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2.4 Social Determinants of Health and the Social Ecological Model
Social Determinants of Health
The World Health Organization describes the conditions in which people are born, grow, live, work and age as the social determinants of health (World Health Organization, 2018b). More broadly, they can be described as the non-medical influences that affect health, including both risk factors and protective factors. Numerous studies have shown that the health determinants with the most powerful and sustained influence on disease, illness, injury, disability, and premature death are social and economic factors (Graham, 2004; Marmot & Wilkinson, 2003). Social and economic factors can include transportation options, social support, access to health care services, public safety, education, and housing stability.
Our social circumstances and physical environment can have both positive and negative effects on our health and wellbeing in ways we may not be able to control. Our personal choices combined with these factors contribute to our overall health status.
People working in the field of public health who attempt to improve health for entire populations consider these social determinants of health in their decision-making. Changes made to environments, policies, services provided, and social circumstances can help change individual behaviors and encourage other protective factors.
Social Ecological Model
Work in public health at the population level often relies on application of aSocial Ecological Model, or SEM, which illustrates the multiple levels of factors influencing health behaviors. An ecological model is usually depicted showing concentric rings representing the factors influencing behavior. Each level is part of other levels in such a way that we cannot attribute behavior to any one specific category and that behavior can be influenced by changes applied at multiple levels.
To show the SEM in practice, let’s look at how it applies to physical activity:
Individual Level: A person’s engagement in physical activity is influenced by their beliefs and attitudes toward physical activity as well as their current skills and knowledge, age, physical ability, health status, sex, and gender.
Interpersonal Level: Physical activity in children is also related to parental engagement in physical activity as well as interactions with friends and physical education teachers. Competition-based activities related to physical activity might also motivate or demotivate an individual from participating in physical activity.
Organizational Level: The degree of importance placed on self-care by the organizations or institutions to which an individual belongs can influence physical activity. We might see this in the form of break time, access to equipment or spaces conducive to physical activity, or rewards for engaging in physical activity.
Community Level: At the community level, how normative engaging in physical activity is can influence an individual’s behaviors. Additionally, the walkability and safety of a neighborhood, and community- or school-based programming around physical activity can influence individual behavior.
Policy Level: Policies include physical activity requirements, national recommendations around physical activity, policies around park use, and funding around physical activity initiatives. This also includes land use and health care policies and incentives that surround physical activity. All of these policy-level factors can influence individual behavior.
In looking at factors within these categories we can better understand the multiple and interacting determinants of health behaviors. Public health professionals can attempt to develop approaches that systematically influence behavior change at each level of influence. Individuals can use the Social Ecological Model as a lens through which to view their own overall health and wellbeing and to provide perspective when it comes to the choices and experiences of others.
Example: Tobacco-use and the Social Ecological Model
See the social ecological model at work by considering various factors across the SEM influencing how Nic, a smoker, influences their likelihood of quitting smoking. Click on each icon in the interaction below to see examples on how the Social Ecological Model can apply to tobacco-use.
Self-Assess Your Understanding
Provide examples of social and economic factors which contribute to health disparities
Describe the levels of the Social Ecological Model
definition
the conditions in which people are born, grow, live, work and age
(SEM) a model which illustrates the multiple levels of factors influencing health behaviors, and includes individual, interpersonal, organizational, community, and policy.
