The World Health Organisation (WHO) defines the social determinants of health (SDOH) as the conditions in which people are born, grow, live, work and age . These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
Further background reading is available at the “Social Determinants of Health: The Solid Facts 2nd Edition”  and “Social determinants of health inequalities” , while the relevance in Australia is discussed in Australia’s Health 2016 .
Sir Michael Marmot, Professor of Epidemiology and Public Health, University College London delivered the 2016 Boyer lectures – “Fair Australia: Social Justice and the Health Gap - exploring the challenges faced by communities in solving issues around health inequality” . Whether you are new to, or are fully aware of, the social determinants of health and their importance, we highly recommend listening to these lectures (or reading the transcript) – they provide an excellent overview.
But how much of the expression of a population’s health is a consequence of these social determinants? According to the British Academy  (reflected in material at WHO and at the Centers for Disease Control and Prevention ), social determinants, risk factors (like smoking and physical inactivity – which are themselves strongly influenced by social determinants), environment (eg housing and climate) and health services (eg access to primary health care services) account respectively for 40%, 30%, 10% and 20% of the expression of a population’s health – although it is probably reasonable to assume that these proportions will vary depending on the population. SDOH have a powerful influence on health.
In discussing the contributors to the health gap of Aboriginal and Torres Strait Islander peoples, Australia’s Health 2014  reported that 31% of the gap was explained by socioeconomic factors (eg access to work and education), 11% by biomedical and other risk factors (eg smoking), 15% by the combined effects of both, and 43% by other factors (potentially including poorer access to services including culturally safe and appropriate services).
Source: Australia’s Health 2014
Socioeconomic status (ie average incomes, educational levels, career choices, etc) declines with remoteness, and this lower socioeconomic status is frequently cited (along with higher prevalence of Aboriginal and Torres Strait Islander people and lower levels of access to services) as one of the main reasons for poorer health outcomes for people living in rural and remote Australia. The inference is that poorer health outcomes in rural and remote Australia has little to do with rurality and much to do with the lower socioeconomic status of the people living in these areas.
But this misses the point – that employment, career opportunities and consequently education in regional, rural and remote places are restricted precisely because of the nature of towns and communities in these areas. For example:
- the percentage of the workforce engaged in primary production (including forestry and fishing) is negligible (<1%) in Major cities, rising to 18% in Outer regional areas and around 30% in remote areas, while;
- the percentage working in finance and as professionals decreases from 6% and 9% in Major cities respectively, to less than 2% and less than 4% in rural/regional areas, and to less than 1% and around 2% in remote areas.
By way of occupation, the percentage of the workforce who are managers or professionals is around 40% in Major cities, around 30% in rural/regional areas and around 40% in remote areas while the percentage who are machinery operators, drivers or labourers is 14% in major cities, 20% in rural/regional areas and 23% in remote areas.
These inter-regional differences reflect the nature of available work in these areas, which in turn influences the educational status of people living and working there. The types of available employment in rural and remote Australia are often in industries that are less well remunerated than the available employment in major cities.
In addition to these occupational differences for people who are employed, unemployment rates (as expressed by the percentage of people receiving unemployment benefits in June 2014) increases with remoteness from 5% in Major cities to 7% in rural, regional and Remote areas, to 12% in Very remote areas; while the percentage of families with children classified as low income and welfare dependent increased with remoteness from 9% in Major cities, through 11%, 12% and 14% in regional and Remote areas, to 26% in Very remote areas.
Many of the issues related to the level of control over one’s own life can become increasingly influential in rural, regional and remote areas. For example:
- Rural economies, notwithstanding a broad economic base, frequently rely heavily on the quality of the season to ensure employment and a buoyant economy; but regional rainfall in Australia is notoriously variable from year to year, with greater variation developing as the climate changes.
- Regional economies dependent on long term climate stability (eg those dependent on tourism reliant on snowfields and coral reefs), are likely to be increasingly adversely affected as temperatures and ocean acidity rise.
- Economies reliant on mining are ephemeral by nature, with the need for community transformation when the resource is depleted.
- Commodity prices (eg iron ore and wheat prices) and the cost of inputs (eg diesel and fertiliser) are subject to fluctuation beyond the control of rural and regional businesses.
- Some communities experience unrest and violence issues and some population groups can experience discrimination and racism.
The health effects of income and educational disadvantage can be compounded in many communities by poor access to a range of goods and services including affordable healthy food, high-speed broadband, mobile phone coverage and public transport.
On the other hand, people living in rural towns (particularly small ones) have, on average, greater life satisfaction than those living in Major cities, as measured in a number of studies including HILDA . This positive influence benefits health, and hints at what many who live there experience and appreciate about the peace, freedom, attachment, sense of community and connectedness that can be found there.
You can read an Alliance factsheet  about the determinants of health in rural and remote Australia.
You can also access the NRHA Little Book of Rural Health Numbers , which contains data tables and links to the original sources, for a range of rural health topics, including social determinants.
The Public Health Information Development Unit , Regional Development Australia’s “Insight”  and the ABS  are all good sources of online regional data including those related to social determinants.
The 2017 Aboriginal and Torres Strait Islander Health Performance Framework report describes a substantial number of health (including social determinants) indicators for Aboriginal and Torres Strait Islander peoples, frequently by remoteness, typically showing greater disadvantage with remoteness.
An older (2012), but still valuable report by NATSEM “The cost of inaction on addressing the social determinants of health”  estimates the substantial dollar value of the benefits in Australia of implementing the WHO recommendations on the social determinants of health.
The NRHA is a member of the Social Determinants of Health Alliance
A number of relatively recent NRHA factsheets relate to social determinants, including:
- Poverty (October 2015)
- Illicit drug use in Australia (June 2015)
- Climate change (Nov 2014)
A number of relatively recent NRHA submissions relate to social determinants, including:
- Domestic violence (June 2015)
- Aboriginal and Torres Strait Islander Education (November 2015)
- Arts in Health (February 2016)
A number of priority recommendations from the 14th National Rural Health Conference relate to social determinants – namely cultural safety, strong families, Arts in Health and access to Broadband.
Previous archived edition can be found here.
 WHO on social determinants http://www.who.int/social_determinants/en/
Lancet 2005; 365: 1099–104 http://www.who.int/social_determinants/strategy/Marmot-Social%20determinants%20of%20health%20inqualities.pdf?ua=1
 The British Academy 2014. ‘If you could do one thing …’: nine local actions to reduce health inequalities. London: The British Academy. http://www.britac.ac.uk/publications/if-you-could-do-one-thing