1.socio Economic Determinants of Health

Determinants of Health:
Socio economic determinants of

health
Fantahun Ayenew (BSc, MPH)
College of Medicine
Institute of Medicine and Health Science
Debre Berhan University
Determinants of health
Factors that contribute to a person's current

state of health.
Scientists generally recognize five
determinants of health of a population:
These include,
Biology and genetics. Examples: sex and
age
Individual behavior. Examples: alcohol
use, injection drug use (needles),
unprotected sex, smoking etc.
Social environment. Examples:
Fantahun A. (MPH- Epidemiology
2
and
Biostatistics), DBU,May,
discrimination, income,
and2014
gender
Determinants of health cont
Physical environment. Examples: where a

person lives and crowding conditions
Health services. Examples: Access to
quality health care and having or not having
health insurance.

and Biostatistics), DBU,May, 2014
Determinants of health cont
But these five categories can be broadly

classified in to
three. These include
1. Socioeconomic Determinants
2. Psychosocial and Behavioral determinants
3. Ecology and environmental determinants

Health and health related condition

terms
Health equity
Health inequalities
Health disparity

Health Equity
The opportunity for everyone to attain his or her full health
potential and no one is disadvantaged from achieving this
potential because of his or her social position or other
socially
determined circumstance.
Examples:
Equal access to quality education, healthcare, housing,
transportation, other resources
Equitable pay/income
Equal opportunity for employment
Absence of discrimination based upon social status/other
factors
Health equity is distinct
from health equality
Health Inequities
Systematic and unjust distribution of social,
economic,
and environmental conditions needed for health
Unequal access to quality education,
healthcare, housing, transportation, other
resources.
Unequal employment opportunities and
pay/income
Discrimination based upon social conditions or
others
Health Disparities
A type of difference in health that is closely
linked
with social or economic disadvantage.
Differences in the incidence and prevalence
of health conditions and health status
between groups, based on:
Race/ethnicity
Socioeconomic status
Sexual orientation
Gender
Health Disparities cont

Disability
status
Geographic location
Combination of these
Health disparities negatively affect groups
of people who have systematically
experienced greater social or economic
obstacles to health.

Social Determinants of Health

Social determinants of health are the
conditions in
which people are born, grow up, live, work
and age.
These conditions influence a persons
opportunity to
be healthy, his/her risk of illness and
life expectancy.
Social inequities in health are those that
result from the uneven distribution of social
determinants.
10
Social determinants of health and health
Social Determinants of Health

cont
Are life-enhancing resources whose distribution across
populations effectively determines length and quality of
life, this include ,
- Access to health care
- Education
- Employment
- Housing
- Racism/Discrimination
- Transportation

11
Social determinants of health cont

Interactions with families, friends, co-workers and
others that shape everyday experiences in
neighborhoods, communities, and institutions (such
as schools, the workplace, places of worship,
government agencies, etc.).
This means that individual and community social
factors; social norms, social support and community
connectedness; employment and working conditions;
living conditions; and culture, religion, and ethnicity
shape health.
12

The social environment of a community is created by the
individual and actions of its members and is unique because
of social norms and cultural customs.
People are healthiest when they feel safe, supported and
connected to and can trust others in their families,
neighborhoods, workplaces, and communities.
Workers are healthiest when they believe that their jobs are
secure, when they feel that the work they do is important
and valued, when the workplace is safe and there are ample
opportunities for control over their work life, including
decision-making, advancement and personal growth.

