JIMMA UNIVERSITY

INSTITUTE OF HEALTH
SCIENCE
SPH-I: Determinants
of health
For Medical students
Temesen K
April 2023
 Outline
Definition of Health

Determinants of Health

Socio-economic factor

 Unemployment, poverty, income inequality

 Economic growth, neighborhood deprivation

 Globalization

Healthcare cost
 What Is Health

 The term health refers to a state either of an

individual or of a community.

 The WHO defines health as ‘a state of physical,

mental and social well being and not merely the

absence of disease.
What is Good Health?
 To say a population of one nation is enjoying a

good health it should involve

 Reduced insecurity

 Reduced unemployment

 Improved housing condition and

 Reduced levels of educational failure

 What affects health
Health care system only?
No!
Peoples lifestyle and the condition in which they live and work strongly influence their
health.


Health system is the most important factor but not the only one that affect health of
individual and society.

 The other factors are

 poverty,

 level of education,

 food intake,

 access to clean water and

 sanitary and housing conditions.

 This factors known as determinants of health.

 Health determinants – many
definitions

• Health is more than medical care and occurs outside of the clinical

space.

• Determinants of health are factors that affect a person's health

status. They may be biological, behavioral, sociocultural, economic,

and ecological. They include genetics, lifestyle, environment,

income, social status, and access to healthcare, education, and other

 Health determinants…
• Definition: The determinants of health refer to the range of

personal, social, economic and environmental factors which determine

the health status of individuals or populations (Health Promotion

Glossary-1998).

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 our health

 Health of Determinants

Determinant of health have been classified by different entities.

Dahlgren and Whitehead (1991) talk about layers of influence on health

 Personal behaviors and lifestyles

 Support and influence within communities which can sustain or

damage health.

 Living and working conditions and access to facilities and services

 Economic, cultural and environmental conditions such as standard of

living
 Determinant of health (Canada)
Health Canada (1999) has identified 12 determinants of health

1. Income and social status

2. Employment

3. Education

4. Social environments

5. Physical environments

6. Healthy child development

7. Personal health practices

 Health Determinants (WHO)

• Whether people are healthy or not, is determined by their

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.
 In general determinants of
health are classified under:
General socioeconomic, cultural and
environmental condition
Social and community network

Individual lifestyle factors

Generic Determinants of health
 Socioeconomic factor

• The social determinants of health are the conditions in which people are
born, age compositions, the way they grow, where they live, work
including the health system. (WHO 2010).

• Socioeconomic refers to society related to economic factors. A way of

describing people based on their education, income, and type of job.
Socioeconomic status is usually described as low, medium, and high.

• The socioeconomic factors that determine health include: employment,

education, and income, poverty, globalization etc.
 Income factor
Income is major determinant of standard of living. People in low‐income group
include unemployed, pensioners, the low paid, and those included in social class of
partly skilled and unskilled.

Those with higher incomes tend to have safe housing and access to adequate and

good nutritious food.

 There are three ways in low income can affect the health:

 Physiological – inadequate or unfit housing or lack of food.

 Psychological – stress and lack of social support.

 Behavioral: health‐damaging behaviors such as smoking and drinking. Poverty also

reduces people’s choices of a healthier lifestyle.
 Employment factor
Employment is another important socioeconomic determinant of health:

It determines income levels;

It affects self‐esteem; and

Employment has a considerable effect on people’s physical, mental and social

health.

The type of employment itself may directly affect health.

Unemployment can damage health

Some of the illnesses associated with unemployment include

depression, anxiety, sleep disturbances, and suicide.

 Income Inequality

Data from different countries have shown that it is not the

richest countries which have the best health, but those that have
smallest income differences between rich and poor.

This small income differences across society mean an

egalitarian society which has a strong community life and better
quality of life in terms of strong social networks, less social stress,
higher self‐esteem, less depression and anxiety, and more sense of
self control.
 Poverty

 The lowest economic status is poverty.

 Poverty can be defined as insufficient resources to meet basic

human needs.

 Poverty increases the risk of poor nutrition, which can have

far-reaching and lifelong impacts on health.

 Cont.
• Globally, poverty is associated with chronic kidney disease (CKD.
As kidney function decreases, CKD progresses in stages from one
to five. At stage five, a person requires ongoing dialysis treatment
or a kidney transplant.

• Diet can influence a person’s risk for hypertension, and

hypertension is a significant risk factor for CKD

• In the US, the urban poor are the most at risk for CKD based on
their dietary intake.
 Education factor

• More education generally leads to better income, fewer workplace

exposures and more access to health care. Individuals with higher

educational attainment are more likely to live longer and healthier

lives, as are their children.

 Education factor

• Three pathways though which education affects health:

 Increased health knowledge, which enables healthier behaviors and medical care
management.

