HNC Health Care
Behavioural Science in Health Care
HEALTH ANDSOCIAL CLASS
HEALTH ANDSOCIAL CLASS
"Official statistics reveal massive class inequalities in health"– Ken Brown and Ian Bottrill, 1999, Our unequal, unhealthy nation, Sociology Review vol.9, no.2
All studies show a close link between health and social inequality. Working class people have more time off work, pay more visits to the doctor and are more likely to be chronically ill. As part of the 1999 General Household Survey, ONS statisticians looked at 1,200 workless households, containing at least one person of working age. They found that 32% of the members of workless households reported chronic illnesses, compared with 12.5% of those in working household.
In the 1980s, two official reports (The Black Report of 1980 and The Health Divide of 1987), both of which highlighted class-based inequalities, were subsequently suppressed by the Tory Government. However, New Labour's consultation paper,Saving Lives: Our Healthier Nation (1999), has been widely circulated and finally exposes to full public gaze the extent of "this inequality [which] has widened since the early 1980s."
(See also the Child Poverty Action Group’s 2001 report on the relationship between income and diet, Poverty Bites - Food, Health and Poor Families, which is summarised in thepoverty file.)
There is a marked class difference in life expectancy:
Life expectancy at birth: unskilled and salaried compared, 1997-99
Class groups Men Women
One and two 78.5 82.8
Four and five 71.1 77.1
Gap 7.4 5.7
(Note: although life expectancy has increased for people of all classes, the gap between unskilled and salaried people has grown – in 1972-76, it was 5.5 years for men and 5.3 for women.)
Location – which reflects social class – can over-ride gender as the most salient determinant of life expectancy. For example, men in Dorset can expect to live three and a half years longer than women in Glasgow:
Life expectancy at birth by gender, selected British authorities, 1997-99
Highest fiveMale Highest five Female
East Dorset 79.0 East Dorset 83.5
Three Rivers(Herts) 78.7 North Dorset 83.3
Horsham 78.5 Mid Devon 83.2
Mid Devon 78.4 Guildford 83.1
Suffolk Coastal 78.3 Epsom and Ewell 82.9
Lowest five Male Lowest five Female
Glasgow City 68.7 Glasgow City 75.4
West Dumbartonshire 69.5 West Dumb. 76.3
Inverclyde 69.6 West Lothian 76.5
Manchester 70.2 Manchester 76.6
Eilean Siar(Western Isles) 70.9 East Ayrshire 76.7
[Source: Health Statistics Quarterly, August 2001, ONS]
Studies link serious illness to geographic location
Researchers at Bristol University's Townsend Centre for International Poverty Research (CIPR) have found that 15.5% of the population in Springburn, Glasgow, a predominantly working class area, suffer from chronic illnesses; whereas in mainly middle class Wokingham in Berkshire, the percentage is a mere 3.6. According to the CIPR, 71% of the deaths of people under 65 between 1991 and 1995 would not have occurred if people in all parts of Britain had the same health chances as those in the most prosperous areas. 10,000 lives would have been saved.
Most high mortality districts in the UK are found in manufacturing centres, coalfields and ports – areas with predominantly disadvantaged communities. Although most of these districts are in Scotland, Wales, Northern Ireland and northern England, the highest death rate for men aged between 15 and 44 is found in the London borough of Hammersmith and Fulham with 220 per 100,000. This compares with 70 per 100,000 in Hertsmere (Herts), Melton (Leics) and Wokingham (Berks).
The Widening Gap, 1999, CIPR, University of Bristol]
Health Statistics Quarterly, August 2000 – figures adjusted to eliminate differences in the age profile in each location
Mapping Health Inequalities Across London
The first report, from the London Health Observatory (LHO) reveals a widening gap in life expectancy between people in rich and poor areas – baby boys born in the east end borough of Newham, one of the capital's poorest areas, have a life expectancy of 71 years, almost six years less than boys born in the central borough of Westminster, one of the richest; whereas the life expectancy gap for baby boys born in the early 1990s was only five years. (Out of 352 authorities in England, Westminster ranks 26th in the national life expectancy league table for men and 13th for women, and Newham ranks 349th and 320th.) The report also notes that even within boroughs, there are vast differences in average life expectancy according to levels of deprivation.
Using a London Underground analogy, the report says: "There are six stops on the Jubilee Line between Westminster and Canning Town. As one travels east, each can be seen as marking a year of shortened lifespan."
