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International Centre for Health and Society
SOCIAL DE TER MI NANTS OF HEALTH
THE SOLID FACTS
Edited by Richard Wilkinson and Michael Marmot
WHO Library Cataloguing in Publication Data Social determinants of health: the solid facts. 2nd edition / edited by Richard 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)
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ISBN 92 890 1371 0
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The social gradient 2. Unemployment 7. Work 6. Social exclusion 5.CONTENTS Foreword Contributors Introduction 1. Food 10. Addiction 9. Early life 4. Transport WHO and other important sources 5 6 7 10 12 14 16 18 20 22 24 26 28 30 . Social support 8. Stress 3.
Through its publications. 4 . urban planning. The Centre is responsible for the Healthy Cities and urban governance programme. WHO Centre for Urban Health This publication is an initiative of the Centre for Urban Health. a responsibility that it fulfils in part through its publications programmes. To ensure the widest possible availability of authoritative information and guidance on health matters. The European Region embraces some 870 million people living in an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of the Russian Federation. each with its own programme geared to the particular health problems of the countries it serves. One of WHO’s constitutional functions is to provide objective and reliable information and advice in the field of human health. The WHO Regional Office for Europe is one of six regional offices throughout the world. the Organization seeks to support national health strategies and address the most pressing public health concerns.The World Health Organization was established in 1948 as a specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. The European programme of WHO therefore concentrates both on the problems associated with industrial and post-industrial society and on those faced by the emerging democracies of central and eastern Europe and the former USSR. By helping to promote and protect health and prevent and control disease. integrated planning for health and sustainable development. at the WHO Regional Office for Europe. WHO secures broad international distribution of its publications and encourages their translation and adaptation. The technical focus of the work of the Centre is on developing tools and resource materials in the areas of health policy. WHO’s books contribute to achieving the Organization’s principal objective – the attainment by all people of the highest possible level of health. governance and social support.
In the past five years. as well as with the benefits that investing in health policies can bring. It is concerned with key aspects of people’s living and working circumstances and with their lifestyles. action. Centre for Urban Health WHO Regional Ofﬁce for Europe 5 . Tsouros Head. further reading and recommended web sites. The good news is that an increasing number of Member States today are developing policies and programmes that explicitly address the root causes of ill health. health inequalities and the needs of those who are affected by poverty and social disadvantage. which was translated into 25 languages and used by decisionmakers at all levels. since the publication of the first edition of Social determinants of health. I should like to express my gratitude to Professor Richard Wilkinson and Professor Sir Michael Marmot. I am convinced that it will be a valuable tool for broadening the understanding of and stimulating debate and action on the social determinants of health.FOREWORD The need and demand for clear scientific evidence to inform and support the health policymaking process are greater than ever. It is concerned with the health implications of economic and social policies. Agis D. This publication was achieved through close partnership between the WHO Centre for Urban Health and the International Centre for Health and Society. Our goal is to promote awareness. The field of the social determinants of health is perhaps the most complex and challenging of all. United Kingdom. public health professionals and academics throughout the European Region and beyond. informed debate and. new and stronger scientific evidence has been developed. This second edition integrates the new evidence and is enriched with graphs. The solid facts in 1998. University College London. above all. who edited the publication. and to thank all the members of the scientific team who contributed to this important piece of work. We want to build on the success of the first edition.
Department of Epidemiology and Public Health and International Centre for Health and Society. United Kingdom Dr Mary Shaw. International Centre for Health and Society. University College London. Health Behaviour Unit. United Kingdom Professor Mark McCarthy. University College London. Medical Research Council. University College London. United Kingdom Professor Aubrey Sheiham. Department of Social Medicine. United Kingdom Professor Danny Dorling. United Kingdom Professor Stephen Stansfeld. School of Geography. Bristol University. Imperial College London. United Kingdom Dr Eric Brunner.CONTRIBUTORS Professor Mel Bartley. University of Leeds. Cancer Research UK. University College London. Barts and The London. United Kingdom 6 . United Kingdom Dr Jane Ferrie. University College London. University College London. University of Nottingham. University College London. International Centre for Health and Society. United Kingdom Professor Richard Wilkinson. United Kingdom Professor Sir Michael Marmot. United Kingdom Professor Martin Jarvis. United Kingdom Dr David Blane. University College London. London Professor Mike Wadsworth. Queen Mary’s School of Medicine and Dentistry. National Survey of Health and Development.
or at more structural issues such as unemployment. This publication outlines the most important parts of this new knowledge as it relates to areas of public policy. For both publications. But however important individual genetic susceptibilities to disease may be. This is now changing. universal access to medical care is clearly one of the social determinants of health. drugs. In each case. in a new publication on the determinants of health.INTRODUCTION Even in the most affluent countries. we are indebted to researchers in the forefront of their fields. exercise and substance abuse. more important for the health of the population as a whole are the social and economic conditions that make people ill and in need of medical care in the first place. Health policy was once thought to be about little more than the provision and funding of medical care: the social determinants of health were discussed only among academics. Oxford University Press. most of whom are associated with the International Centre for Health and Society at University College London. people who are less well off have substantially shorter life expectancies and more illnesses than the rich. A few key references to the research are listed at the end of each chapter. Why also. This is why life expectancy has improved so dramatically over recent generations. which was prepared to accompany the first edition of Social determinants of health. unemployment. eds. followed by an explanation of how psychological and social influences affect physical health and longevity. poverty and the experience of work. such as the quality of parenting. Wilkinson RG. nutrition. To provide the background. the focus is on the role that public policy can play in shaping the social environment in ways conducive to better health: that focus is maintained whether we are looking at behavioural factors. Nevertheless. we start with a discussion of the social gradient in health. good food and transport policy. The ten topics covered include the lifelong importance of health determinants in early childhood. it is also why some European 7 . Oxford. is there nothing about genes? The new discoveries on the human genome are exciting in the promise they hold for advances in the understanding and treatment of specific diseases. the common causes of the ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live. The solid facts. and the effects of poverty. They have led in particular to a growing understanding of the remarkable sensitivity of health to the social environment and to what have become known as the social determinants of health. While medical care can prolong survival and improve prognosis after some serious diseases. they have also drawn scientific attention to some of the most powerful determinants of health standards in modern societies. but a fuller discussion of the evidence can be found in Social determinants of health (Marmot M. followed by a list of implications for public policy. 1999). Each of the chapters contains a brief summary of what has been most reliably established by research. social support. Not only are these differences in health an important social injustice. working conditions. They have given their time and expertise to draft the different chapters of both these publications.
