Social health

For 75 years, the Constitution of the World Health Organization (WHO) has defined ‘health’ not merely as the absence of disease, but as a ‘state of complete physical, mental and social well-being’ (WHO, 1946). The WHO’s definition certainly isn’t undisputed. However, it does present an opportunity to gain a better understanding of both increasing health inequality and the social aspects of health in general.

Experts from three universities and from the Federal Office of Public Health (FOPH) have compiled different perspectives on the social aspects of health and transformed them into a common, interdisciplinary definition.

The shared objective of establishing a definition for ‘social health’ was based on the belief that, in order to develop public health, greater focus must be placed on social aspects. The results of this process, which lasted several days, will be published on this website and presented for discussion. 

‘My research focuses on the role of religious models of interpretation in vaccine-sceptical discourse. This issue is inextricable from the context of the public and media arenas in which social health is negotiated. This workshop allowed me to engage constructively with a very topical issue in a highly interdisciplinary context.’
Ass. Prof. Andrea Rota

‘When it comes to health promotion, it’s important to establish a common understanding of social health in terms of social quality of life and cohesion. The workshop provided an opportunity to define this term in an interdisciplinary and transdisciplinary context.’
Dr. Sebastian Mader

References, bibliography

• Knapp, J., Zeratsky, J., & Kowitz, B. (2016). Sprint: How to Solve Big Problems and Test New Ideas in Just Five Days (1st edition). Redline Verlag. 
• Max-Neef, M. A. (ed.). (1991). Human scale development: Conception, application and further reflections. Apex press. 
• Obrecht, W. (2005). Umrisse einer biopsychosoziokulturellen Theorie menschlicher Bedürfnisse: Geschichte, Probleme, Struktur, Funktion. [Outline of a biopsychosociocultural theory of human needs: History, Problems, Structure, Function]. Zurich. Hochschule für Soziale Arbeit. 
• Pauls, H. (2004). Klinische Sozialarbeit: Grundlagen und Methoden psycho-sozialer Behandlung. (Grundlagentexte soziale Berufe) [Clinical Social Work: Foundations and Methods of Psycho-Social Treatment. (Fundamental texts on social professions)]. Juventa-Verlag.  
• Pfaff, H., Ernstmann, N., Driller, E., Jung, J., Karbach, U., Kowalski, C., Nitzsche, A., & Ommen, O. (2011). Elemente einer Theorie der sozialen Gesundheit [Elements of a social health theory]. In Gesundheit und Gesellschaft [In Health and Society]. Die Gesellschaft und ihre Gesundheit: 20 Jahre Public Health in Deutschland / Bilanz und Ausblick einer Wissenschaft [Society and its health. 20 years of public health in Germany/Review and outlook of a science] (pp. 39– 68). VS Verlag für Sozialwissenschaften.
• WHO. (1946). Constitution of the World Health Organization. New York. WHO. 
   

Definition

We understand social health as a series of dynamic processes of dialogue and negotiation, in which participants discuss existing knowledge about the social determinants of health, as well as different visions regarding the desired state of health and society.  

The process of developing social health involves researchers who focus on the determining factors for the attainment of health. It also involves representatives of different social groups who present varied and competing physical, mental and social objectives and needs. In processes of dialogue, and taking into account the scarcity of resources, these parties plan, implement and evaluate community health services.

Application

This definition of social health can be applied to a wide range of social settings, social systems and communities.

• A socially healthy company will invest in occupational health and invite its employees to take part in discussions on setting health-related goals.
• A socially healthy community will identify the key health risks impacting its residents and work with them, and with the affected groups, to find solutions.
• A socially healthy family will discuss its health-related strengths and challenges together. Its members will reflect on their behaviours and habits, and acquire the skills necessary to achieve the health-related goals they have set.
   

Relevance

The definition of social health presented here fills the vacuum surrounding the concept of ‘social health’. When it came to defining this term, we made a conscious effort to maintain great analytical distance, so that the results could be applied to different fields of application.

The problem, i.e. a lack of definition for ‘social health’, was addressed using the SPRINT method (Knapp et al., 2016). In the course of two workshops, the participating experts presented how they define social health, identified similarities and differences, and then transformed them into a common definition. In two subsequent workshops, the results were refined and participants discussed publications and further projects.

Fundamental assumptions

The term ‘social health’ fundamentally refers to the fact that health is always a result of collective action. Health is therefore a communal outcome that depends both on the resources available to the community and on personal social relationships. In this context, the individual participates in a reciprocal exchange with their community services. The individual contributes to the functioning of the group or community and, in return, benefits from its health services (Pfaff et al., 2011).

Taking into account the finite resources available, the members of these communities not only need to discuss the distribution of community services, but also the desired state of health. Based on a biopsychosocial understanding of health (Obrecht, 2005; Pauls, 2004), it is assumed that social objectives – alongside physical and mental objectives – should be given equal weight in the discussion of desired states of health. Social needs, such as justice, social participation, social recognition and a sense of purpose, could lead the way in this discussion (Max-Neef, 1991; Obrecht, 2005). 

Defining social health

Socially healthy communities take into account the social determinants of health, as well as social objectives and needs. Their members not only discuss the distribution of community health services, but also the desired underlying state of health in general. The social health of a community is built on two independent aspects: knowledge bases and health dialogue.

