Table of contents

Part 1 - Theory: Thinking About Health

Chapter 2 Determinants of Health and Health Inequities

Determinants of Health

Almost every characteristic of a society can affect the health of its citizens, so could be considered a health determinant. To make this topic manageable, agencies such as Health Canada and the WHO have identified key health determinants that deserve special attention; the major ones are reviewed below, while the supplementary materials box shows a fuller listing of determinants.

Public Health Agency of C…

Public Health Agency of Canada list of health determinants10

Income and social status

Social support networks

Education and literacy

Employment & working conditions

Social environments

Physical environments

Personal health practices and coping skills

Healthy child development

Biology and genetic endowment

Health services



World Health Organization list of social determinants of health3

Improve daily living conditions:

Early child development

Urban planning

Fair employment & decent work

Social protection systems

Universal health care

Tackle the inequitable distribution of power, money and resources:

Make health equity a priority for all government sectors

Allocate resources to health

International regulations

Gender equity & empowerment

Good global governance

Measure and understand the problem and assess the impact of action:

Monitoring, research, training

Early childhood development

In treating a disease, a doctor intervenes in a process that was often established many years earlier. In thinking about causes, many take a life courselife coursea perspective in considering the causes of health conditions that traces antecedent circumstances back to early childhood and emphasizes the long-term impact of distant causal influences. perspective that extends the disease origins even further than that shown in Figure 2.4, sometimes even to exposures faced by a person’s parents. The life course perspective emphasizes that early experiences have a profound formative impact on an adult. Early nutrition, physical development and fitness are important, as is emotional development which, if positive, builds resiliency, and if negative, enhances vulnerability. Timing of exposures and experiences can be critical.11 For example, traumatic experiences in early childhood shape personality and have a lasting impact on how a person views his world, how he relates to others, and how he interprets events. The impact of broken homes, chronic childhood stresses and so forth have non-specific effects, acting mainly to increase emotional vulnerability in adult life. The recognition of critical periods in early child development has led to the popularity of infant stimulation programs, such as Head Start.

Head Start Head Start …

Head Start

Head Start was established in the U.S. in 1965 as a way to ensure that young children from impoverished families were ready for entry into kindergarten at age five. They offer a comprehensive preschool and family support program for families with low incomes, preparing children to succeed in their early educational experience. Programmes typically offer access to prenatal care, child care and nutritious meals for young children. In Canada, Head Start programmes were developed for indigenous peoples starting in 1995; there are now 125 Aboriginal Head Start sites in urban and northern communities across Canada (see

Income and social status

Figure 2.1 gave just one example of a link between a person’s social status and their health. A person’s social status is defined by a combination of their wealth, education, occupation and lifestyle, and (secondarily and to a varying extent) by other factors such as ethnicity, personality, and happenstance. Each of these, alone or in combination, can exert positive or negative influences on a person’s health. Whatever marker of social status is used (wealth, education, occupation, or power), and whatever the health indicator (longevity, death rates, morbidity, or self-reported distress), there is a universal tendency for those in higher social positions to enjoy better health. Exceptions are rare and often transient (an example occurred in the 1930s, when heart disease was on the rise, and cases often occurred in richer people who could afford a cardiogenic diet and sedentary lifestyle. Subsequently, the decline in heart disease has occurred more steeply among richer people so that the familiar social class gradient now holds).12 The association between social status and health is now termed social inequalities in health (see Health inequality in Glossary) and is summarized in many sources.1,13,14

Indicators of social posi…

Indicators of social position

A person’s position in society influences his or her health in a myriad of ways: through lifestyle (diet and opportunities for healthy exercise will vary according to wealth), educational level (which may affect understanding of health risks, and may influence ability to follow treatment guidelines), occupation (which may pose health hazards for those in dangerous or stressful occupations—Paul’s accident was caused by working in a dangerous occupation at a particularly stressful time), living conditions (Mrs. Sulawesi’s son Peter’s asthma attacks are likely exacerbated by the damp conditions in their apartment), and so on.

