Summarizing the results, the most common reason for women opting out of health-improving interventions was a lack of support from others, both from their husbands and their families. Support systems are a crucial component of the largest social determinant of health known as social cohesion and have been linked with greater physical and mental health outcomes. Support systems have been found to improve access to health-enhancing resources [9], increase health-related behaviors, and lessen the effect of psychological stressors [10]. The relationship is particularly important between socioeconomic resources and strong social support as women who did not receive adequate support from their families were unable to participate in interventions that would both improve their health and the health of their children.
This study also provides evidence for associations between various social and demographic determinants of health. Lower education levels, larger family size, lower age, and women who were not previously pregnant were all classifications that were more likely to cite a lack of spousal or familial support. Women who fit into one or more of these categories are more likely to hold lesser sway regarding familial and personal decision-making. As a result, many women may not be able to maximize their health outcomes as they do not possess the autonomy required to make their own health decisions [11]. Globally, a multitude of studies focusing on women has reported familial support to be a positively correlated predictor of health outcomes [12] with a large portion of these studies emphasizing partner support as particularly significant [13, 14].
Other than familial support, a lack of time was the third most cited reason for not participating in the health interventions. This finding supports similar studies that cite busy lifestyles as participants' primary reason for not participating in health-improving programs [15]. Many have postulated that time itself was considered a social determinant of health as recent research has found that time-poor people have greater barriers to physical activity and poorer physical and mental health [16]. In addition, the fourth most cited reason was a migratory lifestyle. A migratory lifestyle can be linked to the social determinant of health known as housing stability (which falls under the category of economic stability) and has been linked to poorer physical health and decreased access to health care [17, 18, 19]. Both these findings reveal that the health interventions or lack of concern about their health were not preventing the women from improving their health outcomes but rather a limitation of various social factors. This conclusion was furthered by the fact that the majority of women agreed that the study and its staff were ethical and trustworthy. The presence of community healthcare workers likely contributed to this belief and strengthened the validity of the study.
We were able to effectively analyze a rural population by delivering the survey through a group of local community health workers. These workers came from the communities that the study itself was focusing on and thus had a greater understanding of the local context and population. This proved useful as women who had chosen to opt-out of the health interventions were still willing to work with the familiar community health workers to fill out the social determinant screening. In addition, the presence of community workers generally increased response rates as participants were more likely to favor direct oral communication as opposed to a written survey given both social relations and the proportion of illiterate women in the community. However, the study had some limitations in regards to its sample size because the study itself aimed to study women who opted out of the original intervention and subsequently were more likely to deny their participation in our additional studies.
Our study is particularly significant as it explores a previously understudied population and can be applied to a variety of disciplines. Though prior research has been performed on the social determinants of health among a variety of populations including both women, adolescents, and the elderly, rural women have not been studied on an international scale extensively before this study. Our results can also be applied to the field of research methodology by allowing researchers to understand the key features that encourage people to opt out of research studies. On a global scale, this research can be used to address the most pressing social determinants of health affecting rural women to improve the health outcomes of both themselves and their children.