen, a middle-aged, unmarried woman, living in a resource-poor setting in Rawalpindi, Pakistan, and the interplay of the social determinants and inadequate safety nets on her health and wellbeing.
Results: Shahida's narrative unveiled a poignant journey marked by health challenges early in her lifetime, her profound losses and the systemic barriers to accessing healthcare. Poverty, limited social support, and healthcare disparities emerged as central factors in shaping her health outcomes.
Conclusion: This case report highlights the need for a more just and more inclusive healthcare system that guarantees comprehensive social safety nets and accessible health care services for vulnerable populations.
Keywords: social determinants, healthcare, poverty, vulnerable population, inclusion, safety nets, access, Pakistan
Citation: Abdullah MA, Shaikh BT, Sattar NY, Gillani SM, Ahmed AS, Shaikh WQ. Beyond illness: Understanding the social determinants in the life of a middle-aged Pakistani woman. East Mediterr Health J. 2024;30(12):847–850. https://doi.org/10.26719/2024.30.12.847.
Received: 05/06/2024; Accepted: 03/10/2024
Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
The theoretical and practical implications of the social determinants of health are often neglected and their impact on the health and well-being of individuals from impoverished backgrounds underestimated, resulting in healthcare inequities (1). Socioeconomic factors, living conditions and access to healthcare contribute significantly to the poverty-disease cycle, perpetuating a vicious cycle of worsening health and deepening poverty (2).
Pakistan's per capita health spending is considerably lower than the projected costs needed to access basic health care services (3). A major proportion of the population lives below the poverty line partly because their catastrophic health expenditure accounts for more than 60% spending on family health (4). Recently, the social health protection programme showed a little glimmer of hope (5), but with uncertainty due to the political instability and economic challenges in the country. Low public health financing has caused overreliance on private providers even for primary care, which implies a significant out-of-pocket expenditure for services, a push factor for the increasing poverty (6). Out-of-pocket expenditure, mostly incurred when accessing services from private providers, has soared to 83%, with two-thirds spent on outpatient services, particularly for purchasing medicines (7).
Within this context, we present this case report, which explored the experiences of a middle-aged, unmarried woman living in Rawalpindi, Pakistan, whose life has been profoundly affected by the interplay of the social determinants and the inadequacy of safety nets. All necessary ethical considerations were observed and written informed consent was obtained from the woman before documenting her case. Measures were taken to ensure her privacy and confidentiality, including the use of a pseudonym.
This report aims to elucidate the intricate relationships between her socioeconomic circumstances, limited access to healthcare and the resulting health outcomes. It confirms that the poverty-disease cycle exacerbates the challenges faced by resource-poor individuals. Poverty acts as both a cause and a consequence of poor health and limited resources causes inadequate access to essential health care services. In turn, the compromised health limits the opportunities of affected individuals for education, employment and economic advancement, trapping them in a cyclical pattern of deprivation and ill-health (8).
The case of Shahida Parveen (pseudonym)
Shahida Parveen, a middle-aged woman, experienced a series of devastating personal losses, including the untimely deaths of her sister, mother and brother due to untreated and unmanaged health conditions. As a result, she began living alone, burdened with multiple ailments and unable to afford essential healthcare. The financial constraints she experienced forced her to seek relief from unqualified service providers, commonly referred to as quacks or sham healers.
Her case provides a glimpse into the social determinants that have shaped people’s health and well-being, including the participant's, the challenges they face in accessing appropriate health care, and the implications for their overall health outcome. The case primarily aligns with the phenomenology, delving into her experiences and perceptions.
Shahida was a regular patient at the Health Academy Services family clinic, where regular interactions with her led to the idea of writing this case report. We interviewed her about her early health struggles and the profound losses that shaped her journey, from the unexpected diagnosis of hypertension to the devastating loss of family members. We navigated through her cumulative health burdens, exacerbated by financial constraints and a lack of supportive healthcare system, and explored the glaring absence of safety nets and social welfare in Pakistan’s healthcare system.
