• social, family, and community relationships and networks;

  • living and working conditions; and

  • societal, economic, cultural, and environmental policies and conditions.

Some determinants may operate at more than one level, and most health outcomes will be related to determinants from more than one level of the model. The model is consistent with the committee’s belief that quality of life is a particularly important component of women’s health. The determinant-based framework has advantages over a strictly disease-based framework in that it more readily allows consideration of functioning, wellness, and quality of life in addition to the understanding, detecting, and treating of diseases. It also allows discussion of interventions that can occur at the individual, community, and population levels, and how determinants are related to health across a woman’s life span.

This chapter presents evidence of the impact of a number of behavioral factors (smoking, eating habits and physical activity, sexual risk behavior, and alcohol use), social and community factors (violence against girls and women, social connections and stress, and social disadvantage), and societal factors (cultural factors and health care) that affect women’s health. Those factors are discussed as examples of factors that affect women’s health and should not be considered a comprehensive list of determinants of women’s health. Biologic determinants are discussed in Chapter 3 in the context of their roles in specific diseases.


In the last 20 years, there has been substantial progress in understanding how behavior affects people’s health, including the health of women and girls. Research has identified modifiable risk factors for a variety of health outcomes and has led to a better understanding of the level at which behavior leads to improvements in or deterioration of health. Human behavior is one of the biggest contributors to death and disease (McGinnis and Foege, 1993; McGinnis et al., 2002). With respect to US women, for example, substantial numbers of deaths have been attributed to smoking, physical inactivity, and dietary factors, which are preventable (Figure 2-2). As discussed in the Institute of Medicine (IOM) report Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences, the extent to which a given behavior affects health varies during the course of life (IOM, 2001a), and life span and stage of development are important to consider. Several IOM reports have also discussed strategies for modifying behavioral norms to improve the health of specific populations (IOM, 2000b, 2005a,b, 2010). This section discusses research on behavioral factors that are major contributors to morbidity and mortality among women: smoking, eating habits and physical activity, sexual risk behavior, and alcohol use.

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