Transcript SOCIAL CLASS - Swansea University

The Social Context of Health,
Illness and Recovery
Lyn Gardner
Lecturer, Centre for Mental Health
Studies
NB this lecture is available at
http://shswebspace.swan.ac.uk/HNGardnerLD/
What is Sociology?
‘Sociology offers a distinct and highly illuminating
perspective on human behaviour. Learning sociology
means taking a step back from our own personal
interpretations of the world, to look at the social
influences which shape our lives.
Sociology does not deny or diminish the reality of
individual experience rather, we obtain a richer
awareness of our own individual characteristics, and
those of others, by developing a sensitivity towards the
wider universe of social activity in which we are all
involved.’
Giddens, A., 1989
Thinking Sociologically
• Published in 1990 by Zygmunt Bauman
• ‘sociology is first and foremost a way of
thinking about the human world’.
THINKING SOCIOLOGICALLY
‘Those human actions and interactions that
sociologists explore have all been given names
and theorised about by the actors themselves.
Before sociologists started looking at them, they
were objects of commonsensical knowledge’.
Bauman, Z., 1990
Meddlesome Sociologists….
• The questioning and critical stance taken by
sociology can sometimes be perceived as
intrusive and unsettling, or even politically
motivated (usually the left!)
• Bauman recognises this:
‘In an encounter with that familiar world ruled by
habits…sociology acts as a meddlesome and
often irritating stranger…’ (cited in Kirby et al.
1997:3)
Cont.
Yet sociology adheres to
‘the rigorous rules of responsible speech’,
argues Bauman.
Thinking sociologically ’helps us to
understand other forms of life,
inaccessible to our direct experience’
and accordingly we can ‘understand
more fully the people around us’.
Alan Bennett
The well know English writer makes a similar point
in his book Writing Home (1996) when he
comments on the usefulness of sociology in
providing insights into social life:
‘I go to sociology not for analysis or
explications but for access to experiences
I do not have and often do not want
(prison, mental illness, birth marks)’.
THE SOCIOLOGICAL IMAGINATION
‘The ability to recognise that personal troubles are
in fact public ills – what we perceive as
individual problems can be understood and
explained only when we examine social,
economic and political factors.
Sociology, then, is about understanding the
relationship between our own experience and
the social structures we inhabit.’
C. Wright Mills, 1954
USING A SOCIOLOGICAL
IMAGINATION
‘The worker may have exploited a
sociological imagination to question
commonsense understandings of
poverty…leading to a conceptualisation of
poor people as victims of a social system
predicated on inequality.’
Sullivan, 1987
The Social Model of Health, Illness
and Recovery
• This model, or approach, suggests that social
•
factors influence health: from mortality rates to
recovery
Accordingly, it is important to look at the
significant structural factors which may influence
health, illness and recovery: social class/socioeconomic status, gender and ethnicity, and the
impact of poverty and mental illness
HEALTH INEQUALITIES
• Social circumstances across the entire life-course
•
•
– from birth to late adulthood – influence
people’s health and well-being.
Different socio-economic indicators –
income, wealth, educational attainment and
occupational group – are all related to and help
explain people’s health status.
Health inequalities are produced by the
clustering of disadvantage – in opportunity,
material circumstances and behaviours related
to health – across people’s lives.
Social determinants of health (Acheson, 1998)
Interaction of structural factors and individual
behaviour
SOCIAL STRATIFICATION
THE RICH MAN IN HIS CASTLE
THE POOR MAN AT HIS GATE
GOD MADE THEM HIGH AND LOWLY,
AND ORDERED THEIR ESTATE.
All Things Bright and Beautiful,
Mrs. C.F. Alexander, 1848.
STRATIFICATION
• DIVISION OF SOCIETY INTO
HIERARCHICALLY ORDERED LAYERS
• MEMBERS OF EACH LAYER BROADLY
EQUAL, BUT INEQUALITY BETWEEN
LAYERS
SOCIAL CLASS
‘A large scale grouping of people who share
common resources which strongly
influence the type of lifestyle they are able
to lead.’
(Giddens, 2001, p.282)
LIFE CHANCES
• ‘The chances of obtaining those things
defined as desirable and avoiding those
things defined as undesirable in society.’
(Haralambos, 1995)
‘Inequality in health is the worst inequality
of all. There is no more serious inequality
than knowing you’ll die sooner because
you’re badly off.’
Frank Dobson, Secretary of State for
Health, 1997.
