Day 2: Determinants of Health

Activity 5: SSDoH: A conceptual foundation through Vuyo’s Story

3 hours


To help us to:

  • Deepen our understanding of health
  • Understand various determinants of health within the South African context
  • Engage with the complexity of determinants of health in South Africa
  • Reflect on the power and influence of each determinant of health

Task 1
Group work: Identifying and Defining Determinants

1 hour   

Working in four (4) groups, you have 40 minutes to read Vuyo’s Story below and answer the questions below. In answering these questions, we are beginning to grapple with the issues of SSDoH:

  1. How are disparities in health and health-related outcomes illustrated in this case study?
  2. While these may not all be evident, identify the determinants affecting Vuyo’s health.  Why do you say so?
  3. Finally, draft a mini definition of the one determinant allocated to your group.  The facilitator will come round to tell you which determinant you are defining:
    • Political Determinants of Health
    • Social Determinants of Health
    • Structural Determinants of Health
    • Commercial Determinants of Health
  4. Write up your allocated determinant definition on flipchart paper. Please do liven it up with colour and/or illustrations.

Our Case Study: Vuyo’s Story

(Adapted from Posel, D. A matter of Life and Death, At Risk, McGregor & Nuttall (Eds.). 2007. Jonathan Ball: Johannesburg & Cape Town, edited by Tekano.)

Vuyo is the 23-year-old mother of Iyana, her five-year-old daughter. She was born in the township of Gqeberha (or Walmer township) in what was known as Port Elizabeth, in the Eastern Cape. Gqeberha, one of the oldest townships in the city, is the most impoverished, faced with dire issues of housing, water, and sanitation. This township was established in the early 1900s nearby a wealthy predominately white suburb called Walmer.  A huge number of the population lives in shacks, collecting food and clothing from a local dump site. Diseases like TB and HIV thrive in this community, along with many sufferers of high blood pressure and diabetes, with them having recorded the highest numbers across the Nelson Mandela Bay district according to the department of health. 

Vuyo grew up with two brothers and a sister. Her father, an activist in the community, was called to work on the gold mines in Johannesburg. She remembers a happy early childhood, but her mother died when she was young, and her siblings were cared for by their grandmother who suffered from ill health. The only source of income for the family was money sent by her father and her grandmother’s pension grant. Vuyo went to school but spent a lot of time out of school, helping cook for the family, especially when her maternal grandmother was bed-ridden. There was no clinic near where Vuyo lived. Her grandmother regularly consulted a traditional healer and would light impepho (incense) when she needed guidance.  Vuyo has memories of attending the local Apostolic church with her mother every Sunday.  She also has memories of her father’s participation in community meetings, where many failed community attempts were undertaken to better the living and working conditions within the community.

At 14, Vuyo was raped by an older cousin but never told anyone as she felt ashamed. She also didn’t want to cause any trouble for her family. This coincided with the first democratic elections in South Africa. The country was filled with excitement and hope. At 15 her grandmother died, and Vuyo was forced to move to Motherwell, a township about 30 kms from Gqeberha CBD. They lived in an RDP house with electricity and water.  The house had an asbestos roof with no ceiling. 

At 17, Vuyo met Simphiwe, a 21-year-old, who worked in town. He started waiting for Vuyo after school and after a few weeks he invited her to a party. He told her that she was pretty and that he liked her. He started treating Vuyo like a girlfriend and she felt flattered. A few weeks later he wanted to have sexual intercourse. Vuyo felt hesitant and was initially reluctant, but Simphiwe persuaded her. They did not use a condom. They continued to have sex every few weeks.

A few months later Vuyo noticed that she had stopped menstruating. She became very frightened but did nothing hoping that all would return to normal. Eventually she couldn’t ignore her symptoms and went to the clinic. Vuyo was pregnant. She dropped out of school and had a baby. Simphiwe left the area to look for better opportunities in Johannesburg. Vuyo tried her best to breastfeed her child, but her milk dried up and she turned to formula feed. When her formula food ran out, she fed her little baby, Iyana, water and mealie-meal porridge. 

Jobs were hard to come by in the area where Vuyo lived. She got piece work from time-to-time washing clothing, but struggled financially. Vuyo received a child support grant, but the money wasn’t enough, and she collected food parcels from a local NGO when they were offered, but this was inconsistent.  Vuyo started having sexual intercourse with a married man who gave her money to help her buy food for her child and family. She also continued to have a sexual relationship with Simphiwe when he returned for a visit from Johannesburg. 

Vuyo started having chronic diarrhoea and vomiting. Her aunt advised her to go to the local Zionist Christian Church to take the tea to cleanse her stomach. After several weeks of taking tea, her symptoms did not improve, and she developed swellings on her feet and coughing. She went to the local clinic where she was given medicine. She felt better for a while but then the pain returned. She went back to the clinic several times and eventually the clinic sister recommended an HIV test. The test was positive. Vuyo told no one. 

Shortly after, Vuyo became very ill. Her family took her to the provincial hospital where she was diagnosed with TB. The illness continued on and off. Her uncle became worried that her episodes of illness were because of her ancestral calling and suggested she visit a local healer.  So Vuyo consulted a local healer who encouraged her to take an immune booster and visit the local clinic to get ARVs. She followed the healer’s advice, and her health improved. 

Throughout this period, Vuyo continued to have sexual intercourse with the two men. She told neither man about her HIV status and did not insist on using condoms if they did not want to. She fell pregnant for the second time. This time, her pregnancy was complicated, and she died in childbirth.

Task 2
Plenary: Understanding the social and structural determinants of Vuyo’s health

30 minutes  

In plenary, we will explore the four definitions of SSDoH through Vuyo’s Story and how Fellows grappled with the questions.

Task 3
Plenary: Mapping Social determinants of health using complex systems thinking –  pathways to intervention

1 hour 30 minutes

Working in plenary, we will use Vuyo’s Story, to practice applying the social determinants of health (SSDoH) framework to the South African context, using root cause analysis (5 whys).

Fellows will be invited to embody one of the following SSDoH elements: individual, community, social, political, structural and commercial.  Working alone for 5 minutes, Fellows will look at Vuyo’s Story again and think through their SSDoH and how it manifests in the story.

In plenary, Fellows will then physically position themselves in relation to the power and influence of each determinant. We will reflect on what this teaches us about SSDoH and the complexity and interrelationship of determinants.

Our closing to this session will be to get ready for tomorrow’s site visits, with groups assigned and overnight reading prescribed. See below!

Site Visits Preparation


There are four site visits tomorrow, and for you to do your overnight reading, you will need to know which site you will be visiting. So we will start with group allocations and then look at the reading task.

You will find your reading task below in Activity 6. Read the Overview and the Core Reading. For high achievers ;-), you can read further into the set of links. It will certainly enrich your site visit experience and analysis, but hey, no pressure!