Skills and competencies
critical thinking, using frameworks to identify probable causes of health issues

Duration and scheduling
60-minute session

Mode of delivery
In person


A group of students read a case study aloud. By answering the question “But why?” at each stage, they identify the social determinants underlying the public health issues in this life history. Using string, they spin a physical “web” and recognise how these different factors intertwine. They take turns to propose strategies to address each factor and, in this way, thread by thread, they dismantle the web. Finally, they discuss what they have learned from this activity.

For doctoral students to acquire the skills to apply the social determinants of health and gender framework to shape and inform health policies and interventions

Read the case study, Miriam’s story and mark the points at which you will ask “But why?”up to a maximum of ten or twelve points.
Print enough copies of the case study for each student to have one
Have a ball of twine or string or wool and a large pair of scissors
Prepare the venue – a fairly large room – by marking lines on the floor with chalk or masking tape to create and label five big sections
In one half of the room, label three sections with three factors that women have in common with men of the same social group:

  • economic
  • socio-cultural
  • political

Divide the other half of the into two squares and label them

  • sex
  • gender

Make each of the five sections large enough for five people to stand in it

1. Introduction
As the facilitator, explain that this session refreshes the concept of the social determinants of health.  Here, we distinguish between the determinants that affect both men and women and those that affect men and women differentially, either because of their biological differences (sex) or because of their gender-based differences. We explore how these factors may be interlinked.

2. Activity – spin the web
Give each person a copy of Miriam’s story. Read aloud a sentence or concept and then stop to ask, “But why did this happen?” For example:

  • Facilitator: “Miriam stopped schooling after her second grade. But why?”
  • Participant: “Her school was three kilometres away from the village.”
  • Facilitator: “But why?”
  • Participant: “The village was poor and far from the capital so there was no school.”
  • Facilitator: “But why?” …

Participants may reach the conclusion that it was a political issue (not enough voters for a candidate to seek their vote so no need to provide services to this small village). This last answer would affect both boys and girls in Miriam’s village. This factor could be classified as economic (the backwardness of the village) or as political (the village’s lack of bargaining power to secure resources).
Once a participant identifies that the reason is that the village is powerless, ask, “So how would you classify this factor?” If the participant says it is an economic factor, they stand in the section labelled “economic”.

  • Standing at the centre with the ball of twine, hold one end of the twine and throw the ball to the participant standing in the “economic” square.

Probe further: “Could you classify it as any other factor?” Another participant may say “political”. They go and stand in the “political’ square and the person standing in the “economic” square would throw the ball to her or him, while holding the twine. Now all three are linked with the twine.

  • Continue reading.

You discover that another reason why Miriam stopped schooling is that her father did not think education was necessary for girls. This would be classified as “gender”, and the ball would pass from the person in the “political” square to the person identifying this factor and occupying the “gender” square.
This continues, until the group is left with a complex spider’s web of factors underlying the woman’s ill health.

  • Keep up a brisk pace.

After each “But why?”, participants quick call out and classify factors rapidly, and a new participant enters into the web speedily.

3. Activity – cut the web
When the spider’s web is complete with participants standing entangled in it, challenge participants to find the point at which they can cut the web. What interventions could they make which would make a difference to Miriam’s situation?
You could ask participants to respond from a specific vantage point. For example:

  • Facilitator: “If you were a local activist, where would you cut the web?”
  • Participant: “I would intervene to help Miriam stand up to her husband’s violence; I would give her shelter in my house, and help her farm her land.”
  • Facilitator: “If you were the nurse at the clinic, where would you cut the web?”
  • Participant: “I would be sensitive to signs and symptoms of battering in women who come to the clinic. I would help her find shelter and social support through a suitable agency.”
  • Facilitator: “If you were from the department of health of the national government, where would you cut the web?”
    Participant: “I would advocate for one-stop centres within major hospitals to help women affected by domestic violence.”

And so on.
Cut participants free.
As each participant answers, use the scissors to cut them free. After three or four such examples, participants return to their seats for debriefing and discussion.

4. Discussion: how factors are linked
Ask participants for feedback, beginning with their feelings about the exercise.

  • How did you feel when you were entangled?
  • What lessons do you draw from the exercise?
  • What do you think the entanglement signified?

