HEALTH PSYCHOLOGY: Theory, Research and Practice

D. Marks, M. Murray, B. Evans and C. Willig

London: Sage, 2000.

Chapter Two

THE MACRO-SOCIAL ENVIRONMENT AND HEALTH

The health and survival of children depend an many factors on the health of their fathers and
mothers; on the survival skills of their families; on the relative peace or violence in their
communities; on the economic and political status of their nations; on whether the wages that
people earn or the land they till provide enough to eat; on the availability, quality and cost of
education, health services, water, shelter and transportation; an the ability of people to organize
and defend their rights; on local consumption of alcohol, tobacco and narcotics; on who hos
power aver whom; on war . on military expenditures relative to public service expenditures; on
international trade relations; on preservation or destruction of the environment; on how far 0
mother has to walk to get firewood or cow manure for cooking an undermining of grassroots
movements on whether the banks will be permiffed to conf,nue protecting their billions by taking
away food, health care and education from destitute children. [Werner, 1992, p 10)

OUTLINE

This chapter describes the economic and societal context for the study of health psychology
Global trends and health variations between and within societies are discussed. The chapter then
describes and discusses the relationship between health experience and social position as
indicated by socio-economic status, gender, and ethnicity The explanation of health variations
creates an important challenge for health psychology.

GLOBAL HEALTH TRENDS

The health of human populations is shaped by historical, political and economic forces which are
unpredictable and uncontrollable. Societies are dependent upon their economic power and shifts
in the balance of power between themselves and others. The health of individuals is dependent
upon the communities to which they belong and on the balance of economic power between the
individual members. All are influenced by powerful economic forces which are impossible for
anyone to control.
On a global scale, human well-being is determined by a host of factors, the most significant
being droughts, famines, epidemics, wars and poverty.
In spite of all of these, life expectancy has increased almost everywhere and there has been a
dramatic decrease in both infant and adult mortality.
These improvements have resulted largely from a decline in the occurrence of fatal infectious
diseases. However, there are still a large number of such deaths annually (16.4 million in 1993,
one-third of all deaths) and the massive regional differences that existed in 1950 remain almost
unchanged to the present day (Figure 2.1).
Of 5.6 billion people in the world population, 4.4 billion live in developing countries. The
greatest influence on health at the global level is poverty. There are many different definitions of
poverty but one defines it as 'a level of income below which people cannot afford a minimum,
nutritionally adequate diet and essential non-food requirements' (UN Development Programme,
1995). Half of the world's population lacks regular access to treatment of common diseases and
most essential drugs.
In the rnid-1990s there were approximately 15 million refugees and 15 million intemally
displaced persons.
In 1995 the World Health Organization (WHO) renewed its global strategy, Health for All. In
launching this strategy, the WHO's then Director-General, Dr Hiroshi Nakajima (1995),
suggested that a two-track society divided by poverty is a 'global time bomb'. Nakajima warned
that if poverty alleviation policies fail, further improvements in global health would be
impossible to achieve. The WHO (1995) report presented some striking statistics. In
industrialized countries, two-thirds of all deaths occur after the age of 65 while, in developing
countries, two-thirds of all deaths occur before the age of 65, and nearly one-third before the age
of 5. In spite of the overall improvements in health, there are huge inequities which, if anything,
are increasing.
The greatest cause of ill health and early mortality is poverty . The health effects of poverty are
tangible in both industrialized and no industrialized countries and the biological mechanisms are
the same. The major impacts of poverty on health are caused by the absence of:
. safe water;
. environmental sanitation;
. adequate diet;
. secure housing;
. basic education;
. income generating opportunities;
. access to health care.

The most common health outcomes are infectious diseases, malnutrition and reproductive
hazards (Anand and Chen, 1996).
In 1991, the number of people living in extreme poverty was estimated by Oxfam to be
approximately 1.1 billion - one-fifth of the world's population. It was also estimated that the
wealthiest fifth of the world's population controlled 85% of global gross national product (GNP)
and 85% of world trade, while the poorest fifth controlled only 1.4% of GNP and 0.9% of world
trade (Oxfam, 1991). In the 1990s, the gap between the 'haves' and 'have-nots' continued to
widen and it appears most unlikely that it will narrow within the next 50 to 100 years.
The WHO (1995) report stated that poverty causes 12 million deaths annually in children under
the age of 5; one-quarter of these deaths arise from acute lower respiratory tract infections and
one-quarter from diarrhea and dysentery . The WHO estimated that malnutrition is an underlying
cause in 30% of child deaths and produces growth retardation in 230 million children and severe
wasting in another 50 million. Among adult deaths, poverty accounts annually for up to 2.7
million deaths from tuberculosis and 2 million from malaria. Maternal mortality, running at
500,000 deaths a year in 1995, is associated with high fertility and poor access to health services
(Kevany, 1996).

