DETERMINANTS

 OF  HEALTH  
 Determinant    
•  Determinant  is  used  to  refer  to  any  factor,  
whether  an  event,  characterisAc,  or  other  
definable  enAty,  that  brings  about,  or  
contributes  to,  a  change  in  health.    
 Importance  of  Health  Determinants    
•  Common  diseases  have  roots  in  lifestyle,  
social  factors  and  environment,  and  successful  
health  promoAon  depends  upon  a  populaAon-­‐
based  strategy  of  prevenAon    
Importance  of  Health  Determinants  
•  As  health  professionals,  training  and  reimbursement  
systems  emphasize  diagnosAc  and  treatment  
services  to  individuals.  

•  We  need  to  focus  on  those  factors  (DETERMINANTS)  

which  have  the  most  influence  on  the  health  of  the  
populaAon.  

Rose 1992
Importance  of  Health  Determinants  
•  Focus  on  those  determinants  which  have  the  most  
influence  on  the  health  of  the  populaAon.  
–  Environment  
–  Social  
–  Biology  

•  Current  aPempts  at  health  reform  will  not  be  

successful  at  improving  health  unless  the  populaAon  
health  determinants  are  addressed.  
Determinants  of  Health  

Novick,  LF.    Used  with  permission.  

 Contemporary  Concept  of  Health  
•  Health  has  mulAple  determinants.    
 
•  Factors  important  to  health,  illness,  and  injury  are  
social,  economic,  geneAc,  perinatal,  nutriAonal,  
behavioral,  infecAous,  and  environmental.  
 

Omenn  1998  
 Contemporary  Concept  of  Health    
•  Biologic  or  host  factors  include:  
–  geneAcs    
–  behaviors  that  determine  the  suscepAbility  of  the  
individual  to  disease  
–  other  factors  related  to  suscepAbility  
 Environmental  Determinants  
•  Environment  includes:    
–  physical  environment  
–  condiAons  of  living  
–  toxic  agents  
–  infecAous  agents  
 Social  Determinants  
•  Social  factors  of  importance  include:  
–  poverty  
–  educaAon  
–  cultural  environments  (including  isolaAon)  
 HIV  Example  
•  A  contemporary  example  of  the  agent-­‐host-­‐
environment  model  can  be  seen  with  the  
transmission  of  HIV  in  a  community,  which  is  
determined  by:    
–  infec&ous  agent  
–  host  individuals  
–  environment  
•  The  agent-­‐host-­‐environment  model  facilitates  public  
health  intervenAon  because  disease  can  be  
interdicted  by  addressing  any  one  of  these  factors    

 
 Occurrence  

InformaAon   Sexual  behaviors  

EducaAon   Environment  
Condom  uAlizaAon  
Peer  norms   MulAple  partners  
Drug  use   Intravenous  drug  use  
Condom  
availability  
Agent   Individual  
Preven*on  

Environment   Individual  

Partner  no*fica*on/  Needle  

exchange/  Safe  sex/  Condoms  

Agent  

Used  with  permission.  

 Tuberculosis  
•  What  is  the  cause  of  TB?  

•  What  explains  the  condiAon  of  TB  from  1900  to  the  
present?  

•  The  answer  to  both  of  these  quesAons  is  related  to  
the  mulAple  factors  that  cause  TB.  
Determinants  of  Health  
Social  

Novick,  LF.    Used  with  permission.  

 The  Socioeconomic  Determinant  
•  2003  InsAtute  of  Medicine  report  concludes  
Americans  today  “are  healthier,  live  longer,  and  
enjoy  lives  that  are  less  likely  marked  by  injuries,  ill  
health,  or  premature  death”  

•  Gains  are  not  shared  fairly  by  all  members  of  society  
–  Widening  gap  between  upper  and  lower  class  

IOM 2003
 The  Socioeconomic  Determinant  
•  Elevated  death  rates  for  the  poor  are  evident  in  
almost  all  of  the  major  causes  of  death  and  in  each  
major  group  of  diseases,  including  infecAous,  
nutriAonal,  cardiovascular,  injury,  metabolic,  and  
cancers.    

Wilkinson,  1997  
 Socioeconomic  Factors  and  Disparity  
•  Heart  disease  is  the  leading  cause  of  death  in  the  
United  States  and  is  one  of  the  areas  in  which  
dispariAes  are  most  evident.  
 
