DETERMINANS

OF
HEALTH
OBJECTIVES
 Perspectives on health
 Health measurement
 Evolution of determinants of health
 Perspectives on determinants of health
 Contemporary view of determinant of
health
 PERSPECTIVES ON HEALTH
 Right- The WHO constitution “ . . . the enjoyment of the highest
attainable standard of health is one of the fundamental rights of
every human being w/o distinction of race, religion, political
belief, economic or social condition”

 Consumption good- view health as an important individual

objective of material aspect i.e. as consumption good.

 Investment -indicates health as prerequisite for development b/c

of its consequence on the overall production through its effect on
the productive (healthy) popn.
STANDARDIZED MEASURES OF HEALTH
STATUS OF THE POPULATION
 While mortality statistics do not completely describe the
health status of a popn , they can be used to calculate other
useful measurements

 Others include measures of ill health(less pricise than

mortality)

1. LIFE EXPECTANCY-LE Motrality

2.YEARS OF POTENTIAL LIFE LOST-YPLL related

3. DISABILITY ADJUSTED LIFE YEAR-DALY

Ill health
4.HEALTH ADJUSTED LIFE EXPECTANCY - HALE related
 MEASURES OF THE HEALTH STATUS OF
THE POPULATION…
1. LIFE EXPECTANCY/LE
Average no of yrs a person from a specific cohort is projected to
live from a given point in time.
Doesn’t tell about the quality of ones life

Indicates that some of the factors that contribute to death were

controlled/managed
2.YEARS OF POTENTIAL LIFE LOST/YPLL
Life expectancy minus age at death

E.g. deaths due to leading causes

It is higher for diseases w/c kill younger than for equal amount of
deaths from diseases w/c kill elderly
MEASURES OF THE HEALTH STATUS OF
THE POPULATION…
3. DISABILITY ADJUSTED LIFE YEAR/DALY;
 One DALY is one lost yr. of healthy life

 Total DALY= total YPLL plus total life lived with disability E.g.
Fire injury
 DALY=YPLL+YLLD(yrs lost due to disability)
 YLLD= L(length of stay in a disease condition)* WX (average
severity of the disease from
0(perfect health) to 1(dead)
MEASURES OF THE HEALTH STATUS OF
THE POPULATION…

4. Health-Adjusted Life Expectancy (HALE)

 Is a measurement that attempts to capture a more
complete estimate of health than standard LE rates
 Previously referred to as Disability-Adjusted Life
Expectancy or DALE.
 HALE estimates the nO of healthy yrs an individual is
expected to live at birth by subtracting the yrs of ill
health – weighted according to severity – from overall
life expectancy
 HALE is also calculated at age 65 to provide a
measurement of the quality of life of seniors.
CONT…
 Healthy life expectancy (HALE) at birth adds up expectation of
life for d/t health states, adjusted for severity distribution
making it sensitive to changes over time or d/ces b/n countries
in the severity distribution of health states.
 HE1,0 to HE4,0 are the health state expectancies at birth for
each of the four states, and we give age-independent weights
w2, w3, w4(less than 1) to the three states of less than full
health, then the disability-adjusted life expectancy at birth and
total life expectancy at birth are given by:
 LE0=HE 1,0 +HE2,0 +HE3,0 +HE4,0

 DALE0=HE 1,0 +W2*HE2,0 +W3*HE30 +W4*HE4,0

 POTENTIAL USES OF SUMMARY
MEASURES OF HEALTH
1) Comparing the health of one population to the health of another population.
2) Comparing the health of the same population at d/t points in time.
3) Identifying and quantifying overall health inequalities within populations.
4) Providing appropriate and balanced attention to the effects of non-fatal
health outcomes on overall population health.
5) Informing data on priorities for service delivery and planning.
6) Informing data on priorities for research and development in the health sector.

7) Analyzing the benefits of health interventions for use in cost-effectiveness

analyses.
 HEALTH INEQUALIITIES & DETERMINANTS OF
HEALTH
 Health inequalities
 Two types

 Health Disparities

 Health Inequities

 Health Disparities: any d/ces in health outcomes b/n groups of

people
 Male babies are born at a heavier birth wt than female babies 
 Health Inequities: d/ces in health outcomes b/n groups of people
that are considered preventable or unfair
 Educated women are more likely to use contraceptives than
uneducated
 COMPLEXITIES OF HEALTH
1. Multiple determinants
2. Multiple dimensions: mortality, morbidity, functioning, and
well-being.