13

Culture, religion and ethnicity have a
broad influence on beliefs and practices
related to health, illness and healing.
This influence includes definitions of
health and illness, beliefs about the causes
of health and illness, decisions about
whether or not to seek formal health care,
and decisions about the type of health
care provider to be sought

14
Access to Health service

Both access to health services and the quality
of health services can impact health.
Lack of access, or limited access to health
services greatly impacts an individuals health
status.
Barriers to accessing health services include:
High cost
Lack of availability
Limited language access

15
Access to Health service cont

These barriers to accessing health services
impact
to:
Overall physical, social, and mental health
status
Prevention of disease and disability
Detection and treatment of health conditions
Quality of life
Preventable death
Life expectancy
16

1. User charges (cost)
The widespread imposition of user charges in
many low- and middle-income countries
resembles an important barrier to utilizing
services.
Limited user charges, combined with
targeted exemptions for the poor, have been
seen as a way of improving the local revenue
base, thereby increasing the availability of
services.
17

1. User charges (cost)
The widespread imposition of user charges in
many low- and middle-income countries
resembles an important barrier to utilizing
services.
Limited user charges, combined with
targeted exemptions for the poor, have been
seen as a way of improving the local revenue
base, thereby increasing the availability of
services.
18

2. Location
Location of health workers and facilities is
another important dimension of the cost of
care. A study in Burkina Faso, for example,
suggested that transport costs accounted
for 28 percent of the total costs of using
hospital services (Sauerborn, Ibrango et al.
1994).
A recent delivery survey in Bangladesh
found travel costs were the second most
expensive item (after medicines) in
outpatient treatment
(CIETcanada
2000). 19
Fantahun A. (MPHEpidemiology

According to one review of postnatal deaths in
North-East Brazil, in an estimated 25 percent
of cases, mothers reported that delays in
transportation may have contributed to the
death (Souza, Peterson et al. 2000).
Many studies reveal that household use of
services tends to decline with distance. This is
a key reason urban citizens, who are often
also wealthier, use services more than their
rural counterparts.
Lower rural access, reported in many studies,
may well be the impact of an interaction
20
and
Biostatistics), DBU,May,
2014 less knowledge
between longer distances
and

Location is a particularly critical factor in the
uptake of obstetric, and especially delivery
services.
Access for emergency deliveries is clearly
hampered by long distances.
One study, in Zimbabwe, suggested that up
to 50 percent of maternal deaths from
hemorrhage could be attributed to the
absence of emergency transport (Fawcus,
Mbizvo et al. 1996).
21

Yet, at the same time, distance is also
cited as a reason women choose to deliver
at home rather than at a health facility
(see for Philippines (Schwartz, Akin et al.
1993), Uganda (Amooti-Kaguna and
Nuwaha 2000) and Thailand (Raghupathy
1996)).
In other words, women living farther away
are less likely to choose a health facility
for delivery, although their inferior access
makes them the most vulnerable group in
case of an emergency.
22

3. Opportunity costs
Consuming health care can be time
intensive. Both patients and relatives may
have to give up long periods of work (or
leisure) to receive treatment.
This represents an important cost to
individuals, particularly during peak periods
of economic activity such as harvest time.
One study on malaria, for example, found
that 68 percent of the cost of illness was
accounted for in the indirect cost in lost
wages of the patient
or family members
23
(Attanayake, Fox-Rushby et al. 2000).

In some cases nonworking patients with
lower opportunity costs may be more likely
to use services.
A recent study in Pakistan, for example,
found that compliance is more easily
improved for people who are not
economically active since they are more
likely to have time to go for treatment (Khan,
Walley et al. 2002).
The opening hours of public services often
inflate the opportunity cost of treatment.
A study in Vietnam,
Fantahun A. for
(MPH- Epidemiology
example, found that24
Education and health

Peoples health status and life expectancy
increase with increase in their levels of
education.
For example: Women with higher levels of
education are more likely to have normal
birth weight babies, lesser risk for premature
birth and stillbirth.
Low educational levels are also associated
with an increased likelihood of high blood
pressure and poor blood sugar regulation.
Dementia (losing mental abilities) seems to
be higher among
older
people with less
Fantahun
A. (MPH- Epidemiology
25
Education and health cont