Social position cannot be measured directly, but must be described via one or several indicators (rather as health itself cannot be measured directly). The commonest indicators are income (or overall wealth), education, and occupation. There is no simple guideline as to which indicator of social position is best, and the choice will depend on availability of information, and sometimes the nature of the health condition will dictate one indicator or another (a study of occupational lung disease will probably use occupational classification as the main indicator). In non-specific applications each indicator has advantages and limitations. Income offers a useful predictor of lifestyle characteristics, such as diet or living conditions, which may be relevant for some health conditions. But income usually has to be adjusted to consider the number of people the income is supporting and income may give a poor indication of lifestyle for groups such as students, whose poverty is presumably temporary. Educational attainment has the advantage of remaining relatively stable for people over about 25 and to some extent it will predict income, and can also prove useful in predicting conditions such as cognitive impairment. Occupational group can be difficult to classify and, like income, can change rapidly making an occupational history difficult to summarize. But occupation can be very important as a health predictor, for people with identical incomes and education but who work in very different environments are exposed to very different health risks. Occasionally, studies use a composite indicator of social position based on all three indicators, but more commonly one is chosen, based on the nature of the health condition and the availability of the data.

The most obvious of these influences is income − especially insufficient income − described either in relative or absolute terms. Absolute poverty refers to having inadequate resources to meet basic needs for shelter, nutritious food, clothing, and education. People living in poverty lack the resources and opportunities to make choices that promote good health. Being poor may also expose them to inferior physical environments that place them at risk for health problems. Absolute poverty is the leading health determinant in low-income countries; infants and children are particularly susceptible to its effects. In wealthy countries, however, it is not only the very poor who suffer health disparities, as was shown in the health gradient in Figure 2.1.15 The existence of the gradient in health across income groups indicates that relative income, rather than absolute poverty, should be used in analyzing health inequalities in middle and higher income countries. Relative poverty denotes an income level that is substantially lower than that of other groups within the community, and moves beyond a simple binary contrast between rich and poor, to represent the social gradient (see Nerd’s Corner box).

Relative versus absolute …

Relative versus absolute income

An income gradient in health does not necessarily mean that it is income itself that is producing the effect; income may be a marker for a range of possible causal factors (living environment, lifestyle, etc). Indeed, relative social position is often a stronger predictor of health than absolute income level, suggesting that it is not the actual money that is influential. A person who earns $20,000 per year tends to have better health if that is the average income in the country versus when this income places him low down on the income ranking.

If relative position influences health, it follows that population health will be less good in a society where there is a wide spread in the social hierarchy, where there are both very rich and also very poor people, compared to a society with a narrow range of hierarchy or income. Hence income disparity is an important determinant of health: among richer countries the range of income may have a far greater impact on population health than the mean income level. There has been much discussion of this provocative finding, and several plausible explanations have been proposed. Some of the channels through which social status and disparities in status within a region affects health are described by Wilkinson and Marmot, and by Kawachi et al.15,16

We know Paul’s disab…

We know Paul’s disability and precarious work situation may be a source of economic hardship and may affect his standing in the community. He has smoked and gained weight, both of which contribute to his risk of cardiovascular and other diseases. But it may be his perception of his position in life, his status that drives his behaviours. Belief that one’s status is low is more likely to be an issue in a society with wide disparities than in a more egalitarian society. Dr. Rao may need to incorporate this awareness in his approach to Paul’s behaviour.

Working with patients in …

Working with patients in poverty

Many health agencies are designed to deliver care to poor people. For example, Community Health Centres in Ontario often treat uninsured and homeless people, creating an atmosphere in which these people can feel at ease. CHCs are staffed by a medical and social services team that includes physicians, nurse practitioners, nutritionists, social workers, and community outreach workers. They tailor programmes to the needs of their local clientele, and may provide interventions such as a harm reduction unit, workshops for recent immigrants, classes on cooking on a low budget, and so forth. Members of ethnic groups can often use the centre after hours for meetings and to arrange mutual support.

