As a society we can often have a simplistic view of health. However, we know that many complex social factors have a significant impact on a person’s overall wellness. We are all impacted by social determinants of health in one way or another. Understanding what contributes to health from a broad lens is paramount to quality nursing care.

The Government of Canada has listed the following twelve factors as key Social Determinants of Health:

1. Income and Social Status

The higher a person’s income and social status, the better their health will be.

The article Social Determinants of Health: The Canadian Facts, (Mikkonen and Raphael, 2010. Pg. 12) states the following about income:

Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning, and influences health-related behaviours such as quality of diet, extent of physical activity, tobacco use, and excessive alcohol use. In Canada, income determines the quality of other social determinants of health such as food security, housing, and other basic prerequisites of health. (2010)

Have you noticed this connection to income, social status and health in your life, or the lives of people close to you? How did it make you feel?

2. Employment and Working Conditions

People who are unemployed or underemployed are less likely to experience consistently good health. Also, those who work in environments that are unsafe have additional barriers to health. These situations affect us both mentally and physically.

Also from the article Social Determinants of Health: The Canadian Facts, (Mikkonen and Raphael, 2010. Pg. 17):

Employment provides income, a sense of identity and helps to structure day-to-day life. Unemployment frequently leads to material and social deprivation, psychological stress, and the adoption of health-threatening coping behaviours. Lack of employment is associated with physical and mental health problems that include depression, anxiety and increased suicide rates. (2010)

3. Education and Literacy

People who have a higher socioeconomic status are more likely to have post-secondary educational opportunities, and be able to earn degrees and certifications, which increases their determinants of health.

The Government of Canada website article Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities states the following about education:

Generally, being well-educated equates to a better job, higher income, greater health literacy, a wider understanding of the implications of unhealthy behaviour and an increased ability to navigate the healthcare system – all of which lead to better health. The data in Chapter 3 indicate that Canadians with lower levels of education often experience poorer health outcomes, including reduced life expectancy and higher rates of infant mortality. (n.d.)

4. Childhood Experiences

Childhood development sets people on a path towards good health or poor health, enhanced or decreased well-being. Consider the Adverse Childhood Experiences study conducted by the US Center for Disease Control and Kaiser Permanente. The study surveyed 17,000 people and found that those who have adverse childhood experiences are at a greater risk for health issues in adulthood. (It’s important to note that of the 17,000 people studied, 100% had jobs and health insurance, 74.8% were white, 75.2% had attended some college, or had a degree. The study focused on families of origin and didn’t track adverse experiences caused by systems.)

Within this context, we must understand and acknowledge that experiences of intergenerational trauma, discrimination and other factors are important social determinants of health.

What are some ways our childhood experience affect us as adults?

5. Physical Environments

Exposure to unsafe levels of contaminants through water, food, air and soil can negatively affect health. Housing, transportation and access to resources also have a huge impact on health.

Many studies show that unsafe or poor quality housing, homelessness and food insecurity all have direct impacts on our health. We know that some Canadian homes, especially on Indigenous reserves, lack clean water and basic sanitation – and many are overcrowded.

Overcrowding and a lack of clean water or sanitation can lead to the spread of illness and disease. Living in inadequate housing can also increase stress and impact people’s ways of coping, including substance use. We also know that those who are experiencing homelessness have a much higher rate of a wide range of physical health problems and mental health diagnoses than the general population.

The report Key Health Inequalities in Canada: A National Portrait (Pan-Canadian Public Health Network, 2018, Pg. 341 & 342) states:

Poor housing conditions, including issues such as mold, overcrowding, and lack of affordability, have been associated with a wide range of health conditions such as respiratory and other infectious diseases, chronic diseases (e.g. asthma), injuries, inadequate nutrition, adverse childhood development, and poor mental health outcomes… The prevalence of housing below standards among Indigenous peoples in Canada was higher than among non-Indigenous people. First Nations people living off reserve had prevalence of housing below standards 1.5 (95% CI: 1.5–1.6) times that of non-Indigenous people.

What do you think are the drivers that lead someone to live in poor conditions?

What circumstances could be beyond their control that end up affecting their living conditions?

Do you think there are enough services to support people who live in inadequate housing conditions?

6. Social Supports and Coping Skills

High levels of support from family, friends, and communities are associated with better health outcomes. Community and belonging are recognized as being important determinants of health. When people have communities that are stable, diverse, safe, and cohesive, one’s overall health is enhanced.

