Index
CH1: What is Social Inequality?.......................................................................3
Measures of social position............................................................................................. 3
Why measurement matters............................................................................................ 5
CH2: What is Health Inequality?......................................................................5
How unequal is health?................................................................................................... 5
Why health inequality?................................................................................................... 6
CH3: Figuring Out Health Inequality................................................................8
Statistical explanation.................................................................................................... 8
Vital statistics: numerators and denominators................................................................9
Absolute and relative...................................................................................................... 9
Standardisation: what is it and why is it needed?.........................................................10
Observational studies and ‘causality’...........................................................................11
Models of health inequality...........................................................................................11
CH4: Explanatory Models I: Behavioural and ‘Cultural’ Explanations...............14
‘Individualised’ behavioural explanations.....................................................................14
Behaviour as a result of ‘culture’..................................................................................15
‘Cultural shift’............................................................................................................... 15
How important is behaviour for health inequality?........................................................15
Why are risky behaviours unequal?..............................................................................16
CH5: Explanatory Models II: Psycho-Social Factors.........................................16
The biology of stress: fight, flight and defeat................................................................16
Types of psycho-social factor........................................................................................ 17
How important are psycho-social factors?....................................................................19
CH6: Explanatory Models III: Materialist Explanations....................................19
What is the materialist model?.....................................................................................19
Measuring material risk................................................................................................20
Work and environmental hazards.................................................................................20
Can there ever be a ‘pure material’ model?..................................................................20
The puzzle of the gradient............................................................................................20
The cost of a healthy life...............................................................................................21
Commodification........................................................................................................... 21
CH7: Macro-Social Models.............................................................................22
Income inequality and population health......................................................................22
Welfare regimes and health..........................................................................................24
,CH8: Gender and Inequality in Health............................................................25
Gender ‘inequalities’ in health......................................................................................25
Explaining gender differences in health........................................................................25
Is health inequality different in men and women?........................................................26
Reasons for gender differences in health inequality.....................................................26
CH9: Ethnic Inequalities in Health.................................................................27
What is meant by ‘race’ or ‘ethnicity’?.........................................................................27
Ethnicity, biology and health........................................................................................28
How great are ethnic or racial differences in health?....................................................28
Ethnicity and socio-economic conditions......................................................................28
Social ecology of ethnicity and health..........................................................................29
CH10: Health Inequality in the Life Course.....................................................29
Critical and sensitive period models of health in the life course...................................30
Accumulation of advantage and risk across the life course..........................................30
Selection explanations: ‘personal characteristics’ in the life course.............................30
Pathways of life-course aetiology..................................................................................31
How social conditions get under the skin of the life course..........................................31
Life-course and health behaviours: individual choice or circumstances?......................32
CH11: The Way Forward for Research and Policy Debate................................33
Do we need trials of policy options?..............................................................................33
International comparative studies................................................................................34
Implications of recent evidence for policy debate.........................................................34
Evidence-based policy..................................................................................................34
What would an adequate explanation look like?...........................................................35
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,CH1: What is Social Inequality?
Krieger et al. (1997) used the term social position to encompass class and
status and socio-economic position (SEP) to include income and wealth
differences. They argued that the most suitable measure for inequality depends
on the ways in which the researcher thinks social inequality is producing
inequalities in a specific health outcome.
Measures of social position
2 ways in which social position is usually represented: social class and social
status/prestige.
Social class
Measures of social class are based on theories of social structure: people
choose their measure according to the theory they prefer. Two most prominent
theories that work with a concept of class are based on Marx and Weber. They
divide occupations into groups according to typical employment traditions and
employment relationships. These groups are social classes.
Features of social class:
The ownership of assets (e.g. property, factories, firms) determine whether a
person needs to work at all or whether (s)he is the owner of an asset sufficient to
make working for a wage or salary unnecessary.
The relationship of all those who do have to work for a living with those who
supervise their work and also with others whose work they manage or supervise.
Social classes are described as combining occupations whose members would
tend to have similar sources and levels of income job security and chances of
economic advancement, and who would have a similar location within systems of
authority and control within businesses, plus similar degrees of autonomy.
Most basic classificatory division: between those who are owners, and those who
aren’t. The group of people who are employees has more sub-divisions, divided
according to the skill needed for their work and the nature of their employment
contract.
Erikson and Goldthorpe distinguish 2 forms of employment contract:
- Service contract= what you find in managerial and professional work.
