The Solid Facts, social determinants of health.pdf

8/9/2019 The Solid Facts, social determinants of health.pdf

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Healthy CitiesHealth for Al l

SOCIALDETERM INANTS

OF HEALTH

InternationalCentre

Health andSociety


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EUR/IC P/C H VD 03 09 011998

By the year 2000, all settings of social life and activity,such as the city, school, w orkplace, neighbourhoodand hom e, should provide greater opportunities for

prom oting health.

Abstract

Policy and action for health need to be geared tow ardsaddressing the social determ inants of health in orderto attack the causes of ill health before they can leadto problem s. This is a challenging task for bothdecision-m akers and public health actors and

advocates. The scientific evidence on socialdeterm inants is strong but is discussed m ainly byresearchers. This booklet is part of a W H O RegionalO ffice for Europe cam paign to present the evidence onsocial determ inants in a clear and understandableform . The booklet identifies the broad im plications forpolicy in ten selected areas. The cam paign is m eant tobroaden aw areness, stim ulate debate and prom ote

action.

World Health OrganizationA ll rights in this docum ent are reserved by the W H O Regional O fficefor Europe. The docum ent m ay nevertheless be freely review ed,abstracted, reproduced or translated into any other language (butnot for sale or for use in conjunction w ith com m ercial purposes)

provided that full acknow ledgem ent is given to the source. For theuse of the W H O em blem , perm ission m ust be sought from the W H ORegional O ffice. Any translation should include the w ords: Thetranslator of this document is responsible for t he accuracy of th e

translation. The Regional O ffice w ould appreciate receiving threecopies of any translation. A ny view s expressed by nam ed authors aresolely the responsibility of those authors.

Keywords

PU BLIC H EA LTH

SO CIO ECO NO M IC FAC TO RS

SOC IA L ENVIRO N M EN T

SO C IA L SU PPO RT

H EALTH BEHA VIO R

H EA LTH PRO M O TIO N

H EA LTH Y C ITIES

EURO PE

HFA Policy on Europ e: Targ et 14SETTINGS FOR HEALTH PROM OTION

ISBN 9289012870


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SOCIALDETERM INA NTS

OF HEALTH

Edited byRichard W ilkinson and M ichael M arm ot


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Dr Mel BartleyU niversity C ollege London,

U nited K ingdom

Dr David BlaneC haring C ross and W estm inster

M edical School, London,

U nited K ingdom

Dr Eric BrunnerU niversity C ollege London,

U nited K ingdom

Dr Danny DorlingG eography D epartm ent,

Bristol U niversity,

U nited K ingdom

Ms Jane FerrieU niversity C ollege London,

U nited K ingdom

Dr Martin JarvisIm perial C ancer Research Fund

H ealth Behaviour U nit,U niversity C ollege London,

U nited K ingdom

Professor Michael MarmotU niversity C ollege London,

U nited K ingdom

Contributors

Professor Mark McCarthyU niversity C ollege London,

U nited K ingdom

Dr Mary ShawG eography D epartm ent,

Bristol U niversity,

U nited K ingdom

Professor Aubrey SheihamU niversity C ollege London,

U nited K ingdom

Dr Stephen StansfeldU niversity C ollege London,

U nited K ingdom

Professor Mike WadsworthM edical Research C ouncil

N ational Survey of

H ealth and D evelopm ent,

U niversity C ollege London,

U nited K ingdom

Professor Richard WilkinsonU niversity of Sussex, Brighton,and U niversity College London,

U nited K ingdom


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C ontributors 2

Forew ord 4

Preface 5

Introduction 6

1.The social gradient 8

2.Stress 10

3.Early life 12

4.Social exclusion 14

5.W ork 16

6.U nem ploym ent 18

7.Social support 20

8.A ddiction 22

9.Food 24

10.Transport 26

Contents


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A call to decision-m akers and public healthprofessionals to address the social determ inants

of health should rest on clear evidence. M ost

people have an intuitive understanding of the

positive and negative effects of living and

w orking conditions on their health. A lthough

there is no shortage of legitim izing evidence, the

debate on the social determ inants of health

continues to be lim ited m ainly to academ ic fora.The recent history of public health can show

m any exam ples of inexcusable inaction, even

w hen the facts are unequivocal, as in the case of

tobacco. It is disturbing that the tobacco industry

finally adm itted that sm oking is addictive only a

year ago. The lack of sufficient action against

tobacco w as often blam ed on the lack of boldly

presented evidence.

Recognizing the health im pact of econom ic and

social policies and conditions could have far-

reaching im plications for the w ay society m akes

decisions about developm ent, and it could

challenge the values and principles on w hich

institutions are built and progress is m easured.

The good new s is that decision-m akers at all

levels increasingly recognize the need to invest in

health and sustainable developm ent. To do this,

they need clear facts as m uch as they need

strategic guidance and policy tools. N obody

expects science to be black or w hite, but it m ust

be accessible, creating opportunities for debate

and inform ed decision-m aking.

A t the W H O Regional O ffice for Europe, the

C entre for U rban H ealth, in close partnership w ith

the C om m unication and Public A ffairs and the

new European Health C om m unication N etw ork,have, has em barked on a cam paign to prom ote

aw areness, debate and action on the social

determ inants of health. The cam paign aim s at

reaching the w idest possible audiences of public

health advocates and professionals, com m unity

activists and decision-m akers. The cam paign w ill

develop and em ploy m aterials that are attractive

and easy to read and translate. A principal vehiclefor the prom otion of the cam paign throughout

the European Region w ill be the netw orks of the

W H O H ealthy Cities project. The tim ing of this

effort is excellent, as it coincides w ith the

launching of the renew ed strategy health for all

for the tw enty-first century, the launching of

phase III (19982002) of the H ealthy C ities project

and the increasing com m itm ent of a num ber ofcities to local A genda 21.

