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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
Many factors combine together to affect the health of individuals and communities. Whether a person is healthy or unhealthy is determined by his/her 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:
- the social and economic environment,
- the physical environment,
- the person’s individual characteristics and behaviours.
There are many commonly 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 and these have been summarised below:
Policy-making
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. They represent economic and political systems, physical and social environments, as well as health service access.
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 and limited language access. These barriers to accessing health services lead to unmet health needs, delays in receiving appropriate care, inability to get preventive services as well as hospitalizations that could have been prevented.
Individual Behaviour
Individual behaviors such as diet, physical activity, alcohol, tobacco 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 and genetic make-up.
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Improving Health World Wide
WHO have identified three “common interventions” for improving health conditions world wide:
1. Education
A large number of studies have demonstrated a strong link between better education and better health, and education has been shown to be a reliable predictor of lower mortality rates. The probability of being in good or very good health is higher for people with university or post-secondary education.
2. Social Protection
Countries with some sort of social protection (i.e. a safety net or social security system) show improved health and economic outcomes in circumstances where people become unable to earn a living.
3. Urban Development
The physical environment where communities live has a great impact on the health of the residents. Factors which have a negative impact on health include overcrowding, damp living conditions and crime (in particular fear of crime). The WHO concludes that health outcomes “are largely determined by the accessibility to adequate housing and to healthy and safe urban environments and by transport conditions”.
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 the 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.
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 describe opportunities for the 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 the investment of resources, health professionals need to expand their repertoire of skills and activities both with their individual patients and in the policy arena.
who’s response
The determinants of health include:
- the social and economic environment,
- the physical environment, and
- the person’s individual characteristics and behaviours.
The context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the above factors, and many others:
- Income and social status – higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
- Education – low education levels are linked with poor health, more stress and lower self-confidence.
- Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions
- Social support networks – greater support from families, friends and communities is linked to better health. Culture – customs and traditions, and the beliefs of the family and community all affect health.
- Genetics – inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.
- Health services – access and use of services that prevent and treat disease influences health
- Gender – Men and women suffer from different types of diseases at different ages
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