INEQUALITIES BETWEEN COUNTRIES

Studies of life expectancy

Evidence from a wide variety of sources suggests that the average life expectancy is higher when
income differences are relatively small and societies are more socially cohesive (Wilkinson,
1996). It has been suggested that the same basic principles determine the health of populations in
both rich and poor countries (Rogers, 1992). However, recent analyses conducted by one of the
authors suggest that the relationships between ecological variables and life expectancy is quite
different for poor and rich nations (Marks, 1999).
Two important predictors of life expectancy are gross national product per capita (GNppc) and
income distribution. GNPpc is calculated using the World Bank Atlas method which measures
the total domestic and foreign value added claimed by residents converted to US dollars. Income
distribution is measured by examining the percentage share of income or consumption taken by
the lowest and highest income groups in a society.
For example, in one of the poorest countries, Tanzania, in 1991, the best off 20% of households
controlled 62.7% of the country's income while the worst off 20% controlled only 2.4% of
income. In one of the richest nations, the USA, in 1985, the best off 20% of households
controlled 41.9% of the country's income while the worst off 20% controlled only 4.7% of
income (World Bank, 1993). However, GNPpc and income inequality are independent predictors
of life expectancy and of health.
Among rich countries, GNPpc and income inequality are the most significant predictors of
longevity, GNPpc having a positive effect and income inequality a negative effect (Wennemo,
1993). However, Marks (1999) found that female secondary education participation rates are
also positively associated with higher average longevity. More surprising was the finding that
when GNPpc, income inequality and female secondary education participation rates are all
controlled, the average life expectancy in a country is independent of expenditure on health
services, and of the numbers of doctors and nurses (Figure 2.2).
These findings place into context the widely held assumption that if national health services are
allocated more resources, they will necessarily reduce ill health and keep populations living
longer. It has been acknowledged for some time that the health service has only a limited role to
play in the production of a healthy population. There are limits to health care and when those
limits are reached, further health gains appear to follow economic and social changes, not
increased expenditure on biomedical health care.
Among poor countries, ecological influences show a more complex pattem. Although GNPpc
and female secondary education participation rates both have large effects on life expectancy,
income distribution shows a curvilinear relationship with life expectancy (Figure 2.3). The
reason for this remains uncertain but it may be related to changes in the labor market when larger
income differences between unemployed, employed workers, farmers and factory owners are
created during the early stages of industrialization. Unlike rich countries, however, the more
doctors and nurses there are, the higher the average life expectancy. So in these countries, the
more medical care there is available, the longer the average life span. However, the total amount
spent on health care per head of population is not significantly related to life expectancy (see
Figure 2.4).
This analysis and others in the literature suggest that GNPpc and income inequality both have a
large influence on the average life expectancy of a population. Also, when GNPpc and income
inequality are controlled, female literacy is a significant predictor of life expectancy. In poor
countries having a high level of female participation in secondary education is as important as
having large numbers of doctors and nurses while, in rich counties, variations in female
secondary education have a larger influence on life expectancy than variations in the numbers of
doctors and nurses. This study suggests that, over and above the resulting equalization of
opportunities, educating girls has a highly beneficial effect on a society's health. This is a
reflection of the fact that the higher the quality of a mother's education, the more effective she
can be in promoting the health of her family.
In industrialized countries, future improvements in health can be expected if income growth is
accompanied by a more equitable distribution of income. If a society has a highly uneven
distribution of income and contains a high proportion of citizens living in poverty , then
spending more on health care is unlikely to improve health. This is illustrated by the USA which
spends a higher proportion of its GNP on health care than any other country (14%) and yet ranks
twelfth for average life expectancy.

Poverty is linked to debt

If poverty levels are to be significantly reduced it is necessary for wealthier countries to allocate
more resources to the development of poorer countries, but not in the form of further loans. If the
WHO's Health For All strategy is going to have any chance of success, health must be given a
higher priority in global development policies. Intemational debt has a major impact on poverty.
In sub-Saharan Africa which contains 34 of the 41 most indebted countries, the proportion of
people living in absolute poverty (on under one dollar per day) is growing. Human well-being in
sub-Saharan African countries is among the worst in the world. Consider the following
indicators:

. Two-thirds of Africans live in absolute poverty. More than half lack safe water .
. Seventy per cent are without proper sanitation.
. Forty million children are not in primary school.
. Infant mortality is 55% higher than in other low-income countries. An average life expectancy
at 51 is 11 years less.
. The incidence of malaria and tuberculosis is increasing.

A large part of the cause of these problems is sub-Saharan Africa's international debt. It pays at
least four times more on debt repayments than on health care for its citizens. The worst case is
Mozambique which in 1998 owed nearly five times more than its annual national income.
UNICEF estimates that 500,000 children die every week because of the debt crisis (Logie and
Benatar, 1997). In 1995 the Jubilee 2000 campaign was started in the UK with the aim of getting
the unplayable debt of 50 of the world's poorest nations written off by the end of the year 2000.
This would cost no more than US$100 billion, about the same as the amount which in 1997 the
International Monetary Fund (IMF) promised to loan one country , South Korea, because its
economic collapse threatened the value of stocks on financial markets in New York, London and
Tokyo.
The World Bank's (1993) World Development Report 1993: Investing in Health contains
evidence that the post-1950 decline in mortality in developing countries can be attributed to
policies which:

. make investments to reduce poverty;

. make health expenditure more cost effective;
. increase the effectiveness of public health measures;
. improve essential clinical services;
. improve schooling, particularly for girls;
. improve the rights and status of women.

The evidence suggests that, in addition to new biomedical discoveries and technologies, some
dramatic economic changes are needed if we are to experience further health improvements
during the twenty-first century.
Among these changes, the cancellation of unpaid debts of the poorest countries and income
redistribution within the richest countries have the potential to bring health improvements to
match those of the last 50 years of the twentieth century. On the other hand, if current trends
continue, the health of many national populations will actually worsen.

