What are the Determinants of Health?

Many factors contribute to the health of individuals and the communities in which they reside, some of
which are modifiable to promote increased health and wellness. These determining factors are
influenced by a combination of influences such as genetics, circumstances, and environment. Most
characteristics of a society and its infrastructure can, in turn, affect the corresponding health of its
citizens. This article discusses these determinants of health in detail and offers additional links to more
in-depth resources including case studies, tools, and articles.
 Background
 Income & Social Status
 Social Support Network
 Education & Literacy
 Employment & Working Conditions
 Social Environment
 Physical Environment
 Personal Health Practices & Coping Skills
 Healthy Child Development
 Biology & Genetic Endowment
 Health Services
 Gender
 Culture
There are many factors that affect the health of individuals and the communities in which they live. The
health of people is determined by numerous interrelated factors including lifestyle, circumstances and
environment. Some determinants can be influenced, while others are more difficult to control. Some
scholars categorize determinants of health into social versus other factors.

The Determinants of Health Include:

Income and Social Status

Higher income and social status are linked to improved health status. These two factors may be
the most important determinants of health. The greater the gap between the richest and the
poorest people in an area, the greater the disparities in their health.

Social Support Network

Greater support from families, friends, and communities is linked to better health for individuals.
Social support is a source of emotional reassurance and provides a safe place for a person to
discuss their problems, which can help them to cope with adversity. Social networks provide
information and practical support, such as knowing someone who can assist in a time of need. It
can also support people in making healthier behavior choices.

Education and Literacy

Health status improves with a person’s level of education. Education both contributes to and is a
result of social position. Education influences social position in various ways; each of the factors
indirectly influences a person’s health. Education contributes to health and prosperity by
equipping people with knowledge and skills for problem-solving, and helps provide a sense of
control and mastery over life circumstances. It increases opportunities for job and income
security, and job satisfaction. It also improves people's ability to access and understand
information to help keep them healthy.

Employment/Working Conditions

Unemployment, underemployment, stressful or unsafe work is associated with poorer

health. People who have more control over their work circumstances and fewer stress-related
demands on the job are healthier and often live longer than those engaged in more stressful or
riskier work and activities.

Social Environment

The importance of social support also extends to the broader community. Social or community
responses can add resources to an individuals’ repertoire of strategies to cope with changes and
foster good health. The array of values and norms of a society influence in varying ways the
health and well-being of both individuals and populations.

Physical Environment

Factors related to housing, air quality, water quality, safe houses, and transportation systems all
contribute to health. Environmental influences on health can be positive or negative, and range
from global, to national and/or regional issues, to the local built environment, to the social
environment.

Personal Health Practices and Coping Skills

Individuals can prevent diseases, promote self-care and make choices that enhance health.
Lifestyle includes not only individual choices, but also the influence of social, economic, and
environmental factors on the decisions people make about their health. Personal life “choices”
are influenced by the socioeconomic environments in which people live, learn, work and play.
Further reading is available on changing patient behaviour. The Life Expectancy Calculator may
be a useful tool for clinicians in helping patients understands some of the factors within their
control to improve health status (e.g. smoking, alcohol consumption, physical activity, etc).

Healthy Child Development

Early childhood development is a determinant of health later in life. Other determinants of health
in turn also affect the development of children. Determining the inclusion or exclusion, content,
and frequency of a wide variety of preventive health interventions that is particularly useful
during childhood (but covers the entire lifespan) is made useful

Biology and Genetic Endowment

The basic biology and organic makeup of the human body is a fundamental determinant of
health. Genetic inheritance provides pre-disposition to a wide range of individual responses that
can affect health status throughout the lifespan.

Health Services

Access and use of services that promote health and prevent disease influence health. Simple
measures, such as protecting water supplies, often have the greatest impact on overall health.
Examining high-use populations in terms of health care utilization can be an effective way to
target interventions tailored to specific groups such as those with multiple co-morbidities.

Gender

Gender refers to the societal characteristics that society ascribes to the two sexes.
Gendered norms influence the health system's practices and priorities. Gender inequities do not
only result from income disparities; gender is also linked to differential access to health services,
to unequal obligations to provide unpaid family care duties, and to disparities in nutrition. More
on the extent to which gender influences health outcomes, morbidity and utilization patterns can
be found in a presentation entitled Sex, Gender, and Health.

