Social determinants of health inequalities

The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)71146-6/fulltex

International comparators and poverty and health in Europe

Summary points: In 1970 male life expectancy at age 15 was 56 in countries that now form the European Union; 55 in the communist countries of central and eastern Europe (excluding the Soviet Union); and 52 in the Soviet Union. In 1997 male life expectancy was 60 in the countries that now form the European Union; 54 in the former communist countries of central and eastern Europe (excluding the former Soviet Union); and 48 in Russia. The relative disadvantage for women was similar, but the absolute differences were smaller. Mortality changes after 1989 in eastern Europe were correlated with changes in gross domestic product and changes in income inequalities. In the 1980s there were inequalities in health within individual countries in eastern Europe; these were wider after 1989. Inequalities in health within individual countries in eastern Europe were more strongly related to education than to measures of economic wellbeing

Evidence based cardiology - Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies

Summary points: In healthy populations, prospective cohort studies show a possible aetiological role for type A/hostility (6/14 studies), depression and anxiety (11/11 studies), psychosocial work characteristics (6/10 studies), social support (5/8 studies). In populations of patients with coronary heart disease, prospective studies show a prognostic role for depression and anxiety (6/6 studies), psychosocial work characteristics (1/2 studies), and social support (9/10 studies); none of five studies showed a prognostic role for type A/hostility. Although this review can not discount the possibility of publication bias, prospective cohort studies provide strong evidence that psychosocial factors, particularly depression and social support, are independent aetiological and prognostic factors for coronary heart disease

Psychosocial and material pathways in the relation between income and health: a response to Lynch et al

Summary points: Economic and social circumstances affect health through the physiological effects of their emotional and social meanings and the direct effects of material circumstances. Material conditions do not adequately explain health inequalities in rich countries. The relation between smaller inequalities in income and better population health reflects increased psychosocial wellbeing. In rich countries wellbeing is more closely related to relative income than absolute income. Social dominance, inequality, autonomy, and the quality of social relations have an impact on psychosocial wellbeing and are among the most powerful explanations for the pattern of population health in rich countries

Building health: an epidemiological study of "sick building syndrome" in the Whitehall II study

Objectives: Sick building syndrome (SBS) is described as a group of symptoms attributed to the physical environment of specific buildings. Isolating particular environmental features responsible for the symptoms has proved difficult. This study explores the role and significance of the physical and psychosocial work environment in explaining SBS. Methods: Cross sectional data on the physical environment of a selection of buildings were added to individual data from the Whitehall II study—an ongoing health survey of office based civil servants. A self-report questionnaire was used to capture 10 symptoms of the SBS and psychosocial work stress. In total, 4052 participants aged 42–62 years working in 44 buildings were included in this study. Results: No significant relation was found between most aspects of the physical work environment and symptom prevalence, adjusted for age, sex, and employment grade. Positive (non-significant) relations were found only with airborne bacteria, inhalable dust, dry bulb temperature, relative humidity, and having some control over the local physical environment. Greater effects were found with features of the psychosocial work environment including high job demands and low support. Only psychosocial work characteristics and control over the physical environment were independently associated with symptoms in the multivariate analysis. Conclusions: The physical environment of office buildings appears to be less important than features of the psychosocial work environment in explaining differences in the prevalence of symptoms

Should socioeconomic factors be considered as traditional risk factors for cardiovascular disease, as confounders, or as risk modifiers?

A large number of studies show that cardiovascular disease and its traditional risk factors are associated with socioeconomic conditions. However, their etiological role in the development of cardiovascular outcomes is not always well understood. In particular, it is unclear whether socioeconomic factors should be considered as traditional risk factors for CVD, as confounders, or as risk modifiers. In this article, after examining whether socioeconomic conditions meet the criteria for the three definitions, we argue that none of them fully captures the complexity of their contribution in shaping the epidemic of heart disease across and within societies. We argue instead that socioeconomic factors are the “causes of the causes” of heart disease. Implications for research and interventions to reduce heart disease are discussed

Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study

Objective: To determine whether access to cardiac procedures and drugs contributes to social and ethnic differences in coronary heart disease in a population setting. Design: Prospective study with follow up over 15 years. Civil service employment grade was used as a measure of individual socioeconomic position. Need for cardiac care was determined by the presence of angina, myocardial infarction, and coronary risk factors. Setting: 20 civil service departments originally located in London. Participants: 10 308 civil servants (3414 women; 560 South Asian) aged 35-55 years at baseline in 1985-8. Main outcome measures: Use of exercise electrocardiography, coronary angiography, and coronary revascularisation procedures and secondary prevention drugs. Results: Inverse social gradients existed in incident coronary morbidity and mortality. South Asian participants also had higher rates than white participants. After adjustment for clinical need, social position showed no association with the use of cardiac procedures or secondary prevention drugs. For example, men in the low versus high employment grade had an age adjusted odds ratio for angiography of 1.87 (95% confidence interval 1.32 to 2.64), which decreased to 1.27 (0.83 to 1.94) on adjustment for clinical need. South Asians tended to be more likely to have cardiac procedures and to be taking more secondary prevention drugs than white participants, even after adjustment for clinical need. Conclusion: This population based study, which shows the widely observed social and ethnic patterning of coronary heart disease, found no evidence that low social position or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need. Differences in medical care are unlikely to contribute to social or ethnic differences in coronary heart disease in this cohort

Household item ownership and self-rated health: material and psychosocial explanations

