the solid facts social determinants of health

8/10/2019 The Solid Facts Social Determinants of Health

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InternationalCentre forHealth andSociety

SOCIAL

DETERMINANTS

OF HEALTH


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SOCIAL

DETERMINANTS

OF HEALTH

SECOND EDITION

THETHESOLIDSOLIDF TSFACTS


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WHO Library Cataloguing in Publication Data

Social determinants of health: the solid facts. 2ndedition / 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 promotion8.Europe I.Wilkinson, Richard II.Marmot, Michael.

ISBN 92 890 1371 0 (NLM Classification : WA 30)

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PublicationsWHO Regional Office for EuropeScherfigsvej 8DK-2100 Copenhagen , Denmark

World Health Organization 2003

All 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 do

ISBN 92 890 1371 0


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Foreword 5

Contributors 6

Introduction 7

1. The social gradient 10

2. Stress 12

3. Early life 14

4. Social exclusion 16

5. Work 18

6. Unemployment 20

7. Social support 22

8. Addiction 24

9. Food 26

10. Transport 28

WHO and other important sources 30

C O N T E N T S


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The World Health Organization was established in 1948

as a specialized agency of the United Nations serving asthe directing and coordinating authority for internationalhealth matters and public health. One of WHOsconstitutional 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 and

post-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, WHOs books contribute to achieving the

Organizations principal objective the attainment by allpeople of the highest possible level of health.

WHO Centre for Urban Health

This 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 health

policy, integrated planning for health and sustainabledevelopment, urban planning, governance and socialsupport. The Centre is responsible for the Healthy Citiesand urban governance programme.


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The need and demand for clear scientificevidence to inform and support the health policy-making process are greater than ever. The fieldof the social determinants of health is perhapsthe most complex and challenging of all. It isconcerned with key aspects of peoples living andworking circumstances and with their lifestyles.It is concerned with the health implications ofeconomic and social policies, as well as with the

benefits that investing in health policies can bring.In the past five years, since the publication of thefirst edition of Social determinants of health. Thesolid factsin 1998, new and stronger scientificevidence has been developed. This second editionintegrates the new evidence and is enriched withgraphs, further reading and recommended web

sites.

Our goal is to promote awareness, informeddebate and, above all, action. We want to buildon 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 developing

policies and programmes that explicitly address the

root causes of ill health, health inequalities and theneeds of those who are affected by poverty andsocial disadvantage.

This publication was achieved through closepartnership between the WHO Centre for UrbanHealth and the International Centre for Healthand Society, University College London, UnitedKingdom. I should like to express my gratitudeto Professor Richard Wilkinson and ProfessorSir Michael Marmot, who edited the publication,and to thank all the members of the scientific teamwho contributed to this important piece of work.

I am convinced that it will be a valuable tool forbroadening the understanding of and stimulatingdebate and action on the social determinants ofhealth.

Agis D. Tsouros

Head, Centre for Urban HealthWHO Regional Office for Europe

F O R E W O R D


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Professor Mel Bartley, University College London,United Kingdom

Dr David Blane, Imperial College London, UnitedKingdom

Dr Eric Brunner, International Centre for Health andSociety, University College London, United Kingdom

Professor Danny Dorling, School of Geography,University of Leeds, United Kingdom

Dr Jane Ferrie, University College London, UnitedKingdom

Professor Martin Jarvis, Cancer Research UK, HealthBehaviour Unit, University College London, UnitedKingdom

Professor Sir Michael Marmot, Department ofEpidemiology and Public Health and International

Centre for Health and Society, University CollegeLondon, United Kingdom

Professor Mark McCarthy, University College London,United Kingdom

Dr Mary Shaw, Department of Social Medicine, BristolUniversity, United Kingdom

Professor Aubrey Sheiham, International Centre for

Health and Society, University College London, UnitedKingdom

Professor Stephen Stansfeld, Barts and The London,Queen Marys School of Medicine and Dentistry,London

Professor Mike Wadsworth, Medical Research Council,National Survey of Health and Development, UniversityCollege London, United Kingdom

Professor Richard Wilkinson, University of Nottingham,United Kingdom

C O N T R I B U T O R S


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I N T R O D U C T I O N

Even in the most affluent countries, peoplewho are less well off have substantially shorterlife expectancies and more illnesses than therich. Not only are these differences in health animportant social injustice, they have also drawnscientific attention to some of the most powerfuldeterminants of health standards in modernsocieties. They have led in particular to a growingunderstanding of the remarkable sensitivity of

health to the social environment and to whathave become known as the social determinants ofhealth.

This publication outlines the most important partsof this new knowledge as it relates to areas ofpublic policy. The ten topics covered include thelifelong importance of health determinants inearly childhood, and the effects of poverty, drugs,

working conditions, unemployment, social support,good food and transport policy. To provide thebackground, we start with a discussion of the socialgradient in health, followed by an explanationof how psychological and social influences affectphysical health and longevity.

In each case, the focus is on the role that publicpolicy can play in shaping the social environment

in ways conducive to better health: that focus ismaintained whether we are looking at behaviouralfactors, such as the quality of parenting, nutrition,exercise and substance abuse, or at more structuralissues such as unemployment, poverty and theexperience of work. Each of the chapters containsa brief summary of what has been most reliablyestablished by research, followed by a list ofimplications for public policy. A few key referencesto the research are listed at the end of eachchapter, but a fuller discussion of the evidence

can be found in Social determinants of health(Marmot M, Wilkinson RG, eds. Oxford, OxfordUniversity Press, 1999), which was prepared toaccompany the first edition of Social determinantsof health. The solid facts. For both publications,we are indebted to researchers in the forefrontof their fields, most of whom are associated withthe International Centre for Health and Society atUniversity College London. They have given their

time and expertise to draft the different chaptersof both these publications.

Health policy was once thought to be about littlemore than the provision and funding of medicalcare: the social determinants of health werediscussed only among academics. This is nowchanging. While medical care can prolong survivaand improve prognosis after some serious diseases

more important for the health of the populationas a whole are the social and economic conditionsthat make people ill and in need of medicalcare in the first place. Nevertheless, universalaccess to medical care is clearly one of the socialdeterminants of health.

Why also, in a new publication on the determinanof health, is there nothing about genes? The

new discoveries on the human genome areexciting in the promise they hold for advancesin the understanding and treatment of specificdiseases. But however important individualgenetsusceptibilities to disease may be, the commoncauses of the ill health that affectspopulationsareenvironmental: they come and go far more quicklythan the slow pace of genetic change because thereflect the changes in the way we live. This is whylife expectancy has improved so dramatically overrecent generations; it is also why some European


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countries have improved their health while othershave not, and it is why health differences betweendifferent social groups have widened or narrowedas social and economic conditions have changed.

