Determinants of Health:

Testing of a Conceptual Model

BARBARA STARFIELDa AND LEIYU SHI
Department of Health Policy and Management,
Johns Hopkins University School of Hygiene and Public Health,
624 North Broadway, Baltimore, Maryland 21205-1996, USA

Systematic exploration of the relative strength of the many determinants of health

requires a framework or model for organizing research endeavors. Despite the 150year-old literature on social determinants of health, there have been few efforts at
developing such a model. The Lalonde Report (1974),1 which popularized a prior
conceptualization of health as being determined by biological, environmental, life
style, and health care organization, is still cited and even repeated in various incarnations as a prototype, despite the fact that much greater specificity is required if
policy decisions are to result from scholarly inquiry.
In this presentation we provide an example of the evolution of causal diagrams
from the early 1970s to the late 1990s.25 This example shows how discrete lines of
scholarly endeavors can shape the way these diagrams are formed. For example, in
the 1970s and 1980s Aaron Antonovskys work6 on social coherence influenced the
specification of pathways; in the 1990s, social cohesion has replace social coherence, even though it is a variable more related to social context than to individual
psychological representation of feelings. Very few empirical studies address more
than two steps in a postulated pathway.6,7
More recent models (FIG . 1) explicitly represent the ecological context that influences individuals primarily indirectly through more proximate social and environmental phenomena, and even more proximate individual manifestations of these
contextual phenomena. Virtually absent from most of the recent literature is consideration of the contextual variables related to health services organization and delivery and their translation into individual experiences of quality of services received.
When these more comprehensive models are used, it becomes evident that no
single pathway is responsible for manifestation of a populations health. Rather, the
interaction between a variety of types of domains, including the biological, social,
behavioral, environmental, and medical become clear. As noted by Greenland et al.,9
conventional multivariate techniques for assessing the strength of relationships become problematic as the interactions among variables overwhelms the ability of
these techniques to accurately characterize the interactions.
A simple example of these interactions is provided by the work of Shi et al.,10
who used a path analytic strategy informed by F IGURE 1 to examine the relative impact of the contextual variables of income inequality and the supply of primary care
versus specialty physicians in the 50 U.S. states. They found that both income inequality and the supply of primary care physicians directly influenced most of the
aAddress

for correspondence: 410-614-3737 (voice); 410-614-9046 (fax).

e-mail: bstarfie@jhsph.edu [or] Ishi@jhs.edu
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FIGURE 1. Prevention of death, disease, and disability. (Adapted from B. Starfield. 8)

population health indicators and that income equality acted, in part, through primary
care physician, to population ratios. Some health care resources (primary care physicians) but not others (specialty physicians) partly compensated for the adverse effect of income inequality.
REMAINING CHALLENGES
The following are important remaining challenges in the development and application of causal diagrams.
1. Specification and standardization of measures of the important variables in
the pathway, as well as possible modifiers and interaction effects with other
and possibly unknown factors;
2. Standardization of measures of health as appropriate outcomes;
3. Cohort effects and latencies, and critical periods, that is, within cohorts,
historical influences on different cohorts, cumulative effects over time
within cohorts, and presence of critical periods;
4. More appropriate statistical techniques for path analyses;
5. Specification of causal pathways for positive health as a complement to
those for determinants of mortality, morbidity, and disability.

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ANNALS NEW YORK ACADEMY OF SCIENCES

REFERENCES
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