BHD421 Module 1 Discussion
HOMEWORK ASSIGNMENT
The WHO has published an important document titled, Social Determinants of HealthThe Solid Facts. It states:
Even in the most affluent countries, people who are less well off have substantially shorter life expectancies and more illnesses than the rich. Not only are these differences in health an important social injustice, they have also drawn scientific attention to some of the most powerful determinants of health standards in modern societies. They have led in particular to a growing understanding of the remarkable sensitivity of health to the social environment and to what have become known as the social determinants of health.
http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
1. In your opinion, are social determinants of health more important for a health educator to understand than the biological/genetic determinants of health?
2. Additionally, if the social determinants of health are so critical to ones health outcomes how can health education improve the social environment/condition of persons most affected by social determinants? Please post your response by the end of this module and critique the response of at least one other student. Please provide at least two paragraphs for your response.
PLEASE SEE ATTACHMENT FOR READING ATTACHMENT
Member States
Albania
Andorra
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Austria
Azerbaijan
Belarus
Belgium
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Bulgaria
Croatia
Cyprus
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Denmark
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Finland
France
Georgia
Germany
Greece
Hungary
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Ireland
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Italy
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Kyrgyzstan
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Norway
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Portugal
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Romania
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Republic of Macedonia
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United Kingdom
Uzbekistan
The WHO Regional
Offi ce for Europe
The World Health
Organization (WHO) is
a specialized agency
of the United Nations
created in 1948 with
primary responsibility
for international
health matters and
public health. The WHO
Regional Offi ce for
Europe is one of
six regional offi ces
throughout the world,
each with its own
programme geared to
the particular health
conditions of the
countries it serves.
International
Centre for
Health and
Society
SOCIAL
DETERMINANTS
OF HEALTH
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 infl uences 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 determinants
of 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 and
advocates. This publication provides the facts and the policy
options that will enable them to act.
ISBN 92 890 1371 0
World Health Organization
Regional Offi ce for Europe
Scherfi gsvej 8
DK-2100 Copenhagen
Denmark
Tel.: +45 39 17 17 17
Fax: +45 39 17 18 18
E-mail: [emailprotected]
Web site: www.euro.who.int
SOCIAL
DE TER MI NANTS
OF HEALTH
Edited by Richard Wilkinson and Michael Marmot
SECOND EDITION
THETHE
SOLIDSOLID
FACTSFACTS
WHO Library Cataloguing in Publication Data
Social determinants of health: the solid facts. 2nd edition / edited by
Richard Wilkinson and Michael Marmot.
1.Socioeconomic factors 2.Social environment 3.Social support
4.Health behavior 5.Health status 6.Public health 7.Health promotion
8.Europe I.Wilkinson, Richard II.Marmot, Michael.
ISBN 92 890 1371 0 (NLM Classification : WA 30)
Address requests about publications of the WHO Regional Office to:
by e-mail
by post
[emailprotected] (for copies of publications)
[emailprotected] (for permission to reproduce them)
[emailprotected] (for permission to translate them)
Publications
WHO Regional Office for Europe
Scherfigsvej 8
DK-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 part
of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Where the designation country or area appears in
the headings of tables, it covers countries, territories, cities, or areas. Dotted
lines on maps represent approximate border lines for which there may not yet
be full agreement.
The mention of specific companies or of certain manufacturers products does
not 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. Errors
and omissions excepted, the names of proprietary products are distinguished
by initial capital letters.
The World Health Organization does not warrant that the information contained
in 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
not necessarily represent the decisions or the stated policy of the World Health
Organization.
Printed in Denmark
ISBN 92 890 1371 0
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
4
The World Health Organization was established in 1948
as a specialized agency of the United Nations serving as
the directing and coordinating authority for international
health matters and public health. One of WHOs
constitutional functions is to provide objective and reliable
information and advice in the field of human health, a
responsibility that it fulfils in part through its publications
programmes. Through its publications, the Organization
seeks to support national health strategies and address the
most pressing public health concerns.
The WHO Regional Office for Europe is one of six
regional offices throughout the world, each with its own
programme geared to the particular health problems of
the countries it serves. The European Region embraces
some 870 million people living in an area stretching from
Greenland in the north and the Mediterranean in the
south to the Pacific shores of the Russian Federation.
The European programme of WHO therefore concentrates
both on the problems associated with industrial and
post-industrial society and on those faced by the emerging
democracies of central and eastern Europe and the former
USSR.
