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! reduction of risk factors, such as improved working conditions, reduction of unemployment, support in attempts to giving up smoking ! support in dealing with risk factors, such as improvement of counselling and support in case of threatened unemployment ! and in case of illness, improvement of health care for specific groups at risk.
Siegrist (1989) argues that social inequity in health cannot be explained solely by low utilisation of health resources in situations, in case of illness, but by a lack of longterm health strategy. Low utilisation of antenatal and child surveillance programmes, deficits in medical knowledge as well as inappropriate awareness of early symptoms are seen to be encouraged by low socio-economic status, however, influenced by socio-psychological factors.
Siegrist advocates to broaden the socio-economic status as indicator of social inequalities and to include more specific and relevant components, such as psychosocial factors to a more comprehensive pattern of social and health related inequalities. In this argumentation the cumulative effect of both, insufficient prevention behaviour and unequal ability of coping and resistance lead to inequalities in health (Siegrist 1989).
Dimensions of social differences as class and gender Blank and Diderichsen agree that socio-economic factors are found to be related to different ill-health measures. However, as they point out, particular dimensions of social differentiation, such as class and gender, although correlated with health, are unlikely to show direct causal relationship with health outcomes. These dimensions can be said to encompass economic, political and cultural differences representing a complex set of social conditions and processes, which are likely to interact more or less important, according to the person’s social position (Blank, Diderichsen 1996).
The ongoing debate on explanation of socio-economic inequalities in health by ‘cultural/behavioural’ versus ‘materialist/structuralist’ approaches (Townsend and Davidson 1988, Blane 1985, Smith D. et al., 1994) has important consequences for the evaluation of observed inequalities, and the strategies for reducing them. For example: inequalities in health which result from differences in structural living conditions could be regarded as unfair and to be reduced, while inequalities which arise as a result of free choices made by an individual cannot be called unfair and should therefore be accepted (Whitehead 1990, Stronks 1996).
Most empirical studies in their attempt to explain socio-economic inequalities in health consider cultural/behavioural factors (Smith et al., 1994). These studies which analyse data on socio-economic status, health and lifestyle simultaneously, show that a substantial part of the observed inequalities in health is due to the diverse distribution of behavioural factors among different socio-economic groups. For example, the British Whitehall Study and the Regional Heart Study stated that almost half of the increased risk of heart disease mortality of the lowest socioeconomic group could be attributed to lifestyle-related factors (such as smoking, physical exercise, body mass index, blood pressure, cholesterol and obesity) (Marmot et al., 1978, Pacock et al., 1987). But in both studies a gradient remained which was not explained by the traditional risk factors. However, other studies suggest that, given their effect on health (Forsdahl 1977, Martin et al., 1987, Hasan 1989) and their distinctive distribution among socio-economic groups (Hasan 1989, Mackenbach
1992) structural factors (such as housing, working conditions, financial problems employment status) are expected to contribute to the socio-economic gradient in health. Although the input of structural factors is admitted, few studies acknowledge the importance of structural factors in the same way that the contribution of lifestyle has been accepted. Behaviour is to some extent influenced by the cultural environment, through aspects such as low income, living and working conditions, and freedom of choice with respect of lifestyle may be restricted by the environment.
At the same time, an individual may choose to smoke as compensation for unfavourable circumstances such as a low income (Smith et al., 1994). Higher smoking rates among women in lower socio-economic groups for example are associated with a high level of material deprivation among these groups (Graham 1994) The authors concluded from their findings that policies promoting healthy behaviour should in any case be supplemented with measures which aim at a reduction of material inequalities (Stronks et al., 1993).
Greg J. Duncan confirms the economic dimension of socio-economic status as it relates to health. However, he claims that links between socio-economic status (SES) and health are not yet well understood and asks: “Do low-SES individuals have worse health and shorter life expectancy because of a gradual process of accumulation of disadvantages in the form of reduced access to health care, polluted or accident-prone home and work environments, worse health behaviour (e.g.
smoking, drinking and diet), or more stressful and less supportive family, neighbourhood, and employment situations? Or are many of the health differences the result of short-term differences in access to economic resources that could be addressed with tax- and tax transferred changes in the distribution of income?” (Duncan 1996).
He also underlines that the concept of socio-economic status is ‘nebulous’, because past research has used different indicators of SES, with the choice usually dictated by the available data. British studies for example generally rely on an occupation-based measure since that is often provided on vital statistics records. Cross-national comparative studies often find years of schooling the most comparable across countries. US-based research has measured SES as occupational categories, prestige, education and household income. Although ‘household income’ is not consistently used, research evidence has established that household income is a powerful correlate of mortality and the strength of the correlation between income and mortality has increased over the last 30 years (Duncan 1996).
