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Health & Class Inequality

In this series of public health articles, you will be able to learn about the fundamentals of public health which will serve you well for your medical school interviews. These principles will help you to understand how medicine and public health are intertwined especially as a result of the Coronavirus pandemic.

Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. It includes differences in health status, access to healthcare, quality of care, behavioural risks to health and wider determinants of health. Class and socioeconomic status are major factors where we witness many health inequalities. Social class encompasses many elements such as status, wealth, culture, background and employment which makes it a very complex factor to study with many interlinked and intersectional pathways.

Whitehall Study

The Whitehall Study is a landmark cohort study led by Michael Marmot on social class health inequalities in the UK which began in 1967 and was conducted over a ten-year period.

It examined over 17,500 male civil servants between the ages of 20 and 64 in an attempt to investigate associations between mortality and social class. In this study social class was assessed by grade of employment. An inverse association was found between social class and mortality from a wide range of diseases such as coronary heart disease (CHD).

Men in lowest grade jobs such as messengers and doorkeepers etc had a three-fold higher mortality rate than men in the highest grade of employment (administrators). Even after controlling for other risk factors associated with low grade employment such as obesity, smoking, less leisure time, less physical activity and higher blood pressure, men working in the lowest grade jobs still have a relative risk of 2.1 for CHD mortality. This suggests an independent association between low social class and mortality.

A second cohort of 10,314 civil servants, this time both men and women, were recruited between 1985 and 1988 in the Whitehall Study II to further investigate the degree and causes of the social gradient in morbidity. Again, similar social gradients were documented in women as well as men. These social gradients were witnessed in other diseases as well such as some cancers, chronic lung disease, gastrointestinal disease, depression, suicide and more. This study wanted to figure out how social circumstances and psychosocial factors influence biological pathways to cause disease, how can someone’s socioeconomic position ‘get under the skin’ and cause disease?

Lower social class usually indicates lower grade employment, lower income and living in more deprived areas. This is associated with higher mortality and morbidity as we have seen from the Whitehall studies.

One mechanism within this association are the underlying risk factors. Lower grade jobs or lower income are associated with increased risk of obesity, smoking, less leisure time, less physical activity and higher blood pressure.

This can be due to a number of reasons such as unhealthy diets which usually cost less than fruits and vegetables, lower levels of education and knowledge around physical activity and diet, less likely to spend time in the evening doing exercise as their job consists of being on their feet all day and high labour and stress levels leading to higher blood pressure.

These risk factors are linked to many diseases such as CHD, cancers, lung disease etc. These risky behaviours are unevenly distributed between social classes which contributes to the health gradient and inequalities.

Psychosocial factors may explain other aspects of the health inequalities we see within social class. Examples of psychosocial factors are work stress and work-family conflict which has been linked to heart disease and diabetes.

Low grade jobs tend to come with higher work stress seen through low work autonomy and lack of predictability within the job.

This has been linked with raised levels of cortisol in many studies which is hormone produced in response to stress. Lower employment grades showed significantly higher levels of cortisol thirty minutes after waking up compared to individuals in higher grade employment.

Social capital is another concept involved in health inequalities within class. Social capital describes how connected people are to their community through work, family, membership of clubs, faith groups and political and social organisations.

People from lower social class tend to be less involved within their community clubs and organisations leading to lower social capital. Higher levels of social cohesion have been associated with better health.

Studies show that housewives, the unemployed and retired report significantly poorer health than those employed. These inequalities mean that individuals from lower social class tend to be stuck within environments with lower social capital, whether that’s because of the area they are forced to live in or the limited social opportunities that are available to them.

Inverse Care Law

When it comes to healthcare, again we witness inequalities between different levels of social class and socioeconomic status.

A concept known as ‘The Inverse Care Law’ explains this inequality very well. It states how areas of lower social class and, in turn, the most morbidity and mortality, general practitioners face more workload, larger lists, less hospital support with less staff and equipment and more clinically ineffective traditions of consultation than in the healthiest areas.

The need of the population served tends to inversely vary with the availability of good healthcare further increasing health inequalities.

There is unequal socioeconomic distribution of primary care with studies finding that GPs tend to choose to work in more wealthier populations with the poor losing out. This creates a cycle of poor health and limited healthcare.

Overall, health inequalities & class is a very complex issue with many interlinked factors making it difficult to pinpoint exactly why these inequalities occur.

However, understanding and considering all the underlying mechanisms and risk factors that play a role within the association between lower class and poorer health is important to ensure we are tackling these factors to reduce these inequalities. It is not simply about increasing income or creating better jobs, there are many more factors which must be considered.

Empowering local initiatives to ensure change is occurring where it's most needed, rather than a top down approach which mostly benefits the less deprived areas.

Reducing social isolation, improving self-esteem and health literacy are also key to reducing health inequalities within class. Specialised and tailored interventions, programmes and policies must be introduced to create equality between people of all social classes.

By Nafisa Insan BSc MPH

PhD Student in Population Health Sciences