PREVENTIVE MEDICINE
Determinants of Health and Disease [CEF Palaruan II, MD, MPH]
OUTLINE
I. INTRODUCTION
II. EVIDENCE BASE OF HEALTH DETERMINANTS
A. TRANSPORT
B. FOOD AND AGRICULTURE
C. HOUSING
D. WASTE
E. ENERGY
F. INDUSTRY
G. URBANIZATION
III. DETERMINANTS OF HEALTH
IV. COMPLICATING FEATURES OF DETERMINANTS
A. DYNAMISM
B. MULTI-SCALE
C. CROSS-BOUNDARY
I. INTRODUCTION
DETERMINANT – a factor that decisively affects the nature or
outcome of something
Departments
• Health Promotion and Education
• Health Policy and Administration
• Epidemiology and Biostatistics
• Nutrition
• Medical Microbiology
• Parasitology
• Environmental and Occupational Health
The Determinants of Health (WHO)
• 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, and
• person’s individual characteristics and behaviors.
The context of people’s lives determine their health, and
so blaming individuals for having poor health or crediting them
for good health is inappropriate. Individuals are unlikely to be
able to directly control many of the determinants of health.
PFCM 1 VILLANUEVA, M.
These determinants—or things that make people healthy or
not—include the above factors, and many others:
• Income and social status - higher income and social
status are linked to better health. The greater the gap
between the richest and poorest people, the greater
the differences in health.
• Education – low education levels are linked with poor
health, more stress and lower self-confidence.
• Physical environment – safe water and clean air,
healthy workplaces, safe houses, communities and
roads all contribute to good health. Employment and
working conditions – people in employment are
healthier, particularly those who have more control
over their working conditions
• Social support networks – greater support from
families, friends and communities is linked to better
health. Culture - customs and traditions, and the
beliefs of the family and community all affect health.
• Genetics - inheritance plays a part in determining
lifespan, healthiness and the likelihood of developing
certain illnesses. Personal behaviour and coping skills
– balanced eating, keeping active, smoking, drinking,
and how we deal with life’s stresses and challenges all
affect health.
• Health services - access and use of services that
prevent and treat disease influences health
• Gender - Men and women suffer from different types
of diseases at different ages.
II. EVIDENCE BASE OF HEALTH DETERMINANTS
• An evidence base about the impact that projects,
programmes and policies have had on health is
required to carry out HIA.
• The best available evidence is used within the
appraisal stage of HIA to determine what impacts may
occur (both positive and negative), the size of the
impact (if possible) and the distribution of that impact
in different population groups.
• It is generally assumed that the evidence for health
impacts exists, and that searching and collating will
provide the necessary evidence.
• Unfortunately this is not often the case, and the
evidence of health impacts is often not available.
• This is because of the long causal pathway between
the implementation of a project/programme/policy
and any potential impact on population health, and
the many confounding factors that make the
determination of a link difficult.
1 of 5
 PREVENTIVE MEDICINE
Determinants of Health and Disease [CEF Palaruan II, MD, MPH]
A. TRANSPORT
Evidence of health impact focus on:
• Accidents between motor vehicles, bicycles and
• pedestrians (particularly children and young people).
• Pollution from burning fossil fuels such as particulates
and ozone.
• Noise from transportation.
• Psychosocial effects such as severance of
communities by large roads and the restriction of
children’s movement.
• Climate change due to CO2 emission
• Loss of land
• Improved physical activity from cycling or walking
• Increased access to employment, shops and support
services
• Recreational uses of road spaces
• Contributes to economic development
• Vector borne diseases
B. FOOD AND AGRICULTURE
Agricultural production issues and manufacturing
• Tobacco farming and its impact on heart disease,
stroke, certain cancers and chronic respiratory
disease. Including passive smoking and impact of
foetal development. Pesticide policies on tobacco
crops require consideration.
• Changes in land use, soil quality, choice of crop, use
of agricultural labour and occupational health.
• Mechanization of work previously done by hand, and
plantation agriculture.
• Fisheries – biotoxins, pollution, chemical use,
wastewater, processing, and occupational health
• Forestry – vector borne diseases, occupational health,
and food security.
• Livestock use – vector borne diseases, drug residues,
animal feed, waste, and food security.
• Sustainable farming including chemical and energy
use, biodiversity, organic production methods, and
diversity of foods produced.
• Fertiliser use – nitrate levels in food, pollution of
waterways, re-use of agricultural waste.
• Water – irrigation use and its impact on river/water-
table levels and production outputs.
• Pesticide usage and veterinary drugs– legal
requirements, best practice, consumer issues.
• Food packaging, preservation and safety, and
C. HOUSING
avoidance of long storage and travel.
Access to, and distribution of food
• Household food security – appropriate food being
available, with adequate access and being affordable
PFCM 1 VILLANUEVA, M.
(location of markets, supermarkets and closure of
small suppliers creating food deserts in cities).
• Food supplies, including national and regional food
security, and regional production.
• National food security – able to provide adequate
nutrition within a country without relying heavily on
imported products
• Cold-chain reliability – the safety of transporting
products that deteriorate microbiologically in the
heat.
Dietary patterns, diversity of food available and home
production, particularly:
• Fruit and vegetable consumption on reduced stroke,
heart disease and risk of certain cancers,
• Total, saturated and polyunsaturated fat,
carbohydrates and sugars consumption on obesity,
heart disease, stroke and other vascular diseases.
• Alcohol consumption and impact on social effects
related to behaviour (traffic accidents, work/home
accidents, violence, social relations, unwanted
pregnancy and STDs), and toxic effects (all-cause
mortality, alcoholism, certain cancers, liver cirrhosis,
psychosis, poisoning, gastritis, stroke, foetal alcohol
syndrome and others).
• Micronutrients such as iron, vitamin A, zinc and iodine
and their impact on deficiency syndromes.
Food safety and foodborne illness hazards
• Food and water are the major sources of exposure to
both chemical and biological hazards. They impose a
substantial health risk to consumers and economic
burdens on individuals, communities and nations.
• Microorganisms such as salmonella, campylobacter,
E. coli O157, listeria, cholera.
• Viruses such as hepatitis A, and parasites such as
trichomonosis in pigs and cattle.
• Naturally occuring toxins such as mycotoxins, marine
biotoxins and glycosides.
• Unconventional agents such as the agent causing
bovine spongiform encephalopathy (BSE, or "mad
cow disease"),
• Persistant organic pollutants such as dioxins and
PCBs. Metals such as lead and mercury.
• New foods developed from biotechnology such as
crops modified to resist pests, changes in animal
husbandry, antibiotic use and new food additives.
Evidence of health impacts focus on:
• Improvements in housing and improved mental
health and general health
• The possibility of improved housing leading to rent
rises, impacting negatively on health.
2 of 5
 PREVENTIVE MEDICINE
Determinants of Health and Disease [CEF Palaruan II, MD, MPH]

