Our Healthier Nation (OHN) statistics confirm that;
“Over half of infant deaths occur in the manual group. Infant mortality rates in social class V are double, those in social class 1.”
Information provided by OHN states, that babies with fathers in social class 4 and 5 have a birth weight that is on average 130 grams lower than that of babies with fathers in classes 1 and 2.
(reasons for higher infant mortality – behavioural approach
There are a variety of explanations to explain these variations in health among different social classes. One of these explanations is the behavioural/lifestyle approach. (Lecture 8 20/02/03) This analyses, suggests that health can be affected by styles of living and patterns of behaviour and that health differences between classes could be explained by variations in their culture of health. (Moon and Gillespie, 1995: 203) Today there is still the belief that;
“…those who are unthinking, and reckless, lead irresponsible lifestyles which will inevitably make them ill and this is why they will die younger…some people stuff themselves with unhealthy, fatty food, they ‘smoke like chimneys’ and ‘drink like fish‘. During their non-working hours they are ‘couch potatoes ‘ who do no exercise and they also fail to use preventive services, such as antenatal care and screening…the range of unhealthy behaviour could be due to a disproportionately high number of feckless people in the working class. (Jones, 1994: 176)
Results in the ‘Infant Feeding Survey‘ 2000 state that in 1995, 90% of mothers in social class 1 breastfed their babies, in comparison to 50% of those in class 5. OHN claims that breastfeeding decreased the incidence and severity of many infections of infancy and it protects against respiratory illnesses. The Black Report (Black et al. 1982:49) and the Health and Lifestyles Survey 1985-86 (OHN) noted that;
“ The most marked gradients are for deaths from…respiratory diseases.”
If a behavioural/lifestyle approach is to blame then this could explain inequalities in infant mortality rates and respiratory conditions in working class children in comparison with middle class children. Mothers who smoke increase the risk of cot death to their babies. Barker (1998) believes that improving breast-feeding rates of those in lower socio-economic groups will be of a great benefit to the health of their children and that there is a clear need to develop policies to improve the health of (future) mothers and their children. (Barton and Bloor, 2000: 30)
OHN states that the death rates for injuries, is five times higher for lower socio-economic groups than for higher. 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 below shows that mortality from injury and poisoning (accidents) in children aged 0-15 years by social class in England in Wales 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.
(OHN)
Evidence to support the lifestyle/behavioural approach is evident in statistics for lung cancer. The incidence and mortality rates in the most deprived groups for both men and women are around twice those of the more affluent and the ten major cancers share marked adverse social gradients by social class. Research suggests that one third of all cancers are the result of a poor diet. If the incidence of those cancers in people in all deprivation categories were as low as those in the most affluent then it is estimated that 20,000 fewer cases of these cancers would be diagnosed each year. OHN statistics show that in 2000 in Britain 15% of men in professional socio-economic groups smoked compared to 39% in unskilled manual groups. This could when using the behavioural explanation explain why lower socio-economic incidents and mortality from lung cancer are higher. Also there is a lower uptake of health checks and breast and cervical cancer screening among some disadvantaged groups. (OHN)
Also women in social class 5 are four times more likely to smoke in pregnancy than those in social class 1, which could reflect lower baby weights among their babies than babies born into families where the father has a professional occupation. (OHN)
The Acheson Inquiry in 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. This may help to explain obesity variations in social class. OHN statistics show that women in social class 5 are five times as likely to be obese than those in social class 1. 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.
