Examining the Impact of Social Support Networks in Mitigating the Negative Effects of Social Determinants of Health on Msm in South Africa

This cross-sectional study explored the ways in which social support networks protect MSM individual in South Africa from the effects of Social determinant of health. Self-administered questionnaires and indept interview were used to establish the relationship between social support and social determinant of health status of 25 MSM in South Africa.The study established that MSM remains highly adaptable in social determinant of health challenges such that their mental health has greatly improved due to social diversities and structural support systems. Key informants identified peers, friends, family members, and local community based organizations as important in reducing the impact of stigma, discrimination and/or class differences. According to participants, such support networks ensured they received requisite healthcare services without encountering barriers. The study establishes that social support networks are vital in enhancing health equity and wellbeing among MSMs in South Africa. Therefore, the need to call for innovative strategies that increase support structures for MSM population in order to improve their health status cannot be overemphasized. Policy implications emphasize the need for interventions that reinforce supportive structures, promote inclusivity of MSM communities, and improve the health of this population in South Africa.


Introduction
Males who engage in sexual activity with other males, often referred to as Men who have Sex with Men (MSM), are a heterogeneous and consequential demographic group within global communities, including the context of South Africa (Maxwell et al. 2019).Nevertheless, despite the advancements made in recognizing and promoting Lesbian, Gay, Bisexual, Transgender, and Queer Plus (LGBTQ+) rights on a worldwide scale, MSM still encounters a multitude of obstacles, especially in relation to their physical and mental health (Halkitis et al., 2013).The adverse consequences of social determinants of health, including discriminatory practices, stigmatization, socioeconomic inequalities, and restricted healthcare accessibility, have a significant influence on the health outcomes experienced by MSM in South Africa (Borde et al, 2020).
The social determinants of health are intricately linked to societal structures, cultural norms, and institutional policies (Cogburn, 2019), which have the potential to generate and sustain health inequalities among disadvantaged populations, such as MSM.The intersection of these characteristics often results in the presence of many layers of disadvantages and obstacles that impede the attainment of sufficient healthcare for MSM (Cloete et al., 2013).Discrimination predicated upon an individual's sexual orientation may engender a range of adverse consequences, such as social isolation, psychological distress, and hesitancy to avail oneself of critical healthcare services, particularly those pertaining to HIV prevention, treatment, and mental well-being (Ayhan et al. 2019).
In the context of South Africa, where the prevalence of HIV among MSM stays elevated (Scheibe et al., 2020).The epidemic remains a public health concern, with epidemiological evidence among this target population that cannot be ignored (Cloete et al., 2008).Lane et al. (2019) eluded that HIV prevalence among MSM highly surpasses that of the general population due to their susceptible nature of acquiring and transmitting the virus.Stigma and discrimination towards MSM are still high, hindering access to better health services among MSM in South Africa (Burrell et al., 2020).It becomes more imperative to prioritize efforts aimed at mitigating the health inequities experienced by this specific demographic.The nation has made notable advancements in addressing the HIV/AIDS crisis, yet MSM remains disproportionately impacted (Cloete et al., 2008).The complex interplay of several socioeconomic variables adds a layer of complexity, requiring extensive and specifically tailored interventions to enhance the health and overall welfare of MSM within the nation (Cloete et al., 2013).Kecojevic et al (2019) eluded that one of the possible strategy for addressing the adverse impacts of socioeconomic determinants of health on MSM is through the use of social support networks.Berkman and Thomas (2000) affirmed that social support refers to the provision of emotional, informational, and material aid from closer networks.If we understand how important social support networks are for MSM, it might be easier to develop better public health policies and treatments tailored to meet the specific needs of this group (Gyasi et al., 2019).
The main objective of this study is to examine the role of social support networks in mitigating the negative effects of socioeconomic determinants of health on the well-being of MSM in South Africa.Specifically, the research aims to answer the following questions: o How do social support networks help MSM in South Africa cope with social determinant of health challenges and stigma associated with their sexual orientation?o In what ways do social support networks facilitate access to healthcare services for MSM in South Africa?o What are the potential strategies and interventions that can strengthen social support networks for MSM in South Africa to improve their overall health outcomes?
By collecting comprehensive feedback from MSM participants, this research highlights the importance of creating inclusive and supportive environments for this target population.
The overarching purpose is to uplift the quality of life of MSM individuals and ensure equity in health outcomes.This study aims to fill gaps in existing knowledge and present potential areas for further research.Through developing evidence-based interventions and policies, it seeks to enhance the health and well-being of MSM in South Africa.

