Table 1 Social determinants of health definitions and concepts

The concept of the social determinants of health adopted in this paper identifies two key components following the frameworks of Solar and Irwin [17] and the Commission on Social Determinants of Health [1]: “structural determinants” and “intermediate determinants” (see Fig. 1). These grouping emphasize the difference between social and physiological mechanisms resulting in patterns of health equity.

Structural determinants of health equity broadly refer to societal factors giving rise to social position and the association of social position (and access to the power, money and resources) with health impacts. Domains of structural determinants can be characterised as formal and informal rules of institutions (including commercial drivers), policies, culture and values including classism, racism, sexism, able-ism, xenophobia, and homophobia. They are influenced by historical context and operate over the life span [18, 19].

Intermediate determinants of health highlight the biological mechanisms operating through the conditions of daily life. Intermediate determinants impact the health of an individual through physical exposures, material and psychosocial pathways, biological vulnerability, behaviours, and access to health services. The EQuAL framework [20] identifies three domains (beyond “health systems”) describing the conditions of daily life:

 • Environment quality, public services and safe products;

 - housing conditions and amenities (e.g., water, energy, air, digital access); public services (e.g., transport mobility); working environment and conditions; community/public spaces (e.g., green/blue spaces), products’ quality (food) and safety;

 • Accountability, non-discrimination, social well-being and inclusion:

 - participation and involvement; non-discrimination; peace, trust and safety (inter-family, inter-community, inter-country); gender equality; social capital, social, cultural and family support (parenting, work-life balance);

 • Livelihoods and learning:

 - income and food security and social protection); child and youth development and experiences (e.g., trauma); work-life balance and ageing; education and skills; employment relations.

Structural determinants drive the distribution of intermediate determinants across social groups and have the largest influence on the patterns of health equity observed. For this reason they are sometimes referred to as the social determinants of health equity.