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Introduction to Population Health

     Population Health refers to the health status, health outcomes and health distribution of a group of people as opposed to a single individuals health status (Keyes & Galea, 2014). Factors that can influence population health include social determinants of health (SDOH) such as housing, education and poverty.

Social Determinants of Health Overview 

     Social determinants of health (SDOH) can be divided into five domains that describe the conditions that affect a person’s quality of life outcomes and risks. The five domains are economic stability, health care access and quality, social and community context, education access and quality, and neighborhood and built environment. These domains include all conditions or environments where people may live, learn, work, play, worship, and their age that may affect their health. (Social Determinants of Health – Healthy People 2030 | Health.Gov, n.d.) 

   Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [June 19, 2022], from  https://health.gov/healthypeople/objectives-and-data/social-determinants-health  

Domain:	Economic Stability	Health Care Access and Quality	Social and Community Context	Education Access and Quality	Neighborhood and Built Environment
Goal:	To help people earn steady incomes to help them meet their health needs	Increase access to comprehensive, high-quality health care services	Increase social and community support	Increase educational opportunities and help children and adolescents do well in school	Create neighborhoods and environments that promote health and safety
Methods of improvement:	Employment programs	Strategies to increase insurance coverage	Encouraging positive relationships	Tutoring programs	Policy changes to reduce neighborhood violence
	Career counseling	Improve communication	Offering support programs in communities	Financial assistance for college	Adding sidewalks and bike lanes in neighborhoods
	Child care opportunities	Provide transportation		Support for children with disabilities in school	Increasing safety
	Wellfare Policies to help with funding				Reducing unsafe air or water
	Education
Citation:	(Social Determinants of Health – Healthy People 2030 | Health.Gov, n.d.)

 

     “The longer people live in stressfull economic and social circumstances, the greater psychological wear and tear they suffer, and the less likely they are to enjoy a healthy old age (“Social Determinants of Health: The Solid Facts, 2nd Ed,” 2004).” SDOH has a major impact on people’s health and well-being and can act affect them in multiple different ways. For example, if a person does not have access to good education, it reduces their likelihood of graduation, which reduces their ability to get a job that can fund their needs. Without appropriate funds, they will not have access to appropriate health care, healthy food, physical activity opportunities etc. These instances will decrease a person's overall health and can lead to malnutrition, diabetes, heart disease and obesity. This is just one example of how SDOH can impact a person’s life. (Social Determinants of Health – Healthy People 2030 | Health.Gov, n.d.) 

 Countries Reviewed

Egypt-

· Egypt is a developing country. Civilization is molded around religious concepts. Uses Hieroglyphics as a form of written word. The afterlife was more of a consideration than the present, pyramids are shrines to the dead so they can be prepared for the afterlife. (CIB, 2021)

· Egypt demographics are 1/3 made up of people aged 15 and younger. Egypt will be implementing the family planning act to help decrease birth rates currently in the country. (CIB, 2021). 

· Healthcare beds have increased along with the budget from the Ministry of Health to cover public health. Most healthcare offered to the public is of low status. There is no shortage of healthcare workers in larger cities. Preventative medicine is becoming a widespread topic. Mandatory vaccination for smallpox, TB, polio, diphtheria, and other fatal diseases is enforced for infants. Public mosquito control by spraying houses is a common task. (Encyclopedia Britannica, n.d.)

· Strengths include the longevity of the healthcare governing system has good reputation, plenty of local health facilities allowing around 95% of residents to live within 5km, longevity of the insurance and social health program, large pharmaceutical industry, and a focus on immunizations. (Dept of Health, 2022).

· Weaknesses include increased out of pocket spending, lack of integrated services and multigravida communication, low quality of healthcare, fragmented policy to regulate facilities, and lack of workforce demotivation and dual practice. (Dept of Health, 2022). 

· Healthcare has been attempted to become socialized by the government. This would regulate big pharma and insurance boundaries. There is mandatory insurance for companies with greater than 100 workers, people who work for the public offices as well as government agencies also fall in this insurance category. (Encyclopedia Britannica, n.d.)

ACEs

     Adverse Childhood Experiences or “ACEs” are potentially traumatic events that occur between the ages of 0 and 17 years, during childhood. ACEs have been linked to chronic health problems throughout adolescence and adulthood. These experiences are preventable.  

