Democratic South Africa at 25 \u2013 a conceptual framework and narrative review of the social and structural determinants of adolescent health

Tanya Jacobs,Asha George

doi:10.1186/s12992-021-00679-3

Abstract

Twenty-five years into South Africa’s constitutional democracy provides an opportunity to take stock of the social and structural determinants of adolescent health. Those born in democratic South Africa, commonly known as the ‘Born Frees’, are perceived to be able to realise equal rights and opportunities, yet many factors constrain their lives. In bringing together approaches to understanding context in health policy and systems research and the social determinants of health, the paper develops a conceptual framework to guide the narrative review examining the key contextual social and structural determinants of adolescent health in South Africa. Illustrative examples drawing from 65 papers from public health and the social sciences describe and link these determinants across micro, meso and macro levels of society, their global determinants, and their intersections with compounding axes of power and inequality.At a micro level individual adolescent sexual and gender identities are expressed through multiple and evolving forms, while they experience growing autonomy and agency, they do so within a broader context characterised by regressive social norms, gender inequality and other intersecting power relationships. At the meso level, organisational and sectoral determinants shape adolescents health and rights, both in being supportive, but they also replicate the biases and inequalities that characterise South African society. In addition, the macro level national and global determinants, such as the structural colonial and apartheid legacies, shape adolescents' health. Despite constitutional and other legislative rights, these determinants and compound economic, geographic, gender and other intersecting inequalities.A key finding is that current experiences and health of adolescents is shaped by past social and structural determinants and power relations, with apartheid inequalities still echoing in the lives of the adolescents, 25 years into democracy. More research and work is needed to provide insights into determinants of adolescent health beyond just the micro level, but also at the interrelated and dynamic meso and macro levels, nested in global determinants. The findings raise critical considerations and implications for understanding the social and structural determinants in the South African context and what this means for adolescent health in the SDG era.

Highlights

Twenty-five years into South Africa’s constitutional democracy provides an opportunity to take stock of the social and structural determinants that shape adolescent health
Micro level: individual, interpersonal and community we describe micro level determinants which include the individual, interpersonal and community aspects as presented in the conceptual framework (Fig. 1)
Using a conceptual framework (Fig. 1) we describe and illustrate key social and structural determinants across interrelated and dynamic macro, meso and micro levels, as well as key cross-cutting and intersecting determinants, all of which dynamically interact with global determinants, to shape adolescent health in South Africa

Summary

Introduction

Twenty-five years into South Africa’s constitutional democracy provides an opportunity to take stock of the social and structural determinants that shape adolescent health. Those born in democratic South Africa, commonly known as the ‘Born Frees’, are perceived to be able to realise equal rights and opportunities. For example, in terms of adolescent sexual and reproductive health, 16% of women aged 15–19 years have begun childbearing. Of these only 52% were reported to be attending school, compared to 83% of childless adolescents in 2016 [1]. HIV incidence rates for females aged 15–24 years were three-times that of their male counterparts in 2017

Methods

Results

Conclusion