as both health and the major influences on it vary substantially 8 . area. Some of the studies have used prospective methods. and it is why health differences between different social groups have widened or narrowed as social and economic conditions have changed. national or international data.People’s lifestyles and the conditions in which they live and work strongly influence their health. The evidence on which this publication is based comes from very large numbers of research reports – many thousands in all. Others have used cross-sectional methods and have studied individual. Difficulties that have sometimes arisen (perhaps despite follow-up studies) in determining causality have been overcome by using evidence from intervention studies. countries have improved their health while others have not. sometimes following tens of thousands of people over © HEALTHY CITIES PROJECT/WHO decades – sometimes from birth. Nevertheless. and occasionally from studies of other primate species. from so-called natural experiments.
We need friends. As exhortations to individual behaviour change are also a well established approach to health promotion. We hope that by tackling some of the material and social injustices. we need more sociable societies. the reader should keep in mind that the bulk of the evidence on which this publication is based comes from rich developed countries and its relevance to less developed countries may be limited. policy will not only improve health and well-being. but may also reduce a range of other social problems that flourish alongside ill health and are rooted in some of the same socioeconomic processes. we need to feel valued and appreciated. drug use. workplaces and the community – takes proper account of recent evidence suggesting a wider responsibility for creating healthy societies. it looks as if much depends on understanding the interaction between material disadvantage and its social meanings. unemployed. socially excluded. and we need to exercise a significant degree of control over meaningful work. however. public and private institutions. sociology and psychology with neurobiology and medicine. It is not simply that poor material circumstances are harmful to health. Our intention has been to ensure that policy at all levels – in government. the social meaning of being poor. from early childhood onwards. we need to feel useful. or otherwise stigmatized also matters. there is little about what individuals can do to improve their own health. Given that this publication was put together from the contributions of acknowledged experts in each field. anxiety.according to levels of economic development. emphasize the need to understand how behaviour is shaped by the environment and. But a publication as short as this cannot provide a comprehensive guide to determinants of public health. Richard Wilkinson and Michael Marmot 9 . what is striking is the extent to which the sections converge on the need for a more just and caring society – both economically and socially. which all rebound on physical health. Without these we become more prone to depression. Several areas of health policy. we need not only good material conditions but. We do. recommend environmental changes that would lead to healthier behaviour. As social beings. such as the need to safeguard people from exposure to toxic materials at work. and the evidence suggests they may sometimes have limited effect. are left out because they are well known (though often not adequately enforced). consistent with approaching health through its social determinants. hostility and feelings of hopelessness. Combining economics.
1. starting work. having a poorer education during adolescence. the move from primary to secondary education. Policy implications If policy fails to address these facts. THE SOCIAL GRADIENT Life expectancy is shorter and most diseases are more common further down the social ladder in each society. OCCUPATIONAL CLASS Managerial and technical Skilled nonmanual Skilled manual Partly skilled manual Unskilled manual 64 66 68 70 72 74 76 78 80 82 84 LIFE EXPECTANCY (YEARS) 10 . becoming stuck in a hazardous or dead-end job. having insecure employment. trying to bring up a family in difficult circumstances and living on an inadequate retirement pension. living in poor housing. England and Wales. lower ranking staff suffer much more disease and earlier death than higher ranking staff (Fig. it also ignores one of the most important social justice issues facing modern societies. These disadvantages tend to concentrate among the same people. Fig. • Life contains a series of critical transitions: emotional and material changes in early childhood. leaving home and starting a family. the greater the physiological wear and tear they suffer. What is known Poor social and economic circumstances affect health throughout life. and their effects on health accumulate during life. welfare policies need to provide not only safety nets but also springboards to offset earlier disadvantage. Each of these changes can affect health by pushing people onto a more or less advantaged path. The longer people live in stressful economic and social circumstances. It can include having few family assets.1. 1). it not only ignores the most powerful determinants of health standards in modern societies. so that even among middle-class office workers. Health policy must tackle the social and economic determinants of health. Occupational class differences in life expectancy. Disadvantage has many forms and may be absolute or relative. and the less likely they are to enjoy a healthy old age. 1997–1999 Men Professional Women Both material and psychosocial causes contribute to these differences and their effects extend to most diseases and causes of death. and eventually retirement. changing jobs and facing possible redundancy. Nor are the effects confined to the poor: the social gradient in health runs right across society. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Because people who have been disadvantaged in the past are at the greatest risk in each subsequent transition.