     One of Egypt's more notable disparities is child and maternal survival and health. Mortality rates have declined in the last decade but still remain substantial in the most disadvantaged areas of the country.  Under the age of 5 mortality rates have declined from 108 to 27 per 1,000 live births.  By 2014 only around 92 percent of births were attended by a skilled birth attendant.  (Health UNICEF Egypt, n.d.) Improvement requires the country to address geographical inequalities, and improve the quality of health care servcies. Other areas of need to improve are improving resources available, and decreasing pollution. (Health UNICEF Egypt, nd.) The discipline that is making an impact would be primary care in the country.  There is a primay care facilitiy available within five kilometers for 95% of the population. (WHO EMRO, Egypt, 2015)

     In Egypt nutrition is the second largest contributer to poverty in Egypt for children under the age of five. The figure below, from the Unicef child malnutrition snapshot infographic depicts the puzzle pieces that affect a child's well being.  (Data Snapshots | UNICEF Egypt, n.d.) 

    A very preventable adverse childhood experience in Egypt is female gential mutilation (FGM).  Although efforts have been made to decrease FGM drastically, there are still girls at risk of undergoing FGM, and it has already undergone the mutilation.  As of a report in 2015, 78% of girls ages 1-14 were mutilated between the ages of one and fourteen. SDOH affect the chances and outcomes of FGM.  For example the higher the mother's education level, the lower the chances a girl will be forced to undergo the procedure. FGM can cause long term psychological and health complications that are often irreversible.  It is also more prevalent in the rural areas of the country. (Data Snapshots | UNICEF Egypt, n.d.)  

     

Gerontology

Egypt

Less than one in twenty Egyptians are 65 years of age or older (Salama and Roe, 2020). Dementia is a growing issue in this smaller population, but there is little treatment guidance for practitioners to follow. Additionally, depression is an increasing issue in this population that is not widely discussed and is associated with shame (El-Gilany, Elkhawaga, & Sarraf, 2018). Despite the small population, there are social services and services available to the elderly. The Egyptian government provides institutional homes, elder people clubs, social training programs, and discounts for many recreational activities. Gerontological research does predict an incrrease in the elderly population in the upcoming years. Nursing and physician programs also include training modules for improving and caring for the elderly population. 

Economics

In Egypt, one of the largest social determinants of health involved the sex differences in access to care (Assai et al., 2006). Poverty is also a large social determinant of health in Egypt with one third of the population below the poverty line and a low economic freedom at 49.1 (Egypt, 2022) in comparison to Japan's score of 69.9 (Japan, 2022). Similarly both countries have a low participation of female inclusion in the workforce. 

                                           

                                                                                                          Egypt                                                                                                                                                                                                                                                                       

· Population

1. 102.3 million

1. Unemployment rate

2. 10.5%

1. Economic Growth

3. Has accelerated over last 5 years

3. Top Exports

· Oil & Mineral Fuels, Precious Stones & Metals, and Plastics

3. Top Trade Partners

· China, United States, and Saudi Arabi

1. Economic Weakness

4. 1/3 of population in poverty

4. low female labor participation

1. Government

5. Republic

5. 49.1 economic freedom 

5. (Egypt, 2022)

Societal Norms/Intolerances

Egypt

· Relaxed attitudes toward time and punctuality

· The social class an Egyptian is born into tends to dictate many aspects of their everyday life and access to opportunities. 

· The concept of honor or "sharaf" is held to a high regard and regularly influences daily interactions. 

· Family loyatly is highly valued and the society is collectivitist where people do what's best for their family and not themselves. 

· Islam is the predominant religion that guides the social rules, actions, and laws. 

Culture

Culture: “the combination of a body of knowledge, a body of belief, and a body of behavior” 

(Cultural Respect | National Institutes of Health (NIH), n.d.) 

     Culture includes several elements that are specific to a particular culture including but not limited to, racial, religious, geographic, and social groups, including language, thoughts and beliefs. These elements can influence the beliefs and belief systems surrounding health and the delivery of health services. (Cultural Respect | National Institutes of Health (NIH), n.d.) Culture respect is important in delivering high quality health care. Showing respect towards diverse patients and the provider’s willingness to understand the patient’s cultural background increases the responsiveness and understanding. (Cultural Respect | National Institutes of Health (NIH), n.d.)  

