Which of the following explanations about inequality, poverty and health cultural/behavioural, social cohesion, neo-material and psychosocial

l - do you find most convincing and why? In society today those individuals considered from a working class background are in general more likely to have higher mortality and morbidity rates than their middle-class counterparts. Although the stratification of society may have changed throughout history, those at the bottom are generally always worse off. Class is a complex stratification of society based on access to and control of power, status and economic resources (Barry and Yuill 2008). Those at top of this hierarchy are wealthier and have greater control over a range of resources whereas those at the bottom may struggle to meet even the most basic necessities.(Barry and Yuill 2008, Denny and Earle 2008). Measuring class is very difficult it is not simply a case of splitting society in to upper,middle or working class anymore-as was done in the 19th century. The National Statistics Socio-economic Classification (NSSEC) reflects contemporary socio-economic differences in the labour market and work situations(Denny and Earle 2008).It classifies individuals from class1(higher maneggerial and professional) to class 8(never worked or long term unemployed). The first major report on the disparity of health between classes was Chadwicks (1842) report- which revealed the poorest in society had the highest mortality rates and lived in the most unsanitary areas(Denny and Earle 2008). More recently the Black report showed a clear trend in increased mortality and morbidity rates along the class scale of 1(professional) to 5(unskilled)(Black 1980). Although it showed the absolute health of the nation had increased with a decline in death rates in all classes from the period 1841 to 1971, it went on to show the gap between rich and poor had widened. The Acheson Report ( also showed death rates had fallen between the early 1970s and the early 1990s but it too confirmed the gap between classes had widened(Acheson 1998).

The link between socioeconomic status and health is obvious however the link itself is the subject of much debate. The Black report gave four explanations for its findings: the artefact explanation, the social selection explanation, behavioural/cultural explanation and the materialist /structuralist explanation. Since then the psycho-social and neomaterialist theories have also been put forward. This essay will analyse and evaluate just a few of these in attempt to find how persuasive each model is and its limitations if it has any. The first of which will be the behavioural/cultural theory. Culture is defined by Cambridge Advanced Learners Dictionary as the way of life, especially the general customs and beliefs, of a particular group of people. It is this cultural environment which influences the behaviour of a person according to the cultural behaviour theory. It is argued by Gabe et al. (2004) cultural restrictions certainly can be forceful and imposing, which is seen for example in the rules for male and female behaviour in all societies. The different classes are presumed to have different lifestyles, attitudes, behaviours and beliefs i.e. culture, especially concerning health promoting and health damaging activities (Wilkinson 1986).Working class culture seems to value unhealthy behaviours such as smoking, drinking alcohol and eating too much fatty foods, whereas the middle-class culture tends to embrace health enhancing behaviours (Denny and Earle 2008). The Wanless report (2002) cited in Nettleton (2006) showed many of these unhealthy activities were considerably related to socio-economic position . Black (1980) revealed those on an income >110 pw had 16oz more fruit per week and 5.5oz less sugar per week than those on an income of< 40 pw. Peretti-Watel et al.s (2008) study reveals 23 % of executive managers and professional occupations (considered middle) smoked in 2007 whereas 44% of the unemployed and 35% of workers smoked (working or lower class).The same study also suggested that poorer smokers culture sees cigarettes as the first choice relaxant as a possible factor. This suggests cultural values have a large impact to health.

However it can be argued in reality peoples behaviour is not only influenced by their culture or personal taste but by also their material constraints, such as income or housing (Wilkinson 1986). Peretti-Watel et al.s study (2008) showed poor housing and neighbourhood conditions correlated with smoking, for example. Those with a lower income mentioned by Black(1980)may not buy fruit or brown bread simply because they cannot afford it rather than because they prefer it to the unhealthier options. As Wilkinson (1986) further argues peoples taste may also, in part, be determined by their, or their parents, constraints. If the black taken as an example again: those brought up on white bread rather than brown e.g. income group D are likely to prefer white bread and enjoy its taste more than its brown counterpart, as Wilkinson argues these people are likely to develop tastes that accord with their situation. The same study(Peretti-Watel et al.2008) also revealed poor smokers were poor quitters -the prevalence of smoking among professionals decreased by 36% whereas among workers it decreased by a smaller amount of 22%.( Peretti-Watel et al.2008).Some health economist hypothesise this is due to the fact that less educated people are less able to understand the harmful effects of smoking. Education being a material factor also shows the importance of material factors on behaviour.( Peretti-Watel et al.2008) These points reveal the limitations of this theory and perhaps the health inequalities on the basis of behaviour should not only be linked with the cultural environment but also with the material environment. This theory was also suggested by Wilkinson who believes the ways in which behavioural and materialist explanations are separated in the black report may be misguided (Wilkinson 1986). This brings me on to the next theory which is that of the neo-material theory. Neo-material theory deals with the impact of material factors on health (Barry and Yuill 2008). Factors such as poverty, the distribution of income, unemployment, housing conditions, pollution and working conditions in both the public and domestic spheres i.e resources

