Michael G Marmot

Although sick, some people take no time off work, a phenomenon called "sickness presenteeism." This study examined the association between sickness presenteeism and incidence of serious coronary events. The analyses were based on a cohort of 5071 male British civil servants without previous myocardial infarction. Baseline screening included measurements of health status and coronary risk factors. Absence records were assessed for the 3 years subsequent to baseline screening. The outcome of interest was incident nonfatal myocardial infarction or fatal coronary heart disease (mean length of follow-up=9.1 years). Seventeen percent of unhealthy employees took no absence during the 3-year follow-up. Their incidence of serious coronary events was twice as high as that of the unhealthy employees with moderate levels of sickness absenteeism (after adjustment for conventional risk factors, hazard ratio 1.97, 95% confidence interval=1.02, 3.83). Employers and employees should be aware of the potential harmful effects caused by sickness presenteeism.

We examined whether relative occupational social class inequalities in physical health functioning widen, narrow or remain stable among white collar employees from three affluent countries. Health functioning was assessed twice in occupational cohorts from Britain (1997-1999 and 2003-2004), Finland (2000-2002 and 2007) and Japan (1998-1999 and 2003). Widening inequalities were seen for British and Finnish men, whereas inequalities among British and Finnish women remained relatively stable. Japanese women showed reverse inequalities at follow up, but no health inequalities were seen among Japanese men. Health behaviours and social relations explained 4-37% of the magnitude in health inequalities, but not their widening.

Work-family conflicts are associated with poor health. However, work-family conflicts and health behaviors have been little studied. This study examined the associations of conflicts between paid work and family life with unhealthy behaviors among British, Finnish, and Japanese employees. Data were derived from postal questionnaire surveys among 40 to 60 years old employees from three cohorts, the British Whitehall II Study (n = 3,397), the Finnish Helsinki Health Study (n = 4,958), and the Japanese Civil Servants Study (n = 2,901). Outcomes were current smoking, heavy drinking, physical inactivity, and unhealthy food habits. Work-family conflicts were measured with eight items. Age, marital status, and occupational class were adjusted for in logistic regression analyses. Work-family conflicts had few and inconsistent associations with unhealthy behaviors in all three cohorts. In the Finnish cohort, strong work-family conflicts were associated with current smoking among men. Women with strong conflicts had more often unhealthy food habits and were more often heavy drinkers than women with weaker conflicts. Likewise, British women with strong work-family conflicts were more often heavy drinkers. Although work-family conflicts were fairly prevalent in the examined cohorts, these conflicts had but few associations with the studied key health behaviors.

Adverse health behaviors and obesity are key determinants of major chronic diseases. Evidence on work-related determinants of these behavioral risk factors is inconclusive, and comparative studies are especially lacking. We aimed to examine the associations between job strain, working overtime, adverse health behaviors, and obesity among 45-60-year-old white-collar employees of the Whitehall II Study from London (n=3,397), Helsinki Health Study (n=6,070), and the Japanese Civil Servants Study (n=2,213). Comparable data from all three cohorts were pooled, and logistic regression analysis was used, stratified by cohort and sex. Models were adjusted for age, occupational class, and marital status. Outcomes were unhealthy food habits, physical inactivity, heavy drinking, smoking, and obesity. In London, men reporting passive work were more likely to be physically inactive. A similar association was repeated among women in Helsinki. Additionally, high job strain was associated with physical inactivity among men in London and women in Helsinki. In London, women reporting passive work were less likely to be heavy drinkers and smokers. In Japan, men working overtime reported less smoking, whereas those with high job strain were more likely to smoke. Among men in Helsinki the association between working overtime and non-smoking was also suggested, but it reached statistical significance in the age-adjusted model only. Obesity was associated with working overtime among women in London. In conclusion, job strain and working overtime had some, albeit mostly weak and inconsistent, associations with adverse health behaviors and obesity in these middle-aged white-collar employee cohorts from Britain, Finland, and Japan.