Culture

The customs, traditions, and the beliefs of the family and community all affect health. A person’s
cultural background has an influence on their beliefs, behaviors, perceptions, emotions,
language, diet, body image, and attitudes to illness, pain, and misfortune. All of these factors can
influence health and the use of healthcare services.

Leading Health Indicators

The Leading Health Indicators are a select subset of 26 Healthy People 2020 objectives across 12
topics:

Access to Health ServicesExternal

 Persons with medical insurance

 Persons with a usual primary care provider

Clinical Preventive ServicesExternal

 Adults receiving colorectal cancer screening based on the most recent guidelines
 Adults with hypertension whose blood pressure is under control
 Persons with diagnosed diabetes whose A1c value is greater than 9%
 Children receiving the recommended doses of DTaP, polio, MMR, Hib, HepB, varicella
and PCV vaccines by age 19–35 months

Environmental QualityExternal

 Air Quality Index >100

 Children exposed to secondhand smoke

Injury and Violence

 Injury deaths
 Homicides

Maternal Infant and Child HealthExternal

 All Infant deaths

 Total preterm live births

Mental HealthExternal

 Suicide
 Adolescents with a major depressive episode in the past 12 months

Nutrition, Physical Activity, and ObesityExternal

 Adults meeting aerobic physical activity and muscle-strengthening objectives

 Obesity among adults
 Obesity among children and adolescents
 Mean daily intake of total vegetables

Oral HealthExternal

 Children, adolescents, and adults who visited the dentist in the past year

Reproductive and Sexual HealthExternal

  Sexually active females receiving reproductive health services
 Knowledge of serostatus among HIV-positive persons

Social DeterminantsExternal

 Students graduating from high school 4 years after starting 9th grade

Substance AbuseExternal

 Adolescents using alcohol or illicit drugs in past 30 days

 Binge drinking in past month—Adults

TobaccoExternal

 Adult cigarette smoking

 Adolescent cigarette smoking in past 30 days

These objectives were chosen to communicate high-priority health issues and challenges. They
address determinants of health that promote quality of life, healthy behaviors, and healthy
development across all life stages. The indicators are used to assess the health of the country,
facilitate collaboration across sectors, and motivate action to improve health at the national, state,
and community levels.

The Leading Health Indicators were selected and organized using a “Health Determinants and
Health Outcomes by Life Stages” conceptual framework. This approach was intended to draw
attention to both individual and societal determinants that affect the public’s health and
contribute to health disparities from infancy through old age, thereby highlighting strategic
opportunities to promote health and improve quality of life for all Americans. The selection
process was led by the Healthy People 2020 Federal Interagency Workgroup (FIW). In selecting
the indicators, the FIW took into consideration recommendations from the Institute of Medicine
of the National Academy of Sciences and the Secretary’s Advisory Committee on National
Health Promotion and Disease Prevention Objectives for 2020.

Environmental Health
"Many communities lack access to nutritious, affordable food; are denied safe places to walk
and exercise; or live near polluting factories. The health risks for these families are greater. We
support research and action to help ensure healthy environments for all."
Environmental health is the branch of public health that: focuses on the relationships between
people and their environment; promotes human health and well-being; and fosters healthy and
safe communities. Environmental health is a key part of any comprehensive public health
system. The field works to advance policies and programs to reduce chemical and other
environmental exposures in air, water, soil and food to protect people and provide communities
with healthier environments.

Public health is defined as the science of protecting the safety and improving the health of
communities through education, policy making and research for disease and injury prevention.
The definition of public health is different for every person.
 Environmental health is the branch of public health that is concerned with all aspects of the
natural and built environment that may affect human health. Health is the science, practice, and
study of a human's well-being and their health and preventing illnesses and human injuries.

