Determinant Analysis: Understanding the Causes of Population Nutrition Problems

2. Intelligence Step 4 - Determinant Analysis • Population nutrition problems can not efficiently be addressed without understanding their causes • Most problems or issues in public health nutrition (PHN) are not random events but have multiple causes or determinants • Identifying determinants helps focus strategies so that they change upstream the factors that lead to downstream outcomes. Determinant Analysis

3. Determinant Analysis

4. Analysing Determinants • Determinant analysis involves indentifying the factors causing a health problem and reviewing the linkages or relationships among these factors • Most PHN problems have multiple causes so identifying the causal relationships is an important for selecting and prioritisting solutions • 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

5. Analysing Determinants • Determinant analysis begins by identifying the socio-ecological determinants of the PHN problem • Characterising determinants by their effect, level and causal link enables the selection of logical intervention points • Various models exist to assist with determinant identification and classification: • Preceed-Proceed Model • Characterising determinants by effect • Characterising determinants by causal link • Characterising determinants by level Determinant Analysis

6. Preceed-Proceed Model • 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

7. Characterising Determinants by Effect • 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 aredesirable and beneficial and also play a protective role • Protective/promoting factors can be the inverse of a hazard Determinant Analysis

8. Characterising Determinants by Casual Link • 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 • It may be possible (and desirable) to only take action on the contributory determinants rather than the proximate cause Determinant Analysis

9. Characterising Determinants by Level • 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 • Both social and environmental, and specific determinants can have a proximate or contributory effect Determinant Analysis

10. Causal Pathways • The interaction between determinants and how they operate in context is the next step after the determinants have been identified • Examining determinant sequencing and interaction avoids simplistic models of causation that can produce simplistic and ineffective solutions • 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 Determinant Analysis

11. Selection/ quality of fruit and vegetables Store type (supermarket, speciality, limited assortment independent Age Per capita income Fruit and vegetable intake Store location (city, suburb) Years of education Affordability of fruit and vegetable Determinant analysis diagrammatic example - fruit and vegetable intake Determinant Analysis

12. Confirming the Determinant Analysis • Much of the initial illustration and data gathering may have been completed by only a few people – the project team for example • 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 • Consultation and the remaining steps in the intelligence section of the bi-cycle will highlight whether the potential intervention points identified in the determinant diagram are achievable and will be effective Determinant Analysis