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Abstract
The association between contextual factors and health inequalities is well documented, also in Brazil. However, questions about how contextual factors actually affect health and well-being persist. The aim of this qualitative study was to explore how contextual factors—i.e., social stratification and neighborhood opportunity structures—are manifested in the lives of the residents of a vulnerable district in Brazil. We used a Constructivist Grounded Theory approach based on 12 in-depth interviews. The core category constructing social identity through multiple “us and them” is supported by eight main categories that characterize different pairs of “us and them”, based on internal and external aspects of the social processes involved. Our findings strengthen and support the links between contextual factors and health inequalities, highlighting the relevance of downward social comparison, territorial segregation and stigmatization and erosion of social capital in the construction of social identities and the manifestation of social hierarchies and neighborhood structures in the Brazilian context. Ultimately, these create shame and stress but also pride and empowerment, which are recognized determinants of health inequities.
Highlights
Following the renewed interest in social determinants of health in the past decades, contextual factors have become increasingly relevant to the health equity debate [1]
Constructing social identity through multiple us and them We developed one core category “Constructing social identity through multiple us and them”, which describes how people in a vulnerable district socially situate themselves based on reference groups, social comparison and social position indicators, with varying influence on recognized determinants of health such as social stress and empowerment
We found in our study some support to the upward social comparison, in which residents from a vulnerable district compared themselves to references in higher socioeconomic positions, feeling unfairly valued
Summary
Following the renewed interest in social determinants of health in the past decades, contextual factors have become increasingly relevant to the health equity debate [1]. The social determinants of health, comprising these contextual factors, have been defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age” [2] With SUS, healthcare utilization increased, and unmet healthcare needs lessened [6, 7] Alongside this new health system, poverty declined, and overall living conditions improved. There are large disparities within the country in infrastructure and availability of public services—including healthcare access and utilization—between individuals, and across neighborhoods, states and regions Following these disparities, health inequalities with regard to various health outcomes including access to healthcare are markedly evident [3, 5, 10, 11]. With the election of far-right president Jair Bolsonaro in 2018, a democratic crisis is unraveling [12], jeopardizing even more health and health equity in the country [13]
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