Measuring inequalities in health: an analysis of mortality patterns using two social classifications

The paper investigates relationship between mortality and social class as measured by the Erikson-Goldthorpe schema, a validated measure of employment conditions, and compares this with differentials found using the Registrar General's social classes. Two cohorts of men aged 15/16–64 were drawn from the OPCS Longitudinal Study for 1971 and 1981. Mortality differences between social classes were estimated using deaths occurring between 1976 and 1980 in the first cohort and 1986 and 1989 in the second. The two classification were formally compared by means of the Relative Index of Dissimilarity and a likelihood-based statistic. Similar mortality differentials were found using both classifications in the two time periods. The Erikson-Goldthorpe schema showed a clear pattern of higher mortality in those groups without a career structure and with lower discretion over their work. The paper concludes that inequalities in health are seen when a validated social class schema based on employment conditions is used. The use of validated measures will make it possible for health differences to be more clearly interpreted in policy terms.     

The social class gradient in health in Spain and the health status of the Spanish Roma

Objective. To determine the social class gradient in health in general Spain population and the health status of the Spanish Roma.

Design. The National Health Survey of Spanish Roma 2006 (sample size?=?993 people; average age: 33.6 years; 53.1% women) and the National Health Surveys for Spain 2003 (sample size: 21,650 people; average age: 45.5 years; 51.2% women) and 2006 (sample size: 29,478 people; average age: 46 years; 50.7% women) are compared. Several indicators were chosen: self-perceived health, activity limitation, chronic diseases, hearing and sight problems, caries, and obesity. Analysis was based on age-standardised rates and logistic regression models.

Results. According to most indicators, Roma's health is worse than that of social class IV–V (manual workers). Some indicators show a remarkable difference between Roma and social class IV–V: experiencing three or more health problems, sight problems, and caries, in both sexes, and hearing problems and obesity, in women.

Conclusion. Roma people are placed on an extreme position on the social gradient in health, a situation of extreme health inequality.     

Trends in social class inequalities in health status, health-related behaviors, and health services utilization in a Southern European urban area (1983-1994)

BACKGROUND: The objective of this study was to describe the evolution of social class inequalities in Barcelona (Spain) residents in perceived health status, health-related behaviors, and utilization of health services between 1983 and 1994. METHODS: The information was obtained from the Health Interview Surveys conducted in 1983, 1986, 1992, and 1994 in Barcelona. In this study we included noninstitutionalized people ages >14 years. Social class was obtained from the Spanish adaptation of the British Registrar General classification. We studied health status, health-related behaviors, and health services utilization variables. Age-adjusted percentages and the relative index of inequality were obtained. RESULTS: Of the health status variables, having been confined to bed and acute restriction of activity in the 2 weeks prior to the interview showed an increase in inequalities by social class in 1994. The pattern of chronic conditions by social class in men did not change between 1983 and 1994. Women had a higher prevalence of chronic conditions and the inequalities among social classes had increased. In men there were no social class inequalities in smoking in 1983. In 1992 and 1994 smoking was more prevalent in men of social classes IV and V. In women, smoking was more prevalent in social classes I and II in 1983 than in social classes IV and V, something that had changed by 1994. Lack of usual physical activity in men was always more prevalent in social classes I and II, and this difference increased since more people of advantaged classes moved into inactivity. Health services utilization showed no inequalities in the years studied. CONCLUSION: The changing pattern according to social class of smoking and physical activity practice needs to be taken into account by policy-makers and public health workers.     

