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Michael Marmot

Publications and source records attributed to Michael Marmot.

At least 91 records · Page 5Linked to original sources
PubMed2003

Tackling health inequalities in the United Kingdom: the progress and pitfalls of policy.

GOAL: Assess the progress and pitfalls of current United Kingdom (U.K.) policies to reduce health inequalities. OBJECTIVES: (1) Describe the context enabling health inequalities to get onto the policy agenda in the United Kingdom. (2) Categorize and assess selected current U.K. policies that may affect health inequalities. (3) Apply the "policy windows" model to understand the issues faced in formulating and implementing such policies. (4) Examine the emerging policy challenges in the U.K. and elsewhere. DATA SOURCES: Official documents, secondary analyses, and interviews with policymakers. STUDY DESIGN: Qualitative, policy analysis. DATA COLLECTION: 2001-2002. The methods were divided into two stages. The first identified policies which were connected with individual inquiry recommendations. The second involved case-studies of three policies areas which were thought to be crucial in tackling health inequalities. Both stages involved interviews with policymakers and documentary analysis. PRINCIPAL FINDINGS: (1) The current U.K. government stated a commitment to reducing health inequalities. (2) The government has begun to implement policies that address the wider determinants. (3) Some progress is evident but many indicators remain stubborn. (4) Difficulties remain in terms of coordinating policies across government and measuring progress. (5) The "policy windows" model explains the limited extent of progress and highlights current and possible future pitfalls. (6) The U.K.'s experience has lessons for other governments involved in tackling health inequalities. CONCLUSIONS: Health inequalities are on the agenda of U.K. government policy and steps have been made to address them. There are some signs of progress but much remains to be done including overcoming some of the perverse incentives at the national level, improving joint working, ensuring appropriate measures of performance/progress, and improving monitoring arrangements. A conceptual policy model aids understanding and points to ways of sustaining and extending the recent progress and overcoming pitfalls.

Health Plan Implementation↗
PubMed2002

Mortality patterns in the Russian Federation: indirect technique using widowhood data.

OBJECTIVE: The Russian mortality crisis of the early 1990s attracted considerable attention, but information on possible covariates of mortality is lacking, and concerns have been raised about the validity of official mortality data. To help elucidate the determinants of mortality, we examined whether indirect demographic techniques could be used to study mortality in countries such as the Russian Federation, where mortality data are inadequate, using input data independent from official vital statistics. METHODS: A national sample of the population was interviewed (n = 1600, response rate = 67%). Participants who had ever been married (82% of the sample) were asked about the date of birth and vital status of their first spouse. Spousal mortality was then estimated indirectly for the 531 men and 710 women for whom valid data were available. FINDINGS: The estimated risk of death between the ages of 35-69 years was 57% for male spouses and 17% for female spouses. Corresponding figures derived from national data for 1990 were 52% and 25% for the Russian Federation, and 31% and 20% for the United Kingdom. According to spouses' reports, 38% of their husbands died from cardiovascular disease, 22% from cancer, and 14% from injuries and accidents. Mortality of male spouses was inversely related to the education level of their wives, and the age-adjusted hazard ratios for death from all causes, compared to primary education, were 0.77 for secondary education and 0.57 for university education (trend P = 0.03). Mortality was also inversely related to ownership of household items, but not to size of settlement, pride in Russia, membership in the Soviet Communist Party, nationality or self-assessed social status. CONCLUSIONS: Although the indirect estimates were imprecise (partly owing to the small population size of the study), and mortality in women was probably underestimated (owing to many factors, including poorer reporting by males and high male mortality), our results are nevertheless consistent with the mortality pattern observed in official mortality data. The indirect technique thus appears to be a useful tool to study the determinants of mortality in the Russian Federation and other populations, where reliable or sufficiently extensive data are not available.

Adult↗
PubMed2002

Relation between heavy and binge drinking and all-cause and cardiovascular mortality in Novosibirsk, Russia: a prospective cohort study.