The nature of health-care systems

A society's system of health care is a salient manifestation of its desire to care for its most
vulnerable members. A health-care system mirrors a country's political ideology. One
informative illustration of this principle is the British National Health Service (NHS) founded in
1948. It will be helpful throughout this section to use the NHS as an example of more general
principles. The NHS was based on a welfare model of health care following the principles of
Fabian socialism. A welfare model aims to provide a free, comprehensive service regardless of
age, socio-economic status, gender, sexual preference, race or religion. The NHS is the largest
employer in Europe. The political climate of Margaret Thatcher's government of the late 1980s
brought the 'NHS reforms' and created an internal market of purchasers and providers similar to
that operating in the USA.
These changes followed principles of 'value for money' and cost containment within a new
internal market model of competing providers. Similar changes were made to the health-care
system in New Zealand. In the market model, purchasers or insurers pay for services and the
provision of care depends upon contracts and the ability to pay. General practitioners (GPs)
could become direct purchasers of care and become independent and competitive businesses
while fulfilling clinical responsibilities to patients and trying to keep up with medical
developments.
Another important aspect of a health service is the distribution and supply of drugs, technology
and expertise controlled by a multinational medical-industrial complex of organizations.
Whatever principles shape the organization at a structural level, huge numbers of personnel,
products and equipment are necessary to operate the system requiring considerable amounts of
expenditure. In spite of repeated attempts to increase efficiency, health-care costs continue to
rise. The British NHS costs about 3% more each year to run and many commentators believe the
service remains chronically under funded. Policy analysts have suggested that efficiency gains
have been accompanied by rising inequities in the quality and distribution of care.
In 1996 the WHO drew up a charter which held that the fundamental value underlying health-
care reform is the improvement of people's health, not cost containment (Box 2.1).

BOX 2.1 WHO'S LJUBLJANA CHARTER: SUMMARY (RICHARDS, 1996)

European health care systems should be:

Driven by values of human dignity, equity, solidarity and professional ethics Targeted on
protecting and promoting health Centered on people, allowing citizens to influence health
services and take responsibility for their own health Focused on quality , including cost
effectiveness Based on sustainable finances, to allow universal coverage and equitable access
Orientated towards primary care.

The impact of health service reforms on health outcomes is difficult to evaluate. In the NHS, for
example, one impediment to rational appraisal was the refusal of the health ministry to introduce
changes in a pilot region to investigate benefits and any unexpected costs (e.g. administrative
costs) before changing the system nationally. Those with an interest in showing positive results
often choose a purely descriptive approach, measuring changes in performance or activity by
demonstrating more admissions or shorter waiting times. However, the quality of patient
experience is rarely systematically assessed by measuring patient satisfaction or health outcomes
before and after a reform. The evaluation of health care is a multidisciplinary exercise in which
the health psychologist can work collaboratively with other professionals and make a significant
contribution.
One way of evaluating health service changes is to survey health-care personnel regarding their
perceptions of the changes in quality of care. This approach can be illustrated by a study which
assessed the impact of the NHS reforms through random surveys of GPs, consultants, surgeons
and public health physicians (Francome and Marks, 1996). The latter group is responsible for
purchasing health care for their district populations. The study examined the implications of the
contracting process of the internal market on the quality of patient care. The study confirmed the
view of many commentators that the NHS changes led to an upsurgence of managerialism in
which managers - the 'gray suits' - had taken over from the medical consultants - the 'white coats'
- as the power brokers in hospitals. Following the changes, health care was perceived as having
become increasingly determined by costs rather than clinical need. Many believed that a two-tier
system had developed in which the patients of fund-holding GPs were able to obtain faster
treatment than those of nonfundholders. As a result of the changes, one of the founding
principles equity - had been eroded and some patients lost trust in doctors (Francome and Marks,
1996).
Health-care systems are under constant review and subject to reform and change on a regular
basis. Some commentators suggested that the British and other European health reforms failed to
improve the health of communities when considered as a totality. Some have suggested that it is
inappropriate to treat health care as a marketplace in which competition over quality and price is
used to squeeze more health care from a dwindling supply of resources. Richards argued:

There should be a return to the ideology of health as a public good where the rights of
individuals are balanced more equitably with the health needs of the whole community. Control
of spending on health care will not be achieved by minor adjustments to the mix of public and
private sectors. A more radical approach is necessary, based on a much more critical look at
current provision.
(Richards, 1996, p. 1622)

Health-care policies and reforms are controversial with competing values and principles dividing
the various protagonists into camps. Some improvements follow from audits of existing services
to determine how much they contribute to health gain in relation to their costs. Improvements at
a more structural level follow social and economic reforms which focus on poverty , deprivation
and improved education.
As suggested above, there is little evidence that, in industrialized countries, allocating even more
expenditure to health care is likely to make any further improvements to life expectancy. The
World Development Report (1993) stated that between 1960 and 1980 worldwide the number of
hospital beds rose from 5 million to almost 17 million, more than doubling per capita supply.
Between 1955 and 1990, the number of physicians increased from 1.2 million to 6.2 million.
However, the report concluded that costeffective public health and clinical interventions are best
delivered at district, community or household levels, not in expensive specialized hospitals
where 30 to 80% of national expenditures on health services are allocated. This suggests that
billions of dollars are being spent every year for relatively little added value in return.
In the industrialized world it has become fashionable for health services to be restructured in a
search for greater efficiency and value for money. However, the evidence suggests that this is
tinkering which has little if any positive impact on public health. Structural changes at societal
level through policies which bring greater equity in income distribution and the reduction of
poverty are necessary if we are to achieve health gains in the twenty-first century which are
comparable to those of the twentieth century.

INEQUALITIES WITHIN COUNTRIES

In spite of the massive allocation of public resources to health care, inequalities are one of the
most striking features of any health-care system. Inequalities must be taken seriously because of
their pervasiveness, magnitude and continuation into better off social groups (Carroll and Davey
Smith, 1997). In reviewing health inequalities in 14 countries, Benzeval et al. (1995) concluded:

People who live in disadvantaged circumstances have more illnesses, greater distress, more
disability and shorter lives than those who are more affluent. Such injustice could be prevented,
but this requires political will. . . . Health inequalities are endemic characteristics of all modem
industrial societies, but the size of the differential varies between countries and over time,
indicating that there is nothing fixed or inevitable about having such a health divide. (Benzeval
et al., 1995, p. xvii)