Migration-related health inequalities: Showing the complex interactions between gender,social class and place of origin

In this paper, we briefly review theories and findings on migration and health from the health equity perspective, and then analyse migration-related health inequalities taking into account gender, social class and migration characteristics in the adult population aged 25–64 living in Catalonia, Spain. On the basis of the characterisation of migration types derived from the review, we distinguished between immigrants from other regions of Spain and those from other countries, and within each group, those from richer or poorer areas; foreign immigrants from low-income countries were also distinguished according to duration of residence. Further stratification by sex and social class was applied. Groups were compared in relation to self-assessed health in two cross-sectional population-based surveys, and in relation to indicators of socio-economic conditions (individual income, an index of material and financial assets, and an index of employment precariousness) in one survey. Social class and gender inequalities were evident in both health and socio-economic conditions, and within both the native and immigrant subgroups. Migration-related health inequalities affected both internal and international immigrants, but were mainly limited to those from poor areas, were generally consistent with their socio-economic deprivation, and apparently more pronounced in manual social classes and especially for women. Foreign immigrants from poor countries had the poorest socio-economic situation but relatively better health (especially men with shorter length of residence). Our findings on immigrants from Spain highlight the transitory nature of the ‘healthy immigrant effect’, and that action on inequality in socio-economic determinants affecting migrant groups should not be deferred.     

Social inequalities in health related behaviours in Barcelona

OBJECTIVE: This study describes social class inequalities in health related behaviours (tobacco and alcohol consumption, physical activity) among a sample of general population over 14 years old in Barcelona. DESIGN: Cross sectional study (Barcelona Health Interview Survey). SETTING: Barcelona city (Spain). PARTICIPANTS: A representative stratified sample of the non-institutionalised population resident in Barcelona was obtained. This study refers to the 4171 respondents aged over 14. DATA: Social class was obtained from a Spanish adaptation of the British Registrar General classification. In addition, sociodemographic variables such as family structure and employment status were used. As health related behaviours tobacco consumption, alcohol consumption, usual physical activity and leisure time physical activity were analysed. Age adjusted percentages were compared by social class. Multivariate analysis was performed using logistic regression models. MAIN RESULTS: Women in the upper social classes were more likely to smoke, the adjusted odds ratio (OR) for social class V in reference to social class I was 0.36 (95% confidence intervals (95%CI): 0.19, 0.67), while the opposite occurred among men although it was not statistically significant in multivariate analysis. Smoking cessation was more likely among men in the higher classes (OR for class V 0.41, 95%CI: 0.18, 0.90). Excessive alcohol consumption among men showed no differences between classes, while among women it was greater in the upper classes. Engaging in usual physical activity classified as "light or none" in men decreased with lowering social class (OR class IVa: 0.55 and OR class IVb: 0.47). Women of social classes IV and V were less likely to have two or more health risk behaviours (OR for class V 0.33, 95% CI: 0.18, 0.62). CONCLUSION: Health damaging behaviours are differentially distributed among social classes in Barcelona. Health policies should take into account these inequalities.     

Patient cost sharing and social inequalities in access to health care in three western European countries

This study evaluates the association between social class and health services use in France, Germany and Spain, three countries with universal health coverage but with different cost-sharing systems. In France, patients share the cost of both physician visits and hospitalization, in Germany they share the cost of hospitalization, and in Spain there is no system of patient cost sharing. The data were obtained from national health surveys carried out in each of these countries during the last decade of the 20th century. We found that persons belonging to a low social class had fewer physician visits than those belonging to a high social class in France, whereas the opposite occurred in Germany and Spain. After adjusting for a measure of the need for health care, the results in France changed little, whereas no significant differences by social class were seen in Germany and Spain. Persons of low social class had more hospital admissions than those of high social class in France and Spain, while no statistically different differences were seen in Germany. After adjusting for need, no significant differences were seen in any of the three countries. Although other factors related with the structure of the health system can not be ruled out, our findings suggest that patient cost sharing reduces the frequency of physician visits and that this decrease is greater in the low social classes, whereas the effect of co-payment for hospitalization on the frequency of hospital admission is not clear.     