The evidence on which this publication is basedcomes from very large numbers of researchreports many thousands in all. Some of thestudies have used prospective methods, sometimesfollowing tens of thousands of people over

decades sometimes from birth. Others haveused cross-sectional methods and have studiindividual, area, national or international daDifficulties that have sometimes arisen (perhdespite follow-up studies) in determining cahave been overcome by using evidence fromintervention studies, from so-called naturalexperiments, and occasionally from studies oother primate species. Nevertheless, as both and the major influences on it vary substanti

Peoples

lifestyles andthe conditionsin whichthey live andwork stronglyinfluence theirhealth.

HEALTHYCITIESPROJECT/WHO


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according to levels of economic development, the

reader should keep in mind that the bulk of theevidence on which this publication is based comesfrom rich developed countries and its relevance toless developed countries may be limited.

Our intention has been to ensure that policy atall levels in government, public and privateinstitutions, workplaces and the community takes

proper account of recent evidence suggesting awider responsibility for creating healthy societies.But a publication as short as this cannot providea comprehensive guide to determinants of publichealth. Several areas of health policy, such asthe need to safeguard people from exposure totoxic materials at work, are left out because theyare well known (though often not adequatelyenforced). As exhortations to individual behaviour

change are also a well established approach tohealth promotion, and the evidence suggests theymay sometimes have limited effect, there is littleabout what individuals can do to improve theirown health. We do, however, emphasize the needto understand how behaviour is shaped by theenvironment and, consistent with approachinghealth through its social determinants, recommendenvironmental changes that would lead to

healthier 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 more

just 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

social meanings. It is not simply that poor materia

circumstances are harmful to health; the socialmeaning of being poor, unemployed, sociallyexcluded, or otherwise stigmatized also matters.As social beings, we need not only good materialconditions but, from early childhood onwards,we need to feel valued and appreciated. We needfriends, we need more sociable societies, we needto feel useful, and we need to exercise a significan

degree of control over meaningful work. Withoutthese we become more prone to depression, druguse, anxiety, hostility and feelings of hopelessnesswhich all rebound on physical health.

We hope that by tackling some of the materialand social injustices, policy will not only improvehealth and well-being, but may also reduce a rangof other social problems that flourish alongside

ill health and are rooted in some of the samesocioeconomic processes.

Richard Wilkinson and Michael Marmot


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Life expectancy is shorter and most diseases are

more common further down the social ladder ineach society. Health policy must tackle the socialand economic determinants of health.

What is known

Poor social and economic circumstances affecthealth throughout life. People further down thesocial ladder usually run at least twice the risk of

serious illness and premature death as those nearthe top. Nor are the effects confined to the poor:the social gradient in health runs right acrosssociety, so that even among middle-class officeworkers, lower ranking staff suffer much moredisease and earlier death than higher ranking staff(Fig. 1).

Both material and psychosocial causes contri

these differences and their effects extend todiseases and causes of death.

Disadvantage has many forms and may be abor relative. It can include having few family ahaving a poorer education during adolescenhaving insecure employment, becoming stuchazardous or dead-end job, living in poor hotrying to bring up a family in difficult circum

and living on an inadequate retirement pens

These disadvantages tend to concentrate amthe same people, and their effects on healthaccumulate during life. The longer people livstressful economic and social circumstances, greater the physiological wear and tear theyand the less likely they are to enjoy a healthyage.

Policy implications

If policy fails to address these facts, it not onignores the most powerful determinants of hstandards in modern societies, it also ignoresof the most important social justice issues facmodern societies.

Life contains a series of critical transitions

emotional and material changes in earlychildhood, the move from primary to secoeducation, starting work, leaving home anstarting a family, changing jobs and facingpossible redundancy, and eventually retireEach of these changes can affect health bypushing people onto a more or less advanpath. Because people who have beendisadvantaged in the past are at the greatin each subsequent transition, welfare poneed to provide not only safety nets but aspringboards to offset earlier disadvantag

Professional

Skilled non-manual

Managerialand technical

64LIFE EXPECTANCY (YEARS)

Skilledmanual

Partly skilledmanual

Unskilledmanual

Men Women

66 68 70 72 74 76 78 80 82 84

OCCUPATIONALCLASS

1 . T H E S O C I A L G R A D I E N T

Fig. 1. Occupational class differences in lifeexpectancy, England and Wales, 19971999


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KEY SOURCES

Bartley M, Plewis I. Accumulated labour market disadvantage andlimiting long-term illness. International Journal of Epidemiology,2002, 31:336341.

Mitchell R, Blane D, Bartley M. Elevated risk of high blood pressure:climate and the inverse housing law. International Journal ofEpidemiology,2002, 31:831838.

Montgomery SM, Berney LR, Blane D. Prepubertal stature andblood pressure in early old age. Archives of Disease in Childhood,2000, 82:358363.

Morris JN et al. A minimum income for healthy living. Journal ofEpidemiology and Community Health,2000, 54:885889.

Good health involves

reducing levels ofeducational failure,reducing insecurityand unemploymentand improving housingstandards. Societies thatenable all citizens to plaa full and useful rolein the social, economicand cultural life of theirsociety will be healthierthan those where peoplface insecurity, exclusionand deprivation.

Other chapters of thispublication cover specifipolicy areas and suggest

ways of improving healtthat will also reduce thesocial gradient in health

Programme Committee on Socio-economic Inequalities in Health(SEGV-II). Reducing socio-economic inequalities in health.TheHague, Ministry of Health, Welfare and Sport, 2001.

van de Mheen H et al. Role of childhood health in the explanationof socioeconomic inequalities in early adult health. Journal ofEpidemiology and Community Health,1998, 52:1519.

Source of Fig. 1:Donkin A, Goldblatt P, Lynch K. Inequalities in lifeexpectancy by social class 19721999. Health Statistics Quarterly,2002, 15:515.

Poor social and economic circumstances affect health throughout life.JOACHIMLADEFOG

ED/POLFOTO


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Stressful circumstances, making people feel

worried, anxious and unable to cope, aredamaging to health and may lead to prematuredeath.

