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Human Origins and Society: Evolution, Culture and Health Human health is shaped by the interaction of evolution, biology, culture, social organisation, environment, economics and political power. Medical anthropology does not replace anatomy, physiology or pathology. It helps the doctor understand why disease is distributed unevenly, why patients interpret symptoms differently, why behaviours persist, and why treatment can succeed biologically yet fail socially. Learning objective: By the end of these notes, the learner should be able to explain human variation without racial stereotyping, link social organisation to disease risk, apply evolutionary reasoning cautiously, and use a structured social-cultural history in clinical practice. 1. What medical anthropology contributes Medical anthropology studies health, illness, healing and the human body in cultural and social context. It asks how people define normality, explain suffering, select healers, distribute care and respond to public-health messages. It examines both local knowledge and biomedical institutions, including how colonial history, migration and inequality shape health systems. 2. Human origins and the evidence for evolution Modern humans are one species with shared ancestry. Evidence for human evolution comes from fossils, comparative anatomy, archaeology, genetics and population studies. Evolution is a change in inherited characteristics across generations; it is not a ladder from “primitive” to “advanced” societies. All living populations are modern, and no population is biologically or intellectually superior. Clinical meaning Use ancestry only when it changes a specific clinical decision—such as a validated genetic test, a documented drug-response difference, or an exposure history. Never use skin colour, ethnicity or nationality as a shortcut for diagnosis, adherence, intelligence or pain tolerance. 3. Genetic variation, ancestry and race Most human genetic variation occurs within populations rather than between broad racial categories. Ancestry is probabilistic and may involve several geographic lineages. Race is a social classification that can still affect health because racism, discrimination, poverty, residence and access to care affect exposure and treatment. Separate biological evidence from social consequences. 4. Evolutionary forces Mutation: creates new genetic variants. Natural selection: changes the frequency of variants that affect survival or reproduction. Genetic drift: random change, especially in small populations. Gene flow: movement of genes between populations through migration and reproduction. Sexual selection: traits may spread because they influence mate choice or reproductive success. These mechanisms act over generations. They cannot be used to explain an individual patient without direct clinical evidence. 5. Adaptation and the human environment Humans adapt biologically and culturally. Skin pigmentation relates partly to ultraviolet exposure; body composition, lactase persistence and high-altitude physiology illustrate population adaptation. Culture is often faster than genetic change: clothing, shelter, cooking, sanitation, vaccination and technology alter exposure to disease. A trait that was useful in one environment may become harmful after migration or urbanisation. 6. Evolutionary medicine Evolutionary medicine asks why vulnerability exists. Examples include pathogen resistance after antimicrobial exposure, mismatch between modern diets and older metabolic adaptations, trade-offs in immune responses, and the protective value of fever or pain. These ideas generate hypotheses; they do not justify withholding treatment. Avoid evolutionary overreach: “It is evolutionary” is not a diagnosis. Do not use evolutionary explanations to excuse discrimination, dismiss mental illness, blame obesity, or deny the role of poverty, trauma, infection or medication. 7. Culture: learned systems of meaning Culture includes language, values, beliefs, customs, knowledge, rituals, food practices, gender expectations and ways of organising family life. It is learned and shared but not identical for every member. A patient may identify with several cultures, change practices over time, or reject a family tradition. 8. Socialisation across the life course Families and communities teach children what counts as pain, bravery, cleanliness, adulthood, illness and acceptable help-seeking. Adolescents may prioritise peers; adults may prioritise work and dependants; older people may hold decision-making authority. Ask who normally notices illness, who pays, who gives permission and who provides transport. 9. Kinship, household and social support Kinship systems influence caregiving, inheritance, residence, marriage, disclosure and consent. Household support can improve adherence, nutrition and follow-up, but family control can also restrict autonomy or conceal abuse. Involve relatives only with the patient’s permission, except where safeguarding or law requires action. 