Health inequalities and social work policy and practice
'Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you'll die sooner because you are badly off' (Frank Dobson / DoH, 1997a).
Discuss with reference to research on health inequalities and comment on how social work policy and practice can contribute to addressing the problems.
Are there groups in the population who are disadvantaged to such an extent that it affects their opportunity to achieve good health? For instance, does a persons financial resources, social position, ethnic origin or gender affect their chances of good health? Are certain areas of the country or certain neighbourhoods unduly disadvantaged in health terms? Are the unemployed disadvantaged compared with those in work? Does the health care system treat some people more favourably than others? Are the resources available to the NHS fairly distributed around the country? (Whitehead, 1992:222).
Currently there is considerable research into the precise effects of a range of inequalities - economic, class, gender, age and ethnicity for example - on specific patterns of ill health and disease. Each of the above areas merit significant dissertation; however, for the purposes of this assignment, I am going to discuss socio-economic class and exemplify how it influences our chances of health and well-being. The second part of the assignment will focus on social work policy relevant to addressing the above issues.
Inequalities in Health
In order to understand what is meant by inequalities in health, it is necessary to consider primarily, what health is. There has been much debate on the concept of health alone; Baggot (1998) talks about the two main ways of defining health - positively or negatively. The World Health Organisation's positive definition of health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (1946, cited in Baggot 1998: 1) is frequently quoted and views health as something that can be 'possessed'. The negative approach to health considers health to be the absence of illness and disease etc. The latter approach tends to dominate orthodox medicine, which is primarily focused on disease.
With the emphasis on the negative approach to definition, health tends to be measured according to how unhealthy we are. Mortality and morbidity rates are frequently used as indictors of such. The Office for National Statistics (ONS), formerly known as The Office of Population Censuses and Surveys (OPCS), has now took over the responsibility of the General Registrars Office of registering deaths. The measuring and monitoring of socio-economic differentials in mortality and other health inequalities remains a fundamental part of their work. These measurements however have their limitations. For example dependency on mortality rates can induce comparative indifference towards problems of chronic illness from illnesses that do not kill people but lower their well-being and thus distort results. Morbidity illnesses are also problematic as not all illness, are reported. Perceptions vary as to what it means to be ill and this can affect the amount of illness reported
In Britain, for statistical purposes, class has been defined using 'the Registrar General's scale of Social Class' (RGSC) since 1913 when it was developed. Later modified in 1921, it has been of considerable importance in the study of health inequalities. The scale consists of six major classes, ranging from 'Professionals' in class I to 'Unskilled' in class V. Class III is sub-divided into manual and non-manual skills. The scale is based on a man or single women's occupation and so a married women, is classified according to her husbands occupation, meaning the term has an inherent gender inaccuracy (Whitehead 1992). Further problems with this form of measurement is that the information on occupation is obtained from death certificates and can be vague and imprecise, also it may not take into account other jobs held by men throughout their lives that could have had an effect on their health (Busfield 2000).
It has been argued that the level of skill at work may not be the best way of measuring access to social resources. According to Jones (1994), a second approach used in research of inequalities in health, to be superior to the Registrar Generals approach is that which is used in the General Household Survey (GHS), and is known as the classification of, 'Socio-economic groups' (SEGs). It was introduced in 1951, and although this method has no clear conceptual foundation, it does group occupation according to employment relations and conditions.
Infant mortality, because of its sensitivity to social conditions, is a useful indicator when assessing health inequalities. Infant mortality has decreased greatly over the last century. For example 1841 mortality rates show that 68% of men and 71% of women will survive to the age of 15, this compares with mortality rates for 1994-1996, which show, that 99% of both men and women will survive up to the age of 15 (Busfield 2000: 5). However although there has been a decrease in infant mortality, this has done little to lessen inequalities in infant mortality rates between the social ...
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Infant mortality, because of its sensitivity to social conditions, is a useful indicator when assessing health inequalities. Infant mortality has decreased greatly over the last century. For example 1841 mortality rates show that 68% of men and 71% of women will survive to the age of 15, this compares with mortality rates for 1994-1996, which show, that 99% of both men and women will survive up to the age of 15 (Busfield 2000: 5). However although there has been a decrease in infant mortality, this has done little to lessen inequalities in infant mortality rates between the social classes. A report published in 1998 called 'Our Healthier Nation' (OHN), confirmed that 'Over half of infant deaths occur in the manual group. Infant mortality rates in social class V are double, those in social class I'.
