Social class and health inequalities

1
Social class and health inequalities

• Sarah Earthy
• Sociology of Contemporary Societies

2
Social patterning of health and illness

• Social and economic factors behind apparently
  random patterns.
• Gender, age and ethnicity as social categories.
• Proxy measures to represent complex social
  concepts.

3
Definition of health

• Health is a state of complete physical, mental,
  and social well-being and not merely the absence
  of disease or infirmity.
• World Health Organisation

4

• Data on standardised mortality rates for men
  aged 15-64 in England and Wales, 1931-1991 from
  Bartley (2004)

5

• Graph illustrating the widening mortality gap
  between the social classes from Dept of Health
  (2003) Tackling Health Inequalities A Programme
  for Action

6
Recent evidence on trends(Dept of Health Aug
2005)

• Widening gap in life expectancy
• Gap between the fifth of LAs with the lowest life
  expectancy and the national average increased by
  almost 2 for males and 5 for females between
  1997-99 and 2001-03.
•  
• Widening gap in infant mortality
• In 1997-99, the infant mortality rate among the
  routine and manual occupational group was 13
  higher than for the total population. In 2001-03,
  it was 19 higher.
•  
• Gap narrowing for heart disease cancers.

7
Methodological issues

• Measuring rates of death and illness, not health.
• Role of human judgement.
• Reliance on occupational class as an indicator of
  social position and socio-economic circumstances.
• Time lag between childhood experiences of
  deprivation and effects on health in later life.
• Time lag between changes in health behaviour and
  health gain at a population level.
• Absolute versus relative.
• Political sensitivity language measures
  research funding explanations.

8
Stages in developing an illness

• Vulnerability genetic / environmental
• Health-risking behaviours
• Early symptoms / illness behaviour
• Speed of diagnosis
• Efficacy of treatment
• Compliance with treatment
• Underlying resilience / vulnerability
• Response to recurrence patient / health care
  system.

9
Policy interest

• 1942 - Beveridge Report
• 1980 - The Black Report
• 1987 - The Health Divide (Margaret Whitehead and
  the Health Education Council)
• 1990s - Department of Health enquiry into
  variations in health
• 1998 - Independent Inquiry into Inequalities in
  Health (The Acheson Report)
• 2002 Cross Cutting Review of interventions
  (Treasury-led)
• 2003 Dept of Health Tackling Health
  Inequalities A Programme for Action
• 2005 Dept of Health Status Report on the
  Programme for Action.
• http//dh.gov.uk
•  

10
Report of the Working Group on Inequalities in
Health (The Black Report)

• 1977 - Set up by Secretary of State for Social
  Services - David Ennals (Labour).
•  
• Aims
• Review evidence about differences in health
  status amongst social classes.
• Identify possible causes.
• Draw implications for policy and future research.
• 1980 - Reported back to Patrick Jenkin
  (Conservative). Refused to endorse findings -
  cost of recommended action inadequacy of
  explanatory framework.

11
Key findings - Black Report

•        Inequalities in health represented 74,000
  lives lost during 1970-72.
•        Reduced mortality since 1950s in
  occupational groups I II not matched in groups
  IV V.
•        Group V had 2.5 times greater chance of
  dying before retirement age than group I.
•        SMRs were higher for groups IV and V in
  68 out of 92 causes of death for men of working
  age.
•        Perinatal mortality rate in unskilled
  families was double that in professional families
  and widened in first year of childs life.
• -       

12
Types of explanation

• Artefact - how health and social class are
  measured.
• Social selection - direct or indirect.
• Cultural/behavioural - cultural norms of
  particular sub-groups contribute to health
  harming-behaviours.
• Materialist/structural - social class /income/
  status ? health differences.

13
By the 1990s...

• Better measures of socio-economic position showed
  greater inequalities in mortality.
• Social class differences in mortality widening.
• Social patterning of health and illness in UK
  supported by non-UK data.
• Social selection and measurement artefacts
  discounted as explanations (longitudinal
  studies).
• Evidence for ways in which social class affects
  health during life as well as length of life.
•  

14
By the 1990s (continued)...

• More sophisticated understanding of
  socio-economic inequality.
• New models of explanation
• genetic
• life course approaches
• psycho-social
• Neo-political/Neo-Marxist analyses.
• Policy readiness to extend action beyond health
  and health services.

15
Psycho-social explanations

• Stressful conditions at home/work or low social
  status.
• Whitehall II study (Marmot et al 1991) control,
  autonomy, monotony, support from peers,
  relationship with superiors.
• Relationship between level of income inequality
  in a society and health inequalities (Wilkinson
  1996, Kawachi et al 1997).
• Buffer effects of community ties, social cohesion
  and social capital e.g. Roseto.

16
Mechanistic links between psycho-social factors
health

• Deprivation ? physical weakness ? illness.
• Deprivation ? stress ? reduced immunity ?
  illness.
• Deprivation ? stress ? risky health behaviours ?
  illness.
• Relative deprivation ? depleted social cohesion ?
  more crime ? stress ? illness.
• Less education ? risky health behaviours ?
  illness.
• Less education/ deprivation ? fatalism ? risky
  health behaviours ? illness.
• Depleted social support ? absence of buffers
  against stress ? risky health behaviours ?
  illness.

17
Neo-political explanations

• Political and cultural aspects of health
  inequalities.
• Focus on structural factors at the societal level
  e.g. the difference between societies social
  policies and institutions (e.g. Davey-Smith 1996
  Lynch 2000).
• Relationship between the income distribution
  within a society and its policies on welfare,
  education, housing, health, social exclusion etc.
• More egalitarian countries provide buffers to
  protect the individual from the accumulated
  effects of material disadvantage and life events.

18
Neo-Marxist / Critical Realist perspectives

• Effects of industrial accidents, industrial
  diseases, pollution.
• Increase in degenerative diseases due to
  maladaption to industrial environment.
• Relational stressors in workplaces.
• Big business versus health promotion - export of
  health hazards and cures.
• Health inequalities as the unintended
  consequences of the actions of capitalist elites
  (Scambler).

19
Causal factors

• Direct factors
• Genetic vulnerability.
• Occupational exposures.
• Quality of environment.
• Access to health care.
• Health-related behaviours.
• Long range socio-economic factors.

• Indirect factors
• Relative deprivation.
• Life events.
• Chronic stress.
• Social networks / social support / social
  capital.
• Political structures and systems