Research on the association between family-to-work and work-to-family conflicts and sleep problems is sparse and mostly cross-sectional. We examined these associations prospectively in three occupational cohorts. Data were derived from the Finnish Helsinki Health Study (n = 3,881), the British Whitehall II Study (n = 3,998), and the Japanese Civil Servants Study (n = 1,834). Sleep problems were assessed using the Jenkins sleep questionnaire in the Finnish and British cohorts and the Pittsburgh Sleep Quality Index in the Japanese cohort. Family-to-work and work-to-family conflicts measured whether family life interfered with work or vice versa. Age, baseline sleep problems, job strain, and self-rated health were adjusted for in logistic regression analyses. Adjusted for age and baseline sleep, strong family-to-work conflicts were associated with subsequent sleep problems among Finnish women (OR, 1.33 (95 % CI, 1.02-1.73)) and Japanese employees of both sexes (OR, 7.61 (95 % CI, 1.01-57.2) for women; OR, 1.97 (95 % CI, 1.06-3.66) for men). Strong work-to-family conflicts were associated with subsequent sleep problems in British, Finnish, and Japanese women (OR, 2.36 (95 % CI, 1.42-3.93), 1.62 (95 % CI, 1.20-2.18), and 5.35 (95 % CI, 1.00-28.55), respectively) adjusted for age and baseline sleep problems. In men, this association was seen only in the British cohort (OR, 2.02 (95 % CI, 1.42-2.88)). Adjustments for job strain and self-rated health produced no significant attenuation of these associations. Family-to-work and work-to-family conflicts predicted subsequent sleep problems among the majority of employees in three occupational cohorts.

We examined whether relative occupational social class inequalities in physical health functioning widen, narrow or remain stable among white collar employees from three affluent countries. Health functioning was assessed twice in occupational cohorts from Britain (1997-1999 and 2003-2004), Finland (2000-2002 and 2007) and Japan (1998-1999 and 2003). Widening inequalities were seen for British and Finnish men, whereas inequalities among British and Finnish women remained relatively stable. Japanese women showed reverse inequalities at follow up, but no health inequalities were seen among Japanese men. Health behaviours and social relations explained 4-37% of the magnitude in health inequalities, but not their widening.

Multiple deprivation indicators are frequently used to capture the characteristics of an area. This is a useful approach for identifying the most deprived areas, and summary indices are good predictors of mortality and morbidity, but it remains unclear which aspects of the residential environment are most salient for health. A further question is whether the most important aspects vary for different types of residents. This paper focuses on whether associations with neighbourhood characteristics are different for men and women. The sociopolitical and physical environment, amenities, and indicators of economic deprivation and affluence were measured in neighbourhoods in the UK, and their relationship with self-rated health was investigated using multilevel regression models. Each of these contextual domains was associated with self-rated health over and above individual socioeconomic characteristics. The magnitude of the association was larger for women in each case. Statistically significant interactions between gender and residential environment were found for trust, integration into wider society, left-wing political climate, physical quality of the residential environment, and unemployment rate. These findings add to the literature indicating greater effects of non-work-based stressors for women and highlight the influence of the residential environment on women's health.

The status of psychosocial stress at work as a risk factor for type 2 diabetes is unclear because existing evidence is based on small studies and is subject to confounding by lifestyle factors, such as obesity and physical inactivity. This collaborative study examined whether stress at work, defined as "job strain," is associated with incident type 2 diabetes independent of lifestyle factors. We extracted individual-level data for 124,808 diabetes-free adults from 13 European cohort studies participating in the IPD-Work Consortium. We measured job strain with baseline questionnaires. Incident type 2 diabetes at follow-up was ascertained using national health registers, clinical screening, and self-reports. We analyzed data for each study using Cox regression and pooled the study-specific estimates in fixed-effect meta-analyses. There were 3,703 cases of incident diabetes during a mean follow-up of 10.3 years. After adjustment for age, sex, and socioeconomic status (SES), the hazard ratio (HR) for job strain compared with no job strain was 1.15 (95% CI 1.06-1.25) with no difference between men and women (1.19 [1.06-1.34] and 1.13 [1.00-1.28], respectively). In stratified analyses, job strain was associated with an increased risk of diabetes among those with healthy and unhealthy lifestyle habits. In a multivariable model adjusted for age, sex, SES, and lifestyle habits, the HR was 1.11 (1.00-1.23). Findings from a large pan-European dataset suggest that job strain is a risk factor for type 2 diabetes in men and women independent of lifestyle factors.