Education and literacy

Education is one of many characteristics that both contribute to, and also result from, social position. A person’s social position in childhood influences their access to educational opportunities. The resulting education influences their social position in various ways: by its impact on employment opportunities, by determining their income, and by influencing whom they meet and where they live. Each of these factors indirectly influences a person’s health. But education also has a more direct influence on health in that it affects a person’s ability to navigate the health care system, to interpret health information and to communicate effectively with physicians and other professionals.17,18 ‘Health literacy’ refers to the patient’s ability to understand health information and to follow guidelines for their treatment. Physicians need to be aware that a large fraction of their patients may not be able to understand information concerning their health in the format that it is given. Educational attainment can also act as a risk factor for certain conditions; dementia offers an example. Here, a lack of education may lead to careers that expose the worker to neurotoxic substances that damage brain function. Conversely, higher education, and the stimulating careers that go with it, may build complex neural networks that protect the aging brain.19

As a child, Paul was not …

As a child, Paul was not interested in school. He had difficulty keeping up with his class. His parents didn’t see the importance of schooling: there were solid jobs in mining which didn’t require schooling. However, as the mining industry came under pressure, company managers began to take short cuts around safety legislation. Paul began to realise that his job was insecure, this worried him, but he couldn’t see a way out, he was forced ignore safety procedures and work long hours. It was at the end of a 12 hour shift that Paul, carrying a heavy, awkward load, fell and twisted his neck, resulting in the injury that put him off work.

Social support networks

Mrs Sualwesi lacks a supportive social network. No-one else here speaks her native language and she feels alone in a strange place. Social support benefits health in several ways. It is a source of emotional reassurance and provides a safe place for a person to discuss his problems, which helps him to cope with adversity. Social support provides information and practical support, such as knowing someone who can assist in a time of need. It can also support people in making healthier behaviour choices. The 2003 General Social Survey showed that self-reported health was positively associated with having a network of strong social ties, with belonging to organizations, with reciprocity (those who both give and receive assistance) and volunteering, and with receiving help to carry out daily activities.20

The same association between social ties and health holds at the population level: healthy communities establish collaborative networks that help them address social and economic issues. Social capitalSocial capitalthe power to effect social change that derives from people’s willingness to collaborate in groups and engage in collective action; the collaboration generates mutual trust and confidence. refers to people’s willingness to collaborate in groups and engage in collective action, which in turn reinforces trust and confidence within the networks; neighbourhood watch programmes are an example. By contrast, low social capital is characterized by an unwillingness to collaborate with others who are perceived as different and typically occurs where there are wide disparities in income and a perception of social inequalities. Kawachi et al. showed that low social capital was related to higher mortality, while membership in social groups was linked to lower all-cause mortality.16 A cross-national review of research identified links between social capital and improved health, greater well-being, better care for children, and lower crime.21

Employment, working conditions, and occupational health

The WHO recognizes fair employment and decent work as a cornerstone of health, and advocates for fair minimum wages, full employment, and occupational health and safety standards.14 Although Canada’s overall unemployment rate (6.3% in 2008) is enviable in international comparisons, there are inequities across the regions of Canada and across different population groups (for example, 11.5% of recent immigrants are unemployed and many more are underemployed).22

Work stress affects many Canadians, especially women.23 It coincides with other determinants, such as income, in that the lowest income households report high rates of work stress due to job insecurity and dissatisfaction. Workers who perceive work insecurity experience significant adverse effects on their physical and mental health.24 Work strain arises from a combination of high psychological demands (such as having to work fast) at the same time as having little freedom to make decisions affecting the job (e.g., being in a subordinate position)25. All of these challenges describe Mrs. Sulawesi’s job. It also results from a mismatch between work effort and reward: jobs that demand high effort for low gain produce feelings of strain that predict poor health.26 A study that followed 10,000 British civil servants over 10 years showed that those who had little control over their work environment had an increased risk of subsequent heart disease. Providing a greater variety of tasks and more decision-making power at work may decrease risk.27