Many participants feel hopelessly trapped as the spider’s web was spun. They cannot imagine that it will be possible to unravel the problems. Cutting through some parts of the web gives insights in possible actions that individuals or groups can take – no matter how complicated a situation appears or at which level a person is able to intervene: individual, community or national.

  • What to cover in the discussion? Where to start?

Point out that the key to cutting the complex web may lie in starting with the woman herself: create space for her to reflect on her situation, interact with others and see that change is possible.
Draw attention to the fact that many gender factors were also classified as socio-cultural, for example the reason for Miriam’s circumcision or her early marriage. Raise this point for discussion: culture and tradition are not gender neutral and may become tools for discrimination against women. They are likely to be the parts of the spider’s web that are the most difficult to cut through.

  • Where is it appropriate to cut the web?

Economic, socio-cultural and political factors that affect women’s health are so intertwined with factors related to gender and sex that they seem to mesh into one. While it is important to see these links, it is equally important to separate them out analytically so that we can identify where it is most appropriate to cut the web.

5. Discussion: gender
Ask: Which factors affect women exclusively?
Explain that the web exercise identified:

  •  factors that affect women predominantly or exclusively, for example female circumcision, early marriage and battering or domestic violence
  • factors that affect men and women in Miriam’s community, for example the distance from the school and the health centre

It is important to analyse health issues in this way. For example, women in a community are suffering from iron-deficiency anaemia. This may be because of

  • something common to women and men, such as hook worm infestation, or
  • women’s biological difference from men, such as malaria infection during pregnancy, or
  • gender differences, such as discrimination in food allocation leading to malnutrition

Each of these cause calls for a completely different intervention.
Unravel sex, gender and other factors
Ask participants for examples of sex and gender factors – as opposed to economic, socio-cultural and political factors – that operate at various levels and that may be responsible for a health condition or problem. Point out that, unless one carries out an analysis to unravel gender and sex from other factors underlying a problem, interventions may not address the causes, and may in fact further undermine women’s position. Many such examples exist, for example:

  •  targeting women for health education assuming that ignorance is the cause of their malnutrition
  • not dealing with men and safe sex, but testing and treating women for sexual transmitted infections

6. Discussion: social determinants and the rights framework
Draw participants’ attention to the links between a social-determinants perspective and a rights framework in relation to health. Understanding the social causes underlying ill health also helps us identify the economic, socio-cultural, civil or political rights involved. Violating or neglecting these rights may underlie the health problem. Addressing these violations or neglect would create conditions that enable good health.

7. Discussion: connecting social determinants with the multi-level framework
Factors affecting health (those common to both sexes and those specific to women) can be divided into the five levels of the multi-level framework: individual, household, community, national and international. For example:

  • Miriam’s father’s attitude to the education of girls is a gender factor operating at the household level
  • The absence of a school in the community is an economic or political factor operating at the community level

With both frameworks as tools, we are better able to analyse and address health issues.

8. Closing the session
Invite participants to share their conclusions. Emphasise these main points:

  •  We should distinguish between health determinants common to women and men and those that are sex and gender-related, because each of these sets of factors requires a different type of intervention.
  • When we analyse a health situation or a specific health problem, we should explicitly consider the gender dimension and its links to other determinants of the problem.
  • We should base the design of interventions should be based on such an analysis and take into account the potential impact of these interventions on gender power relations.
  • Health problems caused by multiple factors need a multi-pronged strategy. When multiple factors cause a problem, we may need a multi-pronged strategy to address them simultaneously.
  • A social-determinants perspective forces us to look at the issues of rights. When we analyse a health situation this way, we can identify rights that are being neglected or violated and that may be contributing to the health problem. Addressing these rights violations or neglect will create the necessary conditions for addressing the health situation.

By the end of this session, students should be able to distinguish between factors:

  1. that are common to men and women within a specific social group
  2. that arise as a consequence of biological differences between men and women
  3. that are related to gender-based differences in roles and norms and access to and control over resources, and the power relations between men and women within the same social group

The facilitator may assess students’ participation in the group exercise and discussion

You can download these guidance notes and resources

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