What influences health and what can bring about change?


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

Case study 1: Men in Sheds – Age UK, Cheshire

In an industrial unit in Ellesmere Port, the Wirral, a group of men cluster around a lathe, listening carefully to the trainer. This is one of more than 400 Men in Sheds projects around the UK, targeting health and wellbeing in men aged over 50. The sheds act as a community hub, offering a host of activities, including woodwork and metalwork, plus space for a cup of tea.

For men, retirement or redundancy can lead to social isolation, especially for those who are single or widowed, but many are reluctant to seek help. The sheds provide an environment where men feel comfortable developing friendships and accessing support.

The sheds run social events and excursions and the men raise funds themselves, by selling the items they make. They also collaborate with local community groups and churches, including by building facilities for local schools. 

Since the Ellesmere Port shed opened in 2008, the idea has taken off around the UK and beyond, with more than 2,000 shed projects worldwide. The model is evolving over time; for example, some now offer gyms and IT skills.

Find out more https://menssheds.org.uk

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.

Case study 2: Helping wealth stay local – Preston City Council

Since 2011, Preston has been exploring alternative approaches to local economic development that also reduce inequality. One scheme is the Community Wealth Building initiative, which involved cooperating with six local organisations known as ‘anchor institutions’.

The combined procurement spend of these institutions (one of which was Preston City Council) was £750m in 2012/13, but only 5% of this was spent in Preston. The institutions committed to diverting more spend to local businesses.

The scheme included the city’s key employers: the hospital, a housing association and the university. Local suppliers received advice on how to pitch for contracts, which included a £60,000 printing contract for the police and a £1.6m contract to provide school meals, which was divided into lots and awarded to suppliers who use local farmers.

The benefits of this approach are already visible. The six anchor institutions increased their spending with Preston-based suppliers from 5% of total spend in 2012 to 18% in 2017 – an increase of £74m. It is estimated this increase supports around 1,648 local jobs. The city has also made improvements on six out of eight of its local authority summary deprivation measures between 2010 and 2015.

Find out more: https://cles.org.uk/publications/community-wealth-building-through-anchor-institutions


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

Case study 3: Linking fuel poverty to health outcomes – Warm Homes Nest Scheme, Wales

Poor housing stock and mainly rural communities mean that fuel poverty has been a major problem in Wales. To tackle the issue, the government set up the Warm Homes Nest Scheme to target households with the greatest need.

To evaluate the project, the government has linked anonymised data from the scheme with routine health records. This allows the evaluators to analyse the impact of the scheme on individual health. The results have been impressive, with evidence of positive effects on people’s health.

Over the course of a year, for households who received help with their energy efficiency, the average number of times a person had to go to a GP for breathing problems decreased by 3.9% for those on the scheme, and they also experienced a 6.5% decrease in asthma events. These factors increased among people who were eligible for, but not on, the scheme.

Find out more: www.nestwales.org.uk

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

Case study 4: Boosting employability in young people – The North East Ambition programme

The opportunities available to young people on leaving school are pivotal to their futures. Young people who are not in education, employment or training are more likely to suffer worse health outcomes in later life, so targeting this group is an important priority for society.

In 2015, the north east had the highest rate of young people who are not in education, employment or training in the country, so the North East Local Enterprise Partnership started intensive work to tackle this issue. One aim of the programme was for 170 local secondary schools and colleges in the area to meet the eight Good Career Guidance Benchmarks.

These include personal guidance tailored to each pupil, work experience and encounters with employers. The programme was supported by several new cross-sector networks bringing schools, colleges and businesses together to share ideas and pool resources.

2 years after the programme’s launch, 85% of the 70 participating schools and colleges had reached six or more of the Good Career Guidance Benchmarks. Partly as a result of this work, the rate of young people not in education, employment or training in the north east has dropped from 23.4% to 13.5%. The benchmarks have also been adopted as part of the Department for Education’s national career strategy.

Find out more: www.nelep.co.uk/skills/north-east-ambition

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.

Case study 5: Incentivising employers to boost staff mental health – Thrive West Midlands

There are an estimated 70,000 people in the West Midlands who are out of work as a result of mental health problems. The West Midlands Combined Authority’s Mental Health Commission launched an action plan to address the wide impact this has on the region – not least on the local economy, as well as individuals and communities.