What is known

Social and psychological circumstances can causelong-term stress. Continuing anxiety, insecurity,low self-esteem, social isolation and lack of control

over work and home life, have powerful effects onhealth. Such psychosocial risks accumulate duringlife and increase the chances of poor mental healthand premature death. Long periods of anxiety and

insecurity and the lack of supportive friendsh

are damaging in whatever area of life they aThe lower people are in the social hierarchy industrialized countries, the more common tproblems become.

Why do these psychosocial factors affect phyhealth? In emergencies, our hormones and nsystem prepare us to deal with an immediatephysical threat by triggering the fight or flig

response: raising the heart rate, mobilizing senergy, diverting blood to muscles and increalertness. Although the stresses of modern ulife rarely demand strenuous or even modera

Lack of controlover work andhome can have

powerful effectson health.

RIKKESTEENV

INKELNORDENHOF/POLFOTO

2 . S T R E S S


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KEY SOURCES

Brunner EJ. Stress and the biology of inequality. British MedicalJournal,1997, 314:14721476.

Brunner EJ et al. Adrenocortical, autonomic and inflammatorycauses of the metabolic syndrome.Circulation,2002, 106:26592665.

Kivimaki M et al. Work stress and risk of cardiovascularmortality: prospective cohort study of industrial employees.British Medical Journal,2002, 325:857860.

Marmot MG, Stansfeld SA. Stress and heart disease.London,BMJ Books, 2002.

Marmot MG et al. Contribution of job control and other riskfactors to social variations in coronary heart disease incidence.Lancet,1997, 350:235239.

physical activity, turning on the stress response

diverts energy and resources away from manyphysiological processes important to long-termhealth maintenance. Both the cardiovascular andimmune systems are affected. For brief periods, thisdoes not matter; but if people feel tense too oftenor the tension goes on for too long, they becomemore vulnerable to a wide range of conditionsincluding infections, diabetes, high blood pressure,heart attack, stroke, depression and aggression.

Policy implications

Although a medical response to the biologicalchanges that come with stress may be to try tocontrol them with drugs, attention should befocused upstream, on reducing the major causes ochronic stress.

In schools, workplaces and other institutions, thquality of the social environment and materialsecurity are often as important to health asthe physical environment. Institutions that cangive people a sense of belonging, participatingand being valued are likely to be healthierplaces than those where people feel excluded,disregarded and used.

Governments should recognize that welfareprogrammes need to address both psychosocialand material needs: both are sources of anxiety

and insecurity. In particular, governments shoulsupport families with young children, encouragcommunity activity, combat social isolation,reduce material and financial insecurity,and promote coping skills in education andrehabilitation.


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Important foundations of adult health are laid in early childhood.

FINNFRANDSEN/POLFOTO

A good start in life means supporting mothers

and young children: the health impact of earlydevelopment and education lasts a lifetime.

What is known

Observational research and intervention studiesshow that the foundations of adult health are laidin early childhood and before birth. Slow growthand poor emotional support raise the lifetimerisk of poor physical health and reduce physical,cognitive and emotional functioning in adulthood.Poor early experience and slow growth becomeembedded in biology during the processes ofdevelopment, and form the basis of the individuals

health because of the continued malleability

biological systems. As cognitive, emotional asensory inputs programme the brains responinsecure emotional attachment and poorstimulation can lead to reduced readiness foschool, low educational attainment, and probehaviour, and the risk of social marginalizatin adulthood. Good health-related habits, sueating sensibly, exercising and not smoking, associated with parental and peer group exaand with good education. Slow or retarded pgrowth in infancy is associated with reducedcardiovascular, respiratory, pancreatic and kidevelopment and function, which increase tof illness in adulthood.

3 . E A R L Y L I F E

biological and humancapital, which affectshealth throughout

life.Poor circumstancesduring pregnancycan lead to lessthan optimal fetaldevelopment viaa chain that mayinclude deficiencies

in nutrition duringpregnancy, maternalstress, a greaterlikelihood of maternalsmoking and misuseof drugs and alcohol,insufficient exerciseand inadequateprenatal care. Poor

fetal development is arisk for health in laterlife (Fig. 2).

Infant experience isimportant to later


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Policy implicationsThese risks to the developing child are significantlygreater among those in poor socioeconomiccircumstances, and they can best be reducedthrough improved preventive health care beforethe first pregnancy and for mothers and babies inpre- and postnatal, infant welfare and school clinics,and through improvements in the educational levelsof parents and children. Such health and educationprogrammes have direct benefits. They increaseparents awareness of their childrens needs andtheir receptivity to information about health anddevelopment, and they increase parental confidencein their own effectiveness.

KEY SOURCES

Barker DJP. Mothers, babies and disease in later life, 2nd ed.Edinburgh, Churchill Livingstone, 1998.

Keating DP, Hertzman C, eds. Developmental health and thewealth of nations.New York, NY, Guilford Press, 1999.

Mehrotra S, Jolly R, eds.Development with a human face.Oxford, Oxford University Press, 2000.

Rutter M, Rutter M. Developing minds: challenge andcontinuity across the life span.London, Penguin Books, 1993.

Wallace HM, Giri K, Serrano CV, eds.Health care of women andchildren in developing countries,2nd ed. Santa Monica, CA,Third Party Publishing, 1995.

Source of Fig. 2:Barker DJP. Mothers, babies and disease inlater life, 2nd ed. Edinburgh, Churchill Livingstone, 1998.

Policies for improving health in early life should

aim to:

increase the general level of educationand provide equal opportunity of access toeducation, to improve the health of mothersand babies in the long run;

provide good nutrition, health education,and health and preventive care facilities, andadequate social and economic resources, beforefirst pregnancies, during pregnancy, and ininfancy, to improve growth and developmentbefore birth and throughout infancy, andreduce the risk of disease and malnutrition ininfancy; and

ensure that parentchild relations aresupported from birth, ideally through homevisiting and the encouragement of good

parental relations with schools, to increaseparental knowledge of childrens emotionaland cognitive needs, to stimulate cognitivedevelopment and pro-social behaviour in thechild, and to prevent child abuse.

7

6

5

4

3

2

1

0

RISKOFDIABETES(WITHBIRTHWEIGHT>4.3

KG

SETAT1)

BIRTH WEIGHT (KG)

4.3

Fig. 2. Risk of diabetes in men aged 64 years by

birth weightAdjusted for body mass index


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Life is short where its quality is poor. By causing

hardship and resentment, poverty, social exclusionand discrimination cost lives.

What is known

Poverty, relative deprivation and social exclusionhave a major impact on health and prematuredeath, and the chances of living in poverty areloaded heavily against some social groups.