Practices that support disease prevention and promote self-care, including coping with adversity and developing self-reliance, all support people’s overall health. However, it is important to recognize that personal life “choices” are hugely influenced by the socioeconomic environment; some people do not have options for engaging in these practices.

Do you feel like you have a strong support system? If so, how do they support you?

If not, is there anyone in your life right now who you’d like to work on building a stronger relationship with? What will you do to build that connection?

7. Healthy Behaviours

Our behaviours greatly affect our health. The resources available to us impact our access to options and will be drastically different for everyone. Some people who are negatively affected by many of the social determinants of health will have less resources available to them. This affects everything from food choices to leisure and activity options.

From the article Social Determinants and Health Behaviors: Conceptual Frames and Empirical Advances (Short & Mollborn, 2016):

Health behaviors, sometimes called health-related behaviors, are actions taken by individuals that affect health or mortality. These actions may be intentional or unintentional, and can promote or detract from the health of the actor or others. Actions that can be classified as health behaviors are many; examples include smoking, substance use, diet, physical activity, sleep, risky sexual activities, health care seeking behaviors, and adherence to prescribed medical treatments. Health behaviors are frequently discussed as individual-level behaviors, but they can be measured and summarized for individuals, groups, or populations. Health behaviors are dynamic, varying over the lifespan, across cohorts, across settings, and over time. (2016)

8. Access to Health Services

Those who have access to health care services and have the funds to pay for services that are not free, will be healthier than those who can’t access services.

Though we have universal healthcare in Canada, there are still disparities as many services, such as eyecare, dental care, some pharmaceuticals, and access to alternative health practitioners, are not covered.

For example, diabetes is a disease that comes with a high price tag for ongoing care. Medications, pumps, and test strips are very expensive. People who can’t afford these medications and supplies will tend not to keep tight control of their blood sugars, which can have a serious impact on their physical and mental health.

Have you ever been in a position where you haven’t been able to access healthcare services? If so, how did that feel?

9. Biology and Genetic Endowment

Genetic endowment can predispose people to particular diseases or health problems.

The HealthyPeople.gov website article Determinants of Health (n.d.) states,

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

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

10. Gender

Society tends to link different personality traits, attitudes, behaviours, values, and levels of power and influence to gender. These societal norms have a big impact on one’s health in the way the health care system offers treatment.

From Chapter 2 of The Chief Public Health Officer’s Report on the State of Public Health in Canada 2012 – Sex, gender and public health:

Socio-economic factors can contribute to inequalities in health outcomes not only between women and men, but among and between different groups of women and men. These factors can influence opportunities for good health and well-being

Consider gender outside of the binary confines of male and female. Life can be increasingly complex for those who are outside of traditional Western gender norms. Discrimination and prejudice are major issues that affect one’s overall health for those who are Two-Spirit, transgender, and non-binary.

Have you ever noticed your own gender affecting your health outcomes? Why or why not?

11. Culture

People who identify with cultures outside of the dominant culture of Canada can feel marginalized. They often face stigmatization and are not able to receive culturally appropriate services. This important topic is covered extensively in the Cultural Humility module.

In the Canadian Public Health Association article, Racism and Public Health (2018):

Canada remains a nation where a person’s colour, religion, culture or ethnic origin* are determinants of health that result in inequities in social inclusion, economic outcomes, personal health, and access to and quality of health and social services. These effects are especially evident for racialized and Indigenous peoples as well as those at the lower end of the social gradient and those who are incarcerated (populations that are also disproportionately composed of racialized and Indigenous people). Complicating this scenario are government and non-governmental systems that impose barriers on those in need which limits their ability to obtain the services and benefits that are easily available to most Canadians. Steps must be taken to eliminate these systemic barriers. (2018)

12. Race and Racism

Racialized Canadians experience a whole range of adverse living circumstances that threaten not only their health but also the overall health and
well-being of Canadian society. Racism can take three forms, all of which will have impacts on health. Experiences of discrimination, racism and historical
trauma are important social determinants of health for certain groups such as Indigenous Peoples, LGBTQ+ and Black & racialized people, among others.

What do you think is missing from the list above?

Now take some time to consider the following:

• Indigenous culture, and Canada’s Truth and Reconciliation Commission
• Disability and the UN’s Convention on the Rights of Persons with Disabilities
• Food Insecurity
• Homelessness
• Substance use issues

Decolonization: Since Canada’s dominant society reflects a Eurocentric attitude, it is essential that we dig deeper into these SDOH to understand and decrease discrimination. As you consider these social determinants, notice how colonization continues to inform every area of society and how we might work to make change.

Government of Canada. (2022). Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html