The Determinants of

Health
Presented by:
John J. Lanza, MD, PhD, MPH, FAAP
Director and Health Officer
Florida Department of Health
Escambia County
 Objectives
• To understand that epidemiology studies the determinants
of health
• To realize the importance of health determinants to
individual and population health outcomes
• To address the relationship between health status and
biology, individual behavior, health services, social factors,
and policies
• To emphasize an ecologic approach to disease prevention
and health promotion that focuses on both individual and
population-level determinants of health and interventions
 The Basic Premise of Epidemiology
● Disease does not occur at random, but rather in patterns
that reflect the operation of underlying factors.
● Epidemiology is the study of the occurrence and
distribution of health-related states or events in specified
populations, including the study of the determinants
influencing such states and the application of this
knowledge to control the health problem.
The Importance of Health Determinants
to the Health of the Population
1. “Common diseases have roots in lifestyle, social factors
and environment, and successful health promotion
depends upon a population-based strategy of
prevention.”
2. As health professionals, training and reimbursement
systems emphasize diagnostic and treatment services to
individuals.
3. We need to focus on those factors (DETERMINANTS)
which have the most influence on the health of the
population.
 What is Health Equity?
• Health equity is the availability of health care while taking in to
account the other factors that influence health such as employment,
housing, transportation, education, socioeconomic status, food
access, etc.
• When health equity is achieved, no one is excluded because of a pre-
existing health condition or external circumstances. Health equity
acknowledges that everyone does not start from the same place or
needs the same things.
 HP 2020 Definition of Health Equity
Healthy People 2020 defines health equity as the “attainment
of the highest level of health for all people. Achieving health
equity requires valuing everyone equally with focused and
ongoing societal efforts to address avoidable inequalities,
historical and contemporary injustices, and the elimination
of health and healthcare disparities.”
In an equitable society, everyone has the opportunity to:

-Complete the education level desired

-Obtain employment needed to support
themselves and their families
-Find food that sustains health
-Live in safe housing
-Breathe clean air and drink clean water
-Participate in making decisions that
affect their well-being

12
 The 5 Determinants of Health
(from Healthy People 2020)

Determinants of health fall under several broad categories:

● Policymaking
● Biology and genetics
● Health services
● Individual behavior
● Social factors
 HP 2020 Determinants of Health

• Policymaking
• Biology and Genetics
• Health Services
• Individual Behavior
• Social/(Physical) Factors
County Health Rankings Model
 Interrelationships Between Health
Determinants
• Interrelations between these factors determine individual
and population health.
• Interventions that target multiple determinants are more
likely successful.
• Note: Determinants reach beyond traditional healthcare
and public health sectors ►
--Education, housing, transportation,
agriculture, and environmental are
sectors important in improving
population health.
 Interrelationships Between Health
Determinants Example
• Cancer causation is a good example of this interrelationship.
• Depending on the type of cancer, studies have shown that DNA
mutations may account for a majority of cancer cases.
• About 5% of cancer-causing mutations are linked to inherited
genes:
--e.g., Prostate and Eye >Biology & Genetics
∙ About 69% are due to random errors during cell division
--e.g., Pancreatic cancer > Biology & Genetics determinant
• About 29% are related to modifiable environmental factors
--Wearing sun block > Individual Behavior determinant
--HPV vaccine > Health Services
--Environmental toxicants > Social/physical environment
 Policymaking as a Health Determinant
• Local, tribal, state, national, and international policies could have
significant effects on individual and population health.
► Increasing taxes on tobacco sales can reduce
individual use of tobacco products
► Zoning policy limiting liquor stores in a neighborhood
• Policies can affect populations over extended periods and
also change individual behavior
► Federal highway safety laws regulated standards for
vehicles and highways
►Increased safety standards in cars including safety belts
which reduced rates of injuries and deaths in MVAs
 Biology and Genetics as Health Determinants
Some biological and genetic factors (including epigenetics) affect
specific populations more than others:
• Age: older adults are biologically prone to being in poorer health than
adolescents due to the physical and cognitive effects of aging
• Sex: your gender makes you prone to certain diseases at different
ages;
• Immune Status: having HIV makes you susceptible to other diseases
• Inherited condition: sickle cell anemia, hemophilia, cystic fibrosis
• Genetic carrier: BRCA1/2 increases risk for breast/ovarian CA
• Microbiome sciences: multifaceted interactions between intestinal
microbiomes and their human hosts associated with obesity &
Type 2 diabetes; bacteria, viruses, fungi and lung inflammation
Health Services as a Health Determinant
Lack or limited access to health services and the quality of health
services can impact health:

►Barriers to accessing health services:

