Socio-economic position and health
Socioekonomická pozice a zdraví
The social determinants of health
 The principal idea is that social factors (what we
call the social environment) determine human
health.
 The social causation hypothesis
 The solid facts:
http://www.euro.who.int/__data/assets/pdf_file/00
05/98438/e81384.pdf
Socioeconomic inequalities in health – concepts
and dimensions
- Social hierarchy
- Poverty: above or below the official poverty line (i.e <60% of the
median income)
- Absolute poverty <-> Relative poverty/deprivation
- Social mobility – the dynamics of socioeconomic position
- Health inequalities vs. inequities: normal (and therefore expected)
natural differences vs. unfair and unjust socially constructed
differences.
«The term inequity has a moral and ethical dimension. It refers to differences
which are unnecessary and avoidable but, in addition, are also
considered unfair and unjust. So, in order to describe a certain situation
as inequitable, the cause has to be examined and judged to be unfair in the
context of what is going on in the rest of society.»
M.Whitehead WHO paper 1991
Socioeconomic inequalities in health –
concepts, levels, and dimensions (1)
Socioeconomic position (SEP) or status (SES)
Levels:
i) Individual
ii) Family (often whole families classified by the man’s
SC)
iii) Other higher/group (i.e. neighbourhood, community
etc.)
Temporal dimension:
Current vs. past/previous
Life-stages (childhood, adult life, retirement/older age etc.)
Individual-level measures of SEP
Socioeconomic position (SEP)
 Socioeconomic position is one of the most
important dimension of social determinants of
health
 SEP is a multidimensional concept that denotes
one’s social standing as well as their access to and
ownership of social and economic resources.
Socioeconomic position, socioeconomic
status, and social class
 Often used interchangeably
 Socioeconomic position – standing in social hierarchy,
often relates to economic indicators.
 Social class refers to a classification scheme that is based on
people’s access to and command over economic resources.
 Occupation is often used to characterise one’s class as it is a
marker of one’s position in the production process.
 Social status denotes a person’s standing in the social
hierarchy. It is not necessarily defined in economic terms and
is related to one’s prestige.
 According to class theorists, social status and social position
are products of the economic system and the production
process
Socioeconomic position (SEP) – measurement
How do we measure SEP?
Socioeconomic position (SEP) – measurement
How do we measure SEP?
-income
-education
-occupational class
-wealth
-other indicators – any ideas?
UK social class classification until 2000
Grade Occupation
A Higher managerial, administrative
B
Intermediate managerial, administrative or
professional
C1
Supervisory or clerical and junior
managerial, administrative or professional
C2 Skilled manual workers
D Semi and unskilled manual workers
E
Casual or lowest grade workers, pensioners
and others who depend on the state for
their income
UK socio-economic classification since 2001
Group Description NRS equivalent
1
Higher professional and
managerial occupations
A
2
Lower managerial and
professional occupations
B
3 Intermediate occupations C1 and C2
4
Small employers and own
account workers
C1 and C2
5
Lower supervisory and
technical occupations
C1 and C2
6 Semi-routine occupations D
7 Routine occupations D
8
Never worked and long-term
unemployed
E
EU social classification (ISER)
1
Large employers, higher grade
professional, administrative and
managerial occupations
Higher salariat Service Relationship
2
Lower grade professional,
administrative and managerial
occupations and higher grade
technician and supervisory occupations
Lower salariat
Service Relationship
(modified)
3 Intermediate occupations
Higher grade white
collar workers
Mixed
4
Small employer and self employed
occupations (exc agriculture etc)
Petit bourgeoisie or
independents
-
5
Self employed occupations (agriculture
etc)
Petit bourgeoisie or
independents
-
6
Lower supervisory and lower technician
occupations
Higher grade blue
collar workers
Mixed
7
Lower services, sales and clerical
occupations
Lower grade white
collar workers
Labour Contract
(modified)
8 Lower technical occupations* Skilled workers
Labour Contract
(modified)
9 Routine occupations*
Semi- and non-skilled
workers
Labour Contract
10
Never worked and long-term
unemployed
Unemployed -
Alternative measures of SEP
 Car ownership
 House ownership
 Household amenities
 Holidays abroad
 Height of grave stones
 Social ladder
Height of gravestone as marker of SEP
(Davey Smith et al, BMJ, 1992; 1554-7)
The MacArthur Ladder and the social comparison questions presented to
participants.
Amir D, et al. (2019) Measuring subjective social status in children of diverse societies. PLOS ONE
14(12): e0226550. https://doi.org/10.1371/journal.pone.0226550
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226550
Socioeconomic inequalities and mortality by
country (men)
Mackenbach et al. NEJM 2008; 358;2468-81
Socioeconomic inequalities and mortality by
country (women)
Mackenbach et al. NEJM 2008; 358;2468-81
Socioeconomic inequalities and
mortality
Marmot et al., 1984 Lancet 1:1003-1006
in Marmot & Davey Smith, 1997 JHPsych 2(3)283-296
Absolute vs. relative inequality
 Most etiological studies use relative
measures of inequalities (e.g. RR)
 Some studies use absolute
measures (e.g. risk difference)
⚫ What is the difference?
