Broader determinants of health: trends

• McGinnis, J.M., Williams-Russo, P. and Knickman, J.R. (2002) The case for more active policy attention to health promotion. Health Affairs 21 (2) pp.78-93.

• Canadian Institute of Advanced Research, Health Canada, Population and Public Health Branch. AB/NWT 2002, quoted in Kuznetsova, D. (2012) Healthy places: Councils leading on public health. London: New Local Government Network.

• Bunker, J.P., Frazier, H.S. and Mosteller, F. (1995) The role of medical care in determining health: Creating an inventory of benefits. In, Society and Health ed Amick III et al. New York: Oxford University Press. Pp 305-341.

• Dahlgren G, Whitehead M (1993). Tackling inequalities in health: what can we learn from what has been tried? Working paper prepared for the King’s Fund International Seminar on Tackling Inequalities in Health, September 1993, Ditchley Park, Oxfordshire. London, King’s Fund, accessible in: Dahlgren G, Whitehead M. (2007) European strategies for tackling social inequities in health: Levelling up Part 2. Copenhagen: WHO Regional office for Europe.

Climate change will have both a number of implications for health in the UK, largely negative.

Climate change is predicted to lead to greater seasonal variation in weather patterns in the UK, meaning:

• hotter, drier summers, with more heatwaves and droughts

• wetter winters, with more flooding and severe storms.

Ozone pollution and an increased incidence of extreme weather events will have a negative effect on the health of those in affected areas. There will be some direct mortalities, but the main effect on health will be through exacerbation of existing long-term conditions.

The scale of the health impacts will depend on the success of mitigation and adaptation measures, and will vary between geographical areas and population groups. Certain groups (eg, older people) are predicted to be more vulnerable.

There are also predicted to be mental health effects, for example as a result of floods and extreme storms.

Source: Department for Energy, Food and Rural Affairs (2012). Report. UK Climate Change Risk Assessment

If future governments choose to meet existing carbon reduction targets, these are likely to drive considerable technological and social change – not just in the health sector, but across all of society. Such changes may well have significant health implications.

For example, a shift from motorised transport towards increased walking and cycling could be positive for public health, as could reduced consumption of meat and other carbon-intensive foods. Equally, some socio-political responses to climate change could have a negative impact on health – for example, regressive forms of carbon taxation could exacerbate social inequalities.

There is considerable uncertainty around the scale, timing and direction of these effects. Health impacts would depend in part on the nature of the technological or social changes seen. For example, the development of low-carbon vehicles could cut carbon emissions without the potential health benefits associated with increased walking and cycling.

• Kjellstrom T, Butler AJ, Lucas RM, Bonita R. (2010). Journal article. 'Public health impact of global heating due to climate change: potential effects on chronic non-communicable diseases'. International Journal of Public Health, vol 55 pp 97-103

• Haq G, Whitelegg J, Kohler M (2008). Journal article. 'Growing old in a changing climate. Meeting the challenges of an ageing population and climate change'. Stockholm Environment Institute

Early childhood development is a key determinant of educational outcomes.

The Marmot Review discusses Feinstein’s study of the long-term educational outcomes of children in 1970. By the age of six (74 months), children from higher socio-economic groups, that had been classified as 'less bright' in tests at 22 months, performed better in tests of cognitive ability than children classified as 'bright' at 22 months from lower socio-economic groups (see figure). Feinstein went on to show how this early disadvantage for children in lower socio-economic groups went on to predict final educational outcomes in 1996.

Inequality in early cognitive development in the 1970 British Cohort study at age 22 months to 10 years

Source: Marmot Review (2010). Fair Society, healthy lives. Review of health inequalities in England post-2010

Since educational outcomes are good predictors of long-term health, ensuring equal childhood cognitive development is a critical element of any attempt to reduce health inequalities.

Standardising limiting illness ratios in 2001 by educational qualifications

Source: Marmot Review (2010). Fair Society, healthy lives. Review of health inequalities in England post-2010. Executive summary

• Marmot Review (2010). Fair Society, healthy lives. Review of health inequalities in England post-201

• Feinstein (2000). Inequality in the early cognitive development of British children in the 1970 cohort

Economic factors are highly correlated with health outcomes. Lower incomes and lower employment are unambiguously bad for health, and socio-economic status is a major determinant of both life expectancy and healthy life expectancy (see figure below).