Principles Of Health Education

Principles:

1. Credibility
2. Interest
3. Participation
4. Motivation
5. Comprehension
6. Reinforcement
7. Learning by doing
8. Known to unknown
9. Setting an example
10. Good human relations
11. Feedback
12. Leaders
Credibility

1. It is the degree to which the message to be communicated is perceived as

trustworthy by the receiver
2. Good health education must be consistent and compatible with scientific knowledge
and also with the local culture, educational system and social goals
Interest

1. Health teaching should be related to the interests of the people

2. Health programme should be based on the “FELT NEEDS”, so that it becomes
“people’s programme
3. Felt needs are the real health needs of the people, that is needs the people feel
about themselves
Participation

1. A high degree of participation tends to create a sense of involvement, personal

acceptance and decision –making
2. It provides maximum feedback
3. The Alma- Ata Declaration states “The people have a right and duty to participate
individually and collectively in the planning and implementation of their health care”
4. Health programmers are unlikely to succeed if community participation is not an
integral part
Motivation

1. In every person, there is a fundamental desire to learn. Awakening this desire is

called motivation
2. Two types of motives
1. primary motives-are driving forces initiating people into action
2. secondary motives –are created by outside forces or incentives
3. Need for incentives is a first step in learning to change
4. Incentives may be positive or negative
5. Main aim of motivation is to change behavior
6. Motivation is contagious: one motivated person may spread motivation throughout
a group
Comprehension

1. Health educator must know the level of understanding, education and literacy of
people to whom the teaching is directed
2. Always communicate in the language people understand .
3. Teaching should be within the mental capacity of the audience.
Reinforcement

1. Repetition of message at intervals is necessary

2. If the message is repeated in different ways, people are more likely to remember it.
Learning by doing

1. The importance of learning by doing can be best illustrated by the Chinese proverb
“if I hear, I forget; if I see, I remember; if I do, I know”
Known to unknown

We must proceed

 “from the concrete to the abstract”

 “from the particular to the general”
 “from the simple to the more complicated”
 “from the easy to more difficult”
 “from the known to unknown”
Here health communicator uses the existing knowledge of the people as pegs on which to
hang new knowledge

Feedback

1. The health educator can modify the elements of the system (e.g., message,
channels) in the light of feedback from his audience
2. For effective communication, feedback is of paramount importance.
Leaders

 Leaders are agents of change and they can be made use of in health education
work.
 The attributes of a leader are;
 He understands the needs and demands of the community
 Provides proper guidance, takes the initiative, is receptive to the views and
suggestions of the people;
 Identifies himself with the community;
 Selfless, honest, impartial, considerate and sincere;
 Easily accessible to the people;
 Able to control and compromise the various factors in the community;
 Possesses the requisite skill and knowledge of eliciting cooperation and
achieving coordination of the various official and non-official organizations.
HEALTH EDUCATION STRATEGIES IN INDIA

Overview
India like most rapidly growing economies is facing a looming threat of noncommunicable
diseases. NCDs have reached an epidemic proportion in India, largely due to globalization,
industrialization, and rapid urbanization with demographic and lifestyle changes. The epidemic
of NCDs cannot be halted by simply treating the sick, but also the healthy persons have to be
protected by addressing the root causes. Reducing the major risk factors for NCDs by active
health promotion activities particularly with young people as visualized in Government’s recent
initiative of Health & Wellness Centers under Ayushman Bharat is one of the key focus of VHAI
for next two decades.

Our Action Agenda for the year 2015-2025

Current Work
At National Level

Safe & Nutritious Food @ Schools: VHAI is an implementing partner in Safe & Nutritious
Food @ Schools – an initiative by Food Safety & Security Authority of India (FSSAI). Safe and
Nutritious Food at School’ is a nation-wide campaign to help school children inculcate the habit
of eating safe and right food. The Yellow Book has been developed to help children learn about
safe and wholesome food in a fun and interactive way, through curricular and extracurricular
activities. VHAI is actively supporting FSSAI’s in creating awareness among the students on
eating healthy and safe food.

National Technical Working Group on School Health Curriculum under

Ayushman Bharat: VHAI is a member of National Committee on School Health under
Ayushman Bharat. VHAI has played a significant role in development of school health
curriculum by sharing experiences of its work on School Health at the grass root level.

Nasha Mukti Abhiyan: VHAI is an active member of the task force on Nasha Mukti Abhiyan
set up by Ministry of Health & Family Welfare, Government of India.

At Grass-root Level

School Health Promotion Programme

Establishing healthy behaviour during childhood is easier and more effective than trying to
change unhealthy behaviour during adulthood. Children spend about 6 hours in the classroom
every day for up to 13 years which are also the most formative years of their lives. School in
partnership with parents and communities can be powerful agents to promote health and prevent
disease.