Journal of Epidemiology and Community Health. Mitchell R. Inequalities in life expectancy by social class 1972–1999. Lynch K. 2000. van de Mheen H et al. 82:358–363. Source of Fig. Accumulated labour market disadvantage and limiting long-term illness. Welfare and Sport. 2000. Health Statistics Quarterly. Morris JN et al. Montgomery SM. 2002. Bartley M. Archives of Disease in Childhood. Role of childhood health in the explanation of socioeconomic inequalities in early adult health. International Journal of Epidemiology. economic and cultural life of their society will be healthier than those where people face insecurity. 11 .• Good health involves reducing levels of educational failure. 2002. Blane D. A minimum income for healthy living. 31:336–341. Societies that enable all citizens to play a full and useful role in the social. 15:5–15. exclusion and deprivation. Prepubertal stature and blood pressure in early old age. Plewis I. Poor social and economic circumstances affect health throughout life. Journal of Epidemiology and Community Health. The Hague. KEY SOURCES Bartley M. Reducing socio-economic inequalities in health. Goldblatt P. reducing insecurity and unemployment and improving housing standards. 1998. 31:831–838. 52:15–19. Berney LR. Ministry of Health. 54:885–889. © JOACHIM LADEFOGED/POLFOTO • Other chapters of this publication cover specific policy areas and suggest ways of improving health that will also reduce the social gradient in health. International Journal of Epidemiology. Programme Committee on Socio-economic Inequalities in Health (SEGV-II). 2001. 2002. Elevated risk of high blood pressure: climate and the inverse housing law. Blane D. 1: Donkin A.
anxious and unable to cope. What is known Social and psychological circumstances can cause long-term stress. Why do these psychosocial factors affect physical health? In emergencies. the more common these problems become. have powerful effects on health. insecurity. low self-esteem. diverting blood to muscles and increasing alertness. Long periods of anxiety and Lack of control over work and home can have powerful effects on health. Such psychosocial risks accumulate during life and increase the chances of poor mental health and premature death. STRESS Stressful circumstances. making people feel worried. insecurity and the lack of supportive friendships are damaging in whatever area of life they arise. mobilizing stored energy. The lower people are in the social hierarchy of industrialized countries. are damaging to health and may lead to premature death. our hormones and nervous system prepare us to deal with an immediate physical threat by triggering the fight or flight response: raising the heart rate. Although the stresses of modern urban life rarely demand strenuous or even moderate 12 © RIKKE STEENVINKEL NORDENHOF/POLFOTO . social isolation and lack of control over work and home life. Continuing anxiety.2.
Contribution of job control and other risk factors to social variations in coronary heart disease incidence. depression and aggression. turning on the stress response diverts energy and resources away from many physiological processes important to long-term health maintenance. Brunner EJ et al.physical activity. heart attack. 1997. workplaces and other institutions. 2002. 314:1472–1476. Lancet. the quality of the social environment and material security are often as important to health as the physical environment. Kivimaki M et al. • Governments should recognize that welfare programmes need to address both psychosocial and material needs: both are sources of anxiety and insecurity. encourage community activity. disregarded and used. on reducing the major causes of chronic stress. 2002. In particular. Both the cardiovascular and immune systems are affected. governments should support families with young children. Adrenocortical. 13 . reduce material and financial insecurity. Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. high blood pressure. KEY SOURCES Brunner EJ. autonomic and inflammatory causes of the metabolic syndrome. • In schools. attention should be focused upstream. British Medical Journal. and promote coping skills in education and rehabilitation. London. combat social isolation. Marmot MG et al. 350:235–239. stroke. British Medical Journal. Stansfeld SA. Circulation. 2002. Marmot MG. participating and being valued are likely to be healthier places than those where people feel excluded. they become more vulnerable to a wide range of conditions including infections. 325:857–860. this does not matter. Stress and the biology of inequality. Institutions that can give people a sense of belonging. but if people feel tense too often or the tension goes on for too long. Stress and heart disease. BMJ Books. diabetes. 1997. 106: 2659–2665. Policy implications Although a medical response to the biological changes that come with stress may be to try to control them with drugs. For brief periods.
Slow growth and poor emotional support raise the lifetime risk of poor physical health and reduce physical. which increase the risk of illness in adulthood. insecure emotional attachment and poor stimulation can lead to reduced readiness for school. Good health-related habits. As cognitive. which affects health throughout life. Poor circumstances during pregnancy can lead to less than optimal fetal development via a chain that may include deficiencies in nutrition during pregnancy. low educational attainment. Infant experience is important to later health because of the continued malleability of biological systems. pancreatic and kidney development and function. 14 . Slow or retarded physical growth in infancy is associated with reduced cardiovascular.3. and problem behaviour. 2). are associated with parental and peer group examples. © FINN FRANDSEN/POLFOTO Important foundations of adult health are laid in early childhood. What is known Observational research and intervention studies show that the foundations of adult health are laid in early childhood and before birth. E A R LY LIFE A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime. exercising and not smoking. a greater likelihood of maternal smoking and misuse of drugs and alcohol. respiratory. and with good education. cognitive and emotional functioning in adulthood. maternal stress. emotional and sensory inputs programme the brain’s responses. Poor fetal development is a risk for health in later life (Fig. insufficient exercise and inadequate prenatal care. and form the basis of the individual’s biological and human capital. and the risk of social marginalization in adulthood. Poor early experience and slow growth become embedded in biology during the processes of development. such as eating sensibly.
