“The demonstration of a social gradient of health predicts that reducing inequality itself has health benefits for all, not simply for the impoverished or deprived minorities within populations. ” (Devitt, Hall & Tsey 2001) The above quote from Devitt, Hall and Tsey’s paper is a relatively well grounded and well researched statement which draws on contemporary theoretical sociological concepts to support the assertion that reducing inequality is the key to improving health for all.
However the assertion that the demonstration of a social gradient of health predicts that a reduction in inequality will lead to health benefits for all is a rather broad statement and requires closer examination. The intention of this essay is to examine the social gradient of health, whose existence has been well established by the Whitehall Studies (Marmot 1991), and, by focusing on those groups at the lower end of the social gradient, determine whether initiatives to address inequalities between social classes will lead to health benefits for those classes at the lower end of the social scale.
The effectiveness of past initiatives to address these social and health inequalities will be examined and recommendations made as to how these initiatives might be more effective. The social gradient described by Marmot and others is interrelated with a variety of environmental, sociopolitical and socioeconomic factors which have been identified as key determinants of health. These determinants interact with each other at a very complex level to impact directly and indirectly on the health status of individuals and groups at all levels of society; “Poor social and economic circumstances affect health throughout life.
People further down the social ladder usually run at least twice the risk of serious illness and premature death of those near the top. Between the top and bottom health standards show a continual social gradient. ” (Wilkinson & Marmot 1998) In Australian society it is readily apparent that the lower social classes are at greater disadvantage than those in the upper echelons of society; this has been discussed at length in several separate papers on the social gradient of health and its effects on disadvantaged Australian groups (Devitt, Hall & Tsey 2001, Robinson 2002, Caldwell & Caldwell 1995).
Within the context of the social gradient of health it can be inferred that Indigenous groups, for example, are particularly susceptible to ill health and poor health outcomes as they suffer inordinately from the negative effects of the key determinants of health. A simple example of this is the inequality in distribution of economic resources: “Average Indigenous household income is 38% less than that of non-Indigenous households. ” (AHREOC 2004). The stress and anxiety caused by insufficient economic resources leads to increased risk of depression, hypertension and heart disease (Brunner 1997 cited in Henry 2001).
Higher social status and greater access to economic resources is concomitant with a reduction in stress and anxiety levels, as individuals in these groups have more control over economic pressures which create this stress. This simple comparison proves that the social gradient of health accurately reflects how socioeconomic determinants affect the health of specific social classes at the physiological level. An extension of the research into the social gradient and the determinants of health is the examination of the pathways through which specific social groups experience and respond to these determinants.
These ‘psychosocial pathways’ incorporate psychological, behavioural and environmental constraints and are closely linked to the determinants of health; “Many of the socio-economic determinants of health have their effects through psychosocial pathways. ” (Wilkinson 2001 cited in Robinson 2002). These pathways have been demonstrated by Henry (2001) in the conceptual model of resource influences (Appendix A), a model which illustrates the interaction between the constraints mentioned above and their impact on health outcomes.
Henry states that a central differentiator between classes is the amount of control an individual feels they have over their environment. Whereas an individual from a lower class group holds a limited sense of control over their well being and consequently adopts a fatalistic approach to health, those in higher classes with a stronger sense of control over their health are more likely to take proactive steps in ensuring their future wellbeing.
This means that both individuals will cope differently with the same health problem. This is partly as a result of socioeconomic or environmental determinants relative to their situation, but it is also a result of behavioural/physical constraints and, most importantly, the modes of thought employed in rationalising their situation and actions. In essence these psychosocial pathways occupy an intermediate role between the social determinants of health and class related health behaviours.
This suggests that, while the social gradient of health is a good predictor of predisposition to ill health among specific classes, it cannot predict how reducing inequality in itself will affect health outcomes or how a specific social class will respond to these changes. An examination of some initiatives aimed at reducing inequality in the indicators of health outcomes reveals this problem; “In 1996 only between 5% and 6% of NT Aboriginal adults had any kind of post secondary school qualification compared with 40% of non-Aboriginal Territorians. ” (ABS 1998).
Within the context of the social gradient of health, education is an important indicator of health outcomes. It is evident from the quote above that there exists huge inequality within the Northern Territory education system; this suggests an increased likelihood of ill health for Aboriginal people in later life. Even though there have been initiatives to address this inequality in one of the indicators of health outcomes (Colman 1997, Lawnham 2001, Colman & Colman 2003), they have had only a minimal impact on Indigenous second level education rates (ABS 2003).
