Determinants of Health

Original Editor - Rachael Lowe

Top Contributors - Rachael Lowe and Wendy Walker  

Introduction

"Health care is an important determinant of health. Lifestyles are important determinants of health. But... it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place." WHO Director-General Dr Margaret Chan[1]

Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.

Determinants of health

The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health.
These can be classified as:

  1. the social and economic environment,
  2. the physical environment, and
  3. the person’s individual characteristics and behaviours.

There are many comonly accepted determinants of health but there is no single definition.  The Office of Disease Prevention and Health Promotion (ODPHP) has broadly categorised the determinants of health[2], these have been summarised below:

Policymaking

Policies at the local, state, and federal level affect individual and population health. Increasing taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products.

Social Factors

Social and physical determinants of health reflect the conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes.

Examples include:

  • Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
  • Social norms and attitudes, such as discrimination
  • Exposure to crime, violence, and social disorder
  • Social support and social interactions
  • Socioeconomic conditions, such as concentrated poverty
  • Quality schools
  • Transportation options
  • Urbanisation and the built environment, such as buildings or transportation
  • Worksites, schools, and recreational settings

Health Services

Both access to health services and the quality of health services can impact health.  Barriers to accessing health services include lack of availability. high cost, lack of insurance coverage, limited language access.  These barriers to accessing health services lead to unmet health needs, delays in receiving appropriate care, inability to get preventive services, hospitalizations that could have been prevented.

Individual behaviour

Individual behaviors such as diet, physical activity, alcohol, tabacco, and other drug use also play a role in health outcomes.

Biology and genetics

Some biological and genetic factors affect specific populations more than others.  Examples of biological and genetic determinants of health include age, sex, inherited conditions, genetic make up.

Improving Health World Wide

WHO have identified 3 "common interventions" for improving health conditions world wide[3]:

1. Education

A large number of studies have demonstrated a strong link between better education and better health[4], and education has been shown to be a reliable predictor of lower mortality rates[5][6]. The probability of being in good or very good health is higher for people with university or post-secondary education[7].

2. Social Protection

Countries with some sort of social protection, ie. a safety net or social security system, show improved health and economic outcomes in circumstances where people become unable to earn a living[8].

3. Urban Development

The physical environment where communities live has great impact on the health of the residents[9][10]. Factors which have a negative impact on health include overcrowding, damp living conditions and crime (in particular fear of crime). WHo conclude that health outcomes "are largely determined by accessibility to adequate housing and to healthy and safe urban environments and by transport conditions"[3].

Relevance to Physiotherapy

In our contact time with our patients we spend a lot of time understanding their health and social status, in other words we explore and determinants that might be affecting their health, and in particular ones that we can influence. The model we use to analyse and understand these determinants of health is the biopsychosocial model of health care.

Biopsychosocial-model-of-health.PNG

It is essential that health care workers dedicated to improving health increase their effectiveness by addressing the “upstream” causes of health in the community and by engaging in ways to change the broad policies, systems, and environments that shape the social and economic conditions that, in turn, so strongly influence health.  Swain et al[11] describe opportunities for health care professional to address social determinants of health. They suggest that to be most effective at improving the health of families and communities and to ensure the greatest impact for investment of resources, health professionals need to expand their repertoire of skills and activities both with their individual patients and in the policy arena.

Resources

References

  1. Dr Margaret Chan. Launch of the final report of the Commission on Social Determinants of Health. 2008. Accessed online 6 January 2017.
  2. Office of disease prevention and health promotion. Determinants of Health. Accessed online 6 January 2017.
  3. 3.0 3.1 World Health Organization (2013). The economics of social determinants of health and health inequalities: a resource book (PDF). World Health Organization. ISBN 978-92-4-154862-5
  4. Knesebeck O et al. Education and health in 22 European countries. Social Science and Medicine, 2006, 63:1344–1351
  5. Muller A. Education, income inequality, and mortality: a multiple regression analysis. BMJ, 2002, 324(7328):23–25
  6. Deaton A, Paxson C, eds. Mortality, education, income, and inequality among American cohorts. Chicago, University of Chicago Press, 2001
  7. Hurd M, Kapteyn A. Health, wealth, and the role of institutions. Journal of Human Resources, 2003, 38(2):386–415
  8. Chung H, Muntaner C. Welfare state matters: a typological multilevel analysis of wealthy countries. Health Policy, 2007, 80(2):328–339
  9. Chung H, Muntaner C. Welfare state matters: a typological multilevel analysis of wealthy countries. Health Policy, 2007, 80(2):328–339
  10. Thompson S et al. Do urban regeneration programmes improve public health and reduce health inequalities? A synthesis of the evidence from UK policy and practice (1980–2004). Journal of Epidemiology and Community Health, 2006, 60(2):108–115
  11. Swain et al. Health Care Professionals: Opportunities to Address Social Determinants of Health. 2014. WMJ, 113:6