Health & Healthcare Under Siege: Determinant History and Weighting

The United States is abnegating its responsibilities for protecting and promoting the health of its citizenry. Over the past 46 years a series of health determinant categories have been referenced in the literature. Worldwide acceptance of the legitimacy and importance of these determinants has been recognized by?many societies, and most notably by an overwhelming majority of the Healthcare and scientific sectors. By not engaging with these determinants holistically, the U.S. healthcare system is missing an opportunity and ignoring a necessity.

Precise quantification of negative health contributions in each of these determinant categories, and within their respective drilldown subcategories, is not yet possible. Equally unquantifiable are their combinatorial impacts. But health determinants should undeniably be further explored, and sustained initiatives should be undertaken to ameliorate the health hazards that they present.

The first article in this series, Threats and Obstacles, enumerated several longstanding and recent impediments to patient and population health. It presented this graphic displaying an estimated impact of 4 health determinant categories, and presented the value ranges provided from four sources.

It is important to note that there are no accepted standards as to either specific or relative weights of various influence factors often identified as health determinants. In fact, there is no unanimity as to precisely how many there are. However, compartmentalizing and treating these health and illness impact categories as discrete entities is a fool’s errand, as they are all interrelated and must be addressed collectively.

All societal sectors can make positive contributions to health determinant categories, but it is the primary purpose of this series of articles to suggest how and why the Clinical Care sector in particular is arguably best positioned to effect meaningful change. Responsibility calls!

Let us take a look at the design, framing and processes employed to standardize and amalgamate the sources category impacts in our graphic.

The good news is, these four sources highlight the important role that these influences play in the continuum of patient and population health. The bad news is that precious few entities have over the years participated in the quantification Olympics. But those that have should be appreciated for their contributions and persistence in keeping the Health Determinant impact games alive.

This article is not intended as an expression of the writer’s positions as to the snippets included or the articles from which they are taken. It serves to display some thoughts and ideas that each source had when it initially began weighing in on our Health Determinant impact journey. So what they have to say reflects the time when they started their respective inputs and might lend some inkling as to weighting fluctuations over time.

Examples in point are the one-offs Canadian Index of Well Being and Health Affairs, whose categories and relative weightings reflect the thinking of their times. On the other hand, our graph utilizes the current weighting distributions of both AHR and County Health Rankings, both of whom have relentlessly kept the weighting game alive. It is high time for other players to join the weighting bandwagon to reflect the need for more attention, better understand the negative health impacts that they inflict and to contribute to further identifying and ameliorating the damage that they continue to cause.

I must point out that after I selected my four weighting sources, a further drilldown revealed that they often refer to each other, and three of the four directly give credit to the 1974 Lalonde Report which I have chosen to present a trigger for the introduction, identification, nomenclature, and weighting distributions over time.

But Lalonde contributed more than setting the stage for further determinant development and relative impact assessments. It pointed to the fragmentation of responsibilities and efforts among entities that both can and should positively impact health. It postulated that these fragments should be unified to better equip participating entities to establish and maintain a coordinated mission to improve patient and population health. How well are we doing on this score in 2021—feeble at best, in my estimation.

So, what’s it all about Alfie? Why intermingle and graph multiple determinant impact estimates over time? Why present considerations and snippets from our four sources herein and provide source links to permit readers to drill down further? Because they are seeds! Seeds for further analysis, seeds for scientific discovery, seeds for actionable intelligence development, seeds for information and knowledge disbursement and seeds for incremental patient and population health improvements. And also, because our sources have served as trailblazers in grouping and assigning determinant weights.

Let it be said that there exists a plethora of studies, scholarly publications and other valuable resources that can serve as additional and powerful calls to action to work toward positive changes, irrespective of determinant weightings. But these scientific and academic studies and articles must be summarized, simplified and distributed to other determinant sectors and the general population, and not hidden away in scientific and academic receptacles and/or sector silos.

While the remainder of this article will be exploring the past and how we got where we are today, never fear: the next entry in our series, “Stanch the Covid Bleeding”, will draw our attention to Covid disinformation and misinformation and provide some practical steps that should be taken to move toward damage control and hopefully eventual extinction. So let me yield the floor to each of our sources and let them share some respective insights.

The Healthcare space owes a debt of gratitude to a working paper released in April 1974 by Canadian Minister of Health and Welfare Marc Lalonde. “A New Perspective on the Health of Canadians” (PDF) presented a foundational framework that broadened the spectrum of factors contributing to individual and population health. It challenged a traditional view that the level of health was equated to the quality of clinical care. It introduced what it termed the “Health Field Concept,” which has over time morphed into what have come to be referred to as Determinants of Health.