Mothers. and reduce the risk of disease and malnutrition in infancy. CA. Rutter M. Hertzman C. Developmental health and the wealth of nations.4 3.3 BIRTH WEIGHT (KG) Policy implications These risks to the developing child are significantly greater among those in poor socioeconomic circumstances. Edinburgh. babies and disease in later life. Keating DP. Penguin Books. and adequate social and economic resources.5 2. Giri K. to increase parental knowledge of children’s emotional and cognitive needs.5–2.0–3. Edinburgh.5–3. Such health and education programmes have direct benefits. 2000. 1993. They increase parents’ awareness of their children’s needs and their receptivity to information about health and development. 1999. Churchill Livingstone. Oxford. Source of Fig.Fig. 1995. 2: Barker DJP. before first pregnancies. babies and disease in later life. to stimulate cognitive development and pro-social behaviour in the child. NY. Third Party Publishing. 2. and through improvements in the educational levels of parents and children. and they can best be reduced through improved preventive health care before the first pregnancy and for mothers and babies in pre. New York. Risk of diabetes in men aged 64 years by birth weight Adjusted for body mass index 7 Policies for improving health in early life should aim to: • increase the general level of education and provide equal opportunity of access to education. • provide good nutrition. Oxford University Press. London. Rutter M. and in infancy. Mehrotra S. eds. Guilford Press. Wallace HM. 2nd ed. 1998. Development with a human face. eds. Serrano CV. 15 .9 4. Developing minds: challenge and continuity across the life span. to improve the health of mothers and babies in the long run. 2nd ed.0–4. during pregnancy. Barker DJP.and postnatal.9 3. to improve growth and development before birth and throughout infancy.3 KG SET AT 1) 5 4 3 2 1 0 <2. infant welfare and school clinics. Churchill Livingstone. Santa Monica. 2nd ed. Mothers. Jolly R. Health care of women and children in developing countries. and to prevent child abuse.3 >4. and • ensure that parent–child relations are supported from birth. ideally through home visiting and the encouragement of good parental relations with schools. health education. KEY SOURCES 6 RISK OF DIABETES (WITH BIRTH WEIGHT >4. eds. and health and preventive care facilities. 1998. and they increase parental confidence in their own effectiveness.
disability. illness. even in the richest countries of Europe. Absolute poverty – a lack of the basic material necessities of life – continues to exist. transport and other factors vital to full participation in life. They are socially and psychologically damaging. The unemployed. Relative poverty means being much poorer than most people in society and is often defined as living on less than 60% of the national median income. social exclusion and discrimination cost lives. so the number of people who experience poverty and social exclusion during their lifetime is far higher than the current number of socially excluded people. What is known Poverty. particularly cardiovascular disease. or have left. relative deprivation and social exclusion have a major impact on health and premature death. as much as one quarter of the total population – and a higher proportion of children – live in relative poverty (Fig. discrimination. guest workers. The greater the length of time that people live in disadvantaged circumstances. People move in and out of poverty during their lives. the more likely they are to suffer from a range of health problems. and the chances of living in poverty are loaded heavily against some social groups. stigmatization. children’s homes and psychiatric hospitals. poverty. People who live in. Being excluded from the life of society and treated as less than equal leads to worse health and greater risks of premature death. Poverty and social exclusion increase the risks of divorce and separation. 3). By causing hardship and resentment. many ethnic minority groups. to babies.4. disabled people. refugees and homeless people are at particular risk. and harmful to health. materially costly. It denies people access to decent housing. are particularly vulnerable. and gaining access to services and citizenship activities. hostility and unemployment. addiction and social isolation and 16 . The stresses of living in poverty are particularly harmful during pregnancy. institutions. Those living on the streets suffer the highest rates of premature death. Social exclusion also results from racism. SOCIAL EXCLUSION Life is short where its quality is poor. © JAN GRARUP/POLFOTO People living on the streets suffer the highest rates of premature death. In some countries. These processes prevent people from participating in education or training. children and old people. such as prisons. education.
Oxford. • All citizens should be protected by minimum income guarantees. 2003. Policy implications Through policies on taxes. • Legislation can help protect minority and vulnerable groups from discrimination and social exclusion. In: Gordon D. forming vicious circles that deepen the predicament people face. economic management. no government can avoid having a major impact on the distribution of income. Oxford University Press. Gordon D. limited access to services and a poor quality environment. Neighborhoods and health.Fig. Dorling D. Proportion of children living in poor households (below 50% of the national average income) 30 such policies on rates of death and disease imposes a public duty to eliminate absolute poverty and reduce material inequalities. social services and affordable housing. KEY SOURCES Claussen B. Bristol. The Policy Press.1999. education. Environment and Planning A. vice versa. Breadline Europe: the measurement of poverty. Life chances in Britain by housing wealth and for the homeless and vulnerably housed. Routledge. Kawachi I. Thelle D. • Public health policies should remove barriers to health care. Bristol. Townsend P. health can also be compromised indirectly by living in neighbourhoods blighted by concentrations of deprivation. Mackenbach J. 3. 2000. high unemployment. poor quality housing. • Interventions to reduce poverty and social exclusion are needed at both the individual and the neighbourhood levels. 2002. Berkman L. 3: Bradshaw J. Bakker M. Brimblecombe N. benefits. 17 . eds. Journal of Epidemiology and Community Health. 57:40–45. World poverty: new policies to defeat an old enemy. Shaw M. Impact of childhood and adulthood socio-economic position on cause specific mortality: the Oslo Mortality Study. eds. The Policy Press. Reducing inequalities in health: a European perspective. 2002. Townsend P. As well as the direct effects of being poor. and many other areas of activity. Child poverty in comparative perspective. 31:2239–2248. London. 2003. The indisputable evidence of the effects of Source of Fig. minimum wages legislation and access to services. 25 20 PROPORTION (%) 15 10 5 0 Czech Republic United Kingdom Slovakia Sweden Finland Norway Denmark Netherlands Hungary Canada Spain Poland Belgium Germany Italy Israel Russian Federation USA • Labour market. education and family welfare policies should aim to reduce social stratification. Davey Smith G. employment.
