Social determinants of health- how are inequalities expressed in working life?Susanna ToivanenPresentation at ENSP/FiocruzAug 21st, 2013

Current research topics include

• working life and health among the self-employed• foreign born persons' working conditions and health in

Sweden• future workplaces (offices), working life and health• social determinants of health and health inequalities in

working populations• gender and health

Social Inequalities in Health

“Inequalities in health are systematic differences in health between different socio-economic groups within a society.

As they are socially produced, they are potentially avoidable and widely considered unacceptable in a civilized society.”

Margaret Whitehead, 2007

Source: Whitehead, M. J Epidemiol Community Health. 2007;61:473-478

Social Determinants of Health

“The circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness.

The conditions in which people live and die are, in turn, shaped by political, social, and economic forces”.

Source: http://www.who.int/social_determinants/en/

WHO Commission on Social Determinants of Health

“Reducing health inequities is an ethical imperative.

Social injustice is killing people on a grand scale”.

Source: http://www.who.int/social_determinants/en/

The Commission’s overarching recommendations

Marmot M. Status syndrome: how your social standing directly affects your health andlife expectancy. London: Bloomsbury; 2004.

Wilkinson RG, Pickett K. The spirit level: why more equal societies almost always do better. London: Allen Lane; 2009.

http://www.euro.who.int/document/e81384.pdf

Work and employment relations are important factors in explaining the health and quality of life of populations.

Welfare stateLabour market

Organizations

Work places

Workers

macro

meso

micro

Health

Levels of work factors in relation to health

Socio-economic groups in the formal labour market

Non-employed or worklessness

UnemployedWelfare recipients

EmployedProfessionals

Managerial and technicalSkilled non-manual

Skilled manualUnskilled manual

Self-employedIndustrial sectorSize of enterprise

Legal form

Age Gender Ethnicity

Gender discrimination in the labour market - Obesity, Unemployment, and Earnings• Effects of obesity (BMI≥30) on unemployment• Obese women had a significantly higher risk of

unemployment than not obese women• Obese women’s weaker labour market attachment

translated to lower earnings • Similar results were not found among men

www.nordicwl.dk

Source: Härkönen et al, Nordic Journal of Working Life Studies 2011;1:23-38

44

46

48

50

52

54

56

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

Low Medium High

+3,2+2,3+0,7

Life expectancy at 30 years of age according to educational level, men and women in Sweden 1986-2007

44

46

48

50

52

54

56

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

Low Medium High

+4,5

+4,1+3,1

Men Women

Source: Fritzell, J et. at. Health and inequalities in Sweden: long and short-term perspectives. In J. Fritzell & O. Lundberg (Eds.), Health inequalities and welfare resources. (pp. 19-41). Bristol: The Policy Press.

Social inequalities in health – the contribution of adverse work conditions

EmployedProfessionals

Managerial and technicalSkilled non-manual

Skilled manualUnskilled manual

Sources: Hoven H, Siegrist J. Occup Environ Med 2013;70:663–669.Landsbergis, P.A. Am J Ind Med 2010;53:95-103Toivanen, S. Am J Ind Med 2011;54:780-90Toivanen, S & Hemström, Ö. Int J Behav Med 2006;13:89-100

Mediation or moderation?

Organizations and workers health• Lean production, a management model to increase

efficiency and quality of production• In many cases work intensification is reported

influencing workers wellbeing and health• New Public Management

Sources:-Toivanen, S. & Landsbergis, P. [Lean and worker health] in Sederblad, P (Ed.)[Lean in working life]. Stockholm: Liber, 2013-Landsbergis, P. et al. The impact of lean production and related new systems of work organisation on worker health. J Occup Health Psychol. 1999;4:108-130.-Noblet, A. et al. Organizational change in the public sector: Augmenting the demand control model to predict employee outcomes under New Public Management. Work & Stress, 2006;20:335-352

Job strain and coronary heart disease• Meta-analyses from the IPD-Work Consortium, including 13

European cohort studies http://www.ncbi.nlm.nih.gov/pubmed/?term=IPD-Work+Consortium

• Coronary heart disease: HR for job strain 1,23 versus no strain• The population attributable risk for job strain was 3,4%

Source: Kivimäki et al. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data, Lancet 2012;380:1491–97• The population attributable risk for CVD for job strain was 4,5 %

Source: Niedhammer et al. Fractions of cardiovascular diseases and mental disorders attributable to psychosocial work factors in 31 countries in Europe, Int Arch Occup Environ Health. 2013

Job strain and CVD risk factors

• Meta-analyses from the IPD-Work Consortium, including 8

European cohort studies

• Job strain was linked to adverse lifestyle and diabetes

• No association between job strain, clinic blood pressure or blood

lipidsSource: Nyberg ST, et al. Job Strain and Cardiovascular Disease Risk Factors: Meta-Analysis of Individual-Participant Data from 47,000 Men and Women. PLoS ONE 2013;8:e67323

• Single exposure to job strain in cross-sectional studies was

associated with higher work systolic and diastolic ABP• Job strain is a risk factor for blood pressure elevationSource: Landsbergis, P. et al. Job strain and ambulatory blood pressure: A meta-analysis and systematic review, American Journal of Public Health. 2013;103:e61-e71

A model of causal pathways (I-V) from society context and the social position of individuals to health.

MechanismsI Social stratificationII Differential exposureIII Differential susceptibilityIV Differential consequencesV Impact of consequences

Source: Diderichsen, F. et. al. The social basis of disparities in health. In Evans, T. et. al.Challenging inequities in health – from ethics to action. New York: Oxford University Press, 2001

Contactsusanna.toivanen@chess.su.se+46 723 223 889