Determinants of health and health inequities
Determinants and the gradient
Determinants of health include biological, behavioural, social, economic, cultural and environmental factors. They are often grouped as proximal (individual behaviours and biology), intermediate (housing, education, health services) and distal (policy, income distribution, discrimination). Social determinants include income, education, employment, housing, food security, social support and early childhood. Cultural determinants for Aboriginal and Torres Strait Islander peoples include connection to Country, kinship, language and self-determination. Health inequities are avoidable, unjust and unfair differences between groups; they are not the same as all variation. The social gradient shows that health improves stepwise with socioeconomic position.
Traps
Questions often reward blaming individuals for poor health while ignoring structural constraints. Do not label every difference an inequity: biological sex differences or random variation may not be unjust. Avoid confusing risk factors (smoking) with determinants (policy that makes smoking affordable and accessible). Intersectionality matters: a rural, low-income older person may face compounded disadvantage.
Worked example
Two communities have similar smoking rates, but one has poorer lung cancer survival. The difference is linked to delayed diagnosis because of distance and limited specialist services. That is an inequity: it is avoidable, unfair and shaped by service access. A response should improve access, not only tell people to quit.
Rule of thumb: before calling a difference an inequity, test whether it is avoidable, unjust and unfair.