 Socioeconomic  Factors  and  Disparity  
•  The  Whitehall  I  Study,  a  long-­‐term  follow-­‐up  study  of  
male  civil  servants,  was  set  up  in  1967  to  invesAgate  
the  causes  of  heart  disease  and  other  chronic  
illnesses.  

•  Researchers  expected  to  find  the  highest  risk  of  

heart  disease  among  men  in  the  highest  status  jobs;  
instead,  they  found  a  strong  inverse  associaAon  
between  posiAon  in  the  civil  service  hierarchy  and  
death  rates.  

Wilkinson 2009
 Socioeconomic  Factors  and  Disparity  
•  Men  in  the  lowest  grade  (messengers,  doorkeepers,  
etc.)  had  a  death  rate  three  Ames  higher  than  that  of  
men  in  the  highest  grade  (administrators).  

•  Further  studies  in  Whitehall  I,  and  a  later  study  of  

civil  servants,  Whitehall  II,  which  included  women,  
have  shown  that  low  job  status  is  not  only  related  to  
a  higher  risk  of  heart  disease:    it  is  also  related  to  
some  cancers,  chronic  lung  disease,  gastrointesAnal  
disease,  depression,  suicide,  sickness  absence  from  
work,  back  pain  and  self-­‐reported  health.  
Wilkinson 2009
 Income  &  Health  
•  In  the  United  States,  individuals  without  a  high-­‐
school  diploma  as  compared  with  college  graduates  
are  3X  as  likely  to  smoke  and  nearly  3X  as  likely  not  
to  engage  in  leisure-­‐Ame  physical  exercise  

 
 

PraP  et  al.    1999  

 Income  &  Health  
•  As  a  result  of  a  sedentary  life-­‐style  and  unhealthy  
eaAng  habits  (ohen  as  a  result  of  condiAons  in  which  
wholesome  food  is  unavailable  or  exorbitantly  
priced,  public  recreaAon  is  non-­‐existent,  and  
exercising  outdoors  is  dangerous),  obesity  and  the  
diseases  it  fosters  now  characterize  lower-­‐class  life.  
 Income  &  Health  
•  Poor  neighborhoods  
–  ohen  dangerous     •  Offer  residents,  no  
–  high  crime  rates   maPer  what  their  race,  
–  substandard  housing   income  or  educaAon,  
–  few  or  no  decent  medical   liPle  chance  to  improve  
services  nearby   their  lives  and  engage  in  
–  low-­‐quality  schools   health-­‐promoAng  
–  liPle  recreaAon   behaviors.  
–  almost  no  stores  selling    
wholesome  food    

Diez  et  al.    2001  

 Income  &  Health  
•  People  of  lower  socioeconomic  status  are  more  likely  
to  die  prematurely  than  are  people  of  higher  
socioeconomic  status,  even  when  behavior  is  held  as  
constant  as  possible.  
 Understanding  how  Income  Influences  Health  

•  Inequitable  distribuAon  of  income  and  wealth  may  

itself  cause  poor  health.  

Daniels  et  al.  2000  

 Socioeconomic  Factors  and  Disparity  
•  Life  expectancy  appears  to  be  more  related  to  
income  inequaliAes  than  to  average  income  or  
wealth.    
 
•  In  a  study  of  the  relaAonship  between  total  and  
cause-­‐specific  mortality  with  income  distribuAon  for  
households  of  the  United  States,  a  Robin  Hood  index  
measuring  inequality  was  calculated  and  found  to  be  
strongly  associated  with  infant  mortality,  coronary  
heart  disease,  malignant  neoplasms,  and  homicide.    

Wilkinson  1989,  Kennedy  et  al.  1996  

 Socioeconomic  Factors  and  Disparity  
•  Despite  decreases  in  mortality,  widening  dispariAes  
by  educaAon  and  income  level  are  occurring  in  
mortality  rates.  Mortality  rates  for  children  and  
adults  are  related  both  to  poverty  and  to  the  
distribuAon  of  income  inequality.    

•  Growing  inequaliAes  in  income  and  wealth  will  likely  

conAnue  to  be  a  significant  determinant  of  
dispariAes  of  health  in  the  near  future.    

