Led by EuroHealthNet, this work aimed to consolidate existing knowledge of advocacy for health equity, which is dispersed widely across the academic and grey literature, across disciplines, and is contained in a variety of different kinds of publications. Advocates previously had no synthesis of this knowledge to draw upon to inform their efforts.

As a result, EuroHealthNet carried out a systematic review of the academic literature and fixed-length systematic search of the grey. The results of the search which were analysed and synthesised by using a heuristic representation of advocacy for health equity (the "Six Dimensions of Advocacy for Health Equity"), developed jointly with the European Anti-Poverty Network, Business in the Community and Eurochild.

The review shows that the policy world is complex and that scientific evidence is unlikely to be conclusive in the making of decisions policy. Timely qualitative, interdisciplinary, and mixed-methods research may be particularly valuable in advocacy efforts. The potential impact of evidence can be increased by “packaging” it using methods of knowledge transfer and translation. Increased contact between researchers and policy makers could improve the uptake of research in policy processes. Researchers can play a role in advocacy efforts, though health professionals and disadvantaged people, who have direct contact with - or experience of - hardship, can be particularly persuasive in advocacy efforts. Different types of advocacy messages can accompany evidence, but messages should be tailored to the target group. Advocates need to take advantage of “windows of opportunity”, which open and close quickly, and demonstrate expertise and credibility. For this reason, dedicated advocacy organisations that have the resources and experience required to advocate could play a leading role in advocacy efforts, bridging the ‘worlds’ of science, practice and policy.

One surprise finding was the emphasis on barriers that hamper advocacy efforts in the academic literature. The most frequently cited was the current political and economic zeitgeist (variously termed 'market fundamentalism', 'market justice', 'neo-classical economics' and 'neoliberalism') and related public opinion, which tends to blame disadvantaged people for their ill health. Other barriers identified included biomedical approaches to health, market-led reforms of higher education, academic difficulties or reluctance to advocate and political short-termism. Several papers suggested means of overcoming these barriers, including long-term actions to raise public awareness and understanding of the SDH, training health professionals in advocacy or human rights, and bringing students concerned with the determinants of health into closer contact with those experiencing hardship as part of their studies.

The review provided a useful building block for later research on advocacy within DRIVERS: five case studies on advocacy and development of the toolkit on advocacy for health equity. In addition, the findings helped inform the how the project disseminated and presented its results. The paper is available here, and appendices here. The case studies report is available here, and advocacy for health equity toolkit here.

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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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The report also explores the importance of ECEC to reduce socio-economic inequalities and to foster the healthy development of children.

Other aspects:

• Affordability is a very important factor in ensuring that all children have access to ECEC, especially those in most need, i.e. children are at risk of poverty or social exclusion.
• The compulsory qualification levels for ECEC staff vary between countries. Educational staff working with older children is usually required to have a Bachelor's degree as a minimum qualification, while such requirement often does not exist for staff working with younger children.
• The participation in ECEC is low for the under three years old. In contrast, 93% of children attend ECEC before starting primary education.
• The involvement of parents and community representatives creates better conditions for children's learning.

The full study Key Data on Early Childhood Education and Care in Europe – 2014 can be found 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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The report:

• Confirms significant inequalities in health between and within EU Member States, which for the most part are similar to those identified in ‘Health inequalities: Europe in profile’ (2006). Some inequalities have increased, while others have decreased, suggesting that significant headway has not been made in the EU in reducing health inequalities.
• Demonstrates marked differences in the social determinants of health - in turn caused by the existence of marked social inequalities - across EU Member States and inequalities in health between social groups based on these determinants.
• Examines the factors causing health inequalities. Like the WHO CSDH, this report agrees that health inequalities result from social inequalities in the conditions of daily life and their fundamental drivers (e.g. early childhood, employment conditions, social spending and protection, etc.) that give rise to them.
• Presents research showing the policy response to health inequalities in EU member states and regions. Countries' responses are characterised as having a: 1) Relatively positive and active response, 2) Variable response, 3) Relatively undeveloped response to health inequalities. These results, including those showing that serious headway has not been made in tackling health inequalities in EU countries, justify the headline conclusion of the WHO Europe report which was that all countries can do something to improve the social determinants of health, do more, or do better with their existing policies and spending. Worryingly, the research suggests a widening of the policy response across EU member states since 2006.
• Provides a comprehensive set of recommendations for the European Commission, and individual member states and regions.