OHN states that the death rates for injuries, is five times higher for lower socio-economic groups than for higher socio-economic groups and the occurrence of fires in the home is fifteen times higher again for lower socio-economic groups. Drinking is an important factor in accidents, it is estimated that 40,000 deaths each year could be alcohol related.
The graph overleaf shows that mortality from injury and poisoning (accidents) in children aged 0-15 years by social class in England and Wales (1989-1992) is 16.6 per 100,000 among those whose father is a professional and 73 per 100,000 among those children whose father is unskilled and of a lower socio-economic position in the labour market.
(source: Our Healthier Nation, 1998)
Further information provided by OHN states, that babies with fathers in social class IV and V have a birth weight that is on average 130 grams lower than that of babies with fathers in classes I and II. Wadsworth (2004) discusses the correlation between 'maternal health', low-birth weight and health disorders later in life such as heart disease.
The effect of teenage pregnancy on the health and well-being of both mother and baby have been looked at in many studies. The Health Development Agency, in its review of 'Teenage Pregnancy and Parenthood', point out:
It is widely understood that teenage pregnancy and early motherhood can be associated with poor educational achievement, poor physical and mental health, social isolation, poverty and related factors. There is also growing recognition that socio-economic disadvantage can be both a cause and consequence of teenage parenthood (2003:1).
The review shows that girls and young women from social class V are ten times more likely of becoming teenage mothers as those in social class I. The babies of these teenage mothers are more likely to be of a lower than average birth weight and infant mortality is 60% higher than babies born of older women. Other findings show that 44% of mothers under the age of 20 breastfed their babies, compared to up to 80% of older mothers (aged 24+). Results in the 'Infant Feeding Survey' 2000 state that in 1995, 90% of mothers in social class I breastfed their babies, in comparison to 50% of those in class V. OHN claims that breastfeeding decreased the incidence and severity of many infections of infancy and it protects against respiratory illnesses.
If the behavioural / cultural approach is applied, then this could account for some of the inequalities in infant mortality rates and respiratory conditions in working class children in comparison with middle class children. The behavioural / cultural approach, suggests that poorer health in classes IV and V is a consequence of less healthy behaviour associated with the lower classes, for example smoking and excessive drinking. Cultural explanations suggest that inequalities are rooted in the behaviour and lifestyles of the individual, and those suffering from poor health have different attitudes, values and beliefs which mean that they do not look after themselves.
Busfield (2000) however looks at other explanations, which could be used to explain health inequalities between the classes. She states that individuals may choose to buy white bread rather than healthier brown bread, because white bread is cheaper and many people cannot access supermarkets where food is of a more healthy nature, such as fresh fruit and vegetables. Busfield believes that individuals should not be blamed for health inequalities as some individuals do not have a choice and to talk of health related behaviour is misguiding.
The Acheson Report - 'Independent Inquiry into Inequalities in Health', published in November 1998, reported that households in the bottom tenth of the income distribution spend an average of 29% of their disposable income on food compared to 18% of those in the top tenth. Those in the lower socio-economic groups spend more on foods richer in energy, high in fat and sugar, which are cheaper per unit of energy than food rich in protective nutrient such as fruit and vegetables. OHN statistics show that women in social class V are five times as likely to be obese than those in social class I. A further statistic that may be related to obesity is that among lower socio-economic groups unskilled workers are two and a half times less likely to participate in sports than professionals.
A common consequence of poverty is bad housing, which in turn is associated with stress and contagious diseases. For example low income can make it difficult to afford adequate heating, research has shown that the most significant risks from poor housing are associated with damp, which contributes to diseases of the lung and respiratory system, common in the working class.