The basic objective of the School Health Promotion Programme is to create awareness and
inculcate healthy habits among school going children. And to ensure that children take these
health messages and practices to their home, share it with their peer groups, neighbourhood and
wider community. They become an agent of change in the society.

Key Activities:

 Baseline assessment of the schools

 Formation and training of new school health management committee (SHMC) on various issues
such as personal hygiene, healthy eating, physical activity, harmful effects of health destroying
products

 Strengthening of already formed School Health Management Committee

 Distribution of IEC materials such as leaflets and posters in the local language

 Supply of essential materials such as first aid kits, dustbins, hand soaps, cleaners and dusters

 Organizing competitions on health topics like Green Diwali- Rangoli, poster competition on
personal hygiene, road safety and healthy eating; Healthy cooking etc.

 Nukkad Natak (street plays) on various issues such as unhealthy food and drug addiction

 Regular health check-ups in collaboration with Rashtriya Bal Swasthya Karyakram (RBSK)
doctors in few areas.

Workshops on Health and Wellbeing

In a vast multifaceted country like India, making a permanent impact on the health and
development scene, particularly to help the vulnerable people, requires a sophisticated and
dynamic understanding of the changing development panorama so that the response is prompt
and creative. In many ways, VHAI has fulfilled this demand in the past. Perhaps the situation is
getting further complicated with the direct impact of globalization and COVID-19
pandemic. Learnings from COVID-19 pandemic have further reinforced our agenda.
Based on the past experience, VHAI organized a pan India participatory workshop with an
agenda to evolve clear strategies for future action by VHAI and State VHAs on Health
Promotion. The workshop was based on three pillars- Health Promotion, Self-Care for Health
and Social Determinants of Health including entitlements. In a two half-day online sessions, with
active participation of State VHAs, a future roadmap of Health & Wellbeing and its integration
with our ongoing work on the ground was derived. The workshop broadly covered three
modules. Module 1: Concept of Health Promotion and Approach, Module 2: Self-care for Health
and Disease Prevention and Module 3: Social Determinants of Health including social and
economic entitlements for economically disadvantaged groups.

The National workshop was conducted virtually which had a participation of over 40 Executive
Directors from State VHAs followed by a region-wise virtual workshop which was conducted in
4 phases for North India ( including Jammu &Kashmir, Himachal Pradesh, Punjab, Delhi and
Uttar Pradesh) East India (including Bihar, West Bengal, Jharkhand and Odisha), South India
(including Tamil Nadu, Andhra Pradesh, Telangana and Kerala) and North-East India (including
Assam, Arunachal Pradesh, Manipur, Nagaland and Meghalaya). These series of online sessions
witnessed an active participation of over 50 participants from state VHAs and partner
organizations across the states for each session. The workshop entailed discussions on state level
experiences on health promotion, gender empowerment & women rights, supporting &
strengthening food & nutrition security, effective strategies for advocacy, immunization as
specific protection against diseases and Indian system of medicine & self-care which were
comprehensively covered by the eminent speakers.

What is National Health Policy?

National Health Policy was launched in 2017 by the Central Government to replace the existing
health policy. This policy has introduced four significant goals:

1. Changing health priorities

This policy aims to tackle the increasing non-communicable and infectious diseases in
India.

2. Growth of the health care industry

National Health Policy plans to strengthen the health care industry by introducing newer
and more advanced technologies.

3. Lower the expenditure

This policy also aims to reduce medical expenses and other health-related costs. They
aim to provide superior services to poor and backward communities.
 4. Economic growth

It aims to enhance fiscal capacity by boosting economic growth.

What are the Objectives of National Health Policy?

The National Health Policy aims to achieve the following goals:

 It aims to offer superior health services to every age group and gender.
 The policy focuses on providing universal access to excellent quality health care services
at a reasonable cost.
 Promoting health care orientation in every developmental policy.
 Offering access to better treatment, lowering expenses related to health care services and
improving quality.
 It aims to reduce premature mortality from cancer, cardiovascular diseases, chronic
respiratory diseases and diabetes by 25% within 2025.
 This policy recognises the importance of sustainable development and time-bound
quantitative goals.
 National Health Policy in India improves overall health status through promotive,
palliative, and rehabilitative services.

What are the Key Principles of the National Health Policy?

The following are the fundamental principles of the National Health Policy 2017.