10. Gender, power and health Gender roles affect exposure to violence, occupational hazards, reproductive risk, nutrition, health information and control over money. Men may delay care because of norms around toughness; women may face limited decision-making power; gender-diverse patients may avoid services after discrimination. Ask privately about safety, reproductive goals and barriers. 11. Subsistence and livelihood Foraging, pastoralism, farming, fishing, informal work and urban employment produce different risks: zoonoses, pesticides, dust, heat, injuries, malnutrition, road trauma and infectious exposure. Occupational history should include tasks, protective equipment, seasonal work, livestock, water sources and travel. 12. Food, nutrition and the nutrition transition Food is biological fuel and social identity. Economic change can produce a double burden: childhood stunting or micronutrient deficiency alongside adult obesity, hypertension and diabetes. Dietary counselling should consider affordability, cooking facilities, fasting, food taboos, household allocation and locally available alternatives. 13. Migration, urbanisation and displacement Migration changes exposure to infections, stress, housing, occupation, diet and continuity of care. Do not assume a migrant has a particular disease because of origin. Ask about journey, residence, shelters, detention, language, trauma, immunisation, occupational exposure and interrupted medicines. Urbanisation may improve access to hospitals while increasing crowding, air pollution and food insecurity. 14. Social determinants and structural violence Education, income, land, housing, transport, clean water, sanitation, legal status and discrimination shape the distribution of disease. Structural violence means that social arrangements systematically expose some groups to preventable harm. A clinical prescription cannot solve every determinant, but the doctor can identify risk, document it, refer appropriately and advocate for safer systems. 15. Stigma, identity and the sick role Stigma can delay testing and disclosure in HIV, tuberculosis, epilepsy, infertility, mental illness, substance use, cancer and sexually transmitted infections. Explain confidentiality, use neutral language and ask what the diagnosis means to the patient’s family, work and future. Never equate a diagnosis with a moral failure. 16. Environment, climate and health Climate and ecology influence vectors, water

Indigenous African Healing: Knowledge, Practice, Safety and Clinical Integration Indigenous African healing is not a single treatment system. It is a diverse set of knowledge, skills, beliefs, social relationships and healing practices developed in different communities. It may include herbal medicine, spiritual care, prayer, divination, counselling, massage, bone setting, birth support, dietary advice and community reconciliation. Doctors need cultural understanding and scientific caution at the same time. Clinical principle: respect the patient and community; assess the treatment objectively; identify danger; prevent harmful delay; and provide evidence-based care without ridicule. 1. Meaning and diversity Knowledge may be passed through family traditions, apprenticeship, specialist healers, elders, religious institutions and community experience. A herbalist, traditional birth attendant, spiritual practitioner, bonesetter, diviner and community counsellor may have different training and responsibilities. Never assume that one practice represents all African cultures or that every healer makes the same claims. 2. Why patients seek indigenous healers Trust, language, proximity and lower direct cost. Respectful listening and attention to family, spiritual and social concerns. Availability outside hospital hours and in remote areas. Explanations that make sense of suffering and restore meaning. Previous poor treatment, discrimination or long waiting times in formal services. Belief that herbal or spiritual care is safer or more natural. Ask what the patient valued rather than assuming ignorance or rejection of medicine. 3. Explanatory models of illness Illness may be attributed to infection, heredity, diet, pollution, stress, social conflict, spiritual attack, ancestors, witchcraft, imbalance or loss of harmony. Biomedical and indigenous explanations can coexist. The doctor should understand the model because it predicts help-seeking and adherence, while still treating emergencies according to clinical evidence. 4. Types of practice Practice Possible purpose Clinical issues Herbal medicine Symptoms, chronic disease, prevention or cleansing Unknown dose, contamination, toxicity and interactions. Spiritual care Meaning, hope, prayer and social support Potential delay, coercion or harmful rituals. Bone setting Splinting and manipulation after injury Neurovascular injury, infection, malunion and delayed surgery. Traditional maternity care Pregnancy, birth and postpartum support Haemorrhage, sepsis, obstructed labour and delayed referral. Massage and topical care Pain, mobility and comfort Burns, infection, bleeding or worsening fracture. 