These findings held even when adjusting for factors such as occupation – meaning even those in the same job had reduced stress if they had attained a higher level of education. Importantly, integrative labour market policies, such as training for the unemployed, had a greater association with lower stress levels than more passive policies (those based around job loss compensation e.g. early retirement/unemployment benefits). This is possibly a result of integrative policies’ tendency to target disadvantaged groups, and having greater impact in terms of lowering overall labour market disadvantage. With work-related stress leading to reduced physical and mental health, this study provides evidence that policy makers should step up investments in protective and integrative labour market policies to reduce health inequalities.

The study: ‘The Association between Education and Work Stress: Does the Policy Context Matter?’ can be found here: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0121573.

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They gather the latest evidence from the project, provide a synopsis of the issue, solutions, and opportunities to advocate. The briefs have been informed by the findings of work on advocacy for health equity, and are meant for policy makers and practitioners at the European, national and sub-national levels. Translations of the policy briefs into several different European languages are under way, and will be made available from the Translations page.

Download links:

• Early Child Development - Universal, quality early childhood programmes that are responsive to need promote better and more equal outcomes in childhood and later life.
• Fair Employment - Improvements in quality of work, particularly for people in lower occupational groups, would contribute to a significantly healthier and more productive Europe.
• Income & Social Protection - Well-designed social protection systems can improve the lives of people and reduce health inequalities.

Slideshare links:

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The event, co-hosted by Julie Ward MEP (S&D, UK) and Eider Gardiazabal Rubial MEP (S&D, ES), brought together European and national policy-makers, civil society, industry and academics to discuss how DRIVERS’ latest evidence can be taken forward and integrated into existing and future policy initiatives.

For more than three years, scientists, civil society organisations, and representatives from public health and businesses have collaborated to explore how health equity can be improved across policy sectors, through action on three of the most important drivers of health: early childhood, employment & working conditions, and income & social protection.

As a result of their efforts, DRIVERS has identified four principles by which decision makers can design better and ‘healthier’ policies addressing the challenges of our time to help create a fairer Europe. These overarching principles can be applied to any policy context and can bring potential added value especially during times of crisis and cuts to public social spending.

Prof. Sir Michael Marmot in his keynote speech outlined how the principles of ensuring universality of access to services while addressing disadvantage, accounting for context and respecting rights of people concerned and ensuring that policies are evidence-based can guide the development and implementation of policies to improve health and reduce health inequalities. 

Application of these principles would enable children and families to live better and have adequate social protection coverage, enable workers to stay in the labour market for longer, improve productivity at work, reduce social exclusion and, hence, foster greater social cohesion. 

The importance of the life-course should be taken into account in the application of these principles as social inequalities start having an impact on individuals before birth, through early childhood and through life, influencing later life chances and outcomes. Moreover, the systematic deprivation of health for certain social groups, denying them the possibility to participate fully in economic and social life, results in even worse health.

The conference was composed of a scientific and a policy expert panel. During the first panel on taking stock of the evidence base advanced by DRIVERS, representatives from three DRIVERS’ partners (University of Dusseldorf, Centre for Health Equity Studies & University College London) explained how the DRIVERS project enabled them to gain new insights on employment, social protection and early child development & inequalities within and between different EU countries. 

Throughout the discussions, there was a general consensus that solutions to improve health equity solutions do not simply reside within the health sector and that public spending should strengthen sustainable employment and address health-adverse working conditions.

Moreover, other messages echoed that more spending on active labour market policies is correlated with better jobs and lower health inequalities in the same way that more spending on unemployment benefits is linked to a narrower social gradient in health.

In the panel dedicated to policy and how recommendations from DRIVERS can be taken forward to inform EU policy agendas, members of the European Parliament argued that the European Parliament's work can help improve health, but real moves towards health equity require action across sectors and at different levels of governance.

The DRIVERS policy recommendations received broad support and endorsement and several EU policy makers, including a member of the Social Protection Committee, and made concrete proposals and commitments to taking them forward.

Conference co-host Eider Gardiazabal Rubial MEP pledged to make efforts to ensure that the Commission and the Council boost investment in social and health needs and continue to tackle inequalities rather than allow a widening of existing disparities as a result of the crisis.

Ralf Jacob (DG EMPL, European Commission) stated that DRIVERS’ recommendations are in synergy with many of the Commissions priority areas. He also argued that the mid-term review of the Europe2020 Strategy represents a real opportunity for using new knowledge to inform the next phase of the Strategy.

