SOCIALDETERMINANTS  OF HEALTH          International          Centre for          Health and          Society
SOCIAL      DE TER MI NANTS        OF HEALTH THESOLIDFACTSSECOND EDITIONEdited by Richard Wilkinson and Michael Marmot
WHO Library Cataloguing in Publication DataSocial determinants of health: the solid facts. 2nd edition / edited byRichard ...
CONTENTSForeword                           5Contributors                       6Introduction                      71. The ...
The World Health Organization was established in 1948as a specialized agency of the United Nations serving asthe directing...
FOREWORDThe need and demand for clear scientific                 This publication was achieved through closeevidence to in...
CONTRIBUTORSProfessor Mel Bartley, University College London,United KingdomDr David Blane, Imperial College London, United...
INTRODUCTIONEven in the most affluent countries, people             can be found in Social determinants of healthwho are l...
People’slifestyles andthe conditionsin whichthey live andwork stronglyinfluence theirhealth.                  © HEALTHY CI...
according to levels of economic development, the       social meanings. It is not simply that poor materialreader should k...
1.                        THE               SOCIAL                           GRADIENTLife expectancy is shorter and most d...
• Good health involves                                                                                                    ...
2.     STRESSStressful circumstances, making people feel                insecurity and the lack of supportive friendshipsw...
physical activity, turning on the stress response                    Policy implicationsdiverts energy and resources away ...
3.     E A R LY                LIFEA good start in life means supporting mothers                                     healt...
Fig. 2. Risk of diabetes in men aged 64 years by                                                                    Polici...
4.     SOCIAL              EXCLUSION                       Life is short where its quality is poor. By causing     particu...
Fig. 3. Proportion of children living in poor                                                                             ...
5.                                                                         WORKStress in the workplace increases the risk ...
environment, thus enabling employees to                                • Good management involves ensuring                ...
6.     UNEMPLOYMENTJob security increases health, well-being and job    effects on mental health (particularly anxiety and...
Policy implications                                                                                                   • To...
7.    SOCIAL              SUPPORT                         Friendship, good social relations and strong          premature ...
Fig. 6. Level of social integration and mortality in five prospective studies                                     Females ...
8.     ADDICTIONIndividuals turn to alcohol, drugs and tobacco and    The irony is that, apart from a temporary releasesuf...
Fig. 7. Socioeconomic deprivation and risk of                                                                     especial...
Social determinantshealthwho
Social determinantshealthwho
Social determinantshealthwho
Social determinantshealthwho
Social determinantshealthwho
Social determinantshealthwho
Social determinantshealthwho
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Social determinantshealthwho

  1. 1. SOCIALDETERMINANTS OF HEALTH International Centre for Health and Society
  2. 2. SOCIAL DE TER MI NANTS OF HEALTH THESOLIDFACTSSECOND EDITIONEdited by Richard Wilkinson and Michael Marmot
  3. 3. WHO Library Cataloguing in Publication DataSocial determinants of health: the solid facts. 2nd edition / edited byRichard Wilkinson and Michael Marmot. 1.Socioeconomic factors 2.Social environment 3.Social support 4.Health behavior 5.Health status 6.Public health 7.Health promotion 8.Europe I.Wilkinson, Richard II.Marmot, Michael. ISBN 92 890 1371 0 (NLM Classification : WA 30) Address requests about publications of the WHO Regional Office to: • by e-mail (for copies of publications) (for permission to reproduce them) (for permission to translate them) • by post Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, DenmarkISBN 92 890 1371 0© World Health Organization 2003All rights reserved. The Regional Office for Europe of the World Health Organiza-tion welcomes requests for permission to reproduce or translate its publications,in part or in full.The designations employed and the presentation of the material in this pub-lication do not imply the expression of any opinion whatsoever on the partof the World Health Organization concerning the legal status of any country,territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. Where the designation “country or area” appears inthe headings of tables, it covers countries, territories, cities, or areas. Dottedlines on maps represent approximate border lines for which there may not yetbe full agreement.The mention of specific companies or of certain manufacturers’ products doesnot imply that they are endorsed or recommended by the World Health Organi-zation in preference to others of a similar nature that are not mentioned. Errorsand omissions excepted, the names of proprietary products are distinguishedby initial capital letters.The World Health Organization does not warrant that the information containedin this publication is complete and correct and shall not be liable for any dam-ages incurred as a result of its use. The views expressed by authors or editors donot necessarily represent the decisions or the stated policy of the World HealthOrganization.Printed in Denmark
  4. 4. CONTENTSForeword 5Contributors 6Introduction 71. The social gradient 102. Stress 123. Early life 144. Social exclusion 165. Work 186. Unemployment 207. Social support 228. Addiction 249. Food 2610. Transport 28WHO and other important sources 30
