This page contains a brief guide to the wider determinants of health tool and results from user testing and consultation.
The Wider Determinants of Health tool has been developed to support work around the wider determinants of health across the public health system. It was launched in March 2017 with a ‘work in progress’ status: indicators and resources will continue to be developed over time in collaboration with stakeholders.
The aim of the tool is to:
Wider determinants are a diverse range of social, economic and environmental factors which impact on people’s health. Such factors are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life. They determine the extent to which different individuals have the physical, social and personal resources to identify and achieve goals, meet their needs and deal with changes to their circumstances[1]. The Marmot review[2], published in 2010, raised the profile of wider determinants of health by emphasising the strong and persistent link between social inequalities and disparities in health outcomes. Variation in the experience of wider determinants (i.e. social inequalities) is considered the fundamental cause (the ‘causes of the causes’) of health outcomes[3], and as such health inequalities are likely to persist through changes in disease patterns and behavioural risks so long as social inequalities persist. Addressing the wider determinants of health has a key role to play in reducing health inequalities, one of PHE’s core functions.
Several studies have attempted to estimate the contribution of the wider determinants to population health (as presented by The King’s Fund[4]), finding that wider determinants have a greater influence on health than health care, behaviours or genetics. It is therefore an important aspect of public health in terms of informing preventative action and reducing inequality. In addition, both the Marmot review and the Dame Carol Black review[5] highlighted the huge economic costs of failing to act on the wider determinants of health.
The tool presents indicators split into 7 domains: Natural and built environment, Work and the labour market, Vulnerability, Income, Crime, Education, and Marmot indicators. Some domains cover a broader range of topics than others and can be sub-divided into more specific themes (the ‘natural and built environment’ for example covers the five themes of neighbourhood design, housing, healthy food, natural and sustainable environments, and transport networks). However, as the main tool does not currently have the functionality to present sub-domains, their usage is currently limited to the ‘Further resources’ section.
In addition to the 7 domains identified above, a ’health outcomes’ tab is provided to allow cursory explorations of the relationship between these indicators and the wider determinants.
Indicator selection is guided by the literature and expertise within advisory groups. The aim is to provide a selection of indicators across a range of topics, not to cover all wider determinants as this would be a very large set of indicators. The tool contains several types of indicators. There are direct indicators of wider determinants (e.g. greenspace in easy walking distance), indicators of risk factors or health behaviours closely associated with wider determinants (e.g. utilisation of greenspace for health/exercise), and indicators of high-level health outcomes which demonstrate the impact of wider determinants (e.g. inequality in life expectancy). Due to reliance on pre-existing indicators in the early stages of development, many indicators are proxy measures of wider determinants such as behaviours or outcomes (not direct measures) because such indicators are more commonly used in public health. Over time, more direct measures of wider determinants will be developed and will replace proxy measures where appropriate.
The data views in the tool present variation in the wider determinants of health across local areas (dependent on data availability) and allow exploration of indicators over time and by inequalities groups where possible. Through the ‘Further resources’ section, the tool also provides links to information to help users go beyond highlighting variation in the wider determinants and take further action. The section contains links to more data, information and ideas that can help you to explore the issues raised in this profile in more detail and inform actions to improve health outcomes.
For inclusion within the tool indicators typically must be available at upper tier local authority level as a minimum. It is recognised that lower level geographies are often required for local authority colleagues especially when developing interventions. The inclusion of lower level geographies is limited primarily by data availability, but also by functionality within the Fingertips system. Opportunities to include lower level data will be explored, including linking to other PHE tools such as Local Health which specialise in presenting small area data, including that on some health outcomes and some wider determinants.
Further functionality including downloadable local authority profiles and a wider determinants summary measure are planned.
[1] Dennis, R (2004). Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholar’s Pres Inc. [2] Marmot, M. G., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I. (2010). Fair society, healthy lives: Strategic review of health inequalities in England post-2010. [3] Link, B. G. and Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behaviour, extra issue, p80-94. [4] The King’s Fund. Time to Think Differently. Available online at: http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health. [Accessed 01.08.2016]. See citations to McGiniss et al. (2002), Canadian Institute of Advanced Research (2012) and Bunker et al. (1995). [5] Black, C. M. (2008). Working for a healthier tomorrow: Dame Carol Black's review of the health of Britain's working age population: presented to the Secretary of state for health and the Secretary of state for work and Pensions. The Stationery Office.
A user testing exercise was conducted at an early stage in the development of this tool. The results of this exercise can be read here. All feedback received has been considered and will feed into the ongoing development of the tool. Further user testing is planned. In addition to user testing exercises, the development of the tool is being guided by advisory groups.