sex. sickness absence and cardiovascular disease (Fig. A virtuous circle can be established: improved conditions of work will lead to a healthier work force.5. and make it harder for people to get appropriate rewards. having a job is better for health than having no job. Jobs with both high demand and low control carry special risk. Further. Evidence shows that stress at work plays an important role in contributing to the large social status differences in health. management styles and social relationships in the workplace all matter for health. sickness absence and premature death. and hence to the opportunity to create a still healthier. Policy implications • There is no trade-off between health and productivity at work. Current changes in the labour market may change the opportunity structure. What is known In general. effort/reward imbalance.5 1. Some evidence indicates that social support in the workplace may be protective. Some show an interaction between demands and control. Rewards can take the form of money. Mechanisms should therefore be developed to allow people to influence the design and improvement of their work 2. But the social organization of work.0 1. These results show that the psychosocial environment at work is an important determinant of health and contributor to the social gradient in ill health. 4. status and self-esteem.5 RISK OF CORONARY HEART DISEASE (WITH HIGH JOB CONTROL SET AT 1. In short.0 High Intermediate JOB CONTROL Low Adjusted for age. These risks have been found to be independent of the psychological characteristics of the people studied. more productive workplace. coronary risk factors and negative psychological disposition 18 . Self-reported level of job control and incidence of coronary heart disease in men and women 2. 4). Fig.0) Having little control over one’s work is particularly strongly related to an increased risk of low back pain. receiving inadequate rewards for the effort put into work has been found to be associated with increased cardiovascular risk. which will lead to improved productivity. employment grade. Several European workplace studies show that health suffers when people have little opportunity to use their skills and low decision-making authority. WORK Stress in the workplace increases the risk of disease. they seem to be related to the work environment. People who have more control over their work have better health. Studies have also examined the role of work demands. length of follow-up. • Appropriate involvement in decision-making is likely to benefit employees at all levels of an organization.
1997. 2000: 78–83. Kuper K. Evidence-based cardiology. eds. and the SHEEP Study Group. Journal of Epidemiology and Community Health. 1998.environment. Two alternative job stress models and risk of coronary heart disease. Marmot MG et al. 88:68–74. 56(4):294–300.. 350:235–240. Philadelphia. • To reduce the burden of musculoskeletal disorders. Occupational medicine. 15:126. 2002. Peter R et al. American Journal of Public Health. KEY SOURCES Bosma H et al. • Good management involves ensuring appropriate rewards – in terms of money. • As well as requiring an effective infrastructure with legal controls and powers of inspection. In: Schnall PL et al. London.. Two alternative job stress models and risk of coronary heart disease.. 2003:181–217. In: Yusuf S et al. 88:68–74. Karasek R. Source of Fig. Hemingway H. greater variety and more opportunities for development at work. 19 . thus enabling employees to have more control. Schnall P et al. Hanley and Belfus Inc. 2nd ed. The workplace and cardiovascular disease. workplace health protection should also include workplace health services with people trained in the early detection of mental health problems and appropriate interventions. Why the workplace and cardiovascular disease? Occupational Medicine. BMJ Books. © FIRST LIGHT Jobs with both high demand and low control carry special risk. State of the Art Reviews. 4: Bosma H et al. Contribution of job control to social gradient in coronary heart disease incidence. 1998. Lancet. status and self-esteem – for all employees. American Journal of Public Health. Theorell T. Psychosocial work environment and myocardial infarction: improving risk estimation by combining two complementary job stress models in the SHEEP Study. Psychosocial factors in the primary and secondary prevention of coronary heart disease: an updated systematic review of prospective cohort studies. workplaces must be ergonomically appropriate. 2000. Marmot MG. eds. The demand-control-support model and CVD.
and the risk is higher in regions where unemployment is widespread. Evidence from a number of countries shows that. The health effects start when people first feel their jobs are threatened. Job insecurity has been shown to increase effects on mental health (particularly anxiety and depression). it increases sickness absence and health service use. even before they actually become unemployed. unemployed people and their families suffer a substantially increased risk of premature death. well-being and job satisfaction. even after allowing for other factors. heart disease and risk factors for heart disease. 20 © REUTER/POLFOTO . self-reported ill health. it acts as a chronic stressor whose effects grow with the length of exposure. As job insecurity continues. The health effects of unemployment are linked to both its psychological consequences and the financial problems it brings – especially debt. Higher rates of unemployment cause more illness and premature death. This shows that anxiety about insecurity is also detrimental to health. Unemployed people and their families suffer a much higher risk of premature death.6. changes in the economies and labour markets of many industrialized countries increased feelings of job insecurity. UNEMPLOYMENT Job security increases health. During the 1990s. What is known Unemployment puts health at risk. Because very unsatisfactory or insecure jobs can be as harmful as unemployment. 5). merely having a job will not always protect physical and mental health: job quality is also important (Fig.
1987. eds.pdf. The effects of labour market position. In: Gallie D. Oxford. to reduce the hardship suffered by the unemployed. Whitehead M. European Series. Labour market changes and job insecurity: a challenge for social welfare and health promotion. 0 Securely employed Insecurely employed EMPLOYMENT STATUS Unemployed 21 . Stationery Office. Burchell. eds. Fig. Vogler C. H. 5. No.M. Nethercott S. 1985.int/document/e66205. Iversen L et al. British Medical Journal.who. 2001. high standards of education and good retraining schemes are important. and to restore people to secure jobs. unemployment benefits set at a higher proportion of wages are likely to have a protective effect. • Limitations on working hours may also be beneficial when pursued alongside job security and satisfaction. Effect of job insecurity and unemployment on health 300 Long-standing illness Poor mental health RISK OF ILL HEALTH (WITH SECURELY EMPLOYED SET AT 100) • To equip people for the work available. accessed 15 August 2003). Journal of the Royal College of General Practitioners. Marsh C. • For those out of work. 81) (http: //www. WHO Regional Office for Europe. eds.Policy implications Policy should have three goals: to prevent unemployment and job insecurity. and unemployment on psychological health. 250 200 150 100 50 Source of Fig. In: Drever F. 5: Ferrie JE et al. 1999 (WHO Regional Publications.euro. Unemployment and mortality in Denmark. KEY SOURCES Beale N. Unemployment and mortality. 1994:188–212. Job-loss and family morbidity: a study of a factory closure. • Government management of the economy to reduce the highs and lows of the business cycle can make an important contribution to job security and the reduction of unemployment. Health inequalities. 35:510–514.. London. Bethune A. Social change and the experience of unemployment. B. job insecurity. Copenhagen. 322:647–651. Employment status and health after privatisation in white collar civil servants: prospective cohort study. 1997. British Medical Journal. Ferrie J et al. • Credit unions may be beneficial by reducing debts and increasing social networks. 295:879–884. Oxford University Press.