  5. 5. The World Health Organization was established in 1948as a specialized agency of the United Nations serving asthe directing and coordinating authority for internationalhealth matters and public health. One of WHO’sconstitutional functions is to provide objective and reliableinformation and advice in the field of human health, aresponsibility that it fulfils in part through its publicationsprogrammes. Through its publications, the Organizationseeks to support national health strategies and address themost pressing public health concerns.The WHO Regional Office for Europe is one of sixregional offices throughout the world, each with its ownprogramme geared to the particular health problems ofthe countries it serves. The European Region embracessome 870 million people living in an area stretching fromGreenland in the north and the Mediterranean in thesouth to the Pacific shores of the Russian Federation.The European programme of WHO therefore concentratesboth on the problems associated with industrial andpost-industrial society and on those faced by the emergingdemocracies of central and eastern Europe and the formerUSSR.To ensure the widest possible availability of authoritativeinformation and guidance on health matters, WHOsecures broad international distribution of its publicationsand encourages their translation and adaptation. Byhelping to promote and protect health and prevent andcontrol disease, WHO’s books contribute to achieving theOrganization’s principal objective – the attainment by allpeople of the highest possible level of health.WHO Centre for Urban HealthThis publication is an initiative of the Centre for UrbanHealth, at the WHO Regional Office for Europe. Thetechnical focus of the work of the Centre is on developingtools and resource materials in the areas of healthpolicy, integrated planning for health and sustainabledevelopment, urban planning, governance and socialsupport. The Centre is responsible for the Healthy Citiesand urban governance programme.4
  6. 6. FOREWORDThe need and demand for clear scientific This publication was achieved through closeevidence to inform and support the health policy- partnership between the WHO Centre for Urbanmaking process are greater than ever. The field Health and the International Centre for Healthof the social determinants of health is perhaps and Society, University College London, Unitedthe most complex and challenging of all. It is Kingdom. I should like to express my gratitudeconcerned with key aspects of people’s living and to Professor Richard Wilkinson and Professorworking circumstances and with their lifestyles. Sir Michael Marmot, who edited the publication,It is concerned with the health implications of and to thank all the members of the scientific teameconomic and social policies, as well as with the who contributed to this important piece of work.benefits that investing in health policies can bring. I am convinced that it will be a valuable tool forIn the past five years, since the publication of the broadening the understanding of and stimulatingfirst edition of Social determinants of health. The debate and action on the social determinants ofsolid facts in 1998, new and stronger scientific health.evidence has been developed. This second editionintegrates the new evidence and is enriched withgraphs, further reading and recommended web Agis D. Tsourossites.Our goal is to promote awareness, informed Head, Centre for Urban Healthdebate and, above all, action. We want to build WHO Regional Office for Europeon the success of the first edition, which wastranslated into 25 languages and used by decision-makers at all levels, public health professionalsand academics throughout the European Regionand beyond. The good news is that an increasingnumber of Member States today are developingpolicies and programmes that explicitly address theroot causes of ill health, health inequalities and theneeds of those who are affected by poverty andsocial disadvantage. 5
  7. 7. CONTRIBUTORSProfessor Mel Bartley, University College London,United KingdomDr David Blane, Imperial College London, UnitedKingdomDr Eric Brunner, International Centre for Health andSociety, University College London, United KingdomProfessor Danny Dorling, School of Geography,University of Leeds, United KingdomDr Jane Ferrie, University College London, UnitedKingdomProfessor Martin Jarvis, Cancer Research UK, HealthBehaviour Unit, University College London, UnitedKingdomProfessor Sir Michael Marmot, Department ofEpidemiology and Public Health and InternationalCentre for Health and Society, University CollegeLondon, United KingdomProfessor Mark McCarthy, University College London,United KingdomDr Mary Shaw, Department of Social Medicine, BristolUniversity, United KingdomProfessor Aubrey Sheiham, International Centre forHealth and Society, University College London, UnitedKingdomProfessor Stephen Stansfeld, Barts and The London,Queen Mary’s School of Medicine and Dentistry,LondonProfessor Mike Wadsworth, Medical Research Council,National Survey of Health and Development, UniversityCollege London, United KingdomProfessor Richard Wilkinson, University of Nottingham,United Kingdom6
  8. 8. INTRODUCTIONEven in the most affluent countries, people can be found in Social determinants of healthwho are less well off have substantially shorter (Marmot M, Wilkinson RG, eds. Oxford, Oxfordlife expectancies and more illnesses than the University Press, 1999), which was prepared torich. Not only are these differences in health an accompany the first edition of Social determinantsimportant social injustice, they have also drawn of health. The solid facts. For both publications,scientific attention to some of the most powerful we are indebted to researchers in the forefrontdeterminants of health standards in modern of their fields, most of whom are associated withsocieties. They have led in particular to a growing the International Centre for Health and Society atunderstanding of the remarkable sensitivity of University College London. They have given theirhealth to the social environment and to what time and expertise to draft the different chaptershave become known as the social determinants of of both these Health policy was once thought to be about littleThis publication outlines the most important parts more than the provision and funding of medicalof this new knowledge as it relates to areas of care: the social determinants of health werepublic policy. The ten topics covered include the discussed only among academics. This is nowlifelong importance of health determinants in changing. While medical care can prolong survivalearly childhood, and the effects of poverty, drugs, and improve prognosis after some serious diseases,working conditions, unemployment, social support, more important for the health of the populationgood food and transport policy. To provide the as a whole are the social and economic