Presentation for Determinants of Health subject

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Mortality at Titanic
• http://www.icyousee.org/titanic.html
• Of a total of 2,223 people aboard the Titanic
• only 706 survived the disaster and
• 1,517 perished (died)
• The majority of deaths were caused by
hypothermia in the (−2 °C) water.
"Women and children first. " ????

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"First Class first."
Determinants of Health
Dr.Sebahat Dilek TORUN
.
Do people choose their own health?

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Learning Objectives
• At the end of this lecture students will be able to ;
• Explain the changing concepts of health
• Describe determinants of health
• Differentiate “equity” from “equality”
• Explain health disparity
• Identify social factors that serve as fundamental causes of disease
(e.g. education, income, and socioeconomic status, among others)
and understand the ways they impact population health.
Concept of Health

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• Health is a basic need for every individual .
• Health is a fundemental human right !
What is the definition of health ….?
Why is how we define health important ?
"It is health that is real
wealth and not pieces
of gold and silver "
Mahatma Gandhi
Which family is healthy ?
Why ?

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Which family is healthy ?
Why?
How did you decide which family was healthy
in the previous slides ?
“ Health ” is one of the most difficult and complex concepts to define…

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Changing Concepts of Health
• Health has evolved over the centuries from the concept of
individual concern to a worldwide social goal and covers the
whole quality of life:
1. Biomedical
2. Ecological
3. Psychological
4. Holistic
1.Biomedical Concept :
Health = “absence of disease”
 human body = machine
 disease = outcome of the breakdown of the machine
 Doctor’s task = repair the machine
• minimized the role of environmental, social, psychological &
cultural determinants of health.
• Developments in medical and social sciences
the biomedical concept of health was inadequate.

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2. Ecological Concept
 Health = is a dynamic equilibrium between human being & his
environment,
 Disease = maladjustment of the human organisms to the
environment.
• Supports the need for clean air, safe water, ozonic layer in the
atmosphere, etc. to protect man from exposure to unhealthy
factors.
3. Psychosocial Concept:
“health is not only biomedical phenomenon, but is influenced
by social, psychological, cultural, economic and political factors
of the people concerned.”
Health => biological + social phenomenon

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4. Holistic Concept:
Biomedical + Ecological + Psychosocial concept
• Health : multidimensional process involving the wellbeing of the
whole person in the context of his environment.
• Recognizes the strength of social, economic, political and other
environmental influences on health.
• implies that, all sectors of society have an effect on health
(agriculture,food, industry, education, housing etc)
• Emphasis is on the promotion and protection of health.
Definition of “Health”
“Health is a state of complete physical, social and mental well-
being, and not merely the absence of disease or infirmity.”
WHO, 1946
“ Health is a resource for everyday life, not the object of living.
Health is a positive concept emphasizing social and personal
resources, as well as physical capacities.”
WHO, Ottawa Charter, 1986

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New Philosophy of Health
• Health is a fundamental human right.
• Health is essence of productive life.
• Health is inter- sectoral.
• Health is integral part of development.
• Health is central to quality of life.
• Health involves individuals, state and international responsibility.
• Health and its maintenance is major social investment.
• Health is world-wide social goal.
Health :
• is a dynamic state or condition of the human organism
• is multidimensional in nature,
• a resource for living, and results from a person’s interactions with
and adaptations to his or her environment;
• therefore, it can exist in varying degrees and is specific to each
individual and his or her situation.

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How did you decide which family was healthy?
Only the physical component is not sufficient to define “ Health ”
What makes some people healthy and others unhealthy?

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Determinants of Health
occasionally referred to as ‘the causes of the causes’
Determinants of Health
• The health of individuals and populations is influenced by many
factors acting in various combinations.
• In order to improve population health status and reduce health
inequalities, it is important to identify and understand the main
factors that protect and promote good health.

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Determinants of Health - definition
“ The range of
behavioural,
biological,
socio-economic and
environmental factors
that influence the health status of individuals or populations. ”
Health promotion glossary. Geneva: WHO, 1998
Determinants of Health
Many factors have an influence on health of individual :
1. Biology and genetics
2. Indivudual behaviours
3. Health Care services
4. Social and economic environment
5. Physical environment (natural and built)
Interrelationships among these factors that determine individual and
population health.