good social relations and strong supportive networks improve health at home. High levels of mutual support will protect health while the breakdown of social relations. Belonging to a social network of communication and mutual obligation makes people feel cared for. 22 . People who get less social and emotional support from others are more likely to experience less well-being. The amount of emotional and practical social support people get varies by social and economic status. esteemed and valued.7. Support operates on the levels both of the individual and of society. © FOTOKHRONIKA/POLFOTO Belonging to a social network makes people feel cared for. A study of a community with initially high levels of social cohesion showed low rates of coronary heart disease. Supportive relationships may also encourage healthier behaviour patterns. bad close relationships can lead to poor mental and physical health. Societies with high levels of income inequality tend to have less social cohesion and more violent crime. Social isolation and exclusion are associated with increased rates of premature death and poorer chances of survival after a heart attack (Fig. heart disease rates rose. Inequality is corrosive of good social relations. This has a powerful protective effect on health. SOCIAL SUPPORT Friendship. Poverty can contribute to social exclusion and isolation. reduces trust and increases levels of violence. Intervention studies have shown that providing social support can improve patient recovery rates from several different conditions. loved. Policy implications Experiments suggest that good social relations can reduce the physiological response to stress. mutual obligations and respect in communities or in the wider society – helps to protect people and their health. at work and in the community. a greater risk of pregnancy complications and higher levels of disability from chronic diseases. In addition. It can also improve pregnancy outcome in vulnerable groups of women. Social support helps give people the emotional and practical resources they need. Social cohesion – defined as the quality of social relationships and the existence of trust. 6). When social cohesion declined. more depression. sometimes following greater inequality. What is known Social support and good social relations make an important contribution to health.
241:540–545. Earls F. Sampson RJ. American Journal of Epidemiology. 1996. Journal of Epidemiology and Community Health. USA (blacks) 0. 6. KEY SOURCES Berkman LF. Source of Fig. host resistance and mortality: a nine year follow-up of Alameda County residents. 18:182–202. practices that cast some as socially inferior or less valuable should be avoided because they are socially divisive. 50(3):245–251.1 High • Reducing social and economic inequalities and reducing social exclusion can lead to greater social cohesiveness and better standards of health. USA (blacks) Tecumseh. USA (whites) 0. Hsieh CC. American Journal of Epidemiology. 135:356–368.4 AGE-ADJUSTED MORTALITY RATE 0. 1988. USA Eastern Finland 0 Low LEVEL OF SOCIAL INTEGRATION 0. 1997. Pugh MD. Social networks. Syme SL.3 0. 6: House JS.Fig. Criminal Justice Review. • Designing facilities to encourage meeting and social interaction in communities could improve mental health. Poverty. in the workplace and in the community more widely. 1979. income inequality. Neighborhoods and violent crime: a multilevel study of collective efficacy. • In all areas of both personal and institutional life. Science. Social support and depressive symptoms in the elderly. and violent crime: a meta-analysis of recent aggregate data studies. Raudenbush SW. Social relationships and health. USA Tecumseh.1 Eastern Finland 0 High Low LEVEL OF SOCIAL INTEGRATION Gothenburg. USA Evans County.5 Males Evans County. 23 .3 Evans County. American Journal of Epidemiology. Oxman TE et al.2 Alameda County.5 0. 277: 918–924. especially their mental health. 0. Science. Level of social integration and mortality in five prospective studies Females 0. USA 0. 1988.4 Evans County. Umberson D. Social connections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland.2 USA (whites) Alameda County. Landis KR. Kaplan GA et al. 128: 370–380. • Improving the social environment in schools. Sweden 0. will help people feel valued and supported in more areas of their lives and will contribute to their health. 109:186–204. Kawachi I et al. 1993. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. 1992.
The use of alcohol. Their activities are a major barrier to policy initiatives to reduce use among young people. It offers users a mirage of escape from adversity and stress. ADDICTION Individuals turn to alcohol. drugs and tobacco and suffer from their use. but use is influenced by the wider social setting. violence. The causal pathway probably runs both ways. People turn to alcohol to numb the pain of harsh economic and social conditions. The same is true of tobacco. Consequently. © TEIT HORNBAK/POLFOTO The irony is that. and alcohol dependence leads to downward social mobility. lone parenthood. Alcohol dependence is associated with violent death in other countries too. injury and suicide – have risen sharply. But nicotine offers no real relief from stress or improvement in mood. People turn to alcohol. Smoking is a major drain on poor people’s incomes and a huge cause of ill health and premature death. illicit drug use and cigarette smoking are all closely associated with markers of social and economic disadvantage (Fig. unemployment or homelessness – is associated with high rates of smoking and very low rates of quitting. Alcohol dependence. Social deprivation – whether measured by poor housing. What is known Drug use is both a response to social breakdown and an important factor in worsening the resulting inequalities in health. deaths linked to alcohol use – such as accidents. the past decade has been a time of great social upheaval. In some of the transition economies of central and eastern Europe. low income. alcohol intensifies the factors that led to its use in the first place. poisoning. apart from a temporary release from reality.8. but only makes their problems worse. drugs and tobacco to numb the pain of harsh economic and social conditions. tobacco and illicit drugs is fostered by aggressive marketing and promotion by major transnational companies and by organized crime. and their connivance with smuggling. for example. 7). 24 .