To ensure the widest possible availability of authoritative
information and guidance on health matters, WHO
secures broad international distribution of its publications
and encourages their translation and adaptation. By
helping to promote and protect health and prevent and
control disease, WHOs books contribute to achieving the
Organizations principal objective the attainment by all
people of the highest possible level of health.
WHO Centre for Urban Health
This publication is an initiative of the Centre for Urban
Health, at the WHO Regional Office for Europe. The
technical focus of the work of the Centre is on developing
tools and resource materials in the areas of health
policy, integrated planning for health and sustainable
development, urban planning, governance and social
support. The Centre is responsible for the Healthy Cities
and urban governance programme.
The need and demand for clear scientific
evidence to inform and support the health policy-
making process are greater than ever. The field
of the social determinants of health is perhaps
the most complex and challenging of all. It is
concerned with key aspects of peoples living and
working circumstances and with their lifestyles.
It is concerned with the health implications of
economic 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 the
first edition of Social determinants of health. The
solid facts in 1998, new and stronger scientific
evidence has been developed. This second edition
integrates the new evidence and is enriched with
graphs, further reading and recommended web
sites.
Our goal is to promote awareness, informed
debate and, above all, action. We want to build
on the success of the first edition, which was
translated into 25 languages and used by decision-
makers at all levels, public health professionals
and academics throughout the European Region
and beyond. The good news is that an increasing
number of Member States today are developing
policies and programmes that explicitly address the
root causes of ill health, health inequalities and the
needs of those who are affected by poverty and
social disadvantage.
This publication was achieved through close
partnership between the WHO Centre for Urban
Health and the International Centre for Health
and Society, University College London, United
Kingdom. I should like to express my gratitude
to Professor Richard Wilkinson and Professor
Sir Michael Marmot, who edited the publication,
and to thank all the members of the scientific team
who contributed to this important piece of work.
I am convinced that it will be a valuable tool for
broadening the understanding of and stimulating
debate and action on the social determinants of
health.
Agis D. Tsouros
Head, Centre for Urban Health
WHO Regional Offi ce for Europe
5
F O R E W O R D
Professor Mel Bartley, University College London,
United Kingdom
Dr David Blane, Imperial College London, United
Kingdom
Dr Eric Brunner, International Centre for Health and
Society, University College London, United Kingdom
Professor Danny Dorling, School of Geography,
University of Leeds, United Kingdom
Dr Jane Ferrie, University College London, United
Kingdom
Professor Martin Jarvis, Cancer Research UK, Health
Behaviour Unit, University College London, United
Kingdom
Professor Sir Michael Marmot, Department of
Epidemiology and Public Health and International
Centre for Health and Society, University College
London, United Kingdom
Professor Mark McCarthy, University College London,
United Kingdom
Dr Mary Shaw, Department of Social Medicine, Bristol
University, United Kingdom
Professor Aubrey Sheiham, International Centre for
Health and Society, University College London, United
Kingdom
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, University
College London, United Kingdom
Professor Richard Wilkinson, University of Nottingham,
United Kingdom
C O N T R I B U T O R S
6
I N T R O D U C T I O N
Even in the most affluent countries, people
who are less well off have substantially shorter
life expectancies and more illnesses than the
rich. Not only are these differences in health an
important social injustice, they have also drawn
scientific attention to some of the most powerful
determinants of health standards in modern
societies. They have led in particular to a growing
understanding of the remarkable sensitivity of
health to the social environment and to what
have become known as the social determinants of
health.
This publication outlines the most important parts
of this new knowledge as it relates to areas of
public policy. The ten topics covered include the
lifelong importance of health determinants in
early childhood, and the effects of poverty, drugs,
working conditions, unemployment, social support,
good food and transport policy. To provide the
background, we start with a discussion of the social
gradient in health, followed by an explanation
of how psychological and social influences affect
physical health and longevity.
In each case, the focus is on the role that public
policy can play in shaping the social environment
in ways conducive to better health: that focus is
maintained whether we are looking at behavioural
factors, such as the quality of parenting, nutrition,
exercise and substance abuse, or at more structural
issues such as unemployment, poverty and the
experience of work. Each of the chapters contains
a brief summary of what has been most reliably
established by research, followed by a list of
implications for public policy. A few key references
to the research are listed at the end of each
chapter, but a fuller discussion of the evidence
can be found in Social determinants of health
(Marmot M, Wilkinson RG, eds. Oxford, Oxford
University Press, 1999), which was prepared to
accompany the first edition of Social determinants
of health. The solid facts. For both publications,
we are indebted to researchers in the forefront
of their fields, most of whom are associated with
the International Centre for Health and Society at
University College London. They have given their
time and expertise to draft the different chapters
of both these publications.