This is partly due to the inappropriateness of these initiatives (Valadian 1999), but it is also due to the disempowerment and psychosocial malaise (Flick & Nelson 1994 cited in Devitt, Hall & Tsey 2001) which are a feature of Indigenous interaction and responses to the social determinants of health. Research has also been carried out into how effecting change in the inequalities in other indicators of health might affect health outcomes. Mayer (1997) cited in Henry (2001) examined the effects of doubling the income of low income families and concluded it would produce only modest effects.
Henry believes that this points to the strong influence of the psychological domain in influencing health behaviours. This suggests that the key to better health for all lies not just in reducing inequality between the classes but also in changing those elements of the psychological domain which influence health behaviour. Another example of the gap between initiatives to reduce inequality and their impact on those inequalities is evident in an examination of economic constraints experienced by Indigenous Australians on social welfare.
Price and McComb (1998) found that those in Indigenous communities would spend 35% of their weekly income on a basket of food, compared to just 23% of weekly income for those living in a capital city for the same basket of food. To combat this inequality it would seem logical to reduce the price of food in Indigenous communities or else increase the amount of money available to those living in remote communities, i. e. a socioeconomic approach.
It has already been established that increasing income has only modest effects and in combination with the fact that smoking, gambling and alcohol account for up to 25% of expenditure in remote communities (Robinson 2002), how can it be guaranteed that the extra funds made available through either of the two suggestions above would be employed in achieving a desirable level of health? One possible suggestion is that a socioeconomic approach must be complemented by a psychosocial approach which addresses those abstract modes of thought, cultural norms and habits and health related behavioural intentions which dictate healthful behaviours.
“Culture and culture conflict are factors in Aboriginal health. But instead of the emphasis being placed on Aboriginal failure to assimilate to our norms, it should rather be put on our failure to devise strategies that accommodate to their folkways. ” (Tatz 1972 cited in Humphrey & Japanangka 1998) Any initiative which hopes to resolve inequality in health must incorporate a sound understanding of the influence of the psychosocial pathways relative to the class level and cultural orientation of that group, otherwise its success will be modest at best.
Using Henry’s model of resource influences provides a framework for understanding how addressing these psychosocial pathways can lead to greater uptake of initiatives designed to address these inequalities. An analysis of the National Tobacco Campaign (NTC 1999) reveals how this initiative failed to impact significantly on Indigenous smoking rates. This was a purely educational initiative which aimed to raise awareness of the effects of smoking on health.
One of the primary flaws of its design was its failure to even acknowledge those Indigenous groups at the lower end of the social scale; it also failed to communicate the relevance of its message to Indigenous people; “The only thing is that when it comes to Aboriginal people, they will not relate to Quit television advertisements because they don’t see a black face…. I’ve heard the kids say ‘Oh yeah, but that’s only white fellas’. They do. ” (NTC 1999) Not only did this initiative fail to connect with Indigenous people, it also failed to influence the elements of the psychological domain which legitimate such high rates of smoking.
Within Indigenous culture smoking has become somewhat of a social practice, with the emphasis on sharing and borrowing of cigarettes (Gilchrist 1998). It is ineffectual to put across messages about the ill effects of smoking if the underlying motivation of relating to others is not addressed. In a report conducted on Indigenous smoking (AMA & APMA 2000 cited in Ivers 2001), it was suggested that one of the key themes of an initiative aimed at reducing indigenous smoking rates should be that smoking is not a part of Indigenous culture.
The ‘Jabby Don’t Smoke’ (Dale 1999) is an example of an initiative whose design attempted to influence accepted social norms. Its focus was primarily on children, thereby acknowledging the importance of socialization and the instillation of cultural norms at an early age. Unfortunately no data is available detailing its impact on smoking rates. As mentioned earlier in this essay, another feature of the psychological domain which has an effect through the psychosocial pathways is the modes of thought employed in rationalising actions and responses to various determinants and constraints.
Self efficacy or the amount of perceived control over one’s situation is an important contributor to health status; “Empowered individuals are more likely to take proactive steps in terms of personal health, whilst disempowered individuals are more likely to take a fatalistic approach” (Henry 2001) Examples of initiatives which have strived to empower Indigenous people in being responsible for their own health include ‘The Lung Story’ (Gill 1999) and various health promotion messages conveyed through song in traditional language ( Castro 2000 cited in Ivers 2001, Nganampa Health Council 2005).
