The Need for an Integrated Approach to Understanding the Determinants of Health
Steven H. Woolf, MD, MPH, VCU Center on Society and Health, Virginia Commonwealth University Center, USA

Integration is important not only important to how we define health and wellness (e.g., integrative health) or deliver care (e.g., integrated team care) but also to how we understand the complex web of factors that shape health. Society tends to equate health with health care, but our health is determined greatly by health behaviors (e.g., smoking, sedentary activity), lifestyle, and stress. These in turn are shaped by upstream factors, including socioeconomic conditions (e.g., education, poverty, income inequality) and the physical and social environment in which we live. The physical environment includes not only clean air and water but also a built environment that enables active living and heathy food choices, healthy and secure housing, and affordable transportation. The social environment also affects health, as when people experience trauma or toxic stress from racism, residential segregation, exclusion, social isolation, or loneliness. Macrostructural factors - such as public policies, social values, and spending policies - function at the national, state, and local level to influence all of these downstream domains, from socioeconomic and environmental conditions to the ability of people to obtain health care or maintain healthy behaviors. These multilevel relationships are notoriously interdependent, which means that meaningful efforts to improve population health require an integrated approach to policy and practice. For example, efforts to improve access to health care or employment cannot succeed if the people in need of these services lack stable housing, child care, or affordable transportation to reach the health care facility or jobsite. Too often, clinicians, health systems, and communities attempt to improve health by targeting a single domain. These efforts are less likely to “move the needle” than cross-sector partnerships in which stakeholders work across sectors to achieve collective impact through collaboration. Integration is hard work; it requires commitment, resources, and infrastructure. But it is essential to achieve transformational change.