MEASURING SOCIAL CLASS:
The Registrar General’s Scale
In Britain, government statisticians have
measured social class with the Registrar
General’s Social Class (RGSC) scale since
1911
R.G. SCALE
I
Professional
doctor.
e.g. lawyer,
II
Intermediate
e.g. teacher, nurse.
IIIN Skilled non-manual e.g. typist, shop
assistant.
IIIM Skilled manual e.g. carpenter, miner.
IV
Partly skilled manual
worker.
V
Unskilled manual
labourer.
e.g. farm
e.g. cleaner,
REGISTRAR GENERAL’S
SCALE
• MEN ALLOCATED ON BASIS OF
OCCUPATION
• MARRIED/COHABITING WOMEN ON
BASIS OF PARTNER’S OCCUPATION
• CHILDREN ON BASIS OF FATHER’S
OCCUPATION
• SINGLE WOMEN ON BASIS OF OWN
OCCUPATION
MEASURING SOCIAL CLASS II The National
Statistics Socioeconomic Classification (NSSEC)
In use since 2001 census
Reflects:
• growth of middle-class occupations
• changing mature of kinds of work that
people do
• levels of social esteem that these jobs
attract
NS –SEC social class classification system
Social Class
Occupation
1Higher managerial & professional Doctor, lawyer, professor
2 Lower managerial & professional Teacher, nurse, police
sergeant
3 Intermediate
Secretary, fire fighter, HCSW
4 Small employer & self employed
Builder, hairdresser
5 Lower supervisory & technical
Craftsman, supervisor
6 Semi-routine
Shop assistant, postal worker
7 Routine
Bus driver, cleaner
8 Never-worked or long-term
Students, unemployed
Following an extensive review of the evidence,
MacIntyre (1986) concluded that
“occupational class (whether of self, father or
husband) has repeatedly been shown to be
associated with a diverse collection of health
measurements, including death from all causes or
from specific causes, physical or mental illness,
height, weight for height, birth weight, blood
pressure, dental condition, ability to conceive and
self perceived health.” (p.395)
THE BLACK REPORT
• Commissioned at end of 1970s by Labour
government, chaired by Sir Douglas Black.
• To review evidence on inequalities in health
& suggest policy recommendations.
• Published in 1980 at start of Thatcher's new
Conservative administration.
• Not widely disseminated – only 260 copies
printed.
THE HEALTH DIVIDE
• Subsequent edition published by Penguin in
dual volume with Whitehead’s The Health
Divide (1987) which updated the findings,
edited by Peter Townsend and Nick
Davidson.
• This publication made the findings widely
available and made for a shocking
indictment on the state of the nation’s poor.
THE ACHESON REPORT (1998)
• An independent inquiry into inequalities in
health
• Commissioned by the Labour Government
• Access via internet: www.archive.officialdocuments.co.uk
EXPLANATIONS FOR
INEQUALITIES
• ARTEFACT
• SOCIAL SELECTION THEORY
• CULTURAL/BEHAVIOURAL
• MATERIALIST
ARTEFACT
• Relationship between social inequality and
health chances has been created by
researchers - an artefact being something
made by people.
• Official mortality and morbidity statistics
are unreliable and invalid.
SOCIAL SELECTION
EXPLANATION
• Argues that health status influences social
status
• i.e. healthy people - upwardly mobile and
unhealthy drift into lower social classes.
CULTURAL/BEHAVIOURAL
EXPLANATIONS
• Suggests that different social classes
behave in different ways
• i.e. the poorer health of lower social
classes is caused by behaviour that
damages health
• the culture of higher social classes leads
to better health and longer life expectancy
LIMITATIONS TO
CULTURAL/BEHAVIOURAL
THEORY
• Behaviour is often a result of economic
circumstances
• Lifestyle/behaviour make a bigger
contribution to health for the affluent
than for the poor
ALSO
• There are significant cultural variations
within each social class
• There is considerable cultural overlap
between different social classes
• Impact of other social factors such as
ethnicity, gender, location and age
MATERIALIST/STRUCTURAL
EXPLANATION
• Social class differences in health are
caused by the different working and living
conditions of the different social classes
WORKING CONDITIONS
• Manual occupations associated with higher
rates of morbidity and mortality.
• Unemployment associated with higher
rates of morbidity and mortality.
LIVING CONDITIONS
• Blackburn (1991) suggests that low
income damages health in 3 ways
• 1. Lack of resources (for food and shelter)
can make one vulnerable to physical
illness.
