What are determinants of health?

There are many factors or ‘determinants’ that influence health; importantly, there is a close relationship between people's health and the circumstances in which they grow, live, work, play and age (Commission on Social Determinants of Health 2008). These in turn influence various health behaviours and other determinants.

Health determinants may be risk or protective factors, and they interact to influence the health of individuals and communities. These determinants have a considerable impact on health – often a larger impact than the health care individuals may receive (WHO 2017). Individuals have limited control over many determinants as they are shaped outside their area of influence.

A determinant of health impacts on health and wellbeing by increasing or decreasing the risk of disease or injury occurring. However, people can develop diseases without these risk factors. Also, if someone develops a disease when they do have these risk factors, it does not mean the risk factor caused the disease.

Health determinants include general socioeconomic, cultural and environmental conditions; living and working conditions; social and community networks; and individual behavioural and biological factors. The model in Figure 1 shows how these determinants interact with, and impact, health and wellbeing (Dahlgren and Whitehead 2021).

Figure 1: Model showing layers of health determinants

Source: Dahlgren and Whitehead 2021

Understanding health determinants and their relationships

The AIHW's framework for determinants of health illustrates important non-medical determinants that affect the health and wellbeing of individuals, population groups and the Australian population (Figure 2).

In the framework, determinants that can be modified are divided into 4 main groups (large boxes) and ordered from 'upstream' to ‘downstream’, reflecting the relationships shown in Figure 1. Downstream factors have the most direct impact on health and wellbeing. These downstream factors are influenced by midstream factors, which are in turn influenced by upstream factors. Individuals have more control over downstream than upstream factors like structural and environmental factors. This sequence is known as the causal chain and shows the path through which determinants such as the built environment or public policy can influence health and wellbeing. Determinants within each box often interact with, and are closely related to, each other. While the causal chain largely flows from the upstream to downstream factors, the relationships are complex and there are also influences in the other direction. 

Figure 2 also identifies factors that are not generally modifiable once a person has been born. These factors include antenatal and birth influences (including preterm birth and low birthweight), age, sex and intergenerational effects (bottom box). The associations between these and other determinants are important to understand as this will assist with prevention to support better health outcomes.

Figure 2: Framework for determinants of health

The pathways between these determinants and subsequent health outcomes are complex and inter-related. For example, upstream socioeconomic determinants affect many others further downstream, including health behaviours and biological factors. There is also evidence of more direct relationships between socioeconomic determinants and biological factors, such as inflammation (Berger et al. 2019; Hamilton and Steptoe 2023). Health determinants can have different impacts at various life stages, can accumulate over the life course and across generations (Department of Health, Disability and Ageing 2021; van Zwieten 2024). Further, many determinants influence more than one health outcome. This means that improving determinants further upstream (at the system level) is likely to be more effective as it can reduce the risk of poor health outcomes occurring within the population requiring treatment.

Evolution of the framework for health determinants

A framework for health determinants has been included in previous editions of Australia’s health (for example, AIHW 2004, 2010, 2020). The framework has changed over time as research increases our understanding. Some previously included determinants have become more prominent in recent times, such as indoor air quality (part of the built environment) and its importance in reducing the risk from communicable diseases including COVID-19, and exposure to pollutants and allergens (Furlow 2023; Braggion et al. 2024). A specific framework for Aboriginal and Torres Strait Islander people has also been developed and used for reporting since 2006 (AIHW 2020) and is consistent with the version in Figure 2.

Health determinants impact health and health equity

Figure 2 illustrates how health determinants impact on individual and population health and wellbeing. An important consideration is how the health determinants affect health inequalities and inequities. Health inequalities are differences in health between groups and health inequities are differences that are avoidable and unfair.

In all countries, regardless of national income levels, health and illness follow a social gradient: the lower an individual’s socioeconomic position, the higher their risk of poor health (WHO 2022).

To understand why this is, Diderichsen et al. (2001) developed a conceptual model of the relationship between health determinants and health inequalities (adapted in Figure 3). It relates health inequalities to unequal distribution (differentials) of determinants.

The distribution of power and resources that accompanies the socioeconomic gradient in a society is due to a range of social and structural determinants. Differences in power and resources can cause differentials in determinants. For instance, less power and resources can increase a person’s exposure to health risks, mean they are more vulnerable to disease and injury, and increase the social and economic consequences they may suffer because of ill health (Diderichsen et al. 2001; van Zwieten et al. 2024). The model also demonstrates that this relationship is compounding, with the social and economic consequences of ill health affecting upstream determinants that further reduce an individual’s access to power and resources.