There is evidence to suggest that the ‘mortality gap’, between those at the top and those at the bottom may be increasing. Of all long-standing illnesses in 1989 the percentage of professionals was 29.1% in comparison to 47.8% of those who are unskilled. (Moon and Gillespie, 1995: 200)
The culture and behaviour approach however has a ‘common sense’ appeal and it fits very well with assumptions about human rationality and the capacity for self-control and lifestyle through individual choice. However it tends to ignore the social and cultural context in which individual behaviour is located. It also tends to ‘blame the victims’ by focusing on explaining inequalities of health in terms of peoples bad behaviour, whilst ignoring the many reasons why people are often forced to behave in certain ways. (Moon and Gillespie, 1995: 203)
The Black Report on ‘Inequalities in Health’ published in 1980 took a different approach to explaining inequalities in health. The report stressed the emphasis of material conditions of life and factors outside the NHS. (Ham, 1999: 81) Factors such as income, housing and the nature of employment have all fractured working class experiences and need to be considered. (Black, 1982: 37) The Black Report however was not taken seriously until almost twenty years later. When the results of the Acheson inquiry were made available in 1998, they not only confirmed the analysis of the Black Report, they also found that in some respects inequalities had widened. (Ham, 1999: 84)
Busfield (2000) looks at some of these 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 organic products. In this case an appropriate policy response would be to lower prices of healthier foods, which are affordable to all. ((Busfield, 2000: 37) The response under ‘Health of the Nation 1998‘, to educate people about nutritious foods, does little to help people when they still cannot afford to buy the healthier, more expensive option.
Busfield (2000) 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. (Busfield, 2000: 37) Moon and Gillespie (1995) talk about material deprivation. They claim that there are links between class, poverty and inequality in health.
For example poverty can make it difficult to afford to warm your house, 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. Under (SLOHN) £500 million has been allocated to pensioners to make winter fuel payments and ‘A National Licensing System’ for houses will help tackle the worst housing conditions.
Barton and Bloor (2000) suggest that childhood injuries are closely linked with social deprivation and it is important that effective interventions target those in lower socio-economic classes. There is evidence that safety devices in the home such as smoke detectors, child resistant containers and thermostat control for tap water reduces the risks of injuries in the home. (Barton and Bloor, 2000: 30) However income can affect buying smoke alarms. (OHN) Appropriate policy responses in this case would be to promote child restraint devices through legislation and distribute free safety devices and information on domestic safety. (Barton and Bloor, 2000: 30)
Low income is also known to be a big factor in high smoking in class 5. OHN states 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. One study found that one third of children lived with a smoker and this increased to 57% with working class. One of the priorities in (OHN) is the desire to cut the number of people smoking by 2010, in order to reduce death rate from cancer by one fifth. Plans have included the development of smoking cessation clinics and restriction of tobacco advertising, in an attempt to protect young people. (Ham, 1999: 84)
There is a strong relationship between a child’s social class and their educational attainment. A good education gives children the confidence and capacity to make healthier choices and the ability to improve their own and their family’s future. (OHN) (SLOHN) notes that people with low levels of educational attainment are more likely to have poor health as adults, and so by improving education for all will tackle one of the main causes of inequalities in health. (SLOHN) has developed many strategies to do so. These include, ‘Cooking for kids’, a programme that provides facts about nutrition and preparing food. This is an attempt to cut coronary heart disease and cancer, by providing children of an understanding of what fulfils a healthy diet. Also is the ‘Active Schools programme’, which attempts to lay the foundation of lifelong positive attitudes towards health and fitness.
Poor educational achievement and teenage pregnancy are also closely linked. (OHN) Barton and Bloor (2000) state that there is evidence that the teenage pregnancy rate is higher among lower socio-economic groups, with poor educational attainment. Evidence suggests that effective ‘sexual health programmes’, involving provision of condoms and sexual negotiation training in schools is a good method of dealing with the issue of teenage pregnancy. Barton and Bloor, 2000: 31)
Unemployment is often associated with low incomes. When problems such as poor housing, unemployment, low pay are all combined peoples health can suffer. Unemployed men and women are more likely than people in work to die from cancer, heart disease, and suicide. People living in more deprived industrial areas of England and Wales are more likely to be treated for depression than people living in any other area. For example from 1994-1998 there were 34 per 1, 000 males in deprived industrial areas and 77 per 1, 000 females, however in suburban areas there were, a smaller total of 21 per 1,000 males and 55 per 1, 000 females being treated with depression. (OHN)
An explanation for high depression among the working classes may be that they are more likely to like in deprived areas with high unemployment and the unemployed often loose social ties from work. Compared to people with lots of social ties, the socially isolated were six times more likely to die from a stroke and three times more likely to commit suicide. (SLOHN) has promoted a, ‘Welfare to Work’ programme, which will attempt to equip people with the education and skills they need to get jobs and keep them.