Methodology
The research employed a precise mixed methods approach that entailed combining both the qualitative and quantitative approaches to obtain the special features that influence the health of the marginalized groups mainly the MSMs effectively (Creswell and Creswell 2017).The qualitative aspect entailed administering of face-to-face, semi-structured interviews to purposely recruited MSM participants.These interviews focused on learning more about their perceived social networks and the impact of social factors on their quality of life (Smith et al., 2017).As guided by Braun & Clarke (2006) in the process of the analysis, the researchers used thematic analysis to find the patterns and the themes in the participants' narratives, which helped the researchers to analyse the qualitative data in a better way.
In the quantitative part of the study self-completion questionnaire was utilized to elicit biographical and socio-demographic information from the participants in order to easily compare the responses to social support and health domains (Creswell & Creswell, 2017).The questionnaire included items on demographic data, discrimination and stigma, service use and perceived social support.It included sections with standardised measures of perceived social support, resilience, and mental health status.Moreover, it was detected that some of the questions asked enabled the participants to give more detailed answers.The credibility of the quantitative data was ensured through the use of structured questionnaires and assessments that have undergone validity and reliability tests as guided by Creswell & Creswell (2017).Qualitative and quantitative research methods were adopted to achieve the study objective of identifying, comparing, and understanding factors that affect the health status of the targeted, and especially MSM groups of the population.

Sampling:
In this research, purposive sampling was used to identify individuals who are MSM.Purposive sampling is a purposeful and non-random form of participant selection that was applied to assure a focused and specific representation of MSM participants.The study's emphasis on marginalized populations and the need to include a wide range of experiences within this particular group had an impact on the decision to use purposive sampling (Palinkas et al., 2015).The use of this strategic sampling method facilitated the identification of 25 individuals with distinct viewpoints about social support networks, health factors, and obstacles to healthcare accessibility, hence coinciding with the primary research goals of the study.

Data Analysis and Integration:
The research used a rigorous methodology that included qualitative transcription, coding, and theme analysis, as well as quantitative statistical approaches.Its objective was to investigate the correlation between social support and health outcomes among MSM (Braun & Clarke, 2006;Creswell & Creswell, 2017).The comprehensive display of findings offered a nuanced comprehension of the intricate interaction, bolstering suggestions for initiatives targeting social factors that influence health (Creswell & Creswell, 2017).Data integration, based on the combination of qualitative and quantitative data (Palinkas et al., 2015), allowed for a thorough examination of how social support networks affect the health outcomes of men who have sex with men (MSM), taking into account social determinants.An in-depth analysis of the study's limitations and its implications for future research contributed to the study's credibility (Creswell & Creswell, 2017;Palinkas et al., 2015).

Trustworthiness:
Several key characteristics enhance this study's trustworthiness and completeness.A strong research technique that combines quantitative surveys and qualitative interviews allows a comprehensive evaluation of the topic from multiple perspectives, ensuring the study's credibility (Smith et al., 2018).Validated measuring methods improve data reliability for factors like perceived stigma and cultural attitudes (Brown et al., 2020).A detailed discussion of the study's environment, participants, and research methods addresses transferability.This lets readers assess how applicable the findings are to similar scenarios (Lincoln & Guba, 1985).Documenting the study process, including data collection and analysis, is crucial for confirmability.An audit trail promotes study objectivity (Shenton, 2004).Finally, a mixed-methods approach ensures the study's quality and trustworthiness by cross-referencing data from numerous sources (Creswell & Creswell, 2017).The study's methodological rigor, transparency, and rigorous evaluation of several quality indicators boost its credibility.
Ethical Consideration: Ethical considerations are crucial in research, ensuring the protection of participants' rights and well-being (Banks & Brydon-Miller, 2018).To guarantee compliance with ethical rules for research involving human participants, the researcher obtained ethical clearance from the institutional ethical review board, which led to the issue of the ethical clearance approval number (HSHDC/028/2019).Before the selection of MSM that participated in the research, all participants were required to provide informed consent, and pseudonyms were utilized to preserve confidentiality and anonymity throughout the process of data collection, analysis, and reporting.