Early health challenges and losses
Shahida Parveen's ordeal began at a tender age, with an unexpected diagnosis of hypertension, which set the stage for a cascade of health struggles. "I was only 25 when I found out about my high blood pressure," she said as she spoke with a mixture of nostalgia and sadness. "It was unexpected and I had no idea what it meant for my future." The loss of her father during those formative years left her adrift, grappling with profound grief and a sense of uncertainty. "My father's passing was a devastating blow," she recalled. "He was my anchor, my source of strength. Without him, I felt adrift in a sea of uncertainty."
Tragedy struck again with the sudden loss of her sister to stomach cancer, thrusting Shahida into the role of caregiver for her niece, in addition to her existing struggles. "Losing my sister was like losing a piece of myself," she said. "I had to step into the role of a caregiver for my niece, helping her to cope with the loss of her mother and supporting her as she got married." The weight of these losses and the burgeoning responsibilities plunged Shahida into a deepening state of depression, shrouding her world in persistent sadness.
Cumulative health struggles
Over time, her health challenges became compounded with the diagnoses of diabetes, haemorrhoids and rheumatoid arthritis, each adding layers to her already intricate health condition and making even the simplest tasks arduous. "It felt like one thing after another and managing these conditions became a constant struggle, both physically and emotionally," she said. The devastating loss of her brother to suicide stripped her last semblance of familial support, leaving her profoundly isolated.
Navigating healthcare barriers
Navigating Shahida's narrative, we were confronted with the stark realities of a healthcare journey rife with significant barriers. The financial constraints forced her into the arms of unqualified practitioners, by necessity rather than choice. "I had no other choice. I could not afford proper medical care, so I had to rely on whatever options were available to me," she said. The absence of a supportive healthcare system further exacerbated her plight, leaving her feeling lost and vulnerable amidst the labyrinth of available options. "There was no one to guide me through the maze of healthcare options and it left me feeling even more vulnerable," she admitted.
Lack of safety nets and social welfare and influence of the social determinants of health
In Shahida's case, there was a glaring evidence of the absence of safety nets within the health system and a lack of social welfare provisions for patients facing similar circumstances. Despite her manifold health struggles and profound loss, Shahida found herself navigating a system devoid of adequate support mechanisms. “There is no financial help available for people like us in the hospitals, either from zakat or any other government scheme”, she narrated. This absence of safety nets compounded her vulnerabilities, leaving her to grapple with the burdens of illness and bereavement without the necessary resources or assistance. This sheds light on the critical need for comprehensive social welfare initiatives and safety nets within the healthcare system to provide essential support for marginalized individuals.
Through Shahida's story, the intricate interplay of the social determinants of health emerged, weaving a complex tapestry of poverty, illiteracy, loss of social capital, and thus limited access to health care and deeply influencing her physical and emotional wellbeing. “I am here in this situation because I am alone with no family, I am not literate and I have no permanent source of income,” she explained.
Resilience and advocacy
Shahida's narrative underscores the pressing need for holistic and compassionate healthcare approaches tailored to the realities of vulnerable individuals like herself. “Who will take our responsibility: government, health system or this society?” she questioned. Her resilience amidst adversity serves as a poignant call for the establishment of equitable healthcare systems and robust social support structures in Pakistan. In her journey, we found a compelling narrative urging us to confront and address the underlying social determinants of health, fostering a society that prioritizes empathy and inclusivity in its pursuit of collective wellbeing.
Discussion
This case report provides a poignant illustration of how the social determinants of health profoundly shape the wellbeing of individuals, highlighting the intricate interplay of poverty, social support systems, education, and healthcare policies in influencing health outcomes. Globally, empirical evidence has consistently shown that socioeconomic factors such as income, education and employment status have a significant impact on health status and access to health care services (9). Limited access to education and employment opportunities can exacerbate socioeconomic inequalities and further limit the ability of individuals to access resources for managing their health conditions effectively (10).
Shahida's experience of seeking care from unqualified practitioners underscores the importance of addressing structural barriers to healthcare access and ensuring the availability of affordable and quality services for all individuals regardless of their socioeconomic status (11). The absence of a robust social support system left her isolated and with inadequate assistance to cope with the emotional and physical burdens of her health struggles.