A principle reason for the growing life expectancy gap is that differences in infant mortality are increasing – a boy born in Hackney, next to Newham, is more than twice as likely to die in the first year of his life than a boy born in Bexley, in the south-east suburbs. Overall, the infant mortality rate in London compares poorly to that in many other European cities, including Berlin, Madrid and Dublin.
The LHO is one of eight Regional Public Health Observatories set up in 2000 to monitor health inequalities. Its report predicts that the other Observatories will shortly announce a similar widening of the health gap between rich and poor in their areas.
[Mapping Health Inequalities Across London, 10 October 2001, LHO]
(The full LHO report is available atwww.lho.org.uk)
A tale of two cities
Glasgow and Edinburgh are only fifty miles apart but, according to Graham Watt, professor of general practice at Glasgow University, in Glasgow the men live on average five year’s less, and the women two and a half years less, than their Edinburgh counterparts and that the risk of coronary heart disease (Scotland’s biggest killer) is over 50% greater in Glasgow than in Edinburgh. Professor Watt identifies smoking, a fatty diet and alcohol as relevant factors, but claims that differential rates of social deprivation explain most of the inter-City variation in health chances. Two-thirds of Glaswegians live in areas of severe deprivation, compared with seven per cent in Edinburgh, and a third of Edinburgh’s population live in affluent neighbourhoods, compared with 5% of Glasgow’s.
"The health gap is not difficult to explain," says Watt. "The predominant circumstance of Glasgow is quite severe deprivation, in Edinburgh it is one of middle-class affluence . . . People are pre-occupied with diet, but it is not that simple an issue . . . There is a kind of resignation
. . . that health services can’t affect mortality. But if you look at the budget for general medical services, Greater Glasgow and Lanarkshire have 29% of the Scottish population and they get 29% of the budget; but they have two-thirds of the areas of most severe deprivation . . . Consultation rates are higher than in affluent areas, but consultation times are shorter. There is less time to do things, despite the fact there is more to do."
More on inter-regional variation in health chances? àClick here
More on life expectancy?à Click here
The incidence of nearly every kind of illness correlates with social class:
Poor less likely to survive cancer
Over the period 1971 to 1995, the average difference in the five-year survival rate for 14 types of cancer between the most deprived and the most affluent was above five per cent and up to 16 per cent for some types. And researchers at Glasgow University and Leicester Royal Infirmary have subsequently established that women in the lower socio-economic groups are three times more likely to develop cervical cancer than those in higher groups.
Professor Michael Coleman of the London School of Hygiene and Tropical Medicine, says that a major factor is that better off people "press for more thorough investigation and treatment . . . [and] get more attention." Consequently, people living in more affluent areas tend to receive better treatment.
Cancer Survival Trends in England and Wales, 1971-1995, ONS
British Journal Of Cancer, August 2000]
Heart disease linked to class
An April 1999 report from the National Heart Forum showed that the risk of coronary heart disease (Britain’s biggest killer) is closely linked to social class. Whilst the incidence is steeply declining amongst those at the top of the social tree (social class one), the same is not true of people lower down the social scale. The report identified three crucial factors: diet, smoking, exercise and stress. Of these diet was the most important.
More obesity in classes 1V and V
Obesity, measured by the 'body-mass index', correlates with social class. Over 25% of women in social classes 1V and V are obese, compared with under 15% of those in classes 1 and 11. Fewer men than women in each social class are over-weight, but there is a similar inter-class pattern. Part of the explanation lies in the inferior diet of working class people: the middle classes eat far more fruit and vegetables and far less sugar.
