Module 1: Determinants of Health

Health is a complex and multifaceted concept, defined by the World Health Organization as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”(1) It comprises a quality of life determined by various factors beyond biological makeup. Factors may be based on the individual, community, or population; they may be fixed or variable, and rooted in historical context or present condition. While there are many ways to group the determinants of health, we present them below in broad categories that lend themselves to the ultimate question: What influences a person’s health status? Through identifying such factors, we provide an introduction to the consequences of determinants on health behavior and outcomes.

Sociodemographic Factors

Age and Gender

Although varying in degree of impact, age and gender influence opportunities for development and access to health services. For instance, old age increases one’s risk of disability, creating physical limitations to accessing care. Different age groups have distinct priorities and health concerns, and the providers for the same community may not necessarily have adequate resources to serve all groups equally. For example, in Australia, 81% of deaths from stroke are amongst the elderly (75 years or older).(2) Senior citizens often face more expensive insurance rates due to their increased risk of health complications including heart problems, high blood pressure, and diabetes.(3) Coupled with this is the “graying of nations”, the phenomenon of the increasing proportion of elderly people in communities, particularly in developed countries. These increases strain the healthcare economy and family finances.(4) Infants pose similar health risks, as they are especially vulnerable in their first weeks of life. In developing countries specifically, families are often unable to afford post-natal care, and children may die from poor hygiene practices, breathing difficulties, fever, low birth-weight, lack of vaccinations, and malnutrition.(5) Many developing countries have come to accept a high mortality rate among infants, which is compounded by high fertility rates. Oftentimes in these nations, parents do not name their children until weeks after birth, once survival seems likely.(6)

The roles, norms, and perceptions of gender also impact health. In many developing countries, women are still subject to disproportionate barriers to care, resulting from having a “more limited access to, and less control over, resources, and over their bodies and lives, than do men.”(7) Gender can affect relative power, autonomy, poverty, and marginalization; health and illness patterns provide only one such consequence of gender as a determinant. However, gender perceptions vary between cultures. In many countries, women receive a lower income than do men, leaving them financially dependent on their husbands and male family members for access to healthcare and other services. Some women are not allowed to seek out healthcare without the company or approval of a man, restricting their autonomy with regard to personal health decisions. Societal standards for men and women also differ considerably. The WHO uses the example of HIV; in some developing countries, men are expected to be adulterous while their wives may be prevented from using condoms during intercourse, thereby increasing HIV infection rates. Alternatively, according to the WHO, smoking may be perceived as unattractive for women but encouraged for men, resulting in higher rates of smoking-related health complications for males. As gender roles and norms evolve, access to healthcare should become more sensitive to gender-related health as well as to equality in treatment.(8)

Case Study:  Tamil Nadu, India

Females in India, and in Tamil Nadu specifically, experience inequality in access to healthcare and freedom of choice, particularly regarding unwanted pregnancies, childbirth, and childcare. The cultural predisposition for sons in a patriarchal society and the desire for numerous pregnancies reduce the health of women by increasing mortality rates of both mother and child. This can lead to low birth weight for infants and anemia in mothers. Women often do not have reproductive rights over their bodies and cannot choose when and if they would like to be pregnant. The pressure to have sons in their culture can dictate the type of healthcare that women in Tamil Nadu receive. Husbands and male family members make decisions for their wives, daughters, and sisters regarding their pregnancies, leading to various health complications.(9)

