Module 3

Determinants of Health

Learning outcomes

• Apply a working definition of the social and environmental determinants

of health
• Be able to identify positive and negative health impacts
• Be able to identify vulnerable groups in HIA

Definition of health

The preamble to the Constitution of the World Health Organization (WHO) is one
of the most widely cited definitions of health:

“Health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.”

This was adopted by the International Health Conference, New York, 19 June - 22
July 1946; signed on 22 July 1946 by the representatives of 61 States (Official
Records of the World Health Organization, no. 2, p. 100) and entered into force
on 7 April 1948. The definition has not been amended since 1948.

However, in 1990 Maurice King published a commentary in The Lancet

advocating for an addition to the definition so that it states that “Health is a
Sustainable State” of complete physical, mental and social well-being. These
proposed additional words “Sustainable State” are very important symbolically
to move the discussion forward and focus on the long-term future of human
civilisation in the context of climate change and Planetary health (King M. Health
is a sustainable state. The Lancet. 1990;336(8716):664–667.).

Health can be defined across a spectrum. A ‘tight’ definition of health would

apply a biomedical model of health that focuses on diseases and quantitative
evidence on health impacts (Harris et al. 2007). A ‘broad’ definition of health
would capture the range of environmental, social and economic factors that
impact health and would utilise qualitative evidence to investigate health
impacts (Harris et al. 2007). HIA frameworks (including the International
Finance Corporation 2010 and International Council on Mining and Minerals
2009) recommend applying a ‘broad’ definition of health.

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Table 1
Table 1: Features
Characteristics of broad and
of broad and tight focus
tight on health (taken
perspective from Commonwealth
Health of
Impact Assessment
Australia 2001 p.4)
BROAD PERSPECTIVE TIGHT PERSPECTIVE
View of health Holistic Emphasis on defined and observable aspects
Disciplinary roots Sociology Epidemiology; toxicology
Ethos Democratic Technocratic
Quantification In general terms Towards measurement
Types of evidence Key informants; popular concern Measurement
Precision Low High
Sou rce: UK DOH 2000. (3) In set 6A