 Professionalism and ethics

National Health Policy commits to integrity, highest professional standards and ethics. It
integrates these functions in health care delivery services by maintaining transparency and a
sustainable environment.

 Equity

This policy aims to reduce the inequity and disparity based on caste, gender, disability, poverty
and other forms of social exclusions. This also includes offering financial protection to poor and
underprivileged patients.

 Affordability

The policy aims to make health services and medicine affordable. It seeks to prevent disparity in
social, economic or current health status.

 Quality of care
This initiative offers confidentiality in the form of safe, gender-sensitive and convenient
healthcare services. It intends to remove corruption in both private and public healthcare
systems.

 Collaborations

It follows a multistakeholder approach by collaborating with health ministries and communities.

Different academic institutions and non-profit agencies also participate in the initiative.

 Pluralism

Beneficiaries will enjoy features of AYUSH and community-based health facilities.

National Institute of Nutrition (NIN) was founded by Sir Robert McCarrison in

the year 1918 as ‘Beri-Beri’ Enquiry Unit in a single room laboratory at the Pasteur Institute,
Coonoor, Tamil Nadu. Within a short span of seven years, this unit blossomed into a "Deficiency
Disease Enquiry" and later in 1928, emerged as full-fledged "Nutrition Research Laboratories"
(NRL) with Dr. McCarrison as its first Director. It was shifted to Hyderabad in [Link] the time
of its golden jubilee in 1969, it was renamed as National Institute of Nutrition (NIN).

The stepping stones

NIN has attained global recognition for its pioneering studies on various aspects of nutrition
research, with special reference to protein energy malnutrition (PEM). Institute’s activities are
broad-based, encompassing the whole area of food and nutrition. The Institute has achieved close
integration in its research activities between the laboratory, the clinic and the community.

The emphasis shifted to problem-oriented research, with a view to discovering practical solutions
to nutrition problems that can be applied within the existing socio-economic framework.
National Institute of Nutrition, over the Century years of glorious service to the nation, has to its
credit an impressive record of achievements in the amelioration of several nutritional disorders
of our people.

Location – a landmark

The Institute is located on the salubrious campus of Osmania University with spacious buildings
surrounded by lush green vegetation. The Institute's strength lies in the dedicated and devoted
scientists belonging to diverse disciplines such as medicine, pediatrics, obstetrics and
gynecology, biochemistry, pathology, community health, social sciences, dietetics, statistics,
communication and other related areas.
The Institute has been recognized by many national and international agencies as Centre for
conducting advanced as well as ad-hoc training courses in nutrition and laboratory animal
sciences. In addition, several reputed universities have recognized NIN as a Centre for Ph.D
programmes in different disciplines.
It possesses sophisticated equipment and swell-equipped modern facilities and for clinical,
laboratory and community based research. Nutrition Wards with adequate inpatient and
outpatient facilities are available at hospitals viz., Niloufer Hospital for Women and Children,
Government Maternity Hospital and Osmania General Hospital to carry out research in clinical
nutrition.

The Institute's library, well stocked with books and journals is considered as one of the best
science libraries in India. In addition, computer facilities are available for sophisticated data
analysis and information retrieval from database.
The "Nutrition Museum" of the institute is an important teaching tool which highlights different
aspects of food and nutrition and also covers the work undertaken at the Institute.
Objectives

1. To identify various dietary and nutrition problems prevalent among different segments of
the population in the country.

2. To continuously monitor diet and nutrition situation of the country.

3. To evolve effective methods of management and prevention of nutritional problems.

4. To conduct operational research connected with planning and implementation of national

nutrition programmes.

5. To dovetail nutrition research with other health programmes of the government.

6. Human resource development in the field of nutrition.

7. To disseminate nutrition information.

8. To advise governments and other organisations on issues relating to nutrition

What We Do ?
Provide Evidence

Evidence based inputs on food and nutrient consumption patterns; trends in nutrition status of
population across age and physiological groups; Micro and Macronutrient values of foods,
maternal and child nutrition, NCD biomarkers, Environmental pollution/toxins affecting health,
Drug nutrient interaction, Nutrition and immune response.

