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Schools

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Temperament

Aptitudes Biology

Motivation Behaviour

ESRC Research NetworkESRC Research Network

“Human Capability and Resilience”“Human Capability and Resilience”

20032003 20062006

Health inequality: importance Health inequality: importance of the life courseof the life course

Moving from description to Moving from description to explanationexplanation

Importance of ‘rainbow model’Importance of ‘rainbow model’

Acknowledges that health inequality Acknowledges that health inequality occurs in a complex context—occurs in a complex context—

““Contextual-systems model”Contextual-systems model”

Causes may act proximally or distallyCauses may act proximally or distally

Need to add longitudinal perspectiveNeed to add longitudinal perspective

Rainbow encourages us to look for Rainbow encourages us to look for resilience factors as well as risk factorsresilience factors as well as risk factors

Look at responsibility of policiesLook at responsibility of policies

What are the causes of health inequality?

Need to understand causes in order to have effective policies

Also, health inequality offers aetiological clues, even if you are not interested in policy at all

Four major approaches to explaining health inequality

“Selection” “Material” “Behavioural” “Psychosocial”

HEALTH

HEALTH

SOCIAL POSITION

DIRECT SELECTION

Personal characteristic “x”

HEALTH

SOCIAL POSITION

INDIRECT SELECTION

BEHAVIOURS

Indirect selection

“Personality” factors are set early in life ?genetics; ?parental care …. These then are the ‘causes’ of social position They also influence health related

behaviours Health behaviours ‘determine’ health No direct causal link between adult social

position and adult health

Indirect selection or life course processes?

Merit of this approach is that it can only be tested in longitudinal research

Up to now, not many studies have done this Seems to be a complex mixture of ‘risk’ and

‘resilience’ over time

Cognitive function at 8 years and mortality Cognitive function at 8 years and mortality up to age 54: men born in 1946up to age 54: men born in 1946

00.5

11.5

2

2.53

3.54

Unadjusted Adj smoking Adj education Adj adultsocial

conditions

Best score

Worst score

Permission granted from International Journal of Epidemiology, Vol 33(2), Kuh et al, Childhood cognitive ability and deaths up until middle age, pp 408-13, Copyright 2005

with permission from Oxford University Press

Developmental contextual model of the development of inequality in psychological health from birth to

age 33 in men and women born 1958

Permission granted from Social Science and Medicine, Vol 57, 2003, Schoon et al , Socio-economic adversity and psychosocial adjustment: a developmental-contextual perspective 

p1001-1015, Copyright 2005 with permission from Elsevier

Material explanations

Industrial hazards Dietary inadequacy Accidents at home, work and on road Area pollution Housing inadequate for climatic conditions

Morris et al. Costs of a healthy life

Healthy food = £14.05 p.w. Heating = £5.41 p.w. Clothes and shoes £10.00 p.w. Lodging = £46.80 Social participation = £38.00 Total is about the same as UK Minimum

Wage but far more than benefit levelSource: Morris et al JECH 2000

Cost of a healthy life

Biological necessities (food, clothing, heat) only make up the minority

Major costs are social participation and lodging

These 2 are determined by wider social forces

No such thing as a ‘pure material’ explanation

Amartya Sen’s “capability” explanations

Affordability of biological necessities depends on the costs of social participation

“Relative deprivation in the space of incomes can yield absolute deprivation in the space of capabilities. In a country that is generally rich, more income may be needed to buy enough commodities to achieve the same social functioning, such as ‘appearing in public without shame’. The same applies to the capability of ‘taking part in the life of the community’”

Material and psychosocial hazards accumulate in the life course

“Social reproduction” Less advantaged family background is linked

to worse educational results Education is strongly linked to social class in

adulthood Social class influences risks e.g. poor

housing, low income, unemployment, job insecurity, low work autonomy

Unemployment 12+ months 1981-1991 by Unemployment 12+ months 1981-1991 by father’s social class at birth father’s social class at birth

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Adj. crowding, education, region,height at 7, BSAG, parents’ heights

Adj. crowding, education, region,height at 7, BSAG, parents’ heights

Father’s social class

Father’s social class

Journal of Epidemiology & Community Health, 1996, 50: 415 -422, reproduced with permission from BMJ Publishing Group

Economic status 1971 and 1981 by semi- or unskilled Economic status 1971 and 1981 by semi- or unskilled manual class membership in 1991manual class membership in 1991

Men 35-60: % in classes RG IV/V in 1991

0

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20

30

40

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Emp 71& 81 Emp 71, Unemp81

Unemp 71, Emp81

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Employed 1991

Unemployed 1991

Sick/inactive 1991

Permission granted from International Journal of Epidemiology, 31(2), Mel Bartley and Ian Plewis, Accumulated labour market disadvantage and limiting long term illness, pp 336-341, Copyright 2005 with permission from Oxford University Press.

““Labour market disadvantage Labour market disadvantage score”score”

Semi or unskilled manual class 1971, Semi or unskilled manual class 1971, 1981, 1991 = 1 point each1981, 1991 = 1 point eachUnemployed 1971, 1981 = 1 point eachUnemployed 1971, 1981 = 1 point eachRange = 0 - 5Range = 0 - 5Total 0 = never unemployed, always in Total 0 = never unemployed, always in skilled or non manual workskilled or non manual workTotal 5 = Always in semi or unskilled Total 5 = Always in semi or unskilled manual work, unemployed in 1971 and manual work, unemployed in 1971 and 19811981

Odds of limiting long standing illness in 1991 by accumulated labour Odds of limiting long standing illness in 1991 by accumulated labour market disadvantage 1971-1991market disadvantage 1971-1991

Men aged 36-60 in 1991Men aged 36-60 in 1991

0

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4

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Permission granted from International Journal of Epidemiology, 31(2), Mel Bartley and Ian Plewis, Accumulated labour market disadvantage and limiting long term illness, pp 336-341, Copyright 2005 with permission from Oxford University Press.

Life-course explanations for health inequality

Health inequality is the result of processes that operate over time in the life of the individual

Consistent with the observation that inequality takes the form of a ‘gradient’

More recently developed approaches

“Neo-material”

“Life-course political economy”: social environments as sources of capability and resilience

“Neo-material explanation”

Originates in the debate on income distribution and overall population health

Why might income inequality damage health and well-being?

“Income inequality” may influence aspects of social relationships: relative importance of domination versus mutual support

It might be acting as an indicator of other social institutions such as welfare, education, housing, transport.

The ‘psychosocial interpretation’: Social relationships vary with income inequality

Social trust Social distance Mutual support Aggression and violence

The ‘neo-material’ explanation: Social policies vary with income inequality

Coverage of social insurance Generosity of welfare provision for parents,

carers, unemployed Percent of GDP devoted to education and

public health (not necessarily acute medicine)

Quality of housing for lower income families

The ‘capability’ interpretation

Social environment influences individual development & resilience through quality of relationships over time

Social and economic policies influence adequacy of individual resources for health and quality of life = ‘capability’

Need for a ‘life course political economy’ of health inequality?

1. The causes of major trends in population health are still poorly understood

2. Economic environment relates to health in the context of the life course;

3. Effects of social policies differ between stages of the life course (childhood, youth, maturity, older age).