Dr Neelamani

Doctor of Medicine, Doctor of

Philosophy

Determinants of
Health
 Goal 3
Promote healthy lives and wellbeing at all ages for all

Risk factors for health (direct effect on health)

2- Food security and 11- Cities
nutrition 13- Climate change
6 - Water and sanitation 16 -Peaceful and inclusive societies
Linkages 7 - Energy
Determinants of health (indirect effect on health)
between 1- Poverty 9 - Infrastructure, industrialization,
health and 4- Education
5- Gender equality
innovation
12 – Consumption and production
other goals 8 -Economic growth and
employment
14 – Oceans, seas and marine resources
15 - Ecosystems

10 – Equity

17 – Means of implementation
list of social determinants of health.
• Initial list: nutrition, education, employment, living environment
• Some dominant in the literature: education , housing and or living environment, income and its
distribution , stress, early life, social exclusion, work, unemployment, social support, addiction, food,
transport.
• Recent additions: health system, gender, sexual orientation, social safety net, culture or social norms ,
media, stigma and discrimination, social capital, conflict, rule of law, racism, racialized legal status ,
immigration , family, religion , colonialism, and marginalization
• NEW: “time” as a social determinant of health, as healthy behavior, accessing health services, resting,
and caring all require time. The amount of time one can use for health-related activates is socially
patterned and could therefore be a source of health inequalities.
• economic sanctions as a social determinant of health.
• access to broadband internet service .
• Social determinants of specific conditions are Ex depression, contraceptive use, and oral health.
Social determinants
• Social determinants of health are conditions or circumstances in which people are born,
grow, live, work, and age (WHO).
• The quality, quantity, and distribution of these resources with equity and equality (ex:
education, a healthy living environment, nutrition, healthcare and employment),
determine citizen's health and well-being.
• These conditions are shaped by political, social, and economic forces .
• Poor policies and programmes, unfair economic arrangements and bad governance may
lead to unfavorable conditions.
WHAT are structural determinants of health?
• Determinants of health which are responsible for major part of health inequalities between and
within countries.
• Determinants of health which are responsible for major part of health inequalities between and
within countries.
• Structural Determinants are the ‘root causes’ of health inequities, because they shape
the quality of the Social Determinants of Health experienced by people in their
neighbourhoods and communities.
• Structural determinants include the governing process, economic and social policies
that affect pay, working conditions, housing, and education.
• The structural determinants affect whether the resources necessary for health are
distributed equally in society, or whether they are unjustly distributed according to race,
gender, social class, geography, sexual identity, or other socially defined group of people.
SOCIAL
FORCES

POLICIES

GOVERN
PUBLIC

ANCE
and
Adopted by Dr
Neelamani
 Determinants

Can be Cannot directly

influenced by be influenced by
individual the individual

Use of health Economic Environmental

Life style
services condition condition
 Personal determinants:
What factors Knowledge, attitudes, beliefs,
determine values, perceptions, self-
efficacy, etc.
individual
behaviors and in the immediate
(inter-personal)

environmental External
determinants that
environment (e.g.,
influence of
parents/friends),

conditions? influence behavior

and/or
in the more
“remote”
can be: environment
(higher ecological
levels)

2012 Goodstadt: University of Toronto 8

Social Class

• Classified by socio-economically determined positioning the society based

on life chances and life style of people.
• Marx says it is a product of mode of production of society
• Weber says it is more than economic status or wealth determined by
consumption pattern.
• Class always influences the mortality morbidity and range of health
indicators
• Poverty and health eg; vicious circle of poverty, malnutrition, unequal
access to health provision.
• Class and its link with non-communicable diseases
• Class and symbolic consumption of health services.
 Social
Equality in A social condition that safeguards the equal access or
provision for medical treatments or healthcare irrespective
Healthcare of class, caste, ethnic, religious, gender, educational
background or any other differences which are found in a
society can be generally called as Social Equality in
Healthcare
Race , Ethnicity and Caste