[Source: Monitoring Poverty and Social Exclusion, 1999, New Policy Institute]
Deaths from various illnesses, males aged 15-64, 1976-89
Illness Variation from mean
Social class V Social class 1
Malignant neoplasms +25% - 40%
Lung cancer +40% - 70%
Injuries and poisoning +60% - 20%
Circulatory diseases +20% - 40%
Heart disease +10% - 30%
Cerebrovascular disease +100% - 50%
Respiratory disease +100% - 75%
[Derived from data in Population Trends 80, 1995]
Self-reported general health, by sex and social class
Very good/good Fair Bad/very bad
Classes 1 and 2 87% 10% 2%
Class 3 (non-manual) 81% 16% 3%
Class 3 (manual) 72% 23% 5%
Classes 4 and 5 67% 25% 8%
Classes 1 and 2 83% 15% 2%
Class 3 (non-manual) 78% 17% 5%
Class 3 (manual) 68% 26% 6%
Classes 4 and 5 66% 26% 8%
[Source: Social Inequalities and Health Status, ONS, 2000]
Social class and mental illness among adolescents
A report from Professor Robert Goodman says that one in ten children in the UK has a psychiatric disorder. More boys (c.12%) than girls (c.8%), and more older than younger children, have problems. But even more striking than gender and age differences is the relationship between social class and mental health. Disorders are more than twice as common among children in workless households and they are nearly three times as likely to afflict children in poor homes (household incomes under £200 per week) as those who are better-off (household incomes of £500 or more). Three times more children in social class V (unskilled parents) suffer mental disorders than those in social class I (professional/managerial parents). If the primary care giver has no educational qualifications, her children are 2.5 times more likely to have a mental health problem than are the children of women with degrees. A child with a single parent has twice the average chance of developing a mental illness, as does one whose parents have split up.
[Source: Goodman R et al, 2000, Mental Health and Adolescents in Great Britain, Stationary Office]
Goodman's research team comprised researchers from the Office for National Statistics, the Institute of Psychiatry and Maudsley Hospital. Their findings resulted from more than 10,000 face-to-face interviews with parents of children aged 5 to 15, 4,500 interviews with young people aged 11 to 15 and questionnaires delivered to the teachers of those children. Goodman says that the research did not set out to identify the causes of mental illness, and has not done so. Correlations between mental illness and social variables such as class and parental education might suggest, but do not establish, causation (see the mental health file).
class inequalities and children's health
The infant mortality rate in the UK is amongst the highest in Europe and working class children are especially vulnerable:
Children of unskilled are more at risk
50% more babies of 'unskilled ' families are still born or die in their first week compared with the babies of professionals, 20% more are born underweight and twice as many die before the age of five. One reason is that the children of unskilled parents are five times more likely to meet accidental death than 'professional' children. According to Bristol University's Townsend Centre for International Poverty Research (CIPR), 7,500 infants would have been saved in the UK between 1991 and 1995 if every area had had the same (low) infant mortality rate as South Suffolk.
Monitoring Poverty and Social Exclusion, 1999, New Policy Institute
The Widening Gap, 1999, CIPR]
However, the infant mortality rate is falling and the class gap is narrowing:
Infant mortality rates, UK
Professional father 7.8 4.5 (per 1000 live births)
Unskilled father 15.7 6.8
[Source: Social Trends 27, 1997]
Part of the explanation for the inferior health of working class children is to be found in behavioural differences. For example, working class children are more likely to have inferior diets:
Inappropriate weaning diets
A British Medical Association study into children's health, carried out byconsultant paediatrician, Dr James Appleyard and associates, was published in 1999. It found that "many British children are given inappropriate weaning foods, including sweet and salty foods such as crisps, sweets and soft drinks". According to the report:
mWithin six months a poor weaning diet causes high blood pressure,
damages the first teeth and establishes harmful eating patterns that can
cause damage for a life-time.
mThe eating habits of working class children tend to be especially harmful -
they are more likely to eat white bread, low fibre cereals, buns, cakes and
pastries, are only half as likely to drink fruit juice, and don't eat enough
fruit and vegetables.
mWorking class children also have less protein and more fat in their diets
than middle class children.
mWorking class women, many of whom themselves have poor diets, are
more likely to have low birth-weight, short babies who are more prone to
disease and mental and physical retardation.
mOnly 44% of working class mums breastfeed, compared with 81% of
explanaining the link between class and health
As suggested in Items F and M, above, differences in mortality and morbidity between social classes are partially explained within the medical model of illness which focuses on quantifiable factors such as:
Sociologists are critical of 'cultural/behavioural' explanations of inter-class variations in health chances, especially those which imply that the relative poor health of working class people is a product of their fecklessness. Behaviour which seems feckless to health professionals can be seen as perfectly rational in the light of sociological verstehen > > > > >
Making sense of smoking
An interpretive study of the smoking habits of working class mothers showed that for many smoking was an essential element of their coping strategies. Graham's in-depth interviewing revealed that smoking provided essential 'time out' for the mothers and was crucial to their maintaining caring roles and thus the welfare of their families.
