1. The determinants of health

A social model of health is a framework for thinking about health. Within this framework, improvements in health and wellbeing are achieved by addressing the social and environmental determinants of health, in tandem with biological and medical factors.¹ Underpinning and supporting this conceptual framework is the Alma Ata declaration and the World Health Organisation definition of health:

Health is a complete state of physical, mental and social wellbeing, not merely the absence of disease or infirmity.²

Planners of services that aim to improve health and wellbeing and reduce the burden of preventable disease, need to be concerned not only with the individual context or factors, but also with the context of broad public policies and environmental influences, group and family influences and the community context.³ It is not possible to decide how best to support the improvement of health without understanding this context as illustrated in Figure 1.⁴

The context of health

For further examples of the relationship between the determinants of health (grouped as protective and risk factors) and health and social outcomes download:

The factors affecting health and wellbeing (89kb, pdf).

There is a growing consensus on the importance of systematic differences in exposure to health hazards and risk conditions in the population. This means some groups in society have a much poorer chance of achieving their full health potential as a result of their life circumstances—including political, social, economic and environmental conditions as illustrated above.

Differences are observed in the health status of groups according to a range of socioeconomic indicators. The most disadvantaged groups have the poorest health and the highest exposure to health-damaging risk factors.⁵

There is evidence that poorer socioeconomic groups tend to have poorer nutrition, less physical activity in leisure time, greater prevalence of smoking and more damaging patterns of alcohol use. However, each factor should not be considered separately. The life circumstances or determinants of health (including people’s social and economic circumstances, indigenous status and ethnicity, stress, gender, early life development and experiences, social exclusion, work and unemployment, and social supports)^{6, 7} of people experiencing disadvantage highlight the greater restrictions on ‘making healthy choices the easy choices’.⁸ Further, cultural diversity and the failure of the system to address issues of access to appropriate services and programs for diverse groups can create inequalities in health status. Integrated health promotion attempts to close the equity gaps by supporting social networks; developing and advocating healthy public policies; and strengthening community capacity.⁹

Inequity and inequality are often used interchangeably, but have very different meanings. If one person lives longer or suffers less sickness and disability than another, then inequalities in health status exist—but not necessarily as a result of inequity. These differences may not have arisen from living conditions, but from genetics, personal lifestyle choices or particular accidents. However, if differences in health status result from different living conditions (such as reduced access to nutritious foods, inadequate housing, lack of access to appropriate health care, lower income levels, stressful work conditions and frequent periods of prolonged unemployment), then inequalities in health status are the result of social inequities.¹⁰

for further information on Determinants of Health, download:

Social Determinants of Health - The solid facts, Second Edition (474kb, pdf)
Note: This publication is located on the World Health Organization Regional Office for Europe website.

A background paper prepared for the Commission on Social Determinants of Health -
Action on the social determinants of health: learning from previous experiences (530kb, pdf)
Note: This publication is located on the World Health Organization website.

Footnotes:

1. Aged, Community and Mental Health Division (1998), A stronger primary health and community support system: policy directions, Victorian Department of Human Services, Melbourne.
2. World Health Organisation 1958, cited by Wass, A. (2000), Promoting health: the primary health care approach, Second edition, Harcourt Saunders, Sydney, p. 7.
3. Victorian Department of Health and Community Services (1991), Promoting health and preventing illness in Victoria, Melbourne.
4. Roe, M. (1995), Working together to improve health: a team handbook, Centre for Primary Health Care, University of Queensland, Brisbane.
5. Marmot, M. (1999), ‘The solid facts: the social determinants of health’, Health Promotion Journal of Australia, vol. 9, no. 2, pp. 133–9.
6. Marmot, M. and Wilkinson, R. (1999), Social determinants of health, Oxford University Press, Oxford.
7. World Health Organisation (1999), Reducing inequalities in health: proposal for health promotion policy and action, Consensus Statement, Health Documentation Services, Copenhagen.
8. Comino, E. and Howell, S. (2000), The facts, in Harris, E., Sainsbury, P. and Nutbeam, D. (eds), Perspectives on health inequity, Australian Centre for Health Promotion, Sydney.
9. International Union for Health Promotion and Education (2000), The evidence of health promotion effectiveness: shaping public health in a new Europe, Report for the European Commission, Brussels.
10. Draper, R. quoted in Restrepo, H. (2000), Increasing community capacity and empowering communities for promoting health, Draft Technical Paper, Fifth Global Conference on Health Promotion, Mexico.

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