Module 3 - The Determinants of Health
MODULE 3 | LESSON 1
What are the 3 Determinants of Health domains?
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The WHO defines the SDoH as “The social determinants of health (SDH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (source).
Whilst each national health authority is in their rights to define the exact list, they are broadly known as:
Income and social protection;
Education; Unemployment and job insecurity;
Working life conditions;
Food insecurity;
Housing, basic amenities and the environment;
Early childhood development;
Social inclusion and non-discrimination;
Structural conflict;
Access to affordable health services of decent quality.
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Commercial determinants of health are the private sector activities that affect people’s health positively or negatively. WHO Director-General Margaret Chan has noted that “efforts to prevent non-communicable diseases go against the business interests of powerful economic operators” (source). This area of research and work is younger than the SDoH area and there are still competing working definitions.
Researchers Ilona Kickbusch, Luke Allen, and Christian Franz define the commercial determinants of health as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (source).
Whereas, researchers Robert West and Theresa Marteau's define it as “factors that influence health which stem from the profit motive” . The definition is ultimately falling on the researchers work and experience in which the role of the commercial actor is with ignorance of the outcome or knowledge of them. (source)
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Looking at health through the lens of political determinants means analysing how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance. Political Determinants of Health (PDoH) frameworks highlight how power structures and political decisions shape health outcomes, often challenging governments and neoliberal economic policies that can exacerbate health inequities.
As a body of work it’s still in its relative infancy, when compared to Social Determinants of Health. The academic body of work is not as complete, however multiple scholars in prestigious journals provide a wide range of literature to help bring forward the context of politics and political systems in relation to health.
Factors within Determinants of Health
Many organisations and researchers have compiled lists, tables, and frameworks to describe the determinants of health. Here we present our version which has brought together a number of different researchers perspectives.
Please note that this is not a comprehensive summation of everything, it is a way for us to communicate to you an understanding of the subject matter. In your own research you may come across other sources that have different categories. Therefore, this is to guide thinking and actions and perhaps inspire you to think of other categories that may be relevant to your work and lived experiences.
Becoming familiar with the determinants of health allows you to critique how a plan on paper may materialise in reality. For example, let’s say that a project makes a claim that the introduction of new homes into an area will improve population health in the long run due to the improved standards of design. However, there are a few angles to critique this claim based on some determinants practice.
Scholars in the commercial DoH field would review whether the ‘healthy design standards’ have had influence from the private sector to suit their advantage. Many private sector companies contribute to the development of practical guidance however this can skew things in their favour. Through this process, and that of active lobbying, private sector organisations can oppose restrictions and shape public understanding to maintain and grow profits. An example of this can be seen in the use of materials such as carpets/curtains, furniture and paints that have high levels of volatile organic compounds which can be hazardous to health. The ‘healthy design standard’ qualifies that they are safe but a hard lined approach would challenge this.
Another example of challenging whether new homes will improve population health on mere design factors alone is not enough. Numerous campaigners highlight the insecurity and fear of eviction people feel when renting homes through the private sector; this is a highly common factor for housing developments where they developers have sold properties to (often overseas) investors before they’re built in order to generate revenues to fund the development, meaning that they can be made rental properties with oversea landlords and under the control of managing agents who can be difficult to liaise with. Housing insecurity is a known psychosocial stressor and conditions of that can be brought on by conditions of how homes are rented and the influence that the private sector has.
The last example of challenging new housing being a positive commercial determinant of health is to consider how the promise of employment improves health outcomes. Numerous campaigners point to how the erasure of employment rights through mechanisms of out-sourcing and contracting companies impacts the health and wellbeing of people in construction and maintenance work. The rise of zero-hour contracts puts stress on employees to always say yes to work even if it causes personal or social issues; many campaigners will point to systems whereby management uses algorithms to prioritise allocating work to people who make themselves more available than others. This coercive behaviour forces people to often accept employment conditions that cause harm to them. Through contracting people don’t receive employment rights around issues of sick-leave, guaranteed schedules/hours, union representation and other factors that give people a sense of dignity and clarity on their futures. In this case, the macro promise of employment cannot be considered a positive commercial determinant of health unless the conditions of those employment meet the needs and rights of people to have a sense of wellbeing.
Through these exercises we can see the interplay between commercial and political determinants of health working together. The political infrastructure can influence the dynamics of power that enable commercial actors to augment situations to their private gain whilst creating a conditional factor in someone having a pathway to poor health. A team of researchers led by Margaret Douglas note that “corporate interests have sometimes co-opted HiAP [Health in All Policies] to influence policy” for their own advantage.
These two examples show how the framework and exercise sheets provided allow you to observe plans and build a robust response. Incorporating determinants of health theory into health impact assessment work allows an assessment to think more about the how rather than the what.
“The macro promise of employment cannot be considered a positive commercial determinant of health unless the conditions of those employment meet the needs and rights of people to have a sense of wellbeing.”
KEY LEARNINGS
This framework allows individuals and/or groups of people to consider how to critically analyse a policy-led intervention to identify and mitigate any unintended consequences on public health - is there a hidden factor preventing a policy/practice from working?
A DoH framework allows for ecological approaches to health to be put into practice by examining the social, commercial, and political dynamics that influence health outcomes.
If we are to truly impact people’s quality of life through health we need to take a critical approach to “non-health” matters. This helps acknowledge how there are multiple pathways to health outcomes that exist within cross-sector actions.
When working in systems we realise that we are all healthcare workers, just at different ends of the supply chain.
QUESTIONS TO ASK YOURSELF
The above list is not exhaustive, you may consider some elements missing. If you notice one, write it down and in an ‘action and consequence’ scenario consider how what you consider a determinant of health plays out in impacting people’s health.
Is there a particular domain or factor you want to focus on further? There’s likely some literature available.
In contrast to negative determinants of health, think positively as what contributes to good health. It’s always good to work in a duality of challenging the bad and creating the new.