2.1 The social and structural determinants of health

The social determinants of health (SDHs) are ‘the conditions in which people are born, grow, live, work and age’, including their positions in hierarchies of power and the money and resources available to them (WHO, 2024a). These include specific factors such as:

  • income levels
  • access to social protection
  • education level and opportunity
  • job security and working conditions
  • food security/insecurity
  • access to safe housing
  • exposure to harmful environmental factors
  • experiences of early childhood development
  • stigma and discrimination
  • exposure to violent conflict
  • access to affordable health services.

These are in turn influenced by broader socioeconomic, political and cultural factors, known as the structural determinants of health, which include:

  • race
  • gender
  • ethnicity
  • age
  • sexuality
  • class
  • disability.

Together, these factors intersect and overlap to produce an unequal distribution of health-damaging or facilitating experiences.

The interrelationships between these social factors, and their influence on health, is illustrated in the Dahlgren-Whitehead ‘rainbow’ model (1991) shown in Figure 2.

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Figure 2 The Dahlgren-Whitehead rainbow.
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At the centre of a series of concentric semi-circles is a group of people with the label ‘Age, sex and constitutional factors’. The second semi-circle is labelled ‘Individual lifestyle factors’. The third semi-circle is labelled ‘Social and community networks’. The fourth semi-circle is labelled ‘Agriculture and food production’, ‘Education’, ‘Work environment’, ‘Living and working conditions’, ‘Unemployment’, ‘Water and sanitation’, ‘Healthcare services’ and ‘Housing’. The fifth and final semi-circle is labelled ‘General socioeconomic, cultural and environmental conditions’.

Figure 2 The Dahlgren-Whitehead rainbow.

  • Now that you have seen the Dahlgren-Whitehead rainbow, can you add any factors that influence your health to your list from Activity 2? Can you match the factors that you have noted to the different parts of the rainbow?

  • The Dahlgren-Whitehead rainbow model places individuals at the centre, with layers of influences on health surrounding them, such as individual lifestyle factors, community influences, living and working conditions, and more general social conditions.

Activity 3 explores some of the structural determinants of health further.

Activity 3: Exploring structural determinants of health

Timing: Allow about 30 minutes

Video 1 is about structural determinants of health. As you watch, think about the following questions:

  1. Think of an example of a structural determinant of health from your country context. How can it impact health equity?
  2. What health system actions or policy actions might address inequities in your context?
  3. How might gender affect some of the specific factors mentioned in Video 1?
Video 1 Understanding structural determinants of health (Let’s Learn Public Health, 2017).
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Discussion

  1. Structural determinants of health can include unequal land rights and access to housing, inequitable education systems, and health systems that do not cover migrant communities or those living in informal settlements.
  2. Think about actions that cut across sectors, including health, housing, food and land rights.
  3. Gender can affect a number of structural determinants of health at multiple levels, including socioeconomic position, ease of accessing a health service and occupation and associated health risk factors.

In summary, prioritising health equity is a basic human right and matter of social justice. A biosocial view of healthcare considers how social factors create unequal health experiences and outcomes and supports the design of interventions and solutions to address the root causes of illness. These SDHs are important because they improve our understanding of the conditions that create unequal health outcomes and experiences. They highlight that these unequal outcomes are largely avoidable if the root causes are addressed.

Optionally, you may like to watch Sir Micheal Marmot discussing the importance of SDHs in social justice (American Public Health Association, 2016).

Later in this course you will explore how SDHs can impact the drivers of AMR, but first you will be introduced to gender as a social determinant of health.

2 A biosocial approach to health

3 Introduction to gender as a social determinant of health