Advanced Grammar: Social Determinants of Health & Sentence Structure

Introduction: How to Use This Grammar Lesson

Welcome, dedicated learners! This grammar session is tailored for upper-intermediate and advanced students aiming for excellence in English, especially on international exams. We’ll examine grammar by analyzing a text about how social factors influence health.

Maximize your learning by following these steps:

1. Read the Text: First, read the ~1000-word passage to grasp the main concepts about social determinants of health. Don’t worry about analyzing every sentence grammatically just yet.
2. Identify Structures (Optional Challenge): As you read, see if you notice particular ways the author structures sentences, connects ideas, or uses verb forms to convey specific meanings.
3. Study the Analysis: Engage deeply with our breakdown of selected grammatical structures. We’ll explain their construction, usage in context, subtle meanings, and common errors.
4. Review the Summary: Check the quick recap of the grammar points covered.
5. Practice and Internalize: Become a structure spotter! Look for these grammatical patterns in academic articles, news reports, and books. Consciously try to use them in your own writing and speaking.

Let’s enhance your grammar!

Beyond Biology: How Social Determinants Influence Health Outcomes

While healthcare systems and individual lifestyle choices undoubtedly play crucial roles in determining health, there is growing recognition within public health that these factors operate within a much broader context. Social determinants of health (SDOH) – the non-medical factors influencing health outcomes – encompass the conditions in which people are born, grow, work, live, and age, along with the wider set of forces and systems shaping daily life. These determinants, ranging from socioeconomic status and education to neighborhood environment and social support networks, significantly impact health equity and are fundamental to understanding persistent health disparities across populations. Addressing them is increasingly seen as indispensable for achieving sustainable improvements in public health.

Socioeconomic status (SES), often measured by income, education, and occupation, is perhaps the most extensively studied social determinant. Individuals with lower SES consistently experience worse health outcomes across a multitude of conditions compared to their more affluent counterparts. This gradient exists for several reasons. Limited income restricts access to nutritious food, safe housing, and quality healthcare, even in countries with universal healthcare systems, due to associated costs like transportation or time off work. Lower educational attainment is often linked to reduced health literacy, making it harder to navigate complex health information and adhere to treatment regimens. Furthermore, occupations associated with lower SES frequently involve greater physical risks, exposure to toxins, or higher levels of chronic stress with less autonomy, all of which contribute negatively to long-term health.

The physical environment in which a person lives exerts a powerful influence. Neighborhood safety, for instance, affects residents’ ability to exercise outdoors or allow children to play freely. Access to parks, green spaces, and recreational facilities promotes physical activity. Conversely, proximity to sources of pollution, such as highways or industrial sites, has been clearly linked to higher rates of respiratory illnesses and other conditions. Food deserts – areas with limited access to affordable and nutritious food retailers like supermarkets – disproportionately affect low-income neighborhoods, contributing to poor nutrition and related health problems like obesity and diabetes. Were policy interventions not implemented to improve neighborhood infrastructure and amenities, these environmentally driven health disparities would likely worsen.

Education, beyond its connection to income and occupation, directly impacts health literacy and health behaviors. Higher levels of education are generally associated with better understanding of health information, healthier lifestyle choices (like lower smoking rates), and more effective management of chronic conditions. Education empowers individuals with critical thinking skills needed to evaluate health claims and navigate healthcare systems. Moreover, schools themselves can be crucial sites for health promotion through physical education, nutrition programs, and health education curricula. Ensuring equitable access to quality education from early childhood onwards, therefore, represents a fundamental public health strategy.

Social support networks and social cohesion also play a vital, albeit sometimes less tangible, role. Strong social ties provide emotional support during times of stress, practical assistance (like help during illness), and reinforcement for healthy behaviors. Social isolation and loneliness, conversely, have been robustly linked to increased risk of mortality, cardiovascular disease, and mental health problems, with some studies suggesting their impact is comparable to well-known risk factors like smoking or obesity. Community cohesion – the level of trust, cooperation, and connectedness among residents – can influence collective efficacy in addressing local problems and fostering safer, healthier environments.

Addressing social determinants requires action far beyond the healthcare sector. Policies impacting housing, education, employment, urban planning, and social welfare are fundamentally health policies. For example, affordable housing initiatives can reduce homelessness and housing instability, both major stressors detrimental to health. Investments in public transportation can improve access to jobs and healthcare services. Minimum wage laws and worker safety regulations directly influence the economic and physical well-being of employees. It requires a ‘Health in All Policies’ approach, whereby the health implications of decisions across various sectors are systematically considered and addressed. Such an approach, though complex to implement, holds the greatest promise for tackling the root causes of health inequities.