(Blackburn 1991,nettleton 2006).Wilkinson also adds inequalities in power in society to this, while Barry adds educational disadvantage and access to decent social welfare. For example in Britain, the least affluent 50% of the population receive only 25 % of the total income while the richest 10% receive 25% of the total income (Denny and Earle 2008). We have already discussed the effect of the material on behaviour and consequently on health. However there are more direct effects of poor living conditions or low income on health. There appears to be a relationship between poor housing and respiratory problems (Eames et al. cited by Nettleton 2006) and heart disease (marmot 2004 cited by Nettleton 2006) when smoking and employment history are held constant. Also a recent South Korean study showed those in the highest income bracket (I) had a relative risk of dying of 1.00 compared to the lowest (IV) of 1.56(Khang et al.2008.). The study which investigated psychosocial contributions to health as well as material through a number off investigations went on to conclude material factors mattered more than psychosocial factors. It is easy to see how low income and poor housing can be detrimental to health. However it is a limited theory in that it does not take into account cultural effects on health-which can be marked as discussed, just as behavioural cultural theory is limited in that it does take into account material effects on health. As suggested above perhaps the two could be fused into one theory- a balance between the two would be more productive it is suggested by Macyntyre() cited in Nettleton (2006). Mainly because as Gabe et al.(2004) suggests by talking about cultural and material factors we are able to include most aspects of human existence. The psycho-social theory deals with the psychological impacts of social structure on mental and consequently physical health as well. Psychosocial theory emphasises the negative emotional experiences of living in an unequal society, particularly feelings of stress, shame and powerlessness (Barry and Yuill 2008).The effect of inequality and social status on health can be summed up in two main ways: lack of social cohesion and lack of self esteem (nettleton,marmot). The more inequality

there is in a society the less socially cohesive and therefore more socially divisive it will be(nettleton 2006) and as result the most disadvantaged will feel more isolated and insecure(Wilkinson cited in understanding). These feelings along with lack of social support (due to less social cohesion)(nettleton 2006) result in greater levels of chronic stress (understanding). The lack of self esteem manifests itself from a feeling of less being able to control circumstances-which is associated with people lower own the social hierarchy, a feeling which can be internalised and reinforce anxiety and stress.(nettleton 2006). These psychosocial injuries and stresses affect a persons health directly such as the cardiovascular system(blood pressure), endocrine system( cortisol secretion) and the immune system(the number of T cells) (Elstad nettleton 2006).The stress also indirectly affects health by causing people to indulge in unhealthy behaviour such as smoking as coping mechanisms.(miles,2467) It was found that in some affluent western countries such as Sweden the health differences between classes were marginal while England and Wales showed sharp differences (barryand Yuill 2008 Wilson). It was suggested this was because of greater income equality in Sweden compared to England and Wales.(Wilkinson cited Barry and Yuill 2008).It was also found the lowest social group in Sweden has a better mortality rate than that of the highest social group in England therefore greater income equality would benefit the highest social groups as well as the lowest.(barry and Yuil 2008) A pregnancy study concluded women with high levels of pregnancyrelated anxiety, high job strain, and exposure to physical/sexual violence more often continued to smoke during pregnancy.( Goedhart et al.2008). It suggested one of the main reasons was because smoking enhances the sense of well-being and is used as a tool to cope with negative mood or stress experiences. (Miles 2006) also agrees.This supports the theory that stress indirectly affects health by causing harmful coping behaviour. The last theory of social cohesion has already been mentioned as it almost stems from psycho-social theory. A healthy society exhibits high

social cohesion (Wilkinson barry) according to this theory. Social cohesion implies feeling part of a society or group it is this feeling part of something which helps people to be healthier Barry. Socially cohesive societies exhibit mutual aid, narrow differences in income and a shared sense of purpose or belief.(barry and Yuill) It was discovered the greatest increases in life expectancy occurred during the world wars. It is suggested this was due to rationing because rationing allowed everyone to access a decent diet but no rationing occurred during the First World War. So improvements in diet did not cause the increase in life expectancy. The fact they lived in a more egalitarian society with a common sense of identity and purpose was the cause argues Wilkinson. Conversely in an unequal society social relations will suffer causing anger, frustration, hostility, fear, insecurity and other negative emotions (Elstad,J.I.1998.). We have already discussed how these negative emotions cause stress which in turn damages health. Lynch et.al cited in Denny and Earle) use an airline travel metaphor to illustrate the shortcomings of the psychosocial theory. First class passengers have more space, better food and seats to recline into beds so they tend to arrive relatively refreshed. Those in economy class lack these advantages and so are likely to arrive feeling tired. Psychosocial theory suggest this is because the economy passengers know the first class passengers have better provisions than them so they cannot sleep whereas it is more likely because the cramped conditions kept them awake-as neo-material theory suggests. This theory ignores the structural causes of inequality such as availability of healthy food which has a major impact on health. Neither does this theory explain the reasons why inequalities exist in the first place e.g in the above example why do the economy passengers travel in economy in the first place. Regarding social cohesion, sometimes tight nit communities may not be a good thing as the minority may become alienated and become stressed or discriminate against. (Barry and Yuill). The neo material theory is certainly more persuasive than the psychosocial or social cohesion theory which is very limited.

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