BACKGROUND: Moderate alcohol consumption is associated with reduced cardiovascular mortality, but binge drinking is thought to be detrimental. We examined effects of heavy and binge drinking in a population with high rates of binge drinking. METHODS: We did a prospective cohort study in Novosibirsk, Russia, in 6502 men aged 25-64 years at baseline who were examined in WHO MONICA (monitoring trends and determinants in cardiovascular disease surveys) in 1985/86, 1988/89, and 1994/95, and in a pilot study in 1984. We assessed alcohol intake and drinking pattern by questionnaire; binge drinking was defined as consumption of 160 g or greater of pure alcohol on a typical occasion. Participants were followed-up for a median of 9.5 years (range 3.1-15.2). FINDINGS: There were 836 deaths in the cohort, 395 of which resulted from cardiovascular diseases. Prevalence of binge drinking at baseline was 16% (n=1005). Adjusted relative risks for binge drinking at least once a month (compared with consumption of <80 g pure alcohol) were 1.05 (95% CI 0.80-1.36) for deaths from all causes, 0.99 (0.66-1.50) for deaths from cardiovascular disease, 1.27 (0.81-1.99) for deaths from coronary heart disease, and 2.08 (1.08-3.99) for death from external causes. Risk of total and cardiovascular mortality was raised in a small group of frequent heavy drinkers (5% [264] of all drinkers); for this group, adjusted relative risks were 1.61 (1.04-2.50) for total mortality and 2.05 (1.09-3.86) for deaths from cardiovascular disease. INTERPRETATION: The risk of death from cardiovascular disease seems to be increased in frequent heavy drinkers, but is not necessarily associated with episodic binge drinking.

Adult↗
PubMed2002

The importance of low control at work and home on depression and anxiety: do these effects vary by gender and social class?

In this study we consider both a gender model, a model that focuses on the stress associated with social roles and conditions in the home environment, and a job model, which addresses the stressful characteristics of the work environment, to investigate patterns of women's and men's psychological morbidity across different social positions. Using data from the Whitehall II Study, a longitudinal study of British civil servants, we hypothesise that a lack of control in the home and work environments affects depression and anxiety differently for women and men and across three social class groups. Both women and men with low control either at work or at home had an increased risk of developing depression and anxiety. We did not find an interaction between low control at home and work. We did, however, find that the risks associated with low control either at home or work were not evenly distributed across different social positions, measured by employment grade. Women in the lowest or middle employment grades who also reported low control at work or home were at most risk for depression and anxiety. Men in the middle grade with low work control were at risk for depression while those in the lowest grade were at risk for anxiety. Men in the middle and highest grades, however, were at greatest risk for both outcomes if they reported low control at home. We conclude that, in addition to social roles and characteristics of the work environment, future investigations of gender inequalities in health incorporate variables associated with control at home and social position.

Adult↗
PubMed2002

Systematic review of prospective cohort studies of psychosocial factors in the etiology and prognosis of coronary heart disease.

The extent to which the associations between psychosocial factors and coronary heart disease (CHD) are causal has seldom been the subject of systematic enquiry. We are updating our previous systematic review up to 2001. The objective of this study is to assess the relative strength of the epidemiological evidence for causal links between psychosocial factors and CHD incidence among healthy populations, and prognosis among CHD patients. Our methods were to systematically review prospective cohort studies identified through the Science Citation index, which met pre-specified quality criteria. We found that the proportion of etiologic studies reporting a strong or moderate association was: 6/18 for Type A behavior and hostility, 15/22 for depression, 4/8 for anxiety, 10/13 for psychosocial work characteristics and 6/9 for social support. For prognostic studies the proportions were: 2/15 for type A behavior and hostility, 18/34 for depression, 8/18 for anxiety, 2/4 for psychosocial work characteristics and 14/21 for social support. Positive studies were more likely to be cited by other papers than negative studies. We concluded that, based on prospective epidemiological data, there was evidence for an association between depression, social support and psychosocial work characteristics and CHD aetiology and prognosis. Evidence for an effect of anxiety or type A behavior was less consistent. Methods to address bias in the reporting of psychosocial data are required.

Adult↗
PubMed2002

Multiple measures of socio-economic position and psychosocial health: proximal and distal measures.