Work stress (see Work-rel…

Work stress (see Work-related diseasesWork-related diseasesdisease that is caused or exacerbated by the patient’s work. (Distinguish from Occupational disease.) in Glossary) derives from the amount of a person’s perceived control over demands at work, their work satisfaction, perceived levels of physical risk, and job security.

Currently, Paul is not em…

Currently, Paul is not employed and is receiving Worker’s Compensation benefits. We do not know his level of work stress at the time of his accident, but it is likely that mining created significant physical and perhaps mental stress associated with high-risk work. While Worker’s Compensation may address some of his financial worries, it is not going to match the income he earned as a miner, and his prospects for future employment are limited. The symptoms he is experiencing are worsened by this stress. This further reduces his likelihood of finding work.

The strain of family duti…

The strain of family duties: caregiving

Having a sick or aging relative often imposes unpaid work, especially for women. For caregivers who are also employed, it can increase work stress and harm their job security due to absences to care for the relative. The resulting reduced income affects the whole family. In 2006, the Compassionate Care Benefit under the Employment Insurance Program was introduced to reduce stress by providing additional income to individuals caring for sick relatives.

Occupational diseases are disorders that result from conditions in the workplace, typically from exposures to physical, chemical, and perhaps psychological hazards. Asbestos exposure leading to mesothelioma is an example. These are environmental hazards that occur in concentrated form in workplaces; treating and preventing such diseases forms the purview of occupational medicine(see Occupational health in Glossary). Occupational diseases may be distinguished from work-related disorders (see work-related disease in Glossary), which are conditions that originate in other domains of the patient’s life but are exacerbated by their working conditions. Cardiovascular disease or low back pain, for example, may develop over the long term and could have occurred in the absence of work strain, but may be aggravated by a person’s work. Occupational diseases may be distinguished from occupational injuriesoccupational injuries injuries that result from trauma such as strains or sprains, lacerations, burns or bruises acquired in the workplace., which result from trauma such as strains or sprains, lacerations, burns, or bruises acquired in the workplace. Occupational injuries mainly result from mechanical factors, such as lifting or bending, or from failures in safety measures. Work injuries are an important source of disability and mortality in Canada. In 2003, 630,000 workers had at least one activity-limiting occupational injury, occurring more commonly among men than women (5.2% versus 2.2%). The lower a worker’s income, the more likely they are to experience a work-related injury.28

The field of occupational health involves the management and prevention of occupational diseases and injuries, as well as the improvement of work settings in general. It is based on the simple idea that work and health influence each other, at times positively and at times negatively. The role of the occupational health physician is to maintain a positive relationship between the two.

The physical environment

Environmental influences on health can be positive or negative, and cover a wide range of factors, from global (climate change) to national and regional issues (economic recessions, strife, air, and water pollution) to issues in the local built environment (indoor air quality), to the social environment. The positive benefits of spending time in beautiful surroundings are well understood, but most medical research focuses on negative aspects of the environment. Exposures to contaminants in air, water, food and soil, are associated with many chronic diseases and with emerging communicable diseases. Climate change and the associated weather extremes will also affect health: hyperthermia from extreme heat, injury from extreme wind and rain, social disruption from sea level change and agricultural effects, and changing distribution of vectors and infectious agents introduce disease to previously unaffected regions.

