School of Health Sciences

400870
Population Health and
Society
Week 2: Models and determinants
Introduction

1.0 Health models

2.0 Determinants of health

2.1 Individual determinants – biological

2.2 Individual determinants – behavioural

2.3 Social determinants of health (SDH)

2.4 Environmental determinants

3.0 Summary
1.0 Socio-ecological model
Health models

Socio-ecological model of human development. Urie Bronfenbrenner, 1977-

2005.
Health models – The socio-ecological model

• In this unit, we will be using the social-ecological model, also known as

socio-ecological model.

• Developed by Urie Bronfenbrenner- American psychologist from 1970s

• Ecological systems theory has human development as a complex

system of relationships affected by multiple levels of the surrounding
environment.
Ecological systems model
Some terms about socio-ecological model

• Individual factors include gender, age and health status.

• Microsystem are closest relationships and impacts e.g. family, church

• Mesosystem is about interrelationships of those settings where you are an

active participant

• Exosystem is the community settings where you are not an active

participant e.g. organisations, media

• Macrosystem is the overarching culture e.g race, socioeconomic status

Socio-ecological model

• Forms basis of the socio-ecological model

• Community includes work, church, school,

neighbourhood

• Societal are the social, political, economic factors but

also cultures, attitudes and beliefs.
2.0 Determinants of health
What are health determinants?

• The many factors that determine health, wellness and

disease are known as determinants.

• Determinants form, and may explain, part of the elaborate

puzzle of health status, health outcomes and health equity
of populations.
What are health determinants?

The interplay of determinants being explored include:

• Individual determinants including biology and behaviour

• Social determinants including social gradient, education and income

• Environmental determinants including

the built environment and climate.
2.1 Individual determinants

Biological
Individual determinants

• Individual level factors that determine health include:

• Biological – “inner physiological aspects of health and disease”

(Liamputtong, 2019).

• Behavioural –”personal attributes or behaviours that influence an

individual’s risk of experiencing poor health” (Liamputtong, 2019).

But how are many of these created?

Biological factors

• The biological factors of health and disease relate to the biology of

life and living organisms.

• Biological health involves cells, tissues and organs.

• Explores the role of micro-organisms and pathogenesis of disease.

• The biological approach to health also considers genetics and risk

markers of disease.
Biological factors

• Pathogens

• Race, age and sex

• Congenital or acquired

• Epi-genetics

These may be termed ‘risk factors’ as a factor may introduce the

likelihood of developing disease. Behavioural risk factors are closely
related.
Biological factors example

• Syphilis is a sexually transmitted disease that arises from the

Treponema pallidum bacteria.

• Incubation can be 10 days to 3 months.

• Rates of syphilis in Australia rose from 7.8 to 18.3 per 100,000

between 2013 and 2017, are highest in the women 5-19 year age group
and affects Indigenous women at 40 times the rate of non-Indigenous
(Kirby Institute, 2018).
Biological factors example

• Risk factors for this condition are unprotected sexual contact

(behavioural risk factor)

• No known genetic predisposition exists.

• Syphilis can be passed from infected

mother to baby (congenital) and is
implicated in miscarriage and stillbirth.
2.2 Individual determinants

Behavioural factors
Behavioural factors
• Behaviours include personal characteristics (beliefs and values) and
disposition (which may escalate or de-escalate good health).

• Behaviours include protective and risk behaviours.

E.g. diet, exercise, smoking, sexual practices, alcohol, and adherence
to medical advice.

Consider disposition…..how is this created?

Behavioural factors
• Behaviours can reduce, contribute to or exacerbate all types of
disease, whether communicable or non-communicable.

• Blaming people for poor health is called “victim blaming” and is

discouraged in population and public health.

• Behaviours are identified as a means of modifying disease not

blaming people for poor health.

• Knowledge, attitudes and skills modification can positively impact

health outcomes.
Behavioural factors example

Emphysema is one of many respiratory conditions known as Chronic Obstructive

Pulmonary Disease (COPD). Emphysema is a lung condition that results from scarring of
the lungs.

