Social class, health and health care

NUR 129

Lecture 5

Outline

Class – meaning and definitions Poverty – absolute and relative Social class and health inequalities Explanations The ‘inverse care law’ Health inequalities targets

Images of class

What do we mean by class?

Can be used to describe economic relationships – e.g. employer/worker

Can be used to describe social status – e.g. professional/manual

Class is also about a sense of identity

Class identity – British Social Attitudes Survey

No decline in the overall proportion of people identifying themselves as belonging to a social class;

Increasing numbers of people identify themselves as middle class, with fewer describing themselves as working class;

57% still identify themselves as working class, and 37% as middle class. British Social Attitudes Survey (2007)

Ways of defining class: early writers

Karl Marx (1818-1883) – class as primarily an economic relationship (i.e. employer and worker)

Max Weber (1864-1920) – saw class as reflecting economic inequalities, but also emphasised the importance alongside this of status (i.e. social prestige), and other sources of power.

Measurements of social class:1. The Registrar General’s scale

One of the most frequent used classification system during 20th century

Categories: I Professional II Intermediate professional IIIN Skilled non-manual IIIM Skilled manual IV Semi-skilled manual V Unskilled manual

Measurements of social class:2. National Statistics Socio- economic Classification (NS-SEC)

Replaced Registrar Generals’ scale in official statistics

Categories: Higher managerial & professional occupations Lower managerial & professional occupations Intermediate occupations Small employers & own account workers Lower supervisory and technical occupations Semi-routine occupations Routine occupations Never worked & long-term unemployed

Poverty – ‘absolute’ and ‘relative’ “Individuals, families and groups in the

population can be said to be in poverty when they lack the resources to obtain the types of diets, participate in the activities and have the living conditions and amenities which are customary, or are at least widely encouraged or approved, in the societies to which they belong” Townsend, P., in Wedderburn, D. (1974)

Poverty, Inequality and Class Structure (p15)

Child poverty in BritainBradshaw J. Child poverty in comparative perspective. In: Gordon D, Townsend P. Breadline Europe: the measurement of poverty. Bristol, The Policy Press, 2000.

Widening inequalities in income in the UK

Life expectancy at birth: England 1541 - 1994

Despite rising life expectancy, inequalities remain

“In Manchester, boys can expect to live almost eight years fewer, and girls almost seven years fewer than their contemporaries in Kensington, Chelsea and Westminster”

UK Government report, ‘Tackling Health Inequalities: 2002 Cross-Cutting Review’

The gap in life expectancy between men in Kensington & Chelsea and in Glasgow increased from 9.8 years in 1992-4 to 11.00 years in 2001-03

Shaw, M., Smith G.D. & Dorling, D. (2005) Health inequalities and New Labour: how the promises compare with real progress. British Medical Journal, 330: 1016-1021

Health and social classDonkin A, Goldblatt P, Lynch K. Inequalities in life expectancy by social class 1972–1999. Health Statistics Quarterly, 2002, 15:5–15.

The Black Report, 1980

Explanations for health inequalities A ‘statistical artefact’ Social selection Materialist or structuralist

explanations Cultural/behavioural explanation

Recent focus Material factors – home environment,

neighbourhood and workplace; income and living standards

Behavioural factors – routines and habits, including diet, exercise and smoking

Psychosocial factors – e.g. “perceiving oneself to be worse off relative to others may carry a health penalty, in terms of increased stress and risk-taking behaviour”From Graham, H. Understanding Health Inequalities (2000: 14-15)

Individual lifestyle and behaviour

Policy has often focused on individual behaviour:

“The prime responsibility for improving the health of the public does not rest with the NHS nor with the Government, but with the public themselves. . . “no government or doctor can make a person healthy on their own. Ultimately, that responsibility has to lie with the individual. Only they can make the choice to healthy lives, to change their lives for the benefit of themselves and their families.

John Reid, Secretary of State for Health, 3rd February 2004

Smoking and socio-economic category

Behaviour and environment

Higher rates of smoking among those in manual occupations may explain some of the differences in life expectancy – but what about other factors?

Interesting data is being provided by a long-running series of studies of coronary heart disease, sometimes described as the ‘Whitehall Studies’

Context: social class and CHD

The ‘Whitehall Studies’ ‘Whitehall studies’ have examined rates of

CHD among 10,000 civil servants death rates among lowest occupational

groups are 1.8 times higher than among senior grades – but remain 1.5 times higher after controlling for smoking, blood pressure etc

“’Adjusting for these risk factors explains less than a third of the social gradient in mortality from heart disease.”Marmot M. Status Syndrome (2004: 44)

Example: job insecurity and health One part of the study examined the

health of around 700 staff working in a department that was privatised

The study looked at subsequent experiences of long-standing illness and mental health problems among staff who were: (i) in secure employment; (ii) in insecure employment (e.g. temporary contracts); and (iii) unemployed.