Health policy was once thought to be about little
more than the provision and funding of medical
care: the social determinants of health were
discussed only among academics. This is now
changing. While medical care can prolong survival
and improve prognosis after some serious diseases,
more important for the health of the population
as a whole are the social and economic conditions
that make people ill and in need of medical
care in the first place. Nevertheless, universal
access to medical care is clearly one of the social
determinants of health.
Why also, in a new publication on the determinants
of health, is there nothing about genes? The
new discoveries on the human genome are
exciting in the promise they hold for advances
in the understanding and treatment of specific
diseases. But however important individual genetic
susceptibilities to disease may be, the common
causes of the ill health that affects populations are
environmental: they come and go far more quickly
than the slow pace of genetic change because they
reflect the changes in the way we live. This is why
life expectancy has improved so dramatically over
recent generations; it is also why some European
7
countries have improved their health while others
have not, and it is why health differences between
different social groups have widened or narrowed
as social and economic conditions have changed.
The evidence on which this publication is based
comes from very large numbers of research
reports many thousands in all. Some of the
studies have used prospective methods, sometimes
following tens of thousands of people over
8
decades sometimes from birth. Others have
used cross-sectional methods and have studied
individual, area, national or international data.
Difficulties that have sometimes arisen (perhaps
despite follow-up studies) in determining causality
have been overcome by using evidence from
intervention studies, from so-called natural
experiments, and occasionally from studies of
other primate species. Nevertheless, as both health
and the major influences on it vary substantially
Peoples
lifestyles and
the conditions
in which
they live and
work strongly
influence their
health.
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according to levels of economic development, the
reader should keep in mind that the bulk of the
evidence on which this publication is based comes
from rich developed countries and its relevance to
less developed countries may be limited.
Our intention has been to ensure that policy at
all levels in government, public and private
institutions, workplaces and the community takes
proper account of recent evidence suggesting a
wider responsibility for creating healthy societies.
But a publication as short as this cannot provide
a comprehensive guide to determinants of public
health. Several areas of health policy, such as
the need to safeguard people from exposure to
toxic materials at work, are left out because they
are well known (though often not adequately
enforced). As exhortations to individual behaviour
change are also a well established approach to
health promotion, and the evidence suggests they
may sometimes have limited effect, there is little
about what individuals can do to improve their
own health. We do, however, emphasize the need
to understand how behaviour is shaped by the
environment and, consistent with approaching
health through its social determinants, recommend
environmental changes that would lead to
healthier behaviour.
Given that this publication was put together from
the contributions of acknowledged experts in
each field, what is striking is the extent to which
the sections converge on the need for a more
just and caring society both economically and
socially. Combining economics, sociology and
psychology with neurobiology and medicine, it
looks as if much depends on understanding the
interaction between material disadvantage and its
social meanings. It is not simply that poor material
circumstances are harmful to health; the social
meaning of being poor, unemployed, socially
excluded, or otherwise stigmatized also matters.
As social beings, we need not only good material
conditions but, from early childhood onwards,
we need to feel valued and appreciated. We need
friends, we need more sociable societies, we need
to feel useful, and we need to exercise a significant
degree of control over meaningful work. Without
these we become more prone to depression, drug
use, anxiety, hostility and feelings of hopelessness,
which all rebound on physical health.
We hope that by tackling some of the material
and social injustices, policy will not only improve
health and well-being, but may also reduce a range
of other social problems that flourish alongside
ill health and are rooted in some of the same
socioeconomic processes.
Richard Wilkinson and Michael Marmot
Life expectancy is shorter and most diseases are
more common further down the social ladder in
each society. Health policy must tackle the social
and economic determinants of health.
What is known
Poor social and economic circumstances affect
health throughout life. People further down the
social ladder usually run at least twice the risk of
serious illness and premature death as those near
the top. Nor are the effects confined to the poor:
the social gradient in health runs right across
society, so that even among middle-class office
workers, lower ranking staff suffer much more
disease and earlier death than higher ranking staff
(Fig. 1).
Both material and psychosocial causes contribute to
these differences and their effects extend to most
diseases and causes of death.