Education

An individual’s level of educational attainment is a strong indicator of his or her health behavior and perspectives. Economic models suggest that formal education serves to better inform individuals “about the health consequences of certain behaviors… [putting them] in the position to allocate their time and resources to cost-effective health inputs.”(10) Furthermore, a lack of education may limit knowledge of health-related complications, preventing the individual from seeking health care. This can delay medical care, leading to more severe health conditions upon time of treatment. Many interventions focused on both preventive and curative care rely on a base level of education and literacy in order to be effective. Emphasizing education can have long-term financial benefits for state governments. One study done by the Alliance for Excellent Education estimates that each person who graduates from high school rather than dropping out saves $13,706 of government spending on the uninsured. This is because those with low education levels are less likely to have health insurance, leading to inadequate protection and care, thereby increasing their chances of health complications. Education is also linked to awareness of health issues, including the smoking, nutrition, and heart problems, which can prolong lives and lead to early detection of problems. The health and economic benefits of promoting education is worth considering when developing country-wide health plans.(11)

Case Study: Education Levels and Mental Health in Canada

In Canada, mental healthcare (when administered by physicians) is covered by a universal health system. Research has shown that those with low education levels demonstrate much higher anxiety and depression levels than do those with advanced education, though those with higher education levels tend to receive increased mental health services. This is partially because those who are educated reach out to private sector healthcare. However, increased education also corresponds to earlier recognition and self-reporting of signs of mental distress. If patients are not referred by their primary physicians to mental health specialists, they are unlikely to seek help. This implies that those who can identify signs of their own mental distress or the anxiety of those around them will receive specialized care, which is often more easily determined by those with higher education levels.(12)    

Employment

Previous studies have indicated that employment improves health. For instance, it has been observed that full-time employment leads to “slower declines in perceived health and in physical functioning for both men and women.”(13) This hypothesis that employment is a causative determinant of health is called the “social causation hypothesis.” Conversely, an alternative hypothesis called the “selection hypothesis” indicates that better health enables an individual to maintain a full-time job.(14) Though the direction of causation is debatable, both hypotheses present a viable correlation between employment and health. The WHO states that “the greater the gap between the richest and the poorest people, the greater the differences in health.”(15)

Case Study: Medicaid and Unemployment in the United States

If unemployment rates in the United States continue to increase, levels of employer-provided insurance will decrease, leaving the unemployed either uninsured or dependent on government-provided medical relief. In a struggling economy, jobs are being cut as state budgets are reduced, limiting Medicaid benefits that assist low-income families. Those with Medicaid coverage have already had their insurance provisions reduced, and new families cannot be taken on. This is because Medicaid is funded by state and federal revenues, and is greatly affected by economic downturns.(16) Without insurance, families can be driven into financial deprivation with just one trip to the hospital. Additionally, many immigrants in the United States do not qualify for Medicaid coverage, and with low incomes and little private insurance opportunities, they suffer disproportionately. Immigrants are also often hired on contract, allowing employers to legally deny them health benefits. They are then discouraged from seeking medical attention because of the high out-of-pocket expenses.(17)       

Level of Sanitation and Environment

Poor sanitation directly causes disease. This was first observed in 1842 through a report on sanitation among the labor force in Great Britain. While great strides have been made to improve sanitary conditions throughout much of the developed and developing world, there is still a lot to improve upon. Poor sanitation, including the safe elimination of human waste, continues to account for approximately 10% of global diseases, as individuals become predisposed to diarrheal diseases and neglected tropical diseases that are commonly transmitted through the fecal-oral route. Other health effects include childhood and maternal malnutrition and increased vulnerability to communicable diseases.(18) Chemicals used in farming, wastes from nearby industries, and sewage system problems can all pollute water supplies. Because of costs, sanitation is sometimes not included in the primary health care plans of developing countries. Government and non-governmental agencies, such as USAID, can help finance sanitation projects in areas that are not financially capable of doing so without assistance.(19) Improvements in sanitary conditions, including the use of toilets and the availability of a clean water supply are associated with better health outcomes. While such indicators directly denote the quality of sanitation practices of a community, the degree of crowding in homes provides another way to evaluate the health of the living environment. Though crowding facilitates the spread of disease, it has been observed that greater crowding is associated with increased “likelihood of reporting an illness.”(20)