BACKGROUND: The aim of this paper is to compare three models for exploring the links between different measures of adult socioeconomic position (SEP)-education, occupation, income-and psychosocial health. Model I is a basic univariate regression model with psychosocial health as the outcome and a measure of SEP as the predictor. Model II is a multiple regression model with psychosocial health as the outcome with all three measures of SEP allocated the same temporal position as predictors. Model III treats education, a distal measure of SEP, as antecedent to the proximal measures of SEP in the prediction equations linking SEP to health. METHODS: Participants were drawn from the Whitehall II study, a prospective cohort study of British civil servants. Data analysed here are from Phase 5 (1997-1999) of data collection, 7830 individuals in all. The measures of SEP and psychosocial health were assessed via a self-administered questionnaire. RESULTS: The three models can lead to completely different conclusions. Model III, our preferred model, shows education to have a stronger indirect effect on psychosocial health when compared to its direct effect. The indirect effect is due to the effect of education on proximal measures of social position, occupation, and income in this case. CONCLUSIONS: Results reported here support the hypothesis that a comparison of the relative importance of the different measures of social position in predicting health is meaningless if the causal relationships among these measures are not accounted for.

Adult↗
PubMedDate not supplied

Social determinants of health inequalities.

The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action.

Adult↗
PubMedDate not supplied

Trends in alcohol intake by education and marital status in urban population in Russia between the mid 1980s and the mid 1990s.

AIMS: We investigated changes in the distribution of alcohol consumption by education and marital status in Russia during the period of societal transformation after 1990. Such changes would indicate the potential role of alcohol in the rising social inequalities in mortality. METHODS: We analysed data from three surveys in random population samples conducted in Novosibirsk as part of the WHO MONICA project in 1985/86 (1533 men, 1292 women), 1988/89 (1700 men, no women) and 1994/95 (1526 men, 1510 women), coinciding with the period of societal transformation. Four measures of drinking were examined in relation to education and marital status: prevalence of drinking at least twice a week; the mean intake in the last week; the mean intake per drinking occasion; and the prevalence of binge drinking (>80 g ethanol for men and >60 g for women) at least once a month. RESULTS: Among men, those with university education had the lowest levels of all measures of drinking. Drinking indices increased over time in all educational groups but most sharply in men with high education, thus leading to a smaller education-related difference in the last survey. With respect to marital status, divorced and widowed men tended to drink most, but the pattern was inconsistent, and the difference between divorced and married men also narrowed over time. Among women, alcohol intake increased between the first and last survey. Differences by education and marital status in women were smaller than in men, and binge drinking was inversely related to education. CONCLUSIONS: All indices of alcohol consumption in men increased between the mid 1980s and the mid 1990s. The increase in alcohol intake among men was proportionally similar across categories of education and marital status but the absolute differences increased. The contribution of alcohol to the increase in social differentials in mortality in the 1990s was probably modest.

Adult↗
PubMedDate not supplied

Socioeconomic status and stress-related biological responses over the working day.

OBJECTIVES: The influence of low socioeconomic status on cardiovascular disease may be mediated in part by sustained activation of stress-related autonomic and neuroendocrine processes. We hypothesized that low socioeconomic status would be associated with heightened ambulatory blood pressure and cortisol output over the working day. METHODS: One hundred eight men and 94 women from the Whitehall II epidemiological cohort participated. Blood pressure and heart rate were monitored every 20 minutes over a working day and evening, and salivary cortisol was sampled on waking up and at 2-hour intervals. Measures were also taken under resting laboratory conditions. Socioeconomic status was indexed by grade of employment. RESULTS: Resting blood pressure, heart rate, and cortisol did not differ by grade. Ambulatory systolic pressure was greater in the morning in the lower (128.9 +/- 15.7 mm Hg) than the intermediate (122.6 +/- 12.5 mm Hg) and higher grades (123.3 +/- 12.7 mm Hg) after adjustment for age, sex, smoking, and alcohol intake (p =.019). Heart rate was also raised in the morning in the lower grade participants. Differences in morning systolic pressure and heart rate were independent of concurrent physical activity. Cortisol concentration was greater in lower than higher grade men (9.54 +/- 4.1 vs. 7.38 +/- 2.8 nmol/liter, p =.008) but was more elevated in higher than lower grade women (7.84 +/- 2.5 vs. 6.35 +/- 1.9 nmol/liter, p =.014). Differences remained significant after adjustment for age, time of awakening, smoking, and alcohol intake. CONCLUSIONS: Socioeconomic differences in blood pressure and cortisol may reflect stress-related activation of biological pathways that contribute to variations in disease risk.

Alcohol Drinking↗
PubMedDate not supplied

Influence of socioeconomic status and job control on plasma fibrinogen responses to acute mental stress.

