2. Key principles
• Social justice
• Material, psychosocial,
political empowerment
• Creating the conditions
for people to have
control of their lives
www.who.int/social_determinants
3. MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal Early Years Working Age Older Ages
Family building
Perpetuation of inequities
4. Life expectancy in countries in the WHO
European Region, 2010 (or latest available)
Source: WHO Health for all database, 2012
5. Years of life spent free of disability, women in selected
European countries 2009
Source: EC health indicators
6. MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal Early Years Working Age Older Ages
Family building
Perpetuation of inequities
7. 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
8. Children aged 36-59 months that do not attend any form
of early education programme in selected CIS and CEE
countries
Tajikistan
Bosnia and Herzegovina
TFYR Macedonia*
Kazakhstan
Uzbekistan
Montenegro
Kyrgyzstan
Serbia
Georgia
Albania
Ukraine
Belarus
0 20 40 60 80 100
Richest 20% Poorest 20%
Source: Unicef/MICS 2007
9. Differences in PISA scores by attending preschool for more
than one year before and after accounting for socioeconomic
background
Slovenia
Ireland
Netherlands
TFYR Montenegro
Serbia
Lithuania
Turkey
United Kingdom
Denmark
Switzerland
Italy
France
Belgium
Israel
0 20 40 60 80 100 120 140
Before accounting for socioeconomic background
After accounting for socioeconomic background
OECD PISA 2009 database
10. Iceland
Norway
Denmark
Slovenia
Cyprus
Child poverty rates <60% Finland
Sweden
median before and after Czech Republic
Austria
social transfers 2009 Germany
Netherlands
Belgium
France
Slovakia
Ireland
Switzerland
Estonia
Malta
United Kingdom
Hungary
Luxembourg
Portugal
Poland
Spain
Greece
Italy
Lithuania
Bulgaria
Latvia
Romania
0 10 20 30 40 50 60
Poverty rate
Source: EU SILC
Before social transfers After social transfers
11. MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal Early Years Working Age Older Ages
Family building
Perpetuation of inequities
12. Work and employment are of critical importance for
population health and health inequalities
• Participation in, or exclusion from the labour market
determines a range of life chances
• Wages and salaries provide the major component of the
income of most people in employment
• Exposure to hazards at work, demanding or dangerous
work, long or irregular hours, shift work, and prolonged
sedentary work can all adversely affect health
• Psychological and socio-emotional demands and threats
evolving from an adverse psychosocial work
environment have become more widespread
13. Psychosocial environment of work
Stress arises from:
• Demand-control imbalance
• Effort-reward imbalance
• Organisational injustice
• Employment precariousness
14. Psychosocial stress and occupational class
Wahrendorf, Dragano and Siegrist , 2011 SHARE -11 European Countries
15. Wider Society
• Social exclusion
• Social protection across the life course
• Communities
16. Welfare generosity and non employment by
education in 26 European countries
Predicted Predicted
Longstanding limiting illness No Longstanding Limiting Illness
probabilities probabilities
of
0.8 0.8
of
nonemploy nonemploy
ment
0.7 ment
0.7
0.6 0.6
0.5 0.5
0.4 Primary 0.4 Primary
0.3 Secondary 0.3 Secondary
Tertiary Tertiary
0.2 0.2
0.1 0.1
0 0
Wefare generosity Welfare generosity
van der Wel, Dahl & Thielen 2011
18. Social Protections Help…
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
Spending> 190 USD no effect of
0.09%,unemployment unemployment on suicide
benefits
Source: Stuckler et al 2009 Lancet
19. MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal Early Years Working Age Older Ages
Family building
Perpetuation of inequities
. In every country shown in Fig.3.10 women live longer than men but spend more years in poor health. However there was no strong link between the size of these gaps across countries. For life expectancy, it varied from four years in several countries shown in Fig. 2.10 to 11 years in Lithuania while the gap in years in ill health varied from under three years in the United Kingdom to more than eight years in Portugal. Consequently the gender gap in years spent in good health, which is numerically equal to the gap in life expectancy minus the gap in years in poor health – did not favour either sex consistently. In 22 out of the 30 countries shown in Fig.3.10 women spent more years than men in good health, varying from a year or less in nine countries to close to four years more in Poland, Estonia and Lithuania. in the remaining eight of the 30 countries shown women spent fewer years in good health than men - the largest differences - over one and a half years - were in Portugal and the Netherlands In particular, Healthy Life Years (HLY) is a composite indicator of health that takes into account both mortality and ill-health, providing more information on burden of diseases in the population than life expectancy alone. The indicator “Healthy life years at birth”, shown in Fig.3.9, is an EU Structural Indicator and one of the EU Sustainable Development Indicators. It is calculated as life expectancy from which is subtracted the expected number of years lived with long-term activity limitations, currently obtained from EU-SILC.b
Values are all statistically significantSource: OECD PISA 2009 database, Table II.5.5.
Spending on welfare has different impacts on groups depending on their educational level. Figure 5.2 shows the association between increase in social spending (welfare generosity) and decline in probability of non-employment for those with longstanding limiting illness (left hand graph), and those without (right hand graph). Higher amounts of welfare spending benefit all groups, but the effect is greater among ill people than among healthy people, and greater among those with only primary level education, and least among those with tertiary level education (484;485). Those with lower education levels are more likely to be unemployed (see also Chapter 3). Fig. 5.2 shows that more generous welfare spending acts to reduce social inequalities in non-employment, and therefore has a clear potential to contribute to the reduction of health inequities. Fig 5.2 Welfare generosity* and non employment** by education in 26 European countriesPredicted probabilities from multilevel regression analyses. The model controls for GDP and business cycle in addition to individual level variables Source: van der Wel, Dahl & Thielen 2011 data from EU SILC (2005)Note*Welfare generosity - social expenditure data from Eurostat in purchasing power standards per capita, divided on the non-employment rate ( the inverse of Eurostat employment rates in the age group 15-64) in each country.**Non-employment: the category includes unemployed, early retirement/given up business, permanently disabled or unfit for work. Fulfilling domestic tasks and care responsibilities, other inactivity