The debate on socio-economic related inequalities in health recently received a boost when in a series of articles published in British Medical Journal in early 1997 several authors examined factors that affect the relation between deprivation and health.
Some of the arguments are summarised below.
Relative poverty vs. absolute poverty
In his article on socio-economic determinants of health Richard G Wilkinson argues that mortality in industrialised countries is affected more by relative than absolute living standards. In his view, mortality is related more closely to differences in relative income within countries than to differences in absolute incomes between them. National mortality rates, therefore, tend to be lowest in countries with smaller income differences and lower levels of relative deprivation. Most of the long-term rise in life expectancy, ultimately, seems unrelated to the long-term economic growth rate.
Important for the understanding of the reasons for these differences in health is the distinction between the effects of relative and absolute living standards.
Socio-economic gradients in health are associated with social position and with different material circumstances, from which both have implications to health. The question remains whether health disadvantage is a reflection of the direct physiological effects of lower absolute material standards (of bad housing, poor diet etc.) or is it a matter of the direct and indirect effects of differences in psycho-social circumstances associated with social position in relation to others. The indirect effects would include increased exposure to behavioural risk due to resulting from psychosocial stress, such as stress related smoking, drinking, eating disorders. Whereas the direct effects may centre on the physiological effects of chronic mental and emotional stress.
Evidence suggests that the psycho-social effect of social position has a larger part in health in equalities. This perspective would have fundamental implications for public policy and for our understanding of how socio-economic differences have an impact on health (Wilkinson 1997).
The author argues further, that the reasons for the relation between income equality and better health lies in the fact that greater income equality tends to improve social cohesion and reduce social division. Equality is proven as an essential feature of the civic community (Putman et al., 1993) Better integration into a network of social relations is known to benefit health (House et al., 1988). However, social well being is not simply a matter of strong networks. Psycho-social factors, such as low control, insecurity, and low self-esteem are known to interrelate between health and socioeconomic circumstances. Measures, such as integration in the economic life, reduced unemployment, material security and smaller income differences are expected to provide the material base for a more cohesive society (Wilkinson 1997).
Equity, poverty and health for all
In his article ‘Equity, poverty and health for all’ Kenneth C Calman, the Chief Medical Officer in the British Department of Health, confirms that health is determined by a number of factors, including biological and genetic factors, lifestyle and behaviour, the environment, social and economic factors, and health services. In all these, the concepts of equity and equality are important, and the existing variations in health may be related to any of them (Calman 1997).
Lifestyle and behaviour patterns chosen by individuals can also result in inequalities in health (e.g. cigarette smoking). However, lifestyle and behaviour that is not freely chosen, and that results in poorer health might be considered as avoidable and thus inequitable. Examples for this are health inequalities arising from the level of resources, housing conditions, dangerous working conditions, or exposure to environmental hazards, and which lead to health inequalities (Calman 1997).
The author concludes that poverty is an issue that needs special attention and those who are at particular disadvantage need special care and consideration. Tackling poverty is therefore an essential component of improving the population’s health (Calman 1997).
4. HIV/AIDS and ‘class’ and socio-economic factors of risk of HIV infection The HIV/AIDS epidemic has continued to develop, and despite differences in its details within each society, there is a common feature: in each society, the marginalised, stigmatised and discriminated became at highest risk of HIV infection.
“Those whose human rights and dignity are least respected are most vulnerable” (Mann 1995). For example, in the US, the epidemic has moved increasingly towards ethnic minority communities, poor inner city-residents, drug users, and women. In Brazil, the epidemic started among the “jet-set”, but has now become a raging epidemic among women and men in the poor regions around big cities. In Ethiopia, AIDS first seemed to affect mainly the social elite; it has now rapidly become a disease of the poor and the disenfranchised, and in France, AIDS has increasingly moved towards the excluded, those living on the margins of society (Mann 1995).
4.1 What is known about socio-economic differences among people with HIV and AIDS?
In the light of the continuing epidemic a multitude of studies were undertaken which identified the most affected population groups at risk, such as gay men, especially younger ones, women, injecting drug users and ethnic minority groups, and to highlight their knowledge level and their risk behaviour (Bochow et al., 1994, Wadsworth et al., 1994). Subsequently prevention activities have been targeted at these groups. Surprisingly few studies look more closely at the differences within these population groups at risk and relate their socio-economic situation with their risk behaviour.
The following chapter aims to provide an overview on what is known about socioeconomic differences among people with HIV and AIDS.