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Social Determinants of Health

Learn more about the social determinants of health.
If we think of a flowing river and people falling into that river we could spend all of our time pulling people out of the river treating them. This is similar to a healthcare system that is predominantly reliant on tertiary hospitals. If we were to walk further up the river there are still people in the river, but a local person is throwing in life saving equipment that will help them to float. This is similar to work in primary care where people are provided with preventative medication such as hypotensive treatment or supported to stop smoking.
However, if we were to move further upstream, we may find that the reason people are falling into the river is because the bridge is broken or perhaps the path is too near the cliff edge. So, by moving upstream and repairing the bridge or moving the path people it is hoped can remain safe. This upstream approach can be equated to preventative work on policy to improve our environment, food supply and education, for example, which all have a positive impact on our health. So now that you have explored the concept of moving health upstream lets look at a model of the social determinance of health. The Dahlgren and Whitehead model displays the multi factorial nature of health.
It is also known as the policy rainbow. At the centre we have aspects that are not readily amenable to change such as age, sex and hereditary factors. From here the rainbow moves to help us consider issues that are modifiable. Lifestyle factors such as diet, tobacco use, alcohol use and physical activity are influenced not purely by choice but also the social and community networks in which we live. For example, if we live in an area where most people smoke, we might consider this is a norm and be more likely to smoke.
At the top level of general socio economic cultural and environmental conditions you can see from the policy rainbow the multitude of different elements that impact on our health, such as education, water and sanitation and healthcare services. These issues have a profound impact on our health and require the organised efforts of society to ensure that there is a systematic industrial scale approach to all of these issues. Health is, therefore, not just about lifestyle. People who live in poor socio economic circumstances are more likely to be in poorer health that results in premature death than those living in higher socio economic groups. Evidence shows that prolonged stress as a result of unemployment damages peoples health.
Worldwide there is a clear social gradient on health with the poorer in society facing the biggest burden of premature mortality and morbidity. In some countries, people can still live until they are over 80 years of age in others less than 45 years. Therefore, if we are to improve health we need to ensure there is a system wide approach to intervention. System wide incorporates all elements of the national and local health systems to improve health outcomes.
Closing the gap in a generation by the World Health Organisation identified the need to address this social injustice by improving daily living conditions by ensuring equity from the start with a comprehensive approach to early years support for children, healthy places, healthy people to ensure that health is central to governments and planning, fair employment and decent work, social protection policies to support income levels, universal healthcare, tackle the inequitable distribution of power, money and resources and measure and understand the problem and assess the impact of action. As a nurse, it is therefore, important to understand not only the patient presents to you but to think about the impact that their social determinance may have on their health.
Do you routinely ask patients questions about lifestyle, social and community networks, socio economic cultural and environmental conditions? What about the needs of the population that you work for?

In this step, we will explore a model of the social determinants of health, review how this model of the social determinants of health can impact on your practice, and look at the points at which you, as a nurse, can intervene to improve health.

As healthcare practitioners, it is important that we recognise that health is a much bigger issue than only ensuring a population has access to good quality healthcare services. As Nightingale understood, health is a social, political, environmental, and economic issue.

Watch this video, in which Pauline starts by explaining the concept of downstream, midstream, and upstream healthcare and the importance of moving health upstream. She then goes on to look at the Dahlgren and Whitehead model which displays the multifactorial nature of health – aspects that are not readily amenable to change and lifestyle factors that are modifiable. This model is also known as the policy rainbow.

You can access a copy of the Dahlgren and Whitehead policy rainbow from the Downloads section at the bottom of the page.

Your Task

In the discussion, share your area of nursing practice (e.g. diabetes, intensive care, children and young people) and identify how you can intervene upstream on up to four elements of the Dahlgren and Whitehead model.


Dahlgren, G., and Whitehead, M. (1991) Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Future Studies Stockholm

Dahlgren, G., and Whitehead, M. (2007) European Strategies for Tackling Social Inequities in Health: Levelling up Part 2. [online] Copenhagen: WHO. available from [18 June 2018]

WHO (2008) Closing the Gap in a Generation. Geneva: WHO

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