Claire Johnson, DC, MSEd, Bart N. Green, DC, MSEd
Health and illness are affected by many factors, which may be explained using a model of determinants of health. This article provides a brief overview and discussion of determinants of health and suggests how this model may assist the chiropractic profession with communicating and applying best practices in public health.
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Determinants of health are factors that impact the health of individuals and populations. [1-3] As health care providers, we tend to focus on individual patients. When we become more involved in public health activities, we focus on prevention and health promotion for the community (eg, population health). The approaches we use for individuals and populations can be complementary rather than exclusive. For example, a doctor of chiropractic can educate his or her individual patients during clinical encounters about the benefits of good posture and workplace injury prevention. From a public health perspective, to help the community, the same chiropractor could participate in a program focused on educating large numbers of people about healthy posture and/or workplace injury prevention.
Prevention, wellness, and health promotion are often neglected when compared to short-term care treatments (eg, antibiotics) and disease prevention (eg, vaccinations). Unfortunately, many people presently rely upon the health care system to fix their health problems that may have developed over a period of years rather than modifying their behaviors to promote good health and prevent chronic illnesses. For example, cardiovascular and musculoskeletal conditions may be prevented by years of healthy diet and regular physical activity. However, some health problems may not be addressed until it is too late, such as when the patient presents to an emergency department showing signs of chest pain or osteoporotic fracture. With chronic diseases on the rise, using population health methods may help us better understand the various factors involved in health promotion and disease prevention. The population health approach toward specific conditions, especially chronic or musculoskeletal disorders, is relatively new. Collaborative programs, such as the Bone and Joint Decade 2000-2010 (www.boneandjointdecade.org and www.usbjd.org) and the Neck Pain Task Force, [3-5] have recently raised greater awareness of these important issues. We should take a closer look at how we can best address them.
Doctors of chiropractic focus on individual patients by providing care, counseling, and interventions; thus, the individual patient is at the center of most chiropractic processes. Known as patient-centered practice, it is a primary element of evidence-based practice and is an area in which chiropractors excel. [6, 7] However, due to historical marginalization and ostracization, the chiropractic profession was not always considered to be a part of the public health community.  Fortunately, chiropractic has been included and is now becoming more aware of its responsibility in public health matters. 
In public health, there is a focus on the “greater good” of the community.  Interactions and measurements of populations are more complex than those of individuals. Therefore, the interventions to modify factors on a population level are typically more involved. And, it may be more challenging for providers to participate at a population level.  As well, research has historically used reductionistic models to measure health outcomes. Such approaches tend to focus on diseases or smaller causative factors, instead of the whole person, multiple factors, or the population, and have been ineffective in many cases.  Recently, the research paradigm has shifted from trying to address isolated risk factors of individuals to a model in which biologic, psychosocial, and sociocultural effects contribute to health and disease.  This results in a more holistic, qualitative, and practical approach to both individuals and populations and may be in concordance with most chiropractic approaches to health.
Chiropractic’s historical approach to patient health has focused on the patient’s innate, homeostatic powers of the body to heal, which include physical, psychosocial, emotional, and/or spiritual components.  As stated by Palmer,  chiropractic’s founder, “Functions performed in a normal manner and amount result in health. Diseases are conditions resulting from either an excess or deficiency of functioning.” Thus, the chiropractic profession embraced a broad definition of health years before the World Health Organization adopted its 1946 definition that health is,  “[a] state of complete physical, mental, and social well-being and not merely the absence of disease.” The chiropractic profession may be poised to offer considerable contributions to improving the health of both individuals and populations using this health care model. As well, doctors of chiropractic collaborate with other providers as part of the health care team to provide the best possible patient care. Thus, chiropractic is a part of the global web of health care and is in a position to contribute to population health.  Having a better understanding of the determinants of health may provide a model by which we can be even more effective.
Health and illness are affected by a multiplicity of factors, which can be explained as determinants of health (Fig 1). Doctors of chiropractic typically consider these factors in the care of patients and communities to positively impact their health. These factors include conditions in which people live and work in addition to individual characteristics that are modifiable, such as environment and behaviors, and those that are not modifiable, such as age, sex, and genetic background. Social determinants of health are socioeconomic factors that impact health.  Social determinants include access to healthy food, safe drinking water, social networks, healthy work/living environments, and access to health care. Individual determinants of health are specific to individuals such as personal choices (eg, behaviors, attitudes) and attributes (eg, sex/gender, age, race). 
The communities we serve are made up of a complex mixture of people, cultures, and environments; therefore, multifactorial and teamed approaches may be the best way to address health issues. As health care providers, we must focus on our communities’ needs and be both willing and prepared to help. We should strive to be more involved in our communities and work within the larger health care and public health environment. Even a small amount of effort can make a difference if it is applied appropriately. The following is a brief overview and discussion of determinants of health with suggestions for how using this model may assist the chiropractic profession with communicating and applying best practices in public health.
As health care providers, we must understand how the determinants of health interact with each other so that we may best serve the needs of our patients and communities. Many determinants of health overlap or have a direct influence on one another. Poverty can directly relate to working conditions, physical environment, education, and maternal health. Healthy choices and lifestyles may be influenced by education, physical environment, and social/family networks. We cannot address one health determinant without considering the interaction of the other determinants of health. Various new methods for evaluating how chiropractic and musculoskeletal care can be better investigated, such as through qualitative and population health methods, may assist with obtaining a more clear view of chiropractic’s impact on population health.63, 64 An integrated and holistic approach may assist us to help our communities achieve better health. If we are to make an impact on the health of the population, we must take the time to address the unique characteristics of our patients and the communities that we are serving.