The backbone of the cam paign is the provision of

up-to-date inform ation on the key areas of social

determ inants, in a concise, clear and authoritative

form . This w as achieved through close

partnership betw een W H O and the International

C entre for H ealth and Society, U niversity C ollege

London, U nited Kingdom . I should like to express

m y gratitude to Professor M ichael M arm ot and

Professor Richard W ilkinson, w ho coordinated the

preparation and edited the m aterials for this

booklet. The drafting process consisted of a series

of brainstorm ing sessions and consultations. I

should like to thank all the m em bers of the

scientific team w ho contributed to this excellent

piece of w ork. I am convinced that the booklet

w ill be a valuable tool for understanding and

dealing w ith social determ inants.

FOREWORD

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Translating scientific evidence into policy andaction is alw ays a com plex process. It is

particularly difficult w hen the im plications for

action m ay change the w ay w e think about

policies that affect health. G overnm ents and

decision-m akers have taken over half a

generation to recognize and begin to address

social inequalities in health.

Today, scientific know ledge on the social

determ inants of health is accum ulating quickly.

The need to direct our efforts there has becom e

increasingly clear. This m eans up-stream ing

public health, spreading aw areness of and

prom oting debate on social determ inants.

The International C entre for H ealth and Society iscom m itted to research on the social determ inants

of health and translating research findings into a

form that is useful to policy-m akers and the

public. This W H O cam paign is a m ost w elcom e

opportunity to contribute to the challenging task

of prom oting healthy public policies.

Sir Donald AchesonC hairm an, International C entre forH ealth and Society

U niversity College London

A special w ord of thanks is due to D r JillFarrington, W H O consultant and focal point for

the social determ inants cam paign, for her creative

ideas and valuable editorial input and for ensuring

good com m unications w ith the C entre. M any

thanks are due to M s Patricia C row ley,

adm inistrator the International C entre for H ealth

and Society, for the efficient and effective w ay

she m onitored all the stages of the preparation ofthe scientific papers. Finally, a w ord of thanks to

M ary Stew art Burgher, w ho edited the text of the

booklet on a short deadline.

Dr Agis TsourosH ead, C entre for U rban H ealth

W H O Regional O ffice for Europe

PREFACE

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Even in the richest countries, the better off liveseveral years longer and have few er illnesses than

the poor. These differences in health are an

im portant social injustice, and reflect som e of the

INTRODUCTION

m ost pow erful influences on health in them odern w orld. People's lifestyles and the

conditions in w hich they live and w ork strongly

influence their health and longevity.

People's l i festyles and t he condit io ns in w hich they l ive and w ork strong ly influence their health.PhotobyW

H

O

H

ealthy

C

ities

Project

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M edical care can prolong survival after som eserious diseases, but the social and econom ic

conditions that affect w hether people becom e ill

are m ore im portant for health gains in the

population as a w hole. Poor conditions lead to

poorer health. A n unhealthy m aterial

environm ent and unhealthy behaviour have direct

harm ful effects, but the w orries and insecurities

of daily life and the lack of supportiveenvironm ents also have an influence.

This booklet discusses ten different but

interrelated aspects of the social determ inants of

health. They explain:

1.the need for policies to prevent people

from falling into long-term

disadvantage;

2.how the social and psychologicalenvironm ent affects health;

3.the im portance of ensuring a goodenvironm ent in early childhood;

4.the im pact of w ork on health;

5.the problem s of unem ploym ent and jobinsecurity;

6.the role of friendship and socialcohesion;

7.the dangers of social exclusion;

8.the effects of alcohol and other drugs;

9.the need to ensure access to supplies ofhealthy food for everyone; and

10.the need for healthier transportsystem s.

Together the m essages provide the keys to higherstandards of population health in the developed

industrial countries of Europe. These m essages

are intended to point out how social and

econom ic factors at all levels in society affect

individual decisions and health itself. Each person

is responsible for ensuring that he or she eats a

healthy diet, gets enough exercise and avoids

sm oking and excessive drinking. N evertheless, w enow know the im portance to health of social and

econom ic circum stances that are often beyond

individual control. The booklet is therefore

intended to ensure that policy at all levels in

governm ent, public and private institutions,

w orkplaces and the com m unity takes proper

account of the w ider responsibility for creating

opportunities for health. The booklet therefore

provides inform ation on the social and econom ic

environm ent that is conducive to higher standards

of health in the population.

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Peo ples social and econo m iccircumstances strong ly affe ct theirhealth througho ut life, so health po licymust be linked to the social andeconom ic determinants of health.

The eviden cePoor social and econom ic circum stances affect

health throughout life. People further dow n the

social ladder usually run at least tw ice the risk of

serious illness and prem ature death of those near

the top. Betw een the top and bottom , health

standards show a continuous social gradient, so

even junior office staff tend to suffer m uch m ore

disease and earlier death than m ore senior staff.

M ost diseases and causes of death are m ore

com m on low er dow n the social hierarchy. The

social gradient in health reflects m aterial

disadvantage and the effects of insecurity, anxiety

and lack of social integration.

D isadvantage has m any form s and m ay be

absolute or relative. It can include: having few

fam ily assets, having a poorer education during

adolescence, becom ing stuck in a dead-end job or

having insecure em ploym ent, living in poor

housing and trying to bring up a fam ily in difficult

circum stances. These disadvantages tend to

concentrate am ong the sam e people, and their

effects on health are cum ulative. The longer

people live in stressful econom ic and social

circum stances, the greater the physiological w ear

and tear they suffer, and the less likely they are to

enjoy a healthy old age.

BARTLEY, M . ET AL. He alt hand t he l i fe course: w hy safetynets mat ter. Brit ish medicaljo urn al, 314 : 1 1 9 4 1 1 9 6(1997) .