Behaviours that contribute to or worsen emphysema are:

• smoking or exposure to environmental tobacco smoke

• exposure to fumes and smoke from carbon-based cooking and heating

• occupational hazards (exposure to pollutants and chemicals)

• poor nutrition (AIHW 2019).

2.3Social determinants of health (SDH)
Social determinants (SDH)

• The “social environment” in which people are born, grow, live, work
and age contributes to health outcomes.

• A “number of factors including social, cultural, economic and

political which can impact on the health of individuals” (Liamputtong,
2019, p11).

• It is well established through research that there are many social

conditions that create unequal health.

• SDH are responsible for up to 55% of health outcomes (WHO, 2020).

Social determinants

Social Determinants of Health

– NSW Health, Agency for Clinical Innovation

(3:58mins)

https://youtu.be/pbP1_qd5FHQ

Although refers to clinical practice, the same understanding is needed by all health
and wellness professionals.
Some main social determinants

• Poverty

• Socio-economic status and social gradient

• Education

• Early childhood

• Social support and exclusion

• Employment and work

• Housing and homelessness

• Gender inequality
Social determinants – Poverty

• Poverty is concerned with material living standards or a lack of means to

participate fully in society.

• Absolute poverty measures people living below income threshold (less than
half the average income).

• Relative poverty measures extent to which the financial resources of a

household fall below the average.

• Poverty can be transient or chronic.

• Unequal access to full-time employment is the largest contributor to

poverty.
Social determinants – SES, social gradient and poverty evidence
Social determinants – SES / Social gradient

• Socio-economic status (SES): the health of people decreases in relation to

their social and economic circumstances.

• A higher socio-economic position results in better health outcomes and

conversely, lower socio-economic position results in poorer health
outcomes.

• The magnitude of the gradient between the top and bottom impacts all
countries, not just the developing countries.

• All people except the very top of the social gradient could achieve better
health.
Social determinants – SES / Social gradient

Premature death between 35 and 74 years of age is double for those is

the lowest socioeconomic areas compared to the highest socioeconomic
areas.
Social determinants – Education

• Education has the strongest association to health outcomes of all the SDH.

• “Low education levels are linked with poor health, lower health literacy,
higher levels of stress and lower self confidence” (Keleher & McDougall,
2016).

• Education is strongly associated with life expectancy, morbidity, health

behaviours and shapes opportunities for employment and income.

• In 2020, 80% of students worldwide were affected by school closures,

interrupting continuity of schooling (UNESCO, 2020).
Social determinants – Translation of low educational attainment

• Lower educational attainment translates to lower health literacy. Health

literacy is the ability to appraise health information and navigate healthcare
systems.

• Low health literacy impacts health outcomes and increases adverse health
behaviours, such as lower engagement with preventative health services,
higher re-admission rates, poorer understanding of medication instructions
and lower ability to self-manage (AIHW, 2020).

• Increased health literacy increases patient involvement in shared decision

making which is important in person-centred care.
Social determinants – Early childhood

• “Early years of life are the most profound in a persons life” (Keleher &
MacDougall, 2016).

• Support in early childhood has positive impacts on physical

development, learning and long term health outcomes.

• Disadvantage as a child can interfere with health and education, which

in turn impacts, employment, income and understanding of health.
Social determinants – Support and exclusion

• Social connectedness is associated with improved health

outcomes i.e. lower morbidity and increased life
expectancy.

• Social exclusion through discrimination and

stigmatisation causes harm to psychological and physical
health.
Social determinants approach – Employment and work

• Employment and work: unemployment and

underemployment is associated with psychological stress,
reduced physical health and higher risk of death.

• Precarious work is a social determinant associated with

causing or exacerbating health problems (Matilla-
Santander et al, 2020).
Social determinants – Housing and homelessness

• Housing and homelessness: safe, affordable housing is

associated with better health outcomes.

• As housing quality (affordable, suitable) and security

decreases, so does health.