Results and Discussion
This study findings unraveled the complex phenomenon of the link between social network and the overall well-being of South African MSM using the WHO social determiant of health theory in explaining the role of socioeconomic factors on the health of MSM (Marmot et al. 2008).Through the surveyed biographic information and narratives of the 25 respondents, the study portrays the key issues that include stigma and discrimination, access to healthcare services, social support networks, coping strategies, and their overall wellbeing.

Quantitative Findings
This demographic analysis thoroughly investigates participant characteristics, including age, gender, sexual orientation, education, income, occupation, socioeconomic position, and geographical area.The comprehensive comprehension acquired improves the rigor of research, enabling the creation of adaptable approaches to address the varied requirements of participants, fostering inclusivity, accessibility, and well-informed decision-making.
The below diagram (Figure 1) shows the pseudonym names of the study participants based on their age at the time of the study.The lowest age is 21 years old, while the median age is 38, and the eldest age is 55 years old.This specific age cohort has great importance due to its role as a critical stage in life when people often encounter several socioeconomic determinants of health that have the potential to impact their overall state of well-being.

Participants Employment Status
The analysis of the participants' 'Employment Status distribution provides valuable insights into the economic dynamics within the research area.Table 1 below shows the employment status of the study participants.The results of the study reveal that a majority of participants, namely 68%, were found to be without employment, and the remaining 32% were seen to be gainfully employed.The observed distribution of work options within the demographic under study reveals a significant discrepancy, hence underscoring the high incidence of unemployment among the individuals involved (Simbayi et al. 2006).The prevalence of unemployment among a significant proportion of people implies possible difficulties in obtaining reliable sources of income, which may subsequently have an influence on their general well-being and health consequences.

"Being unemployment deprive me from accessing the required private medical services as i can't face the unprofessional services in the local clinics" (Bonginkosi)
The significance of taking into account economic considerations becomes evident when analysing the impact of social determinants on participants' health.Employment status intersects with other social determinants, influencing their experiences and the availability of resources.It was noted that the majority of the unemployed participants fall under the category of lower-educated individuals with matriculation certificates.

Participants Income Status
The participants' economic status ranged greatly within the cohort for the research with 68% of them indicating that they had no income and 32% of them were receiving some form of income.The inequality in income levels that is strongly correlated with employment inequality and health insurance drastically shows socioeconomic obstacles to healthcare (Ikhile, 2024).From the group with income, only 12% reported possessing medical insurance, which demonstrates the symptoms of absence of insurance only among this subsegment.Furthermore, some of the participants with income stated that they were not able to afford medical insurance which worsens health inequity.It brings to question the multidimensionality between income, job situation, and medical coverage that govern the way people manage to cope with health outcomes.The diagram (Table 2) shows the disaggregation of the study participants income status.

Income
Count of Income N0 68% Yes 32% Grand Total 100% The dearth of income among the greater portion of participants in the study gives rise to substantial barriers to the health and stability of MSM in South Africa.Lack of a regular source of income may lead to difficulties of people buying essentials such as healthy food, accommodation with security and healthcare."As I do not have any income to rely on, I often have to choose between getting medical treatment or buying food.It is undeniable fact that we are all dealing with this situation, and we get affected by it both psychologically and physically (Thabo)".
This literal economic instability may act to further widen already present health differences and also increase the susceptibility to adverse health results.To illustrate, lack of financial resources can hinder people from timely medical facilities, therefore, promotes late diagnosis and treatment of health conditions.Furthermore, some conditions concerning financial constraints may cause the individuals to pay less attention to preventive measures, such as regular screenings and vaccinations which will only worsen their health.Moreover, in addition to the lack of income can bring about stress at high level and problems of mental health, as people fight with the economic uncertainty and the psychosocial consequences that comes with it.In the end, the interaction between income level and health draws the implication that there is the utmost need for the interventions that would make it possible to deal with the existing socioeconomic imbalances and, consequently, to expand the range of healthcare services which are accessible for the MSM populations throughout South Africa.