All in all, the conference was an excellent opportunity to disseminate the latest pan-European evidence arising from the DRIVERS project and stimulate debate on how action to help reduce health inequalities across sectors can be maximized.

Reducing inequalities and enhancing social cohesion during this economic climate requires collective commitment and co-operation. DRIVERS and EuroHealthNet, a network of agencies and organisations dedicated to improving health equity across Europe, would like to thank all those who have supported us in the execution of our work within DRIVERS. Following the conference, interviews were conducted with several of our speakers. Video footage will be available soon.

“DRIVERS’ recommendations are impressive, very detailed, evidence-based, and integrated across the life course…” Rudi Van Dam (Social Protection Committee)

Did you miss the DRIVERS conference and want to know more? Please visit our Storify page (see below), which summarises the conference key messages that were produced via Twitter.

The news release issued following the conference can be found here.

The key note speech by Sir Michael Marmot can be found here.

The policy recommendations document 'Improving health equity through action across the life course' can be found here.

More information on DRIVERS publications (policy briefs, reports) can be found here.  The policy recommendations and policy briefs are currently being translated into several European languages and will be available shortly.

For more information, please contact us at [email protected]

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They detail the scientific work carried out by teams at University College London/UCL Institute of Health Equity, the Department of Medical Sociology at Universität Düsseldorf, and the Centre for Health Equity Studies (CHESS) at Stockholms Universitet, on (respectively) early child development, employment & working conditions, and income & social protection.

While numerous academic papers have been - and continue to be - published in leading peer-reviewed journals, these reports bring together the expanded evidence base, explaining how the different pieces of work fit together and provide a solid foundation for the development of evidence-based recommendations. These recommendations are detailed in separately published recommendations document and three policy briefs.

The three reports are:

• Social Inequalities in early childhood health and development, evidence and policy implications, by Hynek Pikhart, Milagros Ruiz, Joana Morrison, Peter Goldblatt & Michael Marmot. Also see the Appendices.
• Working conditions and health inequalities, evidence and policy implications, by Johannes Siegrist, Diego Montano & Hanno Hoven.
• The role of income and social protection for inequalities in health, evidence and policy implications, by Olle Lundberg, Monica Åberg Yngwe, Kersti Bergqvist & Ola Sjöberg.

The project's final recommendations will be presented tomorrow, 3 February 2015, at a conference held at the Residence Palace in Brussels. The final recommendations document and policy briefs are available from the publications section of the website.

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DRIVERS participated in several pre-conference sessions, during which project partners presented some key findings of the project and discussed the role of effective advocacy in realising health equity goals.

A session titled “How to tackle health inequalities? Results from four EU-funded projects” saw Prof Olle Lundberg (CHESS) illustrate the limitations of a welfare regime approach to studying social protection and health inequalities. It also saw Dr Hynek Pikhart (UCL) underline methodological and conceptual challenges in the harmonisation of inequality-relevant indicators across Europe.

Dr Claudia Marinetti (EuroHealthNet) gave an overview of the role of advocacy in reducing health inequalities. She emphasised the value of different kinds of evidence in advocacy efforts, in contrast to the well-known ‘hierarchy of evidence’, and the use of different types of advocacy messages.

In a poster walk dedicated to evidence-informed policy, Linden Farrer (EuroHealthNet) presented results from DRIVERS on improving the effectiveness of advocacy for health equity. He stated that it is important for evidence to find its way into policy processes, but doing so requires specific methods of knowledge transfer and translation. As scientists are not always willing or able to advocate, knowledge brokering organisations such as EuroHealthNet can play an extremely important role in facilitating this process.

One of DRIVERS’ aims is to identify solutions to reducing health inequalities through policy and practice in early childhood development. Joana Morrison (UCL) presented a review of early childhood interventions in several European countries conducted over the last two decades with the aim of addressing health and early development. One of the findings is that interventions with better outcomes appear to combine educational activities for both parents and children beginning in early pregnancy and include home visits by specialised staff.

DRIVERS also featured in a packed plenary session on tackling health inequalities organised by EuroHealthNet. The session included a discussion on presenting policy recommendations to policy makers from four EU-funded projects (DEMETRIQ, DRIVERS, SILNE, SOPHIE), all aiming to generate new evidence on the best ways of tackling health inequalities.

