Commission on Social Determinants of Health Conceptual Framework
In recent years, indicator frameworks have become more sophisticated by modeling causality between categories of indicators. By doing so, frameworks move beyond being a categorization mechanism and begin to postulate a more dynamic, interconnected model of health and health behaviours.
One important international example was published by the World Health Organization’s (WHO) Commission on Social Determinants of Health in 2008. It identifies socioeconomic and political factors such as governance, policy, cultural and societal norms and values as fundamental determinants of health responsible for giving rise to social positions including education, occupation, income, gender, ethnicity and race. In turn, these social positions influence specific determinants of health such as material circumstance, social cohesion, psychosocial factors, behaviours and biological factors .
Though the Commissions’ indicator framework was not a women’s health framework, it did recognize gender as a critical aspect of social position and thus an important factor to monitor in any standard set of indicators.
Dynamic Gender-inspired Health Determinants Model
In 2009, the Women’s Health Research Network of BC released a dynamic gender-inspired health determinants model, which unlike the Commission’s framework, posits that sex and gender are fundamental determinants of health that intersect with other key social statuses and processes, including age, race, class, ethnicity, immigrant status and geographic location. In this model, sex and gender are understood to influence access to important resources, including employment, education, childcare, safe neighbourhoods, and health services. Gender is understood to be a structural determinant of health rather than just a characteristic of individuals or populations .
Gender and Equity Health Indicator Framework
Also in 2009, the Project for an Ontario Women’s Health Evidence-Based Report (POWER) featured a Gender and Equity Health Indicator Framework. As with the framework put forth by the Women’s Health Research Network, the POWER framework locates gender as a central element that shapes and is shaped by all other health domains. The framework is based on:
• A holistic definition of women’s health including emotional, social, cultural, spiritual, physical, political, economic and biological aspects.
• The social determinants of health, such as income, education, socio-cultural factors, housing, employment, health services, personal health practices and physical environment are emphasized as being important drivers behind women’s health.
• The distinction between “sex” and “gender”: The framework distinguishes between “sex” which are the biological differences between men and women, from “gender” which refers to “the differences associated with societal roles and the context of women’s lives”.
• Equity is central to the POWER study’s framework, as the Report’s main objective to contribute to the body of evidence on gendered health inequities.
• Stakeholder input from women’s health stakeholders across Ontario was instrumental in indicator selection and identifying priority areas for reporting .
The POWER Study indicator framework recognizes that the non-medical determinants of health are the primary determinants of health status and that population and individual health outcomes are mediated by community and health system characteristics as well as health system performance. The framework also recognizes that sex and gender influence how all these factors impact on experiences with care and health outcomes. The POWER framework is currently being used as the foundation for the POWER report, chapters of which are available on POWER’s website.
The Gender Migration and Health Conceptual Framework
In some cases, researchers have developed indicator frameworks for understanding the health of smaller subpopulations. This specialization is intended to increase accuracy of results by taking the unique experiences of that population into account.
The Gender Migration and Health Conceptual framework is a critical example that focuses on the health of immigrant women. It is found in Measuring Health Inequalities Among Canadian Women: Developing a Basket of Indicators.
The framework asserts that the geopolitical environment encompasses all of the other health determinants including who immigrates, the country of origin and place of settlement. The health of immigrants is influenced by factors in their country of origin as well as factors in their host nation. Socially constructed gender roles from the host and settlement countries act at all levels to create a difference in health outcomes between immigrant men and women .
In addition to showing the directional relationships between indicators, this framework recognizes that different subgroups of women experience distinct sets of health determinants. Gender plays a key role in producing health outcomes and is shown to interact with both pre-migration and resettlement determinants of health to affect health outcomes.
There is a trend towards increasing complexity of women’s health frameworks, as we learn more about women’s health, women’s health indicators and the instrumental role that sex and gender play in shaping women’s health.
 Canadian Institute for Health Information and Statistics Canada(2003). Health Indicators. Accessed on December 8, 2009 from www.cihi.ca/indicators/en/pdf/framework.pdf
 Lin V., Gruszin S., Ellickson C., Glover J., Silburn K., Wilson G. and Poljski C (2007). Comparative evaluation of indicators for gender equity and health. International Journal of Public Health 52(S1): S19-S26.
 PAHO, Gender Ethnicity and Health Unit (2005). Basic Indicators for Gender Equity Analysis in Health. Accessed on December 8, 2009 from www.paho.org/english/ad/ge/basicindicators.pdf
 Commission on Social Determinants of Health (2007). A Conceptual Framework for Action on the Social Determinants of Health. Discussion paper for the Commission on Social Determinants of Health DRAFT. Accessed on December 8, 2009 from www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf
 Benoit C., Shumka L. (2009) Gendering the Health Determinants Framework: Why girl’s and women’s health matters: Women’s Health Research Network. Accessed on December 8, 2009 from www.whrn.ca/why-girls-and-womens-health-matters-download.php.
 Clark J.P. and Bierman Arlene (2009). Ontario Women’s Health Equity Report. The Power Study Framework, Chapter 2. Accessed on December 8, 2009 from www.powerstudy.ca/webfm_send/50