Participants Education Status
Looking at the distribution of "Education Qualification" among the people who took part in the study investigating how social support networks can help lessen the negative effects of social determinants of health on MSM in South Africa gives us important information about their educational background.According to the data gathered as shown in table 3, a significant proportion of participants, namely 44%, had a Matric certification, suggesting that a considerable number of persons had attained a foundational level of education.In addition, it is worth noting that 28% of the individuals included in the study had a Bachelor's degree, while 20% held a Diploma, and a smaller proportion of 8% had successfully obtained a Master's degree.The observed distribution highlights the heterogeneous educational backgrounds present within the community of MSM that were examined in the study.The predominance of persons with Matric and Diploma credentials may be indicative of more extensive social issues pertaining to educational accessibility and achievement (Attewell et al. 2007).Nevertheless, the inclusion of individuals holding Bachelor's and Master's degrees indicates the involvement of a subgroup within the community characterized by elevated levels of educational attainment.The participants affirmed the relationship of attaining education to other social factor like employment, income and access to better health services.

"Being educated open opportunity for jobs, income and better health care services" (Thulani)
These data pertaining to schooling provide a comprehensive viewpoint about the socioeconomic level of individuals and their potential engagement with social support systems.These networks are vital in addressing health-related difficulties among MSM in South Africa.

Participants Physical Environment Status
MSM's physical environment in this study refers to the external and tangible circumstances in which MSM resides, works, and interacts.It includes geographic locations, neighborhoods, communities, structures, public spaces, and natural environments, among other elements.This environment significantly affects the health, well-being, and overall experiences of MSM individuals.This physical environment can either facilitate or impede their access to support, healthcare services, safety, and social inclusion, making it an essential factor in their lives and health outcomes.Table 4 below shows the study participants physical Environment status.The health of MSM in South Africa is substantially affected by whether they reside in a township or a suburb, with distinct advantages and disadvantages associated with each environment (Jobson et al. 2013).

"Living in a township is backward with little or no social facilities as compared to people living in suburb, I can't even express my sexuality as a fear for my life" (Msizi)
Based on the feedback from the study participants in Townships, MSM individuals face an elevated risk of stigma and discrimination due to conservative cultural and religious influences as compared to the suburb which is more liberal.In such a hostile environment, the prevalence of discrimination can contribute to mental health issues, reduced access to healthcare services, and concerns for physical safety (Meyer, 2003).Additionally, limited MSM support structures and a dearth of MSM welcoming spaces can hinder social support and a sense of belonging.In contrast, suburban areas provide greater access to healthcare and established MSM communities, which provide emotional support and opportunities for connection (Ngidi et al. 2020).However, MSM individuals in the suburbs may still face covert forms of discrimination and the pressure to conform to societal norms, which can negatively impact mental health.The key to resolving these disparities is understanding and addressing the unique challenges and opportunities presented by each environment, customizing interventions to mitigate disadvantages and capitalize on advantages for the advancement of the health and well-being of MSM individuals.

Thematic Analysis
The study conducted a thematic qualitative analysis of the data obtained from in-depth interviews of MSM.It started with transcription -analyzing participants' narratives, initial coding, and thematic coding in order to catch repeated patterns and similarities (Vaismoradi et al., 2016).As guided by Seage et al. (2019) the development of superordinate themes, the analysis of broader concepts was made in a detailed manner, whereas the underlying themes were directed at the specific dimensions and challenges within the context (Through triangulation, member checking, and data saturation,the researcher was able to ensure completeness and validity, and thus a write-up includes details of themes infused with illustrative quotes (Shenton, 2004).Thematic analysis was used to reveal the intricate subtleties instead of measuring communication content as guided by Deighton- Smith & Bell (2018), which led to a comprehensive understanding of how gay men are affected by stigma.The superordinate theme bridges more general phenomena, while the subordinate themes allow specific ones to unfold, providing comprehensive insights into MSM real experiences.