This article describes some of the crucial theoretical, methodological and practical issues that need to be considered when evaluating Health in All Policies (HiAP) initiatives. The approaches that have been applied to evaluate HiAP in South Australia are drawn upon as case studies, and early findings from this evaluative research are provided. The South Australian evaluation of HiAP is based on a close partnership between researchers and public servants. The article describes the South Australian HiAP research partnership and considers its benefits and drawbacks in terms of the impact on the scope of the research, the types of evidence that can be collected and the implications for knowledge transfer. This partnership evolved from the conduct of process evaluations and is continuing to develop through joint collaboration on an Australian National Health & Medical Research Council grant. The South Australian research is not seeking to establish causality through statistical tests of correlations, but instead by creating a 'burden of evidence' which supports logically coherent chains of relations. These chains emerge through contrasting and comparing findings from many relevant and extant forms of evidence. As such, program logic is being used to attribute policy change to eventual health outcomes. The article presents the preliminary program logic model and describes the early work of applying the program logic approach to HiAP. The article concludes with an assessment of factors that have accounted for HiAP being sustained in South Australia from 2008 to 2013.

Reports that tobacco smokers are at a lower risk of incurring Parkinson's disease (PD) than are non smokers and that a high percentage of Parkinsonians stop smoking before the onset of the disease, were reinvestigated by study of 110 hospital patients with PD and 110 other patients. In contrast to controls, fewer patients ever smoked cigarettes (39.1% versus 7.3%); moreover, many Parkinsonians (82%) stopped smoking before the onset of the disease. The high percentage of patients with PD who stopped smoking might by explained by premorbid behavioural modifications related to the biochemical cerebral changes already present in the preclinical stage of the disease.

The evidence examining the relationship between specific social factors and early childhood health and developmental outcomes has never been systematically collated or synthesized. This review aims to identify the key social factors operating at the household, neighborhood, and country levels that drive inequalities in child health and development. Medline and CHICOS (a European child-cohort inventory) were systematically searched to identify all European studies published within the past 10 y. 13,270 Medline articles and 77 European child cohorts were searched, identifying 201 studies from 32 European countries. Neighborhood deprivation, lower parental income/wealth, educational attainment, and occupational social class, higher parental job strain, parental unemployment, lack of housing tenure, and household material deprivation were identified as the key social factors associated with a wide range of adverse child health and developmental outcomes. Similar association trends were observed across most European countries, with only minor country-level differences. Multiple adverse social factors operating at both the household and neighborhood levels are independently associated with a range of adverse health and developmental outcomes throughout early childhood. The social gradient in health and developmental outcomes observed throughout the remaining life course may be partly explained by gradients initiated in early childhood.

A healthy start to life is a major priority in efforts to reduce health inequalities across Europe, with important implications for the health of future generations. There is limited combined evidence on inequalities in health among newborns across a range of European countries. Prospective cohort data of 75 296 newborns from 12 European countries were used. Maternal education, preterm and small for gestational age births were determined at baseline along with covariate data. Regression models were estimated within each cohort and meta-analyses were conducted to compare and measure heterogeneity between cohorts. Mother's education was linked to an appreciable risk of preterm and small for gestational age (SGA) births across 12 European countries. The excess risk of preterm births associated with low maternal education was 1.48 (1.29 to 1.69) and 1.84 (0.99 to 2.69) in relative and absolute terms (Relative/Slope Index of Inequality, RII/SII) for all cohorts combined. Similar effe...

We examined the associations of job strain, an indicator of work-related stress, with overall unhealthy and healthy lifestyles. We conducted a meta-analysis of individual-level data from 11 European studies (cross-sectional data: n = 118,701; longitudinal data: n = 43,971). We analyzed job strain as a set of binary (job strain vs no job strain) and categorical (high job strain, active job, passive job, and low job strain) variables. Factors used to define healthy and unhealthy lifestyles were body mass index, smoking, alcohol intake, and leisure-time physical activity. Individuals with job strain were more likely than those with no job strain to have 4 unhealthy lifestyle factors (odds ratio [OR] = 1.25; 95% confidence interval [CI] = 1.12, 1.39) and less likely to have 4 healthy lifestyle factors (OR = 0.89; 95% CI = 0.80, 0.99). The odds of adopting a healthy lifestyle during study follow-up were lower among individuals with high job strain than among those with low job strain (OR = 0.88; 95% CI = 0.81, 0.96). Work-related stress is associated with unhealthy lifestyles and the absence of stress is associated with healthy lifestyles, but longitudinal analyses suggest no straightforward cause-effect relationship between work-related stress and lifestyle.

