Determinants of Health Model

The determinants of health model is a hypothetical construct for understanding population health and the multiple range of factors that determine its level. In a broad sense, the determinants of health model is the most recent and comprehensive explanatory attempt to understand causality in epidemiology and its translation into policy intervention, from both the population and societal perspectives; therefore, the model is particularly relevant to public health research and practice. The current determinants of health model is firmly rooted in the eco-epidemiology paradigm, insofar as it recognizes causes of health—and ‘causes-ofcauses,’ that is, their determinants—at multiple levels of organization and within the historical context of both societies and individuals. Those levels of organization span from the microlevel, downstream, or proximate causes to the macrolevel, upstream, or distal causes of population health and have, as a chief model feature, the multilevel interaction among causes.

Determinants of health are all those factors, whether events, characteristics, or other definable entities that, directly or indirectly, exert an influence on the health of individuals and, by means of their action and interactions among different levels of organization, determine the given status of the health of the population. The understanding of the determinants of the population's health and their complex causal patterns has been originally shaped, and continue to be shaped, by contemporary debates—as well as their historical [Page 264]circumstances—about medical care or curative medicine and health policy, and then by the unremitting need to reexamine and reorient the social debate to better define and put in place the type and scope of reforms that would help improve the health of the population.

Over the course of the second half of the past century, there have been several significant shifts in perspective, each of them associated with correspondingly different models of health determinants. A major motivation for this search for a better health determinants model has been the growing need to define a population health approach, vis-a-vis the emergent understanding that the determinants of health are much broader than the medical care system itself. This evolving thinking can be regarded as a consequence of the recognition of, on the one hand, the unsuitability of the dominant biomedical perspective to guide health policy toward the equitable improvement of a democratic nation's health status and, on the other hand, that approaching health from a population perspective commits a nation to understanding and acting on the full array of factors that determine health.

Marc Lalonde's 1974 report on a new perspective on the health of the population in Canada signaled the emergence of the modern era of health promotion by advancing a more comprehensive conceptual framework for health situation analysis and advocating the role of preventive approaches in national health policy. Under this model, health determinants were deemed as pertaining to four dimensions, or so-called health fields: human biology, environment, lifestyle, and health care organization. The report expressed a widely shared view that health determinants go beyond the individual level and, more specifically, that health was not attainable for the majority of the population through a concentration of public health funds on personal services. Fueled by the prominent risk-factor epidemiology paradigm, however, the emphasis was rapidly placed on the role of personal behavioral choices or individual lifestyles in determining health status.

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