Unemployment, a major factor of low income and poverty, can also have detrimental effects on our health. Unemployed men and women are more likely than people in work to die from cancer, heart disease, and suicide. Although one could blame some factors such as increased smoking on the individual, OHN argues that it is harder to stop smoking when you are worrying about how to make ends meet and people often smoke as a way to cope with stress. When problems such as poor housing, unemployment, low pay are all combined peoples mental health is also likely to suffer; research shows that there is a higher prevalence of mental illness among those who are worse off.
Furthermore, there is a strong relationship between a child's social class and their educational attainment, Wadsworth (2004) points out that:
Educational attainment makes its mark in adulthood in a number of ways, most evidently in occupation and socio-economic status; and these in turn are strongly associated with health. Health related habits of smoking, nutrition, exercise, and alcohol consumption, all have strong socio-economic bias; they are also associated with education, which generally has the effect of reducing adverse health habit practices (2004: 138).
Policy Responses
The Black Report, published in 1980, showed that although there had been an improvement in health across all the classes (during the first thirty-five years of the NHS), there was still a link between social class (as measured by the old Registrar General's scale) and infant mortality rates, life expectancy and inequalities in the use of medical services (Davidson and Townsend, 1992). The report stressed the emphasis of material conditions of life and factors outside the NHS. Factors such as income, housing and the nature of employment have all fractured working class experiences and need to be considered. The Black Report however was not taken seriously until almost twenty years later.
With the election of a Labour government in 1997, the issue of health inequality took a prominent role in public debate. An independent inquiry into health inequalities was chaired by Sir Donald Acheson and reported in December 1998. When the results of the Acheson inquiry were made available, they not only confirmed the analysis of the Black Report, they also found that in some respects inequalities had widened (Ham 1999). The report not only made specific policy recommendations but emphasised the importance of integrating health inequalities into all relevant policy decisions:
those which deal with wider influences on health inequalities such as income distribution, education, public safety, housing, work employment, social networks, transport and pollution, as well as those which have narrower impacts, such as on healthy behaviours (Acheson 1998: 8).
The Green Paper 'Our Healthier Nation: A contract for health' was published in February 1998; it's aim was to improve the health of the population as a whole, and to improve the health of the worst off in society. It proposed a national contract between government, local agencies, communities and individuals to be responsible in improving the health of the population as a whole while also improving the health of the worst off in society at a faster rate in order to decrease the health gap (DoH 1998a).
The next major health strategy published after the Acheson Report was the White Paper 'Saving Lives: Our healthier Nation' (DoH 1999a) in July 1999. It endorsed the Acheson Report by emphasising the need to reduce inequalities in health. It confirmed those health targets originally set in the Green Paper, but did not set health inequality targets. The government established targets for improving living conditions and aimed to address inequality rising from poverty, low pay and poor housing. The secretary of state, Alan Millburn, announced these in February 2001; the targets focused on infant mortality and life expectancy. The government's aim was to reduce by at least 10% by 2010, between manual groups and the population as a whole, the mortality of children under one year old. And with regards to life expectancy, to reduce by at least 10% by 2010 the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.
At the same time as the White Paper, 'Reducing Health Inequalities: an action report' was published. It referred to policies for a fairer society, building healthy communities, education, employment, housing, transport, crime and healthcare (DoH 1999b). Later that year 'Opportunity for all- Tackling poverty and social exclusion' was published with the aim to eradicate child poverty in twenty years time.
Both the Black Report and Acheson Report identified policies to improve the circumstances of children as an essential condition for the reduction of health inequalities. In November 1999, the 'Sure Start' programme began 'to promote the physical, intellectual, social and emotional development of young children and their families' (Sure Start 1999). By May 2003, around 500 Sure Start programmes were in action, reaching about one third of all children aged under four who were living in poverty. Not only do these programmes promote health and family support services but early education also. Another government initiative aimed at improving the education of disadvantaged children is the 'Education Action Zones'. And to encourage children from low-income families to remain on at school an 'Education Maintenance Allowance' was introduced (Graham 2001: 108).
The 'Teenage Pregnancy Strategy' was introduced in 1999, aimed at halving the number of pregnancies to under 18s by 2010 and reducing the number by 15% by 2004. In addition, the strategy set out to increase the number of teenage mothers in education, training or work by 60% by 2010 (JRF 2003).
