This document discusses social determinants of health and health inequalities. It summarizes evidence that social and economic factors like income, education, employment, and housing have a significant impact on health outcomes and lifespan. Health issues like cancer, obesity, and mental health problems vary depending on socioeconomic status. Creating a fair society by addressing these social determinants through policies that support children, families, education, employment and housing can help reduce health inequities.
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Professor Sir Michael Marmot's Charles Cully Lecture on health inequalities and cancer
1. Fair Society Healthy Lives
Annual Irish Cancer Society Charles Cully Memorial
Lecture
2013
Michael Marmot
2. • Health inequalities: social gradient
• Social determinants: the causes of the causes
• Evidence into policy
3. The Commission on
Social Determinants of
Health (CSDH) – Closing
the gap in a generation
Strategic Review of Health
Inequalities in England:
The Marmot Review – Fair
Society Healthy Lives
Review of
Social
Determinants
of Health and
the Health
Divide in the
WHO Euro
Region
4. Deviation of life expectancy at birth from average
life expectancy by deprivation ranking: Ireland
Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011
5. Life expectancy by social class: Ireland
Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011
years
12. • Cancer is the second major cause of death in
Ireland, after cardiovascular disease,
• An average of nearly 30,000 new cases of cancer
are diagnosed each year.
• The number of newly diagnosed cancers is
increasing by 6-7% annually
• Largely due to increasing proportion of elderly
people
Source: Healthy Ireland: a framework for improved health and wellbeing 2013-2025
13. • Clearly identified modifiable risk factors: smoking,
unhealthy diet, physical inactivity, obesity
• Need to look at the causes of the causes of the
social and area distribution
14. Social determinants of health and health inequities
Socioeconomic
and political
context
Governance
Policy
Macroeconomic
Social
Health
Cultural and
societal norms
and values
Education
Occupation
Income
Gender
Ethnicity/race
Social position
Material circumstances
Social cohesion
Psychosocial factors
Behaviours
Biological factors
Health care system
Distribution of
health and
well-being
CSDH Conceptual Framework
15. A. Give every child the best start in life
B. Enable all children, young people and adults to maximise
their capabilities and have control over their lives
C. Create fair employment and good work for all
D. Ensure healthy standard of living for all
E. Create and develop healthy and sustainable places and
communities
F. Strengthen the role and impact of ill health prevention
Fair Society, Healthy Lives:
6 Policy Objectives
16. Obesity prevalence according to educational attainment,
averaged across 19 EU Member States
(Source: Eurothine 2007 reported in Robertson et al 2007)
17. 0 10 20 30
Latvia
Ireland
Finland
Spain
Norway
Portugal
Italy
Percent obese
Overall
prevalence of
obesity
Highest
education
Second Highest
Second Lowest
Lowest
education
0 10 20 30
England
Germany
Hungary
Sweden
Denmark
Estonia
Percentobese
Obesity and education level, females, Eurothine study
Low High
Source: Roskam et al.
18. Causes of the causes
• A life course approach
• Context matters
19. Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
20. Taxation revenue (Including social contributions) as a
percentage of GDP: Ireland and the EU
Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011
21. Total state expenditure v. total tax revenue (including
social contributions) in €ms: Ireland
Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 201
22. The effect of tax and benefit reforms on relative child poverty to
2020:
UK and Northern Ireland, incomes measured before housing costs
Source: IFS Report R78, 2013
23. Impact of modelled tax and benefit reforms since Jan 2010,
by income decile group (percentage points)
Source: IFS Green Budget 2013, Ch 7 Fig 7.4
24. Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
25. Early child care and education
• Parenting and family support
– Perinatal services
– Care before and during pregnancy
– Help for new mothers
• Pre-school education and care
• Primary, secondary and tertiary education and
training
26. Country comparison on average rank in four dimensions of
child wellbeing – material, health, education, behaviours &
risks, in early 2000s and late 2000s
UNICEF 2013
Report Card 11
27. Differences in PISA scores by attending preschool for more
than one year before and after accounting for socioeconomic
background
OECD PISA 2009 database
28. 0 10 20 30 40 50 60
Romania
Latvia
Bulgaria
Lithuania
Italy
Greece
Spain
Poland
Portugal
Luxembourg
Hungary
United Kingdom
Malta
Estonia
Switzerland
Ireland
Slovakia
France
Belgium
Netherlands
Germany
Austria
Czech Republic
Sweden
Finland
Cyprus
Slovenia
Denmark
Norway
Iceland
Poverty rate
Before social transfers After social transfers
Child poverty rates <60%
median before and after
social transfers 2009
Source: EU SILC
29. Children achieving a good level of development at age five, local
authorities 2011: England
Source: LHO (2012)
30. Areas for improving outcomes:
• Child Development
– Cognitive
– Communication & language
– Social & emotional
– Physical
• Parenting
– Safe and healthy environment
– Active learning
– Positive parenting
• Parent’s lives
– Mental wellbeing
– Knowledge & skills
– Financially self-supporting
31. Birmingham Brighter Futures
• Aims to improve the lives of all the city's children
and young people;
• Focus on improving children’s physical health,
literacy and numeracy, behaviour, emotional
health, social literacy, and job skills.