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Necessary conditions for health (WHO)
• Peace
• Shelter
• Education
• Food
• Income
• A stable eco-system
• Sustainable resources
• Mobility
• Social justice and equity
prerequisites for health which
are identified in the Ottawa
Charter for Health Promotion
World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at
<http://www.who.int/hpr/archive/docs/ottawa.html>.
Social Determinants of Health Model
shows …
Dahlgren and Whitehead model of health determinants (1991)
Most of these factors lie
outside of the health care
system but have significant
impact on individual and
population health.

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• Individuals are unlikely to be able to directly control many of the
determinants of health.
• Determinants of health help to explain or predict trends in health and
why some groups have better or worse health than others.
• Health promotion is fundamentally concerned with action and
advocacy to address the full range of potentially modifiable
determinants of health.
Health Equity and Disparities

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Equity versus Equality
Equity versus Equality: Environmental Factors

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Health Equity
• The opportunity for everyone to attain his or her full health
potential
• No one is disadvantaged from achieving this potential because of
his or her social position or other socially determined circumstance.
• Distinct from health equality
Health Inequities
• Systematic and unjust distribution of social, economic, and
environmental conditions needed for health
• Unequal access to quality education, healthcare, housing,
transportation, other resources (e.g., grocery stores, car seats)
• Unequal employment opportunities and pay/income
• Discrimination based upon social status/other factors

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Well established inequalities
• Income
• Poverty
• Education
• Health
Examples of Health Inequities
Education Infants born to African American mothers with only a high
school education were 2.2 times more likely to die in the
first year of life compared to their White counterparts.
Income Low socioeconomic status is associated with an increased
risk for many diseases, including CVH, arthritis, diabetes,
chronic respiratory diseases, cervical cancer and frequent
mental distress.1
Access to resources Lower income and racial/ethnic minority communities are
less likely to have access to grocery stores with a wide
variety of fruits and vegetables.2,3
References: 1Pleis, Lethbridge-Cejku (2006), 2Morland, et al (2002), 3Baker, et al (2006)

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Health Disparities
• Differences in the incidence and prevalence of health
conditions and health status between groups, based on:
• Race/ethnicity
• Socioeconomic status
• Sexual orientation
• Gender
• Disability status
• Geographic location
• Combination of these
Examples of Health Disparities
Diabetes As of 2007, Native Americans and Alaska Natives (17%), African
Americans (12%), and Hispanics/Latinos (10%) were all significantly
more likely to have been diagnosed with diabetes compared to their
White counterparts (7%).1
Heart Disease In 2000, rates of death from diseases of the heart were 29 percent
higher among African American adults than among white adults, and
death rates from stroke were 40 percent higher.2
Infant Mortality In 2002, Sudden Infant Death Syndrome (SIDS) deaths among
American Indian and Alaska Natives was 2.3 times the rate for non-
Hispanic white mothers.3
References: 1CDC (2008), 2NCHS (2002), 3NICHD (2007)

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Health Disparities Health Inequities Health Equity
Differences in the incidence
and prevalence of health
conditions and health status
between groups based on:
•Race/ethnicity
•Socioeconomic status
•Sexual orientation
•Gender
•Disability status
•Geographic location
•Combination of these
Systematic and unjust
distribution of social,
economic, and environmental
conditions needed for health.
•Unequal access to quality
education, healthcare, housing,
transportation, other resources
(e.g., grocery stores, car seats)
•Unequal employment
opportunities and pay/income
•Discrimination based upon
social status/other factors
The opportunity for everyone
to attain his or her full health
potential.
No one is disadvantaged from
achieving this potential
because of his or her social
position or other socially
determined circumstance.
•Equal access to quality
education, healthcare, housing,
transportation, other resources
•Equitable pay/income
•Equal opportunity for
employment
•Absence of discrimination
based upon social status/other
factors
• ”The effects on health of social processes follow the social gradient:
the lower the socioeconomic position the more health is affected by
the social determinants of health”
– Sir Michael Marmot
• “Health inequalities and the social determinants of health are not a
footnote to the determinants of health. They are the main issue.”
– Sir Michael Marmot

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“ There is strong evidence indicating that factors outside the health
care system significantly affect health. These “determinants of
health” include income and social status, social support networks,
education, employment and working conditions, physical
environments, social environments, personal health practices and
coping skills, healthy child development, health services, gender
and culture. “
Taking Action on Population Health: A Position Paper for Health
Promotion and Programs Branch Staff. Ottawa: Health Canada, 1998
Social Determinants of Health

