This document discusses the dimensions and determinants of health. It begins by defining determinants of health as the various social, economic, behavioral, environmental, and healthcare-related factors that influence health outcomes. It then lists six dimensions of health according to a 1976 wellness model: physical, emotional, intellectual, spiritual, occupational, and social/cultural. The document goes on to provide examples and evidence of various social and physical determinants of health, including housing, transportation, food/agriculture, waste, energy, industry, and others. It emphasizes that individual health is determined more by circumstances and environment rather than individual choices.

1. THE DIMENSIONS AND
DETERMINANTS OF HEALTH
Edited and prepared by: Dr Khushhal Farooqi
2023

2. Learning Objectives
By the end of this session, participants will be able to:
1. Define the determinants of health;
2. Explain how inequities in neighbourhood conditions, education, income and wealth, and
socio-political climate affect health outcomes and health disparities;
3. Critically evaluate primary social determinants of health concepts and approaches
4. Develop skills in social determinants of health research methods and approaches
5. Apply key social determinants of health concepts to contemporary population health
problems

3. 1.
What makes some people HEALTHY
and others UNHEALTHY?
Determinants of Health
2. How can we CREATE A SOCIETY in which everyone
has a chance to live a long, healthy life?

9. Adapted from McGinnis
JM, Williams-Russo P,
Knichman JR. Health Aff
(Millwood)2002, 21(2):78-
93.

10. Introduction
• The term "determinants" refers to the factors or elements that contribute to or
influence a particular outcome or result.
• In the context of health, the determinants of health are the various factors that influence an
individual's overall health and well-being.
• These determinants can be:
1. social,
2. economic,
3. behavioral,
4. environmental, or
5. related to healthcare systems and
6. genetics.
• They interact and work together to shape an individual's health status and
outcomes.
• Understanding and addressing these determinants is crucial for promoting better
health and reducing health disparities in populations.

11. 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,
• Education level, and
• Our relationships with friends and family
all have considerable impacts on health,.
Introduction…

12. The range of Personal, Social, Economic, and Environmental
FACTORS that influence health status are known as
DETERMINANTS of HEALTH.
Determinants of Health:

13. The social and
economic
environment,
The physical
environment, and
The person’s
individual
characteristics and
behaviours.
• Focus on those determinants which have the
most influence on the health of the
population.
• E n v i r o n m e n t
• S o c i a l
• B i o l o g y
C u r r e n t a t t e m p t s a t h e a l t h r e f o r m will not be successful at improving health unless
the population health determinants are addressed.

14. Examples of SOCIAL determinants
1. Availability of resources to meet daily needs, such as educational and job opportunities,
living wages, or healthful foods
2. Social norms and attitudes, such as discrimination.
3. Exposure to crime, violence, and social disorder.
4. Social support and social interactions.
5. Socioeconomic conditions, such as concentrated poverty.
6. Transportation options.
7. Public safety.
8. Residential segregation ‫تفکيک‬
Residential segregation is the physical or spatial separation of two or more groups within a geographic area,
based on some criteria such as race, ethnicity, religion, or socioeconomic status. It affects the access to housing,
services, opportunities, and health of the groups involved.

15. Examples of PHYSICAL determinants
1. Natural environment, such as plants, weather, or climate change
2. Built environment, such as buildings or transportation
3. Worksites, schools, and recreational settings
4. Housing, and neighborhoods.
5. Exposure to toxic substances and other physical hazards.
6. Physical barriers, especially for people with disabilities.
7. Aesthetic elements, such as good lighting, trees, or benches.

16. Income and social status –
• Higher income and social status are linked to better health.
• The greater the gap between the richest and poorest people,
the greater the differences in health.
Education – Low education levels are linked with
• Poor health,
• More stress and
• Lower self-confidence.
Physical environment –
• Safe water and clean air,
• Healthy workplaces,
• Safe houses,
• Safe communities and
• Safe roads.

17. AND MANY OTHERS
• Employment and working conditions – people in employment are healthier,
particularly those who have more control over their working conditions.
• Social support networks –
• Greater support from families, friends and communities is linked to better
health.
• Culture - customs and traditions, and the beliefs of the family and
community all affect health.

18. AND MANY OTHERS
• Genetics –
• Inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing certain illnesses.
• Personal behaviour and coping skills –
• Balanced eating,
• Keeping active,
• Smoking,
• Drinking, and
• How we deal with life’s stresses and challenges.
• Health services - access and use of services that prevent and treat disease influences health.
• Gender - Men and women suffer from different types of diseases at different ages.

19. The context of people’s lives determine their health, and so
• Blaming individuals for having poor health? or
• Crediting them for good health is inappropriate?
۩ Individuals are unlikely to be able to directly control many of the
determinants of health.
۩ These DETERMINANTS—or things that make people healthy or not—
include the above factors, and many others.

21. Definition of dimension of health
Dimensions of health refer to various aspects or
components that contribute to an individual's overall
well-being.
• They are interconnected and mutually influencing,
and include
o physical, mental, emotional, social, spiritual,
and environmental dimensions.

