Synthesising Perspectives: Case
Studies for Action
Session outcomes
• Understand the strengths and weakness of
Dahlgren and Whitehead model of
determinants of health
• Understand how different strategies can
be used to tackle health problems by
focusing on case studies
Determinants of Health
Dahlgren and Whitehead 1991
Key strengths of the rainbow model
• Relatively simple to conceptualise
• Demonstrates the interconnectness of the layers
in shaping health
• Demonstrates how individual choice is a
relatively small determinant of health
• Provides a tool to examines complex causal
pathways and how they may determine health
• Acknowledges the necessity for multi-layer
action to address health
Case study
Malaria basics and context
• Globally malaria causes an estimated two million deaths and
300 million diagnoses annually (Walley, Webber & Collins,
• There are four types of malaria which can infect humans and
the potentially most deadly of these is Plasmodium Falciparum
which is carried by a mosquito vector.
• Being bitten by an infected mosquito can cause the
transmission of the parasite from the saliva glands of the
mosquito to the human bloodstream.
• The liver where multiplication of the parasites takes place.
These are released into the bloodstream and produce toxins
which cause the physical symptoms of infection – high
temperature, headaches and pain (Walley, Webber & Collins,
The determinants of malaria
The influence of other
people on using
preventive measures
and seeking help are
Poverty and
disadvantage are directly
linked to malaria, for
example, being able to
afford treatment .
Water storage and
control of vector
breeding sites are
significant for the
management of
Access to quick
and effective
treatment (of lack
of) is a key
determinant of
outcomes once a
person is infected
with malaria.
behaviours such
as using an
insecticide treated
bednet are
significant in the
prevention of
Age is an
important factor.
For example,
children are more
vulnerable to
Addressing malaria
• Primary prevention approaches
Development of vaccinations to protect against
exposure of Plasmodium sp.
Spraying of households and environments to
destroy mosquitos to prevent transmission of
Plasmodium sp.
Use of insecticides and covering skins to avoid
being bitten by mosquitos
Addressing malaria
• Lifestyle and behavioural approaches
Compliance and adherence to preventative
behaviours such as using insecticide treated nets
Understanding the nature of transmission of
malaria and its associated vector.
Lay beliefs about the causes and prevention
startegies of malaria are important in shaping
Addressing malaria
• Changing the social and economic environment
Subsidising or providing free ITNs
Removing stagnant pools of water near dwellings
would prevent reproduction of mosquitos which
need water to breed.
Addressing malaria
• Policy initiatives
Eradication of malaria requires political will to
reduce the poor socio-economic circumstances
in which people live.
For improved access and usage of ITNs political
action is required.
Action on climate change is needed to prevent
wider distribution of infected mosquitos to
more temperate areas of the world.
Case study cervical cancer
• Approximately half a million women develop cervical cancer every year,
and almost half of those diagnosed die as a result (WHO 2010b).
• Cervical cancer accounts for 1 in 10 cancers diagnosed in women
worldwide (Cancer Research UK, 2010) and causes the greatest problems
in low-income countries in which health care resources are limited (Bosch
et al (1995).
• Furthermore, in the UK, approximately 55 women are diagnosed with
cervical cancer every week (Cancer Research UK, 2010).
• Finally, in the UK, around two thirds of women survive the disease for five
years or more with survival rates being much higher in women diagnosed
at a younger age. Women diagnosed under 40 years of age have survival
rates of more than 85% (Cancer Research UK, 2010). Despite these
survival rates, women diagnosed with this type of cancer die younger than
in most other cases of cancer (Currin et al 2009)
• Cervical cancer is caused by particular strains of use a sexually transmitted
virus Human Papilloma Virus (HPV).
The determinants of cervical cancer
Effective screening
programmes are
successful at early
detection and are a
determinant of
Poverty and
disadvantage are directly
linked to cervical cancer
for example, the ability to
negotiate safe sex is
affected by societal
Access to quick and
effective treatment (of
lack of) is a key
determinant of outcomes
once a woman is
diagnosed with cervical.
behaviours such
as not smoking
are important in
reducing the risk
of cervical
Age is an important factor.
For example, delaying the
age of first intercourse is
important in reducing the
risk of cervical cancer.
Addressing cervical cancer
• Primary prevention approaches
Development of Human Papilloma Virus (HPV)
vaccination programme will protect young
women against the causative agent of cervical
Screening programmes (both Pap smears and
HPV swabs) can be used to detect at risk young
women to have preventive treatment.
Addressing cervical cancer
• Lifestyle and behavioural approaches
Delaying the age of first sexual intercourse
Using barrier methods such as condoms will
prevent against transmission of HPV.
Compliance and adherence to both vaccination and
screening programmes.
Education about the risks of HPV via schools SRE
Caution needed here not to victim blame
Addressing cervical cancer
• Changing the social and economic environment
Links between social position and cervical cancer
can be found (Currin, 2009).
Changing the culture of sexual behaviour in which
partners can negotiate safer sex is the goal of
changing to social environment.
Changing the stigma associated with HPV may aid
fuller discussion about cervical cancer.
Addressing cervical cancer
• Policy
Evidence that more liberal approaches such as
those in Holland will lead to reduction in unsafe
sexual behaviour.
Stronger commitment to lifeskills approaches to
Commitment to resourcing vaccination and
screening for HPV.
Case study:
neighbourhoods as a setting for health
• There is a strong relationship between health and place
• A ‘settings approach’ to health promotion came from Ottawa Charter
for health promotion stating that “Health is created and lived by
people within the settings of their everyday life; where they learn,
work, play and love” (WHO, 1986 p 6).
• It was proposed that health promotion activities take place in
settings and their associated systems to improve overall health.
Investments in health are made in social systems for which health is
not their primary remit (Dooris, 2004).
• Neighbourhoods provide a major setting in which people live and
work and can be thought of as a location in which a raft of health
promotion strategies can be applied.
• Naidoo and Wills, (2009) suggest that neighbourhoods are a key
setting for health promotion because physical and social
environments interact with other service provision such as health
care, welfare services, important hubs like a pubs, shops, post
offices, community centre and churches.
Determinants of neighbourhoods
Trust or conflict
Active thriving local
economy for jobs
Physical environment
quality: green spaces
or dirty littered places
Pollution: air
and water
cars, public
transport &
road building
league tables
and distance
of health care
networks &
Local food
Individual factors by definition in this case study
are of less importance except that collectively
they make up a community profile of ages and
genders which will govern the needs of the
Type of
and design
of estates &
Critiques of rainbow model
• The framework tends to be more descriptive rather than
analytical about the relationships between different
influences on health.
• The model, as it stands, neglects global, political and
historical determinants of health.
• As a model to depict the determinants of health, rather
than health inequalities the distinction between the
social factors influencing health and the social processes
determining inequality can easily become confused.
• Determinants of health resulting from the lifespan are
also not considered in the model with any great effect.
Summary Barton and Grant (2006)

Synthesising Perspectives: Case Studies for Action