Eqyptian Culture and Healthcare 

     The Egyptian Culture today combines traditional and modern health practices. Including herbal medications, seers and spirit healers. They also believe in naturalistic and social causes of sickness, like bad luck, stress and bereavements. Therefore, they may not wish to know the possible potential complications of a procedure thinking it may be bad luck. (Egyptian – Cultural Approaches to Pediatric Palliative Care in Central Massachusetts – Resource Guides at University of Massachusetts Medical School, n.d.) 

     Marriage and childbirth are important focuses of the Egyptian culture. Pregnancy is natural and expected, which has led to extremely high birth rates and poses risks for mothers who do not deliver in proper facilities. (Health | UNICEF Egypt, n.d.) Also, all boys are circumcised and 97% of girls experience female genital mutilation. (Egyptian – Cultural Approaches to Pediatric Palliative Care in Central Massachusetts – Resource Guides at University of Massachusetts Medical School, n.d.) 

     Egyptian families may prefer to relay negative prognosis to the patient themselves, in a gradual and prolonged manner. Unlike the Japanese culture, verbal permission is more acceptable than written consent as it is based on trust. (Egyptian – Cultural Approaches to Pediatric Palliative Care in Central Massachusetts – Resource Guides at University of Massachusetts Medical School, n.d.) 

     Because Egypt is a developing country, major efforts have been made to improve outcomes for mothers and babies, and in reducing female genital mutilation. (Data Snapshots | UNICEF Egypt, n.d.; Health | UNICEF Egypt, n.d.) It may not be the case if these efforts had not come from elsewhere. Overall, the country of Egypt needs to be prepared for the increased population and the need to increase hospital beds and facilities in the future.  

Societal Goals

Egypt 

 The developing country of Egypt started a bold legislative framework in 2016 with the hopes of goal achievement by 2030. Egypt Vision 2030 was created to align with the G20 SDG's. Under this new vision, some of the key areas of growth can be found in health and education. These goals would have the potential to decrease the significant social disparities occurring within the country and help combat social determinants of health. Egypt goals in education include ensuring all children can complete free primary and secondary education and reducing the currently 7% illiteracy rate of children and adolescents (Sustainable development, 2021). Health goals are centered around reducing infant mortality rates by 50%, decreasing maternal mortality by 60% and the ability for citizens to have increased equitable healthcare access (Sustainable development, 2021).

 Egypt Vision 2030

I. Environment

     i. Reduce greenhouse gas emissions by 10%

II. Economic Growth

     i. New wage system

III. Education

     i. Reduce current illiteracy rate 

IV. Health

     i. Reduce infant & maternal mortality rates

                                                                                                                 

Health Literacy

  

Health literacy is a term used to describe the ability to understand, analyze, interpret, and access healthcare and health services. People with a well-developed health literacy are knowledgeable about preventative health services and can successfully question their healthcare providers about issues related to their health. Furthermore, invidiuals with health literacy can understand a diganosis being given to them and are able to navigate treatment options moving forward. As Japan and Egypt are vastly different countries in terms of development, health literacy varies as well as it is related to education level, access to resources, and financial constraints, among other things. 

· Egypt

. Recent research has found that around 75% of the population in this developing country have limited health literacy (Anwar, Mostafa, Hakim, Sos, Abozaid, & Osborne, 2020). There is a small percentage of the population in this country that understands healthcare terms, leading to an increase in hospitalizations and longer hospital stays. Much of this lack of health literacy is strongly correlated with lower education levels, specificially those associated with reading comprehension. Egyptians have greater instances of poor reading skills, poor reading comprehension skills, and poor writing ability. Another challenging part of health literacy in Egypt is the fact that there has not be extensive research on this concept and the current numbers are indicative of the population near cities. Many Egyptians live in rural areas and work in hazardous conditions. The level of health literacy in these areas is much worse, necessitating increased awareness and appropriate interventions.

.