conditionsbackground, we start with a discussion of the social that make people ill and in need of medicalgradient in health, followed by an explanation care in the first place. Nevertheless, universalof how psychological and social influences affect access to medical care is clearly one of the socialphysical health and longevity. determinants of health.In each case, the focus is on the role that public Why also, in a new publication on the determinantspolicy can play in shaping the social environment of health, is there nothing about genes? Thein ways conducive to better health: that focus is new discoveries on the human genome aremaintained whether we are looking at behavioural exciting in the promise they hold for advancesfactors, such as the quality of parenting, nutrition, in the understanding and treatment of specificexercise and substance abuse, or at more structural diseases. But however important individual geneticissues such as unemployment, poverty and the susceptibilities to disease may be, the commonexperience of work. Each of the chapters contains causes of the ill health that affects populations area brief summary of what has been most reliably environmental: they come and go far more quicklyestablished by research, followed by a list of than the slow pace of genetic change because theyimplications for public policy. A few key references reflect the changes in the way we live. This is whyto the research are listed at the end of each life expectancy has improved so dramatically overchapter, but a fuller discussion of the evidence recent generations; it is also why some European 7
  9. 9. People’slifestyles andthe conditionsin whichthey live andwork stronglyinfluence theirhealth. © HEALTHY CITIES PROJECT/WHOcountries have improved their health while others decades – sometimes from birth. Others havehave not, and it is why health differences between used cross-sectional methods and have studieddifferent social groups have widened or narrowed individual, area, national or international social and economic conditions have changed. Difficulties that have sometimes arisen (perhaps despite follow-up studies) in determining causalityThe evidence on which this publication is based have been overcome by using evidence fromcomes from very large numbers of research intervention studies, from so-called naturalreports – many thousands in all. Some of the experiments, and occasionally from studies ofstudies have used prospective methods, sometimes other primate species. Nevertheless, as both healthfollowing tens of thousands of people over and the major influences on it vary substantially8
  10. 10. according to levels of economic development, the social meanings. It is not simply that poor materialreader should keep in mind that the bulk of the circumstances are harmful to health; the socialevidence on which this publication is based comes meaning of being poor, unemployed, sociallyfrom rich developed countries and its relevance to excluded, or otherwise stigmatized also matters.less developed countries may be limited. As social beings, we need not only good material conditions but, from early childhood onwards,Our intention has been to ensure that policy at we need to feel valued and appreciated. We needall levels – in government, public and private friends, we need more sociable societies, we needinstitutions, workplaces and the community – takes to feel useful, and we need to exercise a significantproper account of recent evidence suggesting a degree of control over meaningful work. Withoutwider responsibility for creating healthy societies. these we become more prone to depression, drugBut a publication as short as this cannot provide use, anxiety, hostility and feelings of hopelessness,a comprehensive guide to determinants of public which all rebound on physical Several areas of health policy, such asthe need to safeguard people from exposure to We hope that by tackling some of the materialtoxic materials at work, are left out because they and social injustices, policy will not only improveare well known (though often not adequately health and well-being, but may also reduce a rangeenforced). As exhortations to individual behaviour of other social problems that flourish alongsidechange are also a well established approach to ill health and are rooted in some of the samehealth promotion, and the evidence suggests they socioeconomic processes.may sometimes have limited effect, there is littleabout what individuals can do to improve theirown health. We do, however, emphasize the need Richard Wilkinson and Michael Marmotto understand how behaviour is shaped by theenvironment and, consistent with approachinghealth through its social determinants, recommendenvironmental changes that would lead tohealthier behaviour.Given that this publication was put together fromthe contributions of acknowledged experts ineach field, what is striking is the extent to whichthe sections converge on the need for a morejust and caring society – both economically andsocially. Combining economics, sociology andpsychology with neurobiology and medicine, itlooks as if much depends on understanding theinteraction between material disadvantage and its 9
  11. 11. 1. THE SOCIAL GRADIENTLife expectancy is shorter and most diseases are Both material and psychosocial causes contribute tomore common further down the social ladder in these differences and their effects extend to mosteach society. Health policy must tackle the social diseases and causes of death.and economic determinants of health. Disadvantage has many forms and may be absolute or relative. It can include having few family assets,What is known having a poorer education during adolescence,Poor social and economic circumstances affect having insecure employment, becoming stuck in ahealth throughout life. People further down the hazardous or dead-end job, living in poor housing,social ladder usually run at least twice the risk of trying to bring up a family in difficult circumstancesserious illness and premature death as those near and living on an inadequate retirement pension.the top. Nor are the effects confined to the poor: These disadvantages tend to concentrate amongthe social gradient in health runs right across the same people, and their effects on healthsociety, so that even among middle-class office accumulate during life. The longer people live inworkers, lower ranking staff suffer much more stressful economic and social