-Lack of availability
-High cost
-Lack of insurance coverage → ↓preventive care, delayed
treatment
-Limited language access
Health Services as a Health Determinant (2)
Lack or limited access to health services and the quality of
health services can impact health:

►Barriers may lead to:

-Unmet health needs
-Delays in receiving appropriate care
-Inability to receive preventive services
-Preventable hospitalizations
Individual Behavior as a Health Determinant
Individual behaviors (aka lifestyle choices) play a significant
role in an individual’s health status:
-Dietary patterns
-Level of physical activity
-Alcohol, tobacco, and other drug use
-Hand washing behavior
-Sexual behavior
-Inadequate relief of chronic stress
-Use of sun block
Social Factors as Health Determinants
• Social determinants of health reflect the social, personal,
and economic factors and physical conditions of the
environment in which people are born, live, learn, play,
work, worship, and age.
• These are also known as social/physical determinants of
health and impact a wide range of health, functioning, and
quality-of-life outcomes.
General
Socioeconomic,
Cultural, and
Environmental
Conditions

Social and
Community
Networks

Individual
Behaviors
 Examples of Social Determinants
• Availability of resources to meet daily needs, such as educational and
job opportunities, living wages, or healthful foods
• Social norms and attitudes such as discrimination and tolerance
• Exposure to crime, violence, and social disorder such as the presence of
trash, rubble, abandoned buildings, etc.
• Social support networks and social interactions including isolation
• Exposure to mass media and emerging technologies: Internet, cell
phones, social media
• Socioeconomic conditions: concentrated poverty, low social rank
• Transportation options: walking, bus, private vehicle
• Quality of schools
• Public safety situation
• Residential segregation
 Examples of Social/Physical
Determinants
• Natural environment: plants, weather, or climate
change
• Built environment: buildings or transportation,
road trauma
• Worksites, schools, and recreational settings
• Housing, homes, and neighborhoods including
homelessness
• Exposure to toxic substances, physical hazards, infectious
agents, noises, odors
• Physical barriers especially for people with disabilities
• Aesthetic elements: good lighting, trees, or benches
 Why Social Determinants Are So
Important?
● People with a quality education, stable employment, safe homes and neighborhoods, and access to
preventive services tend to be healthier throughout their lives.

● Conversely, poor health outcomes are often made worse by the interaction between individuals
and their social and physical environment.
►Millions of people in the United States live in places that have unhealthy levels of ozone or other
air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of
asthma in both adults and children compared with state and national averages. Poor air quality
can worsen asthma symptoms, especially in children. It increases heart disease and contributes to
premature deliveries.

Source: HP 2020
More Health Impacts of Social Determinants
• Discrimination, stigma, or unfair treatment in the workplace can have a
profound impact on health: discrimination can increase blood pressure, heart
rate, and stress as well as undermine self-esteem and self-efficacy.
• Family and community rejection, including bullying of lesbian, gay, bisexual,
and transgender youth, can have serious and long-term health impacts
including depression, use of illegal drugs, and suicidal behavior.
• Places where people live and eat affect their diet. More than 23 million
people, including 6.5 million children, live in “food deserts”—neighborhoods
that lack access to stores where affordable, healthy food is readily available
(such as full-service supermarkets and grocery stores).
 So then, what is the most important
health determinant?
• Well, as a lawyer would say, “it depends”.
• “Assessments of the relative importance of different
determinants depend critically on the health variation to be
explained.”
• Statements assessing causation responsibility for a health
matter may or may not be correct “depending” on the
“completeness” of the assessment.
• It may be difficult assigning per cent responsibility for outcome
by an individual determinant.
• Multiple factors contribute, independently
and synergistically, so total probably >100%
 Impacts of Various Domains on Early Deaths in the
United States

Genetic Predisposition (30%)

30%
40% Social Circumstances (15%)

Environmental Exposure (5%)

Shortfalls in Medical Care (10%)

15% Behavioral Patterns (40%)

10% 5%

Adapted from McGinnis JM, Williams-Russo P, Knichman JR.