5. Herbal medicines and pharmacology Plant products contain active chemicals, but activity does not guarantee safety. The same plant may vary by species, soil, season, storage and preparation. Adulteration with steroids, antibiotics or heavy metals can occur. Ask for the local name, ingredients, source, preparation, dose, route, frequency, duration and last use. If possible, ask the patient to bring the container or sample. High-risk combinations: unknown remedies with anticoagulants, insulin, antiretrovirals, antiepileptics, tuberculosis treatment, chemotherapy, anaesthetics, antihypertensives or medicines with a narrow therapeutic index. 6. Recognising toxicity Consider herbal or traditional treatment toxicity in unexplained jaundice, dark urine, renal impairment, bleeding, seizures, severe vomiting, hypoglycaemia, altered consciousness, rash, bronchospasm or sudden deterioration. Stop exposure when clinically appropriate, stabilise the patient, document the product and report suspected adverse drug reactions through the national system. 7. Spiritual and religious healing Prayer, ritual, confession and community support can reduce distress and strengthen coping. Ask whether the patient wants a trusted spiritual supporter involved. Consent is essential. Spiritual care becomes unsafe when it replaces urgent treatment, demands payment through coercion, encourages stopping medicines, uses violence or restraint, or exposes children and vulnerable adults to harm. 8. Bone setting and injury Assess circulation, sensation, motor function, skin integrity and compartment syndrome before and after any manipulation. Obtain appropriate imaging. Open wounds, severe deformity, absent pulses, neurological deficit, suspected compartment syndrome, dislocation or unstable fracture require urgent orthopaedic care. Explain that a familiar healer may be respected while the injury still needs hospital treatment. 9. Pregnancy, childbirth and newborn care Traditional birth support may provide companionship and practical help, but danger signs need immediate referral: heavy bleeding, convulsions, severe headache or hypertension, prolonged labour, obstructed labour, fever, malpresentation, fetal distress, retained placenta, reduced fetal movement, premature rupture with infection, or a sick newborn. Newborn breathing difficulty, poor feeding, hypothermia, jaundice in the first day, fever or seizures are emergencies. 10. Children and safeguarding Children cannot consent to harmful procedures. Assess nutrition, immunisation, growth, poisoning, burns, scarification, sexual abuse, restraint and delay in treatment. Explain danger signs to caregivers and document concerns. A child’s best interests override family pressure or healer authority. 11. Mental health and substance use Families may interpret psychosis, epilepsy, depression or substance dependence spiritually or morally. Listen to the explanation while assessing suicide risk, violence, delirium, intoxication, withdrawal and medical causes. Do not permit dangerous restraint, starvation, chaining or assault. Combine psychiatric care with safe family and spiritual support when the patient agrees. 12. Respectful clinical history “What do you call this problem?” “What do you think caused it?” “Which healer, remedy or spiritual practice have you used?” “What exactly was given or done, and when?” “Did you stop any prescribed medicine?” “What outcome are you hoping for?” “Who should be involved in decisions?” Ask privately when coercion, domestic violence, sexual abuse or financial exploitation is possible. 13. Shared decisions and communication Start with respect, not confrontation. Validate the patient’s fear or hope. Explain what is known, what is uncertain, what is dangerous and what treatment is essential. Offer safer alternatives: continue prayer as support while treating sepsis, retain family support while starting antimalarial therapy, or use physiotherapy after fracture assessment. Use teach-back and give clear return precautions. A useful sentence “I respect that this treatment is important to you. I am worried about this finding because it can damage the liver / delay delivery / worsen the fracture. Let us keep the support that helps you while we arrange the treatment that protects your life.” 14. Collaboration and referral Collaboration may improve trust and early referral when it is lawful, voluntary and patient-centred. Do not share confidential information without consent, pay referral commissions, endorse unsupported cures, or imply that every provider is regulated. Agree on danger signs and referral pathways with community partners where appropriate. 15. Research and evidence Traditional knowledge deserves respectful study, but anecdotes do not establish efficacy.