Hubacek, JA and Adamkova, V and Stavek, P and Hubacek, JA and Kubinova, R and Peasey, A and Pikhart, H and Mar-Mot, M and Bobak, M (2008) Apolipoprotein E Arg136 -> Cys mutation and hyperlipidemia in a large central European population sample. CLIN CHIM ...

The association of short sleep duration with cortisol secretion has not been thoroughly examined in large community dwelling populations and the relative importance of short sleep duration and sleep disturbance is unclear. The objective of the study was to assess the relationships between self-reported sleep duration, sleep disturbance, and salivary cortisol secretion. This was a cross-sectional analysis using data from phase 7 (2002-2004) of the Whitehall II study. Sleep disturbances were assessed using a modified version of the Jenkins Scale. The occupational cohort was originally recruited in 1985-1989. Analyses included 2751 participants with complete cortisol measures and who collected their first sample within 15 min of waking, were not on medication affecting cortisol secretion, and had complete information for all covariates. Six saliva samples were taken on waking, waking + 0.5, 2.5, 8, and 12 h and bedtime for the assessment of the cortisol awakening response and the slope in cortisol secretion across the day. In mutually adjusted analyses, both sleep duration and disturbances were independently associated with a flatter diurnal slope in cortisol secretion, such that evening cortisol secretion was raised in those reporting short sleep duration and high sleep disturbance. Short sleep duration was also associated with the cortisol awakening response. These effects were independent of a number of covariates, including waking time on day of sampling and stress on the day of cortisol assessment. Short sleep duration and increased sleep disturbances are independently associated with diurnal slope in cortisol secretion of a large community-based cohort of middle-aged men and women.

Short sleep duration is associated with increased CHD (coronary heart disease) mortality and morbidity, although some evidence suggests that sleep disturbance is just as important. We investigated whether a combination of short sleep duration and sleep disturbance is associated with a higher risk of CHD than their additive effects. The Whitehall II study. The Whitehall II study recruited 10,308 participants from 20 civil service departments in London, England. Participants were between the ages of 35 and 55 years at baseline (1985-1988) and were followed up for an average of 15 years. N/A. Sleep hours and sleep disturbance (from the General Heath Questionnaire-30) were obtained from the baseline survey. CHD events included fatal CHD deaths or incident nonfatal myocardial infarction or angina (ICD-9 codes 410-414 or ICD-10 120-25). Short sleep duration and sleep disturbance were both associated with increased hazards for CHD in women as well as in men, although, after we adjusted for...

Non-drinkers are shown to have worse health than moderate drinkers in later life. We examine the preceding health status of non-drinkers in early adulthood, and secondly whether persistent poor health is associated with persistent non-drinking. Using two prospective British birth cohort studies established in 1958 (National Child Development Study (NCDS)) and in 1970 (British Cohort Study (BCS)), participants who reported 'never' or 'never had an alcoholic drink' to drinking status questions in successive waves from 23 to 26 years in the NCDS/BCS were derived as 'lifetime abstainers'. Logistic regression on the odds of being a lifetime abstainer was carried out on changes in limiting long-standing illness (LLSI) in the NCDS and long-standing illness (LSI) in the BCS, adjusting for sex, education, poor psychosocial health, marital and parental status. Participants with an LLSI in consecutive waves since 23 years had 4.50 times the odds of someone who did not have an LLSI of being a lifetime abstainer at 33 years (95% CI 1.99 to 10.18) and 7.02 times the odds at 42 years (2.39 to 20.66) after adjusting for all factors. Similarly, in the BCS, having an LSI in consecutive waves resulted in higher odds of being a lifetime abstainer at 30 years (OR 2.80, 1.88 to 4.18) and 34 years (OR 3.33, 2.01 to 5.53). Persistent LSI was associated with remaining a non-drinker across adulthood. Studies comparing the health outcomes of moderate drinkers to lifetime abstainers that do not account for pre-existing poor health may overestimate the better health outcomes from moderate alcohol consumption.