These employees have to be trusted on their performances. To motivate
this they are offered more job security, salary increments and a
progressive career. Entails a degree of command. Usually paid monthly.
- Labour contract= more easily monitored work, little autonomy, more
closely supervised and restricted in patterns of work. Payment more
closely tied to hours of work (sometimes in ‘piece rates’). Less likelihood of
career progression, no salary increment, lower job security.
EGP classification
New class schema: National Statistics Socio-economic Classification (NS-
SEC). Both the notions ‘skill’ and the manual/non-manual divide have
disappeared.
Criteria for allocating occupations to different classes:
- Timing of payment for work (monthly, weekly, etc.)
- Presence of regular increments
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, - Job security
- Autonomy in deciding when to start and leave work
- Promotion opportunities
- Degree of influence over planning of work
- Level of influence over designing own work tasks
Social status
The concept of status centrally involves the idea of a hierarchy or ranking ‘from
top to bottom; of society.
Prestige= differential ranking of respect and ‘social honour’ accorded to persons
in a society.
Social classes are essentially groups of occupations.
In the UK, there are 2 measures of social position which explicitly depend on
patterns of interactions between members of different occupations:
1. Cambridge Scale
2. Goldthorpe & Chan: people tend to have friends from among
occupational groups with a similar degree of manual or non-manual work
to their own. Non-manual work is associated with higher prestige.
Socio-economic status in American sociology
An influential school of sociology in the US has long understood inequality in
terms of ‘structural-functionalism’. People naturally have unequal abilities;
society needs its most able members to be attracted to the jobs that are most
important for its basic functions (law, medicine, science). Members of certain
occupations therefore have ‘high socio-economic status’ because of their
qualities, so as the result of their talents. Their status is not due to their family’s
ownership of assets or to their own conditions of work, but to the positive
personal characteristics.
Registrar General’s Social Classes (RGSC)
These classes are based on either ‘general standing in the community’ or
‘occupational skill’. The classification consists of 6 categories:
1. Professional
2. Managerial
3. Clerical, sales
4. Skilled manual
5. Semi-skilled manual
6. Unskilled manual
Prestige is the underlying ordering principle which takes precedence over all
other characteristics of occupations. The assumption seems that occupations
requiring more skill are held to be of higher ‘standing in the community’. Shortly,
skill results in prestige.
Education
Education has a very strong association with health, but using it as a simple
measure of social position doesn’t do justice to the complexity of health
inequality. What happens over the whole childhood has a cumulative effect on
both personal development and social destination. The greater number of
favourable influences during this period, the better the child and young person
will do in education.
Besides, the number of people who reach a given level varies enormously. The
differences between different nations and how these have varied over time are
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, also significant.
Thirdly, there are differences in access to education for girls and boys, for people
of different ethnic or status groups.
The fourth problem is that it is too easy to fall into ‘functionalist’ assumptions and
let these influence the ways in which we reason about health inequality.
If we want to measure status we need to use the results of studies that do show
how the prestige of different occupations is ranked in people’s minds, and which
groups mix together socially and intermarry.
Why measurement matters
The importance of knowing about these different measures for understanding
health inequality is twofold:
- Necessity of defining what we mean by a concept of inequality and of
making sure we use valid measures of the concept
- We need to specify what we think it is about socio-economic position that
may relate to health
In terms of understanding health inequality, we need to think carefully about
what it might be about class position, income and prestige that might plausibly
affect health.
There are strong similarities between the display of prestige in both more and
less traditional societies. An essential part of the claim to prestige includes the
adoption of certain forms of lifestyle.
CH2: What is Health Inequality?
How unequal is health?
Health inequality in England and Wales
The measure of mortality risk is a ‘standardised mortality ratio’ (SMR).
If you take 1000 as the death rate for the average person, a number lower than
100 indicates a lower risk for that social group, and one above 100 a higher risk.
With age standardisation (adjustment to the possibility that different social
classes may have different average ages):
No .∈social class who die
x 100.000
Total no .∈social class
This is the same as a percentage, only it is now divided by 100.000 instead of
100, because death is a rare event in most age groups.
Rate ratio= summarises the difference between most and least advantaged
social classes. This yearly number is important.
Women were excluded from many jobs for a long time, which made it impossible
to carry out matching between population numbers and numbers of deaths in
each occupational class.
Health inequality in the United States
Education can have a very different meaning for different age cohorts, given that
throughout the 20th century an increasingly higher proportion of people
undertook longer periods of education.
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