For example, there is growing research on the impact of insecure housing on the health of individuals and the associated costs to the health system; meeting basic physical needs such as food, water and a place to sleep can be the most important day-to-day priority for people experiencing homelessness, especially those rough sleeping (AIHW 2025).

Health outcomes for people experiencing homelessness can be improved through access to appropriate housing combined with targeted supportive services, such as health or medical, mental health and disability services. While housing alone is not sufficient to improve health outcomes, it is a necessary foundation for creating better conditions that enable better health (Kuehnle et al. 2022).

Additionally, there is evidence that the health benefits associated with secure housing following a period of insecure housing are (Carnemolla and Skinner 2021):

• decreased rates of hospitalisation
• reduced transmission of infectious diseases
• improved mental health symptoms
• overall improved wellbeing.

Another example is social determinants of health influence on a women’s capacity to access and understand health information. Research by Davison et al. (2024) indicated that some social determinants of health limit women’s ability to access and understand health information; speaking a language other than English at home, not having completed tertiary education, being financially disadvantaged, and being of Aboriginal or Torres Strait Islander origin were all associated with a diminished ability to access and understand health information.

Figure 3: How differences in health determinants contribute to health inequalities

Source: Adapted from Diderichsen, Evans and Whitehead (2001) 

Addressing health determinants through prevention

Health prevention is an action to keep people healthy and well, and to prevent or avoid the risk of poor health, illness, injury and early death (The Australian Prevention Partnership Centre n.d.). It aims to increase the likelihood that people will stay healthy for as long as possible. As well as reducing the likelihood that a disease or disorder will affect an individual, it also aims to interrupt or slow the progress of the disorder and reduce associated disability (WHO Global Forum on Chronic Disease Prevention and Control 2004). This is sometimes referred to as secondary and tertiary prevention (Last 2001).

Prevention activities can either be aimed at individuals or small groups such as health advice from general practitioners and preventive treatment at the community level, or provided for the whole population (AIHW 2009). The most effective prevention programs often combine all elements, as well as spanning many components of risk. For example, tobacco control includes individual support to quit, and population wide measures like taxes, regulations around sales and advertising; and road safety spans seat belts, safer cars/roads, drink driving laws and enforcement.

The relationships between the many determinants of health and health outcomes are complex. However, this complexity does provide many potential points of intervention to promote health and reduce the risk of ill health. 

Australia’s National Preventive Health Strategy 2021–2030 (NPHS) aims to improve the health and wellbeing of all Australians at all stages of life, through a whole-of-government approach to prevention that addresses the wider determinants of health, reduces health inequities and decreases the overall burden of disease. The NPHS strongly emphasises that preventive action must focus on the wider determinants of health to address the increasing complexity of health issues and the interconnected causes of poor health and wellbeing.

The NPHS contains 4 high-level aims (Department of Health 2021):

• All Australians have the best start in life.
• All Australians live in good health and wellbeing for as long as possible.
• Health equity is achieved for priority populations.
• Investment in prevention is increased.

The Strategy outlines that the value of prevention is more than preventing disease and promoting a long healthy life. Other benefits include reducing costs (Department of Health 2021):

• of future health care
• for households (such as from tobacco purchases)
• from productivity losses (absenteeism, presenteeism)
• for law enforcement (such as for illicit drug use).

The Strategy also highlights the importance of monitoring and surveillance in tracking the effectiveness of initiatives, as well as where additional effort may be needed. Emerging risks within the natural environment such as chemical contaminants and microplastics in air, water, soil and food are important determinants of health. Ongoing monitoring of evidence and research is required to understand and characterise risks, assess their health impacts, as well as inform health policies. For more information see Natural Environment and Health. 

It is important to monitor the health determinants, particular groups impacted and whether there are changes over time. This can inform specific policy actions for the whole population or for specific population groups, such as First nations people.

Where do I go for more information?

For more information on determinants of health, see:

• World Health Organisation Determinants of health
• Australian Government Department of Health and Aged Care National Preventive Health Strategy 2021–2030
• AIHW Australia’s health 2020: data insights article ‘Social determinants of health in Australia’.