1 Chapter 1: Conceptualizing Health

Learning Objectives:

• Define and differentiate between various concepts of health, including the absence of disease, wholeness, and physical and mental well-being, including challenges in defining and measuring health.
• Conceptualize the roles of genetic, behavioral, and social determinants of health in health outcomes at individual and population levels.
• Describe researching population health as the study of population health outcomes, their determinants, and interventions to improve population health outcomes.

Key Terms:

• Health: A state of complete physical, mental, and social well-being, including the absence of disease or infirmity.
• Genetic Determinants of Health: Factors related to an individual’s genetic makeup that influence susceptibility to certain diseases and health conditions.
• Behavioral Determinants of Health (BDH): Lifestyle choices and behaviors, such as diet, physical activity, smoking, and alcohol consumption, that impact health.
• Social Determinants of Health (SDH): Conditions in the environments where people are born, live, learn, work, play, and age that affect a wide range of health risks and outcomes.
• Health Disparities: Differences in health outcomes and determinants between different population groups, often influenced by social, economic, and environmental factors.

Introduction

We begin by considering different conceptualizations of health, from the traditional view of health as the absence of disease to more holistic perspectives that encompass physical, mental, and social well-being. We then shift our focus to the determinants of health, categorizing them into internal factors, such as genetics and behavior, and external factors, known as social determinants of health. These determinants interact in complex ways to shape individual and population health outcomes. Understanding these interactions is key to addressing health disparities and promoting health equity (Braverman, 2014).

This chapter sets the stage for the subsequent chapters, which will further explore the research process, study design, and methodologies used in investigating health outcomes and determinants in population health studies. By the end of this chapter, readers will have a solid foundation for understanding the multifaceted nature of health and the various factors that influence it.

Conceptualizing Health

Let’s begin with defining our terms, beginning with “what is health?” There are a variety of definitions, approaches, and even philosophies concerning health. The common biomedical understanding defines health as the absence of disease, illness, and adverse biological conditions. The World Health Organization specified health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Durch, Bailey et al. 1997). This broad definition encompasses not only physical health but also mental and social well-being.

There are also holistic approaches, such as:

• Whole Health: This concept emphasizes a multidimensional, integrated approach that recognizes the importance of the therapeutic relationship, acknowledges the clinician’s humanity, recognizes the patient’s individual personhood, and employs a range of treatment modalities using a holistic biopsychosocial approach (National Academies of Sciences 2023).
• Salutogenesis: Focusing on factors that promote health rather than just preventing disease.
• Patient-Centered Care: Tailoring care to individual needs and preferences.
• People-Centered Care: Putting people at the center of health systems.
• Integrated Care: Coordinating services across different providers and settings.
• Public Health: Addressing health at the community level.

Literature also distinguishes different types of health:

• Physical Health: Refers to the state of your physical body and how well it is operating.
• Mental Health: A level of psychological well-being or an absence of mental illness.
• Emotional Health: Encompasses feelings and overall emotional well-being.
• Social Health: Relates to interactions, relationships, and social well-being.
• Environmental Health: Concerns the impact of the environment on health.
• Spiritual Health: Pertains to inner peace, purpose, and connection (Durch, Bailey et al. 1997).

Health is also an individual matter and a concern of wider populations:

• Individual Health: Refers to the overall well-being of a single person, which can encompass physical, mental, emotional, and social aspects of their health.
• Population Health: A concept that focuses on health outcomes for a group of individuals, rather than just an individual patient.

Measures of Health

Albert Einstein has been quoted as saying, “Your theory determines the measurement you make” (Attia 2018). Think of theory as an explanation, particularly a cause-and-effect explanation (covered in greater depth in Chapter 2). As we just reviewed a diversity of theories of health, these theories will guide the distinct and specific ways that health is measured. Chapter 7 (Instrumentation) goes in depth on this topic. Classic population health measures include:

• Life Expectancy: This refers to the average number of years a person is expected to live. It reflects overall health and access to healthcare.
• Mortality: Mortality rates indicate the number of deaths within a specific population. It can be further categorized by age, cause, or other factors.
• Morbidity: Morbidity refers to the prevalence of diseases, illnesses, or health conditions within a population. It includes both acute and chronic condition.
• Health Disparities: Health Disparities refer to differences in health outcomes that are closely linked with social, economic, or environmental disadvantages (Braveman 2014). These disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on factors such as their racial or ethnic group, socioeconomic status, gender, age, or geographic location.

Challenges in Defining and Measuring Health

Defining and measuring health presents numerous challenges due to its multifaceted nature. Cultural and contextual variations play a significant role in how health is perceived and assessed. For example, what is considered healthy in one culture may be viewed differently in another. Additionally, measuring health accurately can be difficult due to the subjective nature of some health indicators and the complexity of accurately capturing all aspects of health.

Determinants of Health

What determines our health at individual and population levels? There is no real consensus on a definitive answer to these questions, other than “it depends.” That said, the literature can be grouped into three interrelated approaches – the genetic, behavioral, and social determinants of health.

Figure 1: Determinants of Health

• Genetic Determinants of Health refer to the roles our genes play in determining health outcomes. Genes influence not only our susceptibility to certain diseases but also other traits that may impact our health indirectly, such as predispositions to certain behaviors.
• Behavioral Determinants of Health encompass the choices we make that affect our health, such as diet, physical activity, smoking, and alcohol use. These choices are often within our control and can significantly impact our overall health and susceptibility to various diseases.
• Social Determinants of Health are perhaps the broadest category, encompassing the environmental conditions in which people are born, grow, live, work, and age. These include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, all of which can have significant impacts on health outcomes.

