Address the relationship between health status
and biology, individual behavior, health services,
social factors, and policies.
Emphasizing an ecological approach to disease
prevention and health promotion (Individual and
population-level determinants determinants of
health and interventions).
The range of personal, social, economic, and
environmental factors that influence health status
Biology and genetics
(from „The future of the Public‘s Health“, IOM 2003)
Policies at the local and State level affect
individual and population health.
Some policies affect entire populations over
extended periods of time while simultaneously
helping to change individual behavior.
For example to set and regulate standards for
motor vehicles and highways.
Disease is caused by either pathology or
There is strong evidence indicating that factors
outside the health care system significantly affect
health. These “determinants of health” include
income and social status, social support
networks, education, employment and working
conditions, physical environments, social
environments, personal health practices and
coping skills, healthy child development, health
services, gender and culture.
Taking Action on Population Health: A Position Paper for
Health Promotion and Programs Branch Staff. Ottawa:
Health Canada, 1998
Social determinants of health reflect social factors
and the physical conditions in the environment in
which people are born, live, learn, play, work and
They impact a wide range of health, functioning
and quality of life outcomes.
Social determinants of health have a
direct impact on health
Social determinants predict the
greatest proportion of health status
Social determinants of health
structure health behaviours
Social determinants of health interact
with each other to produce health
Upstream Approaches –
Social Cohesion, Social Equity,
Downstream Approaches –
Provision of Clinical Services
Adapted from Milstein B, Homer J. The dynamics of upstream and downstream:
why is it so hard for the health system to work upstream, and what can be done
about it? CDC Health Systems Workgroup; Atlanta, 2003.
but with no
Opportunities for Public Health Interventions
A Social Determinants Framework
Both access to health services and the quality of
health services can impact health.
Healthy People 2020 directly addresses access to
health services as a topic area and incorporates
quality of health services throughout a number of
Lack of access, or limited access, to health
services greatly impacts an individual’s health
Lack of availability
Individual behavior also plays a role in health
Many public health and health care interventions
focus on changing individual behaviors such as
substance abuse, diet, and physical activity.
Positive changes in individual behavior can reduce
the rates of chronic disease in this country.
Some biological and genetic factors affect specific
populations more than others.
Sickle cell disease is a common example of a
genetic determinant of health. The gene is most
common in people with ancestors from West
African countries, Mediterranean countries, South
or Central American countries, Caribbean islands,
India, and Saudi Arabia