Social health is not an end state to be achieved. Rather, social health must be understood as a continuous process occurring between a participatory health dialogue and health-related knowledge bases. By means of this process, it is possible – considering the scarcity of resources – to plan, implement and evaluate socially accepted community services (see image 1).

In this context, ‘health’ is understood as an attribute of social communication. ‘Social health’ is the ability of communities to engage in an open, enlightened and respectful dialogue aimed at balancing physical, mental and social objectives. In this dialogue, the participants identify knowledge gaps, which are then incorporated into the ‘knowledge bases’ aspect in the form of research questions.

Normative objective

To cultivate an open dialogue in order to address the question of good physical, mental and social health. In this context, ‘openness’ is characterised by a participatory process that establishes trust, meaning and social cohesion.

Analytical objective

To objectively address the question of how to create balanced community services in order to address health problems. To empirically discuss how a participatory discourse can be conducted.

Examples of implementation

National health act

A national health act would provide an opportunity to define the principles and objectives of a national health policy. In this case, parliament, political parties and civil society would need to cultivate a public health dialogue in order to establish physical, mental and social objectives, as well as an overarching and unifying definition of health. 

Health2030 Strategy

The Federal Health2030 Strategy reflects a consensus among various politicians and experts who have been discussing the most urgent challenges facing Swiss health policy. Based on existing knowledge, four strategic approaches were defined for the promotion of equal opportunities (Chapter 6.1). 

Referenda on the COVID-19 Act

The referenda on these legal provisions result in a public health dialogue that weighs up physical, mental and social objectives and interests. The possibility of a referendum forces both the public and politicians to find a solution in the form of a workable compromise between fundamentally incompatible needs and views.

In this context, ‘health’ is understood as an attribute of individuals. ‘Social health’ is understood as the ability of communities to establish the knowledge bases required to contribute to an improved understanding of health-related phenomena. In particular, this covers the social and environmental determinants of health that result in different means of attaining health. The acquired knowledge is translated into a form that can be used in the health dialogue.

Normative objective

To establish knowledge bases, by means of scientific research, in order to gain a better understanding of health phenomena. To use objective knowledge to improve judgement and informed decision-making processes.

Analytical objective

To empirically and objectively describe and explain health phenomena.

Examples of knowledge bases

Equal opportunities in health promotion and preventive care in Switzerland

The ground-breaking overview document on health inequality and injustice in Switzerland summarises the key findings and models for explaining health inequality. In addition, success criteria and solutions are discussed within three subject areas: nutrition and physical activity, mental health and tobacco consumption.

Health of residents in receipt of social benefits

A study commissioned by the FOPH investigated the state of health among residents in receipt of social benefits over time and compared it with other sections of the population. Among other things, the study shows that these residents experience a deterioration in health even before they start receiving social benefits. Residents in receipt of social benefits consult their doctor twice as often and are treated for mental health problems almost five times as often.  

Access to healthcare

Access to healthcare services is an important determining factor for an equitable healthcare system. A recent international analysis showed that in Switzerland, 26% of people on low incomes report financial barriers to healthcare access. That’s more than twice as many as in the United Kingdom, for example.
 

Both the health dialogue and the development of knowledge bases are underpinned by shared fundamental values that vary over time and depending on locality. These shared fundamental values are found, for example, in international laws, constitutions, professional codes and business strategies. Democratic values such as transparency, freedom of expression and the ability to reach a consensus are particularly significant for the conception of social health presented here.

Community services are the result of public dialogue and knowledge bases. Both of these aspects are essential for the effective planning, implementation and monitoring of community services. If the ‘knowledge bases’ aspect is unbalanced, the steps taken may not be effective. If the dialogue is not participatory enough, or does not exist at all, the steps taken may seem disempowering or paternalistic. 

Case study: social health in an urban neighbourhood

Seventy-two-year-old Ueli has lived in a quiet condominium with a view of the countryside for several decades. He is financially secure and enjoys his retirement. He sings in a choir, which he is very passionate about, and regularly meets up with friends at his local pub to eat and play cards. Until recently, he enjoyed taking trips to the Mediterranean. But over the past few years, travelling has become too strenuous for him.

Ueli is content with his life, but since his wife passed away five years ago, he has been living alone in his large family flat. He rarely sees his two children because they live abroad. Ueli enjoys company, but the isolation of the pandemic – during which his choir practices were cancelled and the pubs were closed – left him lonely and sad.

During the pandemic, a family of five with small children moved into Ueli’s building and rented the flat next door to his. The children hit it off with Ueli right away and now he looks after them on a regular basis. He has found a new lease of life and greatly enjoys this new occupation. In return, the children’s parents help Ueli when he is faced with a new challenge of the digital world.

Ueli’s quality of life has now improved dramatically and he feels part of the community. Thanks to the efforts of local cooperatives and support from the city, it was possible to open a neighbourhood meeting place that includes a spacious playground, as well as a small hall for events. Ueli sits on the local committee, where he represents the interests of his neighbourhood. Thanks to financial support from the city, the community is able to collectively plan, implement and evaluate participatory projects relating to family, ageing and health promotion.
 

The following matrix is proposed for any research on social health. This matrix makes it clear that research questions can be derived from the perspectives of the population and the community. Depending on the perspective in focus, the subject matter of the research is either the healthy life of individuals or healthy coexistence.