OBJECTIVE: An elevation in plasma fibrinogen may be one of the pathways through which low socioeconomic status increases cardiovascular disease risk. This study assessed the influence of socioeconomic status, job control, and social isolation on fibrinogen responses to acute stress. METHODS: The study was conducted with 125 white men and 96 white women aged 47 to 58 years, drawn from the Whitehall II cohort. Socioeconomic status was indexed by grade of employment, with 82 high, 75 intermediate, and 64 low grade participants. Plasma fibrinogen and hematocrit were assessed at baseline, immediately after performance of color-word and mirror tracing tasks, and 45 minutes later. RESULTS: Plasma fibrinogen increased from baseline to stress (from 2.85 +/- 0.57 to 2.92 +/- 0.58 g/liter), remaining elevated 45 minutes after stress (2.89 +/- 0.58 g/liter, p <.001). Fibrinogen concentration was greater in the low than in the high or intermediate employment grade groups, independently of sex, age, body mass index, smoking status, and hematocrit. Fibrinogen responses to acute stress did not differ across employment grades. Women had higher fibrinogen levels than men, but this pattern was abolished in women taking hormone replacement therapy. Men experiencing low job control showed greater fibrinogen responses to acute stress than did those with high job control (p =.003). Fibrinogen levels were greater in socially isolated individuals, but social isolation did not affect responses to acute stress. CONCLUSIONS: Socioeconomic status and acute stress had independent effects on the plasma fibrinogen level. Low job control may influence cardiovascular disease risk in men partly through provoking greater fibrinogen stress responses.

Acute Disease↗
PubMedDate not supplied

Burden of psychosocial adversity and vulnerability in middle age: associations with biobehavioral risk factors and quality of life.

OBJECTIVES: Numerous psychosocial factors are associated with disease risk. This study investigated the possibility that a combination of chronic stress from exposure to multiple sources and absence of protective psychosocial resources would be related to heightened emotional distress, health risk behavior, biological risk factors, and impaired quality of life, independently of socioeconomic position (SEP). MATERIALS AND METHODS: Data were analyzed from 227 men and women aged 47 to 59 years from the Whitehall II epidemiological cohort. A psychosocial adversity and vulnerability index (PAVIX) was constructed from high scores on measures of job demands, neighborhood stress, and financial strain, low emotional support, limited social networks, low active coping, and low sense of control. RESULTS: The measures making up the PAVIX were relatively independent of one another. Scores on the PAVIX were greater in lower SEP participants, and in single, separated, or divorced than married participants. The PAVIX was positively associated with psychological distress, depression, hopelessness, sleep problems, hostility, low self-esteem and loneliness, independently of age, sex, SEP, and marital status. There were no associations with health behaviors, but relationships were observed with glycohemoglobin, plasma fibrinogen, plasma viscosity, and body mass (women), that were again independent of covariates. Individuals with high PAVIX scores also reported impaired health-related quality of life. DISCUSSION: The accumulated burden of life stress coupled with limited protective psychosocial resources is associated with adverse psychological, biological, and quality of life outcomes. This integrated approach to the investigation of psychosocial factors may prove valuable in understanding etiological processes.

Adaptation, Psychological↗
PubMedDate not supplied

Effort-reward imbalance, overcommitment, and measures of cortisol and blood pressure over the working day.

OBJECTIVE: To assess the biological correlates of effort-reward imbalance and overcommitment to work using measurements over the working day. METHODS: Participants were 197 working men and women aged 45 to 59 years, recruited from the Whitehall II epidemiological cohort. Salivary cortisol was sampled on waking, 30 minutes later, and then at 2-hour intervals from 8:00 hours to 22:00 hours. Blood pressure was measured every 20 minutes using ambulatory methods. Effort-reward imbalance and overcommitment to work were assessed with standard questionnaires. RESULTS: Cortisol responses to waking were positively associated with overcommitment in men, with mean increases between waking and 30 minutes of 14.5 and 4.2 nmol/l in high and low overcommitment groups, after adjustment for age, socioeconomic position, smoking, time of waking up, and job demands. Cortisol averaged from 8 samples over the working day was also related to overcommitment in men, with an average difference of 22% between high and lower overcommitment groups. Overcommitment predicted systolic blood pressure over the day in men after adjustment for age, smoking, body mass index, physical activity, and job control, with adjusted means of 132.2 and 125.8 mm Hg in high and low overcommitment groups. There was a significant interaction between overcommitment, socioeconomic position, and time of day in men (p =.016), because systolic pressure was higher in lower status overcommitted men, and rose over the day. Neither effort-reward imbalance nor overcommitment predicted biological responses in women. CONCLUSIONS: Chronic neuroendocrine and cardiovascular activation may mediate in part the impact of overcommitment to work on cardiovascular disease risk in men.