Absolute poverty a lack of the basic materialnecessities of life continues to exist, even in therichest countries of Europe. The unemployed, manyethnic minority groups, guest workers, disabledpeople, refugees and homeless people are at

4 . S O C I A L E X C L U S I O N

particular risk. Those living on the streets suf

highest rates of premature death.

Relative poverty means being much poorer tmost people in society and is often defined aon less than 60% of the national median incodenies people access to decent housing, edutransport and other factors vital to full particin life. Being excluded from the life of societtreated as less than equal leads to worse hea

and greater risks of premature death. The stof living in poverty are particularly harmful dpregnancy, to babies, children and old peopsome countries, as much as one quarter of thpopulation and a higher proportion of chil live in relative poverty (Fig. 3).

People living on the streets suffer the highest ratesof premature death.

JANGRARUP/POLFOTO

Social exclusion also results from racismdiscrimination, stigmatization, hostility

unemployment. These processes prevenpeople from participating in educationtraining, and gaining access to services citizenship activities. They are socially apsychologically damaging, materially cand harmful to health. People who liveor have left, institutions, such as prisonchildrens homes and psychiatric hospitare particularly vulnerable.

The greater the length of time that peolive in disadvantaged circumstances, thmore likely they are to suffer from a rahealth problems, particularly cardiovasdisease. People move in and out of povduring their lives, so the number of peowho experience poverty and social exclduring their lifetime is far higher than t

current number of socially excluded pePoverty and social exclusion increase thrisks of divorce and separation, disabiliillness, addiction and social isolation an


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vice versa, forming vicious circles that deepen thepredicament people face.

As well as the direct effects of being poor, healthcan also be compromised indirectly by living inneighbourhoods blighted by concentrations ofdeprivation, high unemployment, poor qualityhousing, limited access to services and a poorquality environment.

Policy implications

Through policies on taxes, benefits, employment,

education, economic management, and manyother areas of activity, no government can avoidhaving a major impact on the distribution ofincome. The indisputable evidence of the effects of

such policies on rates of death and disease impose

a public duty to eliminate absolute poverty andreduce material inequalities.

All citizens should be protected by minimumincome guarantees, minimum wages legislationand access to services.

Interventions to reduce poverty and socialexclusion are needed at both the individual andthe neighbourhood levels.

Legislation can help protect minority andvulnerable groups from discrimination and sociaexclusion.

Public health policies should remove barriersto health care, social services and affordablehousing.

Labour market, education and family welfare

policies should aim to reduce social stratificatio

Fig. 3. Proportion of children living in poor

households (below 50% of the national averageincome)

KEY SOURCES

Claussen B, Davey Smith G, Thelle D. Impact of childhoodand adulthood socio-economic position on cause specificmortality: the Oslo Mortality Study. Journal of Epidemiologyand Community Health,2003, 57:4045.

Kawachi I, Berkman L, eds.Neighborhoods and health.Oxford,Oxford University Press, 2003.

Mackenbach J, Bakker M, eds. Reducing inequalities in health:a European perspective.London, Routledge, 2002.

Shaw M, Dorling D, Brimblecombe N. Life chances in Britain byhousing wealth and for the homeless and vulnerably housed.Environment and Planning A,1999, 31:22392248.

Townsend P, Gordon D. World poverty: new policies to defeatan old enemy.Bristol, The Policy Press, 2002.

Source of Fig. 3:Bradshaw J. Child poverty in comparativeperspective. In: Gordon D, Townsend P. Breadline Europe: themeasurement of poverty. Bristol, The Policy Press, 2000.

CzechRepublic

Slova

kia

Finla

nd

Swed

en

Norw

ay

Belgium

Denmark

Netherlands

Hungary

Germany

It

aly

Isr

ael

Cana

da

Spain

Pola

nd

UnitedKingdom

RussianFederation

U

SA

PROPORTION(%)

30

25

20

15

10

5

0


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Stress in the workplace increases the risk of

disease. People who have more control over theirwork have better health.

What is known

In general, having a job is better for health thanhaving no job. But the social organization of work,management styles and social relationships in theworkplace all matter for health. Evidence shows

that stress at work plays an important role incontributing to the large social status differencesin health, sickness absence and premature death.Several European workplace studies show thathealth suffers when people have little opportunityto use their skills and low decision-makingauthority.

Having little control over ones work is partic

strongly related to an increased risk of lowback pain, sickness absence and cardiovasculdisease (Fig. 4). These risks have been found independent of the psychological characteriof the people studied. In short, they seem torelated to the work environment.

Studies have also examined the role of workdemands. Some show an interaction betwee

demands and control. Jobs with both high dand low control carry special risk. Some evideindicates that social support in the workplacbe protective.

Further, receiving inadequate rewards for theffort put into work has been found to beassociated with increased cardiovascular riskRewards can take the form of money, status

self-esteem. Current changes in the labour mmay change the opportunity structure, and mharder for people to get appropriate reward

These results show that the psychosocialenvironment at work is an important determof health and contributor to the social gradiill health.

Policy implications

There is no trade-off between health andproductivity at work. A virtuous circle can established: improved conditions of work lead to a healthier work force, which will to improved productivity, and hence to thopportunity to create a still healthier, morproductive workplace.

Appropriate involvement in decision-makis likely to benefit employees at all levels oorganization. Mechanisms should therefobe developed to allow people to influencethe design and improvement of their wor

Fig. 4. Self-reported level of job control andincidence of coronary heart disease in men andwomen

5 . W O R K

Adjusted forage, sex, lengthof follow-up,effort/rewardimbalance,

employmentgrade, coronaryrisk factorsand negativepsychologicaldisposition

RISKOFCORONARYHEARTDISEASE(WITHHIGHJ

OBCONTROLSETAT1.0)

2.5

2.0

1.5

1.0

JOB CONTROL

High Intermediate Low


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Jobs with both highdemand and low controlcarry special risk.

FIRSTLIGHT

KEY SOURCES

Bosma H et al. Two alternative job stress models and risk ofcoronary heart disease. American Journal of Public Health,1998,88:6874.

Hemingway H, Kuper K, Marmot MG. Psychosocial factors in theprimary and secondary prevention of coronary heart disease: anupdated systematic review of prospective cohort studies. In:Yusuf S et al., eds. Evidence-based cardiology,2nd ed. London,BMJ Books, 2003:181217.

Marmot MG et al. Contribution of job control to social gradient incoronary heart disease incidence.Lancet,1997, 350:235240.