Employment changes and healthFerrie JE et al. Employment status and health after privatisation in white collar civil servants: prospective cohort study. British Medical Journal, 2001, 322:647–651.

Health and insecurity ‘Evidence from factory closures studies showed that

much of the deterioration in health started, not when people actually became unemployed, but before that – when redundancies were first announced. . . It provides powerful evidence that one of the clearest categories of deprivation in modern societies affects health predominantly through psychosocial channels’.

‘Job insecurity is presumably only one among several other categories of financial or material insecurity’.

Richard Wilkinson (1996) Unhealthy Societies (p178)

Inequality and social cohesion

‘This book brings together a growing body of new evidence which shows that life expectancy in different countries is dramatically improved where income differences are smaller and societies are more socially cohesive. The social links between health and inequality draw attention to the fact that social, rather than material, factors are now the limiting component in the quality of life in developed societies.’

Richard Wilkinson (1996) Unhealthy Societies

The ‘inverse care law’ “In areas with most sickness and death,

general practitioners have more work, larger lists, less hospital support than in the healthiest areas – the availability of good medical care tends to vary inversely with the need of the population served.” (J. Tudor Hart, ‘The Inverse Care Law’, The Lancet, 1971).

“despite the egalitarian principles of the NHS, inequality of access has persisted within the NHS” (Secretary of State for Health, 2003)

Inequalities in the use of cardiology services: evidence from Sheffield

Sample of 491 people with angina symptoms in Sheffield

11.2% of the sample in the ten most affluent wards had received an angiography, compared to 4.2% in the ten most deprived wards

Deprived wards had only about half the number of revascularisations per head of population estimated to have angina symptoms than did affluent wards

Evidence of the ‘inverse care law’? “We found that the ratio of rates of coronary

artery revascularisation to the prevalence of angina symptom varied substantially across the city and was inversely proportional to deprivation. Thus, use of services was not commensurate with need and seemed to exhibit the inverse care law, even thought the availability of care is the same.” (Payne, N. & Saul, C. 1997 ‘Variations in the use of cardiology services in a health authority’ British Medical Journal, 314.

Social differences in seeking professional help Study of heart disease in Glasgow, interviewed 30

residents in deprived area and 30 in affluent area “People from the deprived area reported greater

exposure to ill health, which allowed them to normalise their chest pain, led to confusion with other conditions, and gave rise to a belief that they were overusing medical services . . . Anxiety about presenting among respondents in the deprived area was heightened by self-blame and fear that they would be chastened by their GP for their risk behaviours.” (Richards, H. et al, 2002, ‘Socio-economic variation in responses to chest pain: qualitative study’ British Medical Journal, 324).

Consultation times A study of GP consultations in the West

of Scotland found an average length of 8.7 minutes – with the two most affluent groups of patients receiving between 9.5 and 10.25 minutes Stirling, A.M., Wilson, P. & McConnachie, A.

(2001) Deprivation, psychological stress and consultation length in general practice. British Journal of General Practice, 51.

Department of Health targets

Concern at the widening inequalities in health status led the Department of Health to introduce two targets for the NHS, aimed at altering these trends

The targets were to reduce inequalities in: Life expectancy Infant mortality

Life expectancy “The target is a 10% reduction in the relative

gap (i.e. percentage difference) in life expectancy at birth between the fifth of areas with the worst health and deprivation indicators (the Spearhead Group) and England as a whole.

“Latest data for 2002-2004 indicate that the relative gap in life expectancy between England and the Spearhead Group is wider than at the baseline (1995-1997) for both males and females. For males the relative gap is 1% wider than at the baseline, for females 8% wider.”

Department of Health (2005)

Infant mortality “The target is a 10% reduction in the relative gap

(i.e. percentage difference) in infant mortality rates between “routine and manual” socio-economic groups and England as a whole from the baseline year of 1998 (the average of 1997-99) to the target year 2010 (the average of 2009-2011).

“Infant mortality rates have declined in the routine and manual group since the baseline period, however, the rate of decline has been faster in other groups. As a result, the trend shows a widening in the relative gap between infant mortality in the routine and manual group and the total population between the target baseline 1997-99 and the latest period 2002-04.”

Department of Health (2005)