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Addressing critical health issues in global health requires that we understand what people get sick, disabled, and die from and why this happens. Answering “why this happens” requires us to understand the determinants of health.

Yet, my own students have often been quite unclear about the difference between “determinants of health”, social determinants of health”, and “risk factors”. They have also been unclear about how to think about different determinants and the extent to which they directly or more indirectly affected health. Moreover, different sources portray social determinants and risk factors in different ways, not all of which fit together very well.

Thus, I offer some comments below on how I taught these topics to undergraduate students in an introductory global health course. The “Determinants of Health” is introduced in Chapter 2 of Global Health 101, Fourth Edition.

The WHO says this about the “determinants of health”:

“Many factors combine together to affect the health of individuals and communities. 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 and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. 

The determinants of health include:

• the social and economic environment
• the physical environment
• the person’s individual characteristics and behaviours.”

Students often enter a global health course with notions that access to health care is the most important determinant of health. However, it takes only a few minutes of discussion about where they live, what they eat, drink, and hopefully don’t smoke, and about their family health history to help them become familiar with the notion of “determinants of health”.

The WHO says this about the “social determinants of health”:

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.” 

I am not sure what you think, but I have never found this a particularly helpful statement. In some respects, I wish WHO had defined “social determinants” more like “the social, political and economic forces that influence health in a range of direct and indirect ways.

In any case, many students also find it hard to grasp this concept when they are first introduced to it. However, one can help them understand the concept better by asking questions such as:

Will society be healthier if its government promotes a growing economy with relatively few economic disparities, access to schooling for all, and fairly distributed health services?

Is society likely to be healthier if its government treats all ethnic groups equally and does not discriminate against people because of their age, sex, ethnicity, or sexual orientation?

The WHO says a risk factor is:

“… any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Some examples of the more important risk factors are underweight, unsafe sex, high blood pressure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene.”

This concept is one that students usually understand and immediately grasp. One can reinforce this by focusing on environmental and behavioral risks. Do they live in an environment with lots of outdoor air pollution? Do they eat sufficient amounts of vegetables? Do they smoke tobacco?

I try to put all of this together for my introductory global health students by encouraging them to see the determinants of health as a “continuum” that does depend, as WHO (mostly) suggests on:

• Social, economic, (and political) forces
• The environment
• Personal behaviors

At the same time, I encourage to always ask:

• How direct is the impact of any determinant? What is the mechanism by which it influences health?
• How indirect is the impact of any determinant and what is the mechanism by which it influences health?
• What are the root, underlying, and immediate causes of the “health conditions” people face?

One can help students think in the above ways, for example, by asking them to talk about the “determinants” of TB, helminthic infections, and maternal mortality. The most immediate cause of maternal mortality, for example, is hemorrhage. However, the underlying causes may have to do with the failure to identify the complication of pregnancy, transport the women to care, and provide good quality emergency obstetric services. The root causes probably relate to a government that does not care much about health services or females, discriminates against women, and fails to provide quality schooling for females. Of course, one can also include economic policies and poverty as root and underlying causes. Hopefully, it won’t take too many sessions of the course before one’s students can take a comprehensive view of the determinants of health, in a sense “working backward” from specific health conditions faced by specific people to the “causes of the causes”.

As you know, there are a number of graphical portrayals of the determinants of health. Some are better than others, I believe, at giving the user a sense of the extent to which different determinants are more or less direct.

Thus, Chapter 2 of Global Health 101, Fourth Edition now includes a figure (2-2) that was suggested to me by some wonderful Dutch colleagues, Carolijn Wentink and Laura Bouwman. This figure, better than others I have seen, should help students understand the notion of “root”, “underlying”, and “immediate” determinants of health.

About the Author

Richard Skolnik, MPA - Yale, School of Public Health, New Haven, Connecticut

Richard Skolnik has spent more than 40 years working on international development and global health and was formerly a lecturer in the Yale School of Public Health, the Yale School of Management, and the George Washington University School of Public Health.