Health outcomes and determinants

Guidelines developed by the National Health and In 1996, Tasmania became the first state to legislate
Medical Research Council (NHMRC) 6 , New Zealand 7 for HIA to be a formal requirement of the EIA
and (to a Health outcomes
lesser extent) Canada include
4
focus infectious
on health diseases, chronic
process. diseases,
Appendix nutritional
1 sets out some of the Tasmanian
disorders, physical injury
impact assessment of individual projects or and mental health and well-being (International
experiences in the conduct of health impact
Council
developments, noton Mining
at the policyand Minerals
or program (ICMM) 2010).
level. These health outcomes can be
assessment.
impacted
Nevertheless, this setbyofaGuidelines,
number of asdeterminants.
well as those It is important that HIA practitioners
Traditional EIA often does not identify the positive
mentioned above, take
recognise thea determinants
broad view of what that can impacteffect health. Tablethat2 provides a listmay
of have. For
constitutes health. In that respect they cannot be on health development
determinants that
regarded as tight in their focus.
can impact population health.
example, as identified in Table 2, one ofthe
The final three columns are the key
social and environmental determinants of health and are
determinants regarded
of health as ‘root
is financial status. There is
1.4causes’
Whyofundertake
health (Health Impact Partners 2011).
health As the aim
ample evidence that of HIA communities
poorer is to influence experience
poorer health andChapterthat improving economic
health
A Healthat a population
impact Impact Assessment
assessment? level, it focuses on these determinants of health rather
Toolkit 1. Introduction to HIA
circumstances can improve health status. HIA should
than individual characteristics and behaviours. explicitly identify the positive effects on health that
HIA is undertaken to ensure explicit and balanced
consideration of the human health impacts of development may have through, say, job creation, as
Table 2: Population health determinants (Healthwell Impact
as anyPartners
negative2011)
effects.
policies, programs and (in relation to these
Table 1. Population Health Determinants !
Guidelines) developments. Furthermore, traditional EIA has not always
Fixed Individual ! Individual Public Service managed Environmental
identification and Social,
reporting of likely human
The importance of human health being more
Health and health Conditions!
effects in an optimum Economic,
manner.and For instance:
explicitly considered in relation to promoting
Behaviors!
sustainable development has already been discussed. Infrastructures! Political !
• the reporting of health effects may be
The costs ofGenetic
failuremakeup
to protectDietand promote health Education Housing adequacy
unstructured, as most Poverty
impact assessment
Gender the community
fall on governments, Physical generally
activity Public
and guidelines
Air, soil,may not callInequality
and water for an explicit section on
individual members
Age of the public. These
Addictions costs aretransportation human health
quality (even though relevant data may
Social cohesion
unlikely to Existing
be bornehealth
by a proponent. Ensuring that appear throughout the document);
Coping Health care Community noise and inclusion
such costs are not incurred by non-beneficiaries is •
conditions and Transportation! Parks the Disease vectors!
consideration of Political
health issues may be too
both equitable and good economics. narrow. As outlined in section 1.5, health is
disabilities! Community participation!
Environmental Impact Assessment (EIA) has been centers influenced by many factors and the lack of a
practised in Australia and elsewhere since the Economic early specific requirement to consider and report on
1970s. While aspects of the physical and natural human health impacts has sometimes seen
development! significant health issues overlooked; and/or
environment are central to EIA, the consideration
given to human health has been generally • regional environmental health considerations are
unstructured and confined
According to the WHOonly Commission
to the most on direct,
the Social Determinants notofcharacterised
Health (2008), in health status
thatis enables
Social and Environmental Determinants ofoften
negative impacts. Health a way
determined by a range of factors, including, genetics (5%), health care of
assessment (10%), behavior (30%),
the incremental and
contribution a
The need forsocial
HIAconditions (55%). The
to be conducted factors listed
explicitly in any development
in the latter three columns oforthe activity
table 1 may have upon
are known as them (eg.
Workoroneconomic
the social determinantsprocess of health wasthebolstered
contributionby the Commission
of pollutants to arooton
regional
the “social and environmental
environmental determinants of health” and
decision-making are generally considered to be the
Social
was strongly Determinants
endorsed byand of
thedisease. Health
NHMRCThe (CSDH)
in 1992. established by WHO in 2005. The
airshed or to dietary intake via the food chain).
causes of health image below provides another depiction of these relationships.
Commission was led by Sir Michael Marmot and included a global network of
policy makers, researchers and civil society organizations. The Commission was
4 HealthaImpact
given Assessment
mandate Guidelines
to identify the social causes of poor health and avoidable health
inequalities (health inequities), and develop a global movement to address them.

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The work of the commission was based on earlier WHO European Region and
University College of London research that identified the following social
determinants of health: social gradient, stress, early life, social exclusion, work,
unemployment, social support, addiction, food and transport (Marmot 2005).

In February 2020, just before the COVID-19 pandemic took hold globally, Sir
Marmot published "Health Equity in England: The Marmot Review 10 Years On."
Then, in December 2020, he followed up with "Build Back Fairer: The COVID-19
Marmot Review." These new developments extend the important work begun by
the initial foundations of the commission. In particular the "Build Back Fairer"
report examines how the COVID-19 pandemic exposed and exacerbated health
inequalities in England. It provides recommendations for a fairer, healthier
society post-pandemic, emphasising the need to address social determinants of
health in the recovery process.

HIA frameworks have incorporated the social factors alongside environmental

determinants to provide a more complete picture of the factors that influence
health at a population level. Environmental determinants of health cover a wide
range of factors that occur in both the natural and built environment. Examples
of the social and environmental determinants of health and well-being are
shown in Figure 1 (ICMM 2010).

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Figure 1: The wider social and environmental determinants of health and well-being
(ICMM 2010)

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Modifiable Determinants of Health

HIA focuses on the modifiable determinants of health. These include those

factors that can be influenced by the project, policy or plan being assessed. By
focussing on modifiable determinants of health, a HIA report can provide
practical and actionable recommendations. Table 3 provides examples of how
determinants of health can be modified through individual/family-,
environmental- or institutional-level, developed by ICMM.

Table 3: Modifiable determinants of health (ICMM 2010 p. 12)

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Figure 2 is taken from the Australian HIA Guidelines. This figure highlights that
many of these factors have an influence at both the community and individual
level.

Figure 2 – Modifiable Determinants of Health (enHealth, 2017)

Positive and Negative Health Impacts

HIA assess the positive and negative health impacts of a program/policy/project.