On behalf of the DRIVERS team, Prof Johannes Siegrist emphasised that public spending should strengthen sustainable employment and address health-adverse working conditions, particularly among lower socio-economic groups. Indeed, he noted that “DRIVERS has demonstrated a social gradient in risk of suffering from work stress, with lower occupational groups facing the greatest risks of psycho-social stress”.

All in all, the EPH conference was an excellent opportunity to disseminate new evidence arising from the DRIVERS project to public health researchers, policy makers, practitioners and health professionals.

If you missed DRIVERS at the EPH conference then please visit our Storify page (see below), which summarises the key events through the tweets that were produced throughout the course of the Pre-conference.

You can find the joint DRIVERS and EuroHealthNet news release issued at the start of the EPH Pre-Conference here.

You can also find the DRIVERS presentations and poster here.

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The new report represents a complete source of information on social protection systems, policy trends and social protection statistics. According to the report, for instance, 73 percent of the population is covered partially or not at all by social security. Inadequate or lack of access to social protection represents a serious impediment to economic and social development, and is related to poverty, economic insecurity, inequality and slow growth.

Overall, the report:

• Presents a global overview of how social protection systems are organised, their coverage, types of benefits, and public expenditures;
• Following a life-cycle approach, presents  the current social protection for children and families, women and men of working age and older people;
• Analyses trends and recent policies; for example from 2010 onwards, several countries have started contracting public expenditures, mainly adjusting their welfare and pension systems or reforming their healthcare;
• Provides the key elements of national policies to promote human development, political stability and inclusive growth.

The full report is available to download here.

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The purpose of this research by Tommy Ferrarini, Kenneth Nelson & Ola Sjöberg from the Swedish Institute for Social Research at Stockholm University was to analyse the role of unemployment insurance on self-rated health in the working age population at the onset of the financial crisis in Europe. They used institutional-level data on coverage and replacement rates in unemployment insurance (SPIN) and EU-SILC panel data covering 23 European countries.

They show that unemployment insurance reduces chances of experiencing ill-health. Increased coverage rates seem to have a stronger effect than the level of replacement (the amount to which the unemployment insurance replaces wages lost), though the effects are intertwined. Moreover, unemployment insurance seems to be particularly effective in reducing chances of experiencing ill-health among individuals with low educational attainment.

Unemployment insurance also had a positive effect on the health of employed people. Previous research by Wilkinson & Marmot suggested that even the possibility of becoming unemployed can lead to ill-health, through stress. This new research indicates that unemployment insurance can counteract this psychosocial mechanism, providing financial support to support material needs for those who become unemployed and a psychological safety net for those in work.

Unemployment insurance and deteriorating self-rated health in 23 European countries was published in the Journal of Epidemiology & Community Health on 10 March 2014. To access the paper click here.

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Joakim Palme is a Swedish political scientist and sociologist, currently Professor of political science at Uppsala University and former Director of the Institute for Future Studies in Stockholm between 2002 and 2011. Between 2003 and 2009, he was Adjunct Professor of sociology at Stockholm University. In 2009 he was appointed Adjunct Professor at the Centre for Velfærdsstatsforskning at the University of Southern Denmark.

 1)      Could you tell us about your work?

For almost ten years my work has focused on comparing welfare states, trying to work out how welfare state programmes, excluding healthcare, impact on inequalities in society. Several years ago my colleagues and I started working as part of the Marmot Commission on Social Determinants of Health, looking at how welfare state programmes relate to people’s health and health inequalities. We took a life-cycle approach and looked at how family policies affect child mortality, how social insurance affects mortality among the working-age population and the links between pension systems and mortality among older people. This led to interesting analyses, and saw us move beyond the welfare regime approach towards examination of specific welfare programmes. That’s the background to my involvement in DRIVERS.

2)      How do welfare programmes affect health and health inequalities?

Income is important because it allows people to pay for products that are good for health, such as food and quality housing. It’s therefore not surprising that levels of income are important for health. The welfare state can play a part in this, because it ensures a consistent stream of income, even when people are temporarily unable to secure them, for example when ill or unemployed. Welfare programmes can also be important in terms of reducing societal inequalities. Large income inequalities put stresses and strains of people’s lives, and the welfare state can help reduce inequalities in society. Moreover, work coming out of DRIVERS shows that welfare programmes are even beneficial to those who are not currently benefiting from them directly. This seems to be because it reduces feelings of insecurity, and provides assurance that unemployment or illness does not necessarily lead to economic disaster.

3)      We are just coming out of a period of crisis, and labour markets and social protection policies have been reformed quite drastically. What trends in social policy and social spending do you observe?