Disadvantage has many forms and may be absolute
or relative. It can include having few family assets,
having a poorer education during adolescence,
having insecure employment, becoming stuck in a
hazardous or dead-end job, living in poor housing,
trying to bring up a family in difficult circumstances
and living on an inadequate retirement pension.
These disadvantages tend to concentrate among
the same people, and their effects on health
accumulate during life. The longer people live in
stressful economic and social circumstances, the
greater the physiological wear and tear they suffer,
and the less likely they are to enjoy a healthy old
age.
Policy implications
If policy fails to address these facts, it not only
ignores the most powerful determinants of health
standards in modern societies, it also ignores one
of the most important social justice issues facing
modern societies.
Life contains a series of critical transitions:
emotional and material changes in early
childhood, the move from primary to secondary
education, starting work, leaving home and
starting a family, changing jobs and facing
possible redundancy, and eventually retirement.
Each of these changes can affect health by
pushing people onto a more or less advantaged
path. Because people who have been
disadvantaged in the past are at the greatest risk
in each subsequent transition, welfare policies
need to provide not only safety nets but also
springboards to offset earlier disadvantage.
10
Professional
Skilled non-
manual
Managerial
and technical
64
LIFE EXPECTANCY (YEARS)
Skilled
manual
Partly skilled
manual
Unskilled
manual
Men Women
66 68 70 72 74 76 78 80 82 84
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1 . T H E S O C I A L G R A D I E N T
Fig. 1. Occupational class differences in life
expectancy, England and Wales, 19971999
11
KEY SOURCES
Bartley M, Plewis I. Accumulated labour market disadvantage and
limiting 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 of
Epidemiology, 2002, 31:831838.
Montgomery SM, Berney LR, Blane D. Prepubertal stature and
blood pressure in early old age. Archives of Disease in Childhood,
2000, 82:358363.
Morris JN et al. A minimum income for healthy living. Journal of
Epidemiology and Community Health, 2000, 54:885889.
Good health involves
reducing levels of
educational failure,
reducing insecurity
and unemployment
and improving housing
standards. Societies that
enable all citizens to play
a full and useful role
in the social, economic
and cultural life of their
society will be healthier
than those where people
face insecurity, exclusion
and deprivation.
Other chapters of this
publication cover specific
policy areas and suggest
ways of improving health
that will also reduce the
social gradient in health.
Programme Committee on Socio-economic Inequalities in Health
(SEGV-II). Reducing socio-economic inequalities in health. The
Hague, Ministry of Health, Welfare and Sport, 2001.
van de Mheen H et al. Role of childhood health in the explanation
of socioeconomic inequalities in early adult health. Journal of
Epidemiology and Community Health, 1998, 52:1519.
Source of Fig. 1: Donkin A, Goldblatt P, Lynch K. Inequalities in life
expectancy by social class 19721999. Health Statistics Quarterly,
2002, 15:515.
Poor social and economic circumstances affect health throughout life.
J
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Stressful circumstances, making people feel
worried, anxious and unable to cope, are
damaging to health and may lead to premature
death.
What is known
Social and psychological circumstances can cause
long-term stress. Continuing anxiety, insecurity,
low self-esteem, social isolation and lack of control
over work and home life, have powerful effects on
health. Such psychosocial risks accumulate during
life and increase the chances of poor mental health
and premature death. Long periods of anxiety and
insecurity and the lack of supportive friendships
are damaging in whatever area of life they arise.
The lower people are in the social hierarchy of
industrialized countries, the more common these
problems become.
Why do these psychosocial factors affect physical
health? In emergencies, our hormones and nervous
system prepare us to deal with an immediate
physical threat by triggering the fight or flight
response: raising the heart rate, mobilizing stored
energy, diverting blood to muscles and increasing
alertness. Although the stresses of modern urban
life rarely demand strenuous or even moderate
Lack of control
over work and
home can have
powerful effects
on health.
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2 . S T R E S S
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KEY SOURCES
Brunner EJ. Stress and the biology of inequality. British Medical
Journal, 1997, 314:14721476.
Brunner EJ et al. Adrenocortical, autonomic and inflammatory
causes of the metabolic syndrome. Circulation, 2002, 106:
26592665.
Kivimaki M et al. Work stress and risk of cardiovascular
mortality: 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 risk
factors 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 many
physiological processes important to long-term
health maintenance. Both the cardiovascular and
immune systems are affected. For brief periods, this
does not matter; but if people feel tense too often
or the tension goes on for too long, they become
more vulnerable to a wide range of conditions
including infections, diabetes, high blood pressure,
heart attack, stroke, depression and aggression.