While genetic and behavioral determinants of health are internal to us as individuals, the social determinants of health are our external social and political environment that impacts our health. With those distinctions in mind, let’s focus on interrelationships among these three concepts, as illustrated in the Venn diagram in Figure 1.

Genetic & Behavioral Determinants of Health (BDH)

Behavioral and Genetic Determinants of Health explore the interplay between personal lifestyle choices and genetic makeup in affecting health. While behaviors are actions we can control, our genes are the basic units of heredity of traits that come from our parents and ancestors. Genetics is the study of genes and their roles in inheritance (passing of traits to children). In biology, genes are segments of DNA that carry the instructions for making proteins, which perform most life functions. Genes and parts of DNA passed down from parents to children, genes carry the instructions for building the proteins that determine everything from hair color to disease risk. Genes also have varying degrees of influence on behavior and lifestyle choices (Dick 2022).

Consider a case of overeating. While deciding how much to eat is a behavior within our control, genetic factors also play a decisive role. Some people may have genetic predispositions that affect their metabolism or increase their propensity to gain weight. These genetic traits can make them more likely to overeat or crave more sugary and fatty foods. For example, a person might be genetically predisposed to feeling less satiated by normal portions due to variations in their leptin genes, which help regulate appetite and metabolism. Or, a person may be genetically prone to addiction (Dick 2022), which can include overeating. This genetic tendency can lead to overeating as a regular behavior, thus increasing their risk of diabetes and other metabolic disorders.

The interaction between genetic and behavioral determinants is complex, but often genetic factors will predispose us to certain behavioral outcomes (Dick 2022). In these contexts, genetic factors are subsumed under BDH frameworks. This is because genetics impacts a person’s health as a factor that is internal to an individual, meaning their origin arises from within the individual.

Social Determinants of Health (SDH)

In contrast to genetic/behavioral determinants of health, the SDH are factors that are external to any individual but impact our health. According to the Centers for Disease Control and Prevention (CDC), SDH are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes (CDCgov 2024). These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. SDH affect health outcomes and often contribute to health disparities seen within and among populations.

Imagine two neighborhoods in the same city: one is close to multiple fresh food markets, parks, and full-service medical facilities; the other has liquor stores, fast food chains, and no medical facilities nearby. Residents from the first neighborhood generally have better health outcomes compared to the second. This is because they have better access to healthy food, safe spaces for physical activity, and healthcare—all of which are social determinants of health. Such differences highlight how where you live can affect your health just as much as your genetics or lifestyle choices.

SDH include:

• Economic Stability: Including employment, income, expenses, debt, and financial support.
• Education Access and Quality: Encompassing early childhood education, higher education, literacy, and language.
• Healthcare Access and Quality: Availability of healthcare services, health insurance, and access to primary care.
• Neighborhood and Built Environment: Quality of housing, access to transportation, availability of healthy foods, and levels of crime and violence.
• Social and Community Context: Social cohesion, civic participation, discrimination, and workplace conditions.

Interactions Between SDH and BDH

The relationship between SDH and BDH is complex and bidirectional. Social determinants can significantly influence behavioral choices and genetic expression, while individual behaviors and genetics can, in turn, have decisive roles in social and economic opportunities and conditions.

• From SDH to BDH: The SDH shape the range of possibilities of behavioral choices. In other words, social factors such as education, income, and access to resources can shape health behaviors. For example, individuals with higher levels of education and income are more likely to engage in healthy behaviors, such as regular exercise and healthy eating, and have better access to healthcare services. Emerging research suggests that social determinants can also influence genetic expression, a concept known as epigenetics. For instance, exposure to chronic stress or adverse social environments can lead to changes in gene expression that impact health outcomes.
• From BDH to SDH: Literature clearly recognizes that genetics predispose individuals to behavioral patterns and outcomes. In turn, people’s choices often impact the SDH. This can occur in a range of ways, such as, favoring political policies/reforms that would improve any of the social determinants of health, or engaging in educational initiatives that would lead to people creating more healthy environments.

While this 1-2-3 framework may appear simple in explaining health outcomes, reality is messy and highly complex. For instance, type 2 diabetes can be influenced by genetic factors, behavioral choices such as diet and physical activity, and social determinants like access to education, healthy foods, stress-free homes, and safe places to exercise.

Researching Population Health

Population health research is an interdisciplinary field that focuses on understanding the factors influencing the health of groups of people or entire populations. The different disciplines that contribute to researching population health are briefly introduced in Chapter 2. Population health research encompasses:

• Health Outcomes: Population health research examines health outcomes, such as disease incidence, prevalence, mortality rates, and overall well-being within specific populations.
• Health Determinants: Researchers explore the various determinants that impact health, including biological, genetic, social, economic, environmental, cultural, and behavioral factors. These determinants can significantly affect population health.
• Policies and Interventions: Researching population health also concerns studying policies, interventions, and strategies aimed at improving population health. This includes assessing the effectiveness of clinical trials, public health programs, preventive measures, and health promotion initiatives.

Summary

In this chapter, we explored the concept of health, including its various definitions and dimensions. We discussed the determinants of health, emphasizing the interplay between genetic, behavioral, and social factors. The next chapter provides an intuition and overview for the research process, which concerns the scientific standards and norms for producing knowledge on health outcomes, determinants, and interventions.