Research has shown that social support plays a crucial role in buffering the negative effects of stress and adversity on health outcomes (12). Individuals with strong social capital are better able to manage chronic illnesses and navigate the healthcare system, leading to improved health outcomes and better quality of life. The impact of social isolation and loneliness can exacerbate health disparities and hinder recovery from illness (). Addressing social isolation and the support needs of vulnerable populations is therefore essential for promoting holistic health and wellbeing.
This case underscores the need for comprehensive social safety nets and accessible health care services for resource-poor individuals. An outreach programme in underserved urban areas and squatter settlements may bring services closer to poor and marginalized communities. Healthcare policies that fail to prioritize the needs of marginalized populations perpetuate disparities and inequities in access to quality services and poor health outcomes (13). There is an urgent need to expand government-subsidized health insurance programmes tailored to low-income and marginalized groups, to ensure that they have access to essential health services without financial burden. Policymakers must recognize the interconnection between health and social factors and prioritize interventions to address the underlying structural inequalities (14). All stakeholders must work towards creating a more equitable and more inclusive healthcare system by implementing targeted interventions that will address the social determinants of health and strengthen healthcare systems.
Funding: None.
Competing interests: None declared.
Au-delà de la maladie : comprendre les déterminants sociaux dans la vie d'une femme d'âge moyen au Pakistan
Résumé
Contexte : La pauvreté est à la fois une cause et une conséquence de la mauvaise santé, et la pénurie de ressources limite l'accès aux services de soins de santé essentiels.
Objectif : Mettre en évidence les implications des déterminants sociaux pour la santé, qui sont souvent négligés.
Méthodes : Nous avons examiné les expériences de Shahida Parveen, une femme célibataire d'âge moyen vivant dans un milieu défavorisé à Rawalpindi (Pakistan), ainsi que l'interaction des déterminants sociaux et de l'insuffisance des filets de sécurité sur sa santé et son bien-être.
Résultats : Le récit de Shahida a dévoilé un parcours poignant marqué par des problèmes de santé survenus au début de sa vie, des pertes tragiques et des obstacles systémiques à l'accès aux soins de santé. La pauvreté, le soutien social limité et les disparités en matière de soins de santé sont apparus comme des facteurs essentiels qui influent sur les résultats qu'elle a obtenus dans le domaine de la santé.
Conclusion : La présente étude de cas met en évidence la nécessité de créer un système de santé plus juste et inclusif qui garantit la mise en place de filets de sécurité sociale complets et de services de soins de santé accessibles aux populations vulnérables.
ما بعد الاعتلال: فهم أثر المُحدِّدات الاجتماعية في حياة امرأة باكستانية في منتصف العمر
محمد أحمد عبد الله، بابر تسنيم شيخ، نرگس یوسف ستار، سید مجاهد كيلاني، أمير إسكندر أحمد، ولید قيصر شيخ
الخلاصة
الخلفية: الفقر سبب من أسباب اعتلال الصحة ونتيجة له، وتساهم ندرة الموارد في الحد من إمكانية الحصول على خدمات الرعاية الصحية الأساسية.
الأهداف: هدفت هذه الدراسة الى تسليط الضوء على آثار المحدِّدات الاجتماعية التي غالبًا ما يجري إغفالها على الصحة.
طرق البحث: درسنا التجارب التي مرت بها شهيدة بارفين، وهي امرأة في منتصف العمر وغير متزوجة، تعيش في بيئة فقيرة الموارد في راولبندي بباكستان، وبحثنا في أثر المُحدِّدات الاجتماعية وعدم كفاية شبكات الأمان على صحتها وعافيتها.
النتائج: كشفت حكاية شهيدة عن رحلتها المُثيرة للأسى بعد أن تعرضت في بداية حياتها لتحديات صحية، فضلًا عن خسائرها الكبيرة، وعقبات النظام التي تحول دون حصولها على الرعاية الصحية. وتبين أن الفقر وقلة الدعم المجتمعي وتفاوتات الرعاية الصحية عوامل رئيسية في تشكيل حصائلها الصحية.
الاستنتاجات: يسلط تقرير الحالة هذا الضوء على الحاجة إلى نظام رعاية صحية أكثر عدلًا وشمولًا يضمن توفير شبكات أمان اجتماعي شاملة، وإتاحة خدمات الرعاية الصحية للفئات السكانية المُستضعفة.
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