[Graham H., 1987, Women's smoking and family health, in Social Science and Medicine, 25]
Many risk factors are not easily controlled by individuals. They result from 'structural' factors such as poor housing, polluted living environments, unhealthy workplaces and difficulties over accessing (cheap) sources of nutritious food and health care services, including leisure facilities:
The 'inverse care' law
One sociological explanation of the poor health of poorer members of society is based on the 'inverse care law', which states that the more health care people require, the less they get. Whilst working class people visit doctors more often than average, private health care is largely the preserve of the middle classes, and health and leisure centres are dominated by middle class customers. And, in line with interactionist analysis, better off people are more successful in negotiating appropriate exploratory and treatment programmes with health professionals. This must, at least in part, explain the better five-year cancer survival rates of those in higher socio-economic groups.
"Consultation rates are higher [in poor areas] . . . but consultation times are shorter. There is less time to do things, despite the fact there is more to do."– Professor Graham Watt of Glasgow University
However, an even more salient objection to the medical model of ill health is that the quantifiable risk factors it identifies explain only about a third of the social class gradient in illness. This observation was first made by Michael Marmot, a young researcher at the University of London, in 1976. Marmot is now professor of epidemiology and public health at University College London. Commenting on new evidence about heart disease (seeabove), he said that his research over a quarter of a century has shown a consistent link between illness and class that is not fully explained by obvious physiological factors (diet, smoking, exercise etc.).
The X factors
Michael Marmot, professor of epidemiology and public health at University College London, suggests two factors which might explain why working class people, with behaviours similar to those of middle class counterparts, have worse health chances:
Stress, which is more commonly found amongst those lower down the occupational scale who lack autonomy and, as a result, do not feel in control of their lives. To put this another way, it’s healthier to give orders than to receive them.
Feelings of inadequacy caused by low status. Analysis of international data shows that if others become richer, while your income remains the same, your chances of becoming ill will have increased. The connection between inequality and poor health chances is stronger than that between poverty and poor health chances.
Further evidence on the elusive X factor comes from Dr Connor O’Shea of Duke Medical Centre in North Carolina, leader of a research team which spent two years looking at 10,000 heart-attack patients throughout the world. The researchers found that those who leave school at 16 are five times more likely to die after suffering a heart attack than university graduates. "There is something about a person’s level of education that leads to different outcomes," says Dr O’Shea. "It could be an unlimited number of factors, including stress, poor understanding of the disease process and not making the necessary lifestyle changes to promote a better outcome."
(Unhealthy societies: how inequality kills (1998), by Richard Wilkinson offers a useful review of the sociology of class and health. It appears in Sociology Review vol.7, no.4)
A major obstacle to reducing health inequalities is that successive governments have been preoccupied with health services rather than health. And whilst there is a relationship between poor care provision and ill health, it is far weaker than that between low economic status and ill health.
Excess deaths attributed to government policy
Government policies since the late 1970s, which induced high rates of unemployment, increased child poverty and promoted greater inequalities of income and wealth, led to the premature deaths of thousands of British people according to researchers at Leeds and Bristol Universities funded by the Joseph Rowntree Foundation (JRF). The researchers found good correlations in just about every parliamentary constituency between the mortality rate and the level of relative deprivation.
Statistical analysis suggests that a return to the (lesser) income and wealth differentials of 1983 would prevent about 7,500 deaths a year among people aged under 65. Another 2,500 lives a year would be saved by eliminating long-term unemployment; eradicating child poverty would reduce the annual death toll among children under 15 by 1,500.
The study identified 45 constituencies where 25 or more lives could be saved each year by reducing relative deprivation and long-term unemployment. In Birmingham Ladywood, one of Britain’s most deprived constituencies, an average of 275 people aged under 65 died each year in the early 1990s, compared with a national average (adjusted for population size) of 182. 54 of the ‘excess’ deaths can be explained by factors other than inequality, child poverty and unemployment. This leaves 39 lives a year lost in just one constituency because of deliberate policy changes implemented by successive governments.
[Source: Inequalities in Life and Death: What if Britain rts at Bristol University's Townsend Centre for International Poverty Research (CIPR), the only way to effect a significant improvement in the nation's health is by pursuing "policies which actively address the reduction of poverty and of inequality through redistribution [of income and wealth]." [The Widening Gap, 1999, CIPR]
The Townsend Centre's critique echoes Ivan Illich's contention that the medical model of health actually increases illness by diverting attention away from its social origins. Illich called this process 'social iatrogenesis'.[Illich I, 1976, Limits to Medicine]