Key Public Health Questions

What causes or influences the issue?

What are the broader determinants of health that contribute to this issue?

What knowledge, attitudes and behaviours are related to the problem?

Use this step if you are:

  • Unsure of the causes of the issue
  • Unsure of the effective solutions.

What are determinants of injury?

This second stage of the Public Health Approach to Injury Prevention is assessing the determinants of injury. Determinants are factors that both raise and lower the risk of that injury occurring.

Those factors that have a positive influence are known as “protective factors” and those that have a negative influence are known as “risk factors”.

Determinants combine to influence the health and safety of individuals and communities therefore various determinants of injury at multiple levels may be considered to effectively target interventions. Determinants include 1:

  • Social including economic, cultural, political determinants
  • Environmental factors
  • Behavioural and individual characteristics of a person.

This section allows you the opportunity to think about the “causes” of injury; with a view to thinking about what you might be able to do to influence the causes in designing an intervention.

What are the social determinants of injury?

Social determinants of injury are the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”2 In other words, how much education a person obtains, what kind a work a person does or how much money a person earns can affect a person’s health – their health outcomes.

Social determinants which influence people’s health include individual and family income, income distribution and socioeconomic status3; determinants that might influence a person’s health include

  1. Education and literacy levels
  2. Employment and job security
  3. Working conditions
  4. Social enrichment in the early developmental stages of life
  5. Food security including quality or quantity of food
  6. Housing access and security
  7. Access to social services such as childcare, housing support and unemployment support.
  8. Social inclusion including access to cultural, social and economic resources
  9. Accessibility and quality of health services
  10. Gender
  11. Race
  12. History of colonisation
  13. Disability

An example of a social determinant of injury:

Risk factor  Social exclusion contributes to lower feelings of self-worth and depression which is a risk factor for self-harm.4
Protective factor  Building healthy self-esteem through positive relationships and other strategies are seen as an effective method of maintaining optimal mental health, which is a protective factor for self-harm.4

Click here for a great resource on the Social Determinants of Injury.

Further examples of social determinants of injury are described in more detail in the Know Section.

What are the environmental determinants of injury?

Environmental determinants are closely linked with the social determinants of health and influence one another. Environmental determinants include what surrounds us- where people live, work and play.5 Examples include the physical and built environment, the social environment and the natural environment.5

Environmental Determinants

An example of an environment determinant of injury:

Risk factor Unsealed roads in rural areas have been known to increase risk of road crashes in rural areas (WA Health, 2015).
Protective factor Speed limits on all roads in Western Australia, ranging from 40 to 110 kilometres an hour are an important protective factor for road crashes, having successfully mitigated the risk of injury due to speeding (WA Health, 2015).

Further examples of environment determinants of injury are described in more detail in the Know Section.

 What are the behavioural and individual determinants of injury?

Behavioural determinants are those that are linked to actions that people take every day that either increase the risk of an injury (called risk behaviours) or decrease the risk of injury (called health protecting behaviours).6 Examples include5:

  • Knowledge, attitudes and beliefs about injuries
  • People’s coping skills
  • Risk taking choices and behaviours.

Physiological and non-modifiable determinants also need to be taken into account when designing interventions. These include but are not limited to: age, gender and genetics,

An example of a behavioural determinant of injury:

Risk factor Wearing inappropriate footwear or not using appropriate mobility devices when required are behavioural factors that increase the risk of injury due to falls (WA Health, 2015).
Protective factor Engaging in a physical activity program that increases strength and balance is a behaviour that older adults can do to decrease their risk of having a fall (WA Health, 2015).

Further examples of behaviour determinants of injury are described in more detail in the Know Section.

Why address the determinants of injury?

Besides understanding what causes or influences an injury, addressing the determinants of injury, in particular the social and environment determinants is the primary approach to reducing health inequities.

Health inequality and health inequity

Some people have poorer health based on their genetics, the choices they make, the job they do or because of where they live. The outcome of these factors is called health inequality. Health inequalities are the differences in health status or in the distribution of determinants between different population groups.7

Some inequalities are simply due to biological differences or individual choices. Other determinants of injury however are due to external environments and conditions that are beyond the individual’s control. The outcome of these factors is called health inequity. Health inequities are avoidable inequalities between groups of people, between communities or between countries that therefore makes their existence unfair and unjust.8 As summarized by the Australian Medical Association:

“Equity can be considered as being equal access to services for equal need, equal utilisation of services for equal need and equal quality of care or services for all. Central to this is the recognition that not everyone has the same level of health or capacity to deal with their health problems, and it may therefore be important to deal with people differently in order to work towards equal outcomes.9

“Why is John in the hospital? Because he has a bad infection in his leg.But why does he have an infection? Because he has a cut on his leg and it got infected.But why does he have a cut on his leg? Because he was playing in the rubbish pile next to his apartment building and there was some sharp, jagged steel there that he fell on.But why was he playing in the rubbish? Because his neighborhood is run down. A lot of kids play there and there is no one to supervise them.But why does he live in that neighborhood? Because his parents can’t afford a nicer place to live.But why can’t his parents afford a nicer place to live? Because his Dad is unemployed and his Mum is sick.