Social inequality and health: the role of social capital

The aim of the article is to examine whether and to what degree the unequal distribution of social capital in the population explains the relationship between socioeconomic position and health in Norway. Theoretical insight and empirical evidence seem to suggest that social capital mediates the effect of socioeconomic position on health outcomes. However, only a few studies have addressed this question and those that have done so have used few and simple indicators of social capital. This study is based on a nationwide cross-sectional survey (N = 3190) commissioned by Statistics Norway. The survey was designed to cover a comprehensive set of variables measuring different aspects of the theoretical construct of social capital. Two health outcomes, self-perceived health and longstanding illness, were analysed. The results showed that the mediating role of social capital between socioeconomic position and health was negligible for both health outcomes. After controlling for socio-demographic variables and socioeconomic position, only neighbourhood satisfaction and generalised trust showed a significant association with self-perceived health, whereas none of the social capital variables had any significant association with longstanding illness. Some theoretical and methodological implications of the results are discussed.     

European health inequality through the ‘Great Recession’: social policy matters

This paper investigates the association between the Great Recession and educational inequalities in self‐rated general health in 25 European countries. We investigate four different indicators related to economic recession: GDP; unemployment; austerity and a ‘crisis’ indicator signifying severe simultaneous drops in GDP and welfare generosity. We also assess the extent to which health inequality changes can be attributed to changes in the economic conditions and social capital in the European populations. The paper uses data from the European Social Survey (2002–2014). The analyses include both cross‐sectional and lagged associations using multilevel linear regression models with country fixed effects. This approach allows us to identify health inequality changes net of all time‐invariant differences between countries. GDP drops and increasing unemployment were associated with decreasing health inequalities. Austerity, however, was related to increasing health inequalities, an association that grew stronger with time. The strongest increase in health inequality was found for the more robust ‘crisis’ indicator. Changes in trust, social relationships and in the experience of economic hardship of the populations accounted for much of the increase in health inequality. The paper concludes that social policy has an important role in the development of health inequalities, particularly during times of economic crisis.     

Stratified users and technologies of empowerment: theorising social inequalities in the use and perception of diabetes self-management technologies

Medical technologies of various kinds play an increasingly important role in medical treatment, but may also increase health inequalities if they are primarily used by high-status patients. While many have problematised inequalities in the material access to medical technologies, differences in use and perception are also salient for explaining the relationship between medical technologies and health inequalities. This article attempts to theorise these inequalities by bringing health inequality research into dialogue with social constructivist perspectives on user-technology relations. Based on qualitative interview data from a case study of the technological self-management of type 1 diabetes, I construct three clusters of technological practices and perceptions corresponding to three broad user types. These user types are then discussed in the context of patient empowerment and the promotion of the active, autonomous and self-reflective ‘expert’ patient in European health care systems. To the extent that they materialise and enforce institutional expectations which only the most resourceful patients will be able to live up to, medical technologies may serve to entrench and legitimate social inequalities in health and medical care. Research therefore needs not only to consider how medical technologies are distributed, but also their design and appropriation by users.     

Explaining the social gradient in smoking and cessation: the peril and promise of social mobility

Smoking in high-income countries is now concentrated in poor communities whose relatively high smoking prevalence is explained by greater uptake but above all by lower quit rates. Whilst a number of barriers to smoking cessation have been identified, this is the first paper to situate cessation itself as a classed and cultural practice. Drawing on ethnographic research carried out in a working-class community in the North of England between 2012 and 2015, I theorise smoking cessation as a symbolic practice in relation to the affective experience of class and social mobility. I show that ambivalence about upward mobility as separation and loss translated into ambivalence about smoking cessation. The reason for this was that the social gradient in smoking operated dynamically at the level of the individual life course, i.e. smoking cessation followed upward mobility. A serious health problem was an appropriate reason to quit but older women continued to smoke despite serious health problems. This was linked to historical gender roles leading to women placing a low priority on their own health as well as the intergenerational reproduction of smoking through close affective links with smoking parents.     