has hampered efforts by governments to use price mechanisms to limit consumption. In: Jha P. but also to address the patterns of social deprivation in which the problems are rooted. 25 . Socioeconomic deprivation and risk of dependence on alcohol. and to inform people about less harmful forms of use. 1995. Effective drug policy must therefore be supported by the broad framework of social and economic policy. London. eds. Smoking. • Policies need to regulate availability through pricing and licensing. • None of these will succeed if the social factors that breed drug use are left unchanged. eds. 7. Policy Studies Institute. to use health education to reduce recruitment of young people and to provide effective treatment services for addicts. Makela P. rather than addressing the complexities of the social circumstances that generate drug use. Chaloupka F. British Medical Journal 1997. 9 Drugs 7 6 5 4 3 2 1 0 0 Most affluent 1 2 DEPRIVATION SCORE 3 4 Most deprived KEY SOURCES Bobak M et al. British Medical Journal. Poverty and smoking. M. eds. 1994. Ryan.Fig. This blames the victim. Report 6). The Policy Press. McKay S. H. 310:646–648. Tobacco control in developing countries. Stationery Office. physical activity and screening uptake and health inequalities.M. Oxford University Press. Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow-up study. Meltzer H. Bristol. Great Britain. nicotine and drugs. drinking. Valkonen T.. 1999: 213–239. Policy implications • Work to deal with problems of both legal and illicit drug use needs not only to support and treat people who have developed addictive patterns of use. 7: Wardle J et al. Martelin T. 1996 (OPCS Surveys of Psychiatric Morbidity in Great Britain. Oxford. Source of Fig. Poor smokers. Trying to shift the whole responsibility on to the user is clearly an inadequate response. Economic activity and social functioning of residents with psychiatric disorders. In: Gordon D et al. Inequalities in health. Alcoholism and rising mortality in the Russian Federation. London. 1993 10 Alcohol Nicotine 8 RISK OF DEPENDENCE (WITH MOST AFFLUENT SET AT 1) especially in the case of tobacco. 315:211–216 Marsh A. 2000:41–61.
such as young families. when diets. obesity became more common among the poor than the rich. changed to overconsumption of energy-dense fats and sugars. Over 100 expert committees have agreed on these dietary goals. elderly people and the unemployed. A shortage of food and lack of variety cause malnutrition and deficiency diseases. and food industry interests are strong. The main dietary difference between social classes is the source of nutrients. With it came a nutritional transition. Economic growth and improvements in housing and sanitation brought with them the epidemiological transition from infectious to chronic diseases – including heart disease. What is known A good diet and adequate food supply are central for promoting health and well-being. 8). are least able to eat well. obesity and dental caries. The important public health issue is the availability and cost of healthy. cancer. In many countries. producing more obesity. more accessible and support the local economy. Access to good. lack public health representatives. Excess intake (also a form of malnutrition) contributes to cardiovascular diseases. refined sugars and salt. fruits and pulses (legumes) and more minimally processed starchy foods.9. Social and economic conditions result in a social gradient in diet quality that contributes to health inequalities. © AILEEN ROBERTSON/WHO Local production for local consumption. At the same time. World food trade is now big business. Local food production can be more sustainable. but less animal fat. International committees such as Codex Alimentarius. People on low incomes. nutritious food (Fig. stroke and cancer. degenerative eye diseases. which determine food quality and safety standards. affordable food makes more difference to what people eat than health education. FOOD Because global market forces control the food supply. Food poverty exists side by side with food plenty. the poor tend to substitute cheaper processed foods for fresh food. diabetes. The General Agreement on Tariffs and Trade and the Common Agricultural Policy of the European Union allow global market forces to shape the food supply. healthy food is a political issue. Dietary goals to prevent chronic diseases emphasize eating more fresh vegetables. High fat intakes often occur in all social groups. 26 . particularly in western Europe.
900 800 700 600 500 400 300 200 100 0 100 150 200 250 300 350 400 450 Poland United Kingdom Germany Spain France Greece Lithuania Russian Federation Ukraine Belarus Source of Fig. especially the most vulnerable. nutrition and the prevention of cancer: a global perspective. • support for sustainable agriculture and food production methods that conserve natural resources and the environment. accessed 14 August 2003). 2000 (http: //www. American Institute for Cancer Research.html. cooking skills.who. Copenhagen. DC. No. nongovernmental organizations and the food industry should ensure: • the integration of public health perspectives into the food system to provide affordable and nutritious fresh food for all. World Health Organization. 1997 (http: //www. Public Health Nutrition. • the availability of useful information about food. • a stronger food culture for health. WHO Regional Office for Europe.who. 2003 (http:// www. KEY SOURCES Diet. Geneva. nutrition and the prevention of chronic diseases. Roos G et al.Policy implications Local. 4:35–43 Systematic reviews in nutrition. Rome. accessed 14 August 2003). Transforming the evidence on nutrition and health into knowledge [web site]. Washington. 25 September 2003. especially aimed at children. WHO Regional Office for Europe. World Health Organization. Geneva. 25 September 2003. World Cancer Research Fund.int/nutrition/ActionPlan/20020729_1.euro. 25 September 2003. University College London. Italy WHO mortality database [database online]. transparent decision-making and accountability in all food regulation matters. Copenhagen. 916) (http://www. Food.org/.pdf. • democratic. national and international government agencies.nutritionreviews.aicr.int/hpr/NPH/docs/who_fao_expert_ report. 2001. London. growing food and the social value of preparing food and eating together. especially through school education. 8: FAOSTAT (Food balance sheets) [database online]. 8. Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European countries AGE-STANDARDIZED DEATH RATES PER 100 000 MEN AGED 35–74 knowledge of food and nutrition. Food and Agriculture Organization of the United Nations. Health for all database [database online]. diet and health. SUPPLY OF FRUIT AND VEGETABLES (KG/PERSON/YEAR) 27 . Disparities in vegetable and fruit consumption: European cases from the north to the south. to foster people’s Fig. Report of a Joint WHO/FAO Expert Consultation. including consumers. accessed 14 August 2003). • the use of scientifically based nutrient reference values and food-based dietary guidelines to facilitate the development and implementation of policies on food and nutrition. with participation by all stakeholders. accessed 14 August 2003) First Action Plan for Food and Nutrition Policy [web pages].org/exreport. 2003 (WHO Technical Report Series.