Education makes it easier for people to access
information and resources to make decisions about
their health.
Education also contributes to health in a number of
other ways. For example, people with higher education
are more likely to be able to find well-paying "good"
jobs. This increases their chances for stable incomes,
job security and job satisfaction.
Education also provides people with the knowledge
and skills they need to solve problems and to cope
with change.
This gives them a sense of control over their
circumstances, which in turn contributes to better
health.
26
Education and health cont
There is a well known, large, and persistent

association between education and health.
This has been observed in many countries
and time periods, and for a wide variety of
health measures.
The differences between the more and the
less educated are significant: in 1999, the
age-adjusted mortality rate of high school
dropouts ages 25 to 64 was more than twice
as large as the mortality rate of those with
some college.
27
Employment and health

There is some evidence that job insecurity
leads to worse self-rated physical health
and an increase in some clinical symptoms.
According to the 1996 survey on working
conditions, temporary employees were more
likely to report fatigue, backache and
muscular pains.
Similar findings were observed across job
categories and and countries.
The working conditions of temporary
employees are worse than those of
permanent workers. The former are more
exposed to painful
positions,
intense noise, 28
and Biostatistics),
DBU,May, 2014
Employment and health cont

From the point of view of work organization
temporary workers although are more
exposed than permanent workers to high
speed work, have much less autonomy over
the management of their work and time.
Even if working conditions are the main
explanatory variable for differences on
health outcomes between permanent and
temporary workers, associations between the
types of employment status and health
outcomes almost always persist after the
adjustment by individual working conditions.
29
Employment and health

cont
Temporary workers are less consulted about

organizational change, receive less training
and have fewer discussions about their work
problems with colleagues, bosses and
personnel representatives.

30
Housing and Health

The focus is on three important and inter-related
aspects of residential housing and their links to health:
- The physical conditions within homes;
- Conditions in the neighborhoods surrounding
homes; -- Housing affordability
1. Housing condition and health
Good physical and mental health depends on having
homes that are safe and free from physical hazards.
When adequate housing protects individuals and
families from harmful exposures and provides them
with a sense of privacy, security, stability and control,
it can make important contributions to health.

31
Housing and Health cont..

In contrast, poor quality and inadequate
housing contributes to health problems such
as infectious and chronic diseases, injuries,
and poor childhood development.
Substandard housing conditions such as
water leaks, poor ventilation and pest
infestation can lead to an increase in mold,
mites and other allergens associated with
poor health.
Indoor allergens and damp housing
conditions play an important role in the
development and exacerbation of respiratory
32
conditions including
asthma.
and Biostatistics),
DBU,May, 2014

Exposure to very high or very low indoor
temperatures can be detrimental to health.
Cold indoor conditions have been associated
with poorer health, including an increased risk
of cardiovascular disease.
Extreme low and high temperatures have
been associated with increased mortality,
especially among vulnerable populations such
as the elderly.
Housing can be a source of exposure to
various carcinogenic air pollutants. Radon, a
natural radioactive gas released from the
33
and
DBU,May, 2014with lung cancer.
ground, has beenBiostatistics),
associated

Residential exposure to environmental tobacco
smoke, pollutants from heating and cooking with
gas, volatile organic compounds and asbestos
have been linked with respiratory illness and
some types of cancer.
Residential crowding has been linked both with
physical illness, including infectious diseases such
as tuberculosis and respiratory infections and
with psychological distress among both adults
and children; children who live in crowded
housing may have poorer cognitive and
psychomotor development or be more anxious,
socially withdrawn, stressed or aggressive.
34

2. Neighborhood conditions and health
Along with conditions in the home, conditions
in the neighborhoods can have powerful
effects on health.
The social, physical, and economic
characteristics of neighborhoods have been
increasingly shown to affect short- and longterm health quality and longevity.
A neighborhoods physical characteristics may
promote health by providing safe places for
children to play and for adults to exercise that
are free from crime,
Fantahun A. violence
(MPH- Epidemiology and pollution.
35
Housing and Health cont

Neighborhoods with strong ties and high
levels of trust among residents may also
strengthen health.
Not all neighborhoods enjoy these
opportunities and resources, however, and
access to neighborhoods with healthpromoting conditions varies both by a
households economic and social resources.