This evidence demonstrates that premature mortality rates, illness and disability are higher
among the more disadvantaged sections of each national population: Australia (National Health
Strategy , 1992), Belgium (Lagasse et al., 1990), Finland (Valkonen, 1993), France
(Desplanques, 1984), Germany (Helmert and Shea, 1994), Ireland (Nolan, 1990), Italy (Pipemo
and Di Orio, 1990), the Netherlands (Mackenbach, 1993), Norway (Dahl, 1993), Spain (Kunst
and Mackenbach, 1994), Sweden (Vagero and Lundberg, 1989), Switzerland (Lehmann et al.,
1990), the UK (Fox and Benzeval, 1995) and the USA (Pappas et al., 1993). The evidence shows
substantial indications that health variations reflect the social and economic circumstances of
individuals.
Inequalities will only be reduced by adopting a thoroughly multi-layered approach. Whitehead
(1995) identified four different levels for tackling health inequalities:

1 Strengthening individuals. 2 Strengthening communities.

3 Improving access to essential facilities and services.
4 Encouraging macro-economic and cultural change.

These four levels correspond to the four layers of influence in Whitehead's 'onion model' of the
determinants of health outlined in Chapter 1 (see Figure 1.1). Some health psychologists would
want to include an extra level between the individual and the community , for the household or
family (Valach et al., 1996). Psychologists do not usually talk quite so simplistically about
'strengthening' individuals, but analyse the personal characteristics and skills associated with
positive health (e.g. self-efficacy, hardiness, sense of coherence, social skills). In fact, as we shall
see later, developing interventions aimed at individual health beliefs and behaviours are a core
feature of psychological theory, research and practice.
However, interventions aimed at tackling inequalities at an individual level have shown mixed
results. There are four possible reasons. First, people living and working in disadvantaged
circumstances have fewer resources (time, space, money) with which to manage the process of
change. Second, health-threatening behaviours such as smoking tend to increase in difficult or
stressful circumstances as they provide a means of coping (Graham, 1993). Third, there may
have been a lack of insensitivity to the difficult circumstances in which people work and live
which constrain the competence to change. Fourth, there has been a tendency to blame the
victim. For example, cancer sufferers may be blamed for the disease if they are smokers on the
grounds that they are responsible for the habit which caused it.
Overall, efforts directed at the individual level have been inconclusive and small scale. Because
many health determinants are beyond the control of the individual, psychological interventions
aimed at individuals are likely to have limited impact on public health problems when
considered on a wider scale. This suggests that there is a need for psychologists to work beyond
the individual level, with families, communities, work sites and community groups.
Benzeval et al. (1995) suggested that efforts to tackle inequalities typically have two
shortcomings: (1) Excessive attention is given to the health experiences of white males of
working age as compared to women, older people and minority ethnic groups. More attention
must be given to the health concerns of these under-served groups. (2) The policy areas dealt
with in detail - housing, income maintenance, smoking and access to health care - are
insufficiently comprehensive as an agenda for tackling inequalities. Tackling health inequalities
at the level of services to individuals is insufficient. The correction of inequalities in health
demands 'a wide-ranging and radical reshaping of economic and social policies' (Benzeval et al.,
1995, p. 140). In other words, action in the form of policy change is required to bring about
macro-economic and cultural change.

SOCIO-ECONOMIC STATUS (SES)

In the remainder of this chapter, we examine health variations and their potential causes and
psychosocial mediators. One of the most significant is socio-economic status (SES). We describe
the health gradient correlated with SES and outline different explanations for its existence. We
also briefly outline and discuss the factors of relative deprivation, gender and ethnicity and
explore the psychosocial implications of their association with variations in health.
Socio-economic status (SES) is an important factor in health, illness and health care. SES is
usually defined in terms of occupation, education or income, but it is a complex and multi-
dimensional construct which defies simple definition. The SES construct has traditionally been
analysed from a sociological perspective and has been found to control large amounts of the
variance in health outcomes (Adler et al., 1994; Carroll et al., 1996; Carroll and Davey Smith,
1997). The construct needs to be unpacked for its psychological content because the mediators of
SES effects on health experience are likely, at least in part, to be behavioural and psychosocial.
Data from many hundreds of quantitative studies show that SES is strongly correlated with
illness and mortality. The Black Report (1980;
1988) provided the first major national review of the issue in the UK. The relationship between
mortality and SES is known as a health gradient because plots of mortality rates against SES
reveal a continuous gradient of increasingly poor health as SES changes from high to low. Figure
2.5 shows male all-cause mortality plotted against social class for England and Wales for 1991-
93. Similar gradients exist in the USA (Adler et al., 1994) and throughout industrialized
countries.
Complementing the quantitative data, qualitative data concerning people's experience of health
and illness derived from discourse provides insights into the mediators of gradients. Chamberlain
(1997) reviewed evidence from qualitative research concerning how people from upper and
lower SES positions understand health and ilIness (e.g. CaInan and Williams, 1991a and b).
These studies interviewed small groups of middle-class and working-class women and men
classified on the basis of their occupations, producing a 'white-collar' and 'blue-collar'
distinction. Several differences are evident between these two groups.
Blair (1993) analysed the language used by middle-class and working class groups and
concluded that working-class people tend to use more physicalistic terminology in their accounts
of health and illness while middle-class people are more mentalistic and person centred. Contact
and communication with professionals can be affected by their class relationship with patients
so, not surprisingly, surgeons and doctors are often perceived as 'upper' class by working-class
patients, while nurses are seen as more 'down to earth':

You know how it is, those bloody doctors and their big words. That's enough to scare the shit out
of anyone. I don't know what the hell they're talking about I didn't have no bloody education like
them. Why should I take the stuff they give me when I don't know what the hell they're talking
about (Jim, lower SES).
(Chamberlain, 1997, p. 402)

