Social constructionists argue that the health inequalities relating to socio-economic class are not objectively ‘real’. They believe that statistical evidence about health inequalities is flawed and does not reflect reality as they are socially constructed through labelling and social interaction. For example, when CHD was identified as being associated with lower socio-economic class during the 1930s through to the 1960s the diagnosis of this disease increased whilst the diagnosis of other heart related illnesses decreased. This could be evidence of the social construction of disease as doctors were more inclined to label heart problems in lower socio-economic class patients as CHD as opposed to some other label that could have been applied. Scheff (1975) found that social groups with less power and resources were more likely to be labelled as mentally ill by health professionals than groups possessing more power. Doctors are more likely to apply certain labels to those that they label as being from a particular socio-economic class, this, argue the social constructionists, invalidates the statistical evidence that links socio-economic class to particular health problems as all they measure is the likelihood of doctors and other health professionals to apply labels to particular groups, rather than reflecting reality. Social constructionist explanations fail to recognise the impact of structural and material factors on the health of the lower socio-economic groups and are not able to fully account for the patterns of health inequalities. The Whitehall civil servant and soldier studies clearly demonstrated that health and rank or status is linked. This study found that there was a clear ‘mortality gradient’ linked to class, meaning that those occupying lower ranks experienced higher mortality rates than those of the higher ranks, suggesting that socio-economic class and health are, indeed, linked.
The social selection approach contends that ill health is a cause rather than the result of low socio-economic position. It is argued that those with good health will ‘rise to the top’ of the socio-economic grouping as having good health is necessary to succeed in education and employment. Meadows (1961) found that sufferers of chronic bronchitis were more likely to experience downward social mobility than non-sufferers. In addition, Illsley (1980) found that higher socio-economic class or upwardly socially mobile females in Aberdeen had better health, better physiques, were taller and had babies with a higher birth weight than women in lower socio-economic groups. Although there is some evidence to support the claim that ill health is a cause rather than a result of belonging to lower socio-economic groups or being downwardly mobile there is more compelling evidence to support other explanations for health inequalities in the UK.
The cultural/behavioural approach views health inequalities as being linked to the culture and behaviour of the lower socio-economic groups. This approach is influential in health promotion and has led to many initiatives to ‘re-educate’ particular groups so that they are able to make more healthy choices in terms of their diets and risk behaviour, such as smoking and drinking. This explanation views the voluntary behaviour of the lower socio-economic classes as being the cause of their relative ill health. In particular smoking, drinking, lack of exercise, poor diet leading to malnutrition or obesity, lack of exercise and not accessing health services due to not placing as high a value on health as those in the higher socio-economic classes are viewed as being responsible for ill health. Blaxter (1990) found that individuals belonging to higher socio-economic groups were more likely to exercise and eat healthily. This approach has been accused of blaming the victim by some sociologists, particularly those from the materialist/Structuralist school of thought who argue that it is the conditions of living that causes ill health rather than the ‘choices’ made by members of lower socio-economic groups. For example, is it really a choice to eat an unhealthy diet when unhealthy food is less expensive than healthy food, or to work in a dangerous job? Cultural/behavioural explanations have cited under use of health services as a cause of ill health and although there are links between use of health services and socio-economic class there is more compelling evidence for the impact of other factors on health (MacIntyre, 1986).
The Black Report used a Structuralist/Materialist approach to explain the health inequalities in the UK. This explanation views ill health as resulting from differences between the material conditions of those in lower and higher socio-economic groups. The poorest in society tend to live in sub-standard accommodation, damp and overcrowded living conditions can cause a range of illnesses, specifically, lower socio-economic classes suffer from higher prevalence of respiratory illnesses which could be caused by housing. Lower socio-economic groups tend to spend more time unemployed and unemployment is linked to poor diet due to not being able to afford healthy foods, feelings of hopelessness and helplessness resulting in higher instances of depressive illnesses and stress related risk behaviour (smoking and drinking for example). The quality of health care provision in poorer areas is worse than in more affluent areas and there are also problems associated with accessing services. Poorer groups are more likely to be socially isolated or excluded, for example; many of the newer supermarkets, where food is cheaper, are now ‘out of town’ as lower socio-economic groups are less likely to have their own transport these supermarkets are less accessible and the poor may have to resort to shopping in local stores where food prices are higher. This could contribute to having to eat less nutritious food as this could be too expensive. Men from lower socio-economic groups are more likely to suffer work related illness, injury and death due to the hazardous nature of their jobs, it is not a choice to work in dangerous employment, rather, it is a product of the material conditions in which people live. The material deprivation of many areas means that there are limited facilities for leisure and exercise. Dangerous streets and the lack of green spaces in urban areas mean that lower socio-economic groups are less likely to be able to exercise.
Poor health and mortality rates are not random but are patterned in relation to social group membership. Sociological explanations offer insight into why this is the case. Whilst some sociological explanations have more credibility than others, there is no one explanation that can fully explain health inequalities and socio-economic class. However, the most compelling explanations for health inequalities are offered by examining both the culture and behaviour of the different socio-economic groups and the material conditions in which they find themselves.