Doctor–Patient Relationship and Clinical Communication The doctor–patient relationship is the professional relationship in which a doctor and patient work together to understand illness, make decisions, provide treatment and promote health. It is built through trust, respect, competence, communication, confidentiality and shared responsibility. Good communication is a clinical skill, not an optional courtesy. Learning objectives Explain the meaning and importance of the doctor–patient relationship; describe models of the relationship; demonstrate a structured consultation; apply principles of consent, confidentiality and shared decision-making; manage difficult conversations; and identify barriers to effective communication. 1. Importance of the relationship A strong relationship improves history-taking, diagnostic accuracy, disclosure of sensitive information, adherence, satisfaction, safety and continuity. Trust makes patients more likely to report symptoms, ask questions and return when a condition worsens. A technically correct plan may fail if the patient does not understand it, cannot afford it or does not believe the doctor respects them. 2. Essential qualities Respect: recognise dignity, autonomy, culture and preferences. Empathy: understand the patient’s experience and communicate that understanding. Compassion: respond to suffering with a willingness to help. Honesty: communicate truthfully while remaining sensitive. Confidentiality: protect private information within legal and ethical limits. Competence: maintain knowledge, judgement, examination skill and referral awareness. Reliability: explain the plan, follow up results and keep promises. 3. Models of the doctor–patient relationship Model Main feature Strength and limitation Paternalistic Doctor decides what is best Useful in emergencies, but may restrict autonomy if used routinely. Informative Doctor provides facts and patient chooses Respects autonomy but may abandon a patient who needs guidance. Interpretive Doctor helps clarify values and options Supports personalised decisions and requires listening. Deliberative or shared Doctor and patient discuss evidence, values and preferences together Usually suitable for modern patient-centred care. Partnership model Both contribute expertise: the doctor knows medicine and the patient knows their life Promotes trust, adherence and continuity. 4. Structure of a clinical consultation Prepare: review available information, ensure privacy and reduce interruptions. Connect: greet the patient, introduce yourself, confirm identity and explain your role. Set the agenda: ask what brought the patient and what they most want addressed. Explore: begin with an open question, then clarify symptoms, concerns, ideas, expectations and effects on life. Examine and assess: explain what you are doing, seek permission and maintain dignity. Explain: give the working diagnosis and uncertainty in language the patient understands. Plan: discuss options, benefits, risks, costs, alternatives and follow-up. Close: ask the patient to repeat the plan, invite questions and explain danger signs. 5. Verbal and non-verbal communication Verbal communication includes word choice, pace, tone, questions, explanations and checking understanding. Non-verbal communication includes eye contact, posture, facial expression, distance, silence and attention to the patient’s emotional cues. Looking continuously at a computer can make a patient feel ignored. Explain when you need to document. 5.1 Open and closed questions Open questions invite the patient’s story: “Tell me what happened.” Closed questions clarify details: “Did the pain begin today?” Use open questions early and focused questions later. 5.2 Active listening Do not interrupt unnecessarily. Reflect key words, summarise, clarify contradictions and notice emotion. A pause may allow a patient to disclose important information. 5.3 Teach-back Ask the patient to explain the plan in their own words: “I want to be sure I explained it clearly—how will you take the medicine?” Teach-back checks the doctor’s communication, not the patient’s intelligence. 6. Empathy and responding to emotion Use the NURSE approach when appropriate: Name the emotion, Understand or acknowledge it, show Respect, offer Support and Explore the concern. “You seem frightened by the result” is more therapeutic than immediately changing the subject. 7. Informed consent Consent is a voluntary and informed agreement made by a person with decision-making capacity. The discussion should cover the nature and purpose of the intervention, expected benefits, important risks, alternatives, consequences of no treatment and the opportunity to ask questions. Consent is a process, not merely a signature. Assess capacity by checking whether the patient can understand relevant information, retain it long enough to decide, use or weigh it, and communicate a choice. Capacity is decision-specific and may fluctuate. In emergencies, follow applicable law and professional guidance. 8. Confidentiality and privacy Protect information spoken in the consultation, written in records, stored electronically and shared with other professionals. Discuss information in a private place, verify identity before sharing, secure records and avoid casual conversations in corridors or social media. Disclosure may be justified by patient consent, a legal requirement or a serious and proportionate risk of harm, according to applicable law and professional guidance. 