This guide was written by Natalie Lovell, Policy Analyst, and Jo Bibby, Director, Healthy Lives Strategy, at the Health Foundation.

Thank you to all the public health experts and others who contributed to this guide.

What causes heart disease? To some, the clear answer would be blocked arteries. But what causes those arteries to become blocked? Perhaps it’s the unhealthy food and drink people consume, their lack of exercise, or their stress levels. And what, in turn, makes them feel stressed, shapes their opportunities to be active and determines their choices about what they eat and drink?

The answers lie in the circumstances in which people are born, grow, live, work and age: the social determinants of health (see Box 1). These can enable individuals and societies to flourish, or not. These are the causes of the causes.

The Health Foundation has written this guide as a brief introduction to the social determinants of health. It explains how a person’s opportunity for health is influenced by factors outside the health and social care system. It also shows that many people don’t have the same opportunities to be as healthy as others.

With the help of short case studies, it highlights how action can create improvements in the health of the whole population, for the lasting benefit of individuals, society and the economy.

The guide has been written for anyone with an interest in people’s health and wellbeing. It will be especially useful to those new to the social determinants of health.

Why focus on the social determinants of health?

A person’s opportunity for good health starts long before they need health care., So, there is a compelling case that responsibility for the health of the public should go beyond the health and social care system to span all of society.

A wide range of organisations – across government, the voluntary sector, the private sector, media, advertising and local communities – have it within their power to improve people’s health. By acknowledging and acting on this, it is possible to harness a multitude of opportunities to overcome the big health challenges of today.

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Most people associate the word ‘health’ with hospitals and doctors. When considering ‘good health’ they tend to think simply of an absence of illness. In this guide, we refer to health in its broadest sense: a person’s level of good physical and mental health, and the extent to which individuals in a society are enabled to live healthy and flourishing lives.

This guide describes the factors in the daily lives of people in the UK that create and support health and wellbeing.

Through this lens, a healthy person is someone with the opportunity for meaningful work, secure housing, stable relationships, high self-esteem and healthy behaviours.

A healthy society, in turn, is not one that waits for people to become ill, but one that sees how health is shaped by social, cultural, political, economic, commercial and environmental factors, and takes action on these for current and future generations.

[Health is] not just the physical wellbeing of an individual but also the social, emotional and cultural wellbeing of the whole community, in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their community.

Aboriginal Health and Medical Research Council of New South Wales, Australia

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Good health is of social and economic value to individuals, society and the economy. It is an enabler of the prosperous and flourishing societies that governments strive to achieve.

Thinking about the value of good health encourages a focus on the benefits of creating health and wellbeing in today’s environments, rather than simply treating disease in individuals. It provides the basis for considering the moral, social and economic case for investing in action that creates and maintains health.

The ultimate source of any society’s wealth is its people. Investing in their health is a wise choice in the best of times, and an urgent necessity in the worst of times.

David Stuckler, The body economic: why austerity kills

The moral case

The moral case for maintaining and improving people’s health has been made from several perspectives, including the following.

• The welfare state – in 1942 Sir William Beveridge published a report making recommendations aimed at tackling unemployment, the cost of childcare, a lack of good housing, and public health issues such as malnutrition. The report was popular and the main political parties agreed that the recommendations would help create a more equal society.
• Good health is a basic human right – it featured in the United Nations’ Universal Declaration of Human Rights (Article 25) in 1948. It is also one of the core principles in the Constitution of the World Health Organization.
• The capability approach – this relates to the moral importance of a person having what they need (for example, good health and a home) to do the things they wish to do and live a good quality of life. The case for this approach was first made by economist and philosopher Amartya Sen in the 1980s. Seen from this perspective, health and wellbeing is a resource for living, and is a matter of social equity and justice.

Today, the UK is a wealthy society. Yet a baby girl born in Richmond upon Thames is expected to live 17.8 more years in good health than a baby girl born in Manchester. Few would consider this just – there remains a lot of progress to achieve the society that Beveridge, the UN and Sen envisioned.

The social case

Good health is an important enabler of positive family and community life. It enables people to participate in, and contribute to, society in different ways.

• A family member in good health is better able to build foundations that support other family members to thrive. For example, a parent providing emotional support for a child. On the other hand, health challenges such as childhood obesity and poor mental health can negatively affect family life and people’s ability to form and maintain good quality relationships.,,
• Having good health enables people to take part in civic society, including clubs and social groups, while poor health may hinder participation. In turn, engagement with communities can have a positive effect on social cohesion.

