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In the USA in recent years the HIV epidemic has slowed down, partly due to a decrease in sexual transmission between men as a result of behaviour change, although the HIV prevalence is still high. HIV prevalence among IDUs (injecting drug users) has decreased, but there is an increasing number of heterosexuals diagnosed of being infected with the virus, and children being infected through mother to child transmission. Although there has been an overall slow down in AIDS incidence, a substantially shift in the populations affected has been recognised: The AIDS incidence in the USA was found to be 6,5 times greater for black people and 4 times greater for Hispanics than for whites (Vancouver 1996).
In Europe, the AIDS incidence seems to have stabilised in several countries in northwestern Europe (Vancouver 1996), however, in south-western Europe, particularly Italy and Spain, no decrease has been shown. The highest incidence rates in AIDS in these countries are reported from heterosexual adults and children (UNAIDS 1997).
As we can see from these figures the HIV/AIDS pandemic is as powerful as ever.
From a global perspective HIV/AIDS affects disproportionately the countries of the developing world, where it is feared that the social, economic and demographic impact of the disease will increase the existing economic and social burden on individuals, communities and countries (Vancouver 1996).
However, “HIV continues to spread also in the industrialised world, where increasingly it affects people, who for reasons of race, sex, behaviour or social and economic status have lesser access to services.” (Vancouver 1996)
2.2 Focus on EU Countries The focus of this work is why are people still getting infected by the virus, although the ways of transmission are well known and many prevention activities are carried out. Who is being infected by the virus, and do socio-economic differences play a major role? What are the reasons that prevention messages are currently not successful in all population groups? How do they need to be changed to be able to effectively reach all population groups at risk, and to successfully prevent the spread of the virus.
The geographic focus of this report is on European countries with some examples of experiences from other industrialised countries, such as US, Canada and Australia, and also from developing countries, to illustrate the findings and to present different kind of responses to the epidemic.
2.3 Ongoing HIV/AIDS Infection Despite Extensive Prevention Activities
Hardly any other disease has been researched so profoundly as HIV/AIDS.
Many studies have been carried out on the medical, social and psychological issues of the disease, concerns with service provision of statutory and voluntary sector services, and population groups at risks. The epidemiology of the disease is well known as are the ways of transmission of the HIV virus.
However, despite a multitude of prevention and education activities world wide people continue to be infected by HIV. In recent years prevention activities have been improved and are increasingly targeted at the specific population groups at risk, but still prevention seems not to be so successful as hoped. A study on change in
homosexual HIV risk behaviour among gay men in UK concluded:
“Despite an increase in prevention work targeted at this population, aggregate levels of sexual risk-taking have remained very stable. A reassessment of the efficacy of current HIV prevention messages and methods with this population is urgently required.” (Hickson et al., 1996) Various factors may explain why some population groups are not reached by prevention programmes. One possible explanation may be that epidemiological data of HIV infection broken down by risk groups, such as gay men, intravenous drug users (IDUs), and young people, have rarely been interpreted by social classes or socio-economic factors. At the same time most prevention programmes, even when directed at specific population groups at risk, focus only on behaviour change and do not take into account possible class and socio-economic differences and their implications on HIV/AIDS.
However, the relationship between health and class- and/or socio-economic factors is well known and widely acknowledged (Townsend et al., 1998). The issue of class and sexuality has been given a new dimension and a new urgency by AIDS (Connell et al., 1993, Bochow 1997).
3. Definition of ‘class’ and social inequality
3.1 Definition of ‘class’ The terminology ‘class’ seems out of fashion nowadays (Dowsett et al., 1992). The term is often used in a general way to distinguish between different population groups, but without reference to a concrete sociological concept of class.
The ongoing controversy between neo-Marxist and non-Marxist class theorists has drawn attention to the association of social inequality with economic factors, to the continuing differences in the life conditions and also to the characteristic ways of thinking and behaviours of people from different social classes (Geissler 1992).
Supporters of the concept of social inequality question the validity of the concept of class; it is seen to be superficial. In this view ‘class’ reduces the social character of individuals in society to their economic- professional position, ignoring their cultural, political, and psychological condition. Models of class aiming to describe the structure of social inequality are considered too narrowly designed, too simple, too static and too far from life (Hradil 1994).
It is further argued, that the number of different classes and their relative size have been subject to more or less arbitrary sociological definition (Hradil 1994). Models of class diverge greatly. In Germany, for example between 5 and 25% of the adult population are categorised as ‘lower class’. Depending on the model chosen, the ‘lower class’ turns out to be very small when only the marginalised and socially despised individuals are classified in it. It becomes much bigger when unskilled and poorly qualified workers are also included (Geissler 1992).
