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The social class determinants of income inequality and social cohesion.

The authors argue that Wilkinson's model omits important variables (social class) that make it vulnerable to biases due to model mis-specification. Furthermore, the culture of inequality hypothesis unnecessarily "psychopathologizes" the relatively deprived while omitting social determinants of disease related to production (environmental and occupational hazards) and the capacity of the relatively deprived for collective action. In addition, the hypothesis that being "disrespected" is a fundamental determinant of violence has already been refuted. Shying away from social mechanisms such as exploitation, workplace domination, or classist ideology might avoid conflict but reduce the income inequality model to a set of useful, but simple and wanting associations. Using a nonrecursive structural equation model that tests for reciprocal effects, the authors show that working-class position is negatively associated with social cohesion but positively associated with union membership. Thus, current indicators of social cohesion use middle-class standards for collective action that working-class communities are unlikely to meet. An erroneous characterization of working-class communities as noncohesive could be used to justify paternalistic or punitive social policies. These criticisms should not detract from an acknowledgment of Wilkinson's investigations as a leading empirical contribution to reviving social epidemiology at the end of the century.

Authoritarianism↗

[Social class and health].

This publication deals with the German social class and their interactions with health or illness. The analysis uses the data of the German National Health Interview and Examination Survey 1998. The results are as follows: During the last decade the proportion of inhabitants of lower social class has decreased in favour of the proportions of middle and upper social classes. The formerly observed differences between the eastern part (former GDR) and the western part of Germany have diminished or have even levelled to zero. Even today men in Germany belong more often to the upper social class than women. For the risk factors smoking, massive obesity and inactivity in sports a distinct gradient concerning the social class can be observed. Those belonging to lower social class are more often smokers, have significantly more often massive obesity and show more seldom activities in sports. Hypertension and hypercholesterolemia are more often observed in men of the upper social class than in those belonging to lower class while for women both mentioned risk factors are more often seen in the lower social class. With respect to morbidity different patterns can be observed. NIDDM, chronic bronchitis and gastric and duodenal ulcer are examples for higher prevalence data in the lower social class while allergic rhinitis can be observed more often in the higher class. The level of complaints is higher in the lower class than in the upper class. By differentiating according to the eastern or western part clear differences emerge concerning social class especially in the 'old Bundesländer' (western part). Members of the upper class estimates their health status clearly to be better than those study participants belonging to the lower class. This perhaps can be explained by their lower level of complaints. The contentedness concerning live and health-status is higher in the upper than in the lower class. Respecting the highest level of education, class-specific differences concerning drug utilization are observed doubly frequent in the 'old Bundesländer' compared to the 'new Bundesländer'. According to the level of complaints and the prevalence of diseases most drug groups are used more often in the lower than in the upper class whereas drugs with presumed preventive potential are clearly more often consumed in the upper class.

Adolescent↗

Mortality and social class in New Zealand. I: overall male mortality.

Social class differences in New Zealand male mortality are investigated using two different systems of social class classification. In each case it is found that the lower social classes have mortality rates significantly higher than those of the upper social classes with the mortality rate of the lowest class being approximately twice that of the highest class on a six-category scale. The relative risk is higher in the younger age-groups. When the British Registrar-General's scale is used New Zealand exhibits a social class mortality gradient similar to that previously found in England and Wales, but the lowest social class experiences a particularly high mortality rate.

Adolescent↗

[Validity of the occupation as an indicator of social class, according to the British Registrar General classification].

