2a. "Determinants" vs. "Social Determinants" of Health: Is there a Difference?  

Determinants of Health

Following the release of the Lalonde Report¹ over four decades ago, a key tenet of public health is that the health of populations is determined primarily by their circumstances and environments. Factors such as neighbourhood characteristics, environmental conditions (e.g., air and water quality, the built environment), income level and distribution, and the quality of social networks have a considerable impact on population health status, whereas more commonly considered factors, such as access to health care services (which were widely regarded as a key driver of health status prior to the release of the Lalonde Report), have less impact.^2,3 These factors, which encompass general socioeconomic, cultural, and environmental conditions; social and community networks; and individual characteristics (e.g., genetics and individual lifestyle factors), are referred to as the determinants of health.

The following model illustrates how the key levels of health determinants act to influence or “determine” the health of individuals, communities, and entire populations.

 

 

Since the 1990s, when the term “determinants of health” first became widely used in the public health sector, published lists of these determinants have been disseminated to guide population health planning. It’s interesting to note how the content of these lists has evolved over time. Table 1 contrasts one of the first lists of health determinants, which was included in a discussion paper adopted by the Federal/Provincial/Territorial Ministers of Health in 1994², with a more recent list.⁵ 

So what differences do you notice between these two lists? The second list emphasizes that differences in health status are determined by the social conditions in which people are born, grow, live, work, and age⁶ — hence the term social determinants of health (SDH). While biology, genetic endowment, and personal health practices can and do influence health status, they are (as your readings and subsequent sections of this module reveal) profoundly influenced by socially determined conditions such as income and early life experiences. The inclusion of race, gender, and Indigenous (Aboriginal) status on the second list acknowledges the ways in which racism, oppression, and colonialism can affect an individual’s access to prerequisites for good health such as education and employment.

The SDH are shaped by the distribution of money, power, and resources at global, national, and local levels. Disparities in access to many of the SDH (income, employment, education, early life development) are mostly responsible for health inequities — the unfair and avoidable differences in health status seen within and between countries.⁶

The following presentation by Sir Michael Marmot, the former Chair of the WHO Commission on the Social Determinants of Health, provides a more detailed overview of the SDH and their impact on population health status.

The social determinants of health interact to affect population health status in a myriad of ways that cannot be covered in the confines of a single course module. If you are interested in a more detailed overview of the contributions of the SDH to population health status, I recommend reading Closing the Gap in a Generation, the final report of the WHO Commission on the Social Determinants of Health⁷ and the most recent edition of Dennis Raphael’s book Social Determinants of Health: Canadian Perspectives⁸, the source of one of your assigned readings.