ICMM (2010) provides an in-depth overview of the positive and negative health
impacts of a mining project. For example, water and sanitation may be positively
impacted as a new mining project provides new infrastructure for water supply.
Conversely, negative impacts could be experienced if inadequate sanitation is
provided for new employees resulting in the contamination of existing water
supply systems.

Cumulative Health Impacts

Individuals and populations are exposed to numerous health impacts at any one
time. Cumulative health impacts occur where an individual or population is
exposed to more than one health impact e.g. new road infrastructure results in
more traffic emission and noise. The road was built due to the expansion of a
new mine which results in increased dust emissions.

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Equity and vulnerable groups

Health equity is vital component of HIA (Harris et al. 2007). Health equity relates
to HIA through assessing the potential negative impacts experienced of one
group more than others. ‘HIA aims to provide recommendations to reduce the
potential of a proposal to lead to new health inequalities or to widen existing
one. In a HIA, this involves an assessment of whether this difference is significant
in health terms, whether it is likely to be considered unfair by affected people
and whether the proposal can be modified to eliminate or reduce the potential
impact’ (Harris et al. 2007).

Vulnerable groups are people that are disadvantaged through their physical,
social or environmental conditions. Potential vulnerable groups include people
living on a low income, sole parents, children, the elderly and people living with
a disability.

Case study – Definition of Health in an Australian HIA

A good example of a HIA is the Northern Territory Emergency Response (NTER)

(Australian Indigenous Doctors’ Association and Centre for Health Equity
Training, Research and Evaluation, UNSW. 2010). For this HIA, the practitioners
applied a definition of health that was culturally relevant to Indigenous
Australians. The definition was based on a concept developed by Professor Helen
Milroy and is entitled ‘The Dance of Life’. This definition of health included five
dimensions – cultural, spiritual, social, emotional and physical - within which
are a number of layers, which reflect historical, traditional and contemporary
influences on health.

‘This concept emphasises the intersection of both

the layers and dimensions which creates the interconnectedness
for a whole of life approach to Aboriginal wellbeing.’ (Australian Indigenous
Doctors’ Association and Centre for Health Equity Training, Research and
Evaluation, UNSW. 2010).

Reading List
Marmot M. (2005). Social determinants of health inequalities. The Lancet,
365(9464), 1099–1104. https://doi.org/10.1016/S0140-6736(05)71146-6

Marmot M. (2020). Health equity in England: the Marmot review 10 years on.
BMJ. https://www.bmj.com/content/368/bmj.m693.

International Council on Mining and Mineral (2010) Good practice guidance on

health impact assessment pp.8 -21 Good practice guidance on HIA 2010:
https://www.icmm.com/en-gb/guidance/health-safety/2010/guidance-hia
Accessed on 4/8/2024.

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References

Australian Indigenous Doctors’ Association and Centre for Health Equity

Training, Research and Evaluation, UNSW. 2010 Health Impact Assessment of
the Northern Territory Emergency Response, Canberra: Australian Indigenous
Doctors’ Association

Commonwealth of Australia 2001 Health Impact Assessment Guidelines,

Commonwealth Department of Health and Aging, Canberra

Harris P., Harris-Roxas B., Harris E. and Kemp L. 2007 Health Impact
Assessment: A Practical Guide, Sydney: Centre for Health Equity Training,
Research and Evaluation (CHETRE). Part of the UNSW Research Centre for
Primary Health Care and Equity, UNSW

International Council on Mining and Minerals (ICMM) 2010 Good Practice

Guidance on Health Impact Assessment, London UK

International Finance Corporation (IFC) 2009 Introduction to Health Impact

Assessment, Washington USA

Marmot. (2005). Social determinants of health inequalities. The Lancet,

365(9464), 1099–1104. https://doi.org/10.1016/S0140-6736(05)71146-6

Marmot M. (2020). Health equity in England: the Marmot review 10 years on.
BMJ. https://www.bmj.com/content/368/bmj.m693 .

International Council on Mining and Mineral (2010) Good practice guidance on

health impact assessment pp.8 -21 Good practice guidance on HIA 2010:
https://www.icmm.com/en-gb/guidance/health-safety/2010/guidance-hia
Accessed on 4/8/2024.

King M. Health is a sustainable state. The Lancet. 1990;336(8716):664–667.).