OBJECTIVE: Measuring social class is important for evaluating its influence on health status and on the access to health services. This paper is aimed to assess the construct validity of the classification of social class based on the individual's occupation. METHODS: Data come from the Barcelona Health Interview Survey of 1986. In the survey, 2,205 households and 6,894 individuals participated (82% of the eligible households and 84% of the eligible individuals). Information was gathered on, among other issues, the following socioeconomic variables: annual family income, lack of some household services, property of the household, education level and occupation of the individuals, as well as their occupational situation and labor relationship. Data about the value of the household was collected from the City Council census (catastro). Social class was assigned using the individual's occupation or, if none, the head of the household's occupation in the following groups: I, II, III, IVa, IVb, V, and "Not Classified". The association between social class and socioeconomic variables was analyzed using: ANOVA for the comparisons of continuous variables, Chi-squared test for categorical variables, Spearman correlation coefficients and discriminant analysis. RESULTS: A total of 3,357 individuals reported an occupation. "Employed in administrative services" was the most common (14.3%). Social class was "Not classified" in 6.4% of the individuals. All socio-economic variables showed statistically significant differences, following a predicted pattern: better indicators for more favoured social classes. Social class showed a moderate to high correlation with education level (r = 0.57) and somewhat lower with the other variables. Variance in socioeconomic variables explained by social class was higher than the 95% (p < 0.001). CONCLUSIONS: The pattern of relationships between socio-economics variables was intense, monotone and consistent, suggesting that the occupation is a valid and feasible of social class. Routinely including occupation in health information systems should allow to monitor inequalities in health in Spain.

Health Surveys↗

Ethnicity, social class and health. A population-based study on the influence of social factors on self-reported illness in 223 Latin American refugees, 333 Finnish and 126 south European labour migrants and 841 Swedish controls.

This article shows the influence of ethnicity and social class on self-rated illness compared with social factors and lifestyle. We were particularly interested in health differences between refugees and labour migrants. The study population consisted of 223 Latin American refugees domiciled in Lund, 333 Finnish and 126 South European labour migrants and 841 Swedish controls. The data were analysed unmatched with logistic regression (multivariate analyses) in main effect models. The strongest independent risk indicator for long-term illness was being a Latin American refugee, with an estimated odds ratio of 2.78 (1.95-3.81), or a South European 1.80 (1.17-2.71). Low social class, low material standard, age 45-64 years and overweight were significantly associated with long-term illness. There was a strong association between being a Latin American refugee and ill-health, followed by a weaker association for South European labour migrants and no association for Finlanders and Swedes when controlled for other social factors in logistic regression. Low social class, age 45-64 years, poor social network, not feeling secure in daily life and not taking regular exercise were associated with ill-health. South Europeans were the only ethnic group who showed an association to working impairment and disability. Latin Americans were significantly associated with acute illness with an estimated odds ratio of 2.00 (1.32-2.94). In conclusion, ethnicity was shown to be an independent powerful social dimension compared with social class in relation to self-rated illness.

Adolescent↗

Gender, social class and illness among young people.

Gender and social class differences in illness among young people have been a neglected area in research on social inequities in health. It has been assumed that the illness differentials among adults persist throughout their lives. Only recently have social class health differentials among young people become a topic for research. The aim of this study is, first, to examine gender and social class differences in self-reported illness among young Finns; secondly, to determine whether the relationship between social class and limiting long-standing illness is similar among young men and women. In addition to the two main aims, we also examined whether several background variables have any impact on the relationship between class and illness or, directly, on illness. The data were derived from a nationwide Finnish 'Level of Living Survey', which was carried out by the Central Statistical Office of Finland in 1986. This interview material represents the noninstitutional Finnish population aged 15 years old or older. The number of respondents were 12,057, and the response rate was 87%. In the present study we only examined those who were 15-24-year-olds (N = 2238); i.e. 1101 men and 1137 women; the response rates were 91% and 92% respectively. Young women reported a limiting long-standing illness more often than young men. The prevalence of limiting long-standing illness increased with age. Cross-tabulation analyses showed virtually no relationship between social class and limiting long-standing illness. This held true irrespective of the various measures of social class that were used. Controlling the impact of several background variables in the logistic regression analyses did not alter this general result.

Adolescent↗

Social mobility and the interpretation of social class mortality differentials.

The discussion of health inequalities in Britain (e.g. in the Black Report) has been conducted largely on the basis of social class mortality differentials measured by achieved social class and not by social class of origin. It is shown in this paper that social class mortality differentials by achieved social class are not invariant to the rate of social mobility and that the use of them is likely to result in a biased measure of trends in health inequalities when the absolute rate of social mobility varies over time. It is further shown that if, as is likely, health status is a factor systematically affecting the probability for an individual of upward or downward social mobility, then an increase in the rate of social mobility may well result in constant or widening social class mortality differentials by achieved social class even if the differentials are narrowing when measured by social class of origin. It is claimed that this process may well explain why the observed social class mortality differentials, which are measured by achieved social class, have not fallen in Britain during the post-1945 period.

