The relationship between social class and health has been a topic of discussion amongst sociologist and politicians for over 60 years since the beginning of the National Health Service (NHS). Before discussing the relationship between health and social class it is important to consider them as separate entities. Health is defined as, "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." (World Health Organisation)
Social class refers to the hierarchal distinctions between individuals and groups in society and this is difficult to decipher as it involves status, education, wealth, culture, background and employment.
How well and how long one lives is powerfully shaped by one's place in the hierarchies built around occupation education and income, which give rise to socio-economic inequalities.
To understand health inequalities maybe it is important to look at health as a social phenomena rather than just a biological issue. Health and illness are considered to be personal and individual concerns and it is the social processes that shape our lifestyles that affect health. Such as the activities we take part in, the type of work we undertake, whether we smoke, drink or exercise.
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Also other social entities such as the media and families shape our ideas of health.
There are four theoretical explanations to health inequalities and these were examined in the Black Report, published in 1980.
The first explanation is titled the Artefact Explanation which suggest that class based differences are statistical fiction created by the way data was collected and analysed. It highlights the importance of the different methods of measuring health and the problems caused when comparing data. The artefact explanation emphasises that it is hard to define class and it is often based on occupation but with the labour market changes it is difficult to see trends over time.
The second theoretical explanation is the Social Selection Explanation and this approach argue the health determine a person's social class and not a person's class determining their health. An individuals health determines their social mobility however not al cases of illness, such as long term illness, leads to a decline in social status. Although, this explanation does not take into account the health inequalities of infants and children.
The cultural/behavioural explanation looks at health in relation to cultural practices and beliefs. Different social classes behave in different ways that can in turn affect their health, for instance those in lower classes are more prone to drink and smoke socially and have a poor diet, which increases their chances illness such as cancer and kidney failure. The variations in behaviour in social classes can be attributed to two different things, the value that people put on their bodies and coping mechanisms. People in lower classes might consider 'bad' behaviour (smoking, drinking, "bing eating" etc.) as a form of coping with their situation. Whereas people in higher social classes appear to care more about their bodies and health, which could be attributed to good education, lifestyle and the accessibility of good food.
The final explanation is the Material Deprivation Explanation, which states that poverty, poor housing conditions, lack of resources and educational provision are to blame for poor health. Amongst the lower social class there is a higher risk of occupations that can promote poor health. However this the material deprivation explanation alone is not sufficient to explain call class differences in health, as there are certain diseases that are more prevalent in richer societies and other diseases that are prevalent in poorer regions. (Marsh et al 2009)
There are many social factors that can affect a person's health and these therefore show the social inequalities within the health system. One factor is the environment that a person lives in and health inequalities have been found to be mostly associated with poorer areas in the country where poverty and deprivation are strife. This would include high density, low income areas, such as council estates, where there are high levels of crime and antisocial behaviour and cleanliness of the streets and surrounding areas is a dilemma.
People who live in areas that are considered to be poorer may experience health inequalities by having reduced access to facilities such has hospitals, clinics and GP (general practitioners) practices.
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Shaw et al (1999) and Dorling et al (2000) drew attention to the relationship between health and place. Their studies showed that there were high levels of death rates in poorer areas across the UK.
Table 1 Worst health by area in the UK
Avoidable deaths %
Greenock and Inverclyde
Southwark North & Bermondsey
Source: Barry and Yuill 2008, sourced from Shaw et al. 1999
Table 1 shows the standard mortality ratios taken from different areas of Britain and the percentage of the deaths that could have been avoided, meaning that there were external social factors which were due to health inequalities that we the cause of the deaths.
Studies that took interest into geographical differences such as Shaw (1999) also emphasised the North - South divide, which states that the most bad health (not so good health) is reported in the north of the country, when compared with the south of the UK. However, there are pockets of poverty found in the South-East of the Britain. Dorling et al (2000) conducted a study on poverty and health inequality in London. Dorling's study included a street-by-street and house-by-house analysis of poverty and health and found that even in the capital of the country there were people experiencing health inequalities and these people seemed to be those considered to be living below the breadline.
Changes in the labour market from manual work to public sector jobs during the 1970s; meant that there was an emphasis on qualifications for many jobs. Individuals from middle and upper class families are more likely to encourage their children to get a good education to secure a good future job.
Class or socio-economic position can also be defined by the type of work a person does; those in professional and non-manual jobs being in a higher class than those in manual, un-skilled work.
The work environment of a person can affect their health. Exposure to unfavourable working conditions puts and individual at an increased risk level of ill health and a variety of illnesses. For example people that work in the construction industry are often at risk of exposure to harmful substances like asbestos and are at risk of injuries causes by heavy lifting such as back problems.
The harder and more demanding the job the bigger the strain, both physically and mentally and this increases risk of ill health. Also the time spent working could affect the time to go and seek medical assistance - they don't have time to go to the doctors and the stress of having to support themselves and their family often causes people to choose work over their health. The demand-control and the effort-reward imbalance reduces the health and well being of a person (Siegrist & Marmot, 2006)
Employment also determines an individual's access to housing. There has been a rise in people owning their own homes and a decline in the availability of local authority housing (council homes). Those found in council houses are those who are of lower social economic status (SES). The lifestyles that people live, the neighbourhoods they live in are shaped by their SES.
A report by Davidson et al (2006) reported that people with a lower SES are more at risk of health inequalities and they are less likely to readily talk about their risk status; such people "express a feeling of disbelief or unease about the association between SES and health inequalities."
(Blaxter 1997: 753,756).
Figure 1 Self report of poor health by people aged 16 -74
Source: Coulthard et al (2004) Health. Focus on Social Inequalities
The histogram (figure 1) shows that were in long-term unemployment or had never worked reported the most bad health and the those in managerial and professional jobs reported the least bad health; showing that those in better jobs have a lower prevalence of most types of health problems.
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In a consensus taken in 2001, 8.6% of people in lower paid jobs reported 'not good health', almost double the 3.4% of people in professional positions that claimed to not have good health.
Social class is a complex construct that involves status, wealth, culture, education, background and employment. It would be naive to look for a simple causal relationship between class and health inequalities. Each individual could experience a number of different influences that could be material, psychological or environmental, that have the potential to bring ill health, mental or physical. Some of the influences that affect health could come under the umbrella of social class.