circumstances, thedisease and earlier death than higher ranking staff greater the physiological wear and tear they suffer,(Fig. 1). and the less likely they are to enjoy a healthy old age.Fig. 1. Occupational class differences in lifeexpectancy, England and Wales, 1997–1999 Policy implications Men Women If policy fails to address these facts, it not only ignores the most powerful determinants of health Professional standards in modern societies, it also ignores one of the most important social justice issues facing Managerial modern societies. and technicalOCCUPATIONAL CLASS • Life contains a series of critical transitions: Skilled non- emotional and material changes in early manual childhood, the move from primary to secondary education, starting work, leaving home and Skilled manual starting a family, changing jobs and facing possible redundancy, and eventually retirement. Partly skilled Each of these changes can affect health by manual pushing people onto a more or less advantaged Unskilled path. Because people who have been manual disadvantaged in the past are at the greatest risk 64 66 68 70 72 74 76 78 80 82 84 in each subsequent transition, welfare policies LIFE EXPECTANCY (YEARS) need to provide not only safety nets but also springboards to offset earlier disadvantage.10
  12. 12. • Good health involves reducing levels of educational failure, reducing insecurity and unemployment and improving housing standards. Societies that enable all citizens to play a full and useful role in the social, economic and cultural life of their society will be healthier than those where people face insecurity, exclusion and deprivation. • Other chapters of this© JOACHIM LADEFOGED/POLFOTO publication cover specific policy areas and suggest ways of improving health that will also reduce the social gradient in health. Poor social and economic circumstances affect health throughout life. KEY SOURCES Bartley M, Plewis I. Accumulated labour market disadvantage and Programme Committee on Socio-economic Inequalities in Health limiting long-term illness. International Journal of Epidemiology, (SEGV-II). Reducing socio-economic inequalities in health. The 2002, 31:336–341. Hague, Ministry of Health, Welfare and Sport, 2001. Mitchell R, Blane D, Bartley M. Elevated risk of high blood pressure: van de Mheen H et al. Role of childhood health in the explanation climate and the inverse housing law. International Journal of of socioeconomic inequalities in early adult health. Journal of Epidemiology, 2002, 31:831–838. Epidemiology and Community Health, 1998, 52:15–19. Montgomery SM, Berney LR, Blane D. Prepubertal stature and Source of Fig. 1: Donkin A, Goldblatt P, Lynch K. Inequalities in life blood pressure in early old age. Archives of Disease in Childhood, expectancy by social class 1972–1999. Health Statistics Quarterly, 2000, 82:358–363. 2002, 15:5–15. Morris JN et al. A minimum income for healthy living. Journal of Epidemiology and Community Health, 2000, 54:885–889. 11
  13. 13. 2. STRESSStressful circumstances, making people feel insecurity and the lack of supportive friendshipsworried, anxious and unable to cope, are are damaging in whatever area of life they arise.damaging to health and may lead to premature The lower people are in the social hierarchy ofdeath. industrialized countries, the more common these problems become.What is known Why do these psychosocial factors affect physicalSocial and psychological circumstances can cause health? In emergencies, our hormones and nervouslong-term stress. Continuing anxiety, insecurity, system prepare us to deal with an immediatelow self-esteem, social isolation and lack of control physical threat by triggering the fight or flightover work and home life, have powerful effects on response: raising the heart rate, mobilizing storedhealth. Such psychosocial risks accumulate during energy, diverting blood to muscles and increasinglife and increase the chances of poor mental health alertness. Although the stresses of modern urbanand premature death. Long periods of anxiety and life rarely demand strenuous or even moderateLack of controlover work andhome can havepowerful effectson health. © RIKKE STEENVINKEL NORDENHOF/POLFOTO12
  14. 14. physical activity, turning on the stress response Policy implicationsdiverts energy and resources away from many Although a medical response to the biologicalphysiological processes important to long-term changes that come with stress may be to try tohealth maintenance. Both the cardiovascular and control them with drugs, attention should beimmune systems are affected. For brief periods, this focused upstream, on reducing the major causes ofdoes not matter; but if people feel tense too often chronic stress.or the tension goes on for too long, they becomemore vulnerable to a wide range of conditions • In schools, workplaces and other institutions, theincluding infections, diabetes, high blood pressure, quality of the social environment and materialheart attack, stroke, depression and aggression. security are often as important to health as the physical environment. Institutions that can give people a sense of belonging, participating KEY SOURCES and being valued are likely to be healthier Brunner EJ. Stress and the biology of inequality. British Medical places than those where people feel excluded, Journal, 1997, 314:1472–1476. disregarded and used. Brunner EJ et al. Adrenocortical, autonomic and inflammatory • Governments should recognize that welfare causes of the metabolic syndrome. Circulation, 2002, 106: 2659–2665. programmes need to address both psychosocial and material needs: both are sources of anxiety Kivimaki M et al. Work stress and risk of cardiovascular and insecurity. In particular, governments should mortality: prospective cohort study of industrial employees. British Medical Journal, 2002, 325:857–860. support families with young children, encourage community activity, combat social isolation, Marmot MG, Stansfeld SA. Stress and heart disease. London, reduce material and financial insecurity, BMJ Books, 2002. and promote coping skills in education and Marmot MG et al. Contribution of job control and other risk rehabilitation. factors to social variations in coronary heart disease incidence. Lancet, 1997, 350:235–239. 13