By encouraging Indigenous people to address these issues in their own way, the amount of perceived control over their own health is increased thereby facilitating a greater degree of self efficacy. The intention of this essay has not been to deny that the social gradient of health does not exist or that it is not an effective tool in creating understanding of where social and health inequalities lie. Unfortunately programs and initiatives which have been guided by the social gradient of health and have been purely socioeconomic in their approach have failed to have a significant, sustainable effect on health inequalities.
In the US, despite socioeconomic initiatives to resolve inequality, the gap between upper and lower class groups has actually widened in recent times (Pamuk et al 1998 cited in Henry 2001). The scale of the intervention required to ensure a sustained impact on health inequalities has been discussed by Henry (2001), he also highlights the need to garner substantial political will in order for these changes to happen and makes the point that those in the upper classes are relatively content with the present status quo.
This essay has attempted to demonstrate that in an environment where well grounded, evidence based socioeconomic initiatives are failing to have the desired out comes, it is perhaps time to focus more on altering those strongly held health beliefs which not only dictate responses to social determinants of health but also dictate responses to initiatives designed to address these inequalities; “Healthful behaviours are due to more than just an inability to pay. A mix of psychological characteristics combines to form distinctive behavioural intentions”.
(Henry 2001) In the current environment of insufficient political will and finite resources it would be prudent to use every tool available to ensure initiatives aimed at reducing inequality between the classes will have the maximum amount of benefit. This approach is not a long term solution, but until it is possible to achieve the large scale social remodelling necessary to truly remove social inequality, and consequently health inequality, it is the most viable solution available. REFERENCES. ABS, 2003. ‘Indigenous Education and Training’, Version 1301.
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Gilchrist, D. 1998. ‘Smoking Prevalence among Aboriginal Women’, Aboriginal and Islander Health Worker Journal, Vol. 22, No. 4, pp. 4-6. Henry, P. 2001. ‘An Examination of the Pathways through Which Social Class Impacts Health Outcomes’. Academy of Marketing Science Review, vol. 3, pp 1-26. Humphery, K. , Japanangka, M. D. , Marrawal, J. 1998. “From the Bush to the Store: Diabetes, Everyday Life and the Critique of Health Service in Two Remote Northern Territory Aboriginal Communities. ” Diabetes Australia Research Trust and Territory Health Services, Darwin. Ivers, R. 2001.
‘Indigenous Australians and Tobacco; A Literature Review’, Menzies School of Health Research and the Cooperative Research Centre for Aboriginal and Tropical Health, Darwin. pp. 67-80, 93-107. Lawnham, P. 2001. ‘Indigenous Push at UWS’, The Australian, 27th June, 2001. p. 34, viewed 22nd August 2005, EBSCOhost Database Academic Search Premier, item: AN 200106061025662941. Marmot, M. G. , Davey Smith, G. , Stansfield, S. , Patel, C. , North, F. , Head, J. , White, I. , Brunner, E. and Feeney, A. 1991. ‘Health Inequalities among British Civil Servants: the Whitehall II Study’, Lancet, 337, 1387. reading 1. 5.
Mayer, S. 2001. What Money Can’t Buy: Family Income and Children’s Life Chances. Harvard University Press, Cambridge, Massachusetts. National Tobacco Campaign. 1999. ‘Australia’s National Tobacco Campaign: Evaluation report Volume 1’. Commonwealth Department of Health and Aged Care, Canberra. Nganampa Health Council. 2005. Nganampa Health Council, Alice Springs. Viewed 23rd August 2005, http://www. nganampahealth. com. au/products. php Pamuk, E. , Makuc, D. , Heck, K. , Reubin, C. , Lochner, K. 1998. ‘Socioeconomic Status and Health Chartbook’. Health, United States. National Centre for Health Statistics, Maryland.
Price, R. , & McComb, J. 1998. ‘NT and Australian Capital Cities Market Basket Survey 1998’. Food and Nutrition Update, THS, Vol. 6, pp. 4-5. Robinson, G. 2002. ‘Social Determinants of Indigenous Health’, Seminar Series, Menzies School of Health Research. Co-operative Centre for Aboriginal Health. Valadian, M. 1999. ‘Distance Education for Indigenous Minorities in Developing Communities’, Higher Education in Europe, Vol. 24, Issue 2, p. 233, viewed 22nd August 2005, EBSCOhost Database Academic Search Premier, item: AN 6693114. APPENDIX A. CCONCEPTUAL MODEL OF RESOURCE INFLUENCES. [pic] Henry, 2001. .
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