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Taking action on social determinants toimprove mental health in urban settingsMichael MarmotUrban Mental HealthSeptember 2...
Outline• Mental health and socioeconomic position• Social determinants - framework for action
Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003
Working age people in England at high   risk of mental illness by social class                                         Soc...
Risk factors for depression                              Level of evidence Low socioeconomic position   Very convincing Lo...
Odds ratio for depressive symptoms by presenceof social deprivation at different phases of the life      course in Eastern...
Long term outcomes associated with childhood       behavioural problems (New Zealand study)        4.5           OR       ...
Loneliness by wealth                       % often/some of the                       time (except for “Feel in            ...
% depressed (CES-D 4+) by    participation in activities                            Men                                   ...
Social justiceMaterial,psychosocial,politicalempowermentCreating theconditions forpeople to have     The CSDH – closing th...
CSDH – Areas for Action                  Health Equity in all Policies     Fair Financing                                 ...
• Every sector is a health sector  – Health and well being as outcomes
Social determinants of health across the lifecourse
Marmot Review: 6 Policy ObjectivesA. Give every child the best start in lifeB. Enable all children, young people and adult...
MACROLEVEL CONTEXT           WIDER SOCIETY                                  SYSTEMS                             LIFE COURS...
Children achieving a good level of development at age five, local  authorities 2011: England   Good levelof development   ...
Socio-emotional difficulties at age 3 and 5:Millennium Cohort StudyAge 3                                   Age 5Fully adju...
Verbal ability at age 3 and 5 by family income:Millennium Cohort Study  Age 3                                    Age 5   F...
Per cent 5 year olds achieving ‘good developmentscore’,* Birmingham LA, West Midlands & England%      *in personal, social...
Unemployment and Mortality1% rise inunemploymentassociated with:- 0.8% ↑Suicide- 0.8% ↑Homicide- 1.4% ↓Traffic        deat...
Population attributable Risk                                                         (PAR) for all combined*              ...
Gender Equity • Higher risk of depression in women   –   Multiple responsibilities with no financial gain   –   Caring res...
ODDS OF DEPRESSION BY CONTROL AT WORK &AT HOME WITHIN GRADE - WOMEN WHITEHALL II                Decision latitude   Home c...
Percentage of those lacking social support, by deprivationof residential area, 2005
Context matters• Deprivation• Social inequality
Percentage shares of equivalised total gross and post-tax income,by quintile groups for all households, 1978 – 2007/8
Real earnings growth (%) for men and womenworking full time by decile, 1980 - 2005OECD 2008
Trends in income share among top incomedecile, US: 1913-2007
International comparisons of income mobility       Higher score = lower intergenerational mobilitySource: Blanden (2009) i...
• Urban design  – good urban design can encourage social cohesion  – exercise - benefits for mental health  – green spaces
Exercise, green space and mental health                                                 Self-esteemWhat is the Best Dose o...
Average weekly alcohol consumption bysex and socioeconomic class, GB: 2008Mean numberof units a week     ONS General Lifes...
Alcohol-attributable hospital admissions bysmall area deprivation quintile in England,2006-07
• Health inequalities are not inevitable or immutable
SMRs by cause, all ages:Glasgow relative to Liverpool & Manchester                                        All ages, both s...
Health improvement in difficult times • A major element of the excess risk of premature   death seen in Scotland is psycho...
A Fair SocietyConditions in whichindividuals andcommunities have controlover their lives         www.marmot-review.org.uk
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The Social Determinants of Urban Mental Health: Paving the Way Forward: Keynote: Professor Sir Michael G. Marmot

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The Social Determinants of Urban Mental Health: Paving the Way Forward: Keynote: Professor Sir Michael G. Marmot