What does this tell us about health inequalities?

The figure above illuminates many of the key characteristics of importance about health inequalities in England.

The top dotted line is average life expectancy; the bottom dotted line is average disability-free life expectancy. This is plotted against neighbourhood income deprivation for thousands of small areas in England. Therefore, this shows how health varies depending on how poor or disadvantaged the majority of people are in that area. There are some messages we can take from this figure:

• Although we are living longer, many people are living in poor health; this is shown by the fact that disability-free life expectancy – a measure of years spent in good health with no limiting illness – is much lower than life expectancy for everyone.

• Inequalities affect us all, however both life expectancy and disability-free life expectancy are higher in those areas with a higher neighbourhood income.

Having said that,

• the figure above shows that the gap between life expectancy and disability-free life expectancy is larger for poorer people than wealthier people. The more income you have, the more likely you are to live in better health.

• There is a steeper slope at the very ends of the graphs. This means that the very poor and the very rich have particularly low and high life expectancy and disability-free life expectancy respectively.  Becoming very poor affects your health a lot more than the average relationship between health and income.

• Despite this overall relationship, there are lots of areas where health is higher (or lower) than expected based on income deprivation alone. This is shown by the scatter of the dots around the lines. If we can better understand what factors explain this we can improve population health and inequalities.

Recessions are particularly linked to risk factors for poor mental health: unemployment, poverty, unanticipated disruptions in income, uncertain and stressful work environments, debt and financial strain. Emerging evidence suggests the recession has led to an increase in suicide rates in Europe.

Our path to recovery is deeper and slower than for all previous recessions since the Great Depression of the 1930s (3). Real incomes fell in 2010 for the first time since 1977 and there has been a substantial growth in young people not in education, employment or training (NEET), with a record of 1,163,000 people aged 16–24 NEET at the end of 2011. 

We know from previous recessions that being NEET at a young age for a substantial period reduces future employability and leads to poor long-term health.

• Royal College of Psychiatrists, Mental Health Network, NHS Confederation, London School of Economic and Political Science (2009). Report. Mental health and the economic downturn: National priorities and NHS solutions

• Stuckler D, Basu S, Suhrcke C, Coutts A, McKee M (2011). Effects of the 2008 recession on health: A first look at European data. The Lancet, Vol 378 Issue 9786, pp 124–125

• UK GDP since 1955 (2012). Guardian data blog

• BBC News (2011). Article. Young, jobless 'Neets' reach record level. Harrison A, Education Correspondent, 24 November 2011

• Audit Commission (2010). Against the odds: Re-engaging young people in education, employment and training

Increased levels of education are strongly and significantly related to improved health.

'An additional four years of schooling improves five-year mortality rates by 16 per cent (the equivalent of the female-male gap).'

More education reduces the risk of self-reported poor health. Cost-benefit analysis suggests that every £1 invested in education returns £2.25 to £7.20 in the value of additional health gained. 

The number of people in England who go on to higher education has been increasing (2). But university places are disproportionately filled by people from higher-income families, which contributes to long-term inequalities in health. 

However, the proportion of people in higher education from low-income households is growing. In the mid-1990s, people from the highest-income households were three times more likely to go to university than those from lower-income families. By 2009/10 this had reduced to twice as likely.

With pressure on public financing, increased tuition fees and the university sector opening up to a more global market, it is unclear whether improvements in access to higher education will continue.

• Cutler DM, Lleras-Muney A (2006). Education and health: Evaluating theories and evidence. National Bureau of Economic research

• Higher Education Funding Council for England (2010). Trends in young participation in higher education: core results for England, Issue 03

Inadequate housing causes or contributes to many preventable diseases and injuries, including respiratory, nervous system and cardiovascular diseases and cancer. Poor housing is estimated to cost the NHS at least £600 million per year.