Policy implications
Although a medical response to the biological
changes that come with stress may be to try to
control them with drugs, attention should be
focused upstream, on reducing the major causes of
chronic stress.
In schools, workplaces and other institutions, the
quality of the social environment and material
security are often as important to health as
the physical environment. Institutions that can
give people a sense of belonging, participating
and being valued are likely to be healthier
places than those where people feel excluded,
disregarded and used.
Governments should recognize that welfare
programmes need to address both psychosocial
and material needs: both are sources of anxiety
and insecurity. In particular, governments should
support families with young children, encourage
community activity, combat social isolation,
reduce material and financial insecurity,
and promote coping skills in education and
rehabilitation.
Important foundations of adult health are laid in early childhood.
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A good start in life means supporting mothers
and young children: the health impact of early
development and education lasts a lifetime.
What is known
Observational research and intervention studies
show that the foundations of adult health are laid
in early childhood and before birth. Slow growth
and poor emotional support raise the lifetime
risk of poor physical health and reduce physical,
cognitive and emotional functioning in adulthood.
Poor early experience and slow growth become
embedded in biology during the processes of
development, and form the basis of the individuals
health because of the continued malleability of
biological systems. As cognitive, emotional and
sensory inputs programme the brains responses,
insecure emotional attachment and poor
stimulation can lead to reduced readiness for
school, low educational attainment, and problem
behaviour, and the risk of social marginalization
in adulthood. Good health-related habits, such as
eating sensibly, exercising and not smoking, are
associated with parental and peer group examples,
and with good education. Slow or retarded physical
growth in infancy is associated with reduced
cardiovascular, respiratory, pancreatic and kidney
development and function, which increase the risk
of illness in adulthood.
3 . E A R L Y L I F E
biological and human
capital, which affects
health throughout
life.
Poor circumstances
during pregnancy
can lead to less
than optimal fetal
development via
a chain that may
include deficiencies
in nutrition during
pregnancy, maternal
stress, a greater
likelihood of maternal
smoking and misuse
of drugs and alcohol,
insufficient exercise
and inadequate
prenatal care. Poor
fetal development is a
risk for health in later
life (Fig. 2).
Infant experience is
important to later
15
Policy implications
These risks to the developing child are significantly
greater among those in poor socioeconomic
circumstances, and they can best be reduced
through improved preventive health care before
the first pregnancy and for mothers and babies in
pre- and postnatal, infant welfare and school clinics,
and through improvements in the educational levels
of parents and children. Such health and education
programmes have direct benefits. They increase
parents awareness of their childrens needs and
their receptivity to information about health and
development, and they increase parental confidence
in 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 the
wealth 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 and
continuity across the life span. London, Penguin Books, 1993.
Wallace HM, Giri K, Serrano CV, eds. Health care of women and
children in developing countries, 2nd ed. Santa Monica, CA,
Third Party Publishing, 1995.
Source of Fig. 2: Barker DJP. Mothers, babies and disease in
later life, 2nd ed. Edinburgh, Churchill Livingstone, 1998.
Policies for improving health in early life should
aim to:
increase the general level of education
and provide equal opportunity of access to
education, to improve the health of mothers
and babies in the long run;
provide good nutrition, health education,
and health and preventive care facilities, and
adequate social and economic resources, before
first pregnancies, during pregnancy, and in
infancy, to improve growth and development
before birth and throughout infancy, and
reduce the risk of disease and malnutrition in
infancy; and
ensure that parentchild relations are
supported from birth, ideally through home
visiting and the encouragement of good
parental relations with schools, to increase
parental knowledge of childrens emotional
and cognitive needs, to stimulate cognitive
development and pro-social behaviour in the
child, and to prevent child abuse.
7
6
5
4
3
2
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)
BIRTH WEIGHT (KG)
<2.5 2.52.9 3.03.4 3.53.9 4.04.3 >4.3
Fig. 2. Risk of diabetes in men aged 64 years by
birth weight
Adjusted for body mass index
16
Life is short where its quality is poor. By causing
hardship and resentment, poverty, social exclusion
and discrimination cost lives.
What is known
Poverty, relative deprivation and social exclusion
have a major impact on health and premature
death, and the chances of living in poverty are
loaded heavily against some social groups.
Absolute poverty a lack of the basic material
necessi