Case Study: Poor Sanitation in Zambia

Zambia loses the equivalent of nearly US$200 million annually to poor sanitation practices. The nation loses money due to deaths from diarrhea (especially among young children) and malnutrition, leading to a lack of productivity that accompanies increased illness., This, in turn, increases money spent on healthcare. There are also indirect economic losses of inadequate sanitation, including money spent on epidemic mitigation, funeral expenses, and decreases in tourism. Spending more money on sanitation can have tremendous long-term consequences, saving money on healthcare and treatment of associated diseases.(21)  

Social Structure

Studies have revealed the impact on health according to the demographic characteristics of the head of household. With regard to gender, individuals in female-headed households are “more likely to report illness than individuals in households headed by men.”(22) Correspondingly, individuals from male-headed households exhibit greater health care expenditures. With respect to age and education level, heads of households who are older and more educated report lower expenditures on health care.

Community location (urban or rural) also serves as a determinant of health. Whether there are varying risk factors associated with location is subject to analysis. However, it is certain that there remain discrepancies between access to and availability of healthcare services, despite the development of programs to expand outreach to geographically marginalized populations. Comparison studies demonstrate that although individuals from urban households are more likely to report illness, they are less likely to visit a healthcare provider, and they spend less on healthcare than do their rural counterparts.(23) It is possible that such behavioral differences result from variations in healthcare providers between urban and rural areas.

Psychological Factors

Trust and Authority

Perceptions of trust and authoritative roles between patients and healthcare providers may influence health outcomes. For instance, empirical studies have concluded that “less-trusting patients exhibit poorer health behaviors and are less likely to seek necessary care” than more trusting individuals.(24) The degree to which a patient views his physician as an authority figure influences his willingness to trust the provider. When patients are skeptical of physicians, studies find “less healthy behavior, less health care utilization, and lower compliance rates in preventive health care regimens.”(25) Similarly, the provider’s perception of her patients may also determine health outcomes; a physician’s judgment of her patient’s intelligence, propensity towards risky behavior, or likelihood to adhere to treatment may affect the quality of care delivered. Ultimately, “trust is a positive complement to health care” and increased trust between patients and providers alleviates uncertainty.(26) Trusting individuals are typically given more encouragement to adhere to prescribed treatment, thereby promoting positive health behaviors among this patient subgroup. Trust between a physician and a patient is built over time, and requires a long-term healthcare relationship. Particularly in developing countries, where international organizations respond to extreme hardship, healthcare can be immediate and short-term. Though this may be necessary for temporary relief, it does not foster trust or respect for authority. In Sri Lanka, for instance, Sarvodaya (an NGO) has a US$12 million annual budget with thousands of staff members, and has worked to eradicate healthcare problems in cooperation with the community on a long-term basis.(27)  

Perceived Autonomy

An individual’s sense of control over decisions or daily activities can significantly affect health outcomes. This may be due to the fact that perceived autonomy over one’s health is associated with proactive preventive and curative measures. Studies have corroborated this correlation by demonstrating that perceived control over stressful events is connected with greater adjustment to illness, increased happiness, and healthier decision-making. For instance, a study comparing varying beliefs regarding personal control over breast cancer found that women who believed they could control the disease were better able to adjust to its psychological and physiological challenges.(28) Perceived autonomy may also help individuals to handle the challenges of navigating healthcare systems and obtaining adequate treatment. Previous studies have confirmed a “significant and positive relationship between… empowerment and …health service utilization” in certain situations.(29)

Perceived Severity of Disease

An individual’s understanding of his or her condition influences the way in which the patient seeks health care. Specifically, studies have demonstrated that the perceived severity of symptoms is a strong influence in health-seeking behavior. People are more likely to take action when they believe their symptoms are severe.(30) Similarly, studies have shown that self-reported health status is “a strong predictor of mortality,” bolstering the influence from self-assessment in health.(31) This process has been called “health literacy,” which refers to an individual’s understanding of basic health services that can enable informed decisions and can lead to self-reporting of health problems. Without an understanding of the healthcare system and potential complications, people are less likely to take prescribed medication and go to regular examinations, and they are more likely to be hospitalized as a result. For some people, low health literacy may be due to trouble reading and understanding medical directions and hospital notes; others may not have the confidence or education necessary to determine their own health problems.(32)