Health Status Indicators↗

Social class and cardiovascular disease: the contribution of work.

Low social class has been identified as a risk factor for coronary heart disease in highly industrialized countries. The authors discuss the social class concept in relation to psychosocial working conditions. Most of those psychosocial work characteristics that are of relevance to cardiovascular risk, namely, skill discretion, authority over decisions, and social support at work, are unevenly distributed across social classes--the lower the social class, the fewer the resources for coping with psychosocial stressors. Furthermore, biomedical risk factors for cardiovascular illness are also unevenly distributed across social class and associated with psychosocial work characteristics. The main conclusion is that part of the association between social class and cardiovascular illness risk may be due to differences in psychosocial work conditions. The psychosocial work conditions may affect the risk through either neuroendocrine mechanisms or lifestyle. Excessive tobacco smoking, for instance, may be enforced by poor working conditions.

Coronary Disease↗

Social class and access to specialist palliative care services.

OBJECTIVE: To determine any social class differences in place of death of cancer patients in South Bristol; to explore the experience of carers; and to identify inequalities in access to palliative care. DESIGN: Two-part study: (1) A cross-sectional survey of all 960 cancer deaths in South Bristol between September 1999 and December 2002. (2) A qualitative in-depth interview study of 18 carers of patients who died of cancer during the same period in South Bristol. Fourteen of those who died were from social class IIIM (manual), IV and V (i.e. lower social classes). MAIN OUTCOMES: Place of death of patients according to social class and geographical distance from the hospice. Carers' accounts of the way in which illness and death were conducted, and their response to the management of death and dying. RESULTS: The cross sectional survey showed that patients from social class V were less likely to die in the hospice. This finding was independent of geographical proximity. In the qualitative study, no class specific beliefs about death and dying were identified. Attitudes to the way dying should be conducted were common across the classes. Families expected to be present and centre stage at the time of death and for it to be conducted in a dignified and personal manner. Health care staff in all settings supported them in this aim. No one in this study died without a family member present. Some elderly carers were less open than younger carers in the way they talked about death and did not wish to be present at the death. Some carers from social class IV and V were less active in seeking information or asking for hospice admission than carers from other classes. Unrealistic expectations about the availability of hospice beds were common to all carers. Anxiety was common among carers. It was reduced by the provision of reliable and consistent healthcare support, by information provided in a timely and sensitive way, and by open and shared decision making between carer and patient. Most important in reducing anxiety was the support of a second carer who lived locally and was reliable. Carers from social classes IIIM (manual), IV and V were more likely to have this kind of support than carers from social classes I, II and IIIN (non-manual). CONCLUSION: Although cancer patients from social class V were less likely than others to die in the hospice, social inequality in access to or utilisation of healthcare in terminal illness was not prominent in carers' accounts. When it did arise, it was associated with passivity in seeking information and support on the part of some carers from social classes IV and V. Carers from social classes IIIM-V received more regular and reliable support from their families than those from social classes I-IIIN.

Aged↗

The relationship between severe asthma and social class.

Asthma is one of the few diseases which has been reported to be common in the higher social classes. In order to assess the relationship between severe asthma and social class we analysed a national study of disabled adults undertaken by the Office of Population Censuses and Surveys (OPCS). The study estimated that there were 5.8 million people over 16 years with some degree of disability living in private households in England and Wales. Thirteen percent of disabilities were due to respiratory disease: 6% chronic bronchitis and emphysema, 3% asthma and allergy, and 4% other respiratory diseases. Among 10,000 individuals interviewed, 338 disabled adults reported asthma as a contributing cause of their disability. Of 291 cases with social class recorded, 41 (14%) were in social classes 1 and 2, 128 (44%) in social class 3, and 122 (42%) in social classes 4 and 5. An estimate of the relationship between social class and adult asthma in the general population was derived by calculating a morbidity ratio for the different social classes. The morbidity ratio for all social classes combined equals 100: for social classes 1 and 2 it was 63 (95% confidence intervals 48, 91); 93 (95% confidence intervals 77, 109) for social class 3; and 131 (95% confidence intervals 108, 153) for social classes 4 and 5. Adults in social classes 4 and 5 were approximately twice as likely to have severe asthma as those in social classes 1 and 2. This could be as a result of differences in the prevalence or treatment of asthma among the social classes.