US  Department  of  Health  and  Human  Services,  1998  

 Socioeconomic  Factors  and  Disparity  
•  The  problems  in  rich  countries  are  not  caused  by  the  
society  not  being  rich  enough  (or  even  by  being  too  
rich)  but  by  the  scale  of  material  differences  
between  people  within  each  society  being  too  big.  

•  What  maPers  is  where  we  stand  in  relaAon  to  others  
in  our  own  society.  

Wilkinson 2009
 Socioeconomic  Factors  and  
Disparity  
•  In  and  around  Washington  DC,  the  gap  is  bigger  sAll
—a  20  year  gap  between  poor  Blacks  in  downtown  
Washington  and  well-­‐off  Whites  in  Montgomery  
County,  Maryland,  a  short  metro  ride  away.  

Marmot 2006
 Socioeconomic  Factors  and  Disparity  
•  Above  a  level  where  material  deprivaAon  is  no  
longer  the  main  issue,  absolute  income  is  less  
important  than  how  much  one  has  relaAve  to  others.  

•  RelaAve  income  is  important  because,  it  translates  

into  capabiliAes.  

•  What  is  important  is  not  so  much  what  you  have  but  
what  you  can  do  with  what  you  have.    Hence  control  
and  social  engagement.  

Marmot 2006
Determinants  of  Health  
Environment  

Novick,  LF.    Used  with  permission.  

 Environmental  Quality  
•  Hazardous  Wastes  
•  Air  PolluAon  
•  Water  PolluAon  
•  Ambient  Noise  
•  ResidenAal  Crowding  
•  Housing  Quality  
•  EducaAonal  FaciliAes  
•  Work  Environments  
•  Neighborhood  Quality  

Lee, et. al 2003

Determinants  of  Health  
Biology  

Novick,  LF.    Used  with  permission.  

 Behavior  
•  Modifiable  behavioral  risk  factors  are  leading  causes  
of  mortality  in  the  United  States.  
 

Mokdad et al. 2004

 Other  Important  Causes  
•  Microbial  Agents  
•  Toxic  Agents  
•  Motor  Vehicles  
•  Firearms  
•  Sexual  Behavior  
•  Illicit  Use  of  Drugs  

Mokdad et al. 2004

 Behavior  
•  The  burden  of  chronic  diseases  is  compounded  by  
the  aging  effects  of  the  baby  boomer  generaAon  and  
the  concomitant  increased  cost  of  illness  at  a  Ame  
when  health  care  spending  conAnues  to  outstrip  
growth  in  the  gross  domesAc  product  of  the  United  
States.  
 

Mokdad et al. 2004

 Smoking  and  Obesity  
•  Although  there  is  sAll  much  to  do  in  tobacco  control,  
it  is  nevertheless  touted  as  a  model  for  combaAng  
obesity,  the  other  major,  potenAally  preventable  
cause  of  death  and  disability  in  the  United  States.  

•  Smoking  and  obesity  share  many  characterisAcs.  

Schroeder 2007
 Smoking  and  Obesity  
•  are  highly  prevalent  
•  start  in  childhood  or  adolescence  
•  were  relaAvely  uncommon  unAl  the  first  (smoking)  or  
second  (obesity)  half  of  the  20th  century  
•  are  major  risk  factors  for  chronic  disease  
•  involve  intensively  marketed  products  
•  are  more  common  in  low  socioeconomic  classes  
•  exhibit  major  regional  variaAons  (with  higher  rates  in  
southern  and  poorer  states)  
•  carry  a  sAgma  
•  are  difficult  to  treat  
•  are  less  enthusiasAcally  embraced  by  clinicians  than  
other  risk  factors  for  medical  condiAons  
Schroeder 2007
 Lifestyle  
•  Personal  behaviors  play  criAcal  roles  in  the  
development  of  many  serious  diseases  and  injuries.    

•  Behavioral  factors  largely  determine  the  paPerns  of  

disease  and  mortality  of  the  twenAeth-­‐century  
populaAons  of  the  United  States.    

US  Department  of  health,  EducaAon  and  Welfare,  Breslow  1998  

 Fihh  Phase  of  the  Epidemiologic  
TransiAon  
•  The  Age  of  Obesity  and  InacAvity  

Gaziano 2010
 Fihh  Phase  of  the  Epidemiologic  
TransiAon  
•  The  steady  gains  made  in  both  quality  of  life  and  
longevity  by  addressing  risk  factors  such  as  smoking,  
hypertension,  and  dyslipidemia  are  threatened  by  
the  obesity  epidemic.  