The government's main target for poverty was 'to reduce the number of children in low income households by at least a quarter by 2004, as a contribution towards the broader target of halving child poverty by 2010 and eradicating it by 2020'; but by 2001/2002, midway through the period set by the target, the government were only two fifths of the way to meeting this (Palmer et al 2003). Tax and benefit reforms were also introduced by the government, targeted at low income families with children.
As paid employment is seen as the best way to avoid poverty, the government developed and reformed many policies to overcome barriers to employment. The government's biggest investment was £5.2 billion in New Deal initiatives, aimed at promoting employment for different groups but especially young people who have been unemployed for six months and people over twenty five who have been unemployed for two years or more (Graham 2001). The aim of the initiative was to increase long-term employability by offering short-term employment opportunities. In April of 1999, the government introduced the first ever 'National minimal wage' to the UK, this policy was aimed at reducing 'in-work poverty' and decreasing the number of individuals dependent on social security.
Conclusion
To conclude, the above statistics highlight a diminutive of those studies carried out in relation to the inequalities in health that exist between the 'classes'. There is a massive amount of data relating class and ill health, both internationally and within the UK. Of course within the classes there are gender and ethnic differences; the correlation made earlier between unemployment and health inequalities would suggest that ethnic minorities and women, who are more at risk of unemployment, are going to be statistically higher in that area. Therefore separate explanation of each variable (class, gender and ethnicity) will require the other two to be held constant. In each case, the distribution of health and illness will be influenced by both the health chances of each group and the availability and use of healthcare.
As we can see, the subject of inequalities in health is a huge and complex one. However it is easy to see the causes and association of various illnesses with the lower social classes. Individuals in the lower socio-economic groups may find themselves caught in a lifestyle cycle where problems that contribute to health inequalities remain unchanged. For some individuals, the government's initiatives to address inequalities in health have come too late. Key problems that need tackling by the government are the continuous problems of low pay, lack of qualifications and the issues faced by those people living in poor social housing. It is not just enough to educate people on healthier lifestyle choices, when often these choices are not available to them.
Taylor and Field conclude:
There is now a general acceptance in research and policy circles that health inequalities are socially caused, and the major detriment is socio-economic inequality within society (2003:61).
Bibliography
Baggot, R. (1998) Health and Health Care in Britain (2nd edition), Basingstoke: Macmillan
Busfield (2000)
DoH (Department of Health) (1998) Our Healthier Nation, (online)
Htpp://www.official-documents.co.uk./documents/doh/ohn.htm
DoH (Department of Health) (1999) Reducing Health Inequalities: An Action Report, London: Department of Health
Exworthy M., Stuart, M., Blane, D. and Marmot, M. (2003) Tackling health inequalities since the Acheson Inquiry, Bristol: The Policy Press
Graham, H (ed) (2001) Understanding Health Inequalities, Buckingham: Open University Press
Ham, C. (1999) Health Policy in Britain: the politics and organisation of the National Health Service, Basingstoke: Palgrave
Jones, H. (1994) Health and society in twentieth-century Britain, London: Longman
Palmer, G., North, J., Carr, J. and Kenway, P. (2003) Monitoring Poverty and Social Exclusion 2003, York: Joseph Rowntree Foundation
Percy-Smith, J (ed) (2000) Policy Responses to Social Exclusion: towards inclusion?, Buckingham: Open University Press
Swan, C., Bowe, K., McCormick, G. and Kosmin, M. (2003) Teenage pregnancy and Parenthood: A review of Reviews, London: HDA
Taylor, S. and Field, D. (2003) Sociology of Health and Health Care (3rd edition), Oxford: Blackwell
Townsend, P., Davidson, N. (eds) and Whitehead, M. (1992) Inequalities in Health: The Black Report / The Health Divide, Harmondsworth: Penguin
Wadsworth, M. E. J. (2004) Health Inequalities in The Life Cycle Course of Perspective, in Bury, M. and Gabe, J. (eds) The Sociology of health and illness: a Reader, London: Routledge
Wilkinson, RG. (1996) Unhealthy Societies: The Afflictions of Inequality, London: Routledge
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