Cold homes

In England and Wales trends in excess winter deaths have decreased by about 30 per cent since 2008/09, where there were 36,450 deaths attributable to all causes. In 2010/11 there were 25,700 excess winter deaths. The majority of these occurred among those aged 75 and over.

From estimates of the Excess Winter Mortality Index (EWM Index) by the Office for National Statistics, circulatory diseases caused 37 per cent of excess winter deaths in 2009/10. Respiratory diseases came in second and accounted for 32 per cent. Other diseases attributable to excess winter mortality are dementia and Alzheimer’s disease, injury and poisoning.

Cold homes are one contributor to this, and increase the risk of cardiovascular, respiratory and rheumatoid diseases as well as hypothermia and poorer mental health. Older, retired people are particularly at risk.

Damp problems

Around 1.8 million homes had damp problems in 2009. Privately rented homes were most likely to experience damp problems: 15 per cent compared to 8 per cent of owner-occupied homes and 10 per cent of social housing. Twelve per cent of poor households lived with damp problems compared with 7 per cent of other households.

'Non decent' homes

Housing conditions are improving. Some 6.7 million homes (30 per cent) were ‘non-decent’ in 2009, down from 7.4 million (33 per cent) in 2008. Overall, social sector homes were in a better condition than private sector homes.

Source: English Housing Survey 2009/10 (2011) Communities and Local Government

In the early 20th century, less than 10 per cent of homes were owner-occupied, but by the early 21st century, this had risen to 70 per cent, just above the EU average. Home ownership has since fallen from 76 per cent in 2001 to 65 per cent in 2010.

'In 2012, for the first time in almost 50 years, there were more privately rented than socially rented homes.'

Between 2001 and 2010, social renting fell from 20 per cent to 17.5 per cent but private renting grew from 10.1 per cent to 17.4 per cent. This growth seems set to continue – Savills, the global real estate services provider, forecasts that 20 per cent of households will be privately rented by 2020.

There is a body of evidence that shows that home owners have better physical health outcomes, more positive mental health and higher self-esteem, which all contribute to overall wellbeing. However, home ownership, especially cases where home owners have high mortgages, could lead to increased levels of stress, which is detrimental to health. 

Nearly two million households in England spend more than 50 per cent of their income on housing costs, and more than two million households have fallen behind their mortgage or rent payments. There is a shortage of affordable housing in all regions, especially London. Halifax's house-price-to-earnings ratio – a key affordability measure – has fallen from a peak of 5.82 in April 2007 to 4.41 in March 2012. The long-term average is 4.07.

Welfare cuts are likely to place 269,000 households in serious financial difficulty. Recent cuts to housing benefit may force many people to move, particularly from expensive areas such as London. Around 35,000 households are expected to approach their local authority for homelessness advice and assistance, and local authorities will need to provide temporary accommodation to 19,000 households.

• World Health Organisation Regional Office for Europe (2012). Report. Environmental Health Inequalities in Europe

• Building Research Establishment and the Chartered Institute of Environmental Health (2010). Good housing leads to good health

• Office for National Statistics (2010). Statistical bulletin. Excess winter mortality in England and Wales, 2010/11 (provisional) and 2009/10 (final)

• Office for National Statistics (2010). Statistical bulletin (part). Excess winter mortality in England and Wales, 2010/11 (provisional) and 2009/10 (final)

• Communities and Local Government (2011). Report. English Housing Survey 2009/10

• Gallent N (2009). The Future of Housing and Homes. Land use policy S93–S102.

• Office for National Statistics and Communities and Local Government (2010). Housing and planning statistics

• Economics online (2012). The UK Housing Market

• Macintyre S, Ellaway A, Der G, Ford G, Hunt K (1998). ‘Do housing tenure and car access predict health because they are simply markers of income of self-esteem?: a Scottish study’. Journal of Epidemiology and Community Health, vol 52, no 1, pp 657–64.

• Cairney J, Boyle MH (2004). ‘Home ownership, mortgages and psychological distress’. Housing Studies, vol 19, no 2, pp 161–74.

• Cairney J, Boyle MH (2004). ‘Home ownership, mortgages and psychological distress’. Housing Studies, vol 19, no 2, pp 161–74.