The psychosocial effects on health of socioeconomic inequalities

Socioeconomic inequalities are thought to impair health in a way that is independent of the effect of material deprivation on health. But the mechanisms whereby inequalities have such an effect have not been thoroughly explained or explored. Two linked but distinct mechanisms have been suggested: social comparison and hierarchical conflict. In the first case, people compare their social status with that of others, and where this comparison is to their disadvantage they experience negative emotions that impact on their health. Epidemiological data suggest that this is a large area effect but psychological studies of social comparison suggest that small-group comparisons are important for social comparison. No explanation as yet embraces both large and small scales, and much about social comparison and its possible effects on health is poorly understood. Hierarchical conflict has been well documented in non-human primate societies (although with variable effects on health), and it is hypothesized that human hierarchies, in so far as they are structures based on domination, may affect health by means of the chronic stress associated with subordination. However, the degree to which human and non-human behaviour is comparable is unclear; nor is it clear that hierarchy as such is necessary conflictual: this may depend on how it is organized socially and experienced by subordinate groups. Much work needs to be done to understand both hypotheses, although at present the social comparison hypothesis appears to have more explanatory power.     

Linking credentialed skills, social class, working conditions and self-reported health: a focus on health inequality-generating mechanisms

In this study, focus is on the mechanisms linking credentialed skills and social class relations to five dimensions of occupational stressors and three self-reported health outcomes: persistent fatigue, musculoskeletal complaints and emotional wellbeing. We test for direct health associations of skills/class. Moreover, indirect health associations of skills/class, through differential exposure to occupational stressors and effect modifications of the occupational stressors, are tested. A modified LISREL analysis is applied to a representative cross-sectional sample of 11,099 Flemish wage-earners. The direct health effects of credentialed skills/class are limited, but they are clearly indirectly related to the self-reported health outcomes through differential exposure to occupational stressors. The indirect mechanisms point to both reinforcing and moderating effects on socio-economic health inequalities. Two cases of effect modification are also observed: social class modifying the association between control and persistent fatigue; and skills affecting the association between the quality of social relations and emotional wellbeing. Differential exposure to occupational stressors is a crucial mechanism linking skills/class to socio-economic health inequalities. Direct effects and effect modification of class/skills are relevant, but of limited importance. One of the effect modifications found suggests that a specific focus on contradictory class positions might be warranted in future research.     

Community action for health in socioeconomically deprived neighbourhoods in Barcelona: Evaluating its effects on health and social class health inequalities

BackgroundThe aim of this study was to analyse trends in several health-related indicators in socioeconomically deprived neighbourhoods in Barcelona with strong community action for health (CA), and compare them to neighbourhoods without such community action. A secondary goal was to analyse trends in socioeconomic inequalities in health in both types of neighbourhood.MethodsWe performed a quasi-experimental pre-post study using data from the Barcelona Health Surveys of 2001 and 2011. Our dependent variables were self-perceived health, mental health, previous drug use, and smoking cessation. We used Poisson regression with robust variance to calculate prevalence ratios (PR) and 95% Confidence Intervals (95% CI).ResultsThe percentage of men who had ever used drugs decreased over time in neighbourhoods with strong CA (PR = 0.48; 95% CI:0.25–0.92, from 2001 to 2011), but not in neighbourhoods without CA (PR = 1.02; 95% CI:0.74–1.40). However, the prevalence of poor mental health among men increased more in neighbourhoods with strong CA than in neighbourhoods without CA (p-value = 0.025). Among women, social class inequalities in poor mental health and smoking cessation decreased over time in neighbourhoods with strong CA but not in neighbourhoods without CA.ConclusionsOur study shows promising results regarding the effect of community action on health, particularly in terms of inequalities. Our results highlight the importance of allocating resources to implement and continuously evaluate CA initiatives.     