The economic case

Where a person stands in the labour market – such as whether they have a job that pays enough to live on – is key to their financial security and wellbeing.

Yet that person’s wellbeing throughout their life is also crucial to employers, businesses and the economy as a whole.

The potential economic benefits of ensuring the best possible health of the population are huge. A healthy population can be good for the economy because:

• healthier children have better educational outcomes, which positively impact productivity in adulthood,
• a healthy working-age population can lead to economic prosperity by being more engaged and productive
• a healthy person is enabled to continue to work as they get older, whereas poor health can lead to forced early retirement.,,,,

Conversely, a working-age population that is unwell, particularly with mental health problems, will likely negatively impact the UK economy.

• People with health problems are more susceptible to unemployment, lower earnings, sickness absence and lower household income.,,
• Every year, 300,000 people stop work and become reliant on health-related benefits.
• A further 140 million working days are lost to sickness, costing the UK economy £15bn.

Because poor work conditions can in turn affect health, a vicious cycle of poor health and poor wealth emerges, at huge cost to individuals, society and the economy.

A healthy population is therefore essential for a thriving society and economy.

We have a collective responsibility – to bring about a more stable and more prosperous world, a world in which every person in every country can reach their full potential.

Christine Lagarde, Managing Director, International Monetary Fund

Estimates vary, but it is widely accepted that a population’s health is largely shaped by factors beyond access to health care.,, Rather than being something people just get at the doctor’s or at hospital, health is something that starts in families, schools, communities and workplaces. It can be found in parks and in the air people breathe.

The other factors that influence health – the social determinants – affect people in different ways, according to factors like age, gender, ethnicity, sexuality and disability. And they don’t operate in isolation. Rather, they are intricately woven together in a dynamic and mutually reinforcing way.

Take, for example, someone who doesn’t have the opportunity to do well at school. They are less likely to have a job and more likely to suffer poor health outcomes when they’re older.

However, the reason that person doesn’t do well at school might be that their home environment leads them to miss school, and the reason they will struggle to get a job may be partly due to high levels of unemployment in their community, or a lack of public transport to get to where the jobs are. Such factors are multiple and complex (see Figure 1).

Although some diseases are due to genetics, these play a much smaller role in shaping a person’s health than where they are born, grow, live, work and age.

It’s not your genetic code, it’s your [post]code.

Larry Cohen, Building a thriving nation

This can be illustrated by the underlying causes of obesity, which include advertising of unhealthy food and drink; workplaces and routines that restrict people being active; public spaces with few parks; and neighbourhoods where it’s difficult to buy affordable, healthy food.

Figure 1: The factors that influence an individual’s health and wellbeing

Source: Dahlgren and Whitehead.

These causes of the causes can influence our health and wellbeing in many ways, including through people’s health behaviours. Yet individual control over such behaviours is often very limited.

Unhealthy behaviours are usually not the origin of poor health, but the end point of a long chain of causes and consequences in people’s lives.

The rest of this section gives an overview of eight key social determinants of health (see Figure 2). The list is not definitive, but explains some of the key factors

in people’s physical and social environment that can be acted on to increase people’s opportunities to make healthy choices and to live healthy lives.

To show how different sectors might take action on the social determinants of health, we have included case studies to illustrate some direct and indirect ways change can happen.

The fact is that the conditions to which we are exposed influence our behaviour. Most of us cherish the notion of free choice, but our choices are constrained by the conditions in which we are born, grow, live, work and age.

Michael Marmot, The health gap

Figure 2: What makes us healthy?

These images are based on an infographic series on the social determinants of health. Find out more: www.health.org.uk/healthy-lives-infographics

Family, friends and communities

Social isolation and loneliness are associated with a 30% increased risk of heart disease and stroke.

People who are more socially connected to family, friends or their community are happier and live longer, healthier lives with fewer physical and mental health problems than people who are less well connected.,

A positive family life provides a child with opportunities for a healthy life by creating the early life foundations for them to feel loved and valued; build supportive relationships; develop intellectual, social and emotional skills; and develop lifelong healthy habits. During adulthood, a positive family life, including strong spousal relationships, can have positive impacts on a person’s health and provide them with support to deal with life’s challenges.

Happy and positive friendships and feeling part of community life protects them from the damaging health effects of social isolation and provides them with opportunities to develop healthy habits. On the other hand, being lonely can have the opposite effect, such as by reducing the likelihood of exercise. Taking part in community life – such as youth clubs – can be empowering and create a sense of purpose, while also protecting health and wellbeing.