• 2. Lack of control over one’s
circumstances can be psychologically
damaging
• 3. Coping strategies adopted by those on
low income may lead to behaviour that
damages health
Evidence
Most sociologists conclude, as did the
authors of the Black Report and Acheson
Report, that differences in material
circumstances are the main determinants
of inequalities in health
POVERTY, HEALTH AND SOCIAL
EXCLUSION
What contribution can sociology
make to an understanding of
poverty and its impact on
health?
DEFINING POVERTY
‘Poverty means going short materially, socially and
emotionally. It means spending less on food, on
heating, and on clothing than someone on an
average income. Above all, poverty takes away the
tools to build the blocks for the future – your life
chances. It steals away the opportunity to have a
life unmarked by sickness, a decent education, a
secure home and a long retirement’.
Oppenheim and Harker, 1996:4.
Income inequalities lead to lower levels of
social capital, largely through:
‘feelings aroused by social comparisons to do with
confidence, insecurity and fears of inadequacy.
Social hierarchy induces worries about possible
incompetence and inadequacy, feelings of
insecurity and feelings of inferiority’
(Wilkinson, 1999, p.262).
SOCIAL CAPITAL, Wilkinson (1996)
• A high degree of income inequality in a rich
country:
• Makes social divisions worse
• Reduces levels of trust
• Increases social anxiety and stress level
DEFINING POVERTY
Absolute Poverty
Families are in poverty when their incomes
are ‘insufficient to obtain the minimum
necessities for the maintenance of physical
efficiency’ B.S. Rowntree, 1941.
Relative Poverty
‘Individuals, families and groups in the
population can be said to be in poverty
when they lack the resources to obtain the
types of diet, participate in the activities and
have the living conditions and amenities
which are customary, or at least widely
encouraged or approved, in the societies to
which they belong.’
Townsend, 1979.
SOCIAL EXCLUSION
Refers to the ‘dynamic process of being shut
out, fully or partially, from any of the social,
economic, political and cultural systems
which determine the social integration of a
person in society.’
Walker and Walker, 1997.
MANIFESTATIONS OF
EXCLUSION
• Social – isolated, weak or limited social
network.
• Economic – un/employment, insecure, low
paid work.
• Political – links to above re.work, not
registered to vote,no voice/disempowered.
• Cultural – little opportunity to engage in
varied range of cultural activities.
MEASURING POVERTY
• No official poverty line in Britain
• Researchers use statistical indicators such
as benefit provision required to bring
people's income up to subsistence level
• Most commonly used threshold of low
income is 60% of median (middle) income.
SUBJECTIVE MEASUREMENTS OF
POVERTY
Opinion polls conducted on what ordinary
people considered to be ‘necessities' for
an ‘acceptable’ standard of living –
producing ‘deprivation indices’.
EXTENT OF POVERTY IN
BRITAIN
• In 2002/3 12.4 million people on incomes below
•
•
•
this income threshold
This represents a drop of 1.5 million since 1996/97
In 2002/3 3.6 million children were living in
households below this income threshold
The Black Report concluded that ‘above all, we
consider that the abolition of child poverty
should be adopted as a national goal for the
1980s.’Townsend & Davidson, 1988.
WHY ARE POOR PEOPLE POOR?
Two main explanations:
• Responsibility lies with the individual or
group – ‘blame the victim’
• Structural forces in society shape
disadvantage – ‘blame society’
BLAME THE VICTIM
• Poor people are poor because of the things
they do and the choices they make.
• Culture of poverty into which poor
children are socialised. Transmitted across
generations – people resign themselves to
their plight.
• Cycle of poverty
BLAME THE VICTIM cont.
• Very popular theory – regard the poor as
responsible for their own poverty and are
suspicious of those living on welfare
benefits
• Frequently voiced through tabloid press
CRITICISMS OF INDIVUALISTIC
EXPLANATIONS
• Ignores wider issues – too simplistic
• Neither culture of poverty or cycle of
deprivation explain how people came to
be poor in the first place
BLAME THE SYSTEM
• Emphasises wider social processes – political and economic factors –
that produce conditions of poverty which are difficult for individuals to
overcome.
• For example – educational opportunities, employment
patterns/opportunities e.g. Closure/relocation of manufacturing
industries.
• Class, gender and ethnicity.
• Taxation policies that benefit the better off.