  15. 15. 3. E A R LY LIFEA good start in life means supporting mothers health because of the continued malleability ofand young children: the health impact of early biological systems. As cognitive, emotional anddevelopment and education lasts a lifetime. sensory inputs programme the brain’s responses, insecure emotional attachment and poor stimulation can lead to reduced readiness forWhat is known school, low educational attainment, and problemObservational research and intervention studies behaviour, and the risk of social marginalizationshow that the foundations of adult health are laid in adulthood. Good health-related habits, such asin early childhood and before birth. Slow growth eating sensibly, exercising and not smoking, areand poor emotional support raise the lifetime associated with parental and peer group examples,risk of poor physical health and reduce physical, and with good education. Slow or retarded physicalcognitive and emotional functioning in adulthood. growth in infancy is associated with reducedPoor early experience and slow growth become cardiovascular, respiratory, pancreatic and kidneyembedded in biology during the processes of development and function, which increase the riskdevelopment, and form the basis of the individual’s of illness in adulthood.biological and humancapital, which affectshealth throughoutlife.Poor circumstancesduring pregnancycan lead to lessthan optimal fetaldevelopment viaa chain that mayinclude deficienciesin nutrition duringpregnancy, maternalstress, a greaterlikelihood of maternalsmoking and misuseof drugs and alcohol,insufficient exerciseand inadequate © FINN FRANDSEN/POLFOTOprenatal care. Poorfetal development is arisk for health in laterlife (Fig. 2).Infant experience isimportant to later Important foundations of adult health are laid in early childhood.14
  16. 16. Fig. 2. Risk of diabetes in men aged 64 years by Policies for improving health in early life shouldbirth weight aim to:Adjusted for body mass index • increase the general level of education and provide equal opportunity of access to 7 education, to improve the health of mothers and babies in the long run; 6 • provide good nutrition, health education, RISK OF DIABETES (WITH BIRTH WEIGHT >4.3 KG SET AT 1) and health and preventive care facilities, and 5 adequate social and economic resources, before first pregnancies, during pregnancy, and in infancy, to improve growth and development 4 before birth and throughout infancy, and reduce the risk of disease and malnutrition in 3 infancy; and • ensure that parent–child relations are 2 supported from birth, ideally through home visiting and the encouragement of good parental relations with schools, to increase 1 parental knowledge of children’s emotional and cognitive needs, to stimulate cognitive development and pro-social behaviour in the 0 <2.5 2.5–2.9 3.0–3.4 3.5–3.9 4.0–4.3 >4.3 child, and to prevent child abuse. BIRTH WEIGHT (KG) KEY SOURCESPolicy implications Barker DJP. Mothers, babies and disease in later life, 2nd ed. Edinburgh, Churchill Livingstone, 1998.These risks to the developing child are significantly Keating DP, Hertzman C, eds. Developmental health and thegreater among those in poor socioeconomic wealth of nations. New York, NY, Guilford Press, 1999.circumstances, and they can best be reducedthrough improved preventive health care before Mehrotra S, Jolly R, eds. Development with a human face. Oxford, Oxford University Press, 2000.the first pregnancy and for mothers and babies inpre- and postnatal, infant welfare and school clinics, Rutter M, Rutter M. Developing minds: challenge andand through improvements in the educational levels continuity across the life span. London, Penguin Books, 1993.of parents and children. Such health and education Wallace HM, Giri K, Serrano CV, eds. Health care of women andprogrammes have direct benefits. They increase children in developing countries, 2nd ed. Santa Monica, CA,parents’ awareness of their children’s needs and Third Party Publishing, 1995.their receptivity to information about health and Source of Fig. 2: Barker DJP. Mothers, babies and disease indevelopment, and they increase parental confidence later life, 2nd ed. Edinburgh, Churchill Livingstone, their own effectiveness. 15
  17. 17. 4. SOCIAL EXCLUSION Life is short where its quality is poor. By causing particular risk. Those living on the streets suffer the hardship and resentment, poverty, social exclusion highest rates of premature death. and discrimination cost lives. Relative poverty means being much poorer than most people in society and is often defined as living What is known on less than 60% of the national median income. It denies people access to decent housing, education, Poverty, relative deprivation and social exclusion transport and other factors vital to full participation have a major impact on health and premature in life. Being excluded from the life of society and death, and the chances of living in poverty are treated as less than equal leads to worse health loaded heavily against some social groups. and greater risks of premature death. The stresses Absolute poverty – a lack of the basic material of living in poverty are particularly harmful during necessities of life – continues to exist, even in the pregnancy, to babies, children and old people. In richest countries of Europe. The unemployed, many some countries, as much as one quarter of the total ethnic minority groups, guest workers, disabled population – and a higher proportion of children people, refugees and homeless people are at – live in relative poverty (Fig. 3). Social exclusion also results from racism, discrimination, stigmatization, hostility and unemployment. These processes prevent people from participating in education or training, and gaining access to services and citizenship activities. They are socially and psychologically damaging, materially costly, and harmful to health. People who live in, or have left, institutions, such as prisons, children’s homes and psychiatric hospitals, are particularly vulnerable. The greater the length of time that people live in disadvantaged circumstances, the more likely they are to suffer from a range of health problems, particularly cardiovascular disease. People move in and out of poverty during their lives, so the number of people© JAN GRARUP/POLFOTO who experience poverty and social exclusion during their lifetime is far higher than the current number of socially excluded people. Poverty and social exclusion increase the People living on the streets suffer the highest rates risks of divorce and separation, disability, of premature death. illness, addiction and social isolation and 16