9. Shared decision-making Shared decision-making combines best available evidence with the patient’s values, preferences, circumstances and goals. Present reasonable options, use absolute risks where possible, avoid coercion, and allow time for questions. Include cost, travel, work, family responsibilities, cultural values and expected effects on daily life. 10. Culture, language and health literacy Culture may influence explanations of illness, family roles, consent, pain expression, diet, traditional treatment and end-of-life decisions. Ask rather than assume. Use a trained interpreter when language limits safe care; do not rely on children for sensitive interpretation. Adapt explanations to the patient’s level of health literacy and avoid unexplained jargon. 11. Difficult consultations Angry patient Remain calm, listen without interruption, acknowledge the concern, set respectful limits and seek a practical solution. Do not argue or retaliate. Anxious patient Give time, explain what is known and unknown, identify the feared outcome and agree on the next step. Demand for antibiotics Explore the patient’s concern, explain likely cause and harms, offer symptom relief and safety-netting. Unrealistic expectations Clarify goals, explain limits honestly and offer achievable alternatives. 12. Breaking bad news Use a planned approach such as SPIKES: Setting and privacy; assess the patient’s Perception; obtain an Invitation to discuss detail; give Knowledge in small portions; respond to Emotions with empathy; and provide Strategy and Summary. Avoid false reassurance, excessive jargon and delivering serious news while standing at the doorway. 13. Communication about uncertainty and error Medicine often involves probability. Explain uncertainty honestly and

Social Structures and Health Social structures are the organised patterns, institutions and relationships through which society distributes resources, authority, opportunities, duties and risks. They influence who becomes exposed to illness, who receives protection, whose symptoms are believed, and who can obtain timely and effective care. Learning objectives Define social structure; distinguish status, role, institution, group and social stratification; explain how family, education, economy, politics, religion, gender and health institutions influence health; and apply structural analysis to clinical and public-health problems. 1. Meaning of social structure Social structure is the relatively stable pattern of relationships, rules and institutions that organises social life. It is not a physical object. It is seen in repeated patterns such as who controls land and money, who performs unpaid care, who makes decisions, who can access education, and how services are distributed. 2. Key concepts Status: a person’s social position, such as doctor, student, parent, elder or patient. Role: expected behaviour attached to a status. Institution: an organised system such as family, education, government, religion, economy or health care. Social group: people who interact or share an identity, purpose or experience. Norms: expected rules of behaviour. Values: shared ideas about what is important or acceptable. Stratification: the ranking of people into unequal social layers based on income, power, education, gender, ethnicity or other characteristics. 3. Social stratification and the social gradient Stratification affects exposure to hazards and access to protective resources. People at the lower end of the social gradient are more likely to experience unsafe work, poor housing, food insecurity, violence, stress and barriers to care. The gradient is not limited to the poorest group; health often improves step by step as social advantage increases. Structure Health pathway Example Economic system Determines income, employment and ability to afford essentials Loss of income causes missed medicines and poor nutrition. Gender system Shapes autonomy, workload, violence and reproductive decisions A woman may need permission or money to attend care. Education system Shapes literacy, opportunity and health information Low health literacy affects consent and medicine use. Political system Determines laws, services, social protection and resource distribution Unequal facility funding produces unequal outcomes. Health institution Shapes trust, quality, waiting time, safety and continuity Disrespectful care may cause future avoidance. 4. Family structure and health Families provide food, housing, emotional support, childcare, money, transport and decision-making. They also shape beliefs, gender roles, reproductive choices, discipline, diet and health-seeking. Family conflict, violence, neglect, substance use or exclusion can harm health. Doctors should ask who lives with the patient, who provides care, who controls money and who should be involved in decisions. 5. Education and social mobility Education is a pathway to employment, income, confidence, communication and health literacy. Schools can promote nutrition, hygiene, sexual health, immunisation and mental health, but school exclusion, unsafe schools, disability barriers and unequal quality can reproduce disadvantage. Education should not be reduced to individual responsibility; the quality and affordability of schooling matter. 6. Work, occupation and the economy Work may provide income, identity and social connection. Unsafe work can cause injury, occupational lung disease, poisoning, hearing loss, stress and musculoskeletal disease. Informal workers may lack insurance, sick leave or protection. Unemployment and insecure work may produce anxiety, depression, food insecurity and delayed care. Take an occupational history and consider the patient’s ability to follow a treatment plan while working. 7. Gender and health Sex-related biology affects some diseases, but gender is a social system of expectations and power. Gender influences exposure to violence, unpaid work, nutrition, reproductive decisions, access to money, occupational roles and willingness to seek care. Men may face pressure to avoid care or express distress through substance use; women may face restrictions on autonomy and a disproportionate care burden. Avoid stereotypes and assess the individual’s circumstances. 