Behavioural Science in Health Care

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.

There is a marked class difference in life expectancy:

Class groups Men Women

One and two 78.5 82.8

Four and five 71.1 77.1

(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:

Highest five Male Highest five Female

East Dorset 79.0 East Dorset 83.5

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

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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).

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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.

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."

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.

Sources

Cancer Survival Trends in England and Wales, 1971-1995, ONS

British Journal Of Cancer, August 2000]

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%

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%

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.

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.

However, the infant mortality rate is falling and the class gap is narrowing:

1981 1994

Professional father 7.8 4.5 (per 1000 live births)

Unskilled father 15.7 6.8

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:

damages the first teeth and establishes harmful eating patterns that can

cause damage for a life-time.

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.

than middle class children.

more likely to have low birth-weight, short babies who are more prone to

disease and mental and physical retardation.

professionals.

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:

• awareness of / access to health care services and other health-bringing facilities such as sports centres

• access to shops selling cheap, nutritious food

• cohesiveness of local communities / support networks

• smoking / drinking / other drug taking habits

• level of neighbourhood crime

• nature of working environment

• hours worked

• housing (damp, cold, over-crowded . . .)

• diet

• child-care and socialisation skills

• environmental conditions (industrial/vehicular pollution, level of background radiation, hardness of water, climate etc.)

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 > > > > >

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.

Summary comment

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:

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.

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.

(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.

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.