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Key Concepts in Public Health Determinants of Health

Contributors: Soumen Sengupta Edited by: Frances Wilson & Mzwandile Mabhala Book Title: Key Concepts in Public Health Chapter Title: "Determinants of Health" Pub. Date: 2009 Access Date: February 16, 2020 Publishing Company: SAGE Publications Ltd City: London Print ISBN: 9781412948807 Online ISBN: 9781446216736 DOI: http://dx.doi.org/10.4135/9781446216736.n4 Print pages: 16-20

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Determinants of Health SoumenSengupta

Definition

Health is classically defined as ‘a state of complete physical, social and mental health, and not merely the absence of disease or infirmity’ (WHO, 1948). As such, health is as much a social construct as a biological characteristic. It is the product of a complex interaction of different factors: this is true at both individual and population levels. These determinants include not just an individual's particular characteristics and behav- iours but also their economic, physical and social environments (Ashton and Seymour, 1992).

Key Points

• Health is created by a complicated interaction of different factors, only some of which can be directly influenced by individuals.

• Social determinants tend to have a greater impact on population health status than healthcare ser- vices.

• Different determinants have a differential influence on different groups of people: this can contribute to health inequalities.

• An appreciation of the differential influence of determinants should be used to develop and deploy a wider array of public policy activities to promote good health.

Discussion

How different disciplines consider determinants of health is born of their traditions and values. There are four schools of thought (Beaglehole, 2004):

• The biomedical view – emphasis on specific causes and discrete treatments for ill health amongst individuals.

• The lifestyle view – emphasis on individual responsibility for lifestyle choices. • The broad socio-economic approach – emphasis on factors outside the healthcare sector, especially

economic and social. • The population health view – emphasis on the impact on population health of wealth generation and

distribution.

Whilst the biomedical view has traditionally dominated health policy, recent years have seen increasing recog- nition of a more comprehensive suite of determinants (HM Treasury, 2004). Although healthcare services have some impact, more influential on population health are the economic, physical and social conditions that foster ill health – and that, if orientated correctly, should actively engender good health (Ashton and Seymour, 1992).

Developing a Comprehensive Perspective

Canada's Lalonde Report was the first official statement to describe a broader view of health (Lalonde, 1974). Its ‘health field’ concept described how health status was not just affected by biology and healthcare ser- vices, but was explicitly a product of lifestyle behaviours and the environment. This was then developed, most prominently in the Ottawa Charter for Health Promotion (WHO, 1984) which set out nine prerequisites for

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good health:

• Peace • Shelter • Education • Food • Income • A stable ecosystem • Sustainable resources • Social justice • Equity

Consequently, an ambitious proposition has been developed for prioritising resources ‘upstream’, from ser- vices targeted at the individual to policy action on the economic, physical and social determinants of popu- lation health. Unfortunately, most investment in health still reflects and reinforces the biomedical worldview (Hunter, 2003).

Social Determinants of Health

Systems theory states that a system is composed of interdependent and interrelated parts, with change in one part producing changes in others (von Bertalanffy, 1968). In order to explore the impacts of and the po- tential to influence different determinants it is thus necessary to appreciate their interrelationships. A number of conceptual models assist this. The most frequently cited is the Dahlgren and Whitehead ‘rainbow’ – Figure 3.1 (Dahlgren and Whitehead, 1991).

The extent to which different determinants can be influenced varies; certainly no individual is likely to exert direct control over most of them. Furthermore, these determinants can have a differential impact at different stages of an individual's life; between different social groups; and between different countries (Solar and Ir- win, 2007). Clearly context is crucial.

Much of the discussion on determinants within the public health arena has focused on social factors. The ra- tionale is that, however important individual genetic susceptibilities to disease may be, population health has been influenced much more by the rapidly changing social conditions in which people live (WHO, 2003). By focusing on social determinants, Graham and Kelly (2004) has suggested that different models implicitly fol- low a common structure that articulates a causal chain between the wider environmental elements and health status.