8. Religion, culture and social norms Religious and cultural institutions can provide support, meaning, ethical guidance and community resources. They can also influence beliefs about causation, contraception, mental illness, disability, death and acceptable treatment. Clinicians should ask what the patient believes is happening, what help has already been sought and what treatments are acceptable, while explaining danger signs and evidence-based care respectfully. 9. Politics, law and public policy Political decisions shape health through taxation, health financing, public transport, roads, water systems, education, housing, labour regulation, food safety, tobacco and alcohol control, refugee policy, disability rights and emergency response. Laws can protect health or create barriers. Health professionals contribute by documenting patterns, advocating for equity and participating in community and policy discussions. 10. Social capital and community participation Social capital refers to trust, reciprocity, shared networks and the ability to act together. Strong community networks can improve epidemic response, vaccination, sanitation, maternal referrals and support for chronic illness. Weak trust, exclusion, misinformation and stigma can reduce uptake. Community participation should be genuine; communities should help define problems and solutions rather than being treated only as recipients. 11. Social structures and mental health Chronic poverty, discrimination, displacement, violence, insecure housing and unemployment can create sustained stress and loss of control. These exposures may contribute to depression, anxiety, harmful substance use, trauma-related illness and suicide risk. Mental-health assessment should include social stressors, safety, support and access to protection—not only symptoms. 12. Social structures and disease patterns Infectious disease Overcrowding, water, sanitation, mobility, occupation, stigma and access to testing shape transmission and outcomes. Non-communicable disease Food systems, work, stress, tobacco marketing, transport and access to preventive care shape risk. Maternal health Gender power, income, transport, respectful care and referral systems affect antenatal and emergency outcomes. Disability Impairment becomes more disabling when buildings, transport, communication and attitudes exclude people. 13. Structural violence and stigma Structural violence occurs when social arrangements systematically expose some groups to preventable harm. Stigma can reduce employment, housing, relationships and healthcare access. Doctors should use person-first language, protect confidentiality, challenge discriminatory practice and ensure that clinical decisions are based on need rather than social status. 14. Applying structural analysis to a patient Describe the clinical problem clearly. Identify immediate biological and behavioural risks. Ask what family, institutional,

Health-Related Behaviours: Acquisition, Maintenance and Modification Health-related behaviour is any action or pattern of action that influences health, illness, prevention, treatment, recovery or quality of life. This note explains how behaviours are formed, why people maintain them, and how doctors can support safe and lasting change. Learning objectives Define health-related behaviour; classify protective, preventive, illness and risk behaviours; explain biological, psychological, social and cultural influences; apply major behaviour-change theories; and design a patient-centred behaviour-modification plan. 1. Meaning and importance Health-related behaviours include eating, physical activity, sleep, hygiene, sexual practices, tobacco and alcohol use, medicine-taking, immunisation, screening, seeking care, attending follow-up and responding to symptoms. Some behaviours promote health, some increase risk, and many have both benefits and harms depending on context. 2. Types of health-related behaviour Health-promoting behaviour: balanced nutrition, exercise, sleep, hand hygiene, breastfeeding and stress management. Preventive behaviour: vaccination, antenatal attendance, screening, safer sex, mosquito-net use and early testing. Illness behaviour: noticing symptoms, interpreting them, deciding whether they are serious and choosing where to seek help. Sick-role behaviour: accepting treatment, resting, following restrictions and cooperating with rehabilitation. Risk behaviour: tobacco, harmful alcohol use, unsafe sex, inactivity, unsafe driving and medicine misuse. 3. How behaviours are acquired Behaviour develops through observation, imitation, reinforcement, habit, emotion, knowledge, social expectations and the opportunities available in the environment. Children learn from parents and peers. Adolescents are strongly influenced by identity and peer acceptance. Adults may use behaviours to cope with stress, pain, loneliness or economic insecurity. 3.1 Learning and reinforcement A behaviour that produces a rewarding result is more likely to be repeated. Relief after taking a sedative, social approval after drinking, or immediate pleasure from sugary food can reinforce behaviour even when long-term health effects are harmful. Behaviour change therefore requires alternative rewards and practical coping skills. 