Case Study: Self-Reporting in Taiwan

In 2000, a study was done in Taiwan to determine the accuracy of self-reporting of diabetes. The results demonstrate that those with higher education levels as well as the more senior members of communities were more aware of the signs of diabetes and were thus more likely to report it. Those with recent health exams were also more aware of their health condition and were more confident in self-reporting. When looking at hypertension, there were much lower levels of accurate self-reporting, indicating that different conditions are easier to self-report than are others.(33)

Personality and Emotion

Literature has suggested that personality traits and emotion play influential roles in health outcomes. Research has identified a correlation between various character traits and poor health. Traits including “hostility, anger, anxiety, emotional suppression, depression, fatalism, and pessimism,” have been associated with cases of “cancer, heart disease, AIDS, and several other illnesses”.(34) Subsequent studies have attempted to trace the mechanism of this connection, proposing either that negative traits lead to physiological stress and thus increased blood pressure and reduced immunological function, or that individuals with negative traits are less inclined to seek health care and adhere to prescriptive treatments. Negative emotions are further believed to reduce an individual’s emotional resources to cope with illnesses or poor prognoses.(35) Negative emotions can also result in physical symptoms such as insomnia, respiratory problems, heart palpitations, extreme weight gain and loss, and high blood pressure.(36) Regardless of the causal mechanism linking negativity to poor health, emotions undoubtedly have the potential to disrupt the provision of health care and lead to undesirable outcomes.

Social Support

The number and depth of social relationships also affect an individual’s health. Types of social support include emotional care and concern, informational resource and coping mechanisms, and instrumental assistance. Regardless of the type, social support promotes positive psychological feelings that lead to healthy immune function and positive attitudes toward health. Population studies have confirmed the impact of such forms of support or perceived support by revealing associations between “interpersonal relationships and mortality, physical morbidity, and recovery from chronic and other types of illnesses.”(37)

Economic Factors

Monetary Costs

The expenses of health services including insurance fees, medication, and transportation to health facilities constitute monetary costs that may influence health utilization and outcome. The stresses associated with paying healthcare bills can limit the proportion of those who seek institutional care.(38)

Non-monetary Costs

Economic factors also include non-monetary costs related to seeking care, including time lost or gained from health-seeking behavior, income relative to health-related expenditures, and the degree of access to payment.(39)

Individual/Household Income

The income determinant is not isolated. Although it consists of multiple connections to sociodemographic factors, income as a distinguishing characteristic for an individual or household has a strong correlation to health. A general trend indicates that “the poor continue to suffer from higher mortality rates, experience higher morbidity, and self-report significantly less-healthy lives than their middle and upper class counterparts.”(40) Studies also show that “the relationship between income and mortality is strongest for persons in good health and weakest for those in poor health.”(41)

National Economic Development

A country’s overall level of economic development affects the community infrastructure and has corresponding implications for both public and individual health. Specifically, economic development is associated with the level of health services and activities that a community can support. Key health indicators of a society, such as life expectancy and infant mortality, are affected by measures of gross national income; life expectancy increases and infant mortality decreases with increasing national income. Although overall economic development is a strong indicator of health, aggregate values are averaged and may not reflect the real purchasing power at the base of the pyramid.

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Footnotes

(1) World Health Organization. “Frequently asked questions.” Accessed 12 October 2011. <http://www.who.int/suggestions/faq/en/index.html>.

(2) Australian Government. "Authoritative Information and Statistics to Promote Better Health and Wellbeing." Australian Institute of Health and Welfare. N.p., n.d. Web. 13 Aug. 2012. <http://www.aihw.gov.au/risk-factors/>.