In conclusion, health is shaped by a complex interplay of factors, many of which lie outside the traditional boundaries of the healthcare system. Social determinants like socioeconomic status, neighborhood conditions, education, and social support profoundly influence individual and population health outcomes and drive health disparities. Recognizing and addressing these determinants through multisectoral policies and interventions is not merely a social justice issue; it is an essential strategy for creating healthier populations and achieving true health equity.

Grammar Analysis: Unpacking the Structures

Let’s break down some grammar points from the text on social determinants of health. Mastering these can significantly improve the clarity and sophistication of your English.

Existential ‘There’ with Complex Subjects

• Example: “…there is growing recognition within public health that these factors operate within a much broader context.” (Paragraph 1)
  • Explanation: The structure There + be + noun phrase (existential ‘there’) is used to introduce the existence or presence of something. In advanced writing, the noun phrase following ‘be’ can become quite complex, often including prepositional phrases (‘within public health’) or clauses (‘that these factors operate…’).
  • Nuance: It’s a common way to introduce a new topic or state a fact neutrally. The real subject logically follows the verb ‘be’. The verb agrees with the noun phrase that follows it (e.g., There is recognition, There are reasons).
  • Common Mistake: Verb agreement errors (“There are growing recognition…”) especially when the noun phrase is complex or includes plural elements within it; unnecessary use when a more direct subject-verb structure would be better.

Defining Relative Clauses with Prepositions

• Example: “…the conditions in which people are born, grow, work, live, and age…” (Paragraph 1)
  • Example: “The physical environment in which a person lives exerts a powerful influence.” (Paragraph 3)
  • Explanation: These are defining relative clauses (identifying ‘the conditions’/’the environment’) where the relative pronoun (‘which’) is the object of a preposition (‘in’). In formal English, the preposition is often placed before the relative pronoun (‘in which’, ‘for which’, ‘with whom’).
  • Nuance: Placing the preposition before ‘which’ is more formal than placing it at the end of the clause (“…the conditions which people are born… in”). Using ‘that’ instead of ‘which’ is not possible when the preposition comes first.
  • Common Mistake: Using ‘that’ after the preposition (“in that”); putting the preposition at the end in very formal contexts where putting it earlier would be more appropriate; using the wrong preposition.

Apposition and Phrases in Apposition

• Example: “Social determinants of health (SDOH) – the non-medical factors influencing health outcomes – encompass…” (Paragraph 1) (Appositive phrase explaining SDOH, set off by dashes for emphasis)
  • Example: “These determinants, ranging from socioeconomic status… to neighborhood environment…, significantly impact…” (Paragraph 1) (Appositive-like phrase using ‘-ing’, providing examples of determinants)
  • Example: “Food deserts – areas with limited access to affordable and nutritious food retailers – disproportionately affect…” (Paragraph 3) (Appositive phrase defining ‘food deserts’)
  • Explanation: Similar to Post 3, appositives rename or explain adjacent nouns. Here, dashes are used instead of commas for a stronger separation or emphasis. Participial phrases (‘ranging from…’) can also function similarly to provide descriptive examples.
  • Nuance: Dashes can make the appositive stand out more than commas. Phrases like ‘ranging from…’ are efficient ways to list examples that define a preceding noun.
  • Common Mistake: Punctuation errors (using only one dash, mixing dashes and commas inappropriately); lack of clarity about which noun the phrase modifies.

Passive Voice Across Tenses and with Modals

• Example: “…factors influencing health outcomes – encompass the conditions… along with the wider set of forces… shaping daily life.” (Active participle phrase – contrast) vs. ‘…forces by which daily life is shaped.’ (Passive)
  • Example: “Addressing them is increasingly seen as indispensable…” (Present Continuous Passive) (Paragraph 1)
  • Example: “…proximity to sources of pollution… has been clearly linked to higher rates of respiratory illnesses…” (Present Perfect Passive) (Paragraph 3)
  • Example: “Were policy interventions not implemented…” (Past Passive within an inverted conditional) (Paragraph 3)
  • Example: “Higher levels of education are generally associated with…” (Present Simple Passive) (Paragraph 4)
  • Example: “…the health implications… are systematically considered and addressed.” (Present Simple Passive) (Paragraph 6)
  • Explanation: The passive voice is used extensively in scientific and academic writing to maintain objectivity and focus on processes or results rather than agents. The examples show its use in various tenses (Present Continuous, Present Perfect, Present Simple) and constructions (conditionals).
  • Nuance: Essential for formal tone and when the agent is unknown, obvious, or unimportant. Impersonal constructions like ‘is seen as’, ‘is linked to’, ‘is associated with’ are very common in this style.
  • Common Mistake: Incorrect formation (wrong auxiliary ‘be’ form or wrong past participle); overuse leading to vagueness or wordiness.