If we can create a society that brings people together, rather than isolating them, then we will not only have a happier society but one with less health costs to meet.

Dan Corry, New Philanthropy Capital

Money and resources

One in five people in the UK live in poverty, and over half of these people live in working households.

An inadequate income can cause poor health because it is more difficult to avoid stress and feel in control; access experiences and material resources; adopt and maintain healthy behaviours; and feel supported by a financial safety net.

Living with the day-to-day stresses of poverty in early childhood can have damaging consequences for long-term health. Money can enable people to access the support and services they need to participate fully in society. Yet, 48% of 21 to 24-year-olds earn less than the independently set living wage. An inadequate income can also make healthy behaviours feel unattainable: it is three times more expensive to get the energy we need from healthy foods than unhealthy foods.

Saving our planet, lifting people out of poverty, advancing economic growth... these are one and the same fight.

Ban Ki-moon, Secretary-General of the United Nations

A financial safety net enables people to invest in their future. In studies, 40% of people with unmanageable debt said they were less likely to study or retrain. Poverty damages health and poor health increases the risk of poverty.

Housing

Children living in cold homes are more than twice as likely to suffer from respiratory problems than children living in warm homes.

Where people live is more than just a roof over their heads. It’s their home, where they grow up and flourish. A healthy home is affordable, warm and stable: somewhere safe that meets the diverse needs of the people living there and helps them connect to community, work and services.

Investing in housing support for vulnerable people helps keep them healthy. Every £1 invested delivers nearly £2 of benefit through costs avoided to public services including care, health and crime costs.

A safe settled home is the cornerstone on which individuals and families build a better quality of life, access services they need and gain greater independence.

Jake Eliot, Head of Policy, Money Advice Service

Education and skills

People with the lowest healthy life expectancy are three times more likely to have no qualifications compared with those with the highest life expectancy.

Good education and skills can help build strong foundations for supportive social connections, accessing good work, lifelong learning and problem solving, and feeling empowered and valued.

These help people live healthier lives by increasing their opportunities to develop lifelong healthy habits; afford a good quality of life; live and work in safe and healthy environments; and manage and limit exposure to life’s challenges.

The prize [of good education] is simple: healthier, happier, wealthier people, and stronger families, communities and businesses.

David Hughes, Chief Executive, Association of Colleges

Good work

Young adults who are unemployed are more than twice as likely to suffer from mental ill health than those in work.

Good work offers stability, security and a regular income. It provides good working conditions, including a safe working environment, good wages and practices that protect employees’ wellbeing. It provides an environment in which employees are supported, have personal development opportunities, and a degree of control and autonomy over their work.

Ultimately, gaining or maintaining ‘good’ employment and improving workplace health has the potential to make a significant contribution to personal wellbeing, the economy and reducing levels of disease and illness in society.

Professor Dame Carol Black

Good work provides opportunities to afford basic living standards; participate in community and social life; support lifelong healthy habits; and feel a sense of identity, self-esteem, purpose and reward. It offers protection against the harmful effects of unemployment and insecure jobs, which can damage long-term health and wellbeing.

Transport

There are nine times as many fatal and serious injuries among pedestrians aged 5–9 in the most deprived areas than the least.

Healthy transport systems support safe and well-designed communities. They enable more walking, cycling and public transport use, are accessible and efficient for everyone, and minimise harmful impacts of the environment. This helps people to lead healthier lives. For example, people who use public transport are likely to do an extra 12–15 minutes physical activity each day.

Streets and public spaces that are well designed also encourage active travel, and can have other positive impacts such as reducing vehicle speeds.

Transport is not an end in itself, but rather a means... to access what [people] need: jobs, markets and goods, social interaction, education, and a full range of other services contributing to healthy and fulfilled lives.

United Nations Secretary-General’s High-Level Advisory Group on Sustainable Transport

A healthy transport system can provide opportunities to improve air quality – the largest contributor to air pollution in London is road transport. It can also help hard-to-reach or deprived communities to access key services, such as learning opportunities and jobs.

Our surroundings

Children in deprived areas are nine times less likely to have access to green space and places to play.

Health is influenced by how surroundings make people feel and the opportunities they provide. Good places, spaces and buildings enable people to be more physically active, feel safe and secure, use facilities and services, and socialise and play. For example, well maintained and easy to reach green space makes it easier for people to be physically active.,

Being near facilities and services like shops and schools makes it easier to walk to them – this can, for example, help reduce social isolation among older people.