• Movement of original tenants after housing • Iron and steel

improvement and therefore not benefiting from the • Manufacture of rubber and plastic products
improvements. • Metal products
• Housing tenure, outdoor temperature, indoor air • Mining
quality, dampness, housing design, rent subsidies, • Pesticides, paints and pharmaceuticals
relocation, allergens and dust mites, home accident • Petroleum products
prevention, and fire prevention. • Pulp and paper
• Homelessness • Service industries
• Textiles and leather
• Wood and furniture

D. WASTE
G. URBANIZATION
Evidence of health impacts focuses on environmental and
social determinants related to: Evidence of health impacts focus on topics such as:
• the transmission of agents of infectious disease from • Urban housing problems
human and animal excreta (sanitation, hygiene and • City environment and non-communicable diseases
water-related); • Communicable diseases
• exposure to toxic chemicals in human and animal • Road trauma
excreta; and in industrial wastes discharged into the • Psychosocial disorders
environment; • Sustainable urban development
• environmental degradation, direct and indirect • Urban wastes
impacts on health; • Health services
• exposure to radioactive wastes;
• exposure to health-care wastes;
• exposure to solid wastes and involvement in informal
waste recycling; and III. DETERMINANTS OF HEALTH
• breeding of disease vectors.
• are classically categorized into behavioral factors,
impacts of the natural environment, genetic
determinants, and social determinants
E. ENERGY
• have acted, and interacted, within populations in
complex ways throughout history
Evidence of health impacts focus on health hazards such as:
• include disease prevention efforts and medical
• Fossil fuels
interventions, as well as genetic predispositions to
• Biomass fuels
disease and immunological naiveté
• Hydropower and their impact on vector borne
• Additional issues: population dynamics, and political
diseases, and pollution
and cultural factors, which can have a wide range of
• Electricity generation and transmission
impacts both health promoting and health damaging
• Nuclear power
• Other energy sources
For example:
• Occupational health effects of energy workers The European conquest of the Americas in the sixteenth century
• Impacts on ecosystems, agriculture, forests, fisheries decimated native American populations not just through subjugation
and building materials (social determinants), but also through land confiscation and
• Noise associated food insecurity (social and environmental determinants),
• Visual impact and the spread of infectious diseases— smallpox, measles and plague
• Global warming among them—that Europeans had developed moderate resistance to
over generations (biological determinants)