Regular exercise protects against heart disease and. With fewer pedestrians. cycling. Further. Well planned urban environments. Despite their health-damaging © FINN FRANDSEN/POLFOTO Roads should give precedence to cycling. What is known Cycling. suburbs that depend on cars for access isolate people without cars – particularly the young and old. Policy implications The 21st century must see a reduction in people’s dependence on cars. walking and public transport stimulate social interaction on the streets. Reduced road traffic decreases harmful pollution from exhaust. increase social contact and reduce air pollution. It promotes a sense of well-being and protects older people from depression. Road traffic cuts communities in two and divides one side of the street from the other. 28 . streets cease to be social spaces and isolated pedestrians may fear attack. which insulate people from each other. by limiting obesity. increasing walking and cycling. increase the safety of cycling and walking. those involving cyclists injure relatively few people. people need to find new ways of building exercise into their lives. They do not create disease from air pollution. walking and the use of public transport promote health in four ways. In contrast to cars. TRANSPORT Healthy transport means less driving and more walking and cycling. reduces the onset of diabetes. reduce fatal accidents. which separate cyclists and pedestrians from car traffic. Walking and cycling make minimal use of non-renewable fuels and do not lead to global warming. Social isolation and lack of community interaction are strongly associated with poorer health. backed up by better public transport.10. Although accidents involving cars also injure cyclists and pedestrians. and expanding public transport. Transport policy can play a key role in combating sedentary lifestyles by reducing reliance on cars. Because mechanization has reduced the exercise involved in jobs and house work and added to the growing epidemic of obesity. They provide exercise. make little noise and are preferable for the ecologically compact cities of the future. Reducing road traffic would also reduce the toll of road deaths and serious accidents.
journeys by car are rising rapidly in all European countries and journeys by foot or bicycle are falling (Fig. which increase the use of cars. 2003 (http://www. McCarthy M. creating tax disincentives for the business use Making the connections: transport and social exclusion. reduce congestion. WHO Regional Office for Europe.htm. 1999:132–154. Copenhagen. Distance travelled per person by mode of transport. London. Great Britain.Fig.euro. removing car parking spaces. sales and repairs. • Increasingly. for example. dedicating roads to the use of pedestrians and cyclists. Many industries – oil. environment and health in Europe: evidence. New York. Oxford University Press. London. Road transport and health. The social determinants of health.dft.hcsp. Social Exclusion Unit. car manufacturing. the evidence suggests that building more roads encourages more car use. 9). • Incentives need to be changed. such as converting road space into green spaces. 1997. road building. rubber. • Public transport should be improved for longer journeys.gov. Transport and health. with regular and frequent connections for rural areas. especially in towns. Wilkinson R. eds. DISTANCE (KM) 6000 4000 2000 0 Car Train Bus MODE OF TRANSPORT Foot Cycle Fletcher T. accessed 14 August 2003). Department for Transport.uk/stellent/groups/dft_transstats/ documents/page/dft_transstats_506978.socialexclusionunit.uk/ published. 9:Transport trends 2002: articles (Section 2: personal travel by mode).who. and advertising – benefit from the use of cars.int/eprise/main/who/ progs/hcp/UrbanHealthTopics/20011207_1. 9. accessed 18 September 2003). by reducing state subsidies for road building. eds. initiatives and examples. accessed 14 August 2003). McMichael AJ. • Changes in land use are also needed. 1996. increasing bus and cycle lanes. Transport. National and local public policies must reverse these trends. NY. however. Office of the Deputy Prime Minister. increasing financial support for public transport. London. 29 . KEY SOURCES Davies A. In: Marmot MG. while traffic restrictions may. Oxford. and stopping the growth of lowdensity suburbs and out-of-town supermarkets. contrary to expectations. Wiley. 2002 (http://www. British Medical Association. 1985 and 2000 10000 1985 8000 2000 of cars and increasing the costs and penalties of parking. • Roads should give precedence to cycling and walking for short journeys. 2001 (http://www. Health at the crossroads: transport policy and urban health. Yet transport lobbies have strong vested interests. effects.gov. Source of Fig.
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This disparity has drawn attention to the remarkable sensitivity of health to the social environment. Key research sources are given for each: stress.The WHO Regional Ofﬁce for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with primary responsibility for international health matters and public health.int Web site: www. This publication provides the facts and the policy options that will enable them to act.who. It then looks at what is known about the most important social determinants of health today. addiction. attacking the causes of ill health before they can lead to problems. social exclusion.: +45 39 17 17 17 Fax: +45 39 17 18 18 E-mail: postmaster@euro. each with its own programme geared to the particular health conditions of the countries it serves. This publication examines this social gradient in health.int Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia and Montenegro Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan . and the role that public policy can play in shaping a social environment that is more conducive to better health. healthy food and transport policy. This is a challenging task for both decision-makers and public health actors and advocates. The WHO Regional Ofﬁce for Europe is one of six regional ofﬁces throughout the world. Policy and action for health need to address the social determinants of health. early life. Poorer people live shorter lives and are more often ill than the rich. and explains how psychological and social inﬂuences affect physical health and longevity.euro. unemployment. This second edition relies on the most up-to-date sources in its selection and description of the main social determinants of health in our society today. ISBN 92 890 1371 0 World Health Organization Regional Ofﬁce for Europe Scherﬁgsvej 8 DK-2100 Copenhagen Ø Denmark Tel. social support. working conditions.who.
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