  1. 1. Taking action on social determinants toimprove mental health in urban settingsMichael MarmotUrban Mental HealthSeptember 2012
  2. 2. Outline• Mental health and socioeconomic position• Social determinants - framework for action
  3. 3. Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003
  4. 4. Working age people in England at high risk of mental illness by social class Social classes I-IIINM Social classes IIIM-V 20 % with High GHQ12 score 17 15 15 12 10 9 5 Men WomenSource: Health Survey for England, DH; the data is the average for 2004 to 2006;England; updated June 2008
  5. 5. Risk factors for depression Level of evidence Low socioeconomic position Very convincing Low education Very convincing Unemployment and under Very convincing employment Food insecurity and early Strong nutrition deficiency Gender inequity Strong Low income StrongWHO CSDH PPHC KN 2007
  6. 6. Odds ratio for depressive symptoms by presenceof social deprivation at different phases of the life course in Eastern European countries Childhood Education Adult 4 Age adjusted odds ratio 3 2 1 0 Czech men Russian men Polish men Czech Russian Polish women women women From Nicholson et al J Affective Disorders 2008
  7. 7. Long term outcomes associated with childhood behavioural problems (New Zealand study) 4.5 OR 4 4.13 3.5 3 3 2.5 2.39 2 1.95 1.5 1.57 1.69 1.51 1 1.24 1 1 1 1 0.5 Crime Drugs Depression Suicide Top 50% (no conduct problems) Middle 45% (some conduct problems) Bottom 5% (conduct disorder)Source: L. Friedli & M. Parsonage (2007) Mental health promotion: Building an economic case. Based on:Fergusson et al (2005) J. Child Psychl & Psych 46 (8): 837-849
  8. 8. Loneliness by wealth % often/some of the time (except for “Feel in tune with people around” where % refers to hardly ever/never)
  9. 9. % depressed (CES-D 4+) by participation in activities Men Women25 Does activity Does not2015%10 5 0 p p g g g g k k hi hi in in in in or or rs rs er er ar ar w w be be e e C C d d nt ntai ai em em u uP P ol ol m m V V e e iv iv ct ct A A
  10. 10. Social justiceMaterial,psychosocial,politicalempowermentCreating theconditions forpeople to have The CSDH – closing the The Marmot Review – Faircontrol of their gap in a generation Society Healthy Liveslives 2005-2008 2009/10
  11. 11. CSDH – Areas for Action Health Equity in all Policies Fair Financing Good Global Governance Early child development and education Healthy Places Fair Employment Market Social ProtectionResponsibility Universal Health Care Gender Equity Political empowerment – inclusion and voice
  12. 12. • Every sector is a health sector – Health and well being as outcomes
  13. 13. Social determinants of health across the lifecourse
  14. 14. Marmot Review: 6 Policy ObjectivesA. Give every child the best start in lifeB. Enable all children, young people and adults to maximise their capabilities and have control over their livesC. Create fair employment and good work for allD. Ensure healthy standard of living for allE. Create and develop healthy and sustainable places and communitiesF. Strengthen the role and impact of ill health prevention
  15. 15. MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS LIFE COURSE STAGES Accumulation of positive and negative effects on health and wellbeingPrenatal Early Years Working Age Older Ages Family building Perpetuation of inequities
  16. 16. Children achieving a good level of development at age five, local authorities 2011: England Good levelof development at age 5 % 80 75 70 65 60 55 50 45 40 0 30 60 90 120 150 Local authority rank - based on Index of Multiple Deprivation Source: LHO (2012)
  17. 17. Socio-emotional difficulties at age 3 and 5:Millennium Cohort StudyAge 3 Age 5Fully adjusted = for parenting activities and psychosocial markersKelly et al, 2010
  18. 18. Verbal ability at age 3 and 5 by family income:Millennium Cohort Study Age 3 Age 5 Fully adjusted = for parenting activities and psychosocial markers Kelly et al, 2010 in press
  19. 19. Per cent 5 year olds achieving ‘good developmentscore’,* Birmingham LA, West Midlands & England% *in personal, social and emotional development and communication, language and literacy Source: Department for Education: preliminary data
  20. 20. Unemployment and Mortality1% rise inunemploymentassociated with:- 0.8% ↑Suicide- 0.8% ↑Homicide- 1.4% ↓Traffic deathNo effect on all-cause mortalitySource: Stuckler et al 2009 Lancet
  21. 21. Population attributable Risk (PAR) for all combined* 46% 95% CI 37%-53% adjusted for other predictors 34% 95% CI 24%-43% ERI= Effort reward imbalance*calculated from odds ratios adjusted for age, sex, employment grade J Head et al,2007
  22. 22. Gender Equity • Higher risk of depression in women – Multiple responsibilities with no financial gain – Caring responsibilities – Lack of support – Gender based violence – Access to health care – Poor physical health – Level of education – Autonomy in decision making – Migration
  23. 23. ODDS OF DEPRESSION BY CONTROL AT WORK &AT HOME WITHIN GRADE - WOMEN WHITEHALL II Decision latitude Home control 4 ratios 3 odds 2 1 High Medium Low EMPLOYMENT GRADE Griffin et al, Soc Sci Med, 2002
  24. 24. Percentage of those lacking social support, by deprivationof residential area, 2005
  25. 25. Context matters• Deprivation• Social inequality
  26. 26. Percentage shares of equivalised total gross and post-tax income,by quintile groups for all households, 1978 – 2007/8
  27. 27. Real earnings growth (%) for men and womenworking full time by decile, 1980 - 2005OECD 2008
  28. 28. Trends in income share among top incomedecile, US: 1913-2007
  29. 29. International comparisons of income mobility Higher score = lower intergenerational mobilitySource: Blanden (2009) in NEP 2010.
  30. 30. • Urban design – good urban design can encourage social cohesion – exercise - benefits for mental health – green spaces
  31. 31. Exercise, green space and mental health Self-esteemWhat is the Best Dose of Natureand Green Exercise for ImprovingMental Health? A Multi-StudyAnalysis•Both self-esteem and mood showU shapes. Total Mood Disturbance•Greatest changes from 5 min of activity,•The changes are lower for 10-60min and half-day, but still positive;•They rise again for the whole day.
  32. 32. Average weekly alcohol consumption bysex and socioeconomic class, GB: 2008Mean numberof units a week ONS General Lifestyle Survey 2008
  33. 33. Alcohol-attributable hospital admissions bysmall area deprivation quintile in England,2006-07
  34. 34. • Health inequalities are not inevitable or immutable
  35. 35. SMRs by cause, all ages:Glasgow relative to Liverpool & Manchester All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative to Liverpool & Manchester, standardised by age, sex and deprivation decile Calculated from various sources 350 300 248.5 229.5 250 Standardised mortality ratio 200 168.0 150 131.7 126.7 112.2 111.9 100 50 0 All cancers Circulatory system Lung cancer External causes Suicide (inc. Alcohol Drugs-related (malignant undetermined intent) poisonings neoplasms)Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010from H Burns, CMO, Scotland
  36. 36. Health improvement in difficult times • A major element of the excess risk of premature death seen in Scotland is psychosocially determined • Study evidence of low sense of control, self efficacy and self esteem in population in these areas H. Burns, CMO Scotland
  37. 37. A Fair SocietyConditions in whichindividuals andcommunities have controlover their lives www.marmot-review.org.uk

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