It turns out that the key elements necessary for public space to improve people’s health are the same as those needed to make urban space socially and economically vibrant and environmentally sustainable.

Lucy Saunders, Public Health Specialist, Transport for London

The food we eat

It is three times more expensive to get the energy we need from healthy food than unhealthy food.

Poor diet is the one of the biggest risk factors for preventable ill health in England. Everyone should have enough good food to live a healthy life. Healthy food needs to be: affordable for everyone, a bigger part of the food supply chain, available in local areas, and promoted and valued.

Yet many factors in our environment make it hard to eat healthily. It is harder to buy healthy foods in deprived parts of the UK. There is also a higher density of fast food outlets in these areas. The promotion of food may also make healthy behaviours harder: just 1.2% of advertising spend each year goes on vegetables, compared with the 22% spent on confectionary, cakes, biscuits and ice cream.

The healthy choice should be the easy choice.

Rob Beaglehole, Public Health Dentist

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Everyone in society should have the opportunity to make healthy choices and live healthy lives. But inequalities in power, money and resources at local, national and even global levels can make the circumstances of people’s daily lives more challenging. In turn, such circumstances can make people more vulnerable to poor health.

Although people are now living longer than they used to, the fact remains that socially disadvantaged people are more likely to face conditions – such as insecure work, or living in a run-down neighbourhood – that lead to poorer health and an earlier death.

These differences in people’s health and wellbeing are called health inequalities, and they don’t just exist between the very rich and the very poor in society: they span the population and affect people of all ages, at every stage of life, and across all major diseases.

Like slavery and apartheid, poverty is not natural. It is man-made and can be overcome and eradicated by the actions of human beings.

Nelson Mandela, former President of South Africa

It is possible to provide opportunities for people to live healthy lives. Decision makers at all levels can create policies – from international trade deals to lowering local levels of congestion – that will enable people to have greater influence over their own health and health behaviours, as well as those of their families.

The action required is universal: focusing solely on the most disadvantaged would only tackle part of the problem. If action is proportionate to the level of disadvantage, there is an opportunity to both improve the health of the population and reduce health inequalities.

The Marmot review, Fair society, healthy lives, concluded that reducing health inequalities in the UK requires a series of objectives to be met. These are:

• giving every child the best possible start in life
• creating job opportunities and fair working conditions for all
• ensuring a healthy standard of living for the whole population
• developing health-creating physical environments
• empowering communities
• strengthening health prevention.

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At the beginning of this guide, we talked about heart disease and its root causes. By taking action to address these root causes it is possible to prevent many people having heart attacks.

Changing and improving local environments is a more just and effective way to influence the health and wellbeing of an entire population than waiting for people to become ill and treating them as patients, one person at a time.

Yet there is no single idea or policy that will improve the health of the public. Solutions require all members of society to acknowledge the health impact of what they do and work together to take action. If this happens, we could see improvements in people’s health and a reduction in the health inequalities that exist between different groups in society.

The case studies in Section 4 show how efforts to impact the social determinants of health are taking place across a range of sectors. These efforts involve community empowerment, partnership working, helping those most in need, and incorporating health and wellbeing in all policy decisions (reaching far beyond the Department of Health itself). Such action protects people’s health and helps to provide environments that create health and wellbeing. It also highlights the potential that everyone in society has to improve people’s health, either by directly focusing on the social determinants or explicitly addressing health in everything they do.

Change is never easy – especially in changing political and financial contexts. Often, decisions involve difficult trade-offs. Sometimes, the benefits of action taken in one sector are reaped by another. Nevertheless, organisations are finding ways to come together to tackle the social determinants of health, and must continue to do so.

The single most important intervention is to understand that there is no single most important intervention.

Harry Rutter, London School of Hygiene and Tropical Medicine

What can I do to make a difference?

It can be hard to know where to start, but even small changes can influence thinking, narrative and policy. It is likely that such changes would make a difference to people’s health.

Considering the social determinants of health we have outlined in this guide, do you think the last decision you took (or the next one you take) might:

• have an impact on one or more of the social determinants?
• have an impact on health and wellbeing?
• increase or decrease health inequalities?

If the answer is yes to any of those questions, we would ask you to consider:

• how, in the work you’re already doing, you could more explicitly address health and wellbeing
• approaching others to discuss joint working initiatives in new areas where both parties benefit
• talking to your local public health team or a public health expert to find out more about what you can do
• using the facts, figures and case studies in this guide in presentations, reports or funding bids
• engaging others about the part they already play in improving people’s health.

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