Is there a north-south divide in social class inequalities in health in Great Britain? Cross sectional study using data from the 2001 census
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7447.1043 (Published 29 April 2004) Cite this as: BMJ 2004;328:1043All rapid responses
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Doran et al conclude that “a northwest-southeast divide in social
class inequalities existed in Great Britain at the start of the 21st
century”. They present tables and summary statistics, but no analysis to
support this statement. Inspection of their tables suggests that the
differences between the socioeconomic groups are very consistent between
the regions. If we take their data for both men and women, we can examine
the amount of variability in the proportion of people reporting that their
health was not good which is explained by region, socioeconomic class,
sex, and interactions between each pair of these factors. I did this,
carrying out a three-factor analysis of variance with all two-way
interactions, for socioeconomic groups 1 to 7. Socioeconomic class was
the best predictor, accounting for 74.7% of the variation in proportion
reporting poor health, followed by region, which accounted for 18.5%. The
extent to which there is regional variation in social class inequalities,
as measured by the interaction between socioeconomic class and region,
accounted for only 2.5% of the variation. (This was statistically
significant, however, P<0.0001; the sample is very large.) Sex and its
interactions accounted for 3.9% of the variability, leaving only 0.4%
unaccounted for. Hence we should conclude that socioeconomic class is a
far better predictor of rating health as not good than is region and that
although the differences between socioeconomic classes vary between
regions, they do not do so by much.
This analysis is approximate and does not take into account the
relative sizes of the groups, but I doubt that weighting would change
much.
Of course, we should also bear in mind that this is reported, not
actual, health and a pretty crude indicator. Also, association does not
necessarily imply causation. It may be that ill-health leads to a slide
down the socioeconomic ladder and prevents migration to more affluent
areas.
Competing interests:
None declared
Competing interests: No competing interests
Sir
Thank you for publishing this intriguing study. The authors clearly
feel that the term " poor health" is more or less synonymous with "self-
reported poor health", as you do, if you look closely at the text your
commentary box: "What is already known...What this study adds". What
actually constitutes a precise definition of "health" is surely beyond
crisp definition, but we should at least agree that there is a difference
between health as measured objectively and that reported subjectively.
This data derives from boxes ticked in the 2001 census by
householders in the UK. I do not recall being given any guidance when I
filled out my own form in 2001 and it would have been useful if the
researchers could have reminded us what guidance, if any, was given, over
and above the implicit "tell us what you think".
This begs the question of whether people are accurate at objectively
assessing their own state of health. This issue is not addressed here, as
it should be, and the researchers could do worse than develop this theme
in future publications on the subject.
My own perspective, from the leafy southeast, is that it is hugely
biased by individual anxiety and self-esteem. As Alain de Botton has
recently argued on TV, in today's socially mobile environment, we have no
excuses for our failure to achieve other than our own personal
inadequacies (fifty years ago I might have had a case for saying the
reason I am a lowly jobbing GP and not a university professor is that I do
not have the necessary social connections. Nowadays I can only point to my
drive, ambition and intelligence as being too close to the mean). My own
(largely affluent) patients are hugely anxious about their (usually good)
health, at least when they see me, their GP. They regard themselves, when
attending my surgery, as having poor health, but nevertheless are not too
ill to whizz off to the Maldives on a regular basis.
The juxtaposition of admission of social status to self-reported
health status in the Census Questionnaire is likely to introduce some bias
as a result of this. If I am going to have to admit to having a low status
job, then at least self-reported ill-health represents a decent
explanation. My Ill-health I can reasonably see as the consequence of ill-
fortune and not therefore something for which I can be held responsible
(untruthful though this often is). Contrastingly, unintelligence and lack
of drive and ambition (qualities which are quite likely the result of ill-
fortune) are seen by ourselves as things for which we are personally
accountable, and therefore things to which
we are much less ready to admit. Not admitting to poor health begs the
question of why I am a social failure.