BLAN E, D. ET AL. Di seaseet io logy and mater ia l istexplanat ions of

socioeconomic m or tal i tydi fferentials. European jou rnal of pub l ic health, 7 : 3 8 5 3 9 1(1997) .

DAV EY SM ITH, G. ET AL.Li fet ime socioeconomicpos i t ion and mo r tal i ty:prospective observationalstudy. Brit ish medical journal,314

: 547552 (1997) .

THE SOCIAL GRADIENT

Policy im plication sLife contains a series of critical transitions:em otional and m aterial changes in early

childhood, the m ove from prim ary to secondary

education, starting w ork, leaving hom e and

starting a fam ily, changing jobs and facing

possible redundancy, and eventually retirem ent.

Each of these changes can affect health by

pushing people onto a m ore or less advantaged

path.

People w ho have been disadvantaged in the past

are at the greatest risk in each transition. This

m eans that w elfare policies need to provide not

M ON TGOM ERY, S. ET AL.Health an d social precursorsof unemployment in youngmen in Br ita in. Journ al ofepidemiology and commu ni ty heal th, 50 : 415422 (1996) .

WU NCH, G. ET AL.Socioecono mic di ff erences in

mo rtal i ty: a l i fe courseapproach. European journal of populat ion, 12 : 1 6 7 1 8 5(1996) .

KEY SOURCES

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only safety nets but also springboards to offset

earlier disadvantage.

G ood health involves reducing levels of

educational failure, the am ount of job insecurity

and the scale of incom e differences in society. W e

need to ensure that few er people fall and that

Poor social and economic circum stances affect health t hroug hou t l i fe.

they fall less far. Policies for education,

em ploym ent and housing affect health standards.

Societies that enable all their citizens to play a full

and useful role in the social, econom ic and

cultural life of their society w ill be healthier than

those w here people face insecurity, exclusion and

deprivation.

PhotobyJoachim

Ladefoged,Polfoto

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Stress harms hea lth.

The eviden ceSocial and psychological circum stances can cause

long-term stress. C ontinuing anxiety, insecurity,

low self-esteem , social isolation and lack of

control over w ork and hom e life have pow erful

effects on health. Such psychosocial risks

accum ulate during life and increase the chances

of poor m ental health and prem ature death. Long

periods of anxiety and insecurity and the lack of

supportive friendships are dam aging in w hatever

area of life they arise.

H ow do these psychosocial factors affect physical

health? In em ergencies, the stress response

STRESS

Lack of control over wo rk and h ome can have pow erful ef fects on heal th.PhotobyM

ortenO

vergaard,Polfoto

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KEY SOURCES

BRUNN ER, E.J. Stress and th ebiology o f inequal i ty. Britishmedical journal , 314 : 1 4 7 2 1476 (1997) .

KARA SEK, R.A. & THEORELL,T. Healthy w ork: stress,p ro duct iv it y and t hereconstruct ion o f w ork ing l i fe.

New York, Basic Books, 199 0.

M ARM OT, M .G. Does stresscause heart attacks?Postgraduate medical journal,62 : 683686. (1986)

M ARM OT, M .G. ET AL.Contr ibut ion of job controland ot her r isk factors to social

variations in coronary heartdisease. Lancet, 350 : 235239 (1997) .

SAPOLSKY, R.M . & M OTT, G.E.Social subo rdinan ce in w i ldbaboon s is associated w i thsuppressed high d ensityl ipoprotein-cholesterolconcentrations: the possiblerole of chronic social stress.Endocrinology, 121 : 16051610 (1987) .

SHIVELY, C.A . & CLARKSON,T.B. Social status and coronaryartery at herosclerosis infema le monkeys.Arteriosclerosis throm bosis,14 : 721726 (1994) .

activates a cascade of stress horm ones that affect

the cardiovascular and im m une system s. O ur

horm ones and nervous system prepare us to deal

w ith an im m ediate physical threat by raising the

heart rate, diverting blood to m uscles and

increasing anxiety and alertness. N evertheless,

turning on the biological stress response too

often and for too long is likely to carry m ultiple

costs to health. These include depression,

increased susceptibility to infection, diabetes, and

a harm ful pattern of cholesterol and fats in the

blood, high blood pressure and the attendant

risks of heart attack and stroke.

H um ans and various non-hum an prim ates studied

in the w ild and in captivity have sim ilar

m echanism s for dealing w ith psychosocial stress.

Studies of prim ates show that subordinate

anim als are m ore likely than socially dom inant

anim als to suffer from clogged blood vessels and

other changes in their m etabolism . In hum ans,

such changes are linked to a higher risk of

cardiovascular disease. The low er people are in

the social hierarchy of industrialized countries, the

m ore com m on these health problem s becom e.

Policy im plicationsA m edical response to the biological changes that

com e w ith stress m ight be to try to control them

w ith drugs. But attention should be focused

upstream , on tackling the causes of ill health.

In schools, businesses and other institutions, the

quality of the social environm ent and m aterial

security are often as im portant to health as the

physical environm ent. Institutions that can give

people a sense of belonging and of being valued

are likely to be healthier places than those in

w hich people feel excluded, disregarded and

used.

G overnm ents should recognize that w elfare

program m es need to address both psychosocial

and m aterial needs: both are sources of anxiety

and insecurity. In particular, governm ents should

support fam ilies w ith young children, encourage

com m unity activity, com bat social isolation,

reduce m aterial and financial insecurity, and

prom ote coping skills in education and

rehabilitation.

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The ef fects of early developm ent last alife-time; a goo d start in life me anssupporting m others and yo ung children.

The eviden ceIm portant foundations of adult health are laid in

prenatal life and early childhood. Slow grow th

and a lack of em otional support during this

period raise the life-tim e risk of poor physical

health and reduce physical, cognitive and

em otional functioning in adulthood. Poor social

and econom ic circum stances present the greatest

threat to a childs grow th, and launch the child on

a low social and educational trajectory.