Meanings of health show class-related differences. Working-class men and women see health in
a more utilitarian way concerned with an absence of disease, being able to work and get through
the day without feeling ill. Middle-class people see health as a value concerned with feeling
good and having energy to indulge in leisure activities. Chamberlain (1997), however, suggests a
more complex picture with four differing views of health. The solitary view, presented by lower
SES participants, sees health as involving only physical components of energy, lack of
symptoms and a good diet. The dualistic view, held only by lower and some higher SES people,
sees health as having both physical and mental aspects, which act in parallel and independently
of each other. The complementary view, presented mainly by upper SES people, sees physical
and mental elements as integrated together in an alliance. The multiple view, held by higher SES
people, sees multiple aspects to health - physical, mental, emotional, social, spiritual - as
interdependent, interconnected, in balance in health and out of balance in illness. These
comparative studies are few in number and have been conducted in only a few countries,
primarily in New Zealand. Further studies are needed to explore the relationship between social
positioning and health experience.

Explaining the health gradient

Looking at the overall picture, it may be concluded that SES produces a complicated mixture of
impacts on the health of individuals. Wilkinson (1992) suggested that 'social consequences of
people's differing circumstances in terms of stress, self-esteem, and social relations may now be
one of the most important influences on health' (p. 168). Carroll et al. (1996) suggest that the
SES-health gradient is a consequence of class-related differences in social support and personal
control. Both help to ameliorate stress and differ significantly in the predicted direction. An
alternative formulation suggests that depression, hostility , stress and social ordering could be
responsible for the SES-health gradients and that individual control over life circumstances
might be a higher order variable (Adler et al., 1994). Both theories give a primary role to stress
and personal control.
For a more complete account, it is necessary to consider the differing experiences and behaviours
in the life cycle of individuals of differing SES.
Important though feelings of personal control undoubtedly are, it is necessary to contextualize
individual developmental history within family, social and ecological systems (see Box 2.2).

BOX 2.2 BEHAVIOURS AND EXPERIENCES ASSOCIATED WITH LOW SES

. low weight births . family instability . child abuse, poor diet/nutrition . poor educational
outcomes . parental smoking . parental drinking . parental lack of exercise . low household
income . poor housing . overcrowding . environmental pollution . unemployment or unstable
employment . occupational hazards . poorer access to health services . heavier smoking . heavier
drinking . lack of exercise . lawer personal control . less social support

The risk-factors in Box 3.2 can be considered from an ecological perspective or systems theory
approach. Bronfenbrenner's (1979) ecological approach conceptualized developmental
influences in terms of four nested systems:

. microsystems: families, schools, neighbourhoods;

. mesosystems: peer groups;
. exosystems: parental support systems, parental workplaces;
. macrosystems: political philosophy, social policy.

These systems form a nested set, like a set of Russian dolls, microsystems within mesosystems,
mesosystems within exosystems and exosystems within macrosystems (Figure 2.6).
Ecological theory assumes that human development can only be understood in reference to the
structural ecosystems. We have already suggested a general systems framework for
understanding the determinants of health and ilIness in Chapter 1 (Figure 1.2). Of key
importance is the principle that it is the perceived environment and not the so-called 'objective'
environment which affects human behaviour and experience.
Any explanation of the SES-health gradient needs to consider psychosocial systems that
structure inequalities across a broad range of life opportunities and outcomes, health, social and
educational. As illustrated in Box 3.2, in comparison to someone at the high end of the SES
scale, the profile of a low SES person is one of multiple disadvantage. The disadvantages of low
SES accumulate across all four ecosystems: families, schools, neighbourhoods (microsystems);
peer groups (mesosystems);
parental support systems, parental workplaces (exosystems); and political philosophy and social
policy (macrosystems).
Davey Smith et al. (1994) argue that it is the accumulation and clustering of adverse physical,
material, social and psychological effects which explain the health gradient. While each factor
alone can be expected to produce a relatively modest impact on mortality , the combination and
interaction of many kinds of ecosystem disadvantage are likely to be sufficiently large to
generate the observed gradient.
Four explanations of the gradient have been proposed: artefactual, social selection, behavioural,
and materialist. The evidence suggests that the first two factors are incapable of accounting for
the gradient. The second two factors appear to be more plausible, but unfortunately they are not
easy to separate. This is because the social structure both distributes the exposure to
environmental hazards and sets the conditions for the behaviours which damage or promote
health (Davey Smith et al., 1994).
Materialist explanations propose that factors outside the individual's control expose some
sections of the population to a hazard and not others, or differentially exposes the whole
population (Blane et al., 1997). There are four major domains in which these variations occur.
First, exposure to air pollution is likely to depend upon income. Where a person lives, for
example, near main roads or industrial plants, is dependent upon income as is the quality of
protection afforded by a vehicle a person owns to exhaust fumes. Second, the diet is implicated
by epidemiological studies in 35% of all cancer deaths (Doll and Peto, 1981) and also in
cardiovascular disease. Income determines the range of foods to which an individual has access
and so it can perhaps be assumed that a significant proportion, perhaps one-half, of the dietary
effect on total mortality could be caused by materialist factors, less than 15% of all deaths (Blane
et al., 1997). Third, four major causes of mortality are associated with occupational hazards:
cancer, cardiovascular disease, accidents and respiratory disorders. Blane et al. suggest that 10%
of all deaths could be caused by occupational hazards. Fourth, the quality of housing is strongly
related to both income and health. Although no precise figure can be attributed to the housing
factor as an overall cause of mortality, there is a strong link between poor housing and bad health
(SCOPH, 1994).
Blane et al. (1997) suggest that these four materialist causes of mortality combine and
accumulate across the life span in the same individuals bringing about interactive and additive
effects on increasing the risk of serious life-threatening conditions among those sectors of the
population who are most exposed. These materialist factors are separate from the behavioural
and psychosocial differences that also exist between people of differing SES.
Studies in many countries have shown that people with lower SES have a higher behavioural risk
profile. Cavelaars et al. (1997) analysed the gradients in behavioural risk factors in 11 European
countries using data from the Eurobarometer survey. This survey has been conducted twice each
year since 1970 on people over 15 years of age in all countries of the EU. The Eurobarometer
measures public attitudes towards the EU and its policies. Between 1987 and 1991 respondents
were also asked about their consumption of cigarettes, alcohol and vegetables, and also about
their weight and height from which a body mass index could be computed.
Cavelaars et al. investigated inequities between high and low education groups in each country .
Of particular interest was the observation of a north-south difference in behavioural risk
inequalities for heavy smoking and infrequent vegetable consumption in men, with larger
inequalities in northem European countries than in southem European countries. This pattern
matches the gradients for ischaemic heart disease in men, which also show larger gradients in the
north and smaller gradients in the south.
The data of Cavelaars et al. suggest that the behavioural factors of smoking and diet contribute to
the SES-related health gradient.
Taylor et al. (1997) describe the features of 'healthy' and 'unhealthy' environments:
Across multiple environments, unhealthy environments are those that threaten safety, that
undermine the creation of social ties, and that are conflictual, abusive or violent A healthy
environment, in contrast, provides safety , opporhmities for social integration, and the ability to
predict and/or control aspects of that environment (Taylor et al., 1997, p 411)