3. Multiple causal pathways through which determinants influence

each other and health outcomes,
 Direct and indirect influences on health

 D/t time frames across which effects and outcomes are realized
(across the life course & generations).

4 Multiple levels of influence : individual, interpersonal,

community & societal effects
 DETERMINANTS OF HEALTH
 Definition-
Determinants of health are factors, behaviors
and conditions that interrelate to influence health.

 Healthstatus results from the combined influence of

“complex interactions b/n social and economic factors,
the physical environment and individual behavior.”

 Factors affecting health can be outside the health sector.

 DETERMINANTS OF HEALTH HISTORICAL
CONTEXT
 The concept of health determinants has been changing
through time

 Aristotle’s
Ethics and Policy, the concept of health
was located in the broader field of living well, both
morally and socially

 Aristotle identifies 3 kinds of resources for living

well:
 Goods of the body
 Goods of the soul and
 External goods
DETERMINANTS OF HEALTH HISTORICAL
CONTEXT …
 A drop in MR & protection of human life during the
end of the19th & the beginning of the 20th c. were
accredited to the efficiency of medical innovations

 The health concept points to the existence of 3

categories :
 Internal balance

 External factors, health services & functions is major

among external factors
 The equilibrium b/n the two
DETERMINANTS OF HEALTH HISTORICAL
CONTEXT …
 Thequality of interaction b/n an individual &his /her
external environmental factors has been recognized as
crucial for one’s health.

 Theiraccessibility and availability were considered to

be of primary importance, along with their activities.
THE HOLISTIC MODELS
 THE HOLISTIC MODELs
DETERMINANTS OF HEALTH FROM HEALTH FIELD
CONCEPT
 Mc Keown’s “Health Field” concept;
 According to this report 4 determinants /greatest
influences upon health are:

Environment Life style

Human biology Health care organization

 THE HEALTH FIELD CONCEPT
A. HUMAN BIOLOGY
A. Human biology(genetics):
 Mental &physical - organic structure & physiological
functioning of the human body

 The genetic make up -determines the likelihood of inherited

disorders & the predisposition to acquired diseases.

 The individual´s constitution is also a determinant of

susceptibility to risk factors arising from certain lifestyles &
environments.
 HUMAN BIOLOGY...
 Maturation changes and aging are also important in
determining the state of health.

 The human biology has many facets, only a few of which are
adequately understood.
 THE ENVIRONMENT....
The Physical Environment
The factors include:
 Life support, food, water, air etc

 Physical factors, climate, rain fall

 Biological factors: microorganisms, toxins, biological waste,

 Chemical factors: industrial &agricultural wastes , air pollution

Direct effects of P E – by exposure to potentially hazardous agents

(chemicals or radiation) and etc.
Indirect effects of P E – by global warming, etc.
 THE ENVIRONMENT
The Social Environment
 Include education, taxation, labor &housing markets,,
government regulation, health care systems , psycho-social &
economic - crowding, income , access to HC e.t.c.

 Individuals have little or no direct control

 THE SOCIAL ENVIRONMENT
The social determinants of health are responsible for
life expectancy variations like :
 Lower in deprived cities than affluent cities in
developed countries.

 Gap among individuals of d/t socioeconomic status

in the same city.

