SOCIAL

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SOCIAL COMMUNITY PERSPECTIVES

• Inequalities in Health and Health Care (2)
• 4th February 2003

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Objectives

• To reflect on evidence of inequalities in health
  from last week
• To reflect on different explanations for
  inequalities in health

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Black Report Explanations

• Artefactual
• Social Selection
• Behavioural/Cultural
• Materialist

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Artefactual

• Health and class are artificial variables
• Registrar Generals classification is flawed and
  may be circular
• Numerator/denominator bias 
• Lowest social class groups shrinking ? widens
  apparent inequalities

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Social Selection

• Health determines social class through a process
  of Health-related social mobility
• Healthy move up social hierarchy and unhealthy
  move down (Downward drift).
• Some evidences that serious illness in childhood
  can affect occupational class, e.g people with
  mental health problems tend to drift down social
  ladder.
• However not explain all class gradient. e.g.
  children/women, different diseases.

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Behavioural/ Cultural

• Social class determines health through social
  class differences in health damaging/promoting
  behaviour
• These are at least in principle are subject to
  individual choice
• Smoking, diet, exercise, alcohol consumption,
  infant feeding practices all vary by class.
• BEWARE OF VICTIM BLAMING Need to be aware of
  social/economic context in which these behaviours
  occur.

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Smoking

• From 1974 to 1994 smoking in professional groups
  decreased by ½., however, by only a 1/3 in
  unskilled manual groups.
• By 1994 smokers in a minority in all social
  classes, however, unskilled manual workers were
  2-3 times more likely to smoke than those in
  professional groups
• Explanations
• 1
• Self-medication - managing stress?
• Gives people some space?
• 2
• Culture of smoking?
• Less motivated to give up?

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Diet

• Availability at small local shops
• Problems with transport.
• Difficult to have a good diet on a low income.
• Cheaper food often over-refined and processed.

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Not all behaviour.

• Risk factors such as smoking, drinking and diet
  only explain 1/3 of class gradient.
• Diet and smoking behaviour in S Asian population
  is better than white population but excessive CHD
  in this former group.

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Materialist

• Social class determines health through social
  class differences in the material circumstances
  of life.
• Material aspects of living conditions affect
  health.
• Asset based measures strongly associated with
  mortality rates.
• Type of employment and level of employment
  influence health.
• Differences in working conditions, unemployment,
  housing, and diet, is the main cause of illness
  and disease not genetics and lifestyle.
• Poverty is never officially recorded as a cause
  of death, but clearly one of the most important
  determinants of our health status.

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Most Plausible Explanation?

• BR emphasises materialistic
• Need to see how material circumstances influence
  behaviour and affect life generally

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Another Explanation

• Variations in health can be explained by
  variation in quality of and access to health
  services.
• Poorer people consult GPs more often BUT
  relatively less compared with need
• Massive under-utilisation of preventative
  services by people in lower socio-economic
  groups.
• More deprived often get less provision in
  relation to their need.
• Average costs of prescriptions is higher in
  affluent areas.

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Tudor-Hart (1971) Inverse Care Law

• the availability of good medical care tends
  to vary inversely with the population served.
•  
• Access
• Quality
• Uptake.

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Access

• Poorer areas have services, which are more
  difficult to reach compared with affluent areas.

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Quality

• More poorly resourced practices in inner city
  areas.
• Under-provision of GPs compared to average in
  more deprived areas

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Under Uptake

• Under utilisation of preventative services
  antenatal, dentistry, immunisation, cervical
  smears.
• Paradox lower social classes have worst health
  but use services less why?

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Explanations for inequalities between men and
women

• Consider differentials in
• Health behaviour
• Consultation patterns

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Narrowing gap may be explained by

• Improved social circumstances improve womens
  healthsame for men?
• Stricter laws on drinking and driving, compulsory
  seat-belts
• Changes in patterns of work
• Decline in male employment sectors traditionally
  associated with fatal injuries
• Work in female dominated service sector may be
  just as unhealthy ? chronic not terminal

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Smoking

• 1948 approx 65 of men smoke - approx 40 women
  now nearly equal proportions of women and men
  smoke.
• US 1980s substantial increase of female mortality
  from lung cancer and COAD
• UK - male deaths from lung cancer ? female deaths
  ?