36

3. Housing affordability and health
The shortage of affordable housing limits
families and individuals choices about where
they live.
The financial burden of unaffordable housing
can prevent families from meeting other basic
needs including nutrition and health care, and
is particularly significant for low income
families.
The lack of affordable housing affects families
ability to meet other essential expenses,
placing many families
under tremendous and
37
constant financial strain.

High housing payments relative to income,
along with
rising utility costs, force some families to
choose
between eating, and other needs.
A study showed that children who lived in
areas with higher rates of unaffordable
housing tended to have worse health, more
behavioral problems and lower school
performance.
Many live far away from their work, requiring
them to spend Fantahun
more
time and money
38
commuting and less time engaging in health

Families who lack affordable housing are
more likely to move frequently.
Residential instability is associated with
emotional, behavioral and academic
problems among children, and with
increased risk of teen pregnancy, early
drug use, and depression during
adolescence.

39
Beliefs about health and health care
Preceding any action are notions about the

significance of that action.
These notions or beliefs determine whether
in which form the action is taken. In terms
of health and health care, beliefs are
important because they drive behaviors
that have implications for health outcomes.
perceived personal susceptibility to an
illness or ill-health condition, an
understanding of the severity of a given
illness, a position on the benefits of a
course of action and a calculation of the
40
and
Biostatistics),
DBU,May,advantages
2014
barriers (or costs)
versus
of any
Beliefs about health and health care cont
Perceived susceptibility is the subjective

measure of risk to contracting a health
condition. It is an individuals understanding of a
diagnosis or the probability of him/her becoming
ill. For example, before attending a screening for
breast cancer, a woman must believe that she is
vulnerable to the disease.
In addition to perception of vulnerability or risk,
an individuals opinion of the consequences of
becoming ill or leaving an illness untreated also
partly determines his/her decision to take action.
41
Beliefs about health and health

care cont
Again a womans perception of the extent
to which developing breast cancer will be
physically or socially debilitating will
influence whether she will attend
screening.
Additionally a sense of the benefits of a
suggested action is important for health
behaviors.

42
Cultural Factors
Many cultural, religious, or social factors may

impede the demand for health care.
In communities where women are not expected to
mix freely, particularly with men, utilization of
health services from static facilities may be
impeded.
The presence of male practitioners for obstetric and
gynecological care has been shown to be an
important reason for low use of these services.
Cultural and family opinion is particularly important
in the demand for contraceptives and wider family
planning advice.
43
Cultural Factors cont

Wide differences in social status between
practitioner and patient may also inhibit utilization.
This may be through feelings of inferiority or
simply an inability to communicate properly.
One paper reports that the women of the Alur
people of Uganda may be thought weak if they
receive help during delivery (Ndyomugyenyi,
Neema et al. 1998). A similar finding is reported
for the Bariba tribe in Benin (Sargent 1985).
There is also evidence that women often accept
illness with genito-urinary symptoms as part of life
and may be embarrassed to seek medical care
(Bhatia 2001).
44
Religion and health

The Importance of Religion to
Sexual/Reproductive
Health and Rights
It is nearly impossible to consider sexual and
reproductive health and rights without
simultaneously considering the role of
religion.
Religious teachings deeply influence
personal conduct, especially in the areas of
sexuality, marriage, gender, childbearing,
and parental-children relationships.
Moreover, secular
notions of justice and
45
Religion and health cont

Not only do religions shape the values of
individuals and the cultures of societies, they
have the power to influence government
policy.
They affect public policies through the
involvement of religions in political processes
and also through the religious beliefs of
political leaders, policy makers, and civil
servants.
At their best, religions celebrate the dignity
of each human being and of all life as
valuable parts of a sacred whole.
46

They inspire and empower us to compassion
and justice. They provide a framework of
meaning and succor for people all over the
world.
Religions have collaborated with
dehumanizing values of cultural, economic
and political powers. Thus, they have
contributed to the suffering of women:
They have made women invisible by denying
them religious education and excluding them
from decision-making.
They have been
silent when patriarchal
47
systems have legitimated the violence,