 Lowamong low employment grade(in non poor

employees)
 THE ENVIRONMENT

Main social determinants of health:

1. Social organization - stress
2. Unemployment , job insecurity
3. Psychosocial environment at work
4. Transport
5. Social support and social cohesion
6. Food and nutrition
 THE ENVIRONMENT
Main social determinants of health:
7. Poverty, social exclusion
8. Individual health behaviours
9. Ethnic /racial inequalities
10.Neighbourhoods/housing
11.Social vulnerability and inequality
MORTALITY BY GENDER
1000
900
800
700
600
500
400
300
200
100
0
Men Women
(per 100,000)

Source: National Center for Health Statistics, CDC, 2005

MORTALITY BY RACE

1400
1200
1000
800
Male
600 Female
400
200
0
White Black
(per 100,000)

National Center for Health Statistics, cDC, 2005

EDUCATION/DISEASE

Source: National Health interview Survey,2001-05 Robert

Wood Johnson Foundation, 2008
EDUCATION AND MORTALITY
PARENT EDUCATION AND CHILDREN’S HEALTH
PREMATURE MORTALITY BY INCOME
HEALTH AND WEALTH
LIFESTYLE AND BEHAVIOURS

C. Life style & Behavior:

E.g.
 Cigarette smoking

 Unsafe sexual practice

 Eating contaminated food

 Lifestyle consist of aspects of individuals´ behaviour

and surroundings over which they may exercise
control
 Healthy lifestyle comprise patterns of health-related
behaviour, values and attitudes adapted by groups of
individuals in response to their social, cultural and
economic environment.
 RISK CONTINUUM
 Personal decisions and habits that are bad, from a health field
point of view, create self-imposed risks.

 Tobacco (400,000 deaths)

 Nutrition and Physical Activity (325,000)

 Alcohol (85,000)

 Violence

 What is the origin or cause of behavior???????

HEALTH CARE ORGANIZATION
Availability of HCS
 Scarcity of Health Services –inefficient health service
& resulting in poor quality of health status of
people.
 Acceptability - of the service by the community

 Accessibility - in terms of physical distance,

finance etc
 Quality of care - comprehensiveness, continuity and
integration of the HC.
HEALTH CARE ORGANIZATION (HCO)
The HCO / the health care system includes:
 Medical & dental practice

 Nursing

 Hospitals

 Chronic care facilities

 Rehabilitation

 Drugs

 Public health services, and

 Chiropractic

 Podiatric and optometric services

DETERMINANTS OF HEALTH –HEALTH FIELD
CONCEPT

Human The Health care Lifestyles,

Biology=10- Environment= Organization behaviors and
20-25% of =10-15% of
15% of morbidity & Risk Factors= 50-
morbidity&
morbidity& mortality 60% of morbidity
mortality
mortality & mortality

Health Status
BLUM’S MODEL
 Suggesting that  what affects the four major influences
of health mentioned above are five background
influences:
 population,

 culture,

 mental health,

 natural resources, and

 ecological balance.

 How much each of the 4 influences contributes to human

health depends on the combination of these five items.
 CONT..
 In his model, Blum alters the size of the four arrows
according to his perception of their relative contribution
to health of the human population.
 However, the arrow sizes would be different for regions
and countries where health care services are nominal or
where human behavior, to a large extent, dictates the
health of that population (e.g., Canada, where lifestyle
influences are important, leading to heart and lung
disease).
EVANS AND STODDART
 Responding, in part, to this focus on individuals largely
to the exclusion of the communities in which they live.
 Evans and Stoddart (1994) proposed an expanded
version of this model, that identifies both the major
influences on health and well-being and the dynamic
relationships among them.
Evans and Stoddart (1994)/
COMPONENTS
1.Social environment
2.Physical environment
3.Genetic endowment
4.Individual response (behavior and biology)
5.Health care
6.Disease
7.Health and function
8.Well-being, and
9.Prosperity .
 CONT…
 The model emphasizes the importance of considering the origins
of health and the underlying causes of disease in individuals and
populations;

 Explicitly hypothesizes about the production of health in the

community;

 Underscores the interdisciplinary and multi-sectoral efforts often

required to achieve health improvement in communities;
 CURRENT PERSPECTIVES/ ECOLOGICAL
MODEL
 “Determinants of health are the range of personal, social,
economic & environmental factors which determine the
health status of individuals & populations”

 Thecontemporary view is that individual health

determinants do not act in isolation

 There is over-lapping and interdependence among them

 They function as parts of a complex interaction b/n one
another and, as such, have considerable consequences
upon one’s health
 CURRENT PERSPECTIVES…
 Determinants of health have differing effects in d/t
phases of a life

 E.g.
The influence of family factors in childhood is
more important than individual behavior, while in
adult-hood individual behavior has a prominent role

