Determinants of Health

Determinants of Health
Current definitions of health emphasize that health is more than the absence of disease. Health is a state of wellness that hinges on proper function in a variety of dimensions. For example, good health is achieved only when there is a balance between health determinants: personal, social, economic, and environmental. These various factors that impact wellness must be addressed at multiple levels—individual, community, national, international—to ensure population level health. Blum pioneered a “force field” paradigm that posits that population health is directly impacted by four forces: environment, lifestyle, hereditary, and medical care. Dahlgren and Whitehead grouped the determinants of health into fixed factors, such as age and gender; and modifiable factors, such as behavior and access to products.
The most important movement to date is Healthy People 2020. This initiative aims to address questions about what makes some individuals healthy in comparison to others as well as how we can create a healthy society where there is an equal opportunity to be healthy. It is a national agenda to promote health groups, the determinants of health, into the following categories: biology and genetics, individual behavior, health services, social factors, and policy making. The interplay between these different factors is what determines our health at the individual and population levels. Throughout this course, we will focus on policy making at the local, state, and federal levels as well as the impact of policies on individual and population level health.

Biology and Genetics
Biological or genetic factors, such as age, sex, family history, and inherited conditions, impact risk of illness for certain populations. For example, consider the prevalence of dementia in older adults versus young adults or sickle cell disease in West Africans versus Scandinavians.
Individual Behavior
Individual behaviors such as alcohol or tobacco consumption, diet, and activity patterns impact risk of illness. For example, diets high in saturated fats or sedentary lifestyle often result in chronic conditions such as obesity, heart disease, and diabetes.
Health Services
Health services such as routine care and dental exams are important to maintaining health. Limited availability, high cost, and poor language support can result in delayed care and complications due to preventable chronic conditions.
Social Factors
Social factors include social and physical determinants of health, such as social norms, exposure to violence, educational opportunities, and residential segregation, as well as natural environment, transportation, and physical limitations.
Policy Making
Public policies are created at the local, state, and federal levels and can impact health and safety. For example, consider high taxes on tobacco products or the mandate to wear seat belts in moving vehicles.

Health Policy Making
Policies can be created in the private sector (for organizations and industries) or in the public sector (governmental) to guide decision-making processes. While both types of policies, private and public, can certainly impact health status, the focus of this course will be on public policy. Public policy is defined as the government activities that influence citizen lives. This includes the law, regulation, orders, decisions, etc. made by political leaders to promote social welfare. All three branches of our government are involved in making policies; the legislative branch is responsible for formulating appropriate public policies, the executive branch works to implement them, and the judicial branch interprets policy decisions if clarification or revision is needed.
Health policies are the public policies that specifically influence or impact health. There is a great deal of contention involved in the development of health policy as there are differing opinions on whether health should be viewed as a right or a privilege. But, while visions of a quality healthcare system are numerous, many can agree that healthcare requires access and affordability, as well as information exchange, which are important factors for consideration. The Patient Protection and Affordable Care Act (ACA) proposes an improved healthcare policy; however, implementation and enforcement of such a policy are proving difficult. Only time will tell if this “grand experiment” is successful.
The Process of Health Policy Making

Identify
Issues are often identified through public advocacy, crisis scenarios, and lobbying efforts. Due to limited resources and emergencies, the prioritization of problems changes frequently. What is deemed important today may quickly be replaced with changing social and political perspectives.
Formulate
Policy formulation encompasses the process of solution generation to policy issues. Solutions to current problems must be innovative. Also, competing agendas that support opposing policy objectives can significantly inhibit progress.

Adopt
Policies are adopted when there is sufficient evidence to support need and realistic, feasible recommendations that can be implemented at a later date. The media plays a large role in this process and bears the responsibility of a fair, impartial commentary.
Implement
The implementation segment moves a policy solution from a conceptual phase to reality; that is, policy implementation requires resource commitment and integration across agencies. Resistance to change can often be a significant challenge to successful policy implementation.

Evaluate
Once policies are implemented, they must be evaluated or assessed. This is a difficult task, though, as policies often have broad goals and multiple objectives that may or may not be accomplished in the same time and/or are subject to interpretation.

Regulatory vs. Allocative Health Policies
Regardless of their form, policies may be categorized as allocative or regulatory in nature. Allocative policies typically provide net benefits to a certain distinct group of actors at the expense of others in order to meet public objectives. For example, medical education is heavily subsidized by the government in order to prevent undersupply of physicians. Regulatory policies are designed to influence action, behaviors, and decisions of actors within a sector. Regulatory health policies include market-entry restrictions, rate or price setting controls on health service providers, quality controls on the provision of health services, market-preserving controls, and social regulation. The role of the federal government of the United States in health policy making is similar to any other policy making approach. The executive branch, under the president of the United States, implements and enforces laws written by the Congress.
Regulatory vs. Allocative Health Policies

The Department of Health and Human Services (HHS) is one of the fifteen executive departments and is the principal agency responsible for protecting the health of Americans. Health and social science research, disease outbreak prevention, food and drug safety, and health insurance provision come under the purview of HHS agencies. State governments, within the context of their own constitution and bill of rights, are structured similar to the federal government, operating within the state boundaries. States have constitutional authority to establish laws that protect public health and welfare. Furthermore, states, as purchasers of healthcare services, act as regulators, safety net providers, educators, as well as laboratories for experimentation with new policy. In the United States, health policy making is driven by “demanders” of policies. The most effective constituency of demanders seems to be well organized interest groups that are able to exert maximum influence on health policies.