But why is his Dad unemployed? Because he doesn’t have much education and he can’t find a job.

But why …?”

Source: Public Health Agency of Canada (2011)

Upstream, midstream and downstream determinants

Sometimes it is useful to apply a simply river analogy to understand the potential impact of addressing social and environmental determinants.

John McKinlay first used a simple river analogy in his address to the American Heart Association in 1974.10

Watch this short video on upstream, midstream and downstream determinants of health.

McKinlay described a rapidly flowing river to represent injury/disease, and argued that health practitioners were so caught up in rescuing people from the river once they were in the water or ‘downstream’ that they had no time to look for the causes of why people were falling into the water in the first place ‘upstream’.

Upstream determinants are those that occur at the macro level and include global forces and government policies. Midstream determinants are intermediate factors such as health behaviours while downstream determinants occur at the micro level and include one’s genetics.1

While the story is an over-simplification it does help demonstrate the importance of looking at the cause or determinants of an injury.

Factors such as our behaviours and access to health services (which are downstream determinants) contribute to our health and safety status and while acknowledging a level of personal responsibility for health choices is necessary, society also holds responsibility for creating the conditions that give people choice and control over their lives (upstream determinants).11 This impact of determinants is demonstrated in Figure 1.12,13

Interventions to address inequities can also be referred to as occurring upstream, midstream or downstream. See Learn – Interventions for more details.

How to assess determinants of injury?

There are a variety of strategies that practitioners can use to adequately assess the determinants of injury when planning an injury prevention initiative.

Some of these have already been discussed in Learn – Surveillance such as:

  • Data analysis
  • Published evidence and research
  • Stakeholder and community engagement.

For example, data gathered in the Surveillance can be used to help identify determinants, particularly the “Health Condition Overview” data from the Epidemiology Branch. Using assault data, it can be broken down into sub categories such as:

  • Assault by firearm discharge
  • Assault by sharp or blunt object
  • Assault by bodily force, sexual assault by bodily force
  • Neglect, abandonment, maltreatment
  • Other assault, injury caused by other persons and injury where intent unintended
  • All assault and other injury caused by another person.

The information gathered in stakeholder and community engagement may well have incorporated information that was relevant to this determinants section; or this may be an opportunity to further engage with the target audience to gather information about which determinants the program will address. Learn – Surveillance.

Tools to assess determinants of injury

Useful resources to use in the determinants phase of your program include the following:

  • Fishboning
  • Causal Trees
  • Cause and Consequence Analysis.


The Fishbone Diagram, also known as the Cause and Effect Diagram, is a tool for creating a comprehensive list of all the possible causes for the injury that are of concern. 14 Not only will the diagram increase the understanding of the problem, it can identify major causes and areas for further exploration and analysis.

The first step of any Fishbone Diagram is to write down the injury that is under investigation and an arrow pointing to it. This arrow becomes the backbone of the diagram where the broad areas overarching the effects will meet. The final step involves identifying each cause under each area and the specific causes that branch off these causes until all possible causes have been identified.14

The process that is required to produce the diagram is where the value is, as it is the process that leads to the ideas and insights into the injury.14


Click here to download the Know Injury – fishboning template.

Causal Trees

Causal Trees are commonly used to investigate an adverse event, consequence or problem in a hierarchical fashion.15 The tree structure incorporates a large amount of data and displays the relationships that are present, with the problem located at the top of the tree and the resulting effects placed below it.15 The causes of the effects branch off from the effects and can be explored until all resulting effects are explored.

The final product displays a logical hierarchy of all the causes leading to the problem being investigated. The tree is highly influenced by the rigour used when adding effects to the tree and the decision to stop any cause-effect chains at the appropriate endpoints.15 Despite this, if the Decision Tree is completed thoroughly it can be a valuable tool to assess the determinants of injury.


Click here to download a Know Injury – Causal tree template.

Cause and Consequence Analysis

Cause and Consequence Analysis visually represents the consequence chains that develop from an unwanted event.16 The cause and consequence tree combines two different analysis trees, the consequence tree and the cause tree. Working from left to right the consequence tree shows the possible consequence chains and the effects of these events; while from top to bottom the cause tree describes the causes and probabilities of each consequence.16

This diagram allows damaged chains to be recognised, consequences of actions to be highlighted, causes of consequences to be identified and probabilities to be assigned to the consequences.16

Models and theories describe the determinants of injury

Models and theories can help practitioners focus on what is changeable. They are a tool to help explain or predict a determinant, an event or situation. In an ordered manner, they show how concepts relate to one another in an ordered manner to help explain or predict an event or a situation.

Some theories and models are useful for design, planning, implementing and evaluating interventions; and some theories and models are useful in understanding the determinants of an issue. Below is a selection of common models or theories of change which you may be able to use to inform your initiative from the perspective of determinants.