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Womens cigarette smoking by social class
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Womens cigarette smoking by age
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Smoking patterns among Black and minority ethnic
groups in England
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Data from British Household Panel Survey (Graham
and Der, 1999)

• Women on means-tested benefits 33 more likely to
  smoke than those not on benefits
• Women in rented accommodation are twice as likely
  to smoke than women in owner-occupied
  accommodation
• For women, not having a car in household
  increased risk of smoking by 66

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Smoking and caring

• Women with children are more likely to be smokers
  and heavier smokers than those without children
• Those with heavy caring burdens tend to be
  heavier smokers
• Womens smoking is tightly woven in with coping
  strategies
• Smoking plays a contradictory role in womens
  lives is health promoting and health damaging
  (Graham, 93)

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Consulting patterns

• Higher proportion of women as consumers of health
  care.
• On average women visit their GP 6xs/year and men
  4xs/year.
• Working women consult slightly less than
  housewives Easier to visit doctor ?
• Housewives are less likely to define themselves
  as being in excellent health. - under
  reporting

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Provision of services

• Health service generally focused on biological
  difference
• Womens reproductive role ? specialist services
  focusing on reproduction 
• Well woman clinic developed around distinct
  biology (screening)
• Less specialist health care focused on men
  fewer well man clinics and screening for
  prostate and testicular cancer

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Are women sicker?

• Hospital admission, GP contact and community
  surveys tend to reveal higher rates of
  psychosocial ill health among women.
• GP data - women suffer more from mental
  disorders, osteoarthritis, migraine, obesity and
  iron deficiency anaemia (men consult more for
  heart attack and angina)

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Need to be careful when looking at data

• 1994 exactly same number of men and women
  reporting long-standing illness,
• Female excess only found consistently across the
  lifecourse in psychological manifestations of
  distress, less apparent or reversed, for number
  of physical symptoms

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Explanations for different patterns of
consultation

• Higher rates of milder physical problems women
  greater likelihood to seek help?
• Doctors more likely to define women as ill?
• Differences in mild illnesses artefact of
  gender-related health attitudes and behaviours?
• Male stoicism, it might be suggested, is
  complemented by the cultural acceptance of
  vulnerability and sensitivity to symptoms (linked
  to the caring role) within women (Annandale,
  1998)
• Difficult to ascertain whether women over-report
  and men under-report ill health who can act as
  objective arbiter of experience?
• Research suggests women not over-reporting illness

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Macintyre (1993)

• 1700 males and female - MRC Common Cold Unit
  rated presence/absence/ severity of cold.
• Both men and women likely to over-rate severity
  compared to clinical observer.
• Men 1.6 times more likely to over-rate symptoms
  and to complain at any level
• Doctors more likely to observe and diagnose
  symptoms in women
• Concluded at a given level of clinical signs men
  and women equally likely to report related
  symptoms- men more likely to report severe
  symptoms

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Explanations for inequalities in ethnicity and
health

• Artefactual lots of problems with data
• Language
• Significant number of South Asian (particularly
  Bangladeshi women) and Chinese find it more
  difficult to communicate with GP.
• However.. problem with communication in
  consultations generally, but by making it
  language makes it an ethnic problem (Sheldon
  Parker,1992).

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Geographic location

• Unhealthy areas
• Benefits of being concentrated in large numbers ?

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Cultural difference in expression of
symptoms/accessing care ?

• Many women from minority ethnic groups prefer to
  see female GP (preferably same ethnic
  background).
• Ethnocentric western diagnostic approach may be
  inappropriate for some groups (especially with
  regard to mental illness).

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Migration effects?