Policy 

 

· Egypt

. There has been a huge impact on Egyptian healthcare system as of late due to the Syrian Conflict. There is an influx of refugees coming to Egypt looking for solace. With this increase of residents that have the same access to health services as the Egyptian residents this has greatly strained the Healthcare system. (Fares et al., 2021). Egypt policy is an all-inclusive view as well called Universal Health Coverage (UHC). This allows healthcare access to everyone without causing devasting difficult financially from the patient. In many cases these benefits are paid by taxes on items such as tobacco, copays, donations, and other financial sources. There are some flaws to this system. Too much access causes an influx of unnecessary medical visits, to help reform this Egypt is placing a minimum of co-payments, The health program reform is planning to be released in 2032. The hope is that this will help combat some of the issues with the lower classes of citizens of Egypt by helping to educate and care for the prevention of many diseases. Awareness campaigns to help spread the word of disease that can be prevented, and detection and screen availability will all see a reform with this new policy. (Salama, 2022). 

Urbanization

 

Urbanization is defined as the process of cities becoming more industrialized and containing higher percentages of the population. It's counterpart being rural areas of low industrialization and smaller percentages of the population (Urbanization, 2022).

Egypt

Egypt has an annual growth rate of 1.87% with currently 42.71% of the total population considered urban (Egypt: UN-Habitat, 2022). Unfortunately Egypt has had problems with keeping up with its expanding urban population. The rapid urban growth of Egypt has not being able to efficiently provide a safe infrastructure for the citizens of the expanding metropolitan cities. Many people have faced unsafe living conditions because of poor urban planning and service delivery (Egypt-UN-Habitat, 2022). 

Impacts of urbanization on social determinants of health (SDOH)

Urbanization effects SDOH in many of the same fashions as rural living. Transportation, access to care and housing can still be just as inaccessible for urban living if proper care was not taken in transportation logistics or housing availability. Although well developed now, Japan has struggled in the past with rapid urbanization expansion. The developing country of Egypt can take a lesson from the issues Japan faced in the early phases of urbanization.

Housing and transportation are two determinants in need of restructure for Egypt's current urbanization model. Japan learned early on that speed over quality was not the ideal choice when setting up an urban city. Buildings that were too hastily put together became more of a burden for the city in repair costs and buildings that erupted without thought of logistics created crowding and unsafe transportation routes for pedestrians (Hein et al, 2007). 

Urbanization has the potential to create positive change for SDOH. Urban cities can allow individuals easier access to healthcare facilities, increased economic growth and prosperity and more efficient infrastructures (Social determinants of health, 2021). For these positive changes to happen it is important for leaders to understand the proper foundations that must be created to protect and support the flocking population that urban cities inspire. 

Globalization:

 

Labonte and Shrecker (2022) identify globalization as, "a process of greater integration within the world economy through movements of goods and services, capital, technology and (to a lesser extent) labour, which lead increasingly to economic decisions being influenced by global conditions" (Labonte and Shrecker, 2022, pg. 3). 

 

 

EGYPT

 

Egypt has a large tourist population that positively effects the more popular locations with their healthcare system. The more visited the places are the better healthcare and more accessibility there is. This leaves the lower income population with less healthcare and more vulnerable to disease and infection. Khalifa and Haley (2010) states, “Improving standards of care within Egypt’s private health sector, relatively lower health care costs, and an already popular tourism destination have positively positioned Egypt for medical tourism; particularly in such destinations as the Red Sea, Cairo, Alexandria, and Giza” (Khalifa & Haley, 2010, pg. 3). Having the tourist population allows for extra income to help fund education and increase research for many of the highly infectious diseases that are plaquing Egypt. The con to this funding is that it is going to the areas where people already have access to medical treatment instead of trying to fund the lower income communities. There could be future policies that decrease the availability for private practice physicians to access government funded resources. (Khalifa & Haley, 2010). 

 

Environmental Issues

Egypt

· The environment in this developing country has significant issues that threaten the land. There is an abundance of hazardous waste, high levels of air pollution, and rising cases of water scarcity (Asiri, Khan, & Kend, 2020). Egypt is also suffering from deteriorating resources and a lack of governmental legislation regarding the use of resources and protecting the environment. It is important to mention that Egypt is located along the Nile River and can be described as a patch of green that sits in between the desert. More than 50% of its food is imported due to an abundance of people living on a small piece of land that has a limited amount of land available for agriculture (Sarant, 2017). It is also no surprise that living in the middle of a desert results in decreased water supply as Egypt is below the level of water scarcity with only 600m3 - 340m3 available per person. Additionally, Egypt has been battling an increase in dust storms that has caused increasing health issues and hospitalizations in the population (Akpinar-Elci, Berumen-Flucker, Bayram, & Taiar, 2021). The increase in hazardous waste is the result of a combination of poor regulation and the increase in industrialization as private coporations have been purchasing most of the available land. 