3.2 Social learning People learn by observing role models and by judging whether they are capable of performing the behaviour. Confidence, or self-efficacy, is central. A patient who believes that exercise is impossible because of pain, poverty or lack of safety needs a graded and realistic plan. 4. Influences on health behaviour Influence Examples Clinical implication Knowledge and beliefs Perceived causes, benefits, risks and traditional explanations Correct misinformation respectfully and connect advice to the patient’s understanding. Emotion and mental health Stress, depression, trauma, anxiety and coping Screen for psychological drivers before labelling behaviour as non-compliance. Family and peers Support, pressure, modelling and stigma Involve supportive relatives with consent and protect confidentiality. Culture and religion Food rules, healing traditions, gender roles and beliefs about illness Use culturally safe communication and negotiate rather than ridicule. Environment and resources Food prices, transport, safe spaces, work schedules and medicine availability Make the plan achievable in the patient’s real setting. Health services Trust, waiting time, cost, communication and continuity Improve access and service experience, not only patient education. 5. Health Belief Model The Health Belief Model proposes that action is influenced by perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. A patient may not test for HIV if they feel not susceptible. A patient may delay hypertension review if the disease feels harmless. A reminder, family encouragement or a symptom can act as a cue. Transport cost, fear of stigma and side effects are barriers. Doctors should address each belief instead of giving a general lecture. 6. Theory of Planned Behaviour Intention is influenced by attitude toward the behaviour, perceived social expectations and perceived control. A patient may intend to stop smoking but feel unable to do so because friends smoke, stress is high and treatment is unavailable. Strengthen intention and practical control together. 7. Stages of Change Precontemplation: the person is not considering change. Contemplation: the person is ambivalent. Preparation: the person plans a change. Action: the person is actively changing. Maintenance: the new behaviour is sustained. Relapse: the old behaviour returns; this is a learning opportunity, not proof of failure. Advice should match readiness. Motivational interviewing is more useful than arguing with a person who is not ready. 8. Social Cognitive Theory Behaviour is shaped by reciprocal interaction between the person, behaviour and environment. Key ideas include observational learning, self-efficacy, outcome expectations, goals, self-regulation and reinforcement. A doctor can help the patient set a small goal, monitor progress, anticipate barriers and reward improvement. 9. Behaviour modification in clinical practice Ask permission to discuss the behaviour. Assess what the patient does, when, where, with whom and why. Identify benefits and costs from the patient’s perspective. Explore readiness and confidence on a 0–10 scale. Agree on one or two specific changes. Use SMART goals: specific, measurable, achievable, relevant and time-limited. Provide skills, alternatives, reminders and follow-up. Review progress without shame and adapt the plan. 10. Motivational interviewing principles Use open questions, affirmations, reflective listening and summaries. Express empathy, develop discrepancy between goals and current behaviour, avoid direct confrontation, support autonomy and elicit the patient’s own reasons for change. Example Instead of saying “You are careless because you do not take your medicines,” ask: “What makes it difficult to take them every day?” This may reveal cost, shift work, side effects, forgetfulness or misunderstanding. 11. Common behaviours and clinical applications Medication adherence Check access, dosing complexity, beliefs, side effects, memory, literacy and family support before changing treatment. Nutrition Assess food security, culture, income, cooking facilities and the patient’s goals; avoid unrealistic diets. Substance use Screen non-judgementally, assess dependence and safety, offer brief intervention and referral where needed. Prevention Explain absolute benefits, address fear and access barriers, and use reminders for vaccination and screening. 12. Barriers and relapse Relapse may follow stress, illness, social pressure, treatment side effects, financial crisis or loss of support. A prevention plan identifies high-risk situations, coping alternatives, emergency contacts and a rapid return to care. Avoid language that increases shame, because shame can drive concealment and further risk. 13. Doctor’s role Model respectful and healthy professional behaviour. Screen for risk behaviours routinely and privately. Link behaviour to the patient’s own health goals. Address social determinants that make change difficult. Use

Social Determinants of Health: Complete Doctor’s Notes Health is not produced only inside a hospital. A person’s health is shaped by biology, behaviour, family, culture, income, education, housing, work, environment, politics and the health system. These notes provide a detailed, clinically useful explanation of the social determinants of health (SDOH) for medical students, doctors and other health professionals. Learning objectives After studying this topic, the learner should be able to define health and its determinants; explain the social gradient, health inequalities and health inequities; describe the Dahlgren–Whitehead model; classify structural and intermediary determinants; connect each determinant to disease pathways; take a socially informed history; and plan individual, community and policy-level responses. 1. The concept of health 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. In practice, health is multidimensional. It includes physical functioning, emotional and mental well-being, social relationships, ability to work or learn, ability to adapt to change, and the capacity to participate in family and community life. Health can therefore be understood at three related levels: Individual health: the condition and functioning of one person. Population health: the health outcomes of a defined population and how those outcomes are distributed. Health equity: the removal of unfair and avoidable differences between groups. 