A cting through poor or inappropriate

nourishm ent of the m other and through

sm oking, parental poverty can reduce prenatal

and infant developm ent. Slow early grow th is

associated w ith reduced cardiovascular,

respiratory, kidney and pancreatic functioning in

adulthood. Parentssm oking im pedes the childs

EARLY LIFE

Important foundat ions of adul t heal th are la id in ear ly chi ldhood.Photoby

FinnFrandsen,Polfoto

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KEY SOURCES

BA RKER, D. J.P. M others, babiesand d isease in later l i fe.London , BM J Publ ishing Group,1 9 9 4 .

BARKER, W. ET AL. Childp ro t ect io n : t he i m pac t o f t hechi ld development programm e.Bristol , Early Chi ldhoo dDevelopment Uni t , U nivers ity

of Br istol , 199 2.

HERTZM AN, C. & W IENS, M .Chi ld development and long -term outcom es: a populat ionhealth perspective andsumm ary of successfulinterventions. Social scienceand medic ine, 43 : 1083 (1996)

KUH, D. & BEN-SHLOM O, Y. A

li fe course approach to chronicdisease epidemiology. Oxford,Oxford U niversi ty Press, 19 97 .

ROBIN S, L. & RUTTER, M ., ED.Straight and dev iouspat hw ays f ro m ch il dhood t oadu l thood. Camb ridge,Camb ridge Universi ty Press,1 9 9 0 .

TAGER, I.B. ET AL.Longi tudinal s tudy of theef fects of m aternal smoking

on pulmo nary funct ion inchi ldren. New England journal of m edic ine, 309 : 699 (1983) .

SCHWEIN HA RT, L.J. ET AL.Significant benefi ts: the High/Scope Perry Preschoo l Stu dyth rough age 27 . Ypsilant i, TheHigh Scope Press, 19 93 .

respiratory developm ent; this decreases

respiratory functioning and thus increases

vulnerability in the adult.

Poor nutrition and physical developm ent

adversely affect the childs cognitive

developm ent. In addition, the m ental exhaustion

and depression associated w ith poverty reduce

the parentsstim ulation of the child, and can

disrupt em otional attachm ent.

Parental poverty starts a chain of social risk. It

begins in childhood w ith reduced readiness for

and acceptance of school, goes on to poor

behaviour and attainm ent at school, and leads to

a raised risk of unem ploym ent, perceived social

m arginality and to low -status, low -control jobs in

adult life. This pattern of poor education and

em ploym ent dam ages health and, ultim ately,

cognitive functioning in old age.

Policy im plication sN ew action is needed to foster health anddevelopm ent early in life, particularly am ong

people in poor social and econom ic

circum stances. Policy should aim to:

1.reduce parents' sm oking;

2.increase parents' know ledge of health and

understanding of children's em otional needs;

3.introduce pre-school program m es not only to

im prove reading and stim ulate cognitive

developm ent but also to reduce behaviour

problem s in childhood and prom ote

educational attainm ent, occupational chances

and healthy behaviour in adulthood;

4.involve parents in such pre-school program m es

to reinforce their educational effects and

reduce child abuse;

5.ensure that m others have adequate social and

econom ic resources; and

6.increase opportunities for educational

attainm ent at all ages, since education is

associated w ith raised health aw areness and

im proved self-care.

Investm ent in these policies w ould greatly benefit

the health and w orking capacity of the future

adult population.

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Social exclusion creates m isery and costslives.

The eviden ceProcesses of social exclusion and the extent of

relative deprivation in a society have a m ajor

im pact on health and prem ature death. The harm

to health com es not only from m aterial

deprivation but also from the social and

psychological problem s of living in poverty.

Poverty, unem ploym ent and hom elessness have

increased in m any countries, including som e of

the richest. In som e countries, as m uch as one

quarter of the total population and a higher

proportion of children live in relative poverty

(defined by the European U nion as less than half

the national average incom e). Relative poverty, as

w ell as absolute poverty, leads to w orse health

and increased risks of prem ature death. People

w ho have lived m ost of their lives in poverty suffer

particularly bad health.

M igrants from other countries, ethnic m inority

groups, guest w orkers and refugees are

particularly vulnerable to social exclusion, and

their children are likely to be at special risk. They

are som etim es excluded from citizenship and

often from opportunities for w ork and education.

The racism , discrim ination and hostility that they

often face m ay harm their health.

In addition, com m unities are likely to m arginalize

and reject people w ho are ill, disabled orem otionally vulnerable, such as form er residents

of childrens hom es, prisons and psychiatric

SOCIAL EXCLUSION

Photoby

JanG

rarup,Polfoto

14

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KEY SOURCEShospitals. Those w ith physical or m ental health

problem s often have difficulty gaining an

adequate education or earning a living. D isabled

children are m ost likely to live in poverty.

Stigm atizing conditions such as m ental illness,

physical disability or diseases such as A ID S m akes

m atters w orse. People living on the streets, w ho

m ay suffer a com bination of these problem s,

suffer the highest rates of prem ature death.

Societies that pursue m ore egalitarian policies

often have faster rates of econom ic grow th and

higher standards of health.

Im plication s for po licyA variety of actions at a num ber of different levels

is needed to tackle the health effects of social

exclusion. These include the follow ing.

1.Legislation can help protect the rights of

m igrants and m inority groups, and prevent

discrim ination.

2.Public health interventions should rem ove

barriers to access to health care, social services

and affordable housing.

3.Incom e support, adequate national m inim um

w ages and educational and em ploym ent

policies are needed to reduce social exclusion.

4.Incom e and w ealth should be redistributed to

reduce m aterial inequalities and the scale of

relative poverty; m ore egalitarian societies tendto have higher standards of health.

POWER, C. Health an dsocial inequal i ty in Europe.Brit ish medical journal,309 : 11531160 (1994) .