This silence has been deafening in the face of
such atrocities as rape, incest, female genital
mutilation, sex selective abortion, and
discrimination against sexual minorities.
They have not recognized the conscience and
moral agency of women, especially in relation
to their sexuality and reproductive decisions.
Religions can and must do better. They must
reclaim their core values of justice, dignity, and
compassion, and apply these values to women.
Religions should apply the message of social
justice to women.
48

Given the enormous influence of religion on
both personal behavior and government
policy and religions potential to advance
the status of women, it makes sense for
foundations striving to improve womens
health and rights (including sexual and
reproductive health and rights) to
incorporate religion in their grant making.
It is also relevant to know which foundations
are making grants in the area of religion and
sexual and reproductive health and rights,
so that fundingFantahun
gaps
will
become evident. 49
A. (MPHEpidemiology
Discrimination and Health

Discrimination
This is an important factor that must be
considered in explaining disparities;
however, it is a difficult topic not only
because of its political sensitivity, but
because of the difficulties in evaluating and
documenting it.
Discrimination can affect health from a
variety of perspectives.
Discrimination not only can impact
utilization rates directly but can also impact
other factors such as access, referral rates
50
and
Biostatistics), DBU,May, 2014
and patient preferences.
Discrimination and Health cont

Subconscious discrimination can lead to racial
bias, as manifested as differing referral patterns.
It can also affect health directly. For example,
victims of discrimination can face high levels of
stress, which has been associated with a variety
of poor health outcomes, such as high rates of
depression and hypertension.
Discrimination can also impact health in a more
indirect way. A patients perception of
discrimination within the health care system
could conceivably impact his or her utilization of
the health care system. For example, a patients
initial negative interaction with a health care
51
provider may influence
the
patients
decision not
and Biostatistics),
DBU,May,
2014
What is the link between

health and human rights?
There are complex linkages between health and human
rights:
Violations or lack of attention to human rights can have
serious health consequences;
Health policies and programmes can promote or violate
human rights in the ways they are designed or
implemented;
- Vulnerability and the impact of ill health can be reduced by
taking steps to respect, protect and fulfill human rights.

52
What is the link between health

and human rights? Cont
Examples of the language used in human

rights instruments to articulate the normative
content of some of the other key human
rights relevant to health follows:
Torture: .No one shall be subjected to torture or to cruel,
inhuman or degrading treatment or
punishment. In
particular, no one shall be subjected without his
free
consent to medical or scientific
experimentation
53

maltreatment or exploitation, including sexual abuse
shall be taken.
Harmful traditional practices: .Effective and
appropriate
measures with a view to abolishing traditional practices
prejudicial to the health of children shall be taken.
Participation: The right to active, free and meaningful
participation..
Information: Freedom to seek, receive and impart
Information and ideas of all kinds.
Privacy: No one shall be subjected to arbitrary or
unlawful
interference with his Fantahun
Privacy.
54

Education: The right to education, including
access to
education in support of basic knowledge of
child health
and nutrition, the advantages of breastfeeding, hygiene
and environmental sanitation and the
prevention of
accidents.
Food and nutrition: The right of everyone to
adequate
55
food and the fundamental
right
and Biostatistics), DBU,May,
2014 of everyone to

Standard of living: Everyone has the right to
an adequate
standard of living, Including adequate food,
clothing,
housing, and medical care and necessary
social services.
Right to social security: The right of
everyone to social
security, including social insurance
56

What is meant by the right to health?
The right to health does not mean the right to
be healthy, nor does it mean that poor
governments must put in place expensive
health services for which they have no
resources. But it does require governments and
public authorities to put in place policies and
action plans which will lead to available and
accessible health care for all in the shortest
possible time. To ensure that the challenge
facing both the human rights community and
public health professionals..
United Nations High Commissioner
for Human Rights, Mary Robinson
57
Economic determinants of health

Many of the social factors that affect health
have both independent and interactive effects.
For example, people with higher incomes have
more opportunities to live in safe and healthy
homes, good communities, and near high
quality schools.
They are also generally better able to purchase
healthy foods and afford time for physical
activity.
Conversely, people who are poor are more likely
to live in substandard housing or in unsafe
communities
58
Economic determinants of health cont