Environmental health cons…

Environmental health considers all the physical, chemical, and biological factors external to a person that may affect their health, and also social factors that influence health behaviours. It encompasses the assessment and control of these factors in order to prevent disease and create health-supporting environments

For further information o…

For further information on environmental health, the Canadian National Collaborating Centre for Environmental Health is one of six public health collaborating centres.It undertakes systematic reviews of environmental health hazards and prepare policy guidelines. The web site includes literature reviews, news reports, and policy statements and describes innovative practices. See

On a global scale, the World Health Organization maintains and environmental health website at:

Air pollution in Canada …

Air pollution in Canada

Environment Canada reports trends in emissions in the air. Emissions come mainly from metal smelting and refining, followed by electricity generation. Emissions of sulphur oxides in Canada declined steadily from 3.73 million tonnes in 1985 to 1.9 million in 2007. Trends for nitrogen oxides, of which about 50% come from transportation emissions, have held roughly steady over the same time period, running from 2.66 million tonnes to 2.47 million in 2007. Carbon monoxide (CO) emissions have declined from around 16.8 million tonnes in 1985 to 11 million in 2007. The chief source of CO is transportation, which declined steadily with tighter vehicle emissions standards, but CO also comes from natural sources such as forest fires. The level varies widely, from a low of 760,000 tonnes in 1985 to a high of 9.4 million in 1989. Respiratory health is also influenced by total particulate matter (TPM) in the air. TPM from industrial sources was reduced by almost half in the period 1985 to 2007, but this forms only a tiny fraction of the overall problem: roughly 95% of all TPM comes from "open sources" (dust from roads, agriculture, construction sites), which contribute around 17 million tonnes of TPM per year—and these sources have been steadily rising.

Air pollutants can also cause climate change which will affect communities differently. "Communities may have a limited capacity to adapt to climate-related events, due to poor infrastructure, limited knowledge about the risks, lack of human and social capital, or economic disparities. Outdoor workers will be more vulnerable as they are directly exposed to extreme heat events and increased levels of ultraviolet (UV) radiation. Those who live on the land and whose livelihood is tied to natural resource-based employment will also be at greater risk."29

Further information from a Canadian perspective can be found in reports from Natural Resources Canada.30

Outdoor air quality is steadily improving in Canada, although people in urban centres still suffer periods of poor air quality. Indoor air may contain constituents such as asbestos, moulds, radon gas, carbon monoxide and methane that affect health. The ‘sick building syndrome’ describes a range of ailments related to living or working in closed buildings with poor air quality. However, the greatest threat to healthy indoor air quality in Canada remains tobacco smoke, especially for children living in the homes of smokers. These children experience more asthma and bronchitis, are at a higher risk for sudden infant death syndrome and have more lung and ear infections than children living in homes without tobacco smoke.

Design of the built environment also influences health. Overcrowding in housing and community design (which affects transportation and neighbourhood walkability) are increasingly identified as risk factors for chronic diseases, especially respiratory conditions.31 As people live further from the city centre they drive more, resulting in more vehicle collisions, "as well as higher rates of heart and respiratory diseases and obesity, and elevated stress related to both commuting among congested traffic and increased noise levels."14 In rural areas, particularly, where the private car is the only means of transport and where walking or cycling is impractical–and often dangerous because of road conditions–obesity is higher than in urban areas and road traffic injuries are frequent.

Individual and Public Health Services

Advances in health care have conferred immense benefits on health and longevity for countries of the developed world and in many developing countries. The invention of antibiotics, antisepsis, life-saving surgical procedures, as well as advances in pharmaceuticals, have all revolutionized the management of a wide range of diseases.

At the population level, public health interventions (sanitation, communicable disease control measures, etc.) and disease prevention (immunization, tobacco control measures, and screening) have made major contributions to saving lives and improving health.32 Relatively simple measures, such as protecting water supplies, often have the greatest impact on overall health. This is famously illustrated by the decline in tuberculosis in England and Wales. As Figure 2.6 illustrates, tuberculosis mortality had been declining for at least 100 years before the introduction of effective therapy for individual cases; this early decline was achieved by non-specific means such as improvements in housing and nutrition, and through legislative measures such as banning spitting in public which reduced the transmission of the disease. Similar historical declines occurred for polio, smallpox, and whooping cough, all of which responded dramatically to improvements in hygiene long before effective medical treatments were developed.