SIEM , H. Migrat ion andheal th - the internat ionalperspective. SchweizerischeRundschau fur M edizinPraxis, 86 (19): 78879 3(1997) .

WA LKER, R. Povert y andsocial exclusion in Europe.In: Walker, A. & Wa lker, C.,ed. Br ita in d iv ided: thegrow th of social exclus ioni n the 1980s and 1990s .

Londo n, Chi ld PovertyAct ion Group, 199 7.

W ILKINSON, R.G.Unh ealthy societies: theaffl ictions of inequal i ty.London, Rout ledge, 1996 .

VAN DOO RSLAER E. ET AL.Income-related inequal i t ies

in heal th: someinternational comparisons.Journal o f heal theconomics, 16 : 9311 2(1997) .

People l iving on the streetssuffer the highest rates ofpre m ature dea th.

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Stress in the w orkplace increases therisk of disease.

The eviden ceEvidence show s that stress at w ork plays an

im portant role in contributing to the large

differences in health, sickness absence and

prem ature death that are related to social status.

Several w orkplace studies in Europe show that

health suffers w hen people have little opportunity

to use their skills, and low authority over

decisions.

H aving little control over ones w ork is particularly

strongly related to an increased risk of low back

pain, sickness absence and cardiovascular disease.

WORK

Jobs wit h bot h high d emand an d low control carry special risk.Photoby

BavariaB

ild,Polfoto

16

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KEY SOURCES

These risks have been found to be independent of

the psychological characteristics of the people

studied. In short, they seem to be related to the

w ork environm ent.

Studies have also exam ined the role of dem ands

at w ork. Som e show an interaction betw een

dem ands and control. Jobs w ith both high

dem and and low control carry special risk. Som e

evidence indicates that social support in the

w orkplace m ay reduce this effect.

Further, receiving inadequate rew ards for the

effort put into w ork has been found to be

BOSM A, H. ET AL. Low jobcontrol and r isk of coronaryheart d isease in Whit ehal l II(prospective cohort) study.Brit ish medical journal, 314 :5 5 8 5 6 5 ( 1 9 9 7 ).

JOHN SON, J.V. Con cept ualand methodological

developments in occupat ionalstress research inoccupatio nal stress research:an introduct ion to s tate-of-the-art reviews. Journ al ofoccupat ional heal thpsych o lo gy, 1 : 68 (1996) .

KARA SEK, R.A . & THEORELL, T.Healthy w ork: stress,p ro d uct iv it y and t hereconstruct ion o f w ork ing l i fe.New York, Basic Books, 1990 .

associated w ith increased cardiovascular risk.

Rew ards can take the form s of m oney, status and

self-esteem . C urrent changes in the labour m arket

m ay change the opportunity structure, and m ake it

harder for people to get appropriate rew ards.

These results suggest that the psychosocial

environm ent at w ork is an im portant contributor to

the social gradient in ill health.

Policy im plication s1.There is no trade-off betw een health and

productivity at w ork. A virtuous circle can be

established: im proved conditions of w ork w ill

lead to a healthier w ork force; this w ill lead to

im proved productivity, and hence to the

opportunity to create a still healthier m ore

productive w orkplace.

2.A ppropriate involvem ent in decision-m aking is

likely to benefit em ployees at all levels of an

organization.

3.Redesigning practices in offices and other

w orkplaces to enable em ployees to have m ore

control, greater variety and m ore opportunitiesfor developm ent at w ork benefits health.

4.W ork that does not provide appropriate rew ards

in term s of m oney, self-esteem and status

dam ages health.

5.To reduce the burden of m usculoskeletal

disorders, w orkplaces m ust be appropriateergonom ically as w ell as in the organization of

w ork.

SIEGRIST, J. Ad verse he alt hef fec ts of h igh-ef for t / low -reward condi t ions. Journ al ofoccupat ional heal thpsych o lo gy, 1 : 2741(1996) .

THEORELL, T. & KARASEK,R.A. Current issues relating topsychosocial job strain an d

cardiovascular diseaseresearch. Journ al ofoccupat ional heal thpsych o lo gy, 1 :926 (1996) .

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KEY SOURCES

Job security increases health, wellbeingand job satisfaction.

The eviden ceU nem ploym ent puts health at risk, and the risk is

higher in regions w here unem ploym ent is

w idespread. Evidence from a num ber of countries

show s that, even after allow ing for other factors,

unem ployed people and their fam ilies suffer a

substantially increased risk of prem ature death.

The health effects of unem ploym ent are linked to

both its psychological consequences and financial

problem s, especially debt.

The effects start w hen people first feel their jobs

are threatened, even before they actually becom e

unem ployed. This show s that anxiety about

insecurity is also detrim ental to health. Jobinsecurity has been show n to increase effects on

m ental health (particularly anxiety and

depression), self-reported ill health, heart disease

and risk factors for heart disease. Because

unsatisfactory or insecure jobs can be as harm ful

as unem ploym ent, m erely having a job cannot

protect physical or m ental health. Job quality is

im portant.

D uring the 1990s, changes in the econom ies and

labour m arkets of industrialized countries have

increased feelings of job insecurity. A s job

insecurity continues, it acts as a chronic stressor

w hose effects increase w ith the length of

exposure; it increases sickness absence and health

service use.

Policy im plication sPolicy should have three goals:

preventing unem ploym ent and job insecurity;

reducing the hardship suffered by the

unem ployed; and

restoring people to secure jobs.

G overnm ent m anagem ent of the econom y, to

reduce the highs and low s of the business cycle,

can m ake an im portant contribution to job

security and the reduction of unem ploym ent.