Adolescent↗

Social class and heart disease mortality among African Americans.

The purpose of the present study was to examine variation in heart disease death rates by the social class of decedents. The term, "social class" refers to a complex set of phenomena such as control over economic resources, social status, and power relative to others in society. The target population for this study was African-American adults aged 35-74 years old who resided in the United States during the years 1996-1997. As a proxy for social class, we examined 5 levels of educational attainment: 0-8 years of school completed (Social Class I), 9-11 years of school completed (Social Class II), high school graduate/12 years of school completed (Social Class III), some college completed (Social Class IV), and college degree completed (Social Class V). Older age, male gender, and lower social class were all independently associated with higher heart disease death rates. For all ages, more disadvantaged social classes had a higher risk of heart disease mortality. The highest relative risks were found for Social Classes I and II among the younger age groups. Many of the "prerequisites" for the "heart healthy lifestyle" are predicated on the benefits of a privileged social class position. For African Americans, there are the additional stressors of segregation, exclusion, and discrimination to overcome, as well as the cumulative physiological toll of lifetime resistance to various forms of racism. For many African Americans in disadvantaged social class positions, the obstacles to reducing the risk for heart disease are very difficult to overcome.

Adult↗

[Inequalities in health related to social class in women. What is the effect of the measure used?].

Classical theories of social stratification share the assumption that the family is the unit of stratification, using the man's occupation as a measure of social class. These theories were criticized by feminism, which claimed that women were not visible in class analysis. The present article aims firstly to review measurement of women's social class, secondly to review studies on the impact of different measures of social class on inequalities in health among women, and thirdly to illustrate the differences among alternative measures, using data from the Barcelona Health Interview Survey 2000 as an example. There are few studies analyzing inequalities in health among women that take into account several measures of social class; most studies have been performed in the United Kingdom, although some studies have been conducted in other countries. Typically, these studies compare several social class indicators: the conventional social class measure, which uses the husband's occupation or that of the head of household (a household measure); the individual social class measure, which uses women's occupation, and the dominant social class measure, which allocates an individual the highest social class within a household (also a household measure). The impact of the various measures on inequalities in health varies according to the study performed, but is usually greater with the conventional and dominant approaches. Data from the Health Interview Survey of Barcelona 2000 show the existence of inequalities in health using these three approaches, with varied impact according to the health indicators used and women's characteristics.The dominant social class measure has several advantages: it is gender-blind and is not sexist. When the dominant social class is a less privileged class (i.e. manual laborer) it means that both partners have an occupation equal to or lower than this measure. Finally, this indicator is easily obtained.

Female↗

Social class, coronary risk factors and undernutrition, a double burden of diseases, in women during transition, in five Indian cities.