Social Determinant of Health
The superordinate theme of social determinants of health, as derived from this research, aligns with the well-established concept emphasizing the substantial impact of non-medical factors on an individual's health outcomes.Rooted in the influential work of Marmot et al. (2008), the theory posits that social and economic conditions significantly shape individuals' access to resources and opportunities, thereby influencing their overall well-being.
This study operationalized the concept by delving into the biographical information of the 25 respondents and exploring factors such as age, employment status, income, environmental conditions, and access to medical aid as crucial components of the social determinants of health framework.Through this lens, two prominent underlying themes, namely stigma and discrimination and access to health services, emerged vividly from the narratives of the study participants.These themes highlight the intricate interactions of social determinants of health that MSM people in South Africa experience, influencing their overall health trajectories.This insight provides a valuable understanding of the nuanced interplay between socioeconomic factors and health outcomes within this population.The superordinate theme underscores the significance of comprehending how social support networks can serve as a buffer, mitigating the adverse effects that these social variables may exert on the health and overall well-being of individuals who identify as MSM.

Stigma and Discrimination:
It was discovered that stigmatization and discrimination considerably impact MSM individuals in South Africa, creating barriers to obtaining healthcare services and compounding mental health problems as eluded by ikhile & Mavhandu-Mudzus (2024) and Ikekhwa & Azwihangwisi (2023).

''Most of us chose to be in the closet because our society frowns negatively on our sexual orientation through discriminating and stigmatizing every aspect of our lifestyles as promiscuous and taboo" (Thando)
The fear of being stigmatized makes people hide their sexual orientation causing additional pressure and anxiety as affirmed by Logie & Gibson (2013).Discrimination in various aspects, intensifies marginalisation and isolation increasing the chances of risky behaviours (Ehrenfeld & Miller, 2014).

Access to Health Services:
There are various obstacles MSM people are faced with when they try to utilize healthcare services: stigma, discrimination, and a lack of heteronormative services were the 2 main factor strongly higlighted by the study participants.
"As an MSM, it is difficult for me to visit my local clinic for any health services because I will be exposed, as I have heard a lot of stories of the unprofessional services experienced by my other colleagues at the same clinic."(Gatsha) Discriminatory attitudes of health workers and fear of confidentiality become a factor that prevents MSM from accessing health services thereby worsening health inequalities as affirmed by Logie et al. (2011).It is very significant to have culturally sensitive and accepting healthcare services specially tailored to the special needs of MSM in order to improve overall health outcomes (Delany Moretlwe et al., 2015).