• Specific programmes relevant to early years
include: Family Nurse Partnership (FNP),
Incredible Years Parenting Programme, Promoting
Alternative Thinking Strategies (PATHS), Triple P
Parenting Programme.
32. Per cent 5 year olds achieving ‘good development
score’,* Birmingham LA, West Midlands & England
*in personal, social and emotional development
and communication, language and literacy
Source: Department for Education: preliminary data
%
33. Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
34. Occupational stress in European countries
0
10
20
30
40
50
Very low Low High Very high
Effort reward
imbalance
Low control
Per cent
Occupational class
35. Unemployment rates by education and country of
origin in selected countries
Source:
Eurostat
database
36. Evidence from previous economic downturns
suggests that population health will be affected:
• More suicides and attempted suicides; possibly more
homicides and domestic violence
• Fewer road traffic fatalities
• An increase in mental health problems, including
depression, anxiety and lower levels of wellbeing
• Worse infectious disease outcomes such as TB +
HIV
• Negative longer-term mortality effects
• Health inequalities are likely to widen
38. Social Protections: unemployment and suicide
Each 100 USD per
capita greater social
spending reduced the
effect on suicides by:
0.38%, active labour
market programmes
0.23%, family support
0.07%, healthcare
0.09%,unemployment
benefits Spending> 190 USD no effect of
unemployment on suicide
Source: Stuckler et al 2009 Lancet
39. Income, employment, housing and
health
• Unemployment, low incomes and poor
housing contribute to worse health;
• These problems are more likely to occur
among particular groups within the
population and among those already on low
incomes.
41. Rough sleeping counts and estimates by
London and rest of England
Housing Statistical Release Autumn 2012 DCLG
Number
42. We can do better:
• Political prioritisation of health equity
– Advocacy
– Leadership
• Development of effective interventions
• Measure and monitor
CSDH 3 principles of action: Improve the conditions of daily life Tackle the inequitable distribution of power, money and resources – globally, nationally and locally Measure the problem, evaluate action, expand the knowledge base, develop the work force
Source: Central Statistics Office (2010A, p3) Mortality Differentials in Ireland [online]. Available at: http://www.cso.ie/ census/documents/Mortality_Differentials_in_Ireland.pdf [20 January 2010]. 2.19 Social class was also a strong predictor of life expectancy (
Source: Central Statistics Office (2010B, p3) Mortality Differentials in Ireland [online]. Available at: http://www.cso.ie/ census/documents/Mortality_Differentials_in_Ireland.pdf [20 January 2010].
Cancer is the second major cause of death in Ireland, after cardiovascular disease, accounting for over 8,000 deaths per year. [12] An average of nearly 30,000 new cases of cancer are diagnosed each year. [13] This is 50% more cancers per year than in the mid-1990s. The number of newly diagnosed cancers is increasing by 6-7% annually and unless a major reversal of trends occurs in the near future, the number is likely to double in the next 20 years. [14] The underlying risk of developing cancer is increasing by less than 1% annually and the expected increase is primarily due to the higher proportion of elderly people in the population but may also be influenced by the projected growth in the total population. This is the biggest predicted rise in the 27 EU Member States. [15]
Commission on Social Determinants of Health Conceptual Framework
Fig 2.8, page 25 in Obesity and socio-economic groups in Europe: Evidence review and implications for action” A Robertson, T Lobstein, C Knai
Fig.4.18 Child and Working-Age Poverty in Northern Ireland from 2010 to 2020 IFS Report R78 James Browne; Andrew Hood; Robert Joyce
The tables are ranked by each country’s average rank in four dimensions of child well-being – material well-being, health, education, and behaviours and risks – for which comparable data are available towards the beginning and end of the first decade of the 2000s.
Values are all statistically significant Source: OECD PISA 2009 database, Table II.5.5.
‘ possibly’ means the evidence is less strong for these health outcomes Homicides= killing another human, includes murder, manslaughter… Fewer road traffic fatalities likely because lower incomes means less car use (and less commuting to work because of unemployment?) Those infectious diseases likely to increase will depend on location-specific factors such as existing prevalence of infectious diseases within the population Short-term mortality effects are less clear-cut
Trends in the numbers of suicides and unemployment claimants in England, 2000-10, by sex
Homeless: Number of London households accepted as homeless by LAs between 2010 and 2011 rose by 20.4% (from 9700 to 11,680). It was reported the number of rough sleepers rose by 8%, while those under 25 rose by at least 32%. Overcrowding: number of children in overcrowded housing increased by 18% in London between 2008-11, to 24% of all children. Fuel poverty: Over half a million (560,000) Londoners live in fuel poverty. Eg. Unemployed individuals, particularly the LT unemployed, have a higher risk of poor mental and physical health compared with those in employment. The health and social effects resulting from a long period of unemployment can last for years. Self-rated health can also be worse in an economic downturn for those who remain in work. Particular groups = those more likely to become unemployed (low skilled/edu, men, young people); those on low incomes.
Neighbourhoods affordable to housing benefit recipients in 2011 and 2016