SOCIAL & COMMUNITY PERSPECTIVES

Inequalities in Health and Health Care (2):

4th February 2003

Objectives

• To reflect on evidence of inequalities in health from last week

• To reflect on different explanations for inequalities in health

Black Report Explanations:• Artefactual

• Social Selection

• Behavioural/Cultural

• Materialist

Artefactual

• Health and class are artificial variables

• Registrar General’s classification is flawed and may be circular

• Numerator/denominator bias 

• Lowest social class groups shrinking widens apparent inequalities

Social Selection

• Health determines social class through a process of Health-related social mobility

• Healthy move up social hierarchy and unhealthy move down (‘Downward drift’).

• Some evidences that serious illness in childhood can affect occupational class, e.g people with mental health problems tend to drift down social ladder.

• However not explain all class gradient. e.g. children/women, different diseases.

Behavioural/ Cultural

• Social class determines health through social class differences in health damaging/promoting behaviour

• These are at least in principle are subject to individual choice

• Smoking, diet, exercise, alcohol consumption, infant feeding practices all vary by class.

• BEWARE OF ‘VICTIM’ BLAMING: Need to be aware of social/economic context in which these behaviours occur.

Diet

• Availability at small local shops

• Problems with transport.

• Difficult to have a good diet on a low income.

• Cheaper food often over-refined and processed.

Not all behaviour…….• Risk factors such as smoking, drinking

and diet only explain 1/3 of class gradient.

• Diet and smoking behaviour in S Asian population is better than white population but excessive CHD in this former group.

Materialist• Social class determines health through social class

differences in the material circumstances of life.• Material aspects of living conditions: affect health. • Asset based measures strongly associated with mortality

rates.• Type of employment and level of employment influence

health.• Differences in working conditions, unemployment, housing,

and diet, is the main cause of illness and disease not genetics and lifestyle.

• Poverty is never officially recorded as a cause of death, but clearly one of the most important determinants of our health status.

Most Plausible Explanation?

• BR emphasises materialistic

• Need to see how material circumstances influence behaviour and affect life generally

Another Explanation:

• Variations in health can be explained by variation in quality of and access to health services.

• Poorer people consult GPs more often BUT relatively less compared with need

• Massive under-utilisation of preventative services by people in lower socio-economic groups.

• More deprived often get less provision in relation to their need.

• Average costs of prescriptions is higher in affluent areas.

Tudor-Hart (1971) “Inverse Care Law”

“the availability of good medical care tends to vary inversely with the

population served”. • Access • Quality• Uptake.

Access

• Poorer areas have services, which are more difficult to reach compared with affluent areas.

Quality

• More poorly resourced practices in inner city areas.

• Under-provision of GPs compared to average in more deprived areas

Under Uptake

• Under utilisation of preventative services – antenatal, dentistry, immunisation, cervical smears.

• Paradox – lower social classes have worst health but use services less – why?

Explanations for inequalities between

men and women

• Consider differentials in:– Health behaviour– Consultation patterns

Narrowing gap may be explained by……

• Improved social circumstances improve women’s health–same for men?

• Stricter laws on drinking and driving, compulsory seat-belts

• Changes in patterns of work– Decline in male employment sectors

traditionally associated with fatal injuries –– Work in female dominated service sector

may be just as unhealthy chronic not terminal

Smoking• 1948 approx 65% of men smoke -

approx 40% women – now nearly equal proportions of women and men smoke.

• US 1980s substantial increase of female mortality from lung cancer and COAD

• UK - male deaths from lung cancer female deaths

Women’s cigarette smoking by social class

0

5

10

15

20

25

30

35

40

I II IIINM IIIM IV V

Women’s cigarette smoking by age

0

5

10

15

20

25

30

35

16-24 25-34 35-44 45-54 55-64 65-74 75+

Smoking patterns among Black and minority ethnic groups in

England

0%5%

10%

15%20%

25%

30%35%

40%

45%50%

A-C Indian Pakistani Bangladeshi England

Men

Women

Data from British Household Panel Survey (Graham and Der,

1999)• Women on means-tested benefits 33% more

likely to smoke than those not on benefits

• Women in rented accommodation are twice as likely to smoke than women in owner-occupied accommodation

• For women, not having a car in household increased risk of smoking by 66%

Smoking and caring

• Women with children are more likely to be smokers and heavier smokers than those without children

• Those with heavy caring burdens tend to be heavier smokers

• Women’s smoking is tightly woven in with coping strategies

• Smoking plays a contradictory role in women’s lives: is health promoting and health damaging (Graham, 93)

Consulting patterns

• Higher proportion of women as consumers of health care.

• On average women visit their GP 6xs/year and men 4xs/year.

• Working women consult slightly less than ‘housewives’ – ‘Easier’ to visit doctor ?

• ‘Housewives’ are less likely to define themselves as being in ‘excellent health’. - under reporting

Provision of services

• Health service generally focused on biological difference

• Women’s reproductive role specialist services focusing on reproduction 

• ‘Well woman’ clinic – developed around distinct biology (screening)

• Less specialist health care focused on men – fewer ‘well man’ clinics and screening for prostate and testicular cancer

Are women sicker?

• Hospital admission, GP contact and community surveys tend to reveal higher rates of psychosocial ill health among women.