A core part of the plan is the workplace wellbeing premium, which will provide a financial incentive for employers to introduce measures that support the mental health and wellbeing of their workforce. This pilot scheme provides organisations with a grant and various toolkits and resources. These are intended to help them capture and use data better, and put in place initiatives to promote a culture of wellbeing.

The scheme is supported by more than 120 signatories, including the police, local authorities, schools and housing associations, and has been developed with support from people with mental health problems.

Find out more: www.wmca.org.uk/media/1420/wmca-mental-health-commission-thrive-full-doc.pdf


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.

Case study 6: Reducing inequalities through transport – Manchester Metrolink

The Manchester Metrolink is the largest light rail system in the UK. Its benefits to the community have reached beyond transport links, thanks to the vision of local transport planners.

Transport for Greater Manchester collaborated with local authorities to improve connections for 2.7 million residents. Its contribution, along with other public and private sector collaboration, focused on a common goal and long-term economic vision: to use transport to connect commuters from around Greater Manchester to key industrial and commercial districts.

As a result, the system is having a positive influence on the social determinants of health. The latest extension to Oldham and Rochdale town centres, East Didsbury and Ashton-under-Lyne has improved access to employment for 16 to 70-year-olds, further education options for 16 to 19-year-olds, and health care for the whole population. Improved accessibility to these services through public transport has been more marked for the 10% most deprived areas along this route, helping to reduce inequalities.

Find out more: www.volkerrail.co.uk/dynamics/modules/SFIL0200/view.php?fil_Id=8932

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

Case study 7: Investing in healthy streets – Greater London Authority

Recognising the relationship between transport and health, in 2014 Transport for London became the first transport authority in the world to publish a Health Action Plan. It has adopted the Healthy Streets approach, which will help it improve air quality, reduce congestion and create healthy surroundings for people to live, work, commute and play.

The Healthy Streets approach is based on 10 evidence-based indicators. The approach defines a healthy street as one with: things to see and do; places to stop and rest; shade and shelter; clean air; and pedestrians from all walks of life. It must also be easy to cross; and feel safe, relaxing and not too noisy. Put simply, it needs to be an environment in which people choose to walk and cycle.

Action against these indicators ultimately improves health. Transport for London has committed to delivering improvements against these indicators through the 25-year Mayor’s Transport Strategy.

This approach was applied in Archway in north London, which was a large traffic-dominated gyratory. Through a transformative project the 10 indicators showed an overall uplift. Importantly, seven road danger issues were eliminated through the redesign of the junction.

Find out more https://tfl.gov.uk/corporate/about-tfl/how-we-work/planning-for-the-future/healthy-streets

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

Case study 8: Using planning to restrict takeaways – Gateshead Council

Access to healthy food goes far beyond the control of an individual. With this in mind, Gateshead Council has used local planning policy to improve the opportunities its residents have to make healthy food choices. The ambition is to reduce levels of obesity and, in turn, deaths from cancers and circulatory diseases. The approach focuses on reducing health inequalities in Gateshead.

The council won a Local Communities and Government award for its innovative approach: developing a supplementary planning document under its local plan.

This new document means that any application for a hot food takeaway will be declined if it is in an area where more than 10% of children in year 6 are obese; if it is within 400m of secondary schools and other community amenities, or if the number of hot food takeaways in the area is equal to or greater than the UK national average.

The award was made in recognition of the strong joint working between the local elected members, planning teams and public health teams. Judges said the council deserved to win because it had used ‘a strategic, holistic approach with strong political buy-in to tackle a major public health issue, making best use of local authority mechanisms.’

Find out more: www.gateshead.gov.uk/Building%20and%20Development/PlanningpolicyandLDF/LocalPlan/SupplementaryPlanningDocuments/Hot-food-takeaway -SPD.aspx

For the full list of benchmarks developed by Gatsby see: www.gatsby.org.uk/education/focus-areas/good-career-guidance

§ Nearly 75% of people who are in the bottom fifth of income distribution and rent privately pay more than a third of their income in rent.

Healthy Streets is an evidence-based approach for creating sustainable, attractive urban spaces. Find out more: https://healthystreets.com

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