Providing Guidelines
Recommended Dietary Allowances (RDA), Dietary Guidelines for Indians, Diet and Diabetes,
Diet and Heart Diseases, Diet during Pregnancy (region-specific guidelines), Nutrition and
Infection

Influence Policies

National Nutrition programmes such as Integrated Child Development Services (ICDS), Mind-
day Meal (MDM) programme, Clinical Management – Severe Acute Malnutrition (CM-SAM) &
many state level Nutrition programs; Vitamin A prophylaxis, Iron and Folic Acid
Supplementation, Double Fortification of Salt (DFS) with iron and iodine, Recommendations on
vegetable oils Food fortification guidelines to the Food Safety and Standards Authority of India
(-FSSAI), Food and ground water regulations (yellow mustard, flourosis, lead)

Raise Awareness

We broaden knowledge and understanding of how nutrition and balanced diets coupled with
physical activity and lifestyles can help improve mental and physical wellbeing and how they
can reduce communicable and non-communicable diseases by developing tools, sharing best
practices, and holding engaging public events. NIN Mob App, e- Learning modules and host of
videos and pamphlets

Developing Human Resource

Two full time MSc courses, short term certificate courses, [Link], two training programes for
medical college faculty and public health personnel, Anthropometry assessment, Nutrition &
Dietary assessment, National fluorosis training, PCT for regulatory bodies, Animal handling.
Added to these, custom-made training programmes on demand in adhoc mode

Need based support during public health emergencies

Extending support to Governments/ICMR to explore, assess and combat public health issues and
outbreaks – Kidney diseases in Nellore district of Andhra Pradesh; deaths in tribal areas of
Attapady in Kerala, Food and water borne illnesses in Bholakpur area of Hyderabad, Rapid
assessment of nutritional status of children in areas affected with acute encephalitis syndrome
(AES) in Muzzaffarpur, CoVID 19 and so on.
Food and Nutrition Board (FNB)

The Food and Nutrition Board (FNB), set up in 1964, is under the department of Women welfare and
Child Development. The FNB has a technical wing at the centre, 4 regional offices at Delhi, Mumbai,
Kolkata and Chennai. It is engaged in its conventional activities as well as in new initiatives
undertaken as a follow up of National Nutrition Policy. Some of the areas of FNB activities are as
under.

Nutrition Education and Orientation: Nutrition Education of the people in rural, urban and tribal
areas is one of the primary activities of the FNB. Nutrition demonstrations in rural, urban and tribal
areas are organized by each of the 43 Community Food and Nutrition Extension Units (CFNEUS)
indifferent states, 12,000 programmes benefiting about 5 lakh persons are organized annually.

Training in Home Scale Preservation of Fruits and Vegetable: The CFNEUS impart education and
training in home scale preservation of fruits and vegetables to housewives and adolescent girls with
a view to promote preservation and consumption of fruits and vegetable which could be useful for
income generation purposes.

Monitoring of Supplementary Feeding under ICDS: The CFNEUS monitor the supplementary feeding
component of ICDS in areas of their location.

Mass Media Communication: Development of educational and training material on nutrition has
been one of the important activities of FNB Headquarters. Some of the important publications
include Handbook on Integrated Nutrition Education, Guidelines for Nutrition of pregnant women,
posters on child’s Health, Nursing mothers, complementary feeding, instant food mixes, Iodized salt,
folders on mother’s milk, green leafy vegetables, fruits and vegetables for vitality, stickers for school
children, National plan of Action on Nutrition etc. Efforts are made to promote nutrition facts about
infants, pregnant and lactating mothers.

Advocacy and Sensitization of Policy makers and Programme managers: Advocacy and sensitization
of policy makers for integrating nutritional concerns in developmental programmes is a key issue for
promoting nutrition of the people in the country. Regional workshops are planned for this.

Follow Up Action on National Nutrition Policy: A number of initiatives have been taken up since
National Nutrition Policy was adopted by Government of India in 1993. A National Plan of Action on
Nutrition was formulated and approved by the Inter ministerial coordination Committee and
released in 1995. A task force on micronutrient deficiency like Vitamin A and Iron was constituted
and details are worked to eradicate them.

The National Nutrition Mission aims at eradicating malnutrition in a time bound fashion. The three
important areas for action are vigorous awareness campaign in malnutrition and its prevention,
direct interventions for preventing malnutrition, nutrition monitoring, mapping and surveillance to
be established in the country for reducing high levels of malnutrition.