Unhealthy environments are associated with chronic stress and 'the lower one is on the SES
continuum, the greater the amount of hassle and time needed to address basic tasks of living'
(Taylor et al., 1997, p. 419).
As noted above, both behavioural and material circumstances vary with SES. It is impossible to
decide with the presently available information how much each of these causes is contributing to
the gradients in illnesses and deaths. Understanding the material and behavioural causes and the
interactions between the two is a priority for further research.

RELATIVE DEPRIVATION

In addition to striking the health gradients discussed above, there is evidence that relative
deprivation plays an independent role in mediating health experience. Much of the evidence for
relative deprivation has been discussed by Richard G. Wilkinson in Unhealthy Societies (1996).
Wilkinson (1992) found a correlation of 0.90 between life expectancy at birth and the proportion
of income going to the least well-off 70% of the population (after controlling for GNP per head
of population). Major structural shifts during the 1980s and 1990s made income distribution in
many westem countries less equitable. In the UK the percentage of households existing on below
half the average income changed from 9% in 1979 to 24% in 1990-91 (Millar, 1993). In
countries where the income gap widened, life expectancy increased less than in countries where
the gap narrowed (Figure 2.7).
Kaplan et al. (1996) found a correlation of 0.62 (p<.001) between the percentage of household
income received by the less well off 50% and all cause mortality across the 50 states in the USA.
Kaplan et al. (1996) also found that income inequality is associated with a wide range of social
indicators including high rates of low birth weight, homicide, violent crime, work disability ,
smoking, sedentary activity , unemployment, imprisonment, recipients of income assistance and
food stamps, and poor educational outcomes. A similar US study using different measures by
Kennedy et al. (1996) obtained findings which were consistent with those of Kaplan et al.
(1996). Lynch and Kaplan (1997) discuss the methodological and measurement problems
associated with these researches and conclude that it is the 'appraisal of well-being that may
provide a psychosocially mediated link between income inequality and health status. . . so that
even those with good incomes might feel "relatively deprived" compared to the super rich' (p.
308).
Kennedy et al. (1998) investigated the influence of income distribution and socio-economic
status on self-rated health status in a sample of over 200,000 US civilians who were non-
institutionalized (that is, non incarcerated and non-hospitalized) aged 18 years or older. Data
were collected on income distribution in each of the 50 us states. The Gini coefficient was used
to measure statewide inequalities in income. The objective of the study was to determine the
effect of inequalities in income within a state on self-rated health status while controlling for
individual characteristics such as socio-economic status. Random probability samples of
individuals in each state were collected by the 1993 and 1994 behavioural risk factor
surveillance system, a random digit telephone survey. The survey collected information on an
individual's income, education, self rated health and other health risk factors.
The results showed that when personal characteristics and household income were controlled for,
individuals living in states with the greatest inequalities in income were 30% more likely to
report their health as fair or poor than individuals living in states with the smallest inequalities in
income. This study found that:

1 Inequality in the distribution of income is associated with an adverse impact on health

independent of the effect of household income.
2 The effects of income distribution on self-rated health are not limited only to those in the
lowest income groups; those in the middle income groups in states with the greatest inequalities
in income rated themselves as having poorer health than those in middle income groups in states
with the smallest inequalities.
3 The effects of income inequality on self-rated health are as strong as other individual risk
factors.
4 Social and economic policies that affect income distribution may have important consequences
for the health of the population.

We saw above that countries or states with a higher equality of income distribution have
populations with relatively high life expectancy. It was suggested by Wilkinson (1996) that these
socio-economic trends are created by the greater social cohesion and social support existing in
more egalitarian societies. For people suffering the highest levels of distress and poverty , social
integration and support can literally be life or death issues.
Interpersonal processes within networks of relationships entail the giving, receiving and sharing
of support of different kinds (informational, emotional and material).
Interpersonal processes are also engaged in evaluating and comparing one's own socio-economic
position with others. The process of social comparison, and downwards comparison in particular,
is included in judging self-worth, setting aims and ambitions and making changes to lifestyle and
health behaviours. A negative downwards comparison is likely to be associated with only fair or
poor self-ratings of well-being, which in turn are associated with higher rates of morbidity and
mortality .
The consequences of social comparison need to be considered in socio historical context. People
of many backgrounds, nationalities and cultures now share similar aspirations. Once upon a time
the' American dream' gave North Americans the idea that they could drive Cadillacs, own houses
with swimming pools, play the stock market and vacation in exotic places such as Hawaii or the
Caribbean. Similar albeit lower key aspirations have been inculcated among Europeans. Yet, as
the gap between the rich and the poor widens, the economic realities for many people are
dramatically different and the widening wealth gap can only bring increased levels of
hopelessness, frustration and failure. This realityactuality gap is the 'feel-bad' factor of
psychosocial alienation associated with the killer disorders of industrialized societies, cancer,
cardiovascular disease, tobacco addiction, alcoholism and obesity. There are good reasons for
expecting that the prevalence of alienation and stress will be higher in countries or states where
the income distribution is most skewed. The impact of differences in socio-economic position on
health are likely to be psychosocially mediated through a sense of worthlessness, low self-
esteem, and hopelessness. Thus, economic inequality can be seen as a new pathogen in
contemporary societies.