 Health & sickness represent a resultant of effects of the

determinants of health throughout life, as well as of
certain effects of some determinants during critical life
stages.
 KEY DETERMINANTS OF HEALTH
1. Income and social status
2. Social support networks
3. Education
4. Employment , working
conditions
5. Social Environments
6. Physical Environments
7. Personal health, Practice
and Coping Skills
8. Healthy Child
Development
9. Biology and Genetics
10. Health services
11. Gender
12. Culture
 CURRENT PERSPECTIVES…
 Answers to the origin of health &sickness can be found
neither in descriptions of the structure and function of
humans nor in separation or quantification of
individual causes

 Theconcept of health determinants is an encompassing

& synthetic approach to explaining the complex
mechanisms by which an array of factors influences
one’s health.
 $186/
person
76.9 yrs,
$3,300/ ranked
person 28th

$4,500/
person
77 yrs,
ranked
27th

2000, UC Atlas of Global Inequality http://ucatlas.ucsc.edu/spend.php

 EFFECTS OF DISPARITIES

 Some health outcomes are likely of direct

“determinants”

E.g. Parental income associated with educational

attainment and health of child

 Some determinants and outcomes have complex

relationship

E.g. Low education associated with high tobacco use.

Tobacco use associated with…..
CIGARETTE SMOKING BY EDUCATION
SOCIAL EFFECTS OF DISCRIMINATION
 Stress?

 Low self-esteem?
 High-risk behaviors

 Health inequity
 CURRENT PERSPECTIVES…
 “Our understanding of what makes & keeps people
healthy continues to evolve

 Descriptionof individual determinants bears the risk of

oversimplification as the basis for their activity is
interaction

 “About 60 % of preventable morbidity &mortality are

neither within individual sovereignty nor in individual’s
behavior/life style, but within social organization” .
CONT…
 The World Health Organization (WHO) notes that social
determinants of health “are mostly responsible for health
inequities,” and characterizes social determinants of
health as “the conditions in which people are born, grow,
live, work and age, including the health system.”
 CONT…
 Physical environment as a health determinant ,does not
occur in social vacuum, but is in correlation with social
environment.

 Thus people with lower income live and work in

unhealthy environments, sometimes even exposed to
toxic and carcinogen substances.

 Settlementsin which people from socially deprived

groups live are often beleaguered with problems of
elementary hygiene
 HEALTH AND INCOME
Income can lead to health inequality in 2 ways:
1. As the basic cause:
 Unequal distribution of goods/services among d/t
population groups, & causing decreased life
expectancy, mortality, and differing frequency of
certain illnesses
2. Income itself
 A safe dwelling

 Provision of goods

 More comfortable living

 HEALTH AND WORKPLACE
 Stressat one’s workplace increases the risk of getting
a disease and choosing a poor life style

 Unemployment-rates are related to variations in

morbidity and mortality
SOCIAL SUPPORT/SOCIAL CAPITAL

 Men with less social support have higher chance to die

at certain age than their peers with greater social
support.

 Particular importance in childhood.

CULTURAL VALUES
 Like migration, stigmatization, deprivation based on
religious or national characteristics, result in a series of
consequences upon health

 Gender inequality is an important determinant of

health.
HEALTHY CHILD DEVELOPMENT

 Development of children, and particularly of the brain

in early child-hood, is under the strong influence of
diet and early stimulation .

 Life of children in early childhood and the quality of

care that they receive have considerable consequences
on health.
 Parents’ education and their incomes determine the
conditions in which children live
 GENETIC ENDOWMENT
 Riskfor almost any disease in human populations is a
result of interaction b/n inherited gene variations and
environmental factors

 Socio-economic and environmental factors are significant

determinants of health at society level, but when it
comes to which person will get a disease ,this is
determined by genotype.
MESSAGES
 Relation which exists b/n socio-economic determinants and a
person’s health is not of the poverty-consequence type, but of
inequality -consequence one

 Countries with more regular distribution of resources score

better health indicators than the countries with no regular
distribution of resources

 It is necessary to adopt a public health policy that integrates

the whole picture of determinants of health.
THANK YOU