(3) Cornett, J. E. "How Age & Lifestyle Factors Affect Health Insurance Costs." EHow. N.p., n.d. Web. 13 Aug. 2012. <http://www.ehow.com/info_7758888_age-affect-health-insurance-costs.html>.

(4) World Health Organization. "Caring for the Elderly." South-East Asia Regional Office. Proc. of Regional Workshop and Social Symposium on Caring for the Elderly, New Delhi. N.p., 11 Mar. 1996. Web. 13 Aug. 2012. <http://www.searo.who.int/LinkFiles/RD_Speeches_rdv1p154.pdf>.

(5) World Health Organization. "Newborns: Reducing Mortality." WHO Media Centre. N.p., May 2012. Web. 13 Aug. 2012. <http://www.who.int/mediacentre/factsheets/fs333/en/index.html>.

(6) Costello, Anthony, and Dharma Manandhar. "Current State of the Health of Infants in Developing Countries." IC Press. N.p., n.d. Web. 13 Aug. 2012. <http://www.icpress.co.uk/etextbook/p083/p083_chap01.pdf>.

(7) Phillips, S. “Defining and measuring gender: A social determinant of health whose time has come.”International Journal for Equity in Health 4.11(2005). Accessed 11 October 2011. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1180842/>.

(8) WHO. "Gender, Women, and Health." World Health Organization. N.p., n.d. Web. 13 Aug. 2012. <http://www.who.int/gender/genderandhealth/en/index.html>.

(9) Srividya, Patrick V. "Gender Inequality Fails Women's Access to Healthcare." The Hindu. N.p., 16 June 2011. Web. 13 Aug. 2012. <http://www.thehindu.com/news/states/tamil-nadu/article2109983.ece>.

(10) Richman, B. “Behavioral economics and health policy: understanding Medicaid’s failure.”Cornell Law Review 90.3 (2005): 705-768.

(11) Alliance for Excellent Education. Healthier and Wealthier: Decreasing Health Care Costs by Increasing Educational Attainment. Issue brief. MetLife Foundation, Nov. 2006. Web. 14 Aug. 2012. <http://www.all4ed.org/files/HandW.pdf>.

(12) Steele, Leah S., Carolyn S. Dewa, Elizabeth Lin, and Kenneth LK Lee. "Education Level, Income Level and Mental Health Services Use in Canada: Associations and Policy Implications." Healthcare Policy 3.1 (2007): 96-106. Longwoods.com. Web. 13 Aug. 2012. <http://www.longwoods.com/content/19177>.

(13) Ross, C. and J. Mirowsky. “Does employment affect health? [Abstract]”Journal of Health and Social Behavior 36(1995): 230-243. Accessed 11 October 2011. <http://www.ncbi.nlm.nih.gov/pubmed/7594356>.

(14) Ibid.

(15) WHO. "Health Impact Assessment (HIA)." World Health Organization. N.p., n.d. Web. 13 Aug. 2012. <http://www.who.int/hia/evidence/doh/en/>.

(16) Holahan, John, A Bowen Garrett, and The Urban Institute. Rising Unemployment, Medicaid and the Uninsured. Rep. Kaiser Commission on Medicaid and the Uninsured, Jan. 2010. Web. 13 Aug. 2012. <http://www.kff.org/uninsured/upload/7850.pdf>.

(17) Ku, Leighton. "Why Immigrants Lack Adequate Access to Health Care and Health Insurance." Migration Information Source. Migration Policy Institute, Sept. 2006. Web. 15 Aug. 2012. <http://www.migrationinformation.org/usfocus/display.cfm?ID=417>.

(18) Mara, D., Lane, J., Scott, B., Trouba, D. “Sanitation and Health.” PLoS Med 7.11(2010). Accessed 11 October 2011. <http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000363>.