Figure 2.6: The historical decline in tuberculosis in England and Wales, 1840–1970, showing the timing of critical discoveries in understanding the disease

Although most communicabl…

Although most communicable diseases were in decline before immunizations were developed, vaccination has made a profound difference on incidence and death rates. For example, the Public Health Agency of Canada website includes a graph that illustrates how the rising use of hepatitis B vaccination is linked to a significant reduction in the incidence of the disease. ( ).

Public health interventions to improve air or water quality benefit all citizens, whereas the benefits of individual medical care are less evenly spread. Roughly four million Canadians do not have access to a family physician.33 Despite universal insured health care, access to medications, dentistry, home care, and home support can be significantly affected by income, place of residence, and even ethnicity. Practitioners’ offices tend to be built in richer neighbourhoods, where property values will be preserved and quality of life for their employees is more attractive, but where the need for care is lower. The capacity to take advantage of health promotion and prevention programs is influenced by income and education level: facilities relevant to promoting health, like commercial exercise facilities, are less likely to be built in lower-income or immigrant neighbourhoods.34 Even when financial barriers to care are removed, we run the risk of continued health inequalities if programs are not accessible because of location or because of the person’s feeling of discomfort at using facilities. Note that health care facilities are typically located in places that are more readily accessible to the urban rich. A number of specialized services in Canada are now regionalized, making it more difficult for people living in low-income, rural neighbourhoods to access them. It is important to develop clinics that simplify access for disadvantaged groups: clinics for street dwellers, workers in the sex trade and drug addicts; family planning clinics for teenagers; and clinics where staff members speak minority languages and are culturally sensitive.


Sex refers to our biological identity as male or female. Women in contemporary Canada on average live longer than men, as illustrated in Figure 2.1. Biological differences between the sexes, along with contrasts in the distribution of other health determinants (lifestyle, status and access to services) contribute to this difference. The former are termed ‘sex differences’, while the latter are ‘gendergendersocially constructed roles, behaviours, values and relationships that society ascribes to the two sexes on a differential basis. differences’ and the impact of these two may pull in different directions. Largely as a result of the women’s movement, gender disparities have received considerable attention. These occur in all societies in terms of power, freedom, resources and values, and these disparities may affect health. Because disparities (see Health disparitiesHealth disparities consistent contrasts in health status between population groups. A subset of health inequalities that include variations that are probably systematic, and arise from social or other form of disadvantage that may in theory be correctable. The term is often used in the context of policy discussions. (For further information see: Reducing health disparities – roles of the health sector. Discussion paper, 2005. Accessed July 2010) in Glossary) are socially generated they should, in principle, be correctable. The most egregious examples include the exploitation of women in the sex trade, underage marriage, or the work conditions in sweat shops in the garment industry. In developed countries there are often gender inequities in income, such that wages for women (outside of the agriculture industry) may be around 20% lower than those for men.35 Because single parents are almost always women, the lower income of women also affects their children.14

Gender refers to "the arr…

Gender refers to "the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis.36"

Gender inequities do not only result from income disparities; gender is also linked to differential access to health services, to unequal obligations to provide unpaid family care duties, and to disparities in nutrition.13 Gender inequities also exist in health research: studies evaluating various medications historically were more likely to use male experimental subjects. The interaction between sex- and gender-related factors and cardiovascular disease outcomes in women remains an important research area.37 For instance, women present cardiac disease differently than men, and are less likely to be diagnosed accurately and to receive timely treatment, and the benefits of many interventions vary between men and women.38,39


"Culture is a system of ideas, values, and metaphors that are consciously and unconsciously used or enacted by people in their everyday lives. It is not a rigid set of behaviour traits but a fluid and adaptive system of meaning."40 A person’s cultural background has an important influence on his or her beliefs, behaviours, perceptions, emotions, language, diet, body image, and attitudes to illness, pain, and misfortune—all of which can influence health and the use of health care.41 Culture "explains what one must know and do to function in a given society.42" This section outlines the ways in which culture may influence health, while Chapter 3 explores the ways that clinicians can incorporate cultural awareness into their daily practice of medicine.