  18. 18. Fig. 3. Proportion of children living in poor such policies on rates of death and disease imposeshouseholds (below 50% of the national average a public duty to eliminate absolute poverty andincome) reduce material inequalities. 30 • All citizens should be protected by minimum income guarantees, minimum wages legislation 25 and access to services. • Interventions to reduce poverty and social 20 exclusion are needed at both the individual and the neighbourhood levels. PROPORTION (%) 15 • Legislation can help protect minority and vulnerable groups from discrimination and social 10 exclusion. • Public health policies should remove barriers 5 to health care, social services and affordable housing. 0 • Labour market, education and family welfare Czech Republic Slovakia Finland Sweden Norway Belgium Denmark Netherlands Hungary Germany Italy Israel Canada Spain Poland United Kingdom Russian Federation USA policies should aim to reduce social stratification. KEY SOURCES Claussen B, Davey Smith G, Thelle D. Impact of childhoodvice versa, forming vicious circles that deepen the and adulthood socio-economic position on cause specificpredicament people face. mortality: the Oslo Mortality Study. Journal of Epidemiology and Community Health, 2003, 57:40–45.As well as the direct effects of being poor, health Kawachi I, Berkman L, eds. Neighborhoods and health. Oxford,can also be compromised indirectly by living in Oxford University Press, 2003.neighbourhoods blighted by concentrations of Mackenbach J, Bakker M, eds. Reducing inequalities in health:deprivation, high unemployment, poor quality a European perspective. London, Routledge, 2002.housing, limited access to services and a poorquality environment. Shaw M, Dorling D, Brimblecombe N. Life chances in Britain by housing wealth and for the homeless and vulnerably housed. Environment and Planning A,1999, 31:2239–2248.Policy implications Townsend P, Gordon D. World poverty: new policies to defeatThrough policies on taxes, benefits, employment, an old enemy. Bristol, The Policy Press,, economic management, and many Source of Fig. 3: Bradshaw J. Child poverty in comparativeother areas of activity, no government can avoid perspective. In: Gordon D, Townsend P. Breadline Europe: thehaving a major impact on the distribution of measurement of poverty. Bristol, The Policy Press, 2000.income. The indisputable evidence of the effects of 17
  19. 19. 5. WORKStress in the workplace increases the risk of Having little control over one’s work is particularlydisease. People who have more control over their strongly related to an increased risk of lowwork have better health. back pain, sickness absence and cardiovascular disease (Fig. 4). These risks have been found to beWhat is known independent of the psychological characteristics of the people studied. In short, they seem to beIn general, having a job is better for health than related to the work environment.having no job. But the social organization of work,management styles and social relationships in the Studies have also examined the role of workworkplace all matter for health. Evidence shows demands. Some show an interaction betweenthat stress at work plays an important role in demands and control. Jobs with both high demandcontributing to the large social status differences and low control carry special risk. Some evidencein health, sickness absence and premature death. indicates that social support in the workplace maySeveral European workplace studies show that be suffers when people have little opportunity Further, receiving inadequate rewards for theto use their skills and low decision-making effort put into work has been found to beauthority. associated with increased cardiovascular risk. Rewards can take the form of money, status andFig. 4. Self-reported level of job control and self-esteem. Current changes in the labour marketincidence of coronary heart disease in men and may change the opportunity structure, and make itwomen harder for people to get appropriate rewards. 2.5 These results show that the psychosocial environment at work is an important determinant RISK OF CORONARY HEART DISEASE (WITH HIGH JOB CONTROL SET AT 1.0) of health and contributor to the social gradient in ill health. 2.0 Policy implications • There is no trade-off between health and productivity at work. A virtuous circle can be established: improved conditions of work will 1.5 lead to a healthier work force, which will lead Adjusted for to improved productivity, and hence to the age, sex, length opportunity to create a still healthier, more of follow-up, effort/reward productive workplace. 1.0 imbalance, employment • Appropriate involvement in decision-making grade, coronary is likely to benefit employees at all levels of an risk factors organization. Mechanisms should therefore High Intermediate Low and negative JOB CONTROL psychological be developed to allow people to influence disposition the design and improvement of their work18
  20. 20. environment, thus enabling employees to • Good management involves ensuring have more control, greater variety and more appropriate rewards – in terms of money, status opportunities for development at work. and self-esteem – for all employees. • To reduce the burden of musculoskeletal disorders, workplaces must be ergonomically appropriate. • As well as requiring an effective infrastructure with legal controls and powers of inspection, workplace health protection should also include workplace health services with people trained in the early detection of mental health problems and appropriate interventions.© FIRST LIGHT Jobs with both high demand and low control carry special risk. KEY SOURCES Bosma H et al. Two alternative job stress models and risk of by combining two complementary job stress models in the SHEEP coronary heart disease. American Journal of Public Health, 1998, Study. Journal of Epidemiology and Community Health, 2002, 88:68–74. 56(4):294–300. Hemingway H, Kuper K, Marmot MG. Psychosocial factors in the Schnall P et al. Why the workplace and cardiovascular disease? primary and secondary prevention of coronary heart disease: an Occupational Medicine, State of the Art Reviews, 2000, 15:126. updated systematic review of prospective cohort studies. In: Yusuf S et al., eds. Evidence-based cardiology, 2nd ed. London, Theorell T, Karasek R. The demand-control-support model and CVD. BMJ Books, 2003:181–217. In: Schnall PL et al., eds. The workplace and cardiovascular disease. Occupational medicine. Philadelphia, Hanley and Belfus Inc., 2000: Marmot MG et al. Contribution of job control to social gradient in 78–83. coronary heart disease incidence. Lancet, 1997, 350:235–240. Source of Fig. 4: Bosma H et al. Two alternative job stress models Peter R et al. and the SHEEP Study Group. Psychosocial work and risk of coronary heart disease. American Journal of Public environment and myocardial infarction: improving risk estimation Health, 1998, 88:68–74. 19