Background: There has been an ongoing debate whether the effects of socioeconomic factors on health are due to absolute poverty and material factors or to relative deprivation and psychosocial factors. In the present analyses, we examined the importance for health of material factors, which may have a direct effect on health, and of those that may affect health indirectly, through psychosocial mechanisms.Methods: Random national samples of men and women in Hungary (n=973) and Poland (n=1141) were interviewed (response rates 58% and 59%, respectively). The subjects reported their self-rated health, socioeconomic circumstances, including ownership of different household items, and perceived control over life. Household items were categorised as "basic needs", "socially oriented", and "luxury". We examined the association between the ownership of different groups of items and self-rated health. Since the lists of household items were different in Hungary and Poland, we conducted parallel identical analyses of the Hungarian and Polish data.Results: The overall prevalence of poor or very poor health was 13% in Poland and 25% in Hungary. Education, material deprivation and the number of household items were all associated with poor health in bivariate analyses. All three groups of household items were positively related to self-rated health in age-adjusted analyses. The relation of basic needs items to poor health disappeared after controlling for other socioeconomic variables (mainly material deprivation). The relation of socially oriented and luxury items to poor health, however, persisted in multivariate models. The results were similar in both datasets.Conclusions: These data suggest that health is influenced by both material and psychosocial aspects of socioeconomic factors

Neighbourhoods and self rated health: a comparison of public sector employees in London and Helsinki

Study objective: Mortality and morbidity vary across neighbourhoods and larger residential areas. Effects of area deprivation on health may vary across countries, because of greater spatial separation of people occupying high and low socioeconomic positions and differences in the provision of local services and facilities. Neighbourhood variations in health and the contribution of residents' characteristics and neighbourhood indicators were compared in London and Helsinki, two settings where inequality and welfare policies differ.Design: Data from two cohorts were used to investigate associations between self rated health and neighbourhood indicators using a multilevel approach.Setting: London and Helsinki.Participants: From the Whitehall II study (London, aged 39-63) and the Helsinki health study (aged 40-60).Main results: Socioeconomic segregation was higher in London than in Helsinki. Age and sex adjusted differences in self rated health between neighbourhoods were also greater in London. Independent of individual socioeconomic position, neighbourhood unemployment, proportion of residents in manual occupations, and proportion of single households were associated with health. In pooled data, residence in a neighbourhood with highest unemployment was associated with an odds ratio of less than good self rated health of 1.51 (95% CI 1.30 to 1.75). High rates of single parenthood were associated with health in London but not in Helsinki.Conclusions: Neighbourhood socioeconomic context was associated with health in both countries, with some evidence of greater neighbourhood effects in London. Greater socioeconomic segregation in London may have emergent effects at the neighbourhood level. Local and national social policies may reduce, or restrict, inequality and segregation between areas

Alcohol consumption is associated with increased all-cause mortality in Russian men and women: a cohort study based on the mortality of relatives

Objectives: To examine the relationships between frequency of alcohol consumption and of binge drinking and adult mortality in Russian men and women.Methods : Using modified indirect demographic techniques, a convenience cohort was constructed based on survey respondents? information about their close relatives. A random sample general population of the Russian Federation of 7172 respondents (response rate 61%) provided information on 10475 male and 3129 female relatives, including age, vital status and frequency of alcohol consumption and binge drinking. These relatives formed the cohort analysed in this report. The outcome measure was all-cause mortality after the age of 30 years.Findings: There was a strong linear relationship between frequency of drinking and of binge drinking and all-cause mortality in men; after controlling for smoking and calendar period of birth, the relative risk of death in daily drinkers compared to occasional drinkers was 1.52 (95% CI 1.33 ?1.75). Male binge drinkers had higher mortality than drinkers who did not binge, which persisted after adjustment for drinking frequency (adjusted RR 1.09 (1.00-1.19). In women, the increased mortality was confined to a small group of those who binged at least once a month (adjusted relative risk 2.68, 1.54-4.66). Conclusions: The results suggest a positive association between alcohol and mortality in Russia. There was no evidence for the protective effect of drinking seen in western populations. Alcohol appears to have contributed to the high long-term mortality rates in Russian men, but it is unlikely to be a major cause of female mortality. Objectives: To examine the relationships between frequency of alcohol consumption and of binge drinking and adult mortality in Russian men and women.Methods : Using modified indirect demographic techniques, a convenience cohort was constructed based on survey respondents? information about their close relatives. A random sample general population of the Russian Federation of 7172 respondents (response rate 61%) provided information on 10475 male and 3129 female relatives, including age, vital status and frequency of alcohol consumption and binge drinking. These relatives formed the cohort analysed in this report. The outcome measure was all-cause mortality after the age of 30 years.Findings: There was a strong linear relationship between frequency of drinking and of binge drinking and all-cause mortality in men; after controlling for smoking and calendar period of birth, the relative risk of death in daily drinkers compared to occasional drinkers was 1.52 (95% CI 1.33 ?1.75). Male binge drinkers had higher mortality than drinkers who did not binge, which persisted after adjustment for drinking frequency (adjusted RR 1.09 (1.00-1.19). In women, the increased mortality was confined to a small group of those who binged at least once a month (adjusted relative risk 2.68, 1.54-4.66). Conclusions: The results suggest a positive association between alcohol and mortality in Russia. There was no evidence for the protective effect of drinking seen in western populations. Alcohol appears to have contributed to the high long-term mortality rates in Russian men, but it is unlikely to be a major cause of female mortality