“A basic problem in analysing the health field has been the absence of an agreed conceptual framework for sub-dividing it into its principal elements. Without such a framework, it has been difficult to communicate properly or to break up the field into manageable segments which are amenable to analysis and evaluation. It was felt keenly that there was a need to organize the thousands of pieces into an orderly pattern that was both intellectually acceptable and sufficiently simple to permit a quick location, in the pattern, of almost any idea, problem or activity related to health: a sort of map of the health territory.

One of the evident consequences of the Health Field Concept has been to raise HUMAN BIOLOGY, ENVIRONMENT and LIFESTYLE to a level of categorical importance equal to that of HEALTH CARE ORGANIZATION. This, in itself, is a radical step in view of the clear pre-eminence that HEALTH CARE ORGANIZATION has had in past concepts of the health field.?

A second attribute of the Concept is that it is comprehensive. Any health problem can be traced to one, or a combination of the four elements. This comprehensiveness is important because it ensures that all aspects of health will be given due consideration and that all who contribute to health, individually and collectively, patient, physician, scientist, and government, are aware of their roles and their influence on the level of health.?

A third feature is that the Concept permits a system of analysis by which any question can be examined under the four elements in order to assess their relative significance and interaction The paper further espoused that environmental and behavioral threats to health must be counterbalanced by positive environmental and behavioral changes, thus adjusting health care system values and practices to raise “Care” to the same level as “Cure”.?

One of the main problems in improving the health of Canadians is that the essential power to do so is widely dispersed among individual citizens, governments, health professions and institutions. This fragmentation of responsibility has sometimes led to imbalanced approaches, with each participant in the health field pursuing solutions only within his area of interest. Under the Health Field Concept, the fragments are brought together into a unified whole which permits everyone to see the importance of all factors, including those which are the responsibility of others.?

This unified view of the health field may well turn out to be one of the Concept’s main contributions to progress in improving the level of health.”

It took sixteen years for the weighting game to enter the picture and start the numbers game rolling.?

In 1990, the United Health Foundation introduced America’s Health Rankings (AHR) which, to this day, annually provides weights to its menu of Health Determinant categories: currently Social and Economic Factors, Physical Environment, Clinical Care, Behaviors, and Health Outcomes.

Let’s take a gander at how they describe their current model.

“America’s Health Rankings? is built upon the World Health Organization definition of health: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

The understanding of population health has changed considerably over the past 30 years. Beginning in 2020, the America’s Health Rankings is transitioning to a new model that reflects a growing understanding of the impact social determinants have on health and the need for collaboration and action by stakeholders across sectors to reduce inequities and improve health outcomes.

The new model was developed under the guidance of the America’s Health Rankings’ advisory council and committees, with insights from other rankings and health models, namely County Health Rankings & Roadmaps and Healthy People. The model serves as a framework for identifying and quantifying health drivers and outcomes that impact state and national population health.”

It is important to note that America’s Health Rankings treated Policy as a determinant category until 2020. In my view Policy/Legislation is an extremely important individual and population health influence source. However, I prefer to treat it as a subcategory of each of the four determinants in the graphic.

Twenty-seven years after proffering a foundation in Lalonde, Canada came back into the picture and formally joined the quantification Olympics with the Kirby Report. In 2001, The Standing Senate Committee on Social Affairs, Science and Technology published an interim report on the state of the health care system in Canada titled: “The Health of Canadians - The Federal Role - Volume One - The Story So Far” (PDF).

The following brief excerpt from this report echoes Lalonde and updates some terminology and labeling:?

“The term “population health” is used to describe the multiplicity and range of factors which all contribute to health. “Determinants of health” is the collective label given to the multiple factors which are now thought to contribute to population health. While there is no agreement on a finite set or the relative importance of the determinants of health, a certain degree of consensus has developed over the past decade.”

If the spirit moves you to eyeball the weights and not read the 1208 page report in its entirety, the list of Health Determinants Weights presented in Graph 5.10 on page 81 of “The Health of Canadians” was provided by Health Canada.?

“It must be pointed out that the population health approach does not detract from the impact of the health care system, but it includes additional factors or determinants of health and takes the interaction between and among the determinants into consideration.”

Kirby provided relative impacts of four determinant categories: Health Care System, Social and Economic Environment, Biology and Genetic Endowments, and Physical Environment.

