Child Math ExpertHealth Promotion

Determinants of X

By: Scott Orsey

Change is hard, especially where structure creates imbalance in perspectives, power and impact. When years of good intentions yield underwhelming results related to health and well-being outcomes, it is time to question the approach. In this four-part blog series, Scott Orsey explores the model used by scientists to measure health and well-being. He arrives at three conditions for change. Might these be the building blocks for the transformation we seek?

In recent articles, I have drawn conclusions from the structure of a mathematical model we use to represent our work. In doing so, I argued that if we want to improve health or well-being outcomes, we need to take into account all factors, regardless of in which sector they reside. In accepting this, we must look critically at the system and recognize the problem with a structure that gives one sector, healthcare, so much power and influence.

The “we” has generally been meant to refer to those of us within the healthcare sector. We have the most power and influence in the system, so it is we that need to recognize the current structural issues.  Yet, I wonder if there is something that a broader “we” can also learn.

Below is the equation that I developed to explore the relationship of determinants to successful health and well-being outcomes. 


 Ϲ is a constant.

fn are functions representing the influence of each sector on the odds of success.

In my previous discussion, I focused on the right hand side of the equation, but what if we look at the left side of this equation? What are the outcomes for which we are looking to calculate the odds of success? And, who should lead the work to achieve those outcomes?

The Outcomes We Model

I work in a health system within the healthcare sector, so I am generally talking to people who care about health and well-being outcomes. Makes sense. However, what if I worked in a different sector? If, for example, I worked regularly with programs in the housing sector, wouldn’t we be thinking about housing outcomes, maybe topics like homelessness, eviction rates or housing conditions? Similarly, leaders in economic development might focus on outcomes such as job placement, unemployment rates and economic success. And on it goes in whatever sector you might consider.

What would one of these other sectors find if they developed their odds equation for the successes they care about? Well, they would find a set of factors, just like I’ve done previously.

Read Part 1 and Part 2 of this series.

It’s a Matter of Perspective

It strikes me that each of these sectors is observing the same system. Yet, they all have a different perspective and often come to conclusions at odds with each other. This is where a metaphor might help.

A common metaphor used to explore our shortcomings of perspective is that of a number of people who are blind observing an elephant. The person near the trunk might think they are observing a long flexible tube, the person near a leg would feel a tree or a sturdy column and the person near the tail might think of a rope. It’s only when a sighted individual enters the picture that they all realize that they are observing the same thing, an elephant. 

Despite its widespread (almost exclusive) use, I have never liked the elephant metaphor. It suggests that some perspectives are more “right” or privileged than others. This suggestion is as untrue for organizations seeking change as it is for people who are blind or sighted observing an elephant. Different perspectives add richness and dimension to our understanding of the world.

Embrace All Views

I was exposed to a far better metaphor several years ago while attending a leadership course. It went something like this: Imagine a hill or mountain with a number of park benches arranged across the top.  People can sit down on any of these benches to experience the world. Once seated, each person would observe different things through their senses because each bench is in a different location, facing a different direction. Every bench offers a perspective on the world, yet no two perspectives are the same.

We are creatures of habit, and we tend to prefer to sit on just one or two of these metaphorical benches. It’s not that we can’t move from bench to bench, it’s that it is not in our nature to move around much. Incidentally, the leadership course encouraged us to try out different benches every once-in-a-while.

So too goes our Odds equation. Since I sit on a healthcare bench, I have a certain view of the world that undoubtedly would be different if I worked in a different sector.  But, it’s the same world!

Figuring Out What Matters

If we were to take the time, regardless of which park bench we sit on, to discover what matters to our work, we would find the same set of factors as folks sitting on different benches. The factors that affect homelessness are the same factors that affect economic success. And, they are the same factors that drive health and well-being outcomes.

To write this out using the Odds equation:

I should note that the value and influence of the factors can vary depending on your park bench. I am not suggesting that, for example:  

Perhaps others might be so bold as to make that claim. However, as I mentioned in my original blog post in this series, it is still true that one factor, if it is particularly adverse, can derail the outcomes.  And, if we are honest with our definition of factors, then that factor would likely derail the outcomes in all sectors.

Determinants of X – All Sectors In

In health care, it is fashionable to describe these factors as the Determinants of Health (DOH). Because they are also the driving factors of nearly any human outcome you can imagine, I prefer thinking of them as the Determinants of X, or DoX, where X is any outcome of importance. DoX are the underpinning factors that influence all of our goals as a society. They don’t discriminate against one sector and they don’t play favorites. They drive the rules of the world that we observe from our park benches.

If we accept that DoX exist, that the factors that influence our odds of success are the same factors that drive the success of other sectors, we should come to another important conclusion: Perspectives of all sectors are critical. I distinguish this from the “all sectors matter” point that I made in my previous article when looking at the right hand side of the equation. The left-hand side means that we need “all sectors in.”

It is beyond recognizing that efforts in other sectors matter, it is acknowledging that everyone has a seat at the table, that no one sector leads, that no one perspective is better than others. We should not just engage other sectors, we should share the lead, defer to others and (most importantly) make space at the table. It is our burden to make this space available because the healthcare sector has an outsized impact and role. By getting out of the way, ceding some of our power and privilege, and following others who have the expertise that we don’t, we enable structural change that sets up the communities we serve for success in achieving the outcomes they desire.

In the next blog post in this series, I’ll explore the importance of making it safe for all.

Author’s Note: My deepest gratitude to Amy Hunter, PhD, MPH, who reviewed this series, challenged my thinking and offered feedback and insight.

Scott Orsey is the associate director of operations, business strategy and institutional engagement for Connecticut Children’s Office for Community Child Health.

2 replies »

Leave a Reply