OBJECTIVE: To find out the association between social class and coronary risk factors in women. DESIGN AND SETTING: Cross-sectional surveys were conducted in six-twelve urban streets in each of five cities from various regions of India following a common study protocol and criteria of diagnosis. SUBJECTS AND METHODS: We randomly selected 3257 women, aged 25-64 years inclusive, from the cities of Moradabad (n=902), Trivandrum (n=760) Calcutta (n=410), Nagpur (n=405) and Bombay (n=780). Evaluation was by questionnaires validated at Moradabad. All subjects, after pooling of data, were divided into social class 1 (n=985), social class 2 (n=790), social class 3 (n=674), social class 4 (n=602) and social class 5 (n=206), based on various attributes of socioeconomic status. RESULTS: The prevalence of hypertension, diabetes mellitus, family history of coronary disease, obesity, central obesity and sedentary lifestyle were significantly associated with higher social classes and tobacco consumption was not associated with social class. Oral contraceptive intake and postmenopausal status were also more common among higher social classes, which may be due to more education and a longer lifespan among the higher social classes, respectively. Mean total cholesterol, high density lipoprotein cholesterol, systolic and diastolic blood pressure, mean body mass index and waist-hip ratio showed significant association with higher social classes. Mean age, body weight, body mass index, waist-hip ratio, systolic and diastolic blood pressure, total cholesterol and 2-h blood glucose were significantly positively correlated with social class, as assessed by Spearman's rank correlation. Higher social classes 1-3 were more common in Trivandrum and Bombay than in Moradabad. The prevalence of hypertension, diabetes mellitus and being overweight (body mass index >25 kg/m2) were also more common in Trivandrum and Bombay compared to Moradabad. Undernutrition was negatively associated with higher social classes and was more common in Moradabad and Nagpur than Trivandrum. CONCLUSIONS: Higher social classes among Indian urban women have a higher prevalence of coronary risk factors, hypertension, diabetes mellitus, being overweight, central obesity, sedentary lifestyle, family history of coronary disease, oral contraceptive intake and postmenopausal status. Mean concentrations of total and high density lipoprotein cholesterol were also significantly associated with higher social classes.

Adult↗

Does parenting differ based on social class?: African American women's perceived socialization for achievement.

Research has provided some evidence of ethnic group, gender, and class differences in the socialization for achievement. However, there is little research on African American women with the exception of the studies of low-income, single mothers. To understand the similarities and differences in socialization for achievement based on social class, middle-class African American women from working- and middle-class backgrounds were studied using qualitative and quantitative methods to compare them on issues related to achievement socialization. Women from middle-class backgrounds reported that their parents had higher expectations for them and were more involved in their education than did women from working-class backgrounds. More middle-class parents expected their daughters to be successful in careers than did working-class parents. Women from working-class families did receive support from their parents but they did not have as much support as did the women from middle-class backgrounds. Women from working-class families perhaps made use of other sources to support their desire to succeed. There were no differences in perceived race-related socialization based on social class. Implications of these findings for future research are discussed.

Achievement↗

Nutrient intake in Jerusalem--effects of origin, social class and education.

The independent association of ethnic group, social class and education with nutrient intake was studied in a sample of 1,294 adults in the Jerusalem Lipid Research Clinic (LRC) population. By univariate analysis, intake of fat and saturated fatty acids (SFA) was higher (P less than or equal to 0.05) in males and females of the upper social classes (classified by the occupation of the head of the family) than in the lower classes, while the opposite trend was found for the consumption of carbohydrates and starch. In men, an association between social class and the intakes of protein and other carbohydrates (i.e., other than sucrose and starch) and the ratio of polyunsaturated fatty acids (PFA) to SFA (P:S ratio) was also found. In both sexes, the mean intakes of SFA and other carbohydrates were higher and that of starch lower in subjects with a higher level of education (P less than or equal to 0.05). Education was also associated with the consumption of protein and fat in males and with that of carbohydrates and sucrose in females. Country of origin was related (P less than or equal to 0.05) to the intake of fat, SFA and other carbohydrates in both sexes, to that of protein and cholesterol in males and to that of carbohydrates, sucrose and starch in females. The P:S ratio of the diet of male subjects was also associated with origin. Using various models of analysis of variance, it was shown that origin was associated with nutrient intake (P less than or equal to 0.10), independent of the effect of social class and education for protein, fat, SFA, cholesterol, sucrose and other carbohydrates in males, and for fat, SFA, PFA and other carbohydrates in females. The P:S ratio of the male diet was also associated with origin. The level of education was independently related (P less than or equal to 0.10) to the intake of fat, SFA, starch and other carbohydrates in males and to that of sucrose in females, while social class was associated independently with carbohydrate consumption in males only. After prior adjustment for origin, education had a stronger residual effect than did social class in males, while in females the associations of social class and education with nutrient intake were almost identical.

Adolescent↗

Social class and cancer patient survival in Finland.