22. Dimensions of Health Determinants of Health
Physical Health - Genetics - Lifestyle choices (e.g., diet, exercise) - Access to healthcare services
Mental and Emotional Health - Social and economic factors (e.g., income, education)- Social support and
relationships - Exposure to stressors
Social Health - Social determinants (e.g., employment, housing) - Social support and networks -
Social norms and attitudes
Environmental Health - Physical environment (e.g., air and water quality) - Access to safe and healthy
environments - Exposure to environmental hazards
Spiritual Health - Personal beliefs and values - Access to spiritual or religious practices - Sense of
meaning and purpose in life

23. 1. Physical,
2. Emotional,
3. Intellectual (environmental)
4. Spiritual,
5. Occupational ,(academic/Career),
and
6. Social/cultural
In 1976, Dr. Bill Hettler created a wellness model that
identified six dimensions of health:.
Some experts have also included environmental health,
resulting in a list of seven interconnected dimensions of
well-being.

24. The SocioeconomicDeterminant
Elevated death rates for the poor are evident in almost all the major causes of death and in
each major group of diseases, including
• Infectious,
• Nutritional,
• Cardiovascular,
• Injury,
• Metabolic, and
• Cancers.

26. Prevalence of heart disease (per 1,000 persons) among persons 18 years of age
and over, by family income
0
20
40
60
80
100
120
140
160
180

27. SocioeconomicFactorsandDisparity
▪ The Whitehall I Study, a long-term follow-up study of male civil servants, was set up in
1967 to investigate the causes of heart disease and other chronic illnesses.
▪ Researchers expected to find the highest risk of heart disease among men in the
highest status jobs; instead, they found a strong inverse association between position in
the civil service hierarchy and death rates.

28. Men in the lowest grade (messengers, doorkeepers, etc.) had a
death rate three times higher than that of men in the highest
grade (administrators).
▪ Further studies in Whitehall I, and a later study of civil servants,
Whitehall II, which included women, have shown that low job
status is not only related to a higher risk of heart disease: it is
also related to some cancers, chronic lung disease,
gastrointestinal disease, depression, suicide, sickness absence
from work, back pain.
SocioeconomicFactorsandDisparity

29. Relative Rates of Death from Cardiovascular Disease among British
Civil Servants according to the Classification of Employment

32. Regional Convergence of Social Issues
8.3% - 13.2%
13.3% - 16.2%
16.3% - 20.2%
20.3% - 32.0%
Percent Poverty 20051
13.4% - 17.0%
17.1% - 18.6%
18.7% - 20.6%
20.7% - 27.5%
Percent Uninsured 20052
553 - 797
797 - 878
878 - 977
977 - 1250
Low
High
Premature Mortality3
2002-2006
Notes:
1. US Census estimates on poverty
for 2005 with 90% CIs. Interpret
with caution. Accessed
http://www.census.gov on 5-16-08.
2. Sheps Center (UNC) estimates of those
without health insurance for 2005.
Accessed http://www.shepscenter.unc.edu
on 5-16-08.
3. Based on calculations from ECU’s CHSRD
(using data from The Odum Institute, UNC).
Years of life lost before the age of 75.
James Wilson, PhD
Center for Health Services Research and Development
East Carolina University
Greenville, NC.

33. Education EXAMPLE
• In the United States,
individuals without a high-
school diploma as
compared with college
graduates are 3X as likely
to smoke and nearly 3X
as likely not to engage in
leisure-time physical
exercise

35. Occurrence
Environment
Individual
Agent
Information
Education
Peer norms
Drug use
Condom
availability
Sexual behaviors
Condom utilization
Multiple partners
Intravenous drug use
Prevention
Environment Individual
Partner notification/ Needle
exchange/ Safe sex/ Condoms
Agent
The occurrence of HIV

36. Tuberculosis
What is the cause of TB? What explains the decrease in
TB from 1900 to the present?
The answer to both of these
questions is related to the
multiple factors that cause TB.

39. Evidence base of health
determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

40. Transport
1. Evidence of health impact focus on:
2. Accidents between motor vehicles, bicycles and pedestrians (particularly children and young people).
3. Pollution from burning fossil fuels such as particulates and ozone.
4. Noise from transportation.
5. Psychosocial effects such as severance ‫جدا‬
‫سازی‬ of communities by large roads and the restriction of children’s
movement.
6. Climate change due to CO2 emission
7. Loss of land
8. Improved physical activity from cycling or walking
9. Increased access to employment, shops and support services
10. Recreational uses of road spaces
11. Contributes to economic development

42. Evidence base of
health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

43. Food and Agriculture
•Tobacco farming and its impact on NCDs .
•Pesticide policies on tobacco crops.
•Use of agricultural labour and occupational health.
•Mechanisation of work previously done by hand, and plantation
agriculture.
•Fisheries – biotoxins, pollution, chemical use, wastewater, processing,
and occupational health
•Forestry – vector borne diseases, occupational health, and food
security.
when all people, at all times, have physical, AND economic access to sufficient, safe and nutritious
food that meets their dietary needs and food preferences for an active and healthy life.

