Social inequalities in health have been widely accepted and documented (Fox, 1989; Davey-Smith et al., 1990; Macintyre, 1997; Marmot et al., 1997), and have been particularly apparent in The Black Report (Townsend and Davidson, 1982) which has revealed wide disparities (health gap) between people at opposite ends of the social strata, that are widely increasing in the UK (Marmot and McDowell, 1986; Macintyre, 1997) and the US (Papas et al, 1993).
A burgeoning volume of research identifies social factors at the root of much of these health inequalities, for instance, researchers have found health to be socially patterned (gradient effect), where individuals at high ends of the social class experience better health and live longer, than their counterparts (Acheson 1998; Adler et al., 1998) and this has been consistent, even when controlling for other factors (Lantz et al., 1998).Thus, if one moves up the social strata, the better ones health (Kitagawa & Hauser, 1973).
Social economic status (SES) has been used to assess ones social position as a reliable method, and many types of approaches have been used to assess SES, including occupation, household income or level of achieved education (Mackenbach and Kunst, 1997). Research has found that Individuals with a low SES have a lower mortality rate (Benzeval, 1995) and experience greater disability and ill health (Dalstra et al., 2005; Huisman et al., 2005; Marmot, Bosma, Hemingway, Brunner, & Stansfeld, 1997; Marmot, Rose, Shipley, & Hamilton, 1978).
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Deprived individuals may also have a greater propensity to develop diabetes, develop cancer, cardiovascular disease, asthma, infectious diseases and all causes of mortality and even die, as a result of homicide (Adler and Ostrove, 1999; Ecob & Smith, 1999; Schalick, Hadden, Pamuk, Navarro, & Pappas, 2000; Sterling, Rosenbaum, &
Weinkam, 1993). Thus, ill-health can therefore restrict prospects of economic attainment (Adler et al, 1994; Marmot et al, 1997).
One reason for this could be that people have to put up with poorer living conditions, which could result in them being exposed to hazardous and unhealthy environments i.e. pollution, noise, toxic waste, crowding, ambient noise and poor housing quality, which are linked with poor health and disease (Evans and Kantrovitz, 2002).Whilst individuals of a higher (SES) have a reduced risk of exposure to negative life events (Mcleod and Kessler, 1990) hence, decreasing their vulnerability of suffering chronic or acute illness (Cohen and Williamson, 1991).
It is also been found that Children of less affluent families are less likely to succeed at school (Essen and Wedge, 1982), to be employed in more disadvantaged areas, and go through unemployment much earlier in their lives (Ashton et al1987). This can lead smoking, drinking, depression, anxiety, and poor health behaviours (Wilson and Walker, 1993)
One other explanation for this inequality is that deprived individuals display more risk taking behaviours, such as; bad diet, smoking and being physically inactive. However, this view is not always supported, and researchers have found little or no relationship (O'Malley et al., 1993; Donato et al., 1994).
A growing body of research has also acknowledged the relationship between income inequality on individual health (Kawachi, 2002; Wilkinson, 1996), for example, low income has been correlated to show a risk factor for disease and ill-health (Syme, 1998), and according to the relative income hypothesis, people from a low SES are more prone to experience poor health if they feel disadvantaged than others (Marmot et al., 1991; Wilkinson, 1997). They are also more likely to experience depression and stress (Cohen et al., 1997) and this may subsequently hinder or weaken ones power to assess local health-related resources (Deaton, 2003).
TheseÂ consequences of income inequality can affect individuals significantly, resulting in frustration, stress and disruption, which can subsequently increase the rates of crime, violence and homicide (Wilkinson, 1996). Education also influences health through its relation with higher income (Chevalier et al, 2005) and better living environment, as those with a higher educational attainment are less likely to be unemployed, and more likely to have careers with higher earnings (Ross & Wu, 1995).
Furthermore, individuals with higher levels of educational attainment have shown to having certain psychological mechanisms, such as social support, economic resources and a strong sense of personal control, which are associated with a higher mortality rate and higher health status. (Kunst & Mackenbach, 1994; Elo & Preston, 1996).