Science may be universal, but access to it and its interpretation are filtered differently in different cultures. The knowledge we acquire is influenced by our culture, which determines, for example, the subjects we study and books we read in school. Furthermore, when knowledge is lacking, cultural beliefs often take over. No one knows what happens after death, but all cultures prescribe characteristic rituals concerned with death that are based on beliefs. Culture also underpins values, which are deeply held beliefs that define what is desirable and moral. Values influence expectations of behaviour, such as the way a doctor’s actions are perceived by the patient. Interventions designed to support healthy behaviours have been most successful when they consider the culture of the target population and when the community is actively engaged in designing and implementing the intervention.43 However, although cultures may be shared, people are far from homogeneous, and it is dangerous to assume that all people defined as belonging to a certain culture will hold the same norms and values or will react the same way to new ideas and knowledge. Some errors can be avoided by being careful to view culture as influencing behaviour within each specific context, rather than in general.41

Sharing and Transmitting …

Sharing and Transmitting Culture

Culture is learned and is conveyed from generation to generation through the process of socialization. Parents transmit cultural values, but so do peer groups and schools. Children of immigrant families often receive conflicting messages from parents and peers. Much adolescent rebellion, with significant health consequences such as drug use, has roots in the young person’s struggle to define which cultural code to follow.

Culture is not unitary. Most societies identify a mainstream culture and various subcultures. These may be defined in terms of age (teen culture), lifestyle (gay culture), ethnicity (West Indian), location (street culture), or even health problems (drug culture, Alcoholics Anonymous). Most individuals occupy two or more cultures at the same time.

Ethnicity is an imprecise…

Ethnicity is an imprecise term that refers to a collective identity based on a combination of race, religion or a distinctive history. An ethnic group shares cultural customs that distinguish it from neighbouring groups. Ethnicity differs from race in that the shared characteristics are values, norms and ideas rather than physical characteristics. Ethnic groups are generally sub-groups within a culture or within a racial grouping. Ethnicity may refer to how a person describes him- or herself in terms of ancestry, history and culture.

Race is a quasi-biologically defined classification of people based on shared genetically transmitted physical characteristics: "A division of humankind possessing traits that are transmissible by descent and sufficient to characterize it as a distinctive human type." Race is not a scientifically rigorous classification: there is a huge amount of mixing among races; defining racial characteristics do not appear in all individuals, and there may be more genetic differences within a race than between races.

Multiculturalism is the recognition of racial and cultural diversity and respect for the customs and beliefs of others. It includes the right to equal opportunity and recognition regardless of race,colour or religion.

Prejudice is the holding of unfounded ideas (generally negative, but can also be positive) about a group (whether a race, class or ethnic group). These ideas are resistant to change and are rarely open to logical discussion.

Combinations of determinants

The preceding paragraphs discussed each health determinant individually. However, the different determinants often occur in association in individuals and in communities. For instance, a person with little education is likely have an unsatisfactory, poorly paid job and to live in poor housing. At the community level, the neighbourhood in which this person lives is likely to be undesirable, perhaps near an industrial complex with heavy traffic. It unlikely to have many services close by and, having little social cohesion, it is unlikely to develop enough political power to force improvements. This aggregation makes it difficult to tease out the individual determinants that are linked with individual health outcomes. Furthermore, the different determinants can create feedback loops. For instance, overcrowded housing causes increased transmission of infection which causes increased time off work which causes decreased income which forces people to live in overcrowded housing. This idea of multiple associations, links and feedback loops is known as the web of causation.44

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