Life chances v Lifestyles: theSocial Determinants of HealthClare BambraProfessor of Public Health PolicyWolfson Research Institute for Health & Wellbeing
Overview1. Inequalities in health and health behaviours (lifestyles) are socially determined (life chances) ∂2. Effective public health policy therefore needs to focus on altering peoples life chances and getting beyond just looking at lifestyles3. Evidence-based principles for policy and building on past Labour successes
1. Health Inequalities in the UK• Infant mortality rates are 16% higher in children of routine and manual workers as compared to professional and managerial workers• Deaths from cardiovascular diseases are 2.7 times higher in the 20% most deprived areas compared to the 20% least deprived• ∂ Smoking rates are almost twice as high amongst routine and manual workers as compared to professional and managerial workers (16% v 28% men, 14% v 24% women)• Alcohol related hospital admissions are twice as high (2.6 times men and 2.4 women) in the 20% most deprived areas compared to the 20% least deprived areas• Obesity rates are higher in routine and manual groups particularly amongst women (27% v 21% men) (34% to 14% women).
Lifestyle v Life chances 1. Is it all to do with differences in lifestyles? OR ∂ 2. Is it to do with differences in life chances?Answer: Best available data from the Whitehall cohort studies shows that 25-40% due to lifestyle factors. Additionally, lifestyles are themselves effected by life chances – the social determinants of health
2. Life chances: the SocialDeterminants of Health ∂
Example 1: Stressful WorkEnvironmentWhitehall civil service health studiesfound:•Heart disease 50% higher in the lowergrade employees.•Adjustment for lifestyle factors reducedthe inequality by 40% in men and 26% ∂in women•BUT adjustment for stressful workenvironment reduced the inequality by64% in men and 51% in womenExposure to stressful workenvironments higher amongst lowerskilled workers
Work, Stress and Lifestyle•Whitehall II cohort found that adose response relationshipbetween obesity and chronicwork stress (controlled forphysical activity etc) ∂•Greater exposure to stressbeing associated with increasedodds of general obesity (BMI ≥30 kg/m2) and central obesity(waist circumference >102 cmin men and >88 cm in women)
Example 2: Unemployment•Mortality rates double•Suicide up to 10 times•Mental health problemsand long term illnesses ∂•Worse health behaviours•Dual mechanisms –psychological and poverty
Unemployment & HealthInequalities• Unemployment concentrated in lower socio-economic classes• Census 2001 in London, 81.5% of women with a degree were employed compared to 51.8% with no qualifications. ∂• Modelling suggests that adjusting for employment status reduces health inequalities by up to 81%• 5.6.% ill health in men home owners, 19.1% in social renting (13% age-adjusted difference), adjust for employment status = 2.5% difference (81% reduction)
Educational gradient (prevalence difference in % points) in self rated general health with and withoutadjustment for employment status (Women), Census 2001 10 9 8 Prevelance difference 7 6 5 4 ∂ 3 2 1 0 Level 4 / 5 Level 3 Level 2 Level 1 Other No qualifications qualifications Education Age only Age plus employment status
Unemployment and Lifestyles•Unemployment also increases thelikelihood of hazardous healthbehaviours such as smoking or excessalcohol consumption.•Particularly the case amongst youngmen. ∂•1958 British Birth Cohort found that therisk of smoking and problem drinkingincreased after unemployment•Those who had been unemployed inthe last year were 3 times more likely tosmoke and 2 times more likely to drinkheavily or have a drink problem
3. Life chances: Labour PolicySuccesses• Housing: more social housing built• Health care: increased NHS spending, shorter waiting lists and improved outcomes, more GPs in deprived areas ∂• Education: new schools built, more teachers, Surestart Centres• Work and unemployment: minimum wage, increased employment levels and Future Jobs Fund, flexible working, increased employment rights• Food policy: health in pregnancy grant• Environment: smoking ban
Infant mortality rates in England: routine and manualsocio-economic group compared with average ∂ Labour target: cut relative inequalities in infant mortality rates between manual socio-economic groups and the English average by 10% from 13% to 12%.
4. Marmot Review• Importance of life chances captured in the Labour government commissioned Marmot Review.• Six Policy Objectives: 1. Give every child the best start in life ∂ 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives 3. Create fair employment and good work for all 4. Ensure healthy standard of living for all 5. Create and develop healthy and sustainable places and communities 6. Strengthen the role and impact of ill-health prevention• Coalition policy focuses on 4 and 6 - lifestyle elements (e.g. responsibility deal, White Paper talks about individual lifestyles, nudge etc)
5. Three Principles for PolicyDignity – in and out of work Labour success: Minimum wage Evidenced-based future option: Minimum Income for Healthy Living (or Living Wage) ∂The public provision of a minimum income to meet basic and social needs relating to nutrition, physical activity, housing, psychosocial interactions, transport, medical care and hygiene.The MIHL for an older single person would be around £144.20 per week (UK, 2008 prices). This was higher than the 60% of median income poverty line (£115 per week), and more than the minimum pension credit (£124.05 per week).
Equity – provision for all with more for the most in need Labour success: minimum pension credit Evidenced-based future option: proportionate universalism ∂Intention of improving the health of all, but the health of the poorest the most.Interventions are universal ‘but with a scale and intensity that is proportionate to the level of disadvantage’ - proportionate universalism.
Authority – control at work and in the community Labour success: right to flexible working Evidence-based future option: increased control and participation at work ∂Increasing control at work via employee participation and representation in workplace committees – “participatory” or “problem-solving” committeesControl over hours of workControl in the community – increased social participation has health benefits
6. Concluding Comment Health BehavioursSocio-economic Status ∂ Health (income/ Inequalities Education/ occupation)
7. ReferencesBambra (2011) Work, Worklessness and the Political Economy of HealthBambra (2012)Brunner et al (2007) Prospective Effect of Job Strain on General and Central Obesity in the Whitehall II Study. American Journal of Epidemiology, 165, 828–37Egan et al (2007) The psychosocial and health effects of workplace reorganisation 1: a systematic review of organisational-level interventions that aim to increase employee ∂ control. Journal of Epidemiology and Community Health, 61, 945–54Marmot Review (2010) Strategic Review of Health Inequalities in England post-2010.Marmot et al (1997) Contribution of job control and other risk factors to social variations in coronary heart disease. Lancet, 350, 235-40Montgomery et al (1999) Unemployment, cigarette smoking, alcohol consumption and body weight in young British men. European Journal of Public Health, 8, 21-27Morris et al (2009) Defining a minimum income for healthy living (MIHL): older age, England. International Journal of Epidemiology, 36, 1300-07Popham and Bambra (2010) Evidence from the 2001 English Census on the contribution of employment status to the social gradient in self-rated health. Journal of Epidemiology and Community Health, 64, 277-80