Parent's educational attainment is also significant, as this can directly impact the Childs future health via primary socialisation; for example, Blackburn et al (2003) have found that higher levels of maternal education are associated with lower levels of household smoking, and hence, lower levels of tobacco exposure to children.
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An individual's health outcome can also be affected by the type of occupation, for example, The Black Report (Townsend and Davison, 1982) discovered that unskilled manual workers (social class V) regularly suffered from poorer health than those classified as professionals (Social class I). The Whitehall studies were particularly important in highlighting this association, researchers looked at British civil servants, and discovered higher mortality rates were found to be correlated with lower hierarchal rank (Marmot, 2004), and this social gradient was further refined and supported by Siegrist & Marmot (2006).
In addition, a strong inverse association was found, between the grade of employment and absenteeism as a result of health status (Stansfield et al, 1995).
The type and quality of the job the individual has can also have a fundamental difference to their health, i.e. through occupational hazards and unsafe and physically demanding work environments (Lucas, 1974). It can also impact ones health indirectly through income security, or psychological or social mechanisms. Furthermore, Lower employment grades have showed almost three times greater occurrences of coronary heart disease (CHD) and lung cancer than those individuals in the highest employment grades (Marmot, 1986). Thus, one may conclude that the association between grade and type of work is apparent, and the environment of individuals in lower class's may not always be conducive to good health.
An increasing amount of research asserts that health outcomes and health-related behaviour are directly linked with area of residence (Collins, & Margo, 2000; Cubbin, Hadden, & Winkleby, 2001; Guest, Almgren, & Hussey, 1998; Jones and Moon, 1993; MacIntyre, MacIver & Sooman, 1993; Pickett and Pearl, 2001; Ren, Amick, & Williams, 1999; Shaw et al, 1999).People living in Disadvantaged areas usually experience poorer health (Townsend et al., 1988) and increasingly show higher levels of morbidity and mortality than individuals living in more prosperous areas (Achenson, 1998; Mackenbach, Kunst, Cavelaars, Groenhof, & Geurts, 1997; Marmot and McDowell, 1986; Townsend, Whitehead, & Davidson, 1992).
An example of this was seen in the mortality rates ,in different Scottish postal code areas, which revealed a constant gradient of increased mortality from the most affluent, to the most disadvantaged areas, based on; social class, male unemployment, household overcrowding and access to car (Carstairs and Morris, 1991).
The Health Divide (Whitehead,1988), revealed further discrepancies, where a North South health divide in the UK was found, and a higher prevalence of ill health become apparent in the industrialised North (Sidell, 2003). Further health inequalities existing, as a result of area of residence, was seen in Mexico, where a nine year difference in life expectancy was reported between people living in a poor county, and those in a relatively well-off county (Evans et al., 2001).
Implications of living in a less affluent area can also impact the mortality risk for those individuals, of even a higher SES (Yen and Kapplan, 1999a). However, those who perceive themselves to live in deprived neighbourhoods are inclined to have more negative health signs i.e. high body mass index. A lower effective efficacy has also been reported amongst low income residents, whereby individuals perceive less cohesion and social control; this may impact the individual mentally i.e. depression (Cohen et al, 2003; Schafer-McDaniel, 2009) and even prohibit physical activity.
Another barrier to health and its resultant inequalities is ethnicity/race. Ethnic minority groups have an increased rate of health inequalities, which have social consequences, (higher rates of coronary heart disease and diabetes), for example, research by Keppel, Pearcy and Wagener (2002) showed African-Americans in the United States experienced greater levels of illness (breast/lung cancer, cardiovascular disease, and infant mortality rates) than other racial/ethnic minority groups.
Morbidity rates have also been found to be higher for Bangladeshi and Pakistani minority groups, although findings did not generalise to Indian adults, who were found to have a similar health status to white adults (Cooper, 2002).These ethnic disparities have also been seen in the US where blacks seem to have worse health outcomes than whites, for instance, black women were more likely to have a child with a lower birth weight than their white counterparts (David and Collins, 1997).