The case for more active policy attention to health promotion.
Health Aff (Millwood) 2002;21(2):78-93.
 Health Determinants Example
• Why does the Pima Tribe of Arizona have Type 2 diabetes rates of up to
50% in the population?
• Possible explanations include:
1. Policy determinants: Gila River dammed in 1890’s by Federal government
affected agriculture supply and a previously physically demanding lifestyle.
2. Biological/genetic determinants: Genetically similar cousins in Mexico not
as affected but Pima genetically prone to diabetes. Possible “thrifty” gene effect?
3. Health services determinants: Some Indian Health Service clinics available.
4. Individual behavior determinants: Increased caloric diets due to government-
provided unhealthy food; decreased physical activity due to restricted
agriculture/unemployment; increased alcohol and tobacco use due to social
issues (un/under employment).
5. Social determinants: Diversion of water limited type/amounts of agriculture so
tribe lived on subsidized food.
 Health Determinants Example
• Why was there a sharp increase in the life expectancy in the United States during
World War II (1941- 45)?
• Possible explanations include:
1. Policy determinants: no significant changes in that interval
2. Biological/genetic determinants: however, significant biological/genetic
changes were unlikely to have occurred over such as small period of time.
3. Health services determinants: however, there were no significant
technological advances and many healthcare practitioners were at war.
4. Individual behavior determinants: possible decreased caloric diets due to food
rationing; possible increased physical activity due to gas rationing; possible
decreased alcohol and tobacco due to shortages
5. Social determinants: increases in income due to war; decreases in
unemployment; and, morale improvements by working towards a
common goal.
 Health Determinants Example
• Why was there a rapid decline in cardiovascular and
cerebrovascular mortality between 1970 and 1980?
• Possible explanations include:
1. Policy determinants: Public Health Cigarette Smoking Act banning advertising
took effect on January 2, 1971; Clean Air Act of 1970 limited emission from
stationary industrial and mobile sources; EPA required catalytic converter by 1975
2. Biological/genetic determinants: too short an interval for changes
3. Health services determinants: probably more aggressive and effective control of
blood pressure
4. Individual behavior determinants: decreases in smoking among men, but
smoking did not decrease with women who still had a decrease in mortality
5. Social determinants: less toxins in the physical environment & catalytic converters
on cars reduced emissions due to policy determinants
 Health Determinants Example
• What determines the transmission of HIV in a community?
• Possible explanations include:
1. Policy determinants: Partner notification and needle exchange
programs may decrease transmission
2. Biological/genetic determinants: having other STDs may make you
more susceptible to HIV
3. Health services determinants: PEP, PrEP, and treatment availability
may decrease transmission risk
4. Individual behavior determinants: Safer sex practices including
condom use may decrease transmission
5. Social determinants: Peer norms, information/education, mass
media exposure, poverty, drug abuse, and low social rank all affect
transmission
 Health Determinants Example
• Why do Mexican Americans have an IMR slightly less than non-
Hispanic whites?
• Possible explanations include:
1. Policy determinants: unlikely
2. Biological/genetic determinants:
more likely explanation for still unknown reasons
3. Health services determinants: unlikely that they have better care
and more likely that they have less access to health insurance
4. Individual behavior determinants: unlikely as obesity rates are
higher in this population; may have less stress due to bonding?
5. Social determinants: social conditions are probably worse as
reflected in income and educational attainment but may have more
social bonding due to culture
 Health Determinants Example
• In the developed world, why are Adverse Childhood Experiences (ACEs) felt to
be the most important health risk indicator and tied to early developmental
problems and adult health issues?
• Possible explanations include:
1. Policy determinants: Lack of Trauma-Informed Care Learning Communities
2. Biological/genetic determinants: Stress causes secretion of adrenalin, etc. leading to
physiological changes promoting health problems such as heart disease, obesity, etc.;
Experience triggers gene expression (epigenetics)
3. Health services determinants: Lack of availability of community interventions including
counselling from infant to adult ages.
4. Individual behavior determinants: Parental drug abuse; Parental sexual behavior
5. Social determinants: Parental/guardian abuse (sexual, physical, psychological);
Domestic violence on parent/child; Imprisoned family member(s);
Parental divorce/separation
 Health Determinants Example
• Why do Amish children have asthma prevalence just 25% that of Hutterite
children?
• Possible explanations include:
1. Policy determinants: Amish use traditional farming methods while
Hutterites use motor vehicles and advanced farm technology.
2. Biological/genetic determinants: Both are genetically similar populations. Amish
more exposed to allergens and non-pathogenic organisms that stimulates their
innate immune system.
3. Health Services determinants: No significant differences.
4. Individual behavior determinants: Due to population policies, Amish lifestyle
provides increased exposure to the microbial products in farm environment.
5. Social determinants: Amish children have more direct content with their ambient
environment.
 Summary
• Our health is determined by more than the availability of
healthcare.
• Cross-sectional variations in health outcomes are usually best
explained by the social and individual behavior determinants of
health.
• Variations in health outcomes over time (e.g., increased life
expectancy) is best explained by advances in medical sciences
and technology (health services determinants) and
improvements in the physical environment (social
determinants).
• The relative importance of different determinants in affecting
health depends on the variation in health to be explained.
 Questions?

John J. Lanza, MD, PhD, MPH, FAAP

Florida Department of Health in
Escambia County
850.528.5201
JohnJ.Lanza@FlHealth.gov
www.EscambiaHealth.com