Firstly, the behavioural/cultural explanation view tends to blame ill heath on the sufferers because they do not follow a healthy lifestyle. Supporters of this view (such as the former Health Minster Edwina Currie's condemnation of northerners for eating unhealthy foods)7 suggest that working class people smoke and drink too much, eat the wrong kind of food and take little exercise.8 This view argues that the prudent would not waste money on cigarettes and alcohol, would live on healthy vegetable casseroles, and would walk everywhere for exercise. The fact that some do not do this suggests a deficient culture and value system.
Cultural explanations essentially place the blame on individuals themselves, in what are called ‘victim-blaming’ theories.9 Supporters of this explanation argue that different social classes behave differently and that these behavioural differences lead to differences in health. For example, only 4% of women of the professional class smoke during pregnancy, as against 26% of women of the unskilled manual class.10 This behavioural difference between the classes may help to account for differences in the health of babies born to women of different classes. For example, the lower the social class of the mother, the greater the risk of premature birth and low weight and the higher the infant mortality rate.11
In contrast, Townsend (1990) and Davidson (1982) both argue that while some of the links between deprivation and ill health are still very poorly understood, life style is clearly far from the whole answer, as some people have more freedom than others by virtue of their individual situation and circumstances to choose a healthy lifestyle, as the unfortunate ones being restrained from adopting a healthier life, even when they would wish to do so, by income, housing, work and other social constraints.12 While the authors of The Black Report and The Health Divide both accepted that this factor played a role in health differences, however class differences in health remained even when life style was taken onto account, and many class differences were not related to factors such as smoking, drinking and other lifestyle choices.
However, its high profile in political debates in the 1980's led to the inclusion of questions about smoking-related diseases, notably coronary heart disease and lung cancer, in research on Whitehall civil servants by Marmot (1884).13 They found that even with non-smokers the risk of these diseases was still strongly associated with the grade of job held, thereby pointing to the inability of this model to fully explain most health inequalities, as cultural and behavioural differences only accounted for approximately 25% of all social class inequalities.14
The artefact explanation, on the other hand suggests there are real problems of measurement and the statistics themselves may not be reliable indicators.15 This explanation suggests that class inequalities in health do not really exist; they only appear to exist because of the way class is constructed. There are four important points to consider when looking at this explanation: Firstly, the number of people in the lower class groups, especially unskilled manual workers, is in decline, so statistics on health inequalities among the poorer classes are based on fewer people. Secondly, the few workers reaming in lower-class jobs are still experiencing better health than in the past. Thirdly, these suggested figures tend to mask the higher levels of collapse disease among (especially) middle-class women - Alzheimer's - as women and middle-class people live longer, and finally, this explanation also criticises the classification of people by occupation.16 However, the authors of The Black Report argue that this explanation is not particularly convincing, as working class groups do not have as much contact that is often supposed, while poor health affects all manual workers, not just those classified as ‘unskilled’.
The social selection explanation thirdly, suggests that people who experience poor health tend to find it difficult to get good jobs. Therefore they either move into, or remain in, lower-class occupations. This means that people are in lower social classes because of their poor health, rather than their class causing poorer health.17 There is some evidence in support of this theory. Based on research on women in Aberdeen, Illsley (1986) concluded that taller women tended to move up an occupational class at marriage while shorter women tended to move downwards. Since height can be taken as an indicator of health, this research tended to support the social selection model. On the basis of data from a National of Health and Development, Wadswroth (1986) found that seriously ill boys were more likely to suffer a fall in social class than others.
However, longitudinal research contained within the National Child Development Survey - following a group of children born in 1958 - also found that while some social mobility was related to health, such differences in heath experiences could not explain the degree of class differences in health that existed.18 Equally a study of 17,000 Whitehall civil servants Rose (1981) and Marmot (1984) found that, among those with no detectable disease at the start of their career, there were still notably higher death rates among men in the lower grades of the civil service. Sociologists in general regard this explanation as somewhat inconclusive when compared with the cultural explanation, as this approach shows that studies of health differences indicate that poor health is a result of poverty rather than a cause of it.
Finally, the structural/material explanation is viewed favourably by many sociologists and social democratic politicians. The evidence for it is seen as the most convincing by the producers of The Black Report. This explanation suggests that the material situation of the poor is seen as the most important factor in determining their poorer health. Lower income earners are more likely to live in substandard housing which may be damp, overcrowded and possibly dangerous. Many manual workers experience unhealthy and potentially dangerous working conditions, and statistically they have more accidents at work than non-manual workers.19 Manual workers often do work that is physically and mentally draining, leaving little energy for relaxation or exercise, while lower income may lead to poor diet and stress, resulting in increased smoking and drinking, for example, with potentially dangerous consequences for long-term health.
Supporters of the approach accept the behavioural differences stated earlier, but claim that this behaviour has to be seen within a broader context of inequality. To many sociologists poor health is the result of hazards to which some people have no choice but to be exposed given the present distribution of income and opportunity, such as poverty, poor position of work, unemployment, and types of industry.20 Therefore this approach has the advantage of explaining why people make choices about their behaviour, but also that the circumstances within which they make their choices are strongly affected by the extent of inequality exiting in Britain today.
These studies all provide strong evidence in support of the importance of material factors in social-class health inequalities and seem to be more convincing than the behavioural/cultural explanation previously discussed.
Summarising the evidence on the relative importance of the cultural/behavioural and the material/structuralist explanations, many sociologists argue the evidence that health-damaging behaviour is more common in lower social groups continues to accumulate, especially concerning smoking and diet. However, can such life style factors account for the entire observed differentials in health between different social groups? Many sociologists such as Whitehead (1987) argue that this theory does not substantiate the claim, as it is illustrated even when studies are able to control for factors like smoking and drinking, a sizeable proportion of the health gap still remains and factors related to the general living conditions and environment of the poor are indicated.
All in all, the link between class and inequality seems evident as there is widespread agreement among sociologists using evidence from the research of Black, Acheson and The Joseph Rowntree Trust that structural and cultural factors are the main contributors to health differentials between classes, and that in reality these factors are interrelated, with the artefact and selectionist explanations playing some part in the reported differences. In this context there is also a growing number of evidence that material and structural factors, such as housing and income can in fact affect health. Most importantly, several studies have shown that unfavourable social conditions can limit the choice of an individuals life style and it is this set of studies which illustrates most clearly to many sociologists that behaviour and attitudes cannot be separated from its social environment.
As social and economic life have major influences on the patterns of illness and death, many sociologists argue that as long as inequalities of wealth, income, education, occupation and social privilege continue, so will inequalities in health. It is for all these reasons that sociologists have generally given more emphasis to material, social and economic explanations rather than cultural ones for social class inequalities in health, as supposed to the title essay.
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