Health Psychology. Michael Murray
low SES using Bronfenbrenner’s (1979) systems approach. The box shows the many different disadvantages across all four systems of the social, physical and economic environment. In addition, we can add the high levels of perceived injustice that many people with low SES may feel.
Scientific Explanations
Any explanation of the SES–health gradient needs to consider psychosocial systems that structure inequalities across a broad range of life opportunities and outcomes – health, social and educational. As illustrated in Box 5.1, in comparison to someone at the high end of the SES scale, the profile of a low SES person is one of multiple disadvantages. The disadvantages of low SES accumulate across all four ecosystems. It is this kind of accumulation and clustering of adverse physical, material, social and psychological effects that could explain the health gradient. While each factor alone can be expected to produce a relatively modest impact on mortality, the combination and interaction of many kinds of ecosystem disadvantage are likely to be sufficiently large to generate the observed gradient. The socio-economic conditions that contribute to the health gradient can also be experienced by individuals across the life course (Pavalko and Caputo, 2013).
While the Black Report (Townsend and Davidson, 1982) clearly documented the link between social position and health, it also detailed four possible explanations for health inequalities:
An artefact: the relationships between social position are an artefact of the method of measurement.
Natural and social selection: the social gradient in health is due to those who are already unhealthy falling downwards while those who are healthy rise upwards.
Materialist and structuralist explanations: emphasize the role of economic and socio-structural factors.
Cultural and/or behavioural differences: ‘often focus on the individual as the unit of analysis emphasizing unthinking, reckless or irresponsible behaviour or incautious lifestyle as the moving determinant’ (Townsend and Davidson, 1982: 23).
BOX 5.1 Behaviours and experiences associated with low SES
Microsystems: families, schools, neighbourhoods
Low birthweight
Family instability
Poor diet/nutrition
Parental smoking and drinking
Overcrowding
Poor schools and educational outcomes
Poor neighbourhoods
Mesosystems: peer groups
Bullying, gangs and violence
Smoking
Drinking
Drugs
Unprotected sex
Exosystems: parental support systems, parental workplaces
Low personal control
Less social support
Unemployment or unstable employment
High stress levels
Low self-esteem
Poorer physical and mental health
Macrosystems: political philosophy, social policy
Poverty
Poor housing
Environmental pollution
Unemployment or unstable employment
Occupational hazards
Poorer access to health services
Inadequate social services
While accepting that each explanation may contribute something, the report emphasized the importance of the materialist explanations and developed a range of policy options that could address the inequalities. Contemporary research into explanations for social inequalities in health has been reviewed by Macinko et al. (2003). Their classification extends the four-fold explanation developed in the Black Report.
Psychosocial explanations are considered at the individual (micro) and social (macro) levels. At the micro level, it is argued that ‘cognitive processes of comparison’, in particular perceived relative deprivation, contribute to heightened levels of stress and subsequent ill health. Additionally, the Whitehall studies suggested that it was the lack of perceived control over working conditions that increases stress at the lower end of the social scale. At the macro level, psychosocial explanations focus on the impairment of social bonds and limited civic participation, so-called social capital (see below), that flows from income inequality.
The neo-material explanations have drawn increased support in critiques of the psychosocial approaches (see Macleod and Davey Smith, 2003; Marks, 2004; Stephens, 2014). They focus on the importance of income and living conditions. At the micro level, it is argued that in more unequal societies those worse off have fewer economic resources, leading to increased vulnerability to various health threats. At the macro level, high income inequality contributes to less investment in the social and physical environment. In addition, it has been argued that sustained exposure to stress from various sources, including financial hardships and poor living conditions, can have adverse biological effects and subsequently lead to various health problems (Taylor et al., 1997). Those who favour the neo-material explanations argue that the psychosocial explanations ignore the broad political context within which social and health inequalities are nested.
There are also the artefact and selection explanations of the social inequalities in health. Although these initially attracted attention, there is less support for these arguments today.
Contemporary research has focused on the relationship between the extent of social inequality in a particular society and the extent of ill health. Wilkinson (1996) argued that health was poorer in more unequal societies. In their book The Spirit Level, Wilkinson and Pickett (2010) provided a comprehensive analysis of the empirical association that exists between health/social problems and inequality among rich countries. For example, higher infant mortality rates were shown in countries where income inequality is high. The same index of health/social problems was found to be only very weakly related to national income but strongly related to inequality. Wilkinson and Pickett (2010) hypothesized that the structural inequality in society causes people to become more anxious, stressed, ashamed, untrusting and unhappy. In the same year that The Spirit Level was published, the Equality Trust (https://www.equalitytrust.org.uk/) was founded by the authors and Bill Kerry. This charity aims to develop and promote policies to reduce social inequalities.
Torre and Myrskylä (2014) examined the relationship between income inequality and health using data from 21 developed countries over a 30-year period. Findings suggested that income inequality was positively related to the mortality of males and females at ages 1–14 and 15–49 years. The positive correlation between income inequality and mortality of females was also found at ages 65–89 years, although this relationship was weaker than for the younger age groups. These findings suggest that narrowing the income inequality gap may be an effective way to promote health, especially among children and young to middle-aged groups. However, we need to remember, once again, that correlation does not mean causation. As previously argued, the relationship between income inequality and health is not as straightforward as was initially conjectured (Lynch et al., 2004). However, as Lynch and Davey Smith (2002) also warned, we should be careful not to throw the ‘social inequality baby’ out with the ‘income inequality bathwater’. There is much more to social inequality than inequality of income.
Social Justice
Critics of research into social inequalities in health often charge that social inequalities