Health inequalities and the class system

Inequalities in health by social class have been documented for over a century. We know there are health inequalities in society, with people from less advantaged backgrounds suffering poorer health, for longer, and dying younger than their wealthier peers. Research has also shown that health inequalities can be explained by inequalities in income, wealth and power, by a country’s approach to welfare, and by specific economic and social policies.

However, there are many ways of defining social class and, if we had a better understanding of which particular characteristics were most important in explaining ill health, it could help policymakers to tackle the problems better. We wanted to add to the existing research using Understanding Society because its data are representative of the general population and allow us to look at adults of all ages.

What do we mean by ‘class’?

We examined four definitions of social class:

French sociologist Pierre Bourdieu’s theories of ‘habitus’ and ‘distinction’ – based on the premise that we develop an approach to the world based on our experiences, with habits and skills learned from the situations we spend the most time in. These learnt behaviours give us an accent, style of dress, or set of cultural preferences similar to others with the same experiences, allowing us to bond in groups.
German sociologist Max Weber’s theories of opportunity hoarding and social closure – social groups find ways of blocking others from opportunities such as well-paid work or education, by, for example, excluding people of colour and people with a different education, discouraging people from marrying outside their class, and giving opportunities to people in their own class through nepotism.
Karl Marx’s theories of exploitation, domination and power relations – Marx focuses on labour markets, and suggests that people who own capital such as land, businesses or real estate can extract profits and control the activities of those without capital.
Early years – the idea that we are shaped by the family, household and social class that we are born into, and that successive generations are shaped by the one before, meaning that inequalities persist through time.

There are mixed findings on whether social class inequalities widen or narrow over the course of one’s life. Some studies of health inequalities have suggested that inequalities increase as we age, while others seem to show that they decrease. Other work has looked at whether men and women experience class differences differently. Our research asked how much each of these different definitions of class could explain inequalities in different health outcomes, and whether the associations varied by gender and age.

Using the data

We used data from Waves 2 and 3 of Understanding Society, in which participants answered questions about their health – rating it themselves and giving answers to 12-question assessments of physical health (the SF-12 Physical Component Summary), mental health (the SF-12 Mental Component Summary), and psychological distress (the General Health Questionnaire-12, or GHQ-12). Some of our participants also gave us blood samples and had a nurse health assessment, giving us objective health data, or ‘biomarkers’. These allow us to calculate an allostatic load score – a measure of cumulative stress on the body, which captures information on five physiological systems (endocrine, inflammatory/immune, metabolic, cardiovascular and kidney function) and calculates a cumulative score based on whether people’s biomarkers for each system are in the worst quarter given their age and sex.

We measured social class with different questions from the survey.

Bourdieu’s definition: Whether survey participants take part in cultural activities such as reading, writing, playing music, going to exhibitions, galleries or classical concerts, and volunteering or giving to charity.
Weber’s definition: Respondent’s educational qualifications, income and what’s known as individual occupational social class – a measure that combines job security, promotion opportunities and how much control a person has over their own and other people’s work (professional and managerial occupational classes have the most favourable work conditions in these respects, while routine jobs have the least favourable).
Marx’s definition: Does the survey participant own their own home and/or car? Do they have income from property and capital, and not just employment? We also measure their autonomy based on how much they agree with the statement “What happens in life is beyond my control”.
Early years definition: The age at which the respondent left school combined with their parents’ job and level of education.

Over half of the participants – more than 21,000 people – gave complete data for all our social class theory measures, and 5,000 also gave allostatic load data.

Findings

Whichever definition of social class we considered, we found that people with a more advantaged social position had:

better self-rated physical and mental health
lower levels of psychological distress
lower allostatic load.

The strongest associations for self-rated and physical health were with the Marxist and Weberian definitions of class, and the strongest associations with mental health were those with the Marxist definition. Associations with allostatic load were more consistent across the four definitions, although there was a suggestion of stronger associations with Marxist and Weberian theories.

When we considered gender and age, we found that links between health and class were generally stronger for women and older respondents when the Bourdieusian and Marxist definitions of class were used. Physical health links with all social class measures were stronger among those aged 50 or more.

What have we learnt?

Previous research has generated similar findings to ours. For example, twenty years ago, one paper suggested that economic inequality was more important for health than social capital. In the intervening years, autobiographies such as Didier Eribon’s Returning to Reims and Damian Barr’s Maggie and Me have also talked about the interlinked nature of social class mechanisms and structural discrimination.

Our work is further evidence that social class across the full lifecourse has a marked impact on health inequalities. When we used the early years definition of class, there were links with health outcomes even in the oldest groups of people. This research also highlights the importance of recognising the differential impact of different social class mechanisms to different groups, for example those defined by gender and age.

For policymakers interested in reducing social and health inequalities, the finding that the Marxist mechanisms of exploitation and domination have the largest impact suggests that policy should take the structure of the economy into account. Ownership of capital, inequalities in power, and the control different social class groups have over their economic life will therefore be important.

The problem of young people unable to get onto the housing ladder and facing increasing rents, for example, has led to calls for better economic democracy and community wealth-building and for inclusive or wellbeing economies. Policy can also address Weberian ideas of social closure whereby the advantages enjoyed by those who are privately educated could also contribute to health inequalities.

Read the original research