• GP data - women suffer more from mental disorders, osteoarthritis, migraine, obesity and iron deficiency anaemia (men consult more for heart attack and angina)

Need to be careful when looking at data

• 1994 exactly same number of men and women reporting long-standing illness,

• Female excess only found consistently across the lifecourse in psychological manifestations of distress, less apparent or reversed, for number of physical symptoms

Explanations for different patterns of

consultation • Higher rates of ‘milder’ physical problems: women greater

likelihood to seek help?• Doctors more likely to define women as ill?• Differences in mild illnesses: artefact of gender-related

health attitudes and behaviours?• “Male stoicism, it might be suggested, is complemented by

the cultural acceptance of vulnerability and sensitivity to symptoms (linked to the caring role) within women” (Annandale, 1998)

• Difficult to ascertain whether women over-report and men under-report ill health – who can act as objective arbiter of experience?

• Research suggests women not over-reporting illness

Macintyre (1993) • 1700 males and female - MRC Common Cold

Unit rated presence/absence/ severity of cold.• Both men and women likely to ‘over-rate’

severity compared to clinical observer.• Men 1.6 times more likely to ‘over-rate’

symptoms and to complain at any level• Doctors more likely to observe and diagnose

symptoms in women • Concluded: at a given level of clinical signs

men and women equally likely to report related symptoms- men more likely to report severe symptoms

Explanations for inequalities in ethnicity and health

• Artefactual – lots of problems with data

Language • Significant number of South Asian (particularly

Bangladeshi women) and Chinese find it more difficult to communicate with GP.

• However….. problem with communication in consultations generally, but by making it language makes it an ‘ethnic’ problem (Sheldon & Parker,1992).

Geographic location

• ‘Unhealthy’ areas

• Benefits of being concentrated in large numbers ?

Cultural difference in expression of symptoms/accessing care ?

• Many women from minority ethnic groups prefer to see female GP (preferably same ethnic background).

• Ethnocentric – western diagnostic approach may be inappropriate for some groups (especially with regard to mental illness).

Migration effects?

• More healthy more likely to migrate?• Environmental conditions in country of birth,

or mother’s country of birth • Stress• Little difference between migrants and those

born in UK. • Scotland –migrants from Punjab health

deteriorated with time spent in UK (Williams,1993)

Cultural difference in health related

behaviour

• Health behaviour e.g. smoking

• Diet and exercise patterns

• Culture changes over time and according to gender and class.

Genetics

• Haemoglobinopathies related to genetic factors vary across but not exclusive to particular ethnic groups.

• Research continuing re diabetes, coronary heart disease and hypertension

The problem of emphasising “Cultural difference”

“In this perspective, racialized inequalities in both health and access to health care are explained as resulting from cultural differences and deficits. Integration on the part of minority communities, and cultural understanding and ethnic sensitivity on the part of the health professional, then become the obvious solution; personal and institutional racist and racial discrimination have no part to play in this equation”

Ahmad W.I.U. (eds) (1993) ‘Race’ and health in contemporary Britain

The problem of emphasising “Cultural difference”

• Class and consumption only partly explain inequalities need to look at other social disadvantage i.e. racism

• Tendency to explain inequalities by focusing on cultural differences and deficits (Ahmad, 1993).

• Results in unmet need e.g. elderly South Asian patients

• Tend to ignore ‘healthy’ cultural practices e.g. lower alcohol consumption and smoking in Asian women

Sheldon and Parker (1992)

• Often ‘race’ used to explain problems e.g. Glasgow early C20th

• Research focused on nutritional deficiency diseases, tuberculosis, haemoglobinopathies.

• Risk of blaming the individual and culture which is ‘alien and/or deviant’.

• Focus on ethnicity may mask other wider differences related to socio-economic status.

“When we make links between ‘race’ and health status it is not…something that is inherent to black people which shapes their health trajectory, but something inherent to the social context within which they must live their lives.” (Nettleton,1995,189)

Impact of racism

• 1/8 minority ethnic people experienced some form of racial harassment in last year.

• ¼ fearful of racial harassment.• White minority groups e.g. Irish also face extensive racial

harassment.• White respondents admitted racial prejudice (26% against

Asians, 20% Caribbean, 8% Chinese)• Institutional and societal racism – minority ethnic groups

over-represented in disadvantaged sectors of society.• Psychological effects of racism makes people ill  • Ethnocentrism in health services• Experience racism when receiving health care

Benzeval et al (1995) argue we need to be aware of:

• How socio-economic circumstances, ethnicity and racial harassment and/or discrimination interact

• Impact of material and social circumstances on health

• Impact of racial harassment

Conclusion

• Illness does not strike purely at random.

• Strong correlation between health and social class makes assumptions to the contrary difficult to sustain.

• Combination of explanations

Way forward: social class?

• Encourage changes in personal behaviour.

• Improve working conditions.

• Elimination of poverty.

Way forward: Gender• Gender sensitivity and awareness in policy and

practice – need to be aware of how gender, age, ethnicity, class impact on each other

• Ensure equality of healthcare provision for men and women

• Reduce the high mortality rate for young men• Improve material circumstances of lone mothers• Policies to minimise the impact of impairment in older

women• More research on inequalities in women’s health and

in older people

Way forward: ethnicity

• Policies to eliminate poverty and unemployment• Improving housing stock• Urban regeneration• Policies which take into account variety of households• Anti-discrimination policies• Support primary care • Address language and advocacy needs. • Cultural competency should be core part of health

workers’ training.• Supporting doctors from minority ethnic groups

So what can be done?• Improving accessibility of health care provision. • Encouraging groups with the greatest need to

make use of services.• Improve living and working conditions.• EBP:

– Evaluate services– Needs assessments– Multi-agency working– Community participation– Involvement in decision making