Peter R et al. and the SHEEP Study Group. Psychosocial workenvironment and myocardial infarction: improving risk estimation

Good management involves ensuring

appropriate rewards in terms of money, statusand self-esteem for all employees.

by combining two complementary job stress models in the SHEEPStudy. Journal of Epidemiology and Community Health,2002,56(4):294300.

Schnall P et al. Why the workplace and cardiovascular disease?Occupational Medicine, State of the Art Reviews,2000, 15:126.

Theorell T, Karasek R. The demand-control-support model and CVD.In: Schnall PL et al., eds. The workplace and cardiovascular disease.Occupational medicine.Philadelphia, Hanley and Belfus Inc., 2000:7883.

Source of Fig. 4:Bosma H et al. Two alternative job stress modelsand risk of coronary heart disease. American Journal of PublicHealth, 1998, 88:6874.

environment, thus enabling employees to

have more control, greater variety and moreopportunities for development at work.

To reduce the burdenof musculoskeletaldisorders, workplacesmust be ergonomicallyappropriate.

As well as requiring aneffective infrastructurewith legal controls andpowers of inspection,workplace healthprotection should alsoinclude workplace healthservices with peopletrained in the early

detection of mental healtproblems and appropriateinterventions.


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6 . U N E M P L O Y M E N T

Job security increases health, well-being and job

satisfaction. Higher rates of unemployment causemore illness and premature death.

What is known

Unemployment puts health at risk, and the riskis higher in regions where unemployment iswidespread. Evidence from a number of countriesshows that, even after allowing for other factors,

unemployed people and their families suffer asubstantially increased risk of premature death.The health effects of unemployment are linkedto both its psychological consequences and

effects on mental health (particularly anxiety

depression), self-reported ill health, heart diand risk factors for heart disease. Because veunsatisfactory or insecure jobs can be as harmunemployment, merely having a job will notprotect physical and mental health: job qualalso important (Fig. 5).

During the 1990s, changes in the economies labour markets of many industrialized count

increased feelings of job insecurity. As jobinsecurity continues, it acts as a chronic stresswhose effects grow with the length of exposincreases sickness absence and health service

Unemployedpeople and theirfamilies suffer amuch higher riskof prematuredeath.

REUTER/POLFOTO

the financialproblems it brings especially debt.

The health effects

start when peoplefirst feel their jobsare threatened,even before theyactually becomeunemployed. Thisshows that anxietyabout insecurity isalso detrimental

to health. Jobinsecurity hasbeen shownto increase


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KEY SOURCES

Beale N, Nethercott S. Job-loss and family morbidity: a studyof a factory closure. Journal of the Royal College of GeneralPractitioners,1985, 35:510514.

Bethune A. Unemployment and mortality. In: Drever F,Whitehead M, eds.Health inequalities.London, H.M.Stationery Office, 1997.

Burchell, B. The effects of labour market position, jobinsecurity, and unemployment on psychological health.In: Gallie D, Marsh C, Vogler C, eds. Social change and theexperience of unemployment.Oxford, Oxford University Press,1994:188212.

Ferrie J et al., eds.Labour market changes and job insecurity:a challenge for social welfare and health promotion.Copenhagen, WHO Regional Office for Europe, 1999 (WHORegional Publications, European Series, No. 81) (http://www.euro.who.int/document/e66205.pdf, accessed 15

August 2003).Iversen L et al. Unemployment and mortality in Denmark.British Medical Journal,1987, 295:879884.

Source of Fig. 5:Ferrie JE et al. Employment status and healthafter privatisation in white collar civil servants: prospectivecohort study. British Medical Journal, 2001, 322:647651.

Fig. 5. Effect of job insecurity and unemploymenton health

Policy implications

Policy should have three goals: to preventunemployment and job insecurity; to reduce thehardship suffered by the unemployed; and torestore people to secure jobs.

Government management of the economy toreduce the highs and lows of the business cyclecan make an important contribution to jobsecurity and the reduction of unemployment.

Limitations on working hours may also bebeneficial when pursued alongside job securityand satisfaction.

Unemployed

RISKOFILLHEALTH(WITHSECURELYEMPLOYEDSETAT100)

Long-standing illness

Poor mental health

EMPLOYMENT STATUS

Securelyemployed

Insecurelyemployed

300

250

200

150

100

50

0

To equip people for the work available, high

standards of education and good retrainingschemes are important.

For those out of work, unemployment benefitsset at a higher proportion of wages are likely tohave a protective effect.

Credit unions may be beneficial by reducingdebts and increasing social networks.


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Friendship, good social relations and strong

supportive networks improve health at home, atwork and in the community.

What is known

Social support and good social relations make animportant contribution to health. Social supporthelps give people the emotional and practicalresources they need. Belonging to a social network

of communication and mutual obligation makespeople feel cared for, loved, esteemed and valued.This has a powerful protective effect on health.Supportive relationships may also encouragehealthier behaviour patterns.

Support operates on the levels both of theindividual and of society. Social isolation andexclusion are associated with increased rates of

7 . S O C I A L S U P P O R T

premature death and poorer chances of surv

after a heart attack (Fig. 6). People who getless social and emotional support from otherare more likely to experience less well-beingmore depression, a greater risk of pregnancycomplications and higher levels of disabilityfrom chronic diseases. In addition, bad closerelationships can lead to poor mental and phhealth.

The amount of emotional and practical sociasupport people get varies by social and econstatus. Poverty can contribute to social excluand isolation.

Social cohesion defined as the quality of sorelationships and the existence of trust, mutobligations and respect in communities or inwider society helps to protect people and t

health. Inequality is corrosive of goodrelations. Societies with high levels ofinequality tend to have less social cohand more violent crime. High levels ofmutual support will protect health whbreakdown of social relations, sometifollowing greater inequality, reduces and increases levels of violence. A studcommunity with initially high levels of

cohesion showed low rates of coronadisease. When social cohesion declinedisease rates rose.

Policy implications

Experiments suggest that good socialrelations can reduce the physiologicaresponse to stress. Intervention studie

shown that providing social support cimprove patient recovery rates from sdifferent conditions. It can also impropregnancy outcome in vulnerable growomen.Belonging to a social network makes people feel cared for.