Despite these risk factors, discrimination and prejudice faced by ethnic minority group's further increases their chances of illness and death (Williams and Jackson, 2005). For instance, Smaje (1995) and Modood et al., (1997) found that black people in ethnic minority groups suffered greater material disadvantage as a result of discrimination. Less affluent individuals can also be prone to develop mental health problems, as a result of their status. Many studies have looked at the effect of SES, and deprivation
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in relation to mental health (Thornicroft, 1991; Jarman et al, 1992; Harrison et al, 1995). Evidence has shown the incidence of mental illness, is more pronounced in the lower socio-economic groups, for example, it was found that working class women were more likely to suffer from mental health problems i.e. bipolar disorder than middle-class women (Brown and Harris, 1978); A positive association between deprivation, low SES and schizophrenia was further emphasised in Rogers (1991) who reported low SES women were more likely to develop neurotic diagnoses, and those who suffered from 'poverty', were more likely to have an increased risk to develop bipolar disorder, schizophrenia, phobias, depression and suffer from drug related problems (Bruce, 1991).
Reasons for these social inequalities existing are multifaceted, and a matter for continuing debate, however, The Black Report (Townsend and Davidson, 1982) outlined four explanations, the first being Artefact, This points out that inequalities in health are demonstrated using different measuring systems to assess social class, and so, associations are resulting from artefacts (Davey Smith et al, 1991). However, this account has been largely dismissed as evidence has visibly shown a health disparity across occupational groups. Furthermore, these inequalities have been verified using different forms of measurement to assess social class i.e. educational attainment and occupation. Thus, this explanation does not present a superior argument to the complexities of health inequalities in society, and so cannot be sustained.
An alternative method of explaining social inequalities comes from social selection; this suggests healthy individuals move up (social mobilisation) the hierarchy, whilst individuals with poor health escalate downwards-which could be due unemployment, demotion, or disability (Moore and Porter, 1998).However, there is little evidence supports the view of social selection in relation to health inequalities (Whitehead, 1988) for example, Illness does affect social mobility; however, the size of the effect is very little to actually account for overall health differences (Wilkinson, 1997).
The cultural behavioural explanation stipulates that health inequalities occur as a result of individual preferences and lifestyles, comprising of drinking, smoking, diet and exercise (Blaxter, 1990) and cultural factors. These health behaviors have been linked to death (i.e. lung cancer, coronary heart disease), and a social gradient has been found (Wardle and Griffith, 2001).
Whilst there is a causal effect for mortality and morbidity, with health behaviours (i.e. smoking, diet), this explanation does not comprise of a complete explanation of inequalities, for instance, controlling for the risk factors of smoking, cholesterol and blood pressure (Whitehall studies) did not explain the increase in CHD mortality amongst administrative and 'other' grades, Nevertheless they did account for about 25% of the disparity (Rose & Marmot, 1981). This explanation can further be criticised as it tends to classify health behaviours as being synonymous with cultural influences, and fails to acknowledge other variables, it also associates ethnic groups with a pattern of behaviour which may not necessarily signify wide-spread health patterns in cultural groups.
Another approach to explain inequalities in health is the materialistic/structural, which
has been supported by many researchers (Acheson, 1998; Gordon, Shaw, Dorling & Davey Smith 1999; Townsend, Davidson, & Whitehead, 1992). This approach states that inequalities are a result of unequal access to material and physical resources (Raphael, 2006). These include housing, working conditions, quality of available food, among others. Thus, research has consistently shown that social health inequalities exist and need to be dealt with. Health psychologists have played an important part in exposing the individual determinants of health related experiences and behaviour. In particular, highlighting the plight of these psychological and social factors. Therefore, acknowledging these health determinants can be significant in potentially reducing or even diminishing these health disparities, as awareness and research are significant to public health intervention.
The benefits of such research are also advantageous, as it highlights that an individual is not alone responsible for their own health, but a number of factors come in to play. Moreover, future research can thus investigate these social determinants, in particular, distinguishing between factors that affect health and those that form health inequalities. For instance, education as a social factor impinges on health but it is the lack of access to it and associated illiteracy that lead to inequalities.