These links with poverty all make sense, as high rates of death and disease are usually where the standards of living are lowest. The Health of the Nation 1998, sought to promote individual responsibility, rather than acknowledging the link between economic and social deprivation and health. (Moon and Gillespie, 1995: 208) Under (SLOHN) it is easier to escape from the benefits trap into work, through tax and benefit reforms. These include Working Families Tax Credit, the Childcare Tax Credit and a national minimum wage
Areas of social deprivation containing high proportions of people from lower socio-economic groups tend to have access to poorer health services, even though their need is greater. Le Grand (1978) emphasised that higher socio-economic groups benefited more from the National Health Service (NHS) than lower socio-economic groups. (Ham, 1999: 193)
The Acheson Report (1998: 113) reiterates the latter point by noting that, there is a positive relationship between levels of deprivation in an area and hospital admission rates. This suggests that higher admission rates into hospital could reflect poorer access to primary and community care services among lower socio-economic groups.
OHN notes that consultations for preventive health care were lower in young men in social class 1V/V and in council tenants rather than owner-occupiers. The Black Report (1982) states that even though working class patients had been with the same practice for longer, the doctors seemed to have more knowledge of the personal and domestic circumstances of their middle class patients. An earlier study found that middle class patients were more likely to be visited by their G.P. when in hospital. (Black et al., 1982: 71)
Jones (1994: 175) claims that the middle class are more knowledgeable than the working class about health and medicine, which is a reflection of their higher levels of education. They are more critical and display greater confidence in asking questions and so receive longer consultations with their General Practitioner (GP’s) to discuss their problems. Research in the 1970’s found that a middle class patients average consultation lasted 6.2 minutes and a working class consultation only lasted 4.7 minutes. Jones states that patients who are satisfied with the consultation are more likely to follow their doctor’s advice.
Jones (1994) also claims that the geographical distribution of resources favours middle class areas and this has been true throughout the century. She also states that the direct costs of treatment and formal care were removed with the NHS but not the indirect costs of transport and days of work. This may be why there is a lower take up of preventive screening among the lower classes, as they cannot afford the transport or the time of work.
Barton and Bloor (2000) state that given the incidence of disease is greater amongst selected individuals, there is need for a more targeted approach to reducing inequalities. They claim that taking account of the recipients of services and aiming to increase the uptake of services in working class communities could reduce inequalities dramatically. (Barton and Bloor, 2000: 20)
Another argument has been put forward, for the apparent differences in quality of health among different social classes by Illsley et al. (1995). He suggests that health may distribute people in the occupational structure and this explains the association between health inequalities and social class. They claim that ill health negatively affects the ability to work and thus, the healthy are more likely to be upwardly mobile in their jobs and the unhealthy are more likely to be downwardly mobile. Since some cases of ill health are found to be genetically transmitted, this ‘social selection’, will be reinforced by a natural selection over successive generations. However there is little evidence to support this argument. (Moon and Gillespie, 1995: 202)
GEOGRAPHICAL
Health inequalities are also evident in regional distributions of morbidity and mortality. For example OHN notes that in 2000 the infant mortality rate in the Eastern region was around one fifth less than the average for England at 4.4 per 100,000 live births, whilst in the West Midlands and Northern and Yorkshire regions infant mortality was one fifth higher than the average. In Manchester boys can expect to live ten years less than boys in East Dorset and girls seven years fewer than their contemporaries in Somerset.