 Higher chance of being employed and having a job with healthier working
conditions,

 Better employment benefits and higher wages, all of which are important to
health.
 Economic growth

There exists a strong positive association between average income

(or wealth) and health status of population

• This positive association can be in the following ways:

• 1st, growth may affect the consumption of health-relevant

commodities. Well-nourished individuals are in turn in a better
position to resist bacterial diseases and have better prospects to
recover from illnesses.
 Economic growth

2nd , economic growth may affect the supply side

of health if it allows governments to increase

spending on effective public health services and

complements in the production of health (such as

improved transportation infrastructure).

 Cont.
• Although increasing incomes are generally associated with
improvements in health, they can also lead to unexpected
increases in the number of illnesses and diseases.
• As economy of a country grow there may be an increase in the
demand for goods associated with health risks, including alcohol
and smoking consumption.
• Economic development can also be linked to shifts in dietary
structure and lifestyle habits. It can promote a sedentary lifestyle
and adverse eating habits, which may, in turn, result in an
increase in non-communicable diseases such as obesity and
diabetes
 Neighborhood factor
• Residents of poor neighborhoods can also lack access to affordable,
healthy foods. In spite of new laws designed to limit tobacco
advertising, poorer neighborhoods continue to have more exposure
to tobacco advertising than wealthier ones.
Children who live in older, poorly maintained houses often found in
low-income neighborhoods can be exposed to indoor allergens that
increase the frequency and severity of asthma.
• Low wage work environments are more likely to expose workers to
toxins or physical hazards.
Poorer neighborhoods have fewer parks or other places that provide
opportunities for physical activity compared to wealthier
neighborhoods.
 Conti…

• Housing may be unsafe for a variety of reasons, including poor

construction, inadequate ventilation, inadequate heating or
overcrowding. Living in such conditions can contribute to poor
health (e.g. respiratory illnesses and gastro-intestinal

infections)
 Health and Early Child Development
(0 to 6 Years)
• Positive prenatal and early childhood experiences result in
improved learning and behavioral skills and better overall health
in adulthood.
• At the same time, several factors affect the physical, social,
mental and emotional development of children.
For example, a child’s development is influenced by his or her
neighborhood, family income and parents’ education.
• Children born in low-income families are more likely
than those born in high-income families to have low birth
weights, to eat less nutritious foods and to have more difficulties
in school.
 Globalization factor
• Economic globalization has been the fundamental driving force
behind the overall process of globalization over the last two
decades.
• It has been characterized both by a dramatic growth in the volume
of cross-border flows, interdependence and by major changes in
their nature.
Countries are influenced due to globalization in a number of
forces: such as technological developments, political influences,
economic pressures, changing ideas, and increasing social and
environmental concerns.
The linkages between globalization and health are complex.
 Cont.
• There are multiple direct and indirect linkages between
globalization and the determinants of health.
• The direct effects include impacts on health systems and policies
operating directly. and through international markets (e.g. the
effect on pharmaceutical prices of the WTO.
• The other it influences on health at the population level (e.g.
cross-border transmission of infectious disease, and marketing of
tobacco).
• The second category includes effects operating through the
national economy on the health sector (e.g. effects of trade
liberalization and financial flows on the availability of resources
for public expenditure on health, and on the cost of inputs)
 Health care costs

Definition of Cost:
 Cost is valuation of effort, material, resources, time, risks
incurred, and opportunity forgone in production and delivery of a
good or service in terms of money.
These are divided into
 costs borne by the ministry of health (like drug and equipment).
 by patients and their relatives (like transport and food) and
 by the rest of society (lost productivity to society).
 Cont.

Surveys from population at large consistently show that high

costs are the number one health care concern.
• As healthcare cost rises quality will be compromised because
health care providers (either government of privates) will be
more concerned to provide health care to most people.
• As patients face higher out-of-pocket costs, they may face
limited healthcare access and keep patients from accessing care.
 Cont.

• Research has shown a relationship between increasing patient

cost burden and health service utilization, suggesting that when
patients pay more for their healthcare they are less likely to
access treatment.
• One in four patients have skipped a medical treatment or follow-
up appointment because of cost.
• Additionally, patients who prolong emergency department visits
because of cost considerably damage their health in the long run.
Summary
 References
• 1. WHO. Closing the gap in a generation: health equity through
action on the social determinants of health: final report of the
commission on social determinants of health. 2008.
• 2. Lange S, Vollmer S. The effect of economic development on
population health: A review of the empirical evidence. Br Med
Bull. 2017;121(1):47–60.
• 3. Ninla Elmawati Falabiba Unit 2: Derminants of health. 2019;
• 4. Woodward D, Drager N, Beaglehole R, Lipson D.
Globalization and health: A framework for analysis and action.
Bull World Health Organ. 2001;79(9):875–81.
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