Absolute inequality in males death rates by
level of education
Taken from:
the Marmot Review 2010
Taken from:
the Marmot Review 2010
Taken from:
the Marmot Review 2010
Area-based level measures of SEP
Deprivation indexes
 Townsend index (next)
 Carstairs index (next)
 Underpriviliged area score – see Jarman 1983
 Department of Environment Index (index
of urban poverty) – see Elliott 1997
⚫ three dimensions: social, economic, housing
English Index of Multiple Deprivation (IMD)
 The English Indices of Deprivation are
relative measures of multiple
deprivation at the small area level.
 IMD can be used to rank every small
area in England according to the
deprivation experienced by the people
living there.
Domains of IMD
 Seven distinct domains of deprivation –
they are combined and weighted:
⚫ Income (22.5%)
⚫ Employment (22.5%)
⚫ Health Deprivation and Disability (13.5%)
⚫ Education, Skills Training (13.5%)
⚫ Crime (9.3%)
⚫ Barriers to Housing and Services (9.3%)
⚫ Living Environment (9.3%)
Average NO2 concentrations across play spaces in
London by deprivation quintiles (i.e., 5ths), where 1
is least deprived and 5 is most deprived.
Sheridan et al, Int J Environ Res Public Health 2019
Socioeconomic inequalities in health –
The two main theoretical models
 Materialist vs. psychosocial
 Stress and perceptions as mechanisms
that are related to h inequalities
 H inequalities: from description to a
better understanding
Taken from:
the Marmot Review 2010
OR for all-cause and cardiovascular disease mortality
by IMD at neighbourhood (LSOA) level
Ramsay et al, JECH, 2015,
69:1224-1231
OR for CVD mortality by IMD
domains
Ramsay et al, JECH, 2015,
69:1224-1231
Age-standardised rates of all deaths and deaths involving the
coronavirus (COVID-19), by IMD decile, England
(deaths between 1 March and 31 May 2020, per 100,000)
0
20
40
60
80
100
120
140
1 (most) 2 3 4 5 6 7 8 9 10
(least)
All deaths COVID-19 deaths
Source: Office for National Statistics – Deaths involving COVID-19
Source: Office for National Statistics – Deaths involving COVID-19
Age-standardised deaths rates involving the coronavirus (COVID-
19) by IMD, Wales, 1 March-31 May 2020, per 100,000.
Rates nearly twice as high in the most deprived areas.
Czech Republic
 Area level data: CENSUS
districts (median size 1536
ind.)
 HAPIEE study – >8000 ind.
45-69 years old
 Neighbourhood SE
indicators and depressive
symptoms (Pikhartova et
al, IJPH 2009)
Socioeconomic inequalities in health
– multilevel approach
 Many different spatial levels
 Many different time-points within
the same individual
Socioeconomic inequalities in health –
multilevel approach
…Paradoxically, epidemiology, the study of disease in
populations, has largely been reduced to the study of
individual-level risk factors for disease.
Multilevel analysis is one way to begin to restore a
population or societal dimension to epidemiologic
research (i.e., the idea that factors operating at the
levels of groups or societies affect the health of
individuals within them).
It challenges epidemiologists to develop models of
disease causation that integrate macro- and microlevel
determinants…”
(Diez-Roux 1998 AJPH)
Neighbourhood education and mortality
(Dutch men)
Bosma et al AJE
2000
Neighbourhood characteristics and chronic
inflammation (fibrinogen levels)
Nazmi et al. 2010
Socioeconomic inequalities in health
and disease
 Beyond a mere description
 How and why?
 How → mechanisms
 Why → causes
Socioeconomic causation vs. social selection
 The social causation: low SEP causes poor health
 The social selection (drift) hypothesis: poor health causes low SEP
⚫ Illness inhibits individual’s social class attainment or causes
downward drift or never escape poverty
 Longitudinal studies are crucial (temporality!).
 Strength and direction of the relationship can vary by the type of
mental illness and socioeconomic indicator.
 Both social causation and selection/drift are important in advancing our
understanding of the influence of social inequality on people's lives.
 On balance: better evidence on social causation but there is some
evidence on social selection, particularly regarding mental health
WHO Euro Health 2020
Strategic objectives of Health 2020
The philosophy behind the Health 2020 policy framework is that structural advances in
health can be effectuated when governments actively aim to fulfil two linked strategic
objectives.
The two strategic objectives are:
 improving health for all and reducing health inequalities
 improving leadership and participatory governance for health.