Community and Social Level

The Socio-ecological Model

Injury prevention requires an understanding of the factors that influence the injury. In addition to developing an understanding of the influential factors, the model supports the importance of preventing injury across multiple levels.17 The socio-ecological model considers the complex interaction between;17

  • Individuals – biological and personal factors
  • Relationships – social peers, partners and family members
  • Community – schools, workplaces and neighbourhoods
  • Societal factors – social norms, cultural norms and policies

The socio-ecological model considers the complex interaction between individual, relationship, community and societal factors.17


Precede-Proceed is a health promotion planning model that takes into account multiple factors that influence health. More specifically, the model takes into account:

  • Social factors, i.e. living conditions and existing support systems
  • Epidemiological factors
  • Behavioural/environmental factors, i.e. how behaviours affect the environment and vice versa
  • Educational/organisational, i.e. what is currently happening to prevent a health issue
  • Administrative/policy i.e. what policies exist to prevent a health issue from occurring

Determinants Precede Proceed

More information about the Precede-Proceed model can be found in the Community Toolbox

Individual and Interpersonal Level

Stages of Change Theory

The Stages of Change theory, also known as the Trans-theoretical Model, explains the behaviour change process by exploring five stages of change.18 These are;

  • Pre-contemplation (not ready for change)
  • Contemplation (getting ready for change)
  • Preparation (ready for change)
  • Action
  • Maintenance

More information about the Stages of Change theory can be found here.

Health Belief Model

The Health Belief Model is one of the most widely used health promotion theories. The theory is based around an individual’s perceptions and attitudes towards a health issue or a negative consequence of certain behaviour.19

The theory states that behaviour change will occur with three simultaneously existing ideas, which are:

  1. Perceived severity, i.e. a person recognises there is a cause for concern.
  2. Perceived threat, i.e. a person understands that they are at risk.
  3. Perceived benefits, i.e. a person realises that a change in behaviour can be beneficial for them.

More information about the Health Belief Model can be found here.

Click here to download the Know Injury – Health Belief Model template

Reasoned action and planned behaviour model

The theory of reasoned action and the theory of planned behaviour are social cognition models that have been applied to health beliefs and behaviours. Based upon Banduras work on self-efficacy the theories suggest that health behaviours are based upon intentions which are formed by a mixture of personal attitudes and pressure to adopt health related behaviours. 20

The theory of reasoned action and the theory of planned behaviour assume that the immediate determinant of behaviour is people’s intentions to perform that behaviour.21 The theory of reasoned action suggests that behavioural intentions are a function of people attitudes towards the behaviour and their subjective norms.22 Attitude refers to their belief that the behaviour will result in a positive or negative outcome, while subjective norms are shaped by the value that those close to them place on the behaviour. The theory of planned behaviour includes an additional determinant, the individual’s intention to act.22 This relates to the individuals perception of how much control they have over the behaviour.



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2 The World Health Organization. (2015). Social determinants of health. Retrieved from

3 The Atlantic Collaborative on Injury Prevention. (2011). The social determinants of injury. Retrieved from

4 Department of Health, Western Australia. (2015). Injury prevention in Western Australia: A review of statewide activity. Perth; Chronic Disease Prevention Directorate.

5 Australian Institute of Health and Welfare (2010). Determinants: key to prevention. Retrieved from

6 The World Health Organization (1998). Health Promotion Glossary. Geneva. Retrieved from

7 The World Health Organization. (2009).Health Impact Assessment. Retrieved from

8 The World Health Organization. (2009). Social Determinants of Health. Retrieved from

9 Australian Medical Association. (2007). Social Determinants of Health and the Prevention of Health Inequities. Retrieved from

10 Victorian Healthcare Association. (2010). Population Health Planning Framework – addressing the social determinants. Retrieved from…/5-social-determinants

11 Marmot., M. (2005) ‘Social determinants of health inequalities’, The Lancet. 365(1). 99 – 1104.

12 Mikkonen, J. and Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. York University School of Health Policy and Management. Toronto: Canada

13 Public Health Agency of Canada. (2011). What determines health? Retrieved from

14 Laymon, B. and Chudgar, R. (2014). Social Determinants of Health in Community Health Assessment and Improvement Planning. The National Association of Country and City Health Officials. Retrieved from

15 Smits, M., Janssen, J., de Vet, R., Zwaan, L., Timmermans, D., Groenewegen, P. and Wagner, C. (2009). Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. International Journal for Quality Healthcare. 21(4). 292 – 300. DOI: 292-300

16 Ramentor. (2014). Case-Consequence Analysis. Retrieved from

17 World Health Organisation. (2002). Violence – a global public health problem. World Report on Violence and Health. Retrieved from

18 Health Promotion Unit. (2007). Stages of behaviour change: Queensland Stay On Your Feet®

19 Community Good Practice Toolkit. Division of Chief Health Officer, Queensland Health. Retrieved from

20 Glanz, K. et al. (2002). Health Behavior and Health Education. Theory, Research and Practice.San Fransisco: Wiley & Sons.

21 Ajzen, I., Albarracin, D., Hornik, R. (2012). Prediction and Change of Health Behaviour: Applying the Reasoned Action Approach. Psychology Press.

22 Brannon, L. and Feist, J. (2009). Health Psychology: An Introduction to Behavior and Health. 7th Edition. Cengage Learning.