(19) USAID. "Domestic Water and Sanitation." USAID. N.p., May 1982. Web. 15 Aug. 2012. <http://transition.usaid.gov/policy/ads/200/water/ws_context.html>.

(20) Rous, J. and D. Hotchkiss. “Estimation of the determinants of household health care expenditures in Nepal with controls for endogenous illness and provider choice.”Health Econ 12(2003): 431-451.

(21) Water and Sanitation Program. Economic Impacts of Poor Sanitation in Africa. Rep. N.p., Mar. 2012. Web. 15 Aug. 2012. <http://www.scribd.com/doc/90883969/Economics-of-Poor-Sanitation-in-Zambia>.

(22) Rous, J. and D. Hotchkiss. “Estimation of the determinants of household health care expenditures in Nepal with controls for endogenous illness and provider choice.”Health Econ 12(2003): 431-451.

(23) Ibid.

(24) Richman, B. “Behavioral economics and health policy: understanding Medicaid’s failure.”Cornell Law Review 90.3 (2005): 705-768.

(25) Ibid.

(26) Ibid.

(27) Abeykoon, Palitha. Long-Term Care in Developing Countries: Ten Case-Studies: Sri Lanka. Rep. World Health Organization, 2002. Web. 15 Aug. 2012. <http://www.who.int/chp/knowledge/publications/case_study_srilanka.pdf>.

(28) Richman, B. “Behavioral economics and health policy: understanding Medicaid’s failure.”Cornell Law Review 90.3 (2005): 705-768.

(29) Ahmed, S., Creanga, A., Gillespie, D., Tsui, A. “Economic status, education and empowerment: implications for maternal health service utilization in developing countries.” PLoS ONE 5.6(2010). Accessed 13 October 2011. <http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0011190>.

(30) Danso-Appiah, A., et al. “Health seeking behavior and utilization of health facilities for schistosomiasis-related symptoms in Ghana.” PLoS Negl Trop Dis 4.11(2010). Accessed 13 October 2011. <http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000867>.

(31) Kiuila, O. and P. Mieszkowski. “The effects of income, education and age on health.”Health Economics 16(2007): 781-798.

(32) Chew, Lisa D., MD. Self-Report Measures of Health Literacy. Rep. Institute of Medicine Roundtable on Health Literacy, 26 Feb. 2009. Web. 15 Aug. 2012. <http://iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Chew.pdf>.

(33) Goldman, Noreen, I-fen Lin, Maxine Weinstein, and Yu-Hsuan Lin. Evaluating the Quality of Self-Reports of Hypertension and Diabetes. Rep. Office of Population Research Princeton University, 2002-2003. Web. 15 Aug. 2012. <http://opr.princeton.edu/papers/opr0203.pdf>.

(34) Richman, B. “Behavioral economics and health policy: understanding Medicaid’s failure.”Cornell Law Review 90.3 (2005): 705-768.

(35) Ibid.

(36) "Mind/Body Connection: How Your Emotions Affect Your Health." FamilyDoctor.org. N.p., Nov. 2010. Web. 15 Aug. 2012. <http://familydoctor.org/familydoctor/en/prevention-wellness/emotional-wellbeing/mental-health/mind-body-connection-how-your-emotions-affect-your-health.html>.

(37) Richman, B. “Behavioral economics and health policy: understanding Medicaid’s failure.”Cornell Law Review 90.3 (2005): 705-768.

(38) Mills, A., Hoare, G., Cumper, G., Roberts, J. Health Economics for Developing Countries: A Survival Kit. Evaluation and Planning Centre for Health Care. Department of Public Health and Policy at the London School of Hygiene and Tropical Medicine. 1998. <http://helid.digicollection.org/en/d/Jh0197e/1.html>.

(39) Ibid.

(40) Ibid.

(41) Kiuila, O. and P. Mieszkowski. “The effects of income, education and age on health.” Health Economics 16(2007): 781-798.