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What Determines Health?

The Health Promotion Glossary (WHO, 1998) defines determinants of health as:

The range of personal, social, economic and environmental factors which determine the health status of individuals or populations.

The factors which influence health are multiple and interactive. Health promotion is fundamentally concerned with action and advocacy to address the full range of potentially modifiable determinants of health – not only those which are related to the actions of individuals, such as health behaviours and lifestyles, but also factors such as income and social status, education, employment and working conditions, access to appropriate health services, and the physical environments. The Public Health Agency of Canada has identified 12 key determinants of health, including:

  • Income and Social Status
  • Social Support Networks
  • Education and Literacy
  • Employment/Working Conditions
  • Social Environments
  • Physical Environments
  • Personal Health Practices and Coping Skills
  • Healthy Child Development
  • Biology and Genetic Endowment
  • Health Services
  • Gender
  • Culture


What are the Social Determinants of Health?

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.

PDF Cover - the Social Determinants of Health: The Canadian Facts

Social Determinants of Health: The Canadian Facts (Mikkonnen & Raphael, 2010) considers 14 social determinants of health:

  • Income and Income Distribution
  • Education
  • Unemployment and Job Security
  • Employment and Working Conditions
  • Early Childhood Development
  • Food Insecurity
  • Housing
  • Social Exclusion
  • Social Safety Network
  • Health Services
  • Aboriginal Status
  • Gender
  • Race
  • Disability


Health Nexus and the Ontario Chronic Disease Prevention Alliance (2008) have produced a useful resource titled Primer to Action: Social Determinants of Health as a starting point to get people thinking and acting about the social determinants of health and chronic disease. Acknowledging that their list is not exhaustive, the Primer focuses on six of the key social determinants of health: income, education, employment, housing, food, and inclusion.


We need money to help us secure housing, food, clothing, transportation, cultural and recreational opportunities and all the other things we need for a healthy life in society. Adequate income creates opportunities for positive life chances, including healthy choices. How evenly wealth is distributed throughout a country also has a significant influence on how healthy its overall population will be. Studies have demonstrated that where there is a larger income divide between the richest and poorest in a country, there is a higher incidence of disease and a lower average life expectancy for all. Inadequate income has profound effects on those who live in urban areas, but also those who live in rural areas.


Education is seen universally as a necessary condition for personal and societal success. The knowledge of how to live a healthy life is not something we are born with. According to the Canadian Public Health Association, in Canada, 60% of adults lack the capacity to read, understand and act upon health information and services in order to make appropriate health decisions for themselves and their families. In addition, a lack of education often makes it difficult to gain a good standard of employment and financial stability.


A satisfying job can provide a sense of self-worth and engagement that gives people a feeling of control over their lives, and this kind of control has been shown to have a positive effect on health. The more security and choices people have, the more they feel prepared to deal with the biological and social stresses they encounter in their lives. The connection between employment and health is particularly evident when examining the effects of unemployment or job loss on society. Increased rates of depression, anxiety and substance abuse make those without a steady income far more susceptible to developing disease and chronic health problems.

Affordable housing

Our homes must be clean, warm and secure – the absence of these qualities in substandard housing – or no housing – leads directly to illness and poor health. One of the main reasons low-income families are often unable to eat a healthy diet is because they often have to spend much of their monthly income on housing.

Food security

We need healthful, nutritious food to lead productive lives and reach our full potential, however, this is not the reality for many people. Food insecurity is closely linked to income. Studies have shown that people in low-income neighbourhoods have less access to grocery stores and fresh foods and more access to fast-food restaurants. For low-income families, the cost of food represents a larger chunk of the household budget than it does for those with higher incomes. Those groups most likely to be affected by low incomes in Canada include Aboriginal people, single mothers and their children, persons with disabilities, recent immigrants and those who have not completed high school.


The need for social and economic inclusion is a common theme that runs through all of the social determinants. Inclusion is a sense of belonging – to our families, our places of work, and our cultural and community groups–that helps us feel connected to society as a whole and engaged in our lives and the lives of those around us. Inclusion can be a way of addressing the systemic ways in which different groups and communities face exclusion and marginalization in society, and therefore, poorer health outcomes. This is particularly true for those who live on low incomes and lack the advantages that wealthier people take for granted.