• Shelter (2008). Research report: Homes for the future

• Lloyds Banking Group, as cited by Homes and Communities Agency (2012). Monthly Housing Market Bulletin: Intelligence and Analysis

• Birch J (2012). Guardian online housing network. Article. How the private rented sector dominates housing’s future 

• Homeless Link, Crisis, St Mungo’s, Shelter (2012). Briefing. Homelessness trends and projections

There is strong evidence that access to green spaces improves mental health, although the evidence that it increases physical activity is less strong. Use of green spaces is associated with: a decrease in health complaints, improved blood pressure and cholesterol levels, reduced stress, improved general health perceptions and a greater ability to face problems.

The use of green spaces is slowly increasing. In 2011, 56 per cent of people surveyed said they used public gardens, parks, commons or other green spaces at least once a week; in 2009 this was 48 per cent. Twenty-one per cent of respondents reported using green spaces less than once a month or never, compared to 26 per cent in 2009.

People in higher socio-economic groups make more use of green spaces than those in lower socio-economic groups. Sixty-three per cent of people in social grade AB (managerial and professionals) said they visited green spaces on a weekly basis, compared with 47 per cent in grade DE (manual workers, shop workers, apprentices, casual labourers, state pensioners and the unemployed). 

Frequency of visits to public gardens, parks, commons or other green spaces

Source: Department for Environment, Food and Rural Affairs (2011) Survey of public attitudes and behaviours towards the environment

• Boyce T, Patel S (2009). Report. The health impacts of spatial planning decisions

• Marmot Review (2010). Implications for spatial planning

• Department for Environment, Food and Rural Affairs (2011) Survey of public attitudes and behaviours towards the environment

Social relationships are increasingly recognised as being protective of health.

Social relationships are particularly important in increasing resilience and promoting recovery from illness in socio-economic circumstances that otherwise would be detrimental to health.

Data across 308,849 individuals, followed for an average of 7.5 years, indicates that individuals with adequate social relationships have a 50 per cent greater likelihood of survival compared to those with poor or insufficient social relationships. The magnitude of this effect is comparable with quitting smoking and it exceeds many well-known risk factors for mortality (eg, obesity and physical inactivity).

As we explore in the demography section, the number of people living in their own is predicted to rise significantly, particularly amongst older people.

At the same time, social relationships are broadening fast and we are becoming increasingly inter-connected through technological networks such as Facebook, Twitter and LinkedIn. The impact of this on health is highly uncertain. Read more about this in our information technologies section.

• Pevalin DJ, Rose D (2003) Social capital for health: Investigating the links between social capital and health using the British Household Panel Survey. London, Health Development Agency

• Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review

Being in work is generally good for our health. However, working in a stressful environment can be detrimental to mental and physical health in both the short- and the long-term. Poor levels of health are twice as high for those reporting high job stress compared to those with none.

Rates of work-related stress are higher among women and in people working in large organisations, in managerial and professional occupations, and in public administration/health and social care/education.

'Workplace injuries and ill health (excluding cancer) cost society an estimated £14 billion in 2009/10.

Musculoskeletal disorders and stress, depression or anxiety account for around three-quarters of work-related conditions.

Source: Health and Safety Executive, Annual Statistics Report, 2010/11.

According to the Health and Safety Executive's Annual Statistics Report, 1.2 million working people were suffering from a work-related illness in 2010/11.

Rates of work-related musculoskeletal disorders have reduced significantly over the past 10 years. Rates are higher in people who work in manual and skilled occupations, agriculture/ construction /postal and courier activities.

If current trends continue, work-related illness will decrease further. However, the economic climate may increase work-related stress due to job insecurity.

Many companies in England have introduced workplace health programmes to promote active journeys to work, increase fruit availability in offices and provide better in-house catering and gym facilities.

• Siegrest J Benach J, McKnight A, Goldblatt P, Muntaner C (2010). Report. Employment arrangements, work conditions and health inequalities

• Katikireddi, SV, Niedzwiedz CL, Popham CF (2012). Report. Trends in population mental health before and after the 2008 recession: a repeat cross-sectional analysis of the 1991–2010 Health Surveys of England, British Medical Journal