Lim itations on w orking hours m ay also be

UNEM PLOYM ENT

BEALE, N. & NETHERCOTT, S.Job-lo ss and fam ily mo rbidi ty:a study of a f actory closure.Journ al of th e Royal Col legeof General Practi t io ners,35 :5 1 0 5 1 4 ( 1 9 8 5 ).

BETHUNE, A. Unem ploymen tand mor tal i ty . In: Dr eve r, F. &Whi tehead, M ., ed. Health

inequal i t ies. London, H.M .Stationery Office, 1997.

BURCHELL, B. The eff ects o flabour m arket pos i t ion, jobinsecuri ty, and unemploymenton psychological health. In:Gallie, D. et al., ed. Socialchange and t he exper ience of unemployment. Oxford,Oxford Universi ty Press, 199 4,

pp . 188 212.

FERRIE, J. ET AL., ED. Labour market changes and jobinsecuri ty: a chal lenge fo rsocial w el fare and heal thpr om ot io n. Copenhagen,WHO Regional Off ice forEurop e ( in press) (WHORegional Publ ication s,European Series, No. 81).

IVERSEN, L. ET A L.Unemployment and mor tal i tyin Denmark. Brit ish medicaljo urn al, 295 : 8 7 9 8 8 4(1987) .

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beneficial, if they are pursued alongside job

security and satisfaction.

To equip people for the w ork available, high

standards of education and good retraining

Unem ployed people and th eir famil ies suffer a mu ch higher risk of prem ature death .

schem es are im portant. For those out of w ork,

unem ploym ent benefits set at a higher proportion

of w ages are likely to have a protective effect.

Further, credit unions m ay be beneficial by

reducing debts and increasing social netw orks.

PhotobyR

euter,Polfoto

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Friendship, goo d social relations andstrong supportive netw orks improvehealth at hom e, at w ork and in thecommunity.

The eviden ceSocial support and good social relations m ake an

im portant contribution to health. Social support

helps give people the em otional and practical

SOCIAL SUPPORT

Belonging t o a social netw ork m akes people feel cared for.Photoby

Fotokhronika,Polfoto

20

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KEY SOURCES

BERKM AN , L.F. & SYM E, S.L.Social netw orks, hostresistance and m ortal i t y: anine year fo l low-u p of

A lameda County residents.Amer ican journal of epidemiology, 109 : 186 204(1979) .

KAPLAN, G.A . ET AL. Socialconnect ions and m or tal i tyfrom al l causes and fro mcardiovascular disease:prospective evidence fromeastern Finland. American

jo urn al o f e p id em io lo gy, 128 :3 7 0 3 8 0 ( 1 9 8 8 ).

A ccess to em otional and practical social support

varies by social and econom ic status. Poverty cancontribute to social exclusion and isolation.

Social cohesion the existence of m utual trust

and respect in the com m unity and w ider society

helps to protect people and their health. Societies

w ith high levels of incom e inequality tend to have

less social cohesion, m ore violent crim e and

higher death rates. O ne study of a com m unityw ith high levels of social cohesion show ed low

rates of coronary heart disease, w hich increased

w hen social cohesion in the com m unity declined.

Policy im plicationsExperim ental studies suggest that good social

relations can reduce the physical response to

stress. Interventions in high-risk groups haveshow n that providing social support im proves

outcom e after heart attacks, longevity in people

w ith som e types of cancer and pregnancy

outcom e in vulnerable groups of w om en.

In the com m unity, reducing incom e inequalities

and social exclusion can lead to greater social

cohesiveness and better health in the population.Im proving the social environm ent in schools, the

w orkplace and the com m unity in general w ill help

people feel valued and supported in m ore areas

of their lives and w ill contribute to their health,

especially m ental health. In all areas of personal

and institutional life, practices should be avoided

that cast others as socially inferior or less valuable;

they are divisive.

resources they need. Belonging to a social

netw ork of com m unication and m utualobligation m akes people feel cared for, loved,

esteem ed and valued. This has a pow erful

protective effect on health.

Support operates on the levels of both the

individual and the society. Social isolation and

exclusion are associated w ith increased rates of

prem ature death and poorer chances of survivalafter a heart attack. People w ho get less

em otional social support from others are m ore

likely to experience less w ellbeing, m ore

depression, a greater risk of pregnancy

com plications and higher levels of disability from

chronic diseases. In addition, the bad aspects of

close relationships can lead to poor m ental and

physical health.

KAW ACHI, I. ET AL. Aprospective study of socialnetw orks in relat ion to tot almortal i ty and cardiovascular

disease in m en in th e USA.Journal of epidemiology andcommuni ty heal th, 50 (3):2 4 5 2 5 1 ( 1 9 9 6 ).

OXM AN, T.E. ET AL. Socialsupport and depressivesymp tom s in the elderly.Amer ican journal of epidemiology, 135 : 356 368(1992) .

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Individuals turn to alcoho l, drugs andtobacco and suffer fro m their use, b utuse is influenced by the w ider socialsetting.

The eviden ceD rug use is both a response to social breakdow nand an im portant factor in w orsening the

resulting inequalities in health. It offers users a

ADDICTION

People turn t o alcohol, drugs and to bacco to num b the pain of h arsh econo mic and social condit io ns.Photo

by

TeitH

ornbak,Polfoto

22

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KEY SOURCES

M AKELA, P. ET AL.Contr ibut ion of deathsrelated to alcohol use ofsocioeconomic variation inmo rtal i ty: register basedfol low up s tudy. Brit ishmedical journal , 315 : 211216 (1997) .

M ARKOV, K.V. ET AL.Inc idence of alcohol dr ink ingand t he s tructure of causes ofdeath in men 40 -54 years ofage. SovetskoeZdravookhranenie, 4 : 815(1990) .

M ARSH, A. & M CKAY, S. Poorsmokers. London, PolicyStudies Insti tute, 1994.