Other Determinants of Health and Disease

Egypt

     Education is the fourth goal in the United Nations sustainable development goals.  Egypt has been able to create a solid foundation for sustainable development through good leadership and governance appointed in 2014 by the people. This government has a clear and coordinated vision toward inclusive economic growth and sustainable development. This provides a strong foothold for Egypt to take on the goals for 2030, including education as an essential role in reducing poverty. Active policies that have been introduced “include curriculum that integrates social justice, cultural diversity, appropriate development and democracy as an inherent direction of personal and social change and revitalizing the strengths of individuals, communities, and entities.” Also providing values and skills to enable students to become leaders. However, these policies have been met with some resistance as there is still some content that remains unclear. Raising public awareness will be necessary to gain stakeholders support to implement these objectives within the educational systems. (Singer, 2020) 

References

Akpinar-Elci, M., Berumen-Flucker, B., Bayram, H., & Taiar, A. A.-. (2021). Climate Change, Dust Storms, Vulnerable Populations, and Health in the Middle East: A Review. Journal of Environmental Health, 84(3), 8.

Anwar, W. A., Mostafa, N. S., Hakim, S. A., Sos, D. G., Abozaid, D. A., & Osborne, R. H. (2020). Health literacy strengths and limitations among rural fishing communities in Egypt using the Health Literacy Questionnaire (HLQ). PLoS ONE, 15(7).  https://doi.org/10.1371/journal.pone.0235550

Arai, H., Ouchi, Y., Toba, K., Endo, T., Shimokado, K., Tsubota, K., Matsuo, S., Mori, H., Yumura, W., Yokode, M., Rakugi, H., & Ohshima, S. (2015). Japan as the front-runner of super-aged societies: Perspectives from medicine and medical care in Japan. Geriatrics & gerontology international, 15(6), 673–687.  https://doi.org/10.1111/ggi.12450

Asiri, N., Khan, T., & Kend, M. (2020). Environmental management accounting in the Middle East and North Africa region: Significance of resource slack and coercive isomorphism. Journal of Cleaner Production, 267.  https://doi.org/10.1016/j.jclepro.2020.121870

Assai, M., Siddiqi, S., & Watts, S. (2006). Tackling Social Determinants of Health Through Community Based Initiatives. BMJ, 333(7573), 854–856.  https://doi.org/10.1136/bmj.38988.607836.68  

​Blanch, L. (2018, June 24). Healthcare Beliefs of the Japanese. Classroom.  https://classroom.synonym.com/  

Brown, P. C. (2021). Sharing the Pain: Apportioning Natural Hazards Exposure in Early Modern Japan. SUSTAINABILITY, 13(3).  https://doi.org/10.3390/su13031053

Chapman, A. J., & Pambudi, N. A. (2018). Strategic and user-driven transition scenarios: Toward a low carbon society, encompassing the issues of sustainability and societal equity in Japan. JOURNAL OF CLEANER PRODUCTION, 172, 1014–1024.  https://doi.org/10.1016/j.jclepro.2017.10.225

Chikada, A., Takenouchi, S., Nin, K., & Mori, M. (2021). Definition and recommended cultural considerations for advance care planning in Japan: A systematic review. Asia-Pacific Journal of Oncology Nursing, 8(6), 628–638.  https://doi.org/10.4103/APJON.APJON-2137  

CIB. (2021). Why is Egypt a developing country?. CIB Learning Center.  https://www.cibeg.com/en/learning-center/economics-101/why-egypt-is-a-developing-country  

Cultural Respect | National Institutes of Health (NIH). (n.d.). Retrieved July 2, 2022, from  https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect  

Data Snapshots | UNICEF Egypt. (n.d.). Retrieved June 18, 2022, from https://www.unicef.org/egypt/reports/data-snapshots

Department of Health Systems Development (HSD) & Department of Information Evidence and Research (IER). (2022). Egypt: Health system profile. World Health Organization. <a rel='nofollow' target='_blank' href='https://applications.emro.who.int/

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