1. Life chances v Lifestyles: the
Social Determinants of Health
Clare Bambra
Professor of Public Health Policy
Wolfson Research Institute for Health & Wellbeing

2. Overview
1. Inequalities in health and health behaviours (lifestyles) are socially
determined (life chances)
∂
2. Effective public health policy therefore needs to focus on altering
peoples life chances and getting beyond just looking at lifestyles
3. Evidence-based principles for policy and building on past Labour
successes

3. 1. Health Inequalities in the UK
• Infant mortality rates are 16% higher in children of routine and
manual workers as compared to professional and managerial workers
• Deaths from cardiovascular diseases are 2.7 times higher in the 20%
most deprived areas compared to the 20% least deprived
• ∂
Smoking rates are almost twice as high amongst routine and manual
workers as compared to professional and managerial workers (16% v
28% men, 14% v 24% women)
• Alcohol related hospital admissions are twice as high (2.6 times
men and 2.4 women) in the 20% most deprived areas compared to the
20% least deprived areas
• Obesity rates are higher in routine and manual groups particularly
amongst women (27% v 21% men) (34% to 14% women).

4. ∂

5. Lifestyle v Life chances
1. Is it all to do with differences in lifestyles?
OR
∂
2. Is it to do with differences in life chances?
Answer: Best available data from the Whitehall cohort studies shows that
25-40% due to lifestyle factors. Additionally, lifestyles are themselves
effected by life chances – the social determinants of health

6. 2. Life chances: the Social
Determinants of Health
∂

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

8. ∂

9. ∂

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

11. Example 2: Unemployment
•Mortality rates double
•Suicide up to 10 times
•Mental health problems
and long term illnesses ∂
•Worse health behaviours
•Dual mechanisms –
psychological and poverty

12. ∂

13. Unemployment & Health
Inequalities
• Unemployment concentrated in lower socio-economic classes
• Census 2001 in London, 81.5% of women with a degree were
employed compared to 51.8% with no qualifications.
∂
• Modelling suggests that adjusting for employment status
reduces health inequalities by up to 81%
• 5.6.% ill health in men home owners, 19.1% in social renting
(13% age-adjusted difference), adjust for employment status =
2.5% difference (81% reduction)

14. Educational gradient (prevalence difference in % points) in self rated general health with and without
adjustment for employment status (Women), Census 2001
10
9
8
Prevelance difference
7
6
5
4
∂
3
2
1
0
Level 4 / 5 Level 3 Level 2 Level 1 Other No qualifications
qualifications
Education
Age only Age plus employment status

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

16. 3. Life chances: Labour Policy
Successes
• Housing: more social housing built
• Health care: increased NHS spending, shorter waiting lists and
improved outcomes, more GPs in deprived areas
∂
• Education: new schools built, more teachers, Surestart Centres
• Work and unemployment: minimum wage, increased
employment levels and Future Jobs Fund, flexible working,
increased employment rights
• Food policy: health in pregnancy grant
• Environment: smoking ban

17. Infant mortality rates in England: routine and manual
socio-economic group compared with average
∂
Labour target: cut relative inequalities in infant mortality
rates between manual socio-economic groups and the
English average by 10% from 13% to 12%.

18. 4. Marmot Review
• Importance of life chances captured in the Labour government commissioned
Marmot Review.
• Six Policy Objectives:
1. Give every child the best start in life
∂
2. Enable all children, young people and adults to maximise their
capabilities and have control over their lives
3. Create fair employment and good work for all
4. Ensure healthy standard of living for all
5. Create and develop healthy and sustainable places and communities
6. Strengthen the role and impact of ill-health prevention
• Coalition policy focuses on 4 and 6 - lifestyle elements (e.g. responsibility deal,
White Paper talks about individual lifestyles, nudge etc)

19. 5. Three Principles for Policy
Dignity – in and out of work
 Labour success: Minimum wage
 Evidenced-based future option: Minimum Income for Healthy Living (or
Living Wage)
∂
The public provision of a minimum income to meet basic and social needs
relating to nutrition, physical activity, housing, psychosocial
interactions, transport, medical care and hygiene.
The MIHL for an older single person would be around £144.20 per week
(UK, 2008 prices). This was higher than the 60% of median income
poverty line (£115 per week), and more than the minimum pension
credit (£124.05 per week).

20. Equity – provision for all with more for the most in need
 Labour success: minimum pension credit
 Evidenced-based future option: proportionate universalism
∂
Intention of improving the health of all, but the health of the poorest the
most.
Interventions are universal ‘but with a scale and intensity that is
proportionate to the level of disadvantage’ - proportionate universalism.

21. Authority – control at work and in the community
 Labour success: right to flexible working
 Evidence-based future option: increased control and participation at
work
∂
Increasing control at work via employee participation and representation in
workplace committees – “participatory” or “problem-solving” committees
Control over hours of work
Control in the community – increased social participation has health
benefits

22. 6. Concluding Comment
Health Behaviours
Socio-economic
Status ∂ Health
(income/ Inequalities
Education/
occupation)

23. 7. References
Bambra (2011) Work, Worklessness and the Political Economy of Health
Bambra (2012)
Brunner et al (2007) Prospective Effect of Job Strain on General and Central Obesity in the
Whitehall II Study. American Journal of Epidemiology, 165, 828–37
Egan et al (2007) The psychosocial and health effects of workplace reorganisation 1: a
systematic review of organisational-level interventions that aim to increase employee
∂
control. Journal of Epidemiology and Community Health, 61, 945–54
Marmot Review (2010) Strategic Review of Health Inequalities in England post-2010.
Marmot et al (1997) Contribution of job control and other risk factors to social variations in
coronary heart disease. Lancet, 350, 235-40
Montgomery et al (1999) Unemployment, cigarette smoking, alcohol consumption and body
weight in young British men. European Journal of Public Health, 8, 21-27
Morris et al (2009) Defining a minimum income for healthy living (MIHL): older age, England.
International Journal of Epidemiology, 36, 1300-07
Popham and Bambra (2010) Evidence from the 2001 English Census on the contribution of
employment status to the social gradient in self-rated health. Journal of Epidemiology and
Community Health, 64, 277-80