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Social Determinants of Health
“The conditions in which people are born, grow, live, work and age,
including the health system.
These circumstances are shaped by the distribution of money,
power and resources at global, national and local levels, which are
themselves influenced by policy choices.
The social determinants of health are mostly responsible for health
inequities-the unfair and avoidable differences in health status
seen within and between countries. “
(WHO - Commission on Social Determinants of Health)
• They explain health inequalities.
The relevance of a social determinants
perspective
“… The gaps, within and between countries, in income levels,
opportunities, health status, life expectancy and access to care are
greater than at any time in recent history.”
Margaret Chan, Director-General, World Health Organization (2010)

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“The social conditions in which people live powerfully influence
their chances to be healthy. Indeed factors such as poverty, food
insecurity, social exclusion and discrimination, poor housing,
unhealthy early childhood conditions and low occupational status
are important determinants of most diseases, deaths and health
inequalities between and within countries“
(WHO 2004)
Five-key domains of Social Determinants of
Health
• Healthy People 2020
encompasses five key domains for
social determinants of health

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Neighborhood and Built Environment
• Quality of Housing
• Crime and Violence
• Environmental Conditions
• Access to Healthy Foods
Health and Healthcare
• Access to Health services—including
clinical and preventive care
• Access to Primary Care—including
community-based health promotion
and wellness programs
• Health Technology

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Social and Community Context
• Family Structure
• Social Cohesion
• Perceptions of Discrimination and
Equity
• Civic Participation
• Incarceration/Institutionalization
Education
• High School Graduation Rates
• School Policies that Support Health
Promotion
• School Environments that are Safe and
Conducive to Learning
• Enrollment in Higher Education

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How are health and education linked?
There are three main connections:
1. Education can create
opportunities for better health
2. Poor health can put
educational attainment at risk
(reverse causality)
3. Conditions throughout people’s
lives—beginning in early
childhood—can affect both
health and education
Economic Stability
• Poverty
• Employment Status
• Access to Employment
• Housing Stability (e.g., homelessness)

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Is unemployment a threat to health?
• Suicide 40x more common in young men unemployed > 6 months
(Wessely, 2004)
• Suicide 6x more common in general population with longer-term
unemployment (Bartley et al, 2005)
• Health risk = smoking 10 packs of cigarettes/day (Ross 1995)
• Health risk may be comparable to that from “killer diseases” (Waddell
& Aylward, 2005)
• Being unemployed may be as dangerous as certain high-risk
professions.
• Unemployment may exert a negative influence on health by
reducing access to needed material resources.
= > POVERTY

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Poverty
The vicious circle :
• Ill health leads to poverty
• Poverty leads to ill health
The vicious circle :
• Good health is linked to higher income and welfare
• Higher income is linked to good health
Poverty and ill-health: the vicious circle
Characteristics of the poor
Inadequate service utilization,
unhealthy sanitary, dietary
practice, etc.
Causes;
Lack of income&knowledge,
Poverty in community-social norms,
weak institutions and infrastructure,
bad environment;
Poor health provision-inaccessible,
lack of key inputs, irrellevant services,
low quality; excluded from health
finance system-limited insurance,co-
payments
Poor health
outcomes
Ill health
Malnutrition
High fertility
Diminished income
Loss of wages
Costs of health care
Greater vulnerability to
catastrophic illness

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Socioeconomic Status (SES)
• As a general rule: the wealthier you are the healthier you are.
• The poorer you are the worst health outcomes experienced.
• Measured using three components:
SES = INCOME + OCCUPATION + EDUCATION
• All three components impact on each other :
income increases the opportunities for education
A well paying occupation increases ones income
An education increases one job opportunities and therefore income.
Socioeconomic status: Impact on Health
 High SES:
• Income increases ability to purchase healthy foods and therefore
maintain a health BMI, increase immune system etc.
• Access to health care
• Ability to understand health promotion messages
 Low SES:
• Live in poorer areas with lack of physical resources
• Poorer quality of housing and also overcrowding
• More likely to smoke
• More likely to have poor nutrition and lack of physical activity

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74,1
77,3
79,6 80,7 82,5
50,0
70,0
90,0
Less than $35,000 $35,000 to $44,999 $45,000 to $59,999 $60,000 to $74,999 $75,000 or more
LifeexpecantyinYears
Life expectancy by median household income group of ZIP codes, Twin Cities 1998-2002
Source: The unequal distribution of health in the Twin Cities, Wilder Research www.wilderresearch.org
Analyses were conducted by Wilder Research using 1998-2002 mortality data from the Minnesota Department of Health and data from the U.S. Census
Bureau (population, median household income, and poverty rate by ZIP code
Income and Health

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Health disparities are visible even within specific countries.
Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. MillbankQuarterly. 199371(2):279-322

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MensahGA et al., State of disparities in cardiovascular health in the United States. Circlulation. 2005;111:1233-1241.