Blood Pressure↗
PubMedDate not supplied

Psychological distress as a predictor of CHD events in men: the effect of persistence and components of risk.

OBJECTIVE: This paper examines the role of psychological distress in the etiology of coronary heart disease (CHD), with particular reference to the persistence of distress symptoms, the contribution that undetected CHD at baseline makes to the observed associations and to the effect of separate components of psychological distress. METHOD: 5449 men in an occupational cohort (79% of the total), with at least two prior measurements of the General Health Questionnaire (GHQ-30), were followed for CHD events (including CHD death, nonfatal myocardial infarction (MI), and angina) for (mean) 6.8 years. Psychological distress was measured using the GHQ-30, and general/anxiety, depression and sleep subscales were created based on a principal components analysis. RESULTS: Psychological distress increased the risk of CHD events, with the risk highest in men with recent onset of distress. Age-adjusted hazard ratios were 1.48 (1.03-2.13) for persistent and 1.77 (1.13-2.78) for new distress. Angina events accounted for much of the observed associations. This increased risk was independent of conventional CHD risk factors, markers of underlying CHD, or measures of reporting bias, and it was related to anxiety items and sleep disturbance rather than depressive symptoms. CONCLUSIONS: Psychological distress increases the risk of a future diagnosis of angina in men. This risk is not accounted for by the presence of underlying CHD. These results highlight the importance of identifying both the role of underlying atherosclerosis in the pathway linking distress to heart disease and the timing of action of the components of psychological distress.

Angina Pectoris↗
PubMedDate not supplied

Psychosocial, hemostatic, and inflammatory correlates of delayed poststress blood pressure recovery.

OBJECTIVE: Delayed poststress cardiovascular recovery has been associated with cardiovascular disease risk. This study assessed relationships between systolic blood pressure (BP) recovery, psychosocial risk factors, and delayed recovery of inflammatory and hemostatic variables. METHOD: Data were analyzed from 228 middle-aged men and women from the Whitehall Psychobiology study who performed color/word and mirror-tracing tasks. Systolic BP recovery was assessed as the difference between baseline and levels recorded 40 to 45 minutes poststress. Associations were analyzed with socioeconomic markers (grade of employment, education, income), psychosocial factors (social isolation, hostility, mental health, financial strain), and recovery of heart rate, heart rate variability, von Willebrand factor, factor VIII clotting activity, plasma fibrinogen, and plasma viscosity. RESULTS: Systolic BP was on average 6.19 +/- 9.6 mm Hg higher on recovery than baseline. Delayed BP recovery was associated with lower grade of employment, lower education and lower income independently of age, gender, and systolic BP stress reactivity. Delayed BP recovery was related to social isolation and poor mental health independently of age, gender, socioeconomic position, and task reactivity. Delayed systolic BP recovery was also associated with delayed recovery in diastolic BP, heart rate, factor VIII, and plasma viscosity but not delayed heart rate variability recovery, independently of age, gender, body mass, and task reactivity. CONCLUSION: Socioeconomic and psychosocial risk factors for cardiovascular disease are related to delays in poststress recovery. Delayed systolic BP recovery may be a marker for prolonged responses in hemostatic variables that have a direct influence on cardiovascular disease pathogenesis.

Biomarkers↗
PubMedDate not supplied

The influence of income on health: views of an epidemiologist.

Income is related to health in three ways: through the gross national product of countries, the income of individuals, and the income inequalities among rich nations and among geographic areas. A central question is the degree to which these associations reflect a causal association. If so, redistribution of income would improve health. This paper discusses two ways in which income could be causally related to health: through a direct effect on the material conditions necessary for biological survival, and through an effect on social participation and opportunity to control life circumstances. The fewer goods and services are provided publicly by the community, the more important individual income is for health. Under present U.S. circumstances, a policy of counteracting growing income inequalities through the tax and benefit system and of public provision appears justified.

Adult↗