Heart health inequalities in Canada: modules, theory and planning

It is well known that prevalence and incidence rates of cardiovasculardisease (CVD) and CVD risk factors are not equally distributedamong socioeconomic groups. Known risk factors account for part,but not all of unequally distributed CVD rates. Socioeconomicconditions and psychosocial dynamics may explain another pareof the increased CVD rates. Theoretically, it may be possibleto lower CVD rates and CVD risk factor prevalence among lowersocioeconomic status (SES) groups by using a community development(socio-environment) strategy directed towards changes in socioenvrronmentalrisk conditions and psychosocial risk factors, rather than CVDrisk factors per Se. This article describes a protocol for sucha strategy based upon the planning work of Canadian health professionals,loosely organized under a project titled ‘Heart HealthInequalities in Canada’ This protocol incorporates baselinedata on CVD and CVD risk factor prevalence, but is premisedon actions negotiated between community organizations and healthauthorities, rather than defined unilaterally by health authorities.As such, program design activities and evaluation will differfrom a more general population-based risk factor reduction strategy.     

Beyond (financial) accessibility: inequalities within the medicalisation of infertility

There is a significant class disparity within the provision of medical treatments for infertility in the United States. Common explanations attribute this inequality to financial inaccessibility due to sparse insurance coverage and exorbitant costs. However, little is known as to why disparities still exist without the presence of such constraints, such as in states with comprehensive insurance coverage of infertility treatments. Drawing on in‐depth interviews with women of low socioeconomic status (SES), this paper aims to explore the structural and political barriers to receiving medical care for infertility within the United States context. The paper argues that much of the invisible, unidentified treatment disparities of infertility stem from the social control mechanism of medicalisation. Medicalisation perpetuates the stratified system of reproduction through its structural inaccessibility and the institutionalised classism apparent within medicine’s reproductive health practices and policies. The women in this study, however, actively and creatively identified ways to overcome the reproductive limits with which they were faced. In doing so, their solutions served both to accept and reject dominant norms of motherhood and medicine.     

The importance of addressing social determinants of health at the local level: the case for social capital

Social determinants are gaining momentum in public health practice. Many proposed solutions for tackling social determinants are outside the scope of local public health professionals. This article reviews the literature to find possible moderating variables which may buffer the effects of the social determinants of health at the local level, and allow social determinants to be addressed within the purview of local health departments. The systematic approach employed for this article entailed searches of electronic academic databases (PubMed, EBSCO and Medline) and additional searches using Internet search engines and relevant websites for articles published between 1,975 and May 2010. The search revealed 2,554 articles, and 36 were determined appropriate for inclusion. The purpose of the search was to identify published articles relating to social determinants of health, social capital and effective approaches for addressing both at the level of the local health department. The search was then expanded to include unpublished material, to include the perspectives of local health departments. This process resulted in the inclusion of content from five sources. In this article, the case is made for focusing on social capital interventions to mitigate health problems associated with social determinants. Examples of successful interventions are provided to aid public health professionals in developing locale-specific solutions for addressing social determinants.     

Understanding marginalization as a social determinant of health

Population-based studies have drawn attention to the associations between social and material disadvantage and poor mental and physical health over the life course, thereby contributing to inequalities in health. More recently, research in Britain has demonstrated that the effects of such disadvantage are cumulative through childhood and has shown that ‘ethnic minorities’ are at particular risk. This study gathered data from persons at risk, specifically first-generation migrant teenaged girls and their mothers, in Britain and Canada, and identified marginalization as a central feature of their relationships with others. Bourdieu's theoretical perspective is drawn on to examine the processes that contribute to marginalization and the conditions of broader society that sustain and reproduce them. It was the participants’ experience that their potential goes unrecognized, their opportunities to develop new relationships curtailed and possibilities to acquire new competences were eclipsed by others’ assumptions about them. The authors illustrate the social processes that contribute to the creation of tensions between seeking to belong and being assigned to the margins and consider their attendant influences on health. Taking direction from Bourdieu they illustrate ways in which discourses of marginalization and marginalizing practices associated with them can be interrupted, and in so doing work towards redressing processes that create a context for health inequalities.