The chances of dying from a circulatory disease are over one quarter higher in the North Eastern region than in the South Eastern region and five year survival rates from lung cancer for men and women combined are highest in London at 6.1% and lowest in the North and Yorkshire and Trent at 4.4%, the average for England is 5.5%.
In 2001 81% of women aged 50-64 in the Trent region took up the offer of screening for breast cancer, this was 6.1% above the average for England and in London only 62% took up the offer, this was 13% below the average for England.
Graham (2001) claims that the healthy districts are in more rural areas in the South-east of England. She claims that there is still a predominance of manual work in the old northern industrial areas where de-industrialisation has had an effect on health. Champion and Townsend, reported a net loss of three million manufacturing jobs in Britain between 1971 and 1989. Since the manufacturing and mining industries were spatially concentrated, so to were their effects. Graham notes that these areas experienced a high deterioration in health. (Graham, 2001: 143) As well as de-industrialisation, the lower socio-economic position of those in the north in comparison to the higher socio-economic position of those in the south can help to explain health inequalities.
Higher proportions of pupils in the south of England gained five or more passes at GCSE than in the northeast. There is a strong relationship between a child’s social class and their educational attainment. A good education gives children the confidence and capacity to make healthier choices and the ability to improve their own and their family’s future. (OHN)
GENDER
Macintyre (2001) argues that much research on the relationship between socio-economic status and health has been gender blind and this hinders us to understand the causal mechanisms which create and maintain the social patterning of health. (Leon and Walt, 2001: 283)
Ruiz and Verbrugge (1997) state,
“The many clinical trials have been conducted only among men carry the assumption that results can automatically be applied to women as if they had been studied too.” (Leon and Walt, 2001: 284)
Gender inequalities in life expectancy in Britain are very marked. Mortality data for 1987-1991 show women living to 77.9 years of age on average and men to 72.3 years on average. Calculations show that for 1994-1996 in the United Kingdom (UK), 70% of women will live to 75 years of age or more in comparison to 56% of men. Busfield (2001) states that men’s higher levels of mortality, are not matched by higher levels of reported sickness or greater use of the health services, which might be a reason why they do not survive as long as women.
Coronary heart disease in middle age leads to more deaths in men than women. (Busfield, 2000: 25) HON states in 1998 that the proportion of men in England and Wales who had received coronary heart disease during the year was 70% higher for men than women. Reasons for this difference may be due ?
Two and half times more women than men are treated for depression in England and Wales. (HON) This may be a result of domestic violence towards women. Intimate violence is one of the principle factors resulting in health inequalities across gender specifically. It is noted that violence against women has serious consequences for both their physical and mental health and abused women are more likely to suffer from depression. () Under (SLOHN) there is a women’s unit, which is working on tacking violence against women.
