Intelligence
Step 4 - Determinant Analysis
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Population nutrition problems can not efficiently be addressed without
understanding their causes
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Most problems or issues in public health nutrition (PHN) are not
random events but have multiple causes or determinants
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Identifying determinants helps focus strategies so that they change
upstream the factors that lead to downstream outcomes.
Determinant Analysis
Determinant Analysis
Analysing Determinants
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Determinant analysis involves indentifying the factors causing a health
problem and reviewing the linkages or relationships among these factors
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Most PHN problems have multiple causes so identifying the causal
relationships is an important for selecting and prioritisting solutions
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Determinant analysis applies the intelligence collected about the problem
(steps 1-3) to identify and analyse the causes of the identified PHN
problem
Determinant Analysis
Analysing Determinants
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Determinant analysis begins by
determinants of the PHN problem
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Characterising determinants by their effect, level and causal link enables
the selection of logical intervention points
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Various models exist to assist with determinant identification and
classification:
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identifying
Preceed-Proceed Model
Characterising determinants by effect
Characterising determinants by causal link
Characterising determinants by level
Determinant Analysis
the
socio-ecological
Preceed-Proceed Model
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The Precede-Proceed Model suggests determinants that influence health
behaviour can be classified as:
 predisposing factors – personal factors that influence personal
motivation to change, including attitudes, values, beliefs, knowledge
 enabling factors – facilitators or inhibitors that support or hinder
change in behaviour or the environment, including societal forces or
systems, resources or skills
 reinforcing factors – factors that provide feedback and further assist,
hinder or prohibit a behavioural or environmental change.
Determinant Analysis
Characterising Determinants by Effect
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This model distinguishes determinants by whether they have a positive or
negative effect on the problem/issue being considered:
 Hazards are social, biomedical or behavioural determinants which
pose a threat to health
 Protective factors provide a defence against adverse health events or
states, or enhance well-being. Promoting factors are desirable and
beneficial and also play a protective role
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Protective/promoting factors can be the inverse of a hazard
Determinant Analysis
Characterising Determinants by Casual Link
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This model classifies determinants as to whether they have direct or
indirect impact on the PHN problem
 Proximate determinants directly impact on the problem (eg. sedentary
lifestyles and energy-dense diets impact directly on obesity)
 Distal determinants create conditions for or increase the effect of the
proximate determinant
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It may be possible (and desirable) to only take action on the contributory
determinants rather than the proximate cause
Determinant Analysis
Characterising Determinants by Level
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This model classifies states that determinants of health occur at two levels:
 Specific determinants relate to ‘downstream’ health events more
closely related with individual causes of ill health (behavioural and
biomedical factors)
 Social and environmental are broader ‘upstream’ factors external to
the individual and can have either a hazardous or protective effect on
health
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Both social and environmental, and specific determinants can have a
proximate or contributory effect
Determinant Analysis
Causal Pathways
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The interaction between determinants and how they operate in context is
the next step after the determinants have been identified
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Examining determinant sequencing and interaction avoids simplistic
models of causation that can produce simplistic and ineffective solutions
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Determinant analysis and causal pathways is often best presented as a
diagram
A diagrammatic illustration of the determinant analysis helps to logically
isolate the focus points for intervention strategies
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Determinant Analysis
Determinant analysis diagrammatic example - fruit and vegetable intake
Age
Store type
(supermarket,
speciality, limited
assortment
independent
Selection/ quality of
fruit and vegetables
Per capita
income
Years of
education
Store location (city,
suburb)
Determinant Analysis
Fruit and
vegetable
intake
Affordability of
fruit and
vegetable
Confirming the Determinant Analysis
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Much of the initial illustration and data gathering may have been completed
by only a few people – the project team for example
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Further consultation with the community and key stakeholders is important
to ensure engagement and ownership of the intervention process - several
redrafting attempts may be required before the determinant diagram is
finalised
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Consultation and the remaining steps in the intelligence section of the bicycle will highlight whether the potential intervention points identified in the
determinant diagram are achievable and will be effective
Determinant Analysis