Adverbial Phrases and Clauses of Comparison/Concession

• Example: “…consistently experience worse health outcomes… compared to their more affluent counterparts.” (Paragraph 2) (Phrase of comparison)
  • Example: “…restricts access…, even in countries with universal healthcare systems, due to associated costs…” (Paragraph 2) (Concessive idea introduced by ‘even in…’)
  • Example: “…social cohesion also play a vital, albeit sometimes less tangible, role.” (Paragraph 5) (‘Albeit’ introducing a concessive point – formal synonym for ‘although it is/was’)
  • Example: “…impact is comparable to well-known risk factors like smoking or obesity.” (Paragraph 5) (Phrase of comparison)
  • Example: “Such an approach, though complex to implement, holds the greatest promise…” (Paragraph 6) (Concessive clause reduced using ‘though’)
  • Explanation: These structures allow writers to make comparisons or acknowledge contrasting points smoothly. ‘Albeit’ is a formal linker meaning ‘although’. Reduced clauses (‘though complex to implement’) are concise ways to express concession.
  • Nuance: ‘Albeit’ is quite formal. Phrases like ‘compared to’ are standard for comparisons. Reduced clauses increase sentence fluency.
  • Common Mistake: Using ‘albeit’ incorrectly (it usually introduces an adjective, adverb, or phrase, not a full clause); incorrect structure in comparative phrases.

Complex Sentences with Parallelism

• Example: “…conditions in which people are born, grow, work, live, and age…” (Parallel verbs in a relative clause) (Paragraph 1)
  • Example: “…ranging from socioeconomic status and education to neighborhood environment and social support networks…” (Parallel noun phrases in a list structure) (Paragraph 1)
  • Example: “…restricts access to nutritious food, safe housing, and quality healthcare…” (Parallel noun phrases as objects) (Paragraph 2)
  • Example: “…Policies impacting housing, education, employment, urban planning, and social welfare are fundamentally health policies.” (Parallel gerund/noun phrases acting adjectivally) (Paragraph 6)
  • Example: “Recognizing and addressing these determinants… is not merely a social justice issue; it is an essential strategy…” (Parallel gerund phrases as subject; parallel main clauses) (Paragraph 7)
  • Explanation: Parallel structure means using the same grammatical form for items in a list or series connected by conjunctions like ‘and’, ‘or’, ‘but’, or in comparisons. It creates balance, rhythm, and clarity. The examples show parallelism with verbs, nouns, and gerund phrases.
  • Nuance: Essential for clear, elegant, and professional-sounding writing. Lack of parallelism can make sentences awkward and hard to follow.
  • Common Mistake: Faulty parallelism – mixing grammatical forms in a list (e.g., “born, growing, work, live, and how they age”).

Summary of Key Grammar Points

In this lesson examining social determinants of health, we analyzed:

• Existential ‘There’: Introducing subjects neutrally, often followed by complex noun phrases or clauses (There is growing recognition that…).
• Relative Clauses with Prepositions: Formal structure using preposition + ‘which’ (conditions in which…).
• Apposition: Using noun phrases (often set off by commas or dashes) to rename or explain adjacent nouns (SDOH – the non-medical factors…).
• Passive Voice: Employing various passive forms (Present Continuous, Perfect, Simple, Modal) common in academic writing (is seen as, has been linked to, are associated with).
• Comparison/Concession: Using phrases (compared to, comparable to) and formal linkers/clauses (even in, albeit, though complex…).
• Parallel Structure: Maintaining grammatical consistency in lists and series for clarity and style (born, grow, work, live, and age; Recognizing and addressing…).

Keep Practicing!

Understanding how these structures function will greatly enhance your ability to comprehend complex academic texts and express sophisticated ideas in your own English for exams and beyond. Look for existential ‘there’, formal relative clauses, and passive constructions in public health reports or social science articles. Practice parallelism diligently in your writing! Keep up the excellent effort!