• Homelessness can be the cause mental illness and early

mortality.
Social determinants – Gender inequality

• Gender is a social system that defines men and women as different in

relation to power, resources and status.

• Although this gender system could be equitable, to date it has been

intensely patriarchal, valuing men more highly.

• Gender norms dictate social acceptability of attributes and behaviours

valued within this gender system.

• Inequality results in gendered health outcomes e.g. high rates of

occupational injury in men, high risk of sexual violence against women.
Heise, L., et al. (2019). "Gender inequality and restrictive gender norms:
framing the challenges to health." The Lancet 393(10189): 2440-2454.
Social determinants (SDH)

• The social determinants explored today are just a few.

• Determinants do not exist in isolation, as they are intersecting.

• The “Matthews effect” – advantage produces further advantage,

disadvantage produces further disadvantage.

• An increased focus on SDH has arisen as a result of COVID pandemic.

2.4 Environmental determinants
Environmental determinants

• The impact of environment on health outcomes is significant.

• Environment encompasses a number of components.

• Environment can be location e.g. rural and remote or low socio-

economic status (SES) area.

• Environment can be location characteristics e.g. toxicity, available

green space, accessibility.

• Environment can also refer to climate and climate change.

Environmental determinant example

• Exposure to lead at any level is harmful to human health.

• Lead mining and smelting continues in three Australian towns;

Mt Isa, Port Pirie and Broken Hill.

• Tests conducted on children at Mt Isa in 2017 indicated 40% had higher than
permissible levels of lead in their blood.

• The population with the highest lead levels

were Indigenous children.

• Lead poisoning results in neurotoxicity

which presents in children as reduced
brain development and cognitive function.
Combining determinants of health

• Understanding biological, behavioural, social and

environmental determinants of health are central to
providing more comprehensive care for better population
health outcomes.

• These determinant “categories” can be overlapping and

impact on each other.
Case study: Anastasia

Anastasia is a 6 year old girl, living in a remote community. She has had many acute asthma
attacks in the past year which has at times required hospitalisation. She has not been able
to attend school regularly and her family feel she is falling behind in her education.

The medications for her condition are mostly covered by subsidised prescription in
Australia, but her mum struggles to get to the doctor and the chemist, which is in the next
town (50km away), due to work commitments and transport issues.

Q: What factors are influencing Anastasia’s health outcomes?

Q: If we considered just the biomedical parts of this case study, would Anastasia’s health
needs be met?
Case study: Determinants for Anastasia
Biological: Asthma, genetics?

Behavioural: Non adherence, trigger exposure, psychological stress, physical

inactivity, unhealthy diet?

Social: Mum’s work commitments, time off work, cost of care? Anastasia
attendance at school?

Environmental: location (remote), access to

Patient-
services, housing, transport, environmental triggers? centred Care

Important: Consider more broadly, deeply how these factors

came to be e.g. cultural, economic and political
Biological Behavioural
Social Environmental
Thinking outside the box
• This week we have explored the socio-ecological model and determinants
of health as a framework for care.

• This conceptual framework is an anchor for how to organise information in

this unit.

• Putting the biomedical model of health service delivery aside, the

challenge is to reimagine how healthcare
can be delivered to meet peoples needs.

• You are being encouraged to reimagine or

reconceptualise health and healthcare.
3.0 Summary
 Summary

• A socio-ecological model of health is a framework for healthcare used in

Population Health and Public Health.

• The patient/ person is central and nested within relationships,

community, and society. These in turn have been shaped by
macrosystems.

• You will apply this in your assessments for this unit.

 Summary - Conceptualisation

Person
Social-ecological model of health

Individual (biological,
behavioural), social and
environmental determinants

Health outcomes

Healthcare services
 Summary

• A gap in health outcomes results from a widening gap in determinants,

most markedly social determinants.

• Social determinants contribute to poorer health outcomes.

• You are encouraged to think outside the current constraints of how

health is managed with the aim of addressing health inequality.
WESTERNSYDNEY.EDU.AU