The crisis is still on, so we don’t have a final answer, but it does appear to have triggered increased diversity between European countries. This seems to come out very clearly in a recent report from the European Commission on the Employment and Social Development in Europe [1]. We see that the countries most severely affected by the economic crisis have also been those most severely affected in social terms. In order to secure loans, these countries have had to implement nationally and internationally imposed reforms to their social protection systems.

5)      When you talk about diversity, are you talking about divergence between northern and southern European member states?

Yes. So while northern European countries have been comparatively less affected by the crisis, southern ones have been more severely damaged in a number of ways. One could rightfully say that these countries performed worse before the crisis, but that the crisis has been unhelpful in terms of raising the level of their welfare spending ambitions and in putting welfare state financing on a more sustainable path.

6)      So does the economic crisis really matter for health and health inequalities, and if so, how?

Poverty has been aggravated and this increases risks to health. In addition, some groups have been more affected than others. We can see that in southern Europe youth have been severely affected by the crisis and that many have become unemployed. Many older workers have been affected by falling incomes. There have also been cutbacks in a number of countries in terms of generosity of benefits. This was not something seen in the initial phase of the crisis, but became prominent in more recent years. As public deficits increased and unemployment increased, this put a strain on welfare protection budgets and there were consequent overall cutbacks in generosity. We know that youth are a clear at-risk group. Moreover, we know that those who are not covered by welfare programmes are at risk. Worryingly, we can also see that when people do find work, their jobs often don’t provide decent pay. The phenomenon of in-work poverty seems to be increasingly important, and this is a surprise to many European policy makers who have so-far stressed the primary role of employment in combatting poverty and inequality.

7)      Would it be fair to say that the crisis has exacerbated thirty years of stagnant or even real-term cuts to many people’s wages?

I actually think the current crisis is more than that. In fact, in some countries income development has been mixed. Take Sweden, for example. While income inequalities have increased a lot we also see that pay increases among the low paid have been good, and that collectively bargained minimum wages have improved a bit, at least in terms of relationship to median income. Another example is Germany. Here we see the results of labour market reforms that were enacted at the turn of the millennium, and which have resulted not only in increased employment but four million working poor. That’s not a middle-class problem in my view, but a problem concerning the emergence of a new underclass.

Overall, situations differ between countries. In some we see large numbers of people who borrowed money to buy a house before the crisis and now run the risk of becoming homeless. Such people constitute a group that were considered comfortably well-off before the crisis, but who find themselves in a very different situation today. In fact, it is possible to say that the crisis has been of such a magnitude that it has affected very broad parts of the overall European population, though groups traditionally at risk remain so: less education people, newcomers to the labour market, youth, migrants and also women.

8)      What kinds of social policies could help reduce health inequalities?

It is important not to demand the complete overhaul of the system of social protection, because more modest improvements could lead to improved health. First I would suggest a minimum income safety net. The second thing is unemployment protection, with wide coverage and replacement rates. The European Commission has done interesting work on minimum income safety nets and unemployment insurance, showing that they are important not only for the health of a population but also for macro-economic stability [2]. Countries without protection systems fared much worse in the crisis, and social protection systems can be built up on this basis.

Youth is an extremely important issue. It is the only area where the European Union has mobilised common resources to help victims of the crisis. In my view, youth is the big social question of our time. We already know how to combat poverty among children and old people and about how to maintain good unemployment insurance systems, but less about how to facilitate the transition from youth to adulthood and from education to the labour market. I fear that the resources being mobilised will not match needs, and that there will be a scarring effect on the generation entering the labour market for decades to come unless something much more ambitious is attempted.

9)      You mentioned the importance of wages earlier. Do you think collective bargaining is important in maintaining decent levels of pay? Or are legislated levels more important?

Different European countries have very different labour markets. Some countries have national legislation on minimum levels of pay that is important, while in others such as the Scandinavian countries, collective bargaining is important. However, when we look at risk factors for poor health we also see that job quality is important. It should not be forgotten that collective bargaining is a way to ensure a decent level of income and a means of ensuring job quality.

10)   What role does scientific research have in all of this then? Does science have a primary role in informing policy?