FOTOKHRONIKA/POLFOTO


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Eastern Finland

AGE-ADJUSTEDMORTALITYRATE

Females Males

LEVEL OF SOCIAL INTEGRATION LEVEL OF SOCIAL INTEGRATIONLow

Evans County, USA (blacks)

EvansCounty,USA (whites)

Gothenburg, Sweden

Tecumseh, USA

Evans County, USA (whites)

Alameda County,USA

Eastern Finland

Evans County, USA (blacks)

Alameda County,USA

Tecumseh, USA

High Low High

0.5

0.4

0.3

0.2

0.1

0

KEY SOURCES

Fig. 6. Level of social integration and mortality in five prospective studies

Reducing social and economic inequalities andreducing social exclusion can lead to greater socialcohesiveness and better standards of health.

Improving the social environment in schools, inthe workplace and in the community more widely,will help people feel valued and supported inmore areas of their lives and will contribute totheir health, especially their mental health.

Designing facilities to encourage meeting andsocial interaction in communities could improvemental health.

In all areas of both personal and institutionallife, practices that cast some as socially inferior oless valuable should be avoided because they arsocially divisive.

Berkman LF, Syme SL. Social networks, host resistance andmortality: a nine year follow-up of Alameda County residents.American Journal of Epidemiology,1979, 109:186204.

Hsieh CC, Pugh MD. Poverty, income inequality, and violent crime:a meta-analysis of recent aggregate data studies. Criminal JusticeReview,1993, 18:182202.

Kaplan GA et al. Social connections and mortality from all causesand from cardiovascular disease: prospective evidence fromeastern Finland. American Journal of Epidemiology,1988, 128:370380.

Kawachi I et al. A prospective study of social networks in relation tototal mortality and cardiovascular disease in men in the USA. Journalof Epidemiology and Community Health,1996, 50(3):245251.

Oxman TE et al. Social support and depressive symptoms in theelderly. American Journal of Epidemiology,1992, 135:356368.

Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violentcrime: a multilevel study of collective efficacy.Science, 1997, 277:918924.

Source of Fig. 6:House JS, Landis KR, Umberson D. Socialrelationships and health. Science, 1988, 241:540545.

0.5

0.4

0.3

0.2

0.1

0


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The irony is that, apart from a temporary rel

from reality, alcohol intensifies the factors thto its use in the first place.

The same is true of tobacco. Social deprivatio whether measured by poor housing, low inlone parenthood, unemployment or homele is associated with high rates of smoking anlow rates of quitting. Smoking is a major draon poor peoples incomes and a huge cause o

health and premature death. But nicotine ofreal relief from stress or improvement in mo

The use of alcohol, tobacco and illicit drugs ifostered by aggressive marketing and promoby major transnational companies and byorganized crime. Their activities are a major to policy initiatives to reduce use among youpeople; and their connivance with smuggling

8 . A D D I C T I O N

Individuals turn to alcohol, drugs and tobacco and

suffer from their use, but use is influenced by thewider social setting.

What is known

Drug use is both a response to social breakdownand an important factor in worsening the resultinginequalities in health. It offers users a mirage ofescape from adversity and stress, but only makes

their problems worse.Alcohol dependence, illicit drug use and cigarettesmoking are all closely associated with markersof social and economic disadvantage (Fig. 7). Insome of the transition economies of central andeastern Europe, for example, the past decade hasbeen a time of great social upheaval. Consequently,deaths linked to alcohol use such as accidents,

People turn to alcohol,

drugs and tobacco tonumb the pain of harsheconomic and socialconditions.

TEITHORNBAK

/POLFOTO

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.


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KEY SOURCES

Fig. 7. Socioeconomic deprivation and risk of

dependence on alcohol, nicotine and drugs, GreatBritain, 1993

Bobak M et al. Poverty and smoking. In: Jha P, Chaloupka F, eds.Tobacco control in developing countries.Oxford, Oxford UniversityPress, 2000:4161.

Makela P, Valkonen T, Martelin T. Contribution of deaths related toalcohol use of socioeconomic variation in mortality: register basedfollow-up study. British Medical Journal1997, 315:211216

Marsh A, McKay S.Poor smokers.London, Policy Studies Institute,1994.

especially in the case of tobacco, has hampered

efforts by governments to use price mechanisms tolimit consumption.

Policy implications

Work to deal with problems of both legal andillicit drug use needs not only to support andtreat people who have developed addictivepatterns of use, but also to address the patterns

of social deprivation in which the problems arerooted.

Policies need to regulate availability throughpricing and licensing, and to inform peopleabout less harmful forms of use, to use healtheducation to reduce recruitment of youngpeople and to provide effective treatmentservices for addicts.

None of these will succeed if the social factorsthat breed drug use are left unchanged. Tryingto shift the whole responsibility on to the user iclearly an inadequate response. This blames thevictim, rather than addressing the complexitiesof the social circumstances that generate druguse. Effective drug policy must therefore besupported by the broad framework of social aneconomic policy.

Meltzer H. Economic activity and social functioning of residents withpsychiatric disorders.London, H.M. Stationery Office, 1996 (OPCSSurveys of Psychiatric Morbidity in Great Britain, Report 6).

Ryan, M. Alcoholism and rising mortality in the Russian Federation.British Medical Journal,1995, 310:646648.

Source of Fig. 7:Wardle J et al., eds. Smoking, drinking, physicalactivity and screening uptake and health inequalities. In: Gordon Det al, eds. Inequalities in health. Bristol, The Policy Press, 1999:213239.

DEPRIVATION SCORE

RISK

OFDEPENDENCE(WITHMOSTAFFLUENTSET

AT1)

Mostaffluent

Mostdeprived

10

9

8

7

6

5

4

3

2

1

00 1 2 3 4

Alcohol

Nicotine

Drugs


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Because global market forces control the food

supply, healthy food is a political issue.

What is known

A good diet and adequate food supply are centralfor promoting health and well-being. A shortageof food and lack of variety cause malnutritionand deficiency diseases. Excess intake (also a formof malnutrition) contributes to cardiovascular

diseases, diabetes, cancer, degenerative eyediseases, obesity and dental caries. Food povertyexists side by side with food plenty. The importantpublic health issue is the availability and cost ofhealthy, nutritious food (Fig. 8). Access to good,affordable food makes more difference to what

Social and economic conditions result in a so

gradient in diet quality that contributes to hinequalities. The main dietary difference betsocial classes is the source of nutrients. In macountries, the poor tend to substitute cheapprocessed foods for fresh food. High fat intaoften occur in all social groups. People on lowincomes, such as young families, elderly peothe unemployed, are least able to eat well.

