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Social determinants of health. Martin Bobak University College London. OSI conference on Graduate Public Health Education, Kiev, July 1-3, 2004 . Social determinants of health. Ubiquitous Powerful influence on health Underlie: Differences between individuals within countries

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social determinants of health

Social determinants of health

Martin Bobak

University College London

OSI conference on Graduate Public Health Education, Kiev, July 1-3, 2004

social determinants of health2
Social determinants of health
  • Ubiquitous
  • Powerful influence on health
  • Underlie:
    • Differences between individuals within countries
    • Differences between groups, populations and countries
    • Changes in health over time
  • Complex pathways
mortality at titanic by passenger class men and women
Mortality at Titanic by passenger class, men and women

Women

Children

From Broom L & Selznick P, 1968

global burden of disease from ezzati et al lancet 2002
Childhood and maternal undernutrition

Underweight

Iron deficiency

Vitamin A deficiency

Zinc deficiency

Other nutrition-related risk factors and physical activity

High blood pressure

High cholesterol

High BMI (overweight and obesity)

Low fruit and vegetable intake

Physical inactivity

Sexual and reproductive health

Unsafe sex

Lack of contraception

Addictive substances

Tobacco

Alcohol

Illicit drugs

Environmental risks

Unsafe water, sanitation, and hygiene

Urban outdoor air pollution

Indoor smoke from solid fuels

Lead

Global climate change

Occupational risks

Risk factors for injuries

Carcinogens

Airborne particulates

Ergonomic stressors

Noise

Other selected risks

Unsafe health-care injections

Childhood sexual abuse

Global Burden of DiseaseFrom Ezzati et al, Lancet 2002
slide9
Mean score of self-rated health in 25 European countries 1990-91 (higher score means worse health), men and women 35-64, from Carlson 1998.
slide10

LIFE EXPECTANCY AND INCOME FOR SELECTED

COUNTRIES AND TIME PERIODS

World Bank Development Report 1993

mortality ratios east west and low high social class in the uk men
Mortality ratios: East/West and Low/High social class in the UK, men

Chr Rhemat

Stroke

Bronchitis

CHD

Suicide

Ca rectum

Ca larynx

RTA

Ca lung

Melanoma

Ca lymphatic

Ca colon

Ca prostrate

mortality ratios east west and low high social class in the uk women
Mortality ratios: East/West and Low/High social class in the UK, women

TB

Stroke

Ca stomach

CHD

Ca rectum

Bronchitis

Ca uterus

Ca larynx

Suicide

Melanoma

Ca lung

Ca breast

slide14

Mortality rate ratio comparing lower to higher educational group for major causes of death, in Czech Republic, Hungary, Estonia and USA, men 45-59 years.

From Kunst, 1997

figure 17 cvd mortality by education and marital status in warsaw monica 10 yr follow up
Figure 17. CVD mortality by education and marital status in Warsaw MONICA, 10-yr follow-up.

Men

Women

slide18

Mean depression (CES-D) score by material deprivation in Czech Rep, Russia and Poland in 2000.

slide22
Figure 16. Changes in mortality (SMR) in Russia by education between 1988-89 and 1993-94 (from Shkolnikov).

+57%

MEN

WOMEN

+30%

+35%

+8%

SMR in 1988-89 = 100

increase in educational differentials in mortality between 1980s and 1990s in st petersburg men
Increase in educational differentials in mortality between 1980s and 1990s in St Petersburg men

From Plavinski et al 2003

trends in probability of survival in men by education relatives study
Trends in probability of survival in men by education (relatives’ study)

45 p20 = probability of living to 65 yrs when aged 20 yrs

slide25
Trends in birthweight by maternal education in the Czech Republic 1989-1996 (differences from primary educated)
death rates in russia 1980 2002 both genders per 100 000
Death rates in Russia 1980-2002both genders, per 100,000

Coup against

Gorbatchev,

breakup

of USSR

Rouble

crisis

Gorbatchev

elected

rr of cvd death by drinking frequency and mean dose per occasion in novosibirsk men
RR of CVD death by drinking frequency and mean dose per occasion in Novosibirsk men

5% of the men

From Malyutina et al, Lancet 2003

relative risk of all cause mortality by drinking frequency and bingeing in russian men n 8616
Relative risk of all cause mortality by drinking frequency and bingeing in Russian men (n=8616)

Adj. for age, smoking, calendar period of birth and relative

relative risk of all cause mortality by drinking frequency and bingeing in russian women n 2730
Relative risk of all cause mortality by drinking frequency and bingeing in Russian women (n=2730)

