Describe the determinants of health.

Classification of Determinants

• 1. Biological determinants — genetic constitution, which determines chromosomal and single-gene disorders, inborn errors of metabolism, and susceptibility to common multifactorial disease; age and sex; and race and ethnicity
• The genetic contribution is largely non-modifiable, but is increasingly addressed by genetic counselling, carrier screening, antenatal diagnosis and, in India, by discouraging consanguineous marriage in communities where it is common
• 2. Behavioural and lifestyle determinants — tobacco in all its forms, alcohol, diet, physical inactivity, sexual behaviour, drug use, stress and coping, and health-seeking behaviour
• These are the largest modifiable group for non-communicable disease, and are the target of health promotion
• 3. Environmental determinants — water supply and sanitation, air quality, both ambient and indoor (from biomass fuel, which is a major cause of respiratory disease in rural India), housing and overcrowding, waste disposal, vectors, occupational exposures, radiation and noise, and climate change, which is increasingly recognised as a health determinant in its own right
• 4. Socio-economic determinants, which are the most powerful of all — economic status and poverty, education, and particularly female literacy, occupation, political system, social support networks, and gender
• Female education deserves special emphasis, because it is consistently one of the strongest predictors of infant and child mortality, of fertility, of nutritional status and of immunisation uptake — the contrast between KERALA and the northern states of India being the standard illustration, and one worth citing
• 5. Health services — their availability, accessibility, affordability, acceptability and quality
• 6. Other determinants — food and agriculture, education, industry, rural development, communication and social welfare — the "health IN all policies" concept, that decisions taken by ministries other than health have greater effects on health than the health ministry does

The Social Determinants and Health Inequity

• The social determinants OF health are "the conditions in which people are born, grow, live, work and age", and the structural drivers of those conditions — the formulation of the WHO commission on social determinants of health (2008)
• Its central conclusion was that "social injustice is killing people ON A grand scale", and its three overarching recommendations were to improve daily living conditions; TACKLE the inequitable distribution of power, money and resources; and measure and understand the problem and assess the impact of action
• The distinction between inequality and inequity is essential and is frequently examined:
• Inequality is simply a difference or variation in health between groups — a descriptive, measurable term
• Inequity is a difference that is unnecessary, avoidable and additionally considered unfair and unjust — an ethical judgement
• The example makes it clear: the higher mortality of the elderly compared with the young is an inequality but not an inequity, since it is neither avoidable nor unjust; whereas higher infant mortality among the poor is both
• Equality means giving everyone the same; equity means giving according to need, which requires giving more to those who need more — and public health is concerned with equity
• The social gradient in health — health follows a continuous gradient with socio-economic position across the whole of society, not merely a difference between the poor and everyone else. The whitehall studies of British civil servants demonstrated this: each grade had worse health than the grade above, even among employed, housed, insured people
• Its implication is important — targeting only the poorest addresses only part of the problem; proportionate universalism, meaning universal action with intensity proportionate to disadvantage, is the recommended approach
• The inverse care law (TUDOR HART, 1971) — the availability of good medical care tends to vary inversely with the need for it in the population served, and this operates most strongly where care is exposed to market forces — which is directly relevant to India
• The determinants in the INDIAN context — poverty; low female literacy and gender inequality; caste and social exclusion; rural-urban disparity in services and personnel; out-OF-pocket expenditure, which is among the highest in the world and is a major cause of catastrophic health expenditure and impoverishment; malnutrition; unsafe water and sanitation; and indoor air pollution
• The practical conclusion — because the major determinants lie outside the health sector, intersectoral coordination is not an optional extra but the core strategy of public health; and a doctor treating disease without regard to its determinants is treating the same patients repeatedly
• The lalonde (1974) analysis divided the determinants into human biology, environment, lifestyle and health care organisation, and showed that health expenditure was overwhelmingly directed at the last, while the greatest potential for gain lay in the first three — an imbalance that persists
• Most determinants lie outside the health service, which is why intersectoral action is the core strategy of public health
• Inequality is a difference and inequity is unjust, and the distinction is examined more often than almost anything else here
• Equality gives everyone the same and equity gives by need, so equity requires giving more to those who need more
• Female literacy predicts child mortality more strongly than almost any health service variable, as Kerala demonstrates
• The social gradient runs through the whole of society, as the Whitehall studies showed among employed civil servants
• Targeting only the poorest misses the gradient, which is why proportionate universalism is recommended
• The inverse care law is strongest where care is marketised, which makes it directly relevant to India
• Out-of-pocket expenditure impoverishes families in India, and is a health determinant in its own right
• Indoor air pollution from biomass fuel is a major and under-recognised cause of respiratory disease in rural India
• Lalonde showed spending goes to health care while the greatest gains lie in biology, environment and lifestyle
• Health in all policies recognises other ministries affect health more than the health ministry does
• Social injustice kills on a grand scale, which was the central conclusion of the WHO commission and is worth quoting
• Climate change is now a health determinant in its own right, through heat, vectors, food security and displacement
• Genetic determinants are largely non-modifiable but are addressed by counselling, screening and antenatal diagnosis
• Consanguinity raises recessive disease risk, and is a modifiable determinant in communities where it is customary
• Behaviour is the largest modifiable group for non-communicable disease, and is the target of health promotion
• Caste and social exclusion operate as determinants in India, affecting both exposure and access to care
• Health services are only one determinant among many, and improving them alone cannot close the gap
• Treating disease without its determinants means treating the same patients repeatedly
• Rural-urban disparity in personnel is among the sharpest inequities in Indian health care
• Availability is not the same as accessibility, and neither guarantees affordability or acceptability
• The conditions in which people are born and live is the formulation to quote for social determinants
• Gender operates as a determinant through nutrition, education, autonomy and access to care
• Measure the problem and assess the impact, which was the third recommendation and is frequently forgotten