Life chances v Lifestyles: the Social Determinants of Health

Clare BambraProfessor of Public Health PolicyWolfson Research Institute for Health & Wellbeing

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Overview

1. Inequalities in health and health behaviours (lifestyles) are socially determined (life chances)

2. Effective public health policy therefore needs to focus on altering peoples life chances and getting beyond just looking at lifestyles

3. Evidence-based principles for policy and building on past Labour successes

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1. Health Inequalities in the UK

• Infant mortality rates are 16% higher in children of routine and manual workers as compared to professional and managerial workers

• Deaths from cardiovascular diseases are 2.7 times higher in the 20% most deprived areas compared to the 20% least deprived

• Smoking rates are almost twice as high amongst routine and manual workers as compared to professional and managerial workers (16% v 28% men, 14% v 24% women)

• Alcohol related hospital admissions are twice as high (2.6 times men and 2.4 women) in the 20% most deprived areas compared to the 20% least deprived areas

• Obesity rates are higher in routine and manual groups particularly amongst women (27% v 21% men) (34% to 14% women).

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Lifestyle v Life chances

1. Is it all to do with differences in lifestyles?

OR

2. Is it to do with differences in life chances?

Answer: Best available data from the Whitehall cohort studies shows that

25-40% due to lifestyle factors. Additionally, lifestyles are themselves effected by life chances – the social determinants of health

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2. Life chances: the Social Determinants of Health

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Example 1: Stressful Work Environment Whitehall civil service health studies found:•Heart disease 50% higher in the lower grade employees.•Adjustment for lifestyle factors reduced the inequality by 40% in men and 26% in women•BUT adjustment for stressful work environment reduced the inequality by 64% in men and 51% in women

Exposure to stressful work environments higher amongst lower skilled workers

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Work, Stress and Lifestyle

•Whitehall II cohort found that a dose response relationship between obesity and chronic work stress (controlled for physical activity etc)•Greater exposure to stress being associated with increased odds of general obesity (BMI ≥ 30 kg/m2) and central obesity (waist circumference >102 cm in men and >88 cm in women)

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Example 2: Unemployment

•Mortality rates double•Suicide up to 10 times•Mental health problems and long term illnesses•Worse health behaviours •Dual mechanisms – psychological and poverty

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Unemployment & Health Inequalities• Unemployment concentrated in lower socio-economic classes• Census 2001 in London, 81.5% of women with a degree were

employed compared to 51.8% with no qualifications.

• Modelling suggests that adjusting for employment status reduces health inequalities by up to 81%

• 5.6.% ill health in men home owners, 19.1% in social renting (13% age-adjusted difference), adjust for employment status = 2.5% difference (81% reduction)

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Level 4 / 5 Level 3 Level 2 Level 1 Otherqualifications

No qualifications

Education

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Age only Age plus employment status

Educational gradient (prevalence difference in % points) in self rated general health with and without adjustment for employment status (Women), Census 2001

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Unemployment and Lifestyles

•Unemployment also increases the likelihood of hazardous health behaviours such as smoking or excess alcohol consumption. •Particularly the case amongst young men. •1958 British Birth Cohort found that the risk of smoking and problem drinking increased after unemployment •Those who had been unemployed in the last year were 3 times more likely to smoke and 2 times more likely to drink heavily or have a drink problem

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3. Life chances: Labour Policy Successes

• Housing: more social housing built• Health care: increased NHS spending, shorter waiting lists and

improved outcomes, more GPs in deprived areas• Education: new schools built, more teachers, Surestart Centres• Work and unemployment: minimum wage, increased

employment levels and Future Jobs Fund, flexible working, increased employment rights

• Food policy: health in pregnancy grant• Environment: smoking ban

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Infant mortality rates in England: routine and manual socio-economic group compared with average

Labour target: cut relative inequalities in infant mortality rates between manual socio-economic groups and the English average by 10% from 13% to 12%.

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4. Marmot Review

• Importance of life chances captured in the Labour government commissioned Marmot Review.

• Six Policy Objectives:

1. Give every child the best start in life

2. Enable all children, young people and adults to maximise their capabilities and have control over their lives

3. Create fair employment and good work for all

4. Ensure healthy standard of living for all

5. Create and develop healthy and sustainable places and communities

6. Strengthen the role and impact of ill-health prevention

• Coalition policy focuses on 4 and 6 - lifestyle elements (e.g. responsibility deal, White Paper talks about individual lifestyles, nudge etc)

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5. Three Principles for Policy

Dignity – in and out of work Labour success: Minimum wage Evidenced-based future option: Minimum Income for Healthy Living (or

Living Wage)

The public provision of a minimum income to meet basic and social needs relating to nutrition, physical activity, housing, psychosocial interactions, transport, medical care and hygiene.

The MIHL for an older single person would be around £144.20 per week (UK, 2008 prices). This was higher than the 60% of median income poverty line (£115 per week), and more than the minimum pension credit (£124.05 per week).

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Equity – provision for all with more for the most in need Labour success: minimum pension credit Evidenced-based future option: proportionate universalism

Intention of improving the health of all, but the health of the poorest the most.

Interventions are universal ‘but with a scale and intensity that is proportionate to the level of disadvantage’ - proportionate universalism.

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Authority – control at work and in the community Labour success: right to flexible working Evidence-based future option: increased control and participation at

work

Increasing control at work via employee participation and representation in workplace committees – “participatory” or “problem-solving” committees

Control over hours of work

Control in the community – increased social participation has health benefits

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6. Concluding Comment

Socio-economicStatus

(income/Education/occupation)

HealthInequalities

Health Behaviours

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7. References

Bambra (2011) Work, Worklessness and the Political Economy of Health

Bambra (2012)

Brunner et al (2007) Prospective Effect of Job Strain on General and Central Obesity in the Whitehall II Study. American Journal of Epidemiology, 165, 828–37

Egan et al (2007) The psychosocial and health effects of workplace reorganisation 1: a systematic review of organisational-level interventions that aim to increase employee control. Journal of Epidemiology and Community Health, 61, 945–54

Marmot Review (2010) Strategic Review of Health Inequalities in England post-2010.

Marmot et al (1997) Contribution of job control and other risk factors to social variations in coronary heart disease. Lancet, 350, 235-40

Montgomery et al (1999) Unemployment, cigarette smoking, alcohol consumption and body weight in young British men. European Journal of Public Health, 8, 21-27

Morris et al (2009) Defining a minimum income for healthy living (MIHL): older age, England. International Journal of Epidemiology, 36, 1300-07

Popham and Bambra (2010) Evidence from the 2001 English Census on the contribution of employment status to the social gradient in self-rated health. Journal of Epidemiology and Community Health, 64, 277-80