23/216 only

Adj. for age, smoking, calendar period of birth

trends in probability of survival in men by education relatives study35
Trends in probability of survival in men by education (relatives’ study)

45 p20 = probability of living to 65 yrs when aged 20 yrs

change in gdp after 1989 by country
Change in GDP after 1989 by country

Index , 1989 = 100

From Unicef, Social Monitor 2003

change in fertility after 1989
Change in fertility after 1989

Crude birth rate = live births / 1000 population

From Unicef, Social Monitor 2003

change in le by social stress in 12 russian regions 1989 94
CHANGE IN LE BY SOCIAL STRESS IN 12 RUSSIAN REGIONS, 1989-94

STRESS CAUSED BY UNEXPECTED SITUATIONS

CHANGE

IN MALE

LIFE

EXPECTANCY

*UNEMPLOYMENT, LABOUR TURNOVER,

CHANGE IN MARRIAGE AND DIVORCE RATE

(Cornia 1997)

slide41

CHANGE IN LIFE EXPECTANCY BY INCREASE IN

INCOME INEQUALITY, 1989-95

Cze

Slo

Svk

Pol

Hun

Bul

Rom

Mol

Lit

Est

Bel

Rus

Marmot & Bobak, BMJ 2001

slide43

Material factors

Social structure

(1)

(4)

Work

Brain

Neuro-

endocrine and immune

Psychosocial /

psychological

Social

Environment

(5)

(2)

Health

Behaviours

(3)

(6)

Patho-physiological

changes

Organ impairment

Early Life

Well-being

Mortality

Morbidity

Genes

Culture

slide45

Perceived control over own health

and perceived health

)

30

%

(

h

t

l

25

a

Rus

Est-Rus

e

Lat-Rus

h

Lit-Rus

Lat-Lat

r

o

20

Kal

o

Lit-Lit

p

Kau

f

o

Est-Est

15

e

c

Kr

n

e

10

l

War

a

v

r=-0.82 (p=0.001)

Cz

e

r

5

P

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

Perceived control over health

perceived control in national samples and all cause mortality
PERCEIVED CONTROL IN NATIONAL SAMPLES AND ALL CAUSE MORTALITY

RU

LA

ES

SDR all causes (per 100,000)

HU

PO

LI

CZ

CONTROL (AGE-SEX ADJUSTED)

Pikhart, 2000

policy response
Policy response
  • More difficult to quantify
  • Central European countries responded by policy measures to limit the impact of transition
  • Baltic countries responded later
  • FSU - the response was inadequate
  • Why has the policy response been so different?
contribution to risk factors to educational gradient in mortality in the st petersburg
Contribution to risk factors to educational gradient in mortality in the St Petersburg

Men

Women

From Vagero et al, unpublished

depression and effort reward imbalance in russia poland and czech rep
Depression and effort-reward imbalance in Russia, Poland and Czech Rep.

Quartiles of effort-reward ratio

*Adjusted for age, sex and centre

(Pikhart et al. Soc.Sci.& Med. In press 2003)

slide56
“By necessaries I understand not only the commodities which are indispensably necessary for the support of life, but what ever the customs of the country renders it indecent for creditable people, even the lowest order to be without …… the poorest person would be ashamed to appear in public without them.”

Adam Smith, Wealth of Nations 1776

poor health in hungary by basic household items
POOR HEALTH IN HUNGARY BYBASIC* HOUSEHOLD ITEMS

Odds ratio of poor health

Age-sex adjusted Multivariate adjusted+

* washing machine, fridge, freezer, microwave, phone

+ age, sex, educ, marital, material deprivation Pikhart 2000

poor health in hungary by socially oriented items
POOR HEALTH IN HUNGARY BYSOCIALLY* ORIENTED ITEMS

Odds ratio of poor health

Age-sex adjusted Multivariate adjusted+

* colour tv, stereo system, motorbike, car, car radio

+ age, sex, educ, marital, material deprivation Pikhart 2000

poor health in hungary by luxury items
POOR HEALTH IN HUNGARY BY LUXURY* ITEMS

Odds ratio of poor health

Age-sex adjusted Multivariate adjusted+

* cable tv, satellite, video record/cam, CD, PC, dishwasher, dacha

+ age, sex, educ, marital, material deprivation Pikhart 2000

conclusions
Conclusions
  • Socioeconomic factors make major contribution to differentials between and within countries worldwide, included Central and Eastern Europe
  • Play major role in temporal changes
  • Their effect is mediated by a combination of material, behavioural and psychosocial factors