In May 2009 the World Health Assembly passed a resolution on reducing health inequities through action on the social determinants of health, based on the work of the global Commission on Social Determinants of Health, 2005-2008. The Commission's genesis and findings raise some important questions for global health governance. We draw out some of the essential elements, themes, and mechanisms that shaped the Commission. We start by examining the evolving nature of global health and the Commission's foundational inspiration--the universal pattern of health inequity and the imperative, driven by a sense of social justice, to make better and more equal health a global goal. We look at how the Commission was established, how it was structured internally, and how it developed external relationships--with the World Health Organization, with global networks of academics and practitioners, with country governments eager to spearhead action on health equity, and with civil society. We outline the Commission's recommendations as they relate to the architecture of global health governance. Finally, we look at how the Commission is catalyzing a movement to bring social determinants of health to the forefront of international and national policy discourse.

This report reviews the existing evidence of the direct and indirect health impacts suffered by those living in fuel poverty and cold housing. It makes the case for aligning the environmental and health agendas and reviews the evidence on the health benefits of reducing fuel poverty and improving the thermal efficiency of the existing housing stock.

In November 2008, Professor Sir Michael Marmot was asked by the Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010. The strategy includes policies and interventions that address the social determinants of health inequalities. The Review had four tasks:
1. Identify, for the health inequalities challenge facing England, the evidence most relevant to underpinning future policy and action
2. Show how this evidence could be translated into practice
3. Advise on possible objectives and measures, building on the experience of the current PSA target on infant mortality and life expectancy
4. Publish a report of the Review’s work that will contribute to the development of a post-
2010 health inequalities strategy

Background

Population-level data suggest that economic disruptions in the early 1990s increased working-age male mortality in post-Soviet countries. This study uses individual-level data, using an indirect estimation method, to test the hypothesis that fast privatisation increased mortality in Russia.
Methods

In this retrospective cohort study, we surveyed surviving relatives of individuals who lived through the post-communist transition to retrieve demographic and socioeconomic characteristics of their parents, siblings, and male partners. The survey was done within the framework of the European Research Council (ERC) project PrivMort (The Impact of Privatization on the Mortality Crisis in Eastern Europe). We surveyed relatives in 20 mono-industrial towns in the European part of Russia (ie, the landmass to the west of the Urals). We compared ten fast-privatised and ten slow-privatised towns selected using propensity score matching. In the selected towns, population surveys were done in which respondents provided information about vital status, sociodemographic and socioeconomic characteristics and health-related behaviours of their parents, two eldest siblings (if eligible), and first husbands or long-term partners. We calculated indirect age-standardised mortality rates in fast and slow privatised towns and then, in multivariate analyses, calculated Poisson proportional incidence rate ratios to estimate the effect of rapid privatisation on all-cause mortality risk.
Findings

Between November, 2014, and March, 2015, 21 494 households were identified in 20 towns. Overall, 13 932 valid interviews were done (with information collected for 38 339 relatives [21 634 men and 16 705 women]). Fast privatisation was strongly associated with higher working-age male mortality rates both between 1992 and 1998 (age-standardised mortality ratio in men aged 20–69 years in fast vs slow privatised towns: 1·13, SMR 0·83, 95% CI 0·77–0·88 vs 0·73, 0·69–0·77, respectively) and from 1999 to 2006 (1·15, 0·91, 0·86–0·97 vs 0·79, 0·75–0·84). After adjusting for age, marital status, material deprivation history, smoking, drinking and socioeconomic status, working-age men in fast-privatised towns experienced 13% higher mortality than in slow-privatised towns (95% CI 1–26).
Interpretation

The rapid pace of privatisation was a significant factor in the marked increase in working-age male mortality in post-Soviet Russia. By providing compelling evidence in support of the health benefits of a slower pace of privatisation, this study can assist policy makers in making informed decisions about the speed and scope of government interventions.