F. INDUSTRY
Cultural practices can make a population more or less
Evidence of health impacts focus on industrial sectors such as: susceptible to disease
• Asbestos and man-made fibers
• Basic chemicals  The wiping of an infant’s umbilical cord with dung can
• Cement, glass and ceramics raise the risk of tetanus and other infections
• Electronics
PFCM 1 VILLANUEVA, M. 3 of 5
 PREVENTIVE MEDICINE
Determinants of Health and Disease [CEF Palaruan II, MD, MPH]
• Use of lead-containing pigments in cosmetics and
medicaments can lead to anemia, nerve damage, and
other disorders
• Breastfeeding is a cultural practice that is health
protective, reducing the risk of diarrheal infections
and death among infants in particular
• Cultural practices on tobacco use and tobacco
restriction exert strong influences on population
health and well-being, and an improved cultural
understanding of tobacco use can provide new
opportunities for changing smoking behavior and
approaches to tobacco control
Economic conditions are major determinants of health
• Countries that experienced increasing prosperity
achieved better housing, reduced crowding,
improved water and food quality, and reduced
dangerous working conditions leading to reduced
rates of a multitude of diseases and have led to
dramatically increased lifespan and better health
• Increased affluence led to new population health
risks, such as increased consumption of calories and
salt associated with epidemics of obesity, diabetes,
and other chronic diseases across most of the
wealthier nations, as well as in the rising middle class
in certain low- and middle-income countries (LMICs)
• Poverty and resource limitations are associated with
unhealthy housing, deficient infrastructure,
malnutrition, and dangerous sweatshop working
conditions
• As economic conditions improve, opportunities arise
to invest in relatively inexpensive and widely
distributed public health interventions: the provision
and disinfection of water supplies, or the fortification
of foodstuffs—flour and other grain products being
most common—with micronutrients
• Reduction in unventilated cooking with solid fuels in
the home can reduce the risk of severe respiratory
disease, while chemicals can be regulated to reduce
exposures, and vehicular and building safety codes
enacted and enforced
IV. COMPLICATING FEATURES OF DETERMINANTS
D. DYNAMISM
• The common practice of expressing the relationship
between exposure and disease as a relative risk does
little to convey the complexities of the temporal
relationship between exposure and disease
• Time lags between exposure and disease, or disease
responses for which cumulative exposures are
required, have posed significant challenges to
PFCM 1 VILLANUEVA, M.
improving our understanding of important health
risks, such as indoor air pollution and cancer risk
assessment
• Health-damaging exposures themselves have
complex temporal characteristics, with specific time-
scales relevant to particular health outcomes—i.e.
cumulative long-term levels are most relevant to
some exposures, peak levels most relevant to others
• These exposures are experienced over a series of life
stages, and factors influencing growth and
development early in life can have dramatic
consequences for health in adulthood
• A life-course perspective highlights the importance of
considering the dynamic nature of health outcomes,
as insults during fetal, infant, and childhood
development—such as those stemming from
maternal and childhood undernutrition, childhood
infections, and certain environmental exposures—
can lead to susceptibility to multiple health outcomes
later in life
• There is increasing evidence that certain in utero and
early-life conditions of individuals and populations
can lead to both infectious and non-communicable
chronic diseases later in life
E. MULTI-SCALE
• The determinants of health operate at various scales
• Persons who are charged with promoting health—
both directly and indirectly—typically operate at the
scale of their training
• physicians and nurses work at a personal scale
• hospital administrators and health product
manufacturers at a more derivative scale
• ministers of health at a focused governance level
• elected officials develop and execute military,
industrial, agricultural or other policies with sweeping
and sometimes global consequences for health
• It is the role of health officials to assure that political
and institutional leaders at all levels understand
health determinants, which themselves span a wide
range of scales and domains
• Solutions to interconnected challenges, for example,
prevention of waste or contamination of drinking
water, can offer benefits across not just health
domains, but benefits for food and industrial
production, cost, and environmental savings
• Virtually all health challenges span scales ranging
from the molecular to the microscopic to the global.
• For example, transmission of Plasmodium spp.
malaria parasites is regulated by host factors (e.g.
immunological, nutritional, etc.), by the local
population prevalence and dynamics of mosquito
vectors, and by global factors such as climate change
that can influence the parasite’s spread across
regions and continents
4 of 5
 PREVENTIVE MEDICINE
Determinants of Health and Disease [CEF Palaruan II, MD, MPH]

• These scales are not equally valued by health

practitioners, who may, for instance, consult with
immunologists and microbiologists about the first and
second scales, and neglect the latter

F. CROSS-BOUNDARY
• Many key public health threats pose risks that
transcend international borders, such as risks
resulting from mobile atmospheric or aquatic
environmental pollutants, and those that stem from
global socioeconomic integration (e.g. increases in
global air transport, trade, and migration).
• Air pollutants are transported internationally and
intercontinentally and the consequences for public
health thus extend far from the site of emissions
• Dust from sources in Asia traverses the Pacific and has
reached surface locations in the United States in a
matter of days, and mercury emitted mainly from coal
combustion remains in the atmosphere for about a
year and poses a serious cross-boundary threat
• Greenhouse gases lead to global climate change no
matter where emissions occur, and thus the health
and economic consequences, are widely dispersed
across national and continental boundaries
• Tighter global economic integration has important
public health consequences:
• biofuel energy policies in established market
economies can have a nutritional impact in
developing countries when a portion of global
agricultural production is switched to biofuel
feedstocks
• effects of such a switch can yield rapid changes in
prices of global food staples, such as occurred in 2007
when average global grain prices rapidly increased in
part as a consequence of the expansion of biofuels to
meet national blending targets in the European
Union, United States, and other countries
• Increases in food prices, and other economic shocks,
can have major consequences for undernutrition

PFCM 1 VILLANUEVA, M. 5 of 5