M ELTZER, H. ET AL. Economicactivi ty and social functioningof adu l ts wi th psychiatr ic disorders. London, H.M .Stat ionery Office, 19 96 (OPCSSurveys of Psychiatri cM orbidi ty in Great Br ita in,Repor t 3) .

RYAN, M . Alcohol ism an drising mort al i ty in the RussianFederation. Brit ish medicaljo urn al, 310 : 646 648 (1995) .

m irage of escape from adversity and stress, but

only m akes their problem s w orse.

A lcohol dependence, illicit drug use and cigarette

sm oking are all closely associated w ith m arkers of

social and econom ic disadvantage. In the Russian

Federation, for exam ple, the past decade has

been a tim e of great social upheaval. D eaths

linked to alcohol use from accidents, violence,

poisoning, injury and suicide have risen sharply.A lcohol dependence and violent death are

associated in other countries too.

The causal pathw ay probably runs both w ays.

People turn to alcohol to num b the pain of harsh

econom ic and social conditions, and alcohol

dependence leads to dow nw ard social m obility.

The irony is that, apart from a tem porary releasefrom reality, alcohol intensifies the factors that led

to its use in the first place.

The sam e is true of tobacco. Social deprivation

as m easured by any indicator: poor housing, low

incom e, lone parenthood, unem ploym ent or

hom elessness is associated w ith high rates of

sm oking and very low rates of quitting. Sm okingis a m ajor drain on poor peoples incom es and a

huge cause of ill health and prem ature death. But

nicotine offers no real relief from stress or

im provem ent in m ood.

Policy im plicationsW ork to deal w ith drug problem s needs not only

to support and treat people w ho have developedaddictive patterns of use but also to address the

patterns of social deprivation in w hich the

problem s are rooted. Policies need to regulate

availability through pricing and licensing, forinstance, to inform people about less harm ful

form s of use, to use health education to reduce

recruitm ent of young people and to provide

effective treatm ent services for addicts.

N one of these w ill succeed if the social factors

that breed drug use are left unchanged. Trying to

shift the w hole responsibility on to the user is aclearly inadequate response. This blam es the

victim , rather than addressing the com plexities of

the social circum stances that generate drug use.

Effective drug policy m ust therefore be supported

by the broad fram ew ork of social and econom ic

policy.

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FOOD


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KEY SOURCES

Healthy fo od is a political issue.

The eviden ceA good diet and adequate food supply are central

for prom oting health and w ellbeing. The shortage

of food and lack of variety cause m alnutrition and

deficiency diseases. Excess intake (also a form of

m alnutrition) contributes to cardiovascular

diseases, diabetes, cancer, degenerative eye

diseases, obesity and dental caries. Food povertyexists side by side w ith food plenty. The im portant

public health issue is the availability and cost of

healthy, nutritious food. A ccess to good,

affordable food m akes m ore difference to w hat

people eat than health education.

Industrialization brought w ith it the

epidem iological transition from infectious tochronic diseases particularly heart disease,

stroke and cancer. This w as associated w ith a

nutritional transition, w hen diets changed to

overconsum ption of energy-dense fats and

sugars, producing m ore obesity. A t the sam e

tim e, obesity becam e m ore com m on am ong the

poor than the rich.

W orld food trade is now big business. The

G eneral A greem ent on Tariffs and Trade and the

C om m on A gricultural Policy of the European

U nion allow global m arket forces to shape the

food supply. International com m ittees such as

C odex A lim entarius, w hich determ ine food

quality and safety standards, lack public health

representatives, and food industry interests arestrong.

Social and econom ic conditions result in a social

gradient in diet quality that contributes to healthinequalities. The m ain dietary difference betw een

AVERY, N . ET AL. Crackingthe Co dex. An a nalysis of

who sets wor l d foods tandards. London, N at ionalFood Al l iance, 19 93 .

COM M ITTEE ON M EDICALASPECTS OF FOOD POLICY.Nutr i t ional aspects of cardiovascular disease.London, H.M . Stat ioneryOffice, 1994.

Diet , nutr i t ion, and thep re vent io n o f c hro n icdiseases. Geneva, WorldHeal th Organizat ion, 199 0(WHO Technical ReportSeries, No. 79 7).

STALLON E, D.D. ET AL.Dietary assessment inWhi tehal l I I : the inf luence of

repor t ing bias on apparentsocioeconomic variation innutr ient intake. Europeanjo urn al o f c li n ica l n u t ri t io n,51 : 815825 (1997) .

WORLD CAN CERRESEARCH FUN D. Food,nutr i t ion and th e prevent ionof cancer: a globa lper sp ect ive. Washington,

DC, Am erican Insti tute fo rCancer Research, 19 97 .

FOOD

Local produ ction for local consumPhotoby

D

rA

ileenRobertson,W

H

O

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social classes is the source of nutrients. The poor

substitute cheaper processed foods for freshfood. H igh fat intakes often occur in all social

groups. People on low incom es, such as young

fam ilies, elderly people and the unem ployed, areleast able to eat w ell.

D ietary goals to prevent chronic diseases

em phasize eating m ore fresh vegetables, fruits and

pulses (legum es) and m ore m inim ally processed

starchy foods, but less anim al fat, refined sugars

and salt. M ore than 100 expert com m ittees have

agreed on these dietary goals.

Policy im plication sLocal, national and international governm ent

agencies, nongovernm ental organizations and the

food industry should ensure:

1.the availability of high-quality, fresh food to all,

regardless of their circum stances;2.dem ocratic decision-m aking and accountability

in all food regulation m atters, w ith participation

by all stakeholders, including consum ers;

3.support for sustainable agriculture and food

production m ethods that conserve natural

resources and the environm ent;

4.the protection of locally produced foods from

the inroads of the global food trade;5.a stronger food culture for health, fostering

peoples know ledge of food and nutrition,

cooking skills and the social value of preparing

food and eating together;

6.the availability of useful inform ation about food,

diet and health; and

7.the use of scientifically based nutrient reference

values and food-based dietary guidelines tofacilitate the developm ent and im plem entation

of policies on food and nutrition.t ion

25

TRANSPORT10


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Healthy transport m eans reducingdriving and encouraging m ore w alkingand cycling, backed up by b ette r public

transport .

