The social determinants of health (SDH) consist of the structural drivers and daily life conditions that influence a person’s health status [1–4]. The SDH include such factors as income and educational status, employment opportunities, housing conditions, social exclusion, racism, and inequality. Evidence of the impact of such factors on health, including mortality and morbidity, occurs at multiple levels of influence and through a multitude of pathways [3, 4]. Despite a rich history of health promotion in Canada, there has been very little research examining the Canadian public’s perceptions of the SDH . When conducted, studies usually focus on adults rather than adolescents. Research investigating adolescent health knowledge has tended to focus on adolescent knowledge about risky health behaviours (e.g. tobacco and alcohol use, sedentary activity, poor nutrition, safe sexual practices) and not about their understandings of the SDH. Less is known about the behavioural factors that adolescents perceive significant to their health, and whether they even recognize the role of the SDH on health. In short, as expressed by Woodgate and Leach (2010), the focus has been on what youth do, not what they think and feel . Health-related values, attitudes and behaviours formed in adolescence have been shown to predict significant health risks in adulthood, including issues of social and economic disadvantage [6, 7]. Knowing what youth perceive as critical health determinants can help practitioners to identify gaps in health education curriculum. This subsequently can contribute to the design of programs that will foster a broader understanding of health, emphasizing the impact of the social and economic environment alongside lifestyle behaviours on health. This is an integral message within the Ottawa Charter for Health Promotion – a document that has guided health promotion practices globally since its publication [8, 9].
Acting effectively to address the SDH requires in part a greater public understanding and awareness of the SDH . When asked to identify the most important factors that contribute to good health, Canadian adults tend to attribute greater influence to personal health behaviours, such as physical activity and diet than to social and economic conditions . According to the Canadian Public Health Institute (CPHI), only one in three Canadian adults believed that social, economic, and environmental conditions had an impact on health . The research that has explored Canadian adolescents’ perceptions of health has tended to show similar results as those found in Canadian adults. Youth had broad understandings of health, attributing health to a variety of distinct domains including physical, mental, social and environmental health. However, personal behaviors and practices, specifically exercise and diet, were seen as the main determinants of health . Youth descriptions of the connections between the SDH and health outcomes have been described as vague and disjointed, suggesting a noticeable lack of understanding . The lack of relevant literature on how Canadian adolescents perceive the determinants of health has created a noticeable gap in health education and promotion research.
Enhancing education and public awareness of the SDH is a step towards action in reducing health inequalities . The Commission in the Social Determinants of Health (CSDH) (2008) recommends that greater knowledge of the SDH should be encouraged outside the medical and health research community. The exposure to health information may be most beneficial in youth, as adolescents have high learning capabilities, as well as great potential to use health information to their advantage now and as they age [11, 12]. Positive health values, attitudes, and behaviours that are formed at young ages are likely to continue to be encouraged and built upon as youth transition into adulthood . Youth report that their exposure to health information is heavily weighted towards lifestyle behaviours . The majority of health information is delivered to adolescents through the health education curriculum within schools; educational policies are thus in a powerful position to influence adolescent knowledge and understanding of health and the SDH . Review of Ontario guidelines for secondary school education reveals that health curriculum weighs heavily towards lifestyle behaviours . Current health education is relatively void of SDH theory and content, and reinforces the biomedical model of health within secondary school health programs.
Our research on adolescent perceptions of health is a step towards determining a potential knowledge gap in Ontario youth concerning the SDH. The main purpose of this study was thus to evaluate what determinants of health adolescents tend to associate with health, as well as to assess their relative understanding of the influence of the SDH on health in comparison to physical determinants. The research questions which guided our study and analysis were 1) What determinants (social, behavioural, and physical) do Ontario high school students associate with health?, 2) To what degree do Ontario high school students know about the SDH?, and 3) Are there any socioeconomic differences in students’ knowledge of the SDH? Conclusions drawn will inform suggestions for future Ontario health curriculum modification to better educate students about the SDH alongside mainstream physical determinants.