•  The  latest  prevalence  and  trends  in  obesity  data  

from  the  NaAonal  Health  and  NutriAon  ExaminaAon  
Survey  (NHANES),  reported  by  Flegal  and  colleagues,  
show  that  in  2007-­‐2008,  68.0%  of  US  adults  were  
overweight,  of  whom  33.8%  were  obese.  

Gaziano 2010
 Fihh  Phase  of  the  Epidemiologic  
TransiAon  
•  Early  obesity  strongly  predicts  later  cardiovascular  
disease,  and  excess  weight  may  explain  the  dramaAc  
increase  in  type  2  diabetes,  a  major  risk  factor  for  
cardiovascular  disease.  

•  The  longer  the  delay  in  taking  aggressive  acAon,  the  

higher  the  likelihood  that  the  significant  progress  
achieved  in  decreasing  chronic  disease  rates  during  
the  last  40  years  will  be  negated,  possibly  even  with  
a  decrease  in  life  expectancy.  

Gaziano 2010
 Fihh  Phase  of  the  Epidemiologic  
TransiAon  
•  More  men  than  women  were  overweight  or  obese,  
72.3%  compared  with  64.1%.  

•  If  leh  unchecked,  overweight  and  obesity  have  the  

potenAal  to  rival  smoking  as  a  public  health  problem,  
potenAally  reversing  the  net  benefit  that  declining  
smoking  rates  have  had  on  the  US  populaAon  over  
the  last  50  years.  

Gaziano 2010
 Medical  Care  as  a  Determinant  
•  Inadequate  health  care  may  account  for  10%  of  
premature  death  

•  Health  care  receives  by  far  the  greatest  share  of  our  
resources  and  aPenAon.  
 Medical  Care  as  a  Determinant  
•  Missing  rouAne  or  prevenAve  medical  care  can  lead  
to  the  need  for  emergency  care  or  even  to  
preventable  hospitalizaAons.  

•  Lack  of  access  to  transportaAon  due  to  not  owning  a  

vehicle,  not  having  a  vehicle  available  via  a  friend  or  
family  member,  or  not  having  access  to  public  
transportaAon  can  lead  to  difficulty  in  seeking  
medical  care.  

National Center for Health Statistics Health, United States, 2008 With
Chartbook Hyattsville, MD: 2009
 PopulaAon  Health  Challenges  
•  Preventable  chronic  illnesses  
•  Obesity  epidemic  
•  Unsustainable  health  care  delivery  system  

Maeshiro 2008
 PopulaAon  Based  PrevenAon  
•  The  fundamental  principle  is  that  health  of  the  
community  is  dependent  on  many  factors  affecAng  
an  enAre  populaAon.    

•  Thus  the  target  for  public  health  intervenAons  

should  be  a  geographic  or  otherwise  defined  
populaAon.    
 
 PopulaAon  Based  PrevenAon  
•  Because  of  the  broad  distribuAon  of  most  diseases  
and  health  determinants,  using  a  populaAon  as  an  
organizing  principle  for  prevenAve  acAon  has  the  
potenAal  to  have  a  great  impact  on  the  enAre  
populaAon’s  health.    

•  It  takes  partnering  at  all  levels  to  fully  realize  the  

impact  of  any  health  intervenAon.      
 PopulaAon  Based  PrevenAon  
•  PopulaAon-­‐based  and  individual-­‐targeted  prevenAve  
strategies  must  be  considered  to  be  complementary,  
not  exclusive.    

•  Comprehensive  populaAon-­‐based  prevenAon  

strategies  may  involve  screening  programs  for  
individuals,  for  example,  newborn  screening  for  
metabolic  diseases,  childhood  lead  tesAng,  colorectal  
cancer  screening,  mammography,  and  pap  smears.  
 Summary  
•  Successful  health  promoAon  depends  on  a  
populaAon-­‐based  strategy  of  prevenAon  

•  Common  diseases  have  roots  in  lifestyle,  social  

factors,  and  environmental  determinants  

•  Determinants  which  have  the  most  influence  on  

health:    environment,  social  factors,  biology