44. Food and Agriculture…
• Livestock use – vector borne diseases, drug residues, animal feed,
waste, and food security.
• Fertilizer use – nitrate levels in food, pollution of waterways, re-use
of agricultural waste.
• Water – irrigation use and its impact on river/water-table levels.
• Pesticide usage and veterinary drugs– legal requirements, best
practice, consumer issues.
• Food packaging, preservation and safety.

45. Food and Agriculture
• A C C E S S T O, A N D D I S T R I B U T I O N O F
F O O D
• Household food security – appropriate food being
available, with adequate access and being affordable
(location of markets, supermarkets and closure of
small suppliers creating food deserts in cities*).
• Food supplies, including national and regional
food security, and regional production.
• National food security – able to provide adequate
nutrition within a country without relying heavily on
imported products
• Cold-chain reliability – the safety of transporting
products that deteriorate microbiologically in the
heat.
*A food desert is an area, especially one with low-income and
minority residents, that has limited access to affordable and
nutritious food. In contrast, an area with supermarkets is termed a
food oasis.

46. Food and
Agriculture
•Fruit and vegetable consumption
•Total, saturated and polyunsaturated fat, carbohydrates and
sugars.
•Alcohol consumption and impact on social effects related to
behaviour (traffic accidents, work/home accidents, violence,
social relations, unwanted pregnancy and STDs), and toxic
effects (all-cause mortality, alcoholism, certain cancers, liver
cirrhosis and others).
•Micronutrients such as iron, vitamin A, zinc and iodine and
their impact on deficiency syndromes

47. Food and water are the
major sources of exposure
to both chemical and
biological hazzards. They
impose a substantial
health risk to consumers
and economic burdens on
individuals, communities
and nations.
Food saf et y an d f ood b or n e illn ess h azar d s
•Microorganisms such as salmonella, campylobacter, E. coli,
listeria, cholera.
•Viruses such as hepatitis A, and parasites such as
trichomoniasis in pigs and cattle.
•Naturally occurring toxins such as mycotoxins, marine
biotoxins and glycosides.
•Unconventional agents such as the agent causing bovine
spongiform encephalopathy (BSE, or "mad cow disease"),
Food and Agriculture

48. • Harmful algal blooms are natural
phenomena caused by the massive
growth of phytoplankton that may
contain highly toxic chemicals, the
so-called marine biotoxins causing
illness and even death to both
aquatic organisms and humans

50. Evidence base of health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

51. Housing
• Ev i d e n c e o f h e a l t h i m p a c t s
fo c u s o n :
• Improvements in housing and improved
mental health and general health
• The possibility of improved housing
leading to rent rises, impacting negatively
on health.
• Housing : outdoor temperature, indoor
air quality, dampness, housing design, rent
subsidies, relocation, allergens and dust
mites, home accident prevention, and fire
prevention.
• Homelessness.

52. Evidence base of health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

53. Waste
Evidence of health impacts focuses on environmental and
social determinants related to:
1. The transmission of agents of infectious disease from human and
animal excreta.
2. Exposure to toxic chemicals in human and animal excreta; and in
industrial wastes discharged into the environment;
3. Environmental degradation, impacts on health;
4. Exposure to radioactive wastes;
5. Exposure to health-care wastes;
6. Exposure to solid wastes and involvement in informal waste
recycling; and
7. breeding of disease vectors.

54. informal waste
recycling

55. Evidence base of health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

56. Energy
• Evidence of health impacts focus on health hazards such as:
• Fossil fuels
• Biomass fuels.
• Hydropower and their impact on vector borne diseases, and pollution
• Electricity generation and transmission
• Nuclear power
• Occupational health effects of energy workers
• Impacts on ecosystems, agriculture, forests, fisheries and building materials
• Noise
• Visual impact
• Global warming

57. Evidence base of health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

58. Evidence of health
impacts focus on
industrial sectors such as:
Industry
•Asbestos and man made fibres.
•Basic chemicals.
•Cement, glass and ceramics.
•Electronics.
•Iron and steel.
•Manufacture of rubber and plastic products.
•Metal products.
•Mining.
•Pesticides, paints and pharmaceuticals.
•Petroleum products.
•Textiles and leather.
•Wood and furniture.

59. Evidence base of health determinants
• These are presented below:
• Transport
• Food and Agriculture
• Housing
• Waste
• Energy
• Industry
• Urbanization
• Water
• Radiation
• Nutrition and health

60. Both access to health services and the quality of health services can
impact health.
Health Services
Barriers to accessing health services include:
•Lack of availability
•High cost
•Lack of insurance coverage
These barriers to accessing health services lead to:
•Unmet health needs
•Delays in receiving appropriate care
•Inability to get preventive services
•Hospitalizations that could have been prevented