Fuhrer et al. (1999) undertook the ‘Whitehall 11 study’ and concluded that among the reasons why women experience two and a half times more mental health problems than men is that support networks such as marriage have a more positive effect for men than women, and that the trend in negative aspects in close relationships is greater in women. Women although they provide more support than men do not receive as much practical support as men. (Fuhrer et al., 1999: 81)
In young men aged between 15 and 24 years of age suicide is the leading cause of death. The reasons for this variation may be that women are more likely to seek help for a mental health problem and so appear in statistics more than men. And as a result of young men’s failure to seek help suicide is three times more common among men than women. (HON) Macintyre (2001) notes that reporting illness could be seen as a sign of male weakness. (Lecture9 25/02/03)
Prior and Hayes (2001) claim that the increased pattern of vulnerability among young men may be attributed to the impact of changing definitions of mental disorder. Diagnoses among young men are more often associated with dangerous behaviour in the mind of the public than those, precedent amongst young women. (Prior and Hayes, 2001: 544)
Women are at a disadvantage in later life in terms of mobility, however this is because they tend to live longer than men and so are more likely to develop chronic problems. (Busfield, 2001: 28)
Socio-economic explanations may also help to explain gender differences in ill-health. Women are predominantly the occupiers of part time work, which is known to have lower levels of pay and poorer conditions. Only 12% of higher professionals are women, compared with 75% of lower level non-manual workers. However even were women are working in professional occupations the median weekly full-time earnings for a women in 1986 was £191 in comparison to men’s £244. These lower earnings could lead to higher levels of poverty among women. Also women bear a ‘dual burden’, having to care for children and home responsibilities as well as participate in the labour market, which could increase stress levels. (Arber and Gilbert, 1992: 3-7)
(find out bout coronary and obesity lor)
ETHNICITY
Observed differences in both health status and health service use across ethnic groups have been variously attributed to cultural, socio-economic and genetic differences as well as to the impact of individual and institutional racism. (Graham, 2001: 25)
In 2000 the highest infant mortality rate was among babies of mothers born in Pakistan, 12.2 per 1000, a rate more than double the overall infant mortality rate in England. The Health Survey for England (1999) found that one third (32%) of Black Caribbean women and one quarter (26%) of Pakistan women were obese compared to one third (21%) of women in the general population. (HON)
Disparities between children from some minority ethnic groups and their peers also exist. It is known that Black, Pakistani and Bangladeshi children all perform less well at school.
Some authors (Navarro 1990) have interpreted their data as showing that differentials in mortality between ethnic groups are essentially due to income and class inequality. (Graham, 2001: 25)
Abbotts et al. (2001) claim that after the migrant stage some ethnic minority and religious groups may continue to experience disadvantage and health patterns often reflect these experiences. In Britain evidence of this is the Irish. Many of these immigrants settled in the industrial towns of the Northwest, where they found employment as labourers in heavy industry. It is noted that the Irish form 30% of Glasgow’s population.
The Irish mortality rate is 26% higher than the average population for all causes, and they have 52% more cardiovascular disease. At the age of 58 Irish Catholics in Glasgow were more likely to be in manual households, receive most of their income from the state, not to own their own home or car and to have left school at the statutory minimum age. Abbotts et al. (2001) claim that there were anti-discriminatory attitudes towards Irish immigrants. (Abbotts et al. 2001: 1001-1004)
It is also argued that racism exists in the NHS for ethnic minorities as both consumers and employees. In the NHS the medical profession lack knowledge about diseases specific to the black community such as Sickle Cell Anaemia, which is characteristic of Afro Caribbean’s, this could lead to further health problems if a wrong diagnosis is given. Despite inequalities in the health of ethnic minorities and the general population, is a lack of government, funded research in this area. (Jones 1994: 187)
Some studies have produced evidence that bilingual information and interpretive services have helped to improve the health situation of ethnic minorities. (Barton and Bloor, 2000: 31)
Conclusion
There is considerable evidence to suggest that in many countries there are differences in health within the population both between different social groups and between different geographical regions. Such differences in health appear to arise as a result of unequal social positions, for example different social class, or membership of certain social groups such as ethnicity and gender. They are compounded by geography because people of particular social classes or from different ethnic groups concentrate in certain locations. (Moon and Gillespie, 1995: 197)
The extent to which your health is affected depends on how well off you are, whether you are a man or a women, where you are born and brought up and your ethnic background.
Health is now broadly defined, and the wide social influences (relating to class, geographical area, gender and ethnic relationships) on standards of health are receiving increased attention. (Jones, 1994: 172)
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GOVERNMENT POLICIES
(SLOHN) recognises that although individual behaviour is an aspect for well being, poor health can also arise from a variety of aspects such as individual behaviour, social and economic factors, such as employment situation and poverty and indeed genetic makeup. They also recognise that health inequalities exists between social classes, different areas of the country, between men and women and between people from different ethnic backgrounds.