  21. 21. 6. UNEMPLOYMENTJob security increases health, well-being and job effects on mental health (particularly anxiety andsatisfaction. Higher rates of unemployment cause depression), self-reported ill health, heart diseasemore illness and premature death. and risk factors for heart disease. Because very unsatisfactory or insecure jobs can be as harmful asWhat is known unemployment, merely having a job will not always protect physical and mental health: job quality isUnemployment puts health at risk, and the risk also important (Fig. 5).is higher in regions where unemployment iswidespread. Evidence from a number of countries During the 1990s, changes in the economies andshows that, even after allowing for other factors, labour markets of many industrialized countriesunemployed people and their families suffer a increased feelings of job insecurity. As jobsubstantially increased risk of premature death. insecurity continues, it acts as a chronic stressorThe health effects of unemployment are linked whose effects grow with the length of exposure; itto both its psychological consequences and increases sickness absence and health service use.the financialproblems it brings– especially debt.The health effectsstart when peoplefirst feel their jobsare threatened,even before theyactually becomeunemployed. Thisshows that anxietyabout insecurity isalso detrimentalto health. Jobinsecurity hasbeen shownto increaseUnemployedpeople and their © REUTER/POLFOTOfamilies suffer amuch higher riskof prematuredeath.20
  22. 22. Policy implications • To equip people for the work available, high standards of education and good retrainingPolicy should have three goals: to prevent schemes are important.unemployment and job insecurity; to reduce thehardship suffered by the unemployed; and to • For those out of work, unemployment benefitsrestore people to secure jobs. set at a higher proportion of wages are likely to have a protective effect.• Government management of the economy to reduce the highs and lows of the business cycle • Credit unions may be beneficial by reducing can make an important contribution to job debts and increasing social networks. security and the reduction of unemployment.• Limitations on working hours may also be KEY SOURCES beneficial when pursued alongside job security Beale N, Nethercott S. Job-loss and family morbidity: a study and satisfaction. of a factory closure. Journal of the Royal College of General Practitioners, 1985, 35:510–514.Fig. 5. Effect of job insecurity and unemployment Bethune A. Unemployment and mortality. In: Drever F,on health Whitehead M, eds. Health inequalities. London, H.M. Stationery Office, 1997. 300 Burchell, B. The effects of labour market position, job Long-standing illness insecurity, and unemployment on psychological health. Poor mental health In: Gallie D, Marsh C, Vogler C, eds. Social change and the 250 experience of unemployment. Oxford, Oxford University Press, RISK OF ILL HEALTH (WITH SECURELY EMPLOYED SET AT 100) 1994:188–212. Ferrie J et al., eds. Labour market changes and job insecurity: 200 a challenge for social welfare and health promotion. Copenhagen, WHO Regional Office for Europe, 1999 (WHO Regional Publications, European Series, No. 81) (http: //, accessed 15 150 August 2003). Iversen L et al. Unemployment and mortality in Denmark. British Medical Journal, 1987, 295:879–884. 100 Source of Fig. 5: Ferrie JE et al. Employment status and health after privatisation in white collar civil servants: prospective 50 cohort study. British Medical Journal, 2001, 322:647–651. 0 Securely Insecurely Unemployed employed employed EMPLOYMENT STATUS 21
  23. 23. 7. SOCIAL SUPPORT Friendship, good social relations and strong premature death and poorer chances of survival supportive networks improve health at home, at after a heart attack (Fig. 6). People who get work and in the community. less social and emotional support from others are more likely to experience less well-being, What is known more depression, a greater risk of pregnancy complications and higher levels of disability Social support and good social relations make an from chronic diseases. In addition, bad close important contribution to health. Social support relationships can lead to poor mental and physical helps give people the emotional and practical health. resources they need. Belonging to a social network of communication and mutual obligation makes The amount of emotional and practical social people feel cared for, loved, esteemed and valued. support people get varies by social and economic This has a powerful protective effect on health. status. Poverty can contribute to social exclusion Supportive relationships may also encourage and isolation. healthier behaviour patterns. Social cohesion – defined as the quality of social Support operates on the levels both of the relationships and the existence of trust, mutual individual and of society. Social isolation and obligations and respect in communities or in the exclusion are associated with increased rates of wider society – helps to protect people and their health. Inequality is corrosive of good social relations. Societies with high levels of income inequality tend to have less social cohesion and more violent crime. High levels of mutual support will protect health while the breakdown of social relations, sometimes following greater inequality, reduces trust and increases levels of violence. A study of a community with initially high levels of social cohesion showed low rates of coronary heart disease. When social cohesion declined, heart disease rates rose. Policy implications Experiments suggest that good social© FOTOKHRONIKA/POLFOTO relations can reduce the physiological response to stress. Intervention studies have shown that providing social support can improve patient recovery rates from several different conditions. It can also improve pregnancy outcome in vulnerable groups of Belonging to a social network makes people feel cared for. women. 22