Children who grow up in poverty generally
fare worse in school and end up, on average,
with fewer years of education than those in
families with higher incomes.
Further, there is a correlation between
poverty and stress, and health behaviors.
People who are poor are more likely to
engage in risky health behaviors (e.g.
drinking, smoking, eating unhealthy foods or
being inactive) and experience greater levels
of stress than more affluent individuals.
59

Effect of Income on the Health of
Children
Living in poverty or having a lower income
affects a persons health throughout their
lifetime.
However, the impact is especially important
for infants and children, as the conditions
that shape health in childhood influence
opportunities for health throughout life.
60

Infant mortality rates are greater for babies born to low
income mothers compared to high income mothers.
Low-income mothers are also more likely to give birth
to
a low birth weight baby (less than 2,500 grams), which
can result in mental and physical impairments in the
child.
Economic deprivation and hardship in childhood have
been demonstrated to be significant factors for adult
health, with economic hardship experienced in childhood
resulting in significantly higher risk of poor health in
adulthood.
61

Effect of Income on the Health of Adults
Individuals with higher incomes have a
longer life expectancy than people with
lower incomes.
Low family income is also associated with
significantly higher all-cause mortality rates,
even when controlling for age, sex, race,
urbanicity, education, base-line health
status, and health behaviors.
Wealth
Wealth (i.e. total financial resources
62
accumulated over
a lifetime)
and Biostatistics),
DBU,May, 2014 may have an

Annual income is a rather unstable measure,
as incomes vary from year to year. Some
households experience sharp losses or
increases in income with the loss or gain of a
job. Wealth can buffer temporary financial
changes.
For example, sudden or temporary losses in
income could be mitigated by using assets
to cover income deficits. In addition, wealth
can vary dramatically within income levels;.
63

Wealth is generally more difficult to measure, as it
may require information on stocks, retirement
accounts, pensions, real estate, automobiles, and
taxes. The market values for these assets may be
more time-consuming or difficult to determine, and
accuracy in reported assets can be problematic
Studies that have examined the relationship between
wealth and health have shown an association with
mortality, self-reported health status, chronic
conditions, mental health, and some risky health
behaviors.
Greater wealth is generally associated with decreased
mortality, even after controlling for education,
64

1.socio Economic Determinants of Health

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1.socio Economic Determinants of Health

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Determinants of Health:

Socio economic determinants of

Factors that contribute to a person's current

Determinants of health cont

Physical environment. Examples: where a

Fantahun A. (MPH- Epidemiology

Determinants of health cont

But these five categories can be broadly

Fantahun A. (MPH- Epidemiology

Health and health related condition

Fantahun A. (MPH- Epidemiology

Health Disparities cont

Fantahun A. (MPH- Epidemiology

Social Determinants of Health

Social Determinants of Health

Fantahun A. (MPH- Epidemiology

Social determinants of health cont

Social determinants of health cont

Fantahun A. (MPH- Epidemiology

Social determinants of health cont

Fantahun A. (MPH- Epidemiology

Access to Health service

Fantahun A. (MPH- Epidemiology

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Access to Health service cont

Education and health

Education and health cont

Education and health cont

There is a well known, large, and persistent

Employment and health

Employment and health cont

Employment and health

Temporary workers are less consulted about

Fantahun A. (MPH- Epidemiology

Housing and Health

Fantahun A. (MPH- Epidemiology

Housing and Health cont..

Housing and Health cont..

Housing and Health cont..

Housing and Health cont..

Housing and Health cont

Fantahun A. (MPH- Epidemiology

Housing and Health cont..

Housing and Health cont..

Housing and Health cont..

Fantahun A. (MPH- Epidemiology

Beliefs about health and health care

Preceding any action are notions about the

Beliefs about health and health care cont

Perceived susceptibility is the subjective

Beliefs about health and health

Fantahun A. (MPH- Epidemiology

Many cultural, religious, or social factors may

Cultural Factors cont

Religion and health

Religion and health cont