Social determinants of health - how are inequalities expressed in working life? Susanna Toivanen Presentation at ENSP/Fiocruz Aug 21 st, 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:

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:

WHO Commission on Social Determinants of Health “Reducing health inequities is an ethical imperative. Social injustice is killing people on a grand scale”. Source:

The Commission’s overarching recommendations

Marmot M. Status syndrome: how your social standing directly affects your health and life expectancy. London: Bloomsbury; Wilkinson RG, Pickett K. The spirit level: why more equal societies almost always do better. London: Allen Lane; 2009.

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

Welfare state Labour 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 Unemployed Welfare recipients Employed Professionals Managerial and technical Skilled non-manual Skilled manual Unskilled manual Self-employed Industrial sector Size 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 Source: Härkönen et al, Nordic Journal of Working Life Studies 2011;1:23-38

+3,2 +2,3 +0,7 Life expectancy at 30 years of age according to educational level, men and women in Sweden ,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 ). Bristol: The Policy Press.

Social inequalities in health – the contribution of adverse work conditions Employed Professionals Managerial and technical Skilled non-manual Skilled manual Unskilled manual Sources: Hoven H, Siegrist J. Occup Environ Med 2013;70:663–669. Landsbergis, P.A. Am J Ind Med 2010;53: Toivanen, S. Am J Ind Med 2011;54: Toivanen, S & Hemström, Ö. Int J Behav Med 2006;13: 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, 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: 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:

Job strain and coronary heart disease Meta-analyses from the IPD-Work Consortium, including 13 European cohort studies 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 lipids Source: 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 elevation Source: 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. Mechanisms I Social stratification II Differential exposure III Differential susceptibility IV Differential consequences V 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

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