The effect of social class on survival was assessed in a cohort of cancer patients identified from the nationwide population-based Finnish Cancer Registry. The cohort consisted of all reported cases of the 12 most common types of cancer occurring in Finland between 1971 and 1985 among persons born in 1906-1945 (n = 106,661). Social class information based on occupation was obtained individually for each patient from the population census of 1970. Both observed and corrected (i.e., cause of death-specific) 5-year survival rates were used in the analyses. A statistically significant linear effect of social class on age-adjusted relative risk of cancer death was observed in six of 12 cancer types among men and in nine of 12 among women; and the risk was highest for those in the lowest social class. The relative risk of death due to cancer for social class I (highest) relative to social class IV (lowest) was lowest in bladder cancer (relative risk (RR) = 0.46, 95% confidence interval (CI) 0.34-0.61) and kidney cancer (RR = 0.61, 95% CI 0.48-0.78) among men and in corpus uteri (RR = 0.51, 95% CI 0.36-0.72) and rectum cancer (RR = 0.56, 95% CI 0.42-0.74) among women. The differences between results obtained using corrected and observed survival rates were small. These findings indicate that social class is an important determinant of cancer patient survival. Additional research is required to clarify the etiology of the social class differences and to identify factors that could be used for developing strategies to diminish such inequalities.

Adult↗

Evidence of increasing coronary heart disease mortality among black men of lower social class.

PURPOSE: Few data are available to examine coronary heart disease (CHD) mortality trends by social class in the United States, in contrast to ample data and well-documented social class disparities in CHD in Europe. In addition, previous analyses of U.S. national data indicated that the rate of decline in CHD mortality slowed substantially for blacks in the 1980s. Using a recently published method for calculating mortality rates by social class, we examined trends in CHD mortality for black men and white men aged 35-54 in North Carolina from 1984 to 1993. METHODS: Men were assigned to one of four social classes: primary white collar (I), secondary white collar (II), primary blue collar (III), or secondary blue collar (IV), based on usual occupation as recorded on the death certificate. Population denominators for each social class were constructed using data from census Public Use Microdata Sample files. Average annual percent change in mortality rates for each race-social class group was derived from linear regression of the log-transformed age-adjusted rates. RESULTS: For black men, CHD mortality increased by 18% in social class II, by 2% in social class III, and by 6% in social class IV over the 10-year study period. In contrast, CHD mortality decreased by 33% for black men in social class I (the highest class). CHD mortality declined for all white men, with the greatest decline in social class I and the least decline in social class IV. CONCLUSIONS: These results suggest that CHD prevention efforts have not benefited black men of lower social class, and that public health programs need to be targeted to these men.

Adult↗

Depressed autonomic nervous system function in African Americans and individuals of lower social class: a potential mechanism of race- and class-related disparities in health outcomes.

BACKGROUND: Both race and social class influence cardiovascular outcomes, through mechanisms not yet fully understood. Minority race and lower social class are sources of chronic stress, which can alter autonomic nervous system function. Heart rate variability (HRV), a measure of autonomic function, is also an important predictor of cardiovascular outcomes. METHODS: To determine whether minority race/ethnicity and lower social class are associated with depressed HRV, we prospectively collected data on sociodemographic, clinical, psychological, and behavioral factors by survey in 360 outpatients undergoing ambulatory electrocardiographic monitoring. Heart rate variability (24-hour) was measured by frequency domain analysis. RESULTS: In unadjusted analysis, African Americans had lower HRV than whites, and individuals of lower social class as measured by education, occupation, and income had lower HRV than those of higher class. In multivariable analysis, both race and social class were independent predictors of ultralow frequency power after controlling for clinical and psychological factors. African Americans were 3.45 (95% CI 1.74-6.98, P = .0004) times as likely as whites to have depressed HRV (ultralow frequency power, lowest tertile), and non-college graduates 2.94 (95% CI, 1.71-5.14, P = .0001) times as likely as college graduates to have depressed HRV. CONCLUSIONS: Heart rate variability is lower in African Americans and individuals of lower social class, independent of the effects of measured clinical, psychological, or behavioral factors. This suggests that the adverse effects of minority race and lower social class on cardiovascular outcomes may be mediated by dysregulation of autonomic function.

Adult↗