I would hypothesise that social status and ill-health are features
which are independantly associated with individual genetic characteristics
such as self-esteem, intelligence, ambition, drive,(actually total
physical & mental body quality), also environmental exposures such as
a goodenough upbringing and access to inherited wealth. The disparities in
self-perception of ill-health reported in this survey are very likley
influenced by the prevalence of rainfall and grim urban environment,
increasing in the UK the further north and west one goes. This may well
correlate with actual ill-health, but this study is not gospel that it
does. Had, for example, the Welsh rugby team performed significantly
better than it did in the years immediately before the census, there might
well have been a big downward shift in the rate of self-reported ill-
health in Wales, which would have affected these results.
Finally, these researchers are from a Public Health department from
Liverpool. They make no statement of conflicting interest, yet it is clear
that if national policy is influenced by these results, it will be to thier
advantage in terms of funding for their work.
But if it meant more money for the Welsh RFU, then I would not be
averse to that.
Michael Croft
Census data
Competing interests:
I live & work in the affluent South East of the UK
Competing interests: No competing interests
Health inequalities on Wirral: a living Black report?
Sir,
I read with interest the recent paper by Doran et al. Living and
working across the Mersey from Liverpool I can vouch for a significant
further divide in healthcare awareness and access.
Wirral, with a population of approximately 320,000, is longitudinally
divided neatly,by the M53 motorway,into two: a largely affluent, educated,
employed and healthy west section and less prosperous areas such as
Birkenhead, Wallasey and Leasowe. Here there are documented greater levels
of urban deprivation(as measured by the Index of Multiple Deprivation),
increased childhood accidents and teenage pregnancy as well as lower
levels of educational attainment. More specificlly there are striking
contrasts between the divided populations for of coronary heart
disease(CHD). Despite a lower than UK standardised mortality ratio (SMR)
for CHD, affluent west-Wirral residents enjoy a far greater rate of
referral for coronary angiography, angioplasty and bypass surgery than
their poorer neighbours(with higher SMRs).
Private referrals from the affluent sector do not explain this divide
and I suspect belief systems underpin some of it. Affluent educated
patients with information gleaned from the broadsheet media are more
likely to request (demand?) referral for angiography etc. Patients in
poorer areas often tend to act in crisis mode only and do not behave pro-
actively to prevent development of more troublesome outcomes. They still
tend to accept their lot without question.They also are shackled by (?ill-
conceived)yet powerful belief systems. It has been my experience to hear
statements such as "if you have angina you expect to get it two or three
times a day" or patients retelling what relatives and friends had advised
them when they had had a diagnosis of angina made: "don't be taking any
exercise, you'll only give yourself a heart attack" not uncommonly.
Patients aren't the only ones who cling to belief systems: GPs may also
suffer from such gems as "betablockers are bad in heart failure" etc. Such
concepts and ideas as these may have a crucial role in requesting care as
a patient or making a treatment decision as a GP.
Awareness of this Wirral health divide has prompted me to look at
ways of redressing the balance: almost 4 years ago we developed a
primarycare-based , accessible service, Wallasey heart Centre, using a GP
with Special Interest (GPwSI, cardiac rehabilitation and primary
prevention lifestyle services.Locally accessible, patient and carer-
centred with lots of information giving and education, it has prompted a
return to basics with the whole service revolving round the users &
families. Some of our results are striking e.g. the reduction in SMR for
CHD in Wallasey to below UK average (a statistic never before achieved;
progressively improved evidence-based prescribing of aspirin,
betablockers, ACE inhibitors and statins; much greater patient and family
involvement through personal contact; group talks; email and web access to
our service; patient-held records; and all GP letters copied to patients
with terminology increasingly being slanted away from standard medical
jargon (but keeping Read codes for more prompt GP CHD register updating).
We are now looking at further specific aspects of the wider cardiovascular
scene: chronic heart failure and also targetting of type 2 diabetes
sufferers.
PCT-wide GPwSI-driven services: the way forward in reducing UK health
inequalities?
Competing interests:
None declared
Competing interests: No competing interests