Social Support Networks:
It was affirmed by the study participants that social support from family, friends, and the community carries a great significance in MSM's well-being.
"I find strength and acceptance in the support I receive from my immediate family, which also extends to my extended family.This act helped me discover the courage to embrace my authentic self."(Lungelo) Family acceptance and support, along with peer support, can help to alleviate stigma and discrimination.Both types of support bolster resilience and a sense of belonging as affirmed by Ryan et al. (2010).The support from the community in the form of recognition and tolerance helps in creating an atmosphere encouraging the healthy living among the MSM group (Resnick et al., 2020).
Coping Strategies and Well-being: It was also noted that MSM individual are creative at coping, by using resilience, getting social support network, and doing mental health practices, to deal with the societal and health related issues.
"God help those who help themselves, we need to wake up and look for ways we can support ourselves in the communities otherwise we shall be doomed."(Mpilo) Taking resilience makes MSM stronger and helps them to respond to adversity positively while gaining social support can provide emotional support and understanding (Thoits, 2011).According to Keyes (2002) practicing mental health practices prioritizes emotional resilience and self-care that leads to overall emotional well-being.
Overall Well-being: The overall well-being of MSM individuals in South Africa is influenced by social support structures, inclusive environments, and access to affirming healthcare.
"For me, real inclusion starts with acceptance and respect from our family and spreads to the neighbours, government offices, schools, and churches in our communities.It's a group effort to cultivate respect and self-belonging in all facets of our lives."(Solomon) It was denoted by the study participants that MSM individuals total health and quality of life are strongly influenced by socially supportive structures, friendly surroundings, and health systems that treat individuals with empathy.Together, these factors help buffer the negative effects of social determinants of health, while enhancing resilience and improving health outcomes as affirmed in the study of Resnick et al. (2020) and Puckett et al. (2019).
Study Limitations: Creswell & Creswell (2017) stated that using both quantitative and qualitative data strengthens the study design by tapping into the research topic more comprehensively.However, it raises issues accompanying data integration and analysis.As affirmed by Palinkas et al. (2015) Also, the use of purposive sampling technique in this research may constraint the transferability of the findings to the rest of the MSM in South Africa.Nonetheless, these leanings have large implications in policy and practice in accommodating the comprehensive health and well-being of MSM individuals in South Africa.From a policy perspective, the study underlines the significance of package approaches to solve the manifold problems of MSM people.Therefore, there is a need for policy makers to focus on the formation and interdiction policies that address stigma and discrimination, health inequality and limited social support for MSM populations.This may include policies such as anti-discrimination policies, education for health care providers, and support services within the community.Moreover, policies should provide the necessary guarantee that the appropriate resources and funding for these interventions can be provided.
In terms of practice, there is a need to embrace a comprehensive and culturally appropriate model of healthcare provision for MSM individuals.It is therefore important that healthcare professionals undergo training to improve their ability to understand this population's requirements.Moreover, it is important for healthcare facilities to work towards providing a welcoming and affirmative environment and engagement with MSM patients.Apart from the clinic-based intervention strategies which are so important in attending to the healthcare needs of MSM people, community mobilization and partnership also has a crucial role to play in encouraging overall health and ensuring availability of other necessary healthcare services in the societies.
Accordingly, the recommendation and actualization of the suggestions made herein will enable subsequent studies to expound on these findings and assist in creating successful interventions that enhances health equity and improves the quality of life of MSM people in South Africa.

Conclusion
In conclusion, this research has shed light on the intricate dynamics surrounding the wellbeing of men who have sex with men (MSM) in South Africa, particularly in the context of social support networks and their role in mitigating the negative effects of social determinants of health.The overarching theme of "overall well-being" has emerged as the paramount factor in navigating the impact of these determinants.It is evident that robust social support structures, including family, peers, and community, play a pivotal role in alleviating the challenges posed by stigma, discrimination, and barriers to healthcare access.The sub-themes of inclusivity, as well as access to affirming healthcare, have been identified as essential components of overall well-being as shown in the diagram (Figure 2) below: o Enact policy initiatives that address the unique healthcare needs of MSM individuals, ensuring that healthcare systems are affirming, sensitive, and responsive to their specific requirements.This may include incorporating LGBTQ+ inclusive curricula in medical education to enhance cultural competence among healthcare providers.
o Promote a holistic approach to addressing the challenges faced by MSM individuals in South Africa.This approach should encompass efforts to reduce stigma and discrimination, strengthen social support networks, and improve access to affirming and inclusive healthcare services.
Through the implementation of the above recommendations, South Africa could help foster an environment that enhances the health and wellbeing of MSM individuals and hence healthier societies.Thus, the future work should engage policymakers, healthcare professionals, various community organizations, as well as MSM individuals to make significant steps and improve the health of this vulnerable group.

Figure 1 :
Figure 1: Study participant's Pseudonym Names and age

Figure 2 :
Figure 2: Social Support Network Impact on Overall-Well-being of MSM

Table 3 :
Participants' Education Status

Table 4 :
% distribution of Study Participants 'Physical Environment'

Table 5 :
Superordinate and Underlying Themes