• Lack of affordable childcare that reduces parent’s (especially women
and lone parents) ability to work.
STRUCTURAL FORCES SUCH AS:
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•
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Class
Ethnicity
Gender
Age
Occupational position
Educational attainment
Shape the way in which resources are distributed
POVERTY IS BAD FOR YOUR
HEALTH
• Lack of resources (for food & shelter) can
make one vulnerable to physical illness
• Lack of control over one’s circumstances can
be psychologically damaging
• The coping strategies adopted by those on
low income may lead to behaviour that
damages health
POVERTY:THE IMPACT ON
CHILDREN’S MENTAL HEALTH
• 1 in 10 children in the UK had a clinically
•
•
•
•
recognisable mental disorder in 2004 (Office for
National Statistics)
Prevalence varied according to family
characteristics:
More common among single-parent families
More common in families where both parents
were unemployed
More common among children whose parents
had no educational qualifications.
HEALTH RELATED BEHAVIOURS
- SMOKING
• Health-related behaviours – such as smoking and diet –
are strongly influenced by the social environment in which
people live. People do not have equal choices about
how they live their lives. (Shaw et al 1999).
Surviving by Smoking, Hilary Graham, 1994.
• ‘Smoking is one of the ways women handle and diffuse the
contradictory pressures that structure their daily lives. It
provides a way of keeping going when women have little
going for them.’
SMOKING
• ‘The habit identified as the major cause of
•
•
•
premature death and childhood ill-health in Britain
is – paradoxically- one which many women identify
as essential to their survival and to the survival of
their families’
‘Maternal smoking is a habit through which the
welfare of children is simultaneously threatened
and protected’
Smoking can be ‘experienced as a preventive
strategy for non-accidental injury’
Smoking has a clear ‘mood management function’
SPENDING ON TOBACCO
• ‘Like food and fuel, spending on tobacco is
inversely related to income: more is spent
proportionately on tobacco as household
income falls’
• ‘Tobacco spending has the hallmark of
necessity’
• ‘Women recognise the contradictory kind of
support that smoking provides…smoking
illuminates the toll that social divisions take on
the welfare of women and their children’.
Poverty, Smoking and the Health
Professional
‘how can they be poor when they always
have money to spend on cigarettes, a four
pack, and they all have televisions and
videos. I don’t know why they have
children, they can’t look after them, feed
them, or buy then the things they need’
Cont.
‘we spend hours telling them how to eat
properly. What food to buy, what is good
for them and the baby. What do they do?
Live on chips and fags. It’s a waste of my
time and effort. They never breast-feed,
don’t take iron and never take advice’
Hunt, S. 2004.
‘Fags are good…
to relax. After a hard day with the kids I
like to curl up with a fag. I only smoke
when the kids are outside or after they
have gone to bed. I know it’s not good for
them, but it’s good for me, it helps me
unwind’
Emma quoted in Hunt, 2004
WOMEN, POVERTY AND HEALTH
‘Women bear the brunt of poverty, it is
women who manage poverty on a daily
basis and it is women who struggle to feed,
clothe and house themselves and their
children’.
Hunt, 2004:23
The burden of ‘managing poverty’ has clear
consequences for the health status of
women.
WHY ARE WOMEN POOR?
• Multifactoral
• Women who are pregnant, women with small children,
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•
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women from ethnic minority groups and those who have
missed out on education are marginalised and excluded
(Walby, 1997)
Lone parent families – approx 21% of all families; 90% are
mother-headed lone parent families.
Women are more likely to be in low-paid work
Women are more likely to have responsibility for child and
other care, reducing their capacity for employment, secure
work and promotion.
CONCLUSION
‘Poverty is best understood as a function of
social, economic and political structures
and processes which create and
perpetuate an unequal distribution of
resources both within and, in a global
context, between societies’ (Lister, 2004).
Cont.
Reducing health inequalities requires that
the underlying causes of these inequalities
are tackled (Shaw, et al. 1999)
SEMINAR GROUPWORK
• Why are poor people poor?
• What is your response to the contradictory
nature of health damaging behaviour?
• What are the implications of the effects of
health inequalities on the role of the nurse?
RESOURCES
Blackburn, C. (1992) Poverty and Health
Shaw, M. et al (1999) The Widening Gap
http:www.jrf.org.uk (Joseph Rowntree Foundation)
http://www.poverty.org.uk/intro/
www.archive.official-documents.co.uk
www.dh.gov.uk
www.statistics.gov.uk