Identifying and analyzing the interactions of social determinants of health in Iran

Background: Although healthcare is a key determinant of health status, in recent years, the role of non-medical factors in health has become more prominent, and policymaking in the field of social determinants of health has been recognized as one of the most important areas for improving community health. This study aimed to identify and analyze social determinants of health in Iran. Methods: The present study used mixed-methods approach. First, the qualitative approach was conducted using Graneheim and Lundman’s six-step method to analyze the content of 58 sources and identify social determinants of health at the micro level. Subsequently, the quantitative Fuzzy Delphi method and Fuzzy Cognitive Mapping (FCM) were used to determine priorities and interactions. To this end, first, the factors identified by 15 academic and executive experts in the field of health were screened using the fuzzy Delphi method, and then 6 of these experts were purposefully selected to determine the relationships between the factors. Results: The 83 identified determinants were classified into two categories: individual level with seven subcategories (family status, healthy start to life, childhood development, social gradient, individual behaviors, spiritual and mental health, and lifelong programs); and local level with four subcategories (environmental and chemical, physical environment, urban infrastructure, and social environment). After drawing a fuzzy cognitive map and determining causal relationships between factors, social environment (centrality degree = 12.10) and individual behaviors (centrality degree= 11.43) were found to be the most influential factors. Conclusion: The findings of this study, by providing a fuzzy map, identified quantitative relationships between factors and helped policymakers understand priorities and linkages between sectors for the development and implementation of health-oriented policies in all sectors.