Just one year later, Health Affairs presented an article by three Robert Wood Johnson Foundation professionals titled “The Case for More Active Policy Attention to Health Promotion”. In the article, J. Michael McGinnis and two colleagues recognized and built upon themes expressed in Lalonde back in 1974.

“One of the most-cited statistics in public health is the imbalance of social investments in medical care compared with prevention activities. Approximately 95 percent of the trillion dollars we spend as a nation on health goes to direct medical care services, while just 5 percent is allocated to population wide approaches to health improvement.

The fact that medical care historically has had limited impact on the health of populations has been known for many years. In 1974 Marc Lalonde, then the Canadian minister of health and welfare, issued a seventy-six-page governmental working document that advanced the idea that government priority is drawn primarily to the financing and delivery of medical care, with scant attention to many other influences on health.”

The article goes on to present relative impacts of five domains (AKA Determinants) on patient and population health: Behavior. Social Circumstances, Environmental Conditions, Behavioral Choices and Medical Care.

The Health Affairs article also suggested that the enormity of the growing number of?challenges, obstacles and threats that besiege Health and Healthcare from within?each of these determinant categories, and the intersection among categories, combined to further complicate the maze of negative and potentially positive health impact contributors. A new impact assignment hierarchy was introduced, and Behavior and Genetics got first and second place respectively in the impact competition. Behavior stayed at the top of the heap for another 8 years until further studies were conducted and another notable working paper stepped to the fore.

Let’s motor forward to February 2010 when The University of Wisconsin Population Health Institute climbed aboard the Determinant Ranking Train on which they have been riding ever since. “Different Perspectives for Assigning Weights to Determinants of Health” (PDF).

Let’s take a look at some of what this Working Paper had to say.

“The goal of the County Health Rankings is to engage multiple sectors in community health improvement. Some sectors are likely to be able to exert more influence on some health factors than others.. For example, the health care sector not only can influence measure of health care but can also make significant contributions in the area of health behaviors as well. So, even though research may show that clinical care itself may have a smaller impact on health outcomes than health behaviors, the health care sector can influence health behaviors as well as clinical care.

By the beginning of the 21st century, research had begun to focus farther “upstream” on those factors that increase the risk of not only diseases, but also the predisposing behavioral and other risk factors. According to the Institute of Medicine’s report, The Future of the Public’s Health in the 21st Century, “the greatest advances in understanding the factors that shape population health over the last two decades has been the identification of social and behavioral conditions that influence morbidity, mortality, and functioning” (Institute of Medicine 2002). Research has increasingly demonstrated the important contributions to health of factors beyond the physical environment, medical care, and health behaviors, e.g., socioeconomic position, race and ethnicity, social networks and social support, and work conditions, as well as economic inequality and social capital (Institute of Medicine 2002).”

The 4 Determinant Categories addressed by the initial Working Paper were: Health Behaviors, Clinical Care, Social and Economic Environment and Physical Environment. The historical perspective section referenced AHR and Health Affairs as well as our 1974 neighbors to the North. To wit:

Let’s venture on to the year 2018 to bring our forty-four year reminiscence to a close. The County Health Rankings Key Findings Report of 2018 introduced a potential picture of the Health and Healthcare Promised Land.

So, just as Lalonde planted the seed to launch the Health Determinant Journey, the Key Findings report might well be introducing a vision of what an ideal future should look like.

“Imagine a place where everyone has a fair and just chance to lead the healthiest life possible – communities with high quality schools, good paying jobs, access to healthy foods and quality health care, and affordable housing in safe environments. Imagine a place where differences in race, culture, and perspectives are not only tolerated, but are celebrated as fundamental to health and wellbeing. Imagine that this is how we all experience our communities, regardless of where we live, the circumstances we were born into, or how we look. This is the vision of health equity.”

Well folks, how is the Good Old USA doing on the path to the Promised Land as we’ve reached forty-seven years into our Health Determinant journey? Not so well as I suspect you already know!

Let us introduce here a graphic displaying selected subcategories for each of these determinants, to set the stage for developing a blueprint for pathways to positive changes. All societal sectors have a humanitarian responsibility to address and improve all of these potential trouble spots. But this matrix is specifically designed to build and showcase a role for Healthcare.

More trouble ahead! Immediate, mid-term and long-term intervention opportunities down the road. Next Up: Health & Healthcare Under Siege: Stanch the Covid Bleeding. Stay tuned!

Other entries in the Health & Healthcare Under Siege series:

• Article 1: Threats and Obstacles