GENDER
Major differences occur across place and time in the health prospects of men and women. Recent
research has focused on the political, psychosocial and economic implications of gender.
According to a medical textbook from the 19th century: 'child-bearing is essentially necessary to
the physical health and long life, the mental happiness, the development of the affections and
whole character of women. Woman exists for the sake of the womb' (Holbrook, 1871, pp. 13-14;
cited in Gallant et al., 1997).
Attitudes have changed and, supported by policy and legislation, women's health is near the top
of the health researcher's agenda. These changes have been supported in the USA by the
foundation by the National Institutes of Health in 1990 of the Office of Research on Women's
Health (ORWH) leading to a number of special research projects, reports and symposia across
many health disciplines including psychology.
In industrialized societies today men die earlier than women but women have poorer health than
men (Macintyre and Hunt, 1997). In 1996 in the UK boys had a life expectancy of 74.4 years
compared with 79.7 years for girls. This excess mortality of 5.3 years in males in 1996 increased
over the course of the twentieth century from only 3.9 years in 1900-1910. However, the
evidence suggests that from the paleolithic period to the industrial revolution men lived longer
than women, 40 years as compared to 35.
Also, in less developed countries (e.g. India, Bangladesh, Nepal and Afghanistan) women still
live longer than men (WHO, 1989). Thus, there are significant historical and cultural differences
in gender-related health.
To complicate the picture further, the SES-mortality gradient appears to be steeper for men than
for women while illness rates, treatment rates, absenteeism and prescription drug use are
generally higher for women (Macintyre and Hunt, 1997).
Women have higher morbidity rates but lower mortality rates. Women suffer more non-fatal
chronic illnesses and more acute illnesses. They also make more visits to their family physicians
and spend more time in hospital. Women suffer more from hypertension, kidney disease and
auto- immune diseases such as rheumatoid arthritis and lupus (Litt, 1993). They also suffer twice
the rate of depression. Men, on the other hand, have a shorter life expectancy, suffer more
injuries, suicides, homicides and heart disease.
In addition to biological factors, the political and economic causes of gender-related health
differences are complex and multi-faceted. These differences need to be considered in their full
context, including policy issues, SES, psychosocial factors, lifestyle differences, life cycle
changes and violence. Chronic conditions such as cancer, depression and anxiety also show
gender-related differences which merit theoretical analysis.
Psychosocial and lifestyle differences are likely to playa major role in mediating gender-related
health differences. In industrialized societies women suffer more from poverty, stress from
relationships, childbirth, rape, domestic violence, sexual discrimination, lower status work,
concern about weight and the strain of dividing attention between competing roles of parent and
worker. Financial barriers may prevent women, more than men, from engaging in healthier
lifestyles and desirable behaviour change (O'Leary and Helgeson, 1997).
Social support derived from friendships, intimate relationships and marriage, although
significant, appears to be of less positive value to women than to men. Although physical and
mental well-being generally benefit from social support, women often provide more emotional
support to their families than they receive. Thus, the loss of a spouse has a longer and more
devastating effect on the health of men than on that of women (Stroebe and Stroebe, 1983). The
burden of caring for an elderly, infirm or dementing family member also tends to be greater for
females in the family than for males, especially daughters (Grafstrom, 1994). Gallant et al.
(1997) have made a useful review of the literature on the psychological, social and behavioural
influences on health and health care in women. While the health of women is a focus for
renewed efforts in health care, the health of men cannot be taken for granted. Men are more
likely to suffer diseases of the cardiovascular system, more often suffer a violent death and die
younger.

