What is the difference between an internal and external variable impacting an individuals health

• What makes some people healthy and others unhealthy?
• How can we create a society in which everyone has a chance to live a long, healthy life?

Healthy People 2020 is exploring these questions by:

• Developing objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies.
• Emphasizing an ecological approach to disease prevention and health promotion. An ecological approach focuses on both individual-level and population-level determinants of health and interventions.

The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health.

Determinants of health fall under several broad categories:

It is the interrelationships among these factors that determine individual and population health. Because of this, interventions that target multiple determinants of health are most likely to be effective. Determinants of health reach beyond the boundaries of traditional health care and public health sectors; sectors such as education, housing, transportation, agriculture, and environment can be important allies in improving population health.

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Policymaking

Policies at the local, state, and federal level affect individual and population health. Increasing taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products.

Some policies affect entire populations over extended periods of time while simultaneously helping to change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn reduced rates of injuries and deaths from motor vehicle accidents.1

Social Factors

Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes.

Don’t miss the Social Determinants of Health topic area and objectives.

Examples of social determinants include:

• Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
• Social norms and attitudes, such as discrimination
• Exposure to crime, violence, and social disorder, such as the presence of trash
• Social support and social interactions
• Exposure to mass media and emerging technologies, such as the Internet or cell phones
• Socioeconomic conditions, such as concentrated poverty
• Quality schools
• Transportation options
• Public safety
• Residential segregation

Examples of physical determinants include:

• Natural environment, such as plants, weather, or climate change
• Built environment, such as buildings or transportation
• Worksites, schools, and recreational settings
• Housing, homes, and neighborhoods
• Exposure to toxic substances and other physical hazards
• Physical barriers, especially for people with disabilities
• Aesthetic elements, such as good lighting, trees, or benches

Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.

For example, millions of people in the United States live in places that have unhealthy levels of ozone or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of asthma in both adults and children compared with state and national averages. Poor air quality can worsen asthma symptoms, especially in children.2

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Health Services

Both access to health services and the quality of health services can impact health. Healthy People 2020 directly addresses access to health services as a topic area and incorporates quality of health services throughout a number of topic areas.

Lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.3

Don’t miss the Access to Health Services topic area and objectives.

Barriers to accessing health services include:

• Lack of availability
• High cost
• Lack of insurance coverage
• Limited language access

These barriers to accessing health services lead to:

• Unmet health needs
• Delays in receiving appropriate care
• Inability to get preventive services
• Hospitalizations that could have been prevented

Individual Behavior

Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking, his or her risk of developing heart disease is greatly reduced.

Many public health and health care interventions focus on changing individual behaviors such as substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the rates of chronic disease in this country.

Examples of individual behavior determinants of health include:

• Diet
• Physical activity
• Alcohol, cigarette, and other drug use
• Hand washing

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Biology and Genetics

Some biological and genetic factors affect specific populations more than others. For example, older adults are biologically prone to being in poorer health than adolescents due to the physical and cognitive effects of aging.

Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition that people inherit when both parents carry the gene for sickle cell. The gene is most common in people with ancestors from West African countries, Mediterranean countries, South or Central American countries, Caribbean islands, India, and Saudi Arabia.

Examples of biological and genetic social determinants of health include:

• Age
• Sex
• HIV status
• Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis
• Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer
• Family history of heart disease

References

1Centers for Disease Control and Prevention. Achievements in public health, 1900–1999 motor-vehicle safety: A 20th century public health achievement [Internet]. MMWR Weekly. 1999 May 14;48(18);369–74 [cited 2010 August 27]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm.

2State of the Air [Internet]. Washington, DC: American Lung Association. Available from: http://www.stateoftheair.org.

3Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report, 2008. Rockville (MD): U.S. Department of Health and Human Services, AHRQ; 2009 Mar. Pub no. 09-002. Available from: http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf [PDF – 2.6 MB].

Additional Resources

Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health [Internet]. Geneva: World Health Organization; 2008 [cited 2010 May 10]. Available from: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf [PDF – 4.3 MB].

Harris K, Holden C, Chen M. Background information on national indicators for social determinants of health. Paper presented to the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, National Opinion Research Center; January 5, 2010.

Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health. Washington, DC: National Academies Press; 2003.

U.S. Department of Health and Human Services. Draft report of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 on Social Determinants; revised 2009 Sep 9.

Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts [Internet]. 2nd ed. Copenhagen: World Health Organization; 2003 [cited 2010 May 26]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf [PDF – 470 KB].

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Characteristics of the study sample (N=921)