  24. 24. Fig. 6. Level of social integration and mortality in five prospective studies Females Males 0.5 0.5 Evans County, USA (whites) 0.4 0.4 Evans County, USA (blacks) AGE-ADJUSTED MORTALITY RATE Evans County, USA (blacks) Tecumseh, USA 0.3 0.3 Evans County, 0.2 USA (whites) 0.2 Alameda County, Gothenburg, Sweden Alameda County, USA 0.1 USA 0.1 Tecumseh, USA Eastern Finland Eastern Finland 0 0 Low LEVEL OF SOCIAL INTEGRATION High Low LEVEL OF SOCIAL INTEGRATION High• Reducing social and economic inequalities and • Designing facilities to encourage meeting and reducing social exclusion can lead to greater social social interaction in communities could improve cohesiveness and better standards of health. mental health.• Improving the social environment in schools, in • In all areas of both personal and institutional the workplace and in the community more widely, life, practices that cast some as socially inferior or will help people feel valued and supported in less valuable should be avoided because they are more areas of their lives and will contribute to socially divisive. their health, especially their mental health. KEY SOURCES Berkman LF, Syme SL. Social networks, host resistance and Kawachi I et al. A prospective study of social networks in relation to mortality: a nine year follow-up of Alameda County residents. total mortality and cardiovascular disease in men in the USA. Journal American Journal of Epidemiology, 1979, 109:186–204. of Epidemiology and Community Health, 1996, 50(3):245–251. Hsieh CC, Pugh MD. Poverty, income inequality, and violent crime: Oxman TE et al. Social support and depressive symptoms in the a meta-analysis of recent aggregate data studies. Criminal Justice elderly. American Journal of Epidemiology, 1992, 135:356–368. Review, 1993, 18:182–202. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent Kaplan GA et al. Social connections and mortality from all causes crime: a multilevel study of collective efficacy. Science, 1997, 277: and from cardiovascular disease: prospective evidence from 918–924. eastern Finland. American Journal of Epidemiology, 1988, 128: 370–380. Source of Fig. 6: House JS, Landis KR, Umberson D. Social relationships and health. Science, 1988, 241:540–545. 23
  25. 25. 8. ADDICTIONIndividuals turn to alcohol, drugs and tobacco and The irony is that, apart from a temporary releasesuffer from their use, but use is influenced by the from reality, alcohol intensifies the factors that ledwider social setting. to its use in the first place. The same is true of tobacco. Social deprivationWhat is known – whether measured by poor housing, low income,Drug use is both a response to social breakdown lone parenthood, unemployment or homelessnessand an important factor in worsening the resulting – is associated with high rates of smoking and veryinequalities in health. It offers users a mirage of low rates of quitting. Smoking is a major drainescape from adversity and stress, but only makes on poor people’s incomes and a huge cause of illtheir problems worse. health and premature death. But nicotine offers no real relief from stress or improvement in mood.Alcohol dependence, illicit drug use and cigarettesmoking are all closely associated with markers The use of alcohol, tobacco and illicit drugs isof social and economic disadvantage (Fig. 7). In fostered by aggressive marketing and promotionsome of the transition economies of central and by major transnational companies and byeastern Europe, for example, the past decade has organized crime. Their activities are a major barrierbeen a time of great social upheaval. Consequently, to policy initiatives to reduce use among youngdeaths linked to alcohol use – such as accidents, people; and their connivance with smuggling,violence, poisoning,injury and suicide – haverisen sharply. Alcoholdependence is associatedwith violent death in othercountries too.The causal pathwayprobably runs both ways.People turn to alcohol tonumb the pain of harsheconomic and socialconditions, and alcoholdependence leads todownward social mobility. © TEIT HORNBAK/POLFOTOPeople turn to alcohol,drugs and tobacco tonumb the pain of harsheconomic and socialconditions.24
  26. 26. Fig. 7. Socioeconomic deprivation and risk of especially in the case of tobacco, has hampereddependence on alcohol, nicotine and drugs, Great efforts by governments to use price mechanisms toBritain, 1993 limit consumption. 10 Policy implications Alcohol 9 • Work to deal with problems of both legal and Nicotine illicit drug use needs not only to support and Drugs treat people who have developed addictive 8 patterns of use, but also to address the patterns RISK OF DEPENDENCE (WITH MOST AFFLUENT SET AT 1) 7 of social deprivation in which the problems are rooted. 6 • Policies need to regulate availability through pricing and licensing, and to inform people 5 about less harmful forms of use, to use health education to reduce recruitment of young 4 people and to provide effective treatment services for addicts. 3 • None of these will succeed if the social factors that breed drug use are left unchanged. Trying 2 to shift the whole responsibility on to the user is clearly an inadequate response. This blames the 1 victim, rather than addressing the complexities of the social circumstances that generate drug 0 0 1 2 3 4 use. Effective drug policy must therefore be Most Most supported by the broad framework of social and affluent DEPRIVATION SCORE deprived economic policy. KEY SOURCES Bobak M et al. Poverty and smoking. In: Jha P, Chaloupka F, eds. Meltzer H. Economic activity and social functioning of residents with Tobacco control in developing countries. Oxford, Oxford University psychiatric disorders. London, H.M. Stationery Office, 1996 (OPCS Press, 2000:41–61. Surveys of Psychiatric Morbidity in Great Britain, Report 6). Makela P, Valkonen T, Martelin T. Contribution of deaths related to Ryan, M. Alcoholism and rising mortality in the Russian Federation. alcohol use of socioeconomic variation in mortality: register based British Medical Journal, 1995, 310:646–648. follow-up study. British Medical Journal 1997, 315:211–216 Source of Fig. 7: Wardle J et al., eds. Smoking, drinking, physical Marsh A, McKay S. Poor smokers. London, Policy Studies Institute, activity and screening uptake and health inequalities. In: Gordon D 1994. et al, eds. Inequalities in health. Bristol, The Policy Press, 1999: 213–239. 25