This is what we hope, that politicians are informed and willing to take action on the basis of research. I’m quite optimistic on this. We know that the collection of health statistics was tremendously important in the emergence of the first welfare state programmes a century ago; this was the case in Britain, Norway, Sweden, and other countries. I think it is hard for politicians today to run away from facts, and communication of research is very important. In this respect I’m certainly hopeful that research can be a trigger for political change. If we take climate change, for example, we can see that for a time it was possible for politicians to deny the science, but eventually it could barely be denied. I think that health is of real importance, and I hope that research on health will help in terms of promoting desirable policy change.

11)   What kind of research methodologies are needed to help science progress on these issues?

I’m very much in favour of what might be termed mixed-methods. It is important to compare countries because it is often at the country level that policies differ, and it is important to study and evaluate when countries reform their policies because that’s a source of important evidence. I also think it’s important to combine country-level information with detailed information at the individual level. The European Union can be seen as a kind of laboratory for different kinds of policy, between nations, and I think that there is great potential for exploiting this laboratory for enhancing our understanding of what policies are good and bad for health.

12)   We’re nearing the end of the interview. Is there anything you would like to add?

In relation to your question on the links between research and policy, I’d like to stress the importance of having policy advocates, who do not necessarily belong to the political establishment, but who can challenge political parties aiming to get into government. It always takes a lot of time and effort to make reforms, and governments often find there is very little room for manoeuvre. However, there are windows of opportunity when politicians open their minds to what is possible, and when advocates can persuade them that policy change is possible and desirable too.

13)   We are currently involved in a strand of research within DRIVERS focused on advocacy for health equity. What risks do scientists face when involved in policy advocacy?

The risk for scientists is being associated with particular political strategies, rather than being associated with the ambition to reduce ill-health or mortality. However, researchers regularly have to formulate policy recommendations, whatever the research question. I think the more serious risk is that researchers detach themselves from policy making because they’re afraid of losing their integrity as a scientist. That would be an unfortunate development, and in my view unnecessary. I think we should challenge the research community much more when it comes to advocacy and policy making. Speaking from the Swedish perspective, I think the research community is too isolated from policy. We need to work and create an arena for interactions between researchers and policy makers. This arena could play an important role in provoking both politicians and researchers to address the same kinds of issues.

[1] European Commission (2014), Employment and Social Developments in Europe 2013 http://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=7684

[2] European Commission (2013), Paper on Automatic Stabilisers
http://ec.europa.eu/social/BlobServlet?docId=10964&langId=en

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Using data from three longitudinal ageing studies (SHARE, HRS, ELSA), including 5650 men and women in 13 countries, they find significantly increased chances of depressive symptoms two years later among participants experiencing work-related stress in terms of effort-reward imbalance and low job control. In addition, they find that social and labour policies reduce the likelihood of depressive symptoms resulting from effort-reward imbalance. Explaining the results, they suggest that the health threatening stress response of effort-reward imbalance at work may be less pronounced in a 'protective policy context', because job insecurity may seem less threatening if social protection exists. Conversely, work-related stress and resultant depressive symptoms may be much more pronounced in a non-protective policy environment.

These results hold importance in the context of an ageing society and high levels of early labour market exit due to ill health, as they indicate that more ambitious social (protection) spending modifies the health threatening effect of effort-reward imbalance. Furthermore, they show that action is needed in two distinct areas: 1) action to tackle effort-reward and low work control in the workplace, 2) action to support and improve social protection policies.

DRIVERS is building on this knowledge base, and will publish a series of reports over the coming year to highlight specific actions that may be taken to improve health and reduce health inequalities in Europe.

To read the paper, click here.

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Claudia Marinetti presented on the project as a whole. Hynek Pikhart presented on the work on early childhood development on behalf of the UCL team. Next, Hanno Hoven presented the work on employment & working conditions for the University of Dusseldorf team. Then Olle Lundberg of CHESS presented an overview of what’s known and some of the findings of their research network. Finally, Linden Farrer presented on the advocacy work taking place within DRIVERS.

A lively question and answer session followed each presentation, and useful feedback will be incorporated into future work.

Furthermore, DRIVERS had the opportunity to present a rolling presentation of its work at the Third Annual Convention of the Platform against Poverty and Social Exclusion on 26-27 November 2013.

• European Public Health Conference - Introduction to DRIVERS (C. Marinetti)
• European Public Health Conference - Early Childhood Development (P. Pikhart)
• European Public Health Conference - Employment & Working Conditions (H. Hoven)
• European Public Health Conference - Income & Social Protection (O. Lundberg)
• European Public Health Conference - Advocacy for Health Equity (L. Farrer)
• Third Annual Poverty Convention - DRIVERS rolling presentation

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