ETHNICITY

Empirical evidence suggests that the health of minority ethnic groups is generally poorer than
that of the majority of the population. This pattern has been consistently observed in the USA
between African-Americans (or blacks) and whites for at least 150 years (Krieger, 1987). There
has been an increase in income inequality in the USA which has been associated with a levelling
off or even a decline in the economic status of African-Americans.
The gap in life expectancy between blacks and whites widened between 1980 and 1991 from 6.9
years to 8.3 years for males and from 5.6 years to 5.8 years for females (NCHS, 1994b). Under
the age of 70, cardiovascular disease, cancer and problems resulting in infant mortality account
for 50% of the excess deaths for black males and 63% of the excess deaths for black females
(Williams and Collins, 1995). Similar findings exist in other countries. Analyses of three
censuses from 1971 to 1991 have shown that people born in South Asia are more likely to die
from ischaemic heart disease than the majority of the UK population (Balarajan and Soni
Raleigh, 1993).
There are many possible explanations for these persistent health differences between people of
different races who live in the same country and are served by the same educational, social,
welfare and health-care systems (Williams and Collins, 1995; Williams et al., 1997). First, the
social practice of racism means that minority ethnic groups are the subject of discrimination at a
number of different levels. Such discrimination could lead directly or indirectly to health
problems additional to any effects related to SES, poverty, unemployment and education.
Discrimination in the healthcare system exacerbates the impacts of social discrimination through
reduced access to the system and poorer levels of communication resulting from language
differences.
Second, ethnocentrism in health services and health promotion favours the needs of majority
over minority groups. The health needs of members of minority ethnic groups are less likely to
be appropriately addressed in health promotion which in turn leads to lower adherence and
response rates in comparison to the majority population. These problems are compounded by
cultural, lifestyle and language differences. For example, if interpreters are unavailable, the
treatment process is likely to be improperly understood or even impaired and patient anxiety
levels will be raised. The lack of permanent addresses for minority ethnic group families created
by their high mobility makes communication difficult so that screening invitations and
appointment letters are unlikely to be received.
Third, health status differences related to race and culture are to a large extent mediated by
differences in SES. Studies of race and health generally control for SES and race-related
differences frequently disappear after adjustment for SES. Race is strongly correlated with SES
and is even sometimes used as an indicator of SES (Williams and Collins, 1995;
Modood et al., 1997).
Fourth, differences in health-protective behaviour may occur because of different cultural or
social norms and expectations. Fifth, differences in readiness to recognize symptoms may occur
also as a result of different cultural norms and expectations. Sixth, differences could occur in
access to services. There is evidence that differential access to optimal treatment may cause
poorer survival outcomes in African-Americans who have cancer in comparison to other ethnic
groups (Meyerowitz et al., 1998).
Seventh, members of minority ethnic groups are more likely to inhabit and work in unhealthy
environments because of their lower SES. Eighth, there could be genetic differences between
groups which lead to differing incidence of disease and some diseases are inherited. There are
several well-recognized examples, including sickle cell disorder affecting people of African-
Caribbean descent, thalassaemia, another blood disorder which affects people of the
Mediterranean, Middle Eastem and Asian descent, and Tay-Sachs disease which affects Jewish
people.
Other possible mechanisms underlying ethnicity differences in health are differences in
personality , early life conditions, power and control, and stress (Williams and Collins, 1995;
Taylor et al., 1997). Research is needed with large community samples so that the influence of
the above variables and the possible interactions between them can be determined.

FUTURE RESEARCH

1 The SES variable needs to be unpacked in more detail if our understanding of the mechanisms
of health and illness is to make genuine progress. More research is necessary to understand the
effects of disadvantage - both absolute and relative - on individual and population health.
2 Further studies are needed to investigate the psychological and material mediators of health
gradients.
3 Qualitative studies of the health experiences of people from different socio-economic
backgrounds is of particular importance to our understanding of the psychological mechanisms
underlying health variations.
Further qualitative studies are needed to explore the relationship between social positioning and
health experience.
4 Transnational research is needed to unravel the links between relative deprivation and health.
What kinds of psychological and social processes are at stake here? Is lack of social cohesion the
mediator of the relationship between health and relative deprivation as suggested by Wilkinson?
Do social comparisons also playa role?

SUMMARY

The greatest influence on health is poverty. Of 5.6 billion people in the world population, 4.4
billion live in developing countries. Half of the world's population lacks regular access to
treatment of common diseases and most essential drugs.
Globally, the burden of death and disease is much heavier for the poor than for the wealthy.
2 Inequities are one of the most pervasive features of health-care systems There is evidence that
for both wealth and health, the gap between the 'haves' and the have-nots is becoming wider
between and within populations.
3 Health in rich, industrialized countries can be expected to improve if income growth is
accompanied by a more equitable income distribution. When a society contains a large
proportion of citizens living in poverty and a highly uneven distribution of income, spending
more money on doctors, nurses and health care appears to produce little health gain. Improving
female literacy has more impact on overall life expectancy than increasing expenditure on health
care.
4 Health in poor countries is related to GNPpc, income distribution, and female literacy
However, it is also correlated with the numbers of doctors and nurses 5 It is necessary for
wealthier countries to allocate more resources to development of poorer countries. If the WHO's
Health For All strategy is going to have any chance of success, health must be given a higher
priority in global development policies. The international debts of the poorest countries must be
cancelled so that they can afford to spend more on health care and education.
6 Health-care systems undergo continuous change and reform. The aim of such changes is to
increase efficiency and slow the steady escalation of costs Health services provide a mixture of
private insurance schemes, state funding, and voluntary provision Critics have questioned the
applicability of a market model to health care.
7 Socio-economic status (SES) is strongly related to health, illness and mortality. It has been
suggested that health gradients are a consequence of class.related differences in social cohesion,
stress and personal control.
8 Similar arguments con be applied to the influence of relative deprivation.
Inequality in the distribution of income is associated with an adverse impact on health
independent of the effect of household income. Data collected by Kennedy et al. (1998) suggest
that the effects of income distribution on self.
rated health are not limited only to thase in the lowest incame groups; those in the middle income
groups in states with the greatest inequalities in income rated themselves as having poorer health
than those in middle income groups in states with the smallest inequalities.
9 The effects of income inequality on self-rated health are as strong as other individual risk
factors. Social and economic policies that affect income distribution may have important
cansequences for the health of the population I O Gender differences in health, illness and
mortality are significant and show striking interactions with culture, history and SES.
II The health of minority ethnic groups is generally poarer than that of the majority of the
population Possible explanations include racial discrimination, ethnocentrism, SES differences,
behavioural and personality differences, cultural differences and other factors. Discrimination in
the health-care system could exacerbate the impacts of social discrimination by virtue of reduced
access to the system, poorer levels of communication and poorer compliance.
12 Ethnocentrism in health services and health promotion marginalizes minority groups leading
to lower adherence and response rates in comparison to the maiority population. Differences in
culture, language, lifestyle, health-protective and health-seeking behaviours are likely to
compound the problems of racism and ethnocenfrism. Health status differences related to race
and culture appear to be partly mediated by differences in SES.