The eviden ceC ycling, w alking and the use of public transport

prom ote health in four w ays. They provide

exercise, reduce fatal accidents, increase social

contact and reduce air pollution.

Because m echanization has reduced the exercise

involved in jobs and house w ork, people need to

find new w ays of building exercise into their lives.

This can be done by reducing the reliance on cars,

increasing w alking and cycling and expanding

public transport. Regular exercise protects against

heart disease and, by lim iting obesity, reduces theonset of diabetes. It prom otes a sense of

w ellbeing and protects older people from

depression.

Reducing road traffic w ould reduce the toll of

road deaths and serious accidents. A lthough

accidents involving cars injure cyclists and

pedestrians, those involving cyclists injurerelatively few people. W ell planned urban

environm ents, w hich separate cyclists and

pedestrians from car traffic, increase the safety of

cycling and w alking.

M ore cycling and w alking, plus greater use of

public transport, w ould stim ulate social

interaction on the streets, w here cars haveinsulated people from each other. Road traffic

separates com m unities and divides one side of

the street from the other. Few er pedestrians m ean

that streets cease to be social spaces, so thatisolated pedestrians often fear attack. Further,

suburbs that depend on cars for access isolate

people w ithout cars, particularly the young and

old. Social isolation and lack of com m unity

interaction are strongly associated w ith poorer

health.

Reduced road traffic m eans decreasing harm fulpollution from exhaust. W alking and cycling m ake

m inim al use of non-renew able fuels and do not

lead to global w arm ing. They do not create

disease from air pollution, m ake little noise and

are preferable for the ecologically com pact cities

of the future. Bicycles, w hich can be

m anufactured locally, have a good ecological

footprintin contrast to cars.

Policy im plication sD espite their health-dam aging effects, journeys

by car are rising rapidly in all European countries,

w hile journeys by foot or bicycle are falling.

N ational and local public policies m ust reverse

these trends. Yet transport lobbies have strong

vested interests. M any industries oil, rubber,road building, car m anufacturing, sales and

repairs, and advertising benefit from the use of

cars. Just as the tw entieth century has seen a start

m ade on reducing addiction to tobacco, alcohol

and drugs, so the tw enty-first century m ust see a

reduction in peoples dependence on cars.

Roads should give precedence to cycling andw alking for short journeys, especially in tow ns.

Public transport should be im proved for longer

TRANSPORT

26

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KEY SOURCES

journeys, w ith regular and frequent connections

for rural areas. Incentives need to be changed;this m eans, for exam ple, reducing state subsidies

for road building, increasing financial support for

public transport, creating tax disincentives for the

business use of cars and increasing the costs and

penalties of parking. C hanges in land use are also

needed, such as: converting road space into green

spaces, rem oving car parking spaces, dedicating

roads to the use of pedestrians and cyclists,increasing bus and cycle lanes, and stopping the

grow th of low -density suburbs and out-of-tow n

superm arkets, w hich increase the use of cars.

Increasingly, the evidence suggests that building

m ore roads encourages m ore car use, w hile traffic

restrictions m ay, contrary to expectations, reduce

congestion.

DAVIES, A. Road transportand heal th. London , Bri t ishM edical Assoc iat ion, 199 7.

ELKIN, T. ET AL. Reviving th eci ty: towards sustainable

urban development. London,Friends of the Earth, 199 1.

On the s tate of heal th in theEuropean Union. Brussels,Comm iss ion o f the EuropeanCommu ni t ies, 199 6.

PRICE, C. & TSOU ROS, A., e d.Our ci t ies, our fu ture. Pol iciesand act ion plans for heal thand sustainable development.Copenhagen, WHO RegionalOffice for Europ e, 19 96

(document) .

Traf f ic impact of h igh waycapacity reductions. Sum maryrepor t . London , MVA andESRC Transpo rt Stud ies Unit ,Universi ty Col lege, Universi tyo f London, 1998.

oads should give precedence to cycl ing.Photob

y

FinnFrandsen,Polfoto

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Member States

Albania,Andorra,Armenia,Austria,Azerbaijan,Belarus,Belg ium,Bosnia and Herzegovina,Bulgaria,Croatia,Czech Republic,Denmark,Estonia,Finland,France,Georgia,Germany,Greece,Hungary,Iceland,Ireland,Israel,Italy,Kazakstan,Kyrgyzstan,Latvia,Lithuania,Luxembourg,Ma l t a ,Monaco,Netherlands,Norway,Poland,Portugal,Republ ic of M oldova,Romania,Russian Federatio n,San Marino,Slovakia,Slovenia,Spain,Sweden,Switzerland,Tajikistan,The Former Yugoslav Republ ic

of Macedonia,Turkey,Turkmenistan,Ukraine,

Uni ted Kingdom,Uzbekistan,Yugoslavia

The WHO Regiona l Officefor Europe

The Wor ld Heal th Organizat ion(WHO) is a specialized agencyof the Uni ted Nat ions createdin 1948 wi th pr imaryresponsib i l i ty for in ternat ionalheal th mat ters and publ ichealth . The WHO RegionalOffice for Europe is one ofs ix regional of f ices throughoutthe wor ld, each wi th i ts ownprogramme geared to thepar t icular heal th condi t ionsof the coun tries it serves.

C entre for U rban H ealth

W orld H ealth O rganization

Regional O ffice for Europe

Scherfigsvej 8,

D K-2100 C openhagen ,

D enm ark

Telephone +45 39 17 12 24

http://w w w .w ho.dk/tech/hcp/index.htm

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