1. Taking action on social determinants to
improve mental health in urban settings
Michael Marmot
Urban Mental Health
September 2012

2. Outline
• Mental health and socioeconomic position
• Social determinants - framework for action

3. Life expectancy and disability-free life expectancy at birth
by neighbourhood income deprivation, 1999-2003

4. Working age people in England at high
risk of mental illness by social class
Social classes I-IIINM Social classes IIIM-V
20
% with High GHQ12 score
17
15
15
12
10
9
5
Men Women
Source: Health Survey for England, DH; the data is the average for 2004 to 2006;
England; updated June 2008

5. Risk factors for depression
Level of evidence
Low socioeconomic position Very convincing
Low education Very convincing
Unemployment and under Very convincing
employment
Food insecurity and early Strong
nutrition deficiency
Gender inequity Strong
Low income Strong
WHO CSDH PPHC KN 2007

6. Odds ratio for depressive symptoms by presence
of social deprivation at different phases of the life
course in Eastern European countries
Childhood Education Adult
4
Age adjusted odds ratio
3
2
1
0
Czech men Russian men Polish men Czech Russian Polish
women women women
From Nicholson et al J Affective Disorders 2008

7. Long term outcomes associated with childhood
behavioural problems (New Zealand study)
4.5
OR
4 4.13
3.5
3
3
2.5
2.39
2
1.95
1.5 1.57
1.69
1.51
1 1.24
1 1 1 1
0.5
Crime Drugs Depression Suicide
Top 50% (no conduct problems) Middle 45% (some conduct problems)
Bottom 5% (conduct disorder)
Source: L. Friedli & M. Parsonage (2007) Mental health promotion: Building an economic case. Based on:
Fergusson et al (2005) J. Child Psychl & Psych 46 (8): 837-849

8. Loneliness by wealth
% often/some of the
time (except for “Feel in
tune with people around”
where % refers to hardly
ever/never)

9. % depressed (CES-D 4+) by
participation in activities
Men Women
25
Does activity Does not
20
15
%
10
5
0
p
p
g
g
g
g
k
k
hi
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in
in
in
in
or
or
rs
rs
er
er
ar
ar
w
w
be
be
e
e
C
C
d
d
nt
nt
ai
ai
em
em
u
u
P
P
ol
ol
m
m
V
V
e
e
iv
iv
ct
ct
A
A

10. Social justice
Material,
psychosocial,
political
empowerment
Creating the
conditions for
people to have The CSDH – closing the The Marmot Review – Fair
control of their gap in a generation Society Healthy Lives
lives 2005-2008 2009/10

11. CSDH – Areas for Action
Health Equity in all Policies
Fair Financing Good Global
Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity
Political empowerment
– inclusion and voice

12. • Every sector is a health sector
– Health and well being as outcomes

13. Social determinants of health across the lifecourse

14. Marmot Review: 6 Policy Objectives
A. Give every child the best start in life
B. Enable all children, young people and adults to
maximise their capabilities and have control over
their lives
C. Create fair employment and good work for all
D. Ensure healthy standard of living for all
E. Create and develop healthy and sustainable places
and communities
F. Strengthen the role and impact of ill health
prevention

15. MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
LIFE COURSE STAGES
Accumulation of positive and negative
effects on health and wellbeing
Prenatal Early Years Working Age Older Ages
Family building
Perpetuation of inequities

16. Children achieving a good level of development at age five, local
authorities 2011: England
Good level
of development
at age 5
%
80
75
70
65
60
55
50
45
40
0 30 60 90 120 150
Local authority rank - based on Index of Multiple Deprivation
Source: LHO (2012)

17. Socio-emotional difficulties at age 3 and 5:
Millennium Cohort Study
Age 3 Age 5
Fully adjusted = for parenting activities and psychosocial markers
Kelly et al, 2010

18. Verbal ability at age 3 and 5 by family income:
Millennium Cohort Study
Age 3 Age 5
Fully adjusted = for parenting activities and psychosocial markers
Kelly et al, 2010 in press

19. Per cent 5 year olds achieving ‘good development
score’,* Birmingham LA, West Midlands & England
%
*in personal, social and emotional development
and communication, language and literacy
Source: Department for Education: preliminary data

20. Unemployment and Mortality
1% rise in
unemployment
associated with:
- 0.8% ↑Suicide
- 0.8% ↑Homicide
- 1.4% ↓Traffic
death
No effect on all-
cause mortality
Source: Stuckler et al 2009 Lancet

21. Population attributable Risk
(PAR) for all combined*
46% 95% CI 37%-53%
adjusted for other
predictors
34% 95% CI 24%-43%
ERI= Effort reward imbalance
*calculated from odds ratios adjusted for age, sex, employment grade
J Head et al,2007

22. Gender Equity
• Higher risk of depression in women
– Multiple responsibilities with no financial gain
– Caring responsibilities
– Lack of support
– Gender based violence
– Access to health care
– Poor physical health
– Level of education
– Autonomy in decision making
– Migration

23. ODDS OF DEPRESSION BY CONTROL AT WORK &
AT HOME WITHIN GRADE - WOMEN WHITEHALL II
Decision latitude Home control
4
ratios
3
odds
2
1
High Medium Low
EMPLOYMENT GRADE
Griffin et al, Soc Sci Med, 2002

24. Percentage of those lacking social support, by deprivation
of residential area, 2005

25. Context matters
• Deprivation
• Social inequality

26. Percentage shares of equivalised total gross and post-tax income,
by quintile groups for all households, 1978 – 2007/8

27. Real earnings growth (%) for men and women
working full time by decile, 1980 - 2005
OECD 2008

28. Trends in income share among top income
decile, US: 1913-2007

29. International comparisons of income mobility
Higher score = lower intergenerational mobility
Source: Blanden (2009) in NEP 2010.

30. • Urban design
– good urban design can encourage social cohesion
– exercise - benefits for mental health
– green spaces

31. Exercise, green space and mental health
Self-esteem
What is the Best Dose of Nature
and Green Exercise for Improving
Mental Health? A Multi-Study
Analysis
•Both self-esteem and mood show
U shapes.
Total Mood Disturbance
•Greatest changes from 5 min of activity,
•The changes are lower for 10-60
min and half-day, but still positive;
•They rise again for the whole day.

32. Average weekly alcohol consumption by
sex and socioeconomic class, GB: 2008
Mean number
of units a week
ONS General Lifestyle Survey 2008

33. Alcohol-attributable hospital admissions by
small area deprivation quintile in England,2006-07

34. • Health inequalities are not inevitable or immutable

35. SMRs by cause, all ages:
Glasgow relative to Liverpool & Manchester
All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative
to Liverpool & Manchester, standardised by age, sex and deprivation decile
Calculated from various sources
350
300
248.5
229.5
250
Standardised mortality ratio
200 168.0
150 131.7
126.7
112.2 111.9
100
50
0
All cancers Circulatory system Lung cancer External causes Suicide (inc. Alcohol Drugs-related
(malignant undetermined intent) poisonings
neoplasms)
Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010
from H Burns, CMO, Scotland

36. Health improvement in difficult times
• A major element of the excess risk of premature
death seen in Scotland is psychosocially
determined
• Study evidence of low sense of control, self
efficacy and self esteem in population in these
areas
H. Burns, CMO Scotland

37. A Fair Society
Conditions in which
individuals and
communities have control
over their lives
www.marmot-review.org.uk