Figure 3.1 Dahlgren and Whitehead's determinants of health model (1991)

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That said, it is important to recognise the value of healthcare interventions in reducing disease susceptibility (e.g. immunisation programmes). It is also important to remember that wider environmental factors should not be viewed as disconnected from the experiences of individuals. Simply put, these social systems are a prod- uct of individuals and their interactions. Moreover, the choices that individuals make should not be dismissed. However, they are a product of the choices available and the confidence different groups have in exercis- ing them (i.e. the degree of self-efficacy possessed). Circumstances and conditions that provide people with greater control over different facets of their lives (and consequently nurture a greater sense of self-esteem) are associated with better health outcomes (Marmot, 2003).

Health Inequalities

Consideration of the differential influences of health determinants is almost inextricably linked to the question of why economically or socially disadvantaged groups consistently experience relatively poorer health status (Graham and Kelly, 2004). Such disadvantage can manifest in different forms, e.g. limited aspirations, low income and discrimination. Critically, such disadvantages tend to gravitate towards one another, creating vi- cious circles in which people get trapped.

In the UK, the Black Report (Townsend et al., 1992) identified the primary reasons for worsening social gra- dients in mortality and other indicators of ill health as material deprivation and poverty; and its recommen- dations highlighted economic and social policy solutions. These conclusions were reinforced by subsequent publications, with the Acheson Report (Acheson, 1998) stating that: ‘the weight of scientific evidence supports a socio-economic explanation of health inequalities. This traces the roots of ill health to such determinants as income, education and employment as well as material environment and lifestyle.’ While there are clearly overlaps, the determinants of health are not exactly the same as the determinants of health inequality: the latter concerns the unequal (and by implication, unfair) distribution of health determinants (Graham and Kelly, 2004).

Case Study

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Understanding determinants should help identify different policy levers (local, regional, national and transna- tional) that can promote health amongst different communities. This could include action to develop resilience amongst young people and vulnerable adults; strengthen social capital; improve infrastructure and access to services; and tighten environmental legislation. It should enable identification and mitigation of policy action that could have a detrimental impact – this is the essence of health impact assessment (Brown et al., 2005). It should also help develop a realistic sense of the limitations of any given intervention to improve population health. For example, although statins are a relatively effective pharmacological intervention for reducing the risk of heart disease (NICE, 2006), against the backdrop of an escalating obesity epidemic they can only have a limited impact in themselves (WHO, 2007). That does not mean they are not worth providing, but rather that they need to be part of a multi-dimensional package of activities.

Cross-References

Understanding health determinants has relevance to all aspects of public health. In using this textbook, it would be particularly useful to cross-reference with inequalities in health (Chapter 5); assessing public health need (Chapter 21); planning public health initiatives (Chapter 22); health impact assessment (Chapter 24); and collaborative and partnership working (Chapter 34).

Conclusion

Health at both individual and population levels is the product of a complicated interaction of different factors. Health policy is still dominated by a biomedical paradigm, yet there is a substantial theoretical and evidence base to support a more comprehensive perspective. It is now widely understood that the primary determi- nants of health are the economic, physical and social environments within which individuals live. Few deter- minants can be directly influenced by the individual; and most social determinants have a greater impact on population health status than healthcare services. Critically, many determinants have a differential impact on different groups of people: this can contribute to inequalities in health. Developing an understanding of the complex nature of the health determinants is not a merely theoretical exercise; nor should the recognition of that complexity act as an excuse for inaction on discrete issues. Rather this understanding should be used to develop and deploy a wider array of public policy activities to promote good health.

Further Reading Irwin, A. and Scali, E., (2005) Action on the Social Determinants of Health: Learning from Previous Experi- ences. Geneva: World Health Organization. http://dx.doi.org/10.1080/17441690601106304 Kelly, M., Bonnefoy, J., Morgan, A. and Florenzano, F., (2006) The Development of the Evidence Base about the Social Determinants of Health. Geneva: World Health Organization.

• health inequalities • health care services • health care • health impact assessment • health • ill health • health status

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