• Social classification based on physical or biological characteristic is

race.
• Ethnicity is based on cultural features such as religious practice,
language, historical traditions, food habits, dressing and other life
styles.
• significant co-relation between health issues and ethnic background.
• The impact of social discrimination on ethnic minority in terms of
medical services.
• Caste based profession and services in health sector eg; cleaning and
embalming (undertaking) activities in hospital
Social • social isolation and social exclusion- being on the margin
of society and having little control over your life
Exclusion
Knowledge and Education

• Poor education-particularly health education and ignorance of services

and health care available
• According to Foucault’ arguments, the health risk and health seeking
behavior are always socially and culturally reconstructed as medical
or health discourse based on the knowledge of people.
• Medical or health knowledge controls human body (bio-politics) and
health seeking behaviour
• Education has become the main determinant of healthcare provision
• Knowledge based technology is crucial in the process of managing
disease control and health institutions
SEX & GENDER

• Gender matters a lot in the day to-today behavior of people

• The informal mechanism and domestic level management of disease by women
• Gender role and division of labour, dress code, sleeping arrangements at the household
etc..
• Gender and family planning.
• Gender and sexually transmitted diseases eg; HIV
• Gender aspect- eg; Silva-Gender dimension of malaria-why the male rate is higher than
that of female rate?
Stress and work
Lack of experience.
Long hours and stressful or dangerous working
conditions
Lack of enforcement of health and safety at work
Social Support
 • Inadequate childcare and socialization
Early life • Lack of affordable services or access to parks and garden
LOW BIRTH WEIGHT VS
DIABETESE
Unemployment

low income and poverty;

Unemployment and poverty
 Risky behaviours
Smoking and drinking too much and taking illegal drugs,
practicing unsafe sex, living in a high crime area
FOOD
Eating junk food and other unhealthy food
 Transport

Poor transport planning and poor access

to public transport
Dr Neelamani MSc,MD,PhD 26
ctd
Inadequate medical or social care and lack of access to health and
social services
Poor housing with dampness, cold and overcrowding
• Living in industrial areas with risk of pollution, busy roads and poor
air quality
Alcohol Use
Factors which influence use
(Determinants)

• Attractiveness of the image of use

• Availability and affordability
• Influences of the trade
• Influences of the immediate environment
• Privileges for use and users
• No pressure to quit or reduce use
Addressing ‘Image’
1. How the ‘image’ created
2. Discussion with the community – Improving their understanding
3. Identifying sources – within the community and external sources
4. Discuss about the action
5. Checking progress
 Gross inequalities in health which exists within and
between countries present a challenge to the world.

There is a spread of life expectancy of 48 years among

countries and 20 years or more within countries.

Social factors are at the root of much of these inequalities

in health, for communicable and non-communicable
disease alike.
 Social Dimensions

Acknowledge the correlation between health and social

inequalities
Nature and the connection and health inequalities need to
researched
Growing focus on relative importance of individual variables
such as lifestyle, behavior, diet and cultural patterns versus
environmental or structural factors.
Concern on social determinants of health
WHO Social Determinants frame work
Understanding Social Determinants of Health
 Primary
Goup:Individual

ORBITS OF INFLUENCE level: mothers,

youth, ..
Secondary:
Family & relatives:

Tertiary:
Headman, elders,
religious leaders...

Meso Level:
Service delivery
organisations

Macro Level: Policy

makers and
implementers,
national institutions

11/25/2013 36
Equity Vs Equality
Administrators
role
• Continually increasing the understanding of
the professionals of the role of the health
• Helping identify unseen determinants
(Factors)
• Selecting factors to address
• Suggesting interventions
• Encouraging appropriate assessment of
results
• Sharing knowledge and providing feedback
throughout
Working with
determinants
• Identifying determinants
• Analyzing determinants
• Selecting factors to address
• Measuring change
• Modifying on the basis of
ongoing findings
Referance
• Last JM, editor. Dictionary of epidemiology. 4th
ed. New York: Oxford University Press; 2001. p.
61.
• Cates W. Epidemiology: Applying principles to
clinical practice. Contemp Ob/Gyn 1982;20:147–
61.
• Greenwood M.Epidemics and crowd-diseases:
an introduction to the study of epidemiology,
Oxford University Press; 1935.