Dietary goals to prevent chronic diseasesemphasize eating more fresh vegetables, frupulses (legumes) and more minimally processtarchy foods, but less animal fat, refined sugand salt. Over 100 expert committees have aon these dietary goals.

9 . F O O D

Local production for local consumption.

AILEENROBE

RTSON/WHO

people eat than health education.

Economic growth and improvements inhousing and sanitation brought withthem the epidemiological transition frominfectious to chronic diseases includingheart disease, stroke and cancer. With itcame a nutritional transition, when diets,particularly in western Europe, changed tooverconsumption of energy-dense fats andsugars, producing more obesity. At the sametime, obesity became more common among

the poor than the rich.World food trade is now big business. TheGeneral Agreement on Tariffs and Tradeand the Common Agricultural Policy of theEuropean Union allow global market forcesto shape the food supply. Internationalcommittees such as Codex Alimentarius,which determine food quality and safety

standards, lack public health representatives,and food industry interests are strong. Localfood production can be more sustainable,more accessible and support the localeconomy.


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KEY SOURCES

Fig. 8. Mortality from coronary heart disease inrelation to fruit and vegetable supply in selectedEuropean countries

Diet, nutrition and the prevention of chronic diseases. Reportof a Joint WHO/FAO Expert Consultation.Geneva, WorldHealth Organization, 2003 (WHO Technical Report Series, No.916) (http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf, accessed 14 August 2003)

First Action Plan for Food and Nutrition Policy [web pages].

Copenhagen, WHO Regional Office for Europe, 2000 (http://www.euro.who.int/nutrition/ActionPlan/20020729_1,accessed 14 August 2003).

Roos G et al. Disparities in vegetable and fruit consumption:European cases from the north to the south. Public HealthNutrition,2001, 4:3543

Systematic reviews in nutrition. Transforming the evidence onnutrition and health into knowledge [web site]. London,University College London, 2003 (http://

www.nutritionreviews.org/, accessed 14 August 2003).World Cancer Research Fund. Food, nutrition and theprevention of cancer: a global perspective.Washington,DC, American Institute for Cancer Research, 1997 (http://www.aicr.org/exreport.html, accessed 14 August 2003).

Source of Fig. 8: FAOSTAT (Food balance sheets) [databaseonline]. Rome, Food and Agriculture Organization of the UnitedNations, 25 September 2003.

WHO mortality database [database online]. Geneva, World

Health Organization, 25 September 2003.

Health for all database [database online]. Copenhagen, WHORegional Office for Europe, 25 September 2003.

Policy implications

Local, national and international governmentagencies, nongovernmental organizations and thefood industry should ensure:

the integration of public health perspectivesinto the food system to provide affordable andnutritious fresh food for all, especially the mostvulnerable;

democratic, transparent decision-making andaccountability in all food regulation matters,with participation by all stakeholders, includingconsumers;

support for sustainable agriculture and foodproduction methods that conserve naturalresources and the environment;

a stronger food culture for health, especially

through school education, to foster peoples

900

800

700

600

500

400

300

200

100

0 100 150 200 250 300 350 400 450

Greece

AGE-STANDARDIZEDDEATHRATESPER100000MEN

AGED3574

SUPPLY OF FRUIT AND VEGETABLES (KG/PERSON/YEAR)

Ukraine

Russian Federation

Lithuania

Poland

Germany

France

Spain

Belarus

knowledge of food and nutrition, cooking skills

growing food and the social value of preparingfood and eating together;

the availability of useful information about foodiet and health, especially aimed at children;

the use of scientifically based nutrient referencevalues and food-based dietary guidelines tofacilitate the development and implementationof policies on food and nutrition.

United Kingdom

Italy

1 0 T R A N S P O R T


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FINNFRANDSEN/POLFOTO

Roads should give precedence to cycling.

1 0 . T R A N S P O R T

Healthy transport means less driving and more

walking and cycling, backed up by better publictransport.

What is known

Cycling, walking and the use of public transportpromote health in four ways. They provide exercise,reduce fatal accidents, increase social contact andreduce air pollution.

Because mechanization has reduced the exerciseinvolved in jobs and house work and added tothe growing epidemic of obesity, people need tofind new ways of building exercise into their lives.Transport policy can play a key role in combatingsedentary lifestyles by reducing reliance on cars,increasing walking and cycling, and expandingpublic transport. Regular exercise protects againstheart disease and, by limiting obesity, reduces theonset of diabetes. It promotes a sense of well-beingand protects older people from depression.

Reducing road traffic would also reduce the tollof road deaths and serious accidents. Althoughaccidents involving cars also injure cyclists andpedestrians, those involving cyclists injure relativelyfew people. Well planned urban environments,which separate cyclists and pedestrians from car

traffic, increase the safety of cycling and walking.

In contrast to cars, which insulate people fromeach other, cycling, walking and public transportstimulate social interaction on the streets. Roadtraffic cuts communities in two and divides oneside of the street from the other. With fewerpedestrians, streets cease to be social spaces andisolated pedestrians may fear attack. Further,

suburbs that depend on cars for access isolatepeople without cars particularly the youngand old. Social isolation and lack of communityinteraction are strongly associated with poorerhealth.

Reduced road traffic decreases harmful pollu

from exhaust. Walking and cycling make minuse of non-renewable fuels and do not lead global warming. They do not create disease fpollution, make little noise and are preferabthe ecologically compact cities of the future.

Policy implications

The 21st century must see a reduction in peo

dependence on cars. Despite their health-da


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KEY SOURCES

Davies A. Road transport and health.London, British MedicalAssociation, 1997.

Fletcher T, McMichael AJ, eds. Health at the crossroads:transport policy and urban health.New York, NY, Wiley, 1996.

Making the connections: transport and social exclusion.London, Social Exclusion Unit, Office of the Deputy PrimeMinister, 2003 (http://www.socialexclusionunit.gov.uk/published.htm, accessed 14 August 2003).

McCarthy M. Transport and health. In: Marmot MG,Wilkinson R, eds.The social determinants of health.Oxford,

Oxford University Press, 1999:132154.Transport, environment and health in Europe: evidence,initiatives and examples.Copenhagen, WHO Regional Officefor Europe, 2001 (http://www.euro.who.int/eprise/main/who/progs/hcp/UrbanHealthTopics/20011207_1, accessed 14August 2003).

