I first explored major health organization websites for information on the determinants but quickly found that a standard list of determinants did not exist. Surprised to find so much variability, I changed my focus to more academic literature. I wanted to get to the source to ensure that for all determinants I did include, they were as evidence-driven as possible.

I conducted a literature review of publications from 8 different major health organizations. [1-8]

I documented these efforts by summarizing key points and patterns from each publication, which led me to the following insights:

• There is currently no universal standard for the list of health determinants

• Medical care accounts for only 11% of our health. Our healthcare system is too focused on storing clinical information.

• There were several research methodologies used to find correlations between the determinants and health outcomes, leading to wide variability in the estimated correlation of each determinant category to health.

With such variability in the primary sources, I decided to use the most developed model I found among the literature (Institute of Medicine [7]) to inform much of the organizational structure and initial list of determinants.

To address the variability in the estimated correlation of each determinant category to health, the arithmetic mean of estimates from 6 different major health organizations were used (WHO, HHS, among others) [9-15]

I found 95 unique determinants within the literature

I created several sketches exploring how these could be represented. Based on informal feedback from several design and engineer colleagues, I found that a radiating circular representation appeared the most understandable for communicating the data.

There was high engagement in seeing the determinants in a web-like manner, which I noticed tended to prompt discussions on how the determinants connected and influenced each other.

“How are these determinants measured?”

This was one of the questions that surfaced again and again in this early phase from my viewers. For future iterations, I decided to include sources showing how quantitative and qualitative data on many of the determinants could be collected.

This latest version shows an aggregated list of all determinants based on my literature review. [1-8]

To ensure further content accuracy, I set up feedback meetings with 5 population health researchers and primary care clinicians by reaching out to several institutions including my alma mater, the University of Washington.

I wanted viewers to take away information at a glance, but also to continually learn with longer viewings.

I designed the visualization to show major categories of health, but also for these categories to continually break into increasing granularity as the viewer moves to the outer circles of the visual.

I designed and co-developed a web feature for the Determinants of Health.

To further push dissemination of the visual, I decided to open source the visualization online to further drive its use. It is licensed under Creative Commons Attribution v3, and available for download on GitHub. Detailed methodology and references are available at determinantsofhealth.org.

The next step is to make it interactive.

A comment I heard from several SMEs was “is there an interactive version of this?” There was a need for taking it to a level of personalized exploration that mapped additional information on top of the determinants.

For example, highlighting close connections across determinants to show level of correlations, or, slicing the view of the determinants based on preferences like viewing the determinants of lifespan, or the determinants of pediatrics.

Another direction is to map the future health record onto the determinants.

By mapping the data elements of emerging standards such as FHIR and the Standard Health Record onto the determinants of health, the visualization can help lead future health services and data schemas towards a direction where health is not viewed merely through medical data, but through a combination of social, environmental, behavioral, genetic, and biological data.

Determinants of Health’s product goal was to communicate a research driven and visually engaging view of the factors that impact health.

• The visualization content was formulated from the review of literature from several major health organizations and validated with 5 different population health researchers and clinicians.

• Validate the content with health experts in the field to ensure accuracy.

• The visualization is now being used by hundreds of health professionals, researchers, teachers and students in the US and abroad (UK, Canada, Australia, Netherlands).

Determinants of Health’s business goal was to disseminate the visual to the larger healthcare industry.

• Finalist in the 2017 Kantar Information is Beautiful awards for best data visualization.

• Accepted to the 2017 MIT Bioinnovations conference and the 2017 ACM Digital Health conference.

• Presented at the 2017 Fall Managed Care Forum, 2018 Human Factors and Ergonomics Society, as well as the 2018 Consortium of Universities for Global Health.

• Displayed at 2018 SXSW and at the 2017 Convergence conference.

Installed at Human Services Research Institute, Boston Children’s Hospital, Iora Health, MITRE Corporation, Sidewalk Labs, Dell Medical Design Institute for Health, among dozens of other healthcare organizations.

References

1. NCHHSTP Social Determinants of Health. (2014). Retrieved March 14, 2016: http://www.cdc.gov/nchhstp/socialdeterminants/definitions.html

2. The determinants of health. (n.d.). Retrieved March 14, 2016: http://www.who.int/hia/evidence/doh/en/

3. Social Determinants of Health. (n.d.). Retrieved March 14, 2016: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

4. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. (n.d.). Retrieved March 14, 2016: http://kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

5. Schroeder, S. A. (2007). We Can Do Better — Improving the Health of the American People. New England Journal of Medicine N Engl J Med,357(12), 1221-1228.

6. The Relative Contribution of Multiple Determinants to Health Outcomes. (n.d.). Retrieved March 14, 2016: http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_123.pdf

7. Capturing social and behavioral domains and measures in electronic health records: Phase 2. (2014). Washington D.C.: The National Academies Press.

8. Gruszin, S., & Jorm, L. (2010, December). Public Health Classifications Project (Rep.). Retrieved March 15, 2016, from New South Wales Department of Health website: http://www.health.nsw.gov.au/hsnsw/Publications/classifications-project.pdf

9. DHHS, Public Health Service. “Ten Leading Causes of Death in the United States.” Atlanta (GA): Bureau of State Services, July 1980

10. J.M.McGinnis and W.H.Foege. “Actual Causes of Death in the United States.” JAMA 270, No. 18 (1993):2207-12

11. J.M.McGinnis et al, “The Case for More Active Policy Attention to Health Promotion.” Health Affairs 21, no.2 (2002):78-93

12. A.Mokdad et al. “Actual Causes of Death in the United States 2000.” JAMA 291, no.10 (2004):1238-45

13. G.Danaei et al, “The Preventable Cuases of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors.” PLoS Medicine 6, no. 4 (2009):e1000058

14. World Health Organization, Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks, Geneva: WHO, 2009

15. B. Booske et al., “Different Perspectives for Assigning Weights to Determinants of Health.” County Health Rankings Working Paper. Madison (WI): University of Wisconsin Population Health Institute, 2010