Health Psychology. Michael Murray
the United Nations in 2000, 189 countries adopted the ‘Millennium Development Goals’, including halving poverty rates by 2015, reducing child mortality, decelerating the growth of AIDS and educating all children. In the early 2000s Brazil was working towards, and expected to reach, these targets using the Bolsa Família (family stipend) and Fome Zero (zero hunger) programmes (Galindo, 2004). Doctors at a local health clinic in Brazil observed that their patients, who regularly came in with health problems related to poverty, were visiting less often. This can be reasonably attributed to the national, anti-hunger Fome Zero (zero hunger) programme that aimed to give every Brazilian at least three meals a day. With one-quarter of Brazil’s 170 million people below the poverty line, this goal was a challenge. To date, the government has provided emergency help to 13 million families.
The scheme involved giving ‘something for something’ by making cash transfers conditional upon regular school attendance, health checks, and participation in vaccination and nutrition programmes. Almost three-quarters of benefits reached the poorest 20% of the population and absolute poverty halved from 21% in 2001 to 11% in 2008 (Hall, 2012). Opinions vary about the success of the programme. Commentators suggested that the Workers’ Party gained many extra votes as one consequence of Bolsa Família, and also that there was shift in policy towards short-term solutions to poverty rather than long-term investments in health and education (Hall, 2008, 2012).
The production of good population health requires much more than simply providing doctors, nurses and hospital services. Basic economic, educational and environmental foundations need to be put into place. This means that some fairly dramatic economic changes are needed if we are to see health improvements during the twenty-first century. Among these changes, the cancellation of unpaid debts of the poorest countries and trade justice have the potential to bring health improvements to match those of the last 50 years.
A case can be made that health improvements are a necessary precondition of economic growth. This was suggested by the WHO Commission on Macroeconomics and Health. The Commission Report stated: ‘in countries where people have poor health and the level of education is low it is more difficult to achieve sustainable economic growth’ (World Health Organization, 2002). If current trends continue, health in sub-Saharan Africa will worsen over the next decades. If the Millennium Development Goals are going to have any chance of success in Africa, health must be given a higher priority in development policies. Sub-Saharan Africa contains 34 of the 41 most indebted countries, and the proportion of people living in absolute poverty (on under US$1 per day) is growing. The health of sub-Saharan Africans is among the worst in the world. Consider the following indicators:
Two-thirds of Africans live in absolute poverty.
More than half lack safe water.
A total of 70% are without proper sanitation.
Forty million children are not in primary school.
Infant mortality is 55% higher than in other low-income countries.
Average life expectancy is 51 years.
The incidence of malaria and tuberculosis is increasing.
These figures indicate the very large gaps that exist between the ‘haves’ and ‘have-nots’ on the international stage. International debt is a significant factor in poverty. Rich nations will need to honour pledges they have given to cancel debts and establish fair trade to produce reductions in poverty and hunger in Africa.
Inequalities within a Country
The existence of health gradients within health care is a universal constant. Many of the determinants of ill health were identified by Edwin Chadwick in his studies of public health in Victorian England: poverty, housing, water, sewerage, the environment, safety and food. In addition, we recognize today that illiteracy, tobacco, AIDS/HIV, immunization, medication and health services are also important (Ferriman, 2007).
Recent studies of the social determinants of health have pinpointed various kinds of inequity. The first of these is based on socio-economic status (SES): people who are higher up the ‘pecking order’ of wealth, education and status have better health and live longer than those at the lower end of the scale. To illustrate this, Figure 4.3 shows a map of the Jubilee Line, which travels along an east–west axis across London. If you travel eastwards along this tube line from Westminster to Canning Town, the life expectancy of the local population is reduced by one year for every stop.
Health gradients are found in all societies. Wealthier groups always have the best health; poorer groups have the worst health. These differentials occur in both illness and death rates, and health gradients are equally dramatic in both rich and poor countries. The majority of studies have been carried out in rich countries.
Figure 4.3 Differences in life expectancy within a small area of London
Source: Department of Health (2008)
BOX 4.2 KEY STUDY: The Whitehall studies
The Whitehall studies investigated social class, psychosocial factors and lifestyle as determinants of disease. The first Whitehall study of 18,000 men in the Civil Service was set up in the 1960s. The Whitehall I study showed a clear gradient in which men employed in the lowest grades were much more likely to die prematurely than men in the highest grades.
The Whitehall II study started in 1985 with the aim of determining the causes of the social gradient and also included women, including potential psychological mediators. A total of 10,308 employees participated, two-thirds men and one-third women. The cohort was followed up over time with medical examinations and surveys. Most participants are now retired or approaching retirement.
There have been many phases of data collection, alternating postal self-completion questionnaires with medical screenings and questionnaires. In addition to cardiovascular measures, blood pressure, blood cholesterol, height, weight and ECGs were taken, along with tests of walking, lung function and mental functioning, questions about diet, and diabetes screening.
Figure 4.4 Death rates (%) vs. employment grades over a 25-year period in the Whitehall studies
Source: Ferrie (2004). Reproduced with permission
The Whitehall studies found that an imbalance between demands and control lead to illness. Control is less when a worker is lower in the hierarchy and so a worker in a lower position is unable to respond effectively if demands are increased, supporting Karasek and Theorell’s (1990) demand–control model. Other mechanisms can buffer the effect of work stress on mental and physical health: social support (Stansfeld et al., 2000), effort–reward balance (Kuper and Marmot, 2003), job security and organizational stability (Ferrie et al., 2002). Figure 4.4 shows the gradient of death rates versus employment grades over a 25-year period in men from the Whitehall studies. The death rate is shown relative to the whole Civil Service population (reproduced from Ferrie, 2004).
Virtanen et al. (2015) examined whether midlife adversity predicts post-retirement depressive symptoms in 3,939 Whitehall II participants (mean age 67.6 years at follow-up). Strong associations occurred between midlife adversities and post-retirement depressive symptoms, including low occupational position, poor standard of living, high job strain and few close relationships. Associations between socio-economic, psychosocial, work-related or non-work-related exposures and depressive symptoms were of similar strength. The data suggest that socio-economic and psychosocial risk factors for symptoms of depression post-retirement can be detected in midlife.
Source: Ferrie (2004)
There are relatively few studies of health gradients in poor countries. The data are cross-sectional rather than longitudinal, but show a similar pattern to those observed with Whitehall civil servants.