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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 health. Ubiquitous Powerful influence on health Underlie: Differences between individuals within countries

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Social determinants of health

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  1. Social determinants of health Martin Bobak University College London OSI conference on Graduate Public Health Education, Kiev, July 1-3, 2004

  2. 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

  3. Mortality at Titanic by passenger class, men and women Women Children From Broom L & Selznick P, 1968

  4. 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

  5. Global Burden of Disease attributable to risk factors (% of DALY) From Ezzati et al, Lancet 2002

  6. Odds ratio for mammography uptake in London women 65+ (from Harris et al 2002)

  7. Differences between populations

  8. 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.

  9. LIFE EXPECTANCY AND INCOME FOR SELECTED COUNTRIES AND TIME PERIODS World Bank Development Report 1993

  10. 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

  11. 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

  12. Differences between individuals (within populations)

  13. 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

  14. Lower vs higher education mortality rate ratios, Russia, 1989, from Shkolnikov et al 1998.

  15. Figure 17. CVD mortality by education and marital status in Warsaw MONICA, 10-yr follow-up. Men Women

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

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

  18. Changes over time

  19. Life expectancy at age 15 in Europe, men, 1970-2001.

  20. Life expectancy at age 15 in Europe, women, 1970-2001.

  21. 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

  22. Increase in educational differentials in mortality between 1980s and 1990s in St Petersburg men From Plavinski et al 2003

  23. Trends in probability of survival in men by education (relatives’ study) 45 p20 = probability of living to 65 yrs when aged 20 yrs

  24. Trends in birthweight by maternal education in the Czech Republic 1989-1996 (differences from primary educated)

  25. Mortality by education in Czech men and women, 1990/91 and 1995 Men Women From Dzurova et al.

  26. Death rates in Russia 1980-2002both genders, per 100,000 Coup against Gorbatchev, breakup of USSR Rouble crisis Gorbatchev elected

  27. Proportional changes in age-specific mortality in Russia Shkolnikov et al, 2001

  28. Russian mortality from all causes, 35-69 yrs, rate ratios

  29. 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

  30. 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

  31. 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

  32. Trends in probability of survival in men by education (relatives’ study) 45 p20 = probability of living to 65 yrs when aged 20 yrs

  33. Reaction to economic change From Rose 2001

  34. Change in GDP after 1989 by country Index , 1989 = 100 From Unicef, Social Monitor 2003

  35. Change in fertility after 1989 Crude birth rate = live births / 1000 population From Unicef, Social Monitor 2003

  36. Gini coefficient, 1989 and 2000 OECD UNICEF 2003

  37. 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)

  38. 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

  39. Mechanisms (pathways)

  40. 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

  41. Societal factors

  42. 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

  43. 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

  44. INCOME INEQUALITY & MORTALITY IN CANADA & USA Ross et al; BMJ 2000

  45. Hostility and mortality in US metropolitan cities

  46. 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?

  47. Classical risk factors & health behaviours

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