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House JS et al., Age, socioeconomic status, and health. Milbank Quarterly. 1990;68(3):383-411.
Importance of Health Determinants
“Common diseases have roots in lifestyle, social factors and
environment, and successful health promotion depends upon a
population-based strategy of prevention.”

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• SDoH are not usually direct causes of illness but have been
described as the causes of the causes of illness. ROOT CAUSES !
• are the causes of health inequalities.
• The impact of differences in social determinants is a stark
difference between the health and wellbeing of the best off
members of society and that of the worst.
What contributes to UNEQUAL Life Expectancy ?

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“Leading Causes” ofDeath
Source: Mokdad , Marks, Stroup, Gerberding. (2004) Actual Causes of Death in the United States, 2000. JAMA 291 (10): 1238-1245.
Leading
Causes
of Death

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“Actual Causes” of Death
Source: Mokdad , Marks, Stroup, Gerberding. (2004) Actual Causes of Death in the United States, 2000. JAMA 291 (10): 1238-1245.
Leading
Causes
of Death
Actual
Causes of
Death

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Deaths Related to SocialFactors
Source: Galea S, Tracy M, HoggattK, et al. (2011) Estimated Deaths Attributableto Social Factors in the United States. American Journal of Public Health 101(8): 1456-1465.
Leading
Causes
of Death
Actual
Causes of
Death
Social/Root
Causes of
Death

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Childhood
Obesity
Limited
Physical
Activity
Education
Policy
Unsafe
neighborhood
streets
Examples of root factors
• Availability of resources to meet daily needs (e.g., safe housing and
local food markets)
• Access to educational, economic, and job opportunities
• Access to health care services
• Quality of education and job training
• Availability of community-based resources in support of community
living and opportunities for recreational and leisure-time activities
• Transportation options
• Public Safety
http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health

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• Social Support
• Social norms and attitudes (e.g., discrimination, racism and
distrust of government)
• Exposure to crime, violence, and social disorder (e.g., presence
of trash and lack of cooperation in a community)
• Socioeconomic conditions and the stressful conditions that
accompany it
• Language/Literacy
• Access to mass media and emerging technologies (e.g., cell
phones, the Internet, and social media)
• Culture
Root Causes = SocialDeterminants of Health
“…economic and social conditions that influence the health of
people and communities. These conditions are shaped by the
amount of money, power, and resources that people have, all of
which are influenced by policy choices.”
“The social determinants of health are mostly responsible for
health inequities - the unfair and avoidable differences in health
status seen within and between countries.”
- World Health Organization
http://www.cdc.gov/socialdeterminants/FAQ.html
http://www.who.int/social_determinants/sdh_definition/en/

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How much do social determinants matter?
Impact of Social Determinants on Health

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• Medical care is estimated to account for only 10-20 % of the
modifiable contributors to healthy outcomes for a population.
• The other 80 to 90 % are sometimes broadly called the SDoH:
• health-related behaviors,
• socioeconomic factors,
• environmental factors.
• Integrating medical services and social services is much more
effective than waiting for families with unmet social needs to
present to healthcare providers with medical problems.
Spending Mismatch: Health Care and Other Key
Determinants of Health
Access to
Care; 10%
Gentics;
10%
Environment
; 10%
Healthy
Behaviors;
30%
Social
Circumstanc
es
40%
Determinants
Medical
Services;
88%
Other; 8%
Prevention 4%
National Health Expenditures
Source: NEHI, 2012 Access and use of health care services often have less of an impact !

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SDoH are greatly
influenced by policies,
systems, and
environments.

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“Public health is what we, as a society, do collectively to assure the
conditions in which (all) people can be healthy.”
-Institute of Medicine (1988), Future of Public Health
Practice Questions
• Describe the determinants of health providing an example for each.
• How is health affected by the determinants of health?
• Provide a detailed example that clearly shows how a combination of
the determinants of health can affect an individuals health.
• Provide examples of sociocultural factors that may influence health.

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