The report was co-ordinated by the UCL Institute for Health Equity and involved a variety of partners in the DRIVERS consortium.

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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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The review is divided into four main sections: 1) Context and background to the review with key principles underpinning the recommendations, 2) Summary of current evidence on the health divide between countries, 3) A focus on the life-course perspective, wider society, macro-level context, governance, delivery and monitoring systems, 4) Implementation, framework for action, reasons for failure, guidance on good practice.

Overall, the report calls for universal coverage of health care, a focus on health-adverse behaviours, and action on the conditions into which people are born, grow, live, work and age, and the inequalities in power, money and resources that give rise to them.

New themes in the report, compared with the CSDH, include:

• Emphasis on human rights as an approach to tackle the SDH and improve health but continued commitment to social justice.
• Emphasis on empowering communities and individuals to take action.
• Emphasis on the life-course approach, meaning that although early childhood is important every stage of life plays a subsequent part in determining health.
• Emphasis on protecting future generations from perpetuations of social and economic inequalities.

Click here to download.

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This systematic review, by Hanno Hoven & Johannes Siegrist (Heinrich-Heine University Düsseldorf), produced as part of the DRIVERS project, looks at mediation and moderation effects in prospective studies.

Physical stressors and occupational hazards have traditionally been considered the major causes of work-related health risks. With the advent of economic globalisation stressful psychosocial work environments are no longer confined to low-skilled occupational groups and it is therefore important to know more about exactly how work affects the health of working people and to what extent these associations explain the social gradient of health.

Two hypotheses have been applied to tackle this challenge. The mediation hypothesis claims that the association between socio-economic position and health can partly be explained by the effects of work and employment. The moderation hypothesis claims that the effect of work characteristics on health varies according to socio-economic position. The finds moderate support in favour of both hypotheses. In addition, a series of recommendations for further research are set out:

1. Studies should test an explicit hypothesis, rather than exploring what variables may produce statistically significant results; this requires a priori definition of the core variable.
2. Studies should analyse separate and combined effects of the psychosocial and the physical work environment, and focus on appropriate tests of respective theoretical models.
3. Studies should focus on those employment and working conditions that are becoming more prevalent under current worldwide economic and financial conditions (e.g. high job insecurity, contract work, etc..
4. Results should be obtained from cohort studies that do not overemphasise the stable work and employment conditions that are more prevalent in large organisations.
5. It is important to analyse non-western countries and rapidly developing societies, in view of the dynamics of economic globalisation.
6. Despite obvious difficulties, intervention studies should be performed to improve scientific evidence.

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Younger workers across Europe are worst affected by casual employment:

• 50 per cent of employees aged under 25 are on permanent contracts (as opposed to 80 per cent for all age groups)
• 10 per cent of workers aged under 25 have no contract at all (compared to 5.6 for all employees)
• 25 per cent are on temporary contacts (as opposed to 12 per cent of all employees)
• 4 per cent are agency workers (1.5 per cent of all employees)

(Source: European Working Conditions Survey, 2010)

The report argues that casualisation fuels social inequalities, and that the phenomenon needs to be looked at in terms of social class: "young people from disadvantaged backgrounds may be more permanently casualised than young people from more affluent backgrounds. So casualisation is handed on down the generations". As a result, some authors posit the development of a “precariat” – an intergenerational class stripped of the protections that the labour movement managed to win for most workers throughout in the twentieth century.

A number of recommendations are put forward, including:

• Tackling the poverty risk through wage protection, minimum income schemes and access to credit.
• Reducing inequalities in employment opportunities and targeting job mobility support at very young and under-educated workers.
• Providing easier access to the education system for disadvantaged people, for example through scholarships and job placement schemes.
• Re-orientating production processes so that they are skill and innovation based, rather than continuing the cycle of de-skilling.

The report is available to download here.

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