Another criticism of the traditional class model in Germany is that for a long time it has not taken immigrant workers into account. Most native German working-class people have experienced an upgrading in their status as immigrants have replaced them at the lowest level of the social hierarchy (Hradil 1994). In the mid ‘80s 60% of immigrants belonged to the unskilled and less qualified population (Geissler 1992).
3.2 Problems with the ‘class’ model in the context of HIV
A conventional classification of a person’s position within society is ‘prestige’ or ‘social reputation’. These categories are generally determined by objective indicators as education, occupation, income and financial assets (Biechele 1996) But as soon as other criteria of social inequality are taken into account (gender, religion, age, nationality), classification becomes much more complicated (Bolte and Hradil 1988, Biechele 1996).
Recent work on this subject have, besides the conventional criteria of class, also taken into account additional criteria, such as housing and environment, social security (employment, health, old age), stigma and discrimination (Biechele 1996). Another criterion to involve could be the psychological dimension of ‘coping style’: how an individual is able to confront conflicts and problems (Biechele 1996). With the integration of criteria, such as discrimination or coping style, the classification of ‘high’ and ‘low’ class does not make much sense. All gay men, for example, would than be subsumed in the lower level due to discrimination and stigma (Biechele 1996).
Another fact which may hinder the approach of ‘class’-focused research is that the perception of ‘working class’ as class-conscious proletarians who take pride in the product of their labour has largely been displaced by the characteristics of members of the lower class in relation to their perceived ‘deficits’. The picture has changed: the lower classes are seen not as containing potential, but as ‘lacking’ something: lack of self-confidence, lack of perspective, lack of health awareness (Korcak 1994; Bochow 1997b).
The accumulation of deficits may be the reason why researchers are reluctant to undertake studies looking at specific differences in working-class populations. They may perceive it as politically incorrect to talk about lower class deficits. Particularly when measured against middle class life styles, behaviour and living standards, every differentiation might be interpreted as a deficit. (Bochow 1997b) In other words, to differentiate might be to stigmatise. This has been apparent with some British researchers. When faced with criticism that middle-class gay men were overrepresented in their study, they countered that to ‘factor out’ this possible bias would be to run the risk of paternalism and dismissiveness (Davies et al 1993). They were reluctant to distinguish between the ‘good guys’, often middle class men who might be shown to be on the whole more responsible and sensible, and the ‘bad guys’, those who continue to behave irresponsibly and those about whom there is little or no research evidence: the working class, black men, the young and those living in rural areas. Pointing the finger at groups marginalised not only by their sexuality, but also distanced from the established gay culture is held to be unhelpful in the search for appropriate ways of diminishing the risk of HIV infection (Davies et al., 1993).
3.3 Socio-economic related inequalities in health
The British Black Report (1980) on socio-economic inequalities in health encouraged in Western European countries a broader debate on this issue. Subsequently health inequalities have been found in other European countries where research on socioeconomic health differences have been carried out (Hauss F., Naschold, F., Rosenbrock R., 1981, Smith et al., 1990, Donaldson C., K. Gerard,1992, Whitehead M., 1988, Fox 1989).
Different approaches have been developed to explain the relation between increasing mortality and decreasing socio-economic status. In the following some of them are presented.
In Britain and Western Europe mainly four different approaches were used to
interpret the findings on social inequalities:
The artefact explanation that assumes the observed correlation between socioeconomic status and mortality is due to a result of biased data collection and data distortion. The social selection explanation acknowledges the existing correlation between socio-economic status and mortality, yet, explains it by the fact that people who are less healthy are less likely to advance socially and economically and more often to lower their social status. Whereas artefact and social selection find only limited use, the cultural/behavioural explanation is mostly used for interpretation.
The cultural/behavioural explanation accepts the association between socio-economic status and mortality. In contrast to the ‘social selection’ approach, it stresses the importance of differences in the individual risk behaviour, and highlights the fact that risk factors, such as smoking, are more common in persons with a low socioeconomic status.
The structural/material explanation points to the importance of living and working conditions affecting the possibility of falling ill or disease progression. The structural/material approach, however, does not get the same attention as the cultural/behavioural approach (Elkeles T., Mielck A., 1993).
The WHO “Health for all” strategy focuses on unfair or unacceptable inequalities in health, and the proclaimed target is to reduce the actual differences in health status between countries and between groups within countries by at least 25 %, by the year 2000, by improving the level of health of disadvantaged nations and groups (Gepkens et al., 1996, Whitehead 1991).
The WHO considerations give priority to the disadvantaged situation of lower socioeconomic groups. The focus is on the unequal chances of staying healthy, or in case of illness, recovering. The reasons and influences for staying healthy or falling ill and the role of socio-economic differences associated with these are under investigation.
Following these considerations three pragmatic objectives are stated for health
promotion in disadvantaged population groups (Dahlgren/ Whitehead, 1992):