2. What are social determinants of health? Social determinants of health are the conditions in which people are born, grow, learn, work, live and age, together with the wider economic, social, cultural, environmental and political forces that shape those conditions. They include access to power, money, education, food, housing, transport, information and health services. They are called “social” because they are largely created or modified by families, communities, institutions, markets, governments and social relationships. They are called “determinants” because they influence exposure to risks, vulnerability, health behaviours, ability to obtain care and the consequences of illness. Do not oversimplify SDOH do not mean that social factors replace biology. Disease results from interaction between biological susceptibility, exposure, behaviour, environment and access to effective care. A socially informed doctor asks what happened medically and what circumstances made that illness more likely, more severe or more difficult to treat. 3. Why the determinants of health are important They explain why people with the same diagnosis may have different outcomes. They help clinicians identify causes and risks before complications occur. They guide prevention, health promotion and community diagnosis. They reveal why some patients repeatedly return with the same problem. They help health systems target resources where avoidable risk is greatest. They shift practice from blaming individuals to addressing modifiable causes. Social conditions can influence exposure, susceptibility, disease recognition, health-seeking behaviour, treatment adherence, recovery, disability and survival. They may operate before birth, accumulate across life and pass through generations. 4. Dahlgren–Whitehead model: the “rainbow” of determinants The Dahlgren–Whitehead model presents determinants as layers around the individual: Layer Main elements Clinical meaning Individual factors Age, sex, genetic inheritance and constitutional factors Influence vulnerability, development, reproductive health and disease risk. Individual lifestyle Diet, activity, tobacco, alcohol, sleep, coping and sexual behaviour Behaviours affect risk, but choices are constrained by social circumstances. Social and community networks Family, friends, peers, faith groups, community organisations and participation Provide emotional, practical and informational support or may create pressure and stigma. Living and working conditions Housing, education, employment, workplace, water, sanitation, food, transport and health services Shape daily exposure, access and the ability to protect health. General socioeconomic, cultural and environmental conditions Government, policy, economy, culture, social norms, environment and distribution of resources Set the rules and opportunities that produce social position and health inequity. 5. Structural determinants Structural determinants create the social hierarchy in which people live. They include governance, laws, public policy, economic systems, social protection, taxation, education policy, labour markets, gender relations, racism, disability discrimination, conflict and commercial influence. 5.1 Socioeconomic position Income, wealth, education and occupation influence food, housing, transport, safety, social networks, health literacy and the ability to pay for care. Poverty may cause illness directly through deprivation and indirectly through stress, unsafe work and delayed treatment. Wealth can protect health by providing choices and buffers during illness. 5.2 Political and policy environment Government decisions affect health through health financing, public education, water systems, roads, housing regulation, food safety, tobacco and alcohol control, employment protection, social protection, refugee policy and emergency preparedness. A policy can create health or harm even when it is not labelled a health policy. 5.3 Gender, discrimination and social exclusion Gender norms influence autonomy, exposure to violence, nutrition, workload, reproductive decisions and access to money. Discrimination based on ethnicity, disability, HIV status, mental illness, age, religion, sexuality or poverty may reduce trust and delay care. Doctors should recognise discrimination as a health risk, not as a patient defect. 6. Living and working conditions 6.1 Housing and physical environment Overcrowding, poor ventilation and indoor air pollution increase respiratory infections and chronic lung disease. Unsafe structures increase injuries. Dampness and mould can worsen asthma. Insecurity and homelessness increase stress and make storage of medicines and regular follow-up difficult. 6.2 Water, sanitation and hygiene Unsafe water, inadequate sanitation and poor hand hygiene contribute to diarrhoeal diseases, helminthic infections, cholera, typhoid and other outbreaks. Doctors should ask about water source, storage, latrine access, handwashing facilities and household crowding when evaluating recurrent gastrointestinal or infectious illness. 6.3 Food and agriculture Food insecurity can cause undernutrition, anaemia, poor immunity, poor fetal growth and impaired learning. Cheap energy-dense foods can contribute to obesity, hypertension and diabetes. Agricultural work may involve pesticides, injuries, zoonoses, heat exposure and musculoskeletal strain. Food safety includes production, storage, preparation and distribution. 6.4 Employment and unemployment Work can provide income, purpose and social connection, but may also expose people to dust, chemicals, noise, radiation, infection, heat, repetitive strain and injury. Unemployment may cause poverty, anxiety, depression, loss of routine and inability to pay for care. Ask about occupation, hazards, protective equipment, working hours and income insecurity. 6.5 Education and health literacy Education improves employment opportunity,