• More healthy more likely to migrate?
• Environmental conditions in country of birth, or
  mothers country of birth
• Stress
• Little difference between migrants and those born
  in UK.
• Scotland migrants from Punjab health
  deteriorated with time spent in UK
  (Williams,1993)

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Cultural difference in health related behaviour

• Health behaviour e.g. smoking
• Diet and exercise patterns
• Culture changes over time and according to gender
  and class.

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Genetics

• Haemoglobinopathies related to genetic factors
  vary across but not exclusive to particular
  ethnic groups.
• Research continuing re diabetes, coronary heart
  disease and hypertension

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The problem of emphasising Cultural difference

• In this perspective, racialized inequalities in
  both health and access to health care are
  explained as resulting from cultural differences
  and deficits. Integration on the part of minority
  communities, and cultural understanding and
  ethnic sensitivity on the part of the health
  professional, then become the obvious solution
  personal and institutional racist and racial
  discrimination have no part to play in this
  equation
• Ahmad W.I.U. (eds) (1993)
• Race and health in contemporary Britain

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The problem of emphasising Cultural difference

• Class and consumption only partly explain
  inequalities need to look at other social
  disadvantage i.e. racism
• Tendency to explain inequalities by focusing on
  cultural differences and deficits (Ahmad, 1993).
• Results in unmet need e.g. elderly South Asian
  patients
• Tend to ignore healthy cultural practices e.g.
  lower alcohol consumption and smoking in Asian
  women

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Sheldon and Parker (1992)

• Often race used to explain problems e.g.
  Glasgow early C20th
• Research focused on nutritional deficiency
  diseases, tuberculosis, haemoglobinopathies.
• Risk of blaming the individual and culture which
  is alien and/or deviant.
• Focus on ethnicity may mask other wider
  differences related to socio-economic status.

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• When we make links between race and health
  status it is notsomething that is inherent to
  black people which shapes their health
  trajectory, but something inherent to the social
  context within which they must live their lives.
  (Nettleton,1995,189)

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Impact of racism

• 1/8 minority ethnic people experienced some form
  of racial harassment in last year.
• ¼ fearful of racial harassment.
• White minority groups e.g. Irish also face
  extensive racial harassment.
• White respondents admitted racial prejudice (26
  against Asians, 20 Caribbean, 8 Chinese)
• Institutional and societal racism minority
  ethnic groups over-represented in disadvantaged
  sectors of society.
• Psychological effects of racism makes people ill
   
• Ethnocentrism in health services
• Experience racism when receiving health care

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Benzeval et al (1995) argue we need to be aware
of

• How socio-economic circumstances, ethnicity and
  racial harassment and/or discrimination interact
• Impact of material and social circumstances on
  health
• Impact of racial harassment

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Conclusion

• Illness does not strike purely at random.
• Strong correlation between health and social
  class makes assumptions to the contrary difficult
  to sustain.
• Combination of explanations

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Way forward social class?

• Encourage changes in personal behaviour.
• Improve working conditions.
• Elimination of poverty.

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Way forward Gender

• Gender sensitivity and awareness in policy and
  practice need to be aware of how gender, age,
  ethnicity, class impact on each other
• Ensure equality of healthcare provision for men
  and women
• Reduce the high mortality rate for young men
• Improve material circumstances of lone mothers
• Policies to minimise the impact of impairment in
  older women
• More research on inequalities in womens health
  and in older people

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Way forward ethnicity

• Policies to eliminate poverty and unemployment
• Improving housing stock
• Urban regeneration
• Policies which take into account variety of
  households
• Anti-discrimination policies
• Support primary care
• Address language and advocacy needs.
• Cultural competency should be core part of health
  workers training.
• Supporting doctors from minority ethnic groups

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So what can be done?

• Improving accessibility of health care provision.
  
• Encouraging groups with the greatest need to make
  use of services.
• Improve living and working conditions.
• EBP
• Evaluate services
• Needs assessments
• Multi-agency working
• Community participation
• Involvement in decision making