Source of Fig. 9:Transport trends 2002: articles (Section 2:personal travel by mode). London, Department for Transport,2002 (http://www.dft.gov.uk/stellent/groups/dft_transstats/documents/page/dft_transstats_506978.hcsp, accessed 18September 2003).

effects, however, journeys by car are rising rapidlyin all European countries and journeys by footor bicycle are falling (Fig. 9). National and localpublic policies must reverse these trends. Yettransport lobbies have strong vested interests.

Many industries oil, rubber, road building, carmanufacturing, sales and repairs, and advertising benefit from the use of cars.

Roads should give precedence to cycling andwalking for short journeys, especially in towns.

Public transport should be improved for longerjourneys, with regular and frequent connectionsfor rural areas.

Incentives need to be changed, for example,by reducing state subsidies for road building,increasing financial support for public transport,creating tax disincentives for the business use

Car Train Bus Foot Cycle

Fig. 9. Distance travelled per person by mode of

transport, Great Britain, 1985 and 2000

DISTANCE(KM)

MODE OF TRANSPORT

10000

8000

6000

4000

2000

0

1985 2000

of cars and increasing the costs and penalties of

parking. Changes in land use are also needed, such

as converting road space into green spaces,removing car parking spaces, dedicating roads tthe use of pedestrians and cyclists, increasing buand cycle lanes, and stopping the growth of lowdensity suburbs and out-of-town supermarkets,which increase the use of cars.

Increasingly, the evidence suggests that buildinmore roads encourages more car use, whiletraffic restrictions may, contrary to expectationsreduce congestion.

W H O A N D O T H E R I M P O R T A N T S O U R C E S


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W H O A N D O T H E R I M P O R T A N T S O U R C E S

Stress

The world health report 2001. Mental health: newunderstanding, new hope. Geneva, World HealthOrganization, 2001 (http://www.who.int/whr2001/2001/, accessed 14 August 2003).

World report on violence and health. Geneva,World Health Organization, 2002 (http:

//www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en/, accessed 14

August 2003).

Early life

A critical link interventions for physical growthand psychosocial development: a review.Geneva, World Health Organization, 1999 (http:

//whqlibdoc.who.int/hq/1999/WHO_CHS_CAH_99.3.pdf, accessed 14 August 2003).

Macroeconomics and health: investing in healthfor economic development. Report of theCommission on Macroeconomics and Health.Geneva, World Health Organization, 2001 (http:

//www3.who.int/whosis/menu.cfm?path=cmh&language=english, accessed 14 August 2003).

Social exclusion

Ziglio E et al., eds. Health systems confrontpoverty. Copenhagen, WHO Regional Office forEurope, 2003 (Public Health Case Studies, No. 1)(http://www.euro.who.int/document/e80225.pdf,accessed 14 August 2003).

Addiction

Framework Convention on Tobacco Control pages]. Geneva, World Health Organization,(http://www.who.int/gb/fctc/, accessed 14 Au2003).

Global status report on alcohol. Geneva, WoHealth Organization, 1999 (http://www.whosubstance_abuse/pubs_alcohol.htm, accessedAugust 2003).

The European report on tobacco control poliReview of implementation of the Third Actiofor a Tobacco-free Europe 19972001. CopenWHO Regional Office for Europe, 2002 (http

//www.euro.who.int/document/tob/tobconf2edoc8.pdf, accessed 14 August 2003).

Food

Global strategy for infant and young child fe[web pages]. Geneva, World Health Organiz2002 (http://www.who.int/child-adolescent-hNUTRITION/global_strategy.htm, accessed 15August 2003).

Globalization, diets and noncommunicablediseases.Geneva, World Health Organizatio(http://www.who.int/hpr/NPH/docs/globaliza

diet.and.ncds.pdf, accessed 15 August 2003)WHO Global Strategy on Diet, Physical Activiand Health [web pages]. Geneva, World HeaOrganization, 2003 (http://www.who.int/hprglobal.strategy.shtml, accessed 15 August 20


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Transport

A physically active life through everyday transportwith a special focus on children and older peopleand examples and approaches from Europe.Copenhagen, WHO Regional Office for Europe,2002 (http://www.euro.who.int/document/e75662.pdf, accessed on 15 August 2003).

Charter on Transport, Environment and Health.Copenhagen, WHO Regional Office for Europe,

1999 (EUR/ICP/EHCO 02 02 05/9 Rev.4) (http://www.euro.who.int/document/peh-ehp/charter_transporte.pdf, accessed on 15 August 2003).

Dora C, Phillips M, eds. Transport, environmentand health. Copenhagen, WHO RegionalOffice for Europe, 2000 (WHO RegionalPublications, European Series, No. 89) (http:

//www.euro.who.int/document/e72015.pdf,

accessed on 15 August 2003).

Transport, Health and Environment Pan-EuropeanProgramme (THE PEP) [web pages]. Geneva,United Nations Economic Commission for Europe,2003 (http://www.unece.org/the-pep/new/en/welcome.htm, accessed 15 August 2003).

The WHO RegionalOffice for Europe

The World HealthO i ti (WHO) i


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Member States

AlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermany

GreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoNetherlandsNorway

PolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbia and MontenegroSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former YugoslavRepublic of Macedonia

TurkeyTurkmenistanUkraineUnited KingdomUzbekistan

Organization (WHO) isa specialized agencyof the United Nationscreated in 1948 withprimary responsibilityfor internationalhealth matters andpublic health. The WHORegional Office for

Europe is one ofsix regional officesthroughout the world,each with its ownprogramme geared tothe particular healthconditions of thecountries it serves.

Poorer people live shorter lives and are more often ill than

the rich. This disparity has drawn attention to the remarkable

sensitivity of health to the social environment.

This publication examines this social gradient in health,

and explains how psychological and social influences affect

physical health and longevity. It then looks at what is known

about the most important social determinants of health

today, and the role that public policy can play in shaping a

social environment that is more conducive to better health.

This second edition relies on the most up-to-date sources in

its selection and description of the main social determinantsof health in our society today. Key research sources are

given for each: stress, early life, social exclusion, working

conditions, unemployment, social support, addiction, healthy

food and transport policy.

Policy and action for health need to address the social

determinants of health, attacking the causes of ill health

before they can lead to problems. This is a challenging

task for both decision-makers and public health actors andadvocates. This publication provides the facts and the policy

options that will enable them to act.

ISBN 92 890 1371 0

World Health OrganizationRegional Office for Europe

Scherfigsvej 8DK-2100 Copenhagen DenmarkTel.: +45 39 17 17 17

Fax: +45 39 17 18 18E-mail: [email protected] site: www.euro.who.int

the solid facts social determinants of health

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