Where we live, work, and move through the world shapes our health in ways that are increasingly impossible to ignore. The distance to the nearest grocery store, the density of our neighbourhoods, the presence of green parks or polluted waterways, the quality of our housing, and the reach of public transport all leave measurable fingerprints on disease risk, life expectancy, and wellbeing. Yet according to a new systematic review published in Public Health in Practice, the scientific community still cannot agree on what these spatial factors actually are, how they should be defined, or where they fit within the broader framework of health determinants. The finding is striking: of 59 publications analysed, only three bothered to define what they meant by spatial determinants of health at all.
The review, conducted by Predrag Duric and colleagues, set out to answer a deceptively simple question: what do researchers actually mean when they talk about spatial determinants of health? The team searched EBSCOhost, Scopus, and PubMed for literature discussing spatial determinants, drivers, factors, or aspects of health, with the final search completed on 1 September 2025. Following PRISMA 2020 guidelines, the reviewers screened 190 database records, selected 64 articles for full-text review, and eventually included 59 publications after adding 25 more through citation chaining and targeted Google Scholar searches. The result is the most comprehensive map to date of how a rapidly growing but conceptually fragmented field talks about space.
The temporal pattern of the literature tells its own story. Nearly 70 percent of the included publications appeared between 2020 and September 2025, with a further 29 percent published between 2010 and 2019, and only a single study predating 2010. This explosion of recent interest likely reflects both the expansion of spatially informed health research and the gravitational pull of the social determinants of health framework, which since the late twentieth century has redirected attention from purely biological explanations of disease toward the social, economic, and structural conditions that produce health and inequality. Spatial determinants of health emerged as a concept relatively recently, riding on this wave, but without the conceptual groundwork that older categories received.
The definitional vacuum is the review’s central finding. Only three publications offered any definition of spatial determinants of health. Davies and colleagues framed them as area-level determinants, while Pilkington and colleagues described them as contextual determinants spanning multiple dimensions, including contributors to spatial inequalities and the geographic patterning of all-cause mortality at the subnational scale in France. Only one study, by Pandey and colleagues, provided a formal definition, describing spatial determinants of health as social, infrastructural, and environmental features of a place that shape infectious disease. Everything else in the literature simply assumed the term was understood, a dangerous assumption for a concept meant to guide research priorities and targeted interventions.
What the field does talk about, however, is remarkably diverse. Through inductive thematic analysis guided by Braun and Clarke’s six-phase framework, the reviewers extracted 84 distinct topics from the included studies, organised them into 18 thematic categories, and consolidated these into six overarching domains plus a residual category. The domains include geographic and environmental context, covering topography, green and blue spaces, and climate; spatial structure and urban configuration, encompassing urban planning, land use, and multiple measures of density; accessibility, mobility and connectivity; socio-demographic and economic context; residential and neighbourhood context; and healthcare context. The sheer breadth reveals a field in which nearly anything geographically patterned can be labelled spatial.
One theme dominated all others. Accessibility, mobility, and connectivity was the most frequently cited category, with distance alone appearing in 25 publications. Researchers measured the kilometres to the nearest grocery store, transit centre, or city centre; the proximity of community support centres; residence in areas with limited public transport or no services within walking distance; and even distance to natural water bodies. This theme was also the most consistently operationalised across disease areas, making it the common entry point for empirical studies. By contrast, measures of density proved more contested, with authors distinguishing population density, urban density, and residential density in incompatible ways, some defining residential density as average address density per square kilometre and others as the number of people living in an urban area.
The review also exposed a subtle but consequential confusion: the difference between studying space as an active determinant and merely analysing spatial variation in other determinants. In many studies, the term spatial determinants of health was used primarily to indicate spatial analyses comparing social, epidemiological, or environmental variables across census units. The reviewers argue this usage likely reflects the influence of spatial epidemiology, defined in the literature as the description and analysis of geographic patterns and variations in disease risk factors, morbidity, and mortality. When spatial epidemiology is applied within a determinants-of-health framework, it creates terminological ambiguity, with any geographically patterned variable treated as spatial, which weakens the explanatory specificity of the concept.
The relationships between spatial and other determinants of health remain understudied. Only four publications explicitly examined how spatial determinants interact with social, political, or commercial factors. Among them, Augustin and colleagues argued that virtually all determinants of health possess a spatial component, proposing a conceptual framework organised across three levels: a micro level of households and neighbourhoods, a meso level of local and regional contexts including healthcare services, and a macro level of national and global policies and governance. Kroesen and colleagues modelled how spatial and demographic factors influence behavioural determinants, which in turn affect health outcomes. The available evidence, though thin, suggests spatial and other determinants are mutually reinforcing rather than independent.
The reviewers propose three paths forward. First, analyses that merely examine spatial variations in other determinants should stop using the term spatial determinants of health, since such analyses do not reflect the active role of space as a determinant. Second, they suggest spatial determinants remain a distinct category, potentially as a subset of environmental determinants, and include density, distance, and mobility, while place-related factors such as natural resources and climate belong with environmental or ecological determinants, and socio-demographic factors belong with social determinants. Third, and perhaps most ambitiously, they call for introducing geographical, sociological, and philosophical debates about the nature of space into public health, arguing that the evolving concept of space has remained outside the field for too long.
The study has limitations the authors acknowledge candidly. It was restricted to academic sources, potentially missing valuable contributions from grey literature such as governmental spatial strategies and urban planning documents, and only publications with English full texts were assessed. The absence of common definitions also limited comparability across studies and may partly explain the heterogeneity observed. Still, the conclusion stands: spatial determinants of health offer a valuable lens for understanding how place conditions health, but the field is evolving without a shared theoretical core. Until researchers agree on what they are talking about, the promise of spatially informed policy, from equitable service allocation to healthier urban design, will remain harder to realise than it should be.
Subject of Research: Conceptualisation and definition of spatial determinants of health in public health research
Article Title: What do we talk about when we talk about spatial determinants of health? A systematic review
Article References: What do we talk about when we talk about spatial determinants of health? A systematic review. (n.d.). Original publication
Image Credits: AI Generated
DOI: Not provided
Keywords: spatial determinants of health, systematic review, public health, health equity, social determinants, urban health, accessibility, geographic variation, spatial epidemiology, neighbourhood, environmental determinants, PRISMA
News Source: Phoebe Ingram. (October 10, 2026). Health Is Shaped by Where We Live, but Scientists Still Can’t Agree What Space Actually Does. Scienmag.
