How do culture and social backgrounds influence health? - Chapter 2

What do health differentiations entail?

The environment in which we live has just as much effect on our health as the way we live. It matters a lot whether you belong to a majority (high social economic status) or to a minority (low social economic status) in a country. People who are poor live, on average, five years shorter than the richer ones in the society. On average, women live longer than men. This chapter describes how different groups experience different levels of health.

Clear health differentiations (differences in health status and life expectancy among different groups) can both be found within and between countries. The World Health Organization developed a method to calculate the expected lifespan of people, which is called healthy life expectancy. This calculation is based on the number of years that a person can live in full health, taking the number of years that the person lived in poor health due to illness into account or taking an accident into account. 

Poverty probably has the most important social and economic impact on health. In a developing country, one third of the population dies at the age of 5 years. The most common causes of death are diarrhea, dysentery, and lower respiratory tract infections. Another third dies before the age of 65 and finally, another third dies at the age of 65 or older. In developed countries, only a third dies before the age of 65. This is explained by differences in the availability of clean water, sanitation, food and access to health care institutions. The causes of death of young children in particular are often very easy to prevent or remedy in Western countries.

Explanations of socio-economic health inequalities

It is clear that there is a connection between health and SES, but the question is still in which direction the conclusions can be drawn. Is it the case that a low SES is the cause of poor health (social causation model)? Or does poor health prevent you from holding a job or have a lower education (social drifting model)?

Most studies show that the SES has a significant impact on health. When people change jobs often because of reorganisations for example, it appears that these people experience emotional and physical problems.

Different health behaviors

Premature mortality means that someone dies at an age when they are not normally expected to die. This is usually set at deaths under the age of 65. Premature mortality is found more often among people with a low SES than among people with a high SES. There are a number of explanations for this. It appears that people with a low SES exhibit more health-deteriorating behavior and less health-promoting behavior. These people smoke and drink more, eat less healthy, and exercise less than people with a high SES.

It appears that there is no shortage of knowledge, but a voluntary choice based on a comparison between the costs and benefits of such behaviors. 

Access to healthcare

Access to health care appears to differ between both personality characteristics and the health systems to which the individual has access. It appears that people with a low SES have poorer access to healthcare. Poorer access to health care appears to be associated with a poorer quality of life, more hospital admissions and a higher prevalence of angina. A study in Scotland showed that there were differences in the number of medical and surgical procedures in poorer and richer areas in Scotland. For example, the number of hip replacements per head was higher among the better-off than those living in economically deprived areas. Several studies have confirmed this inequality in health care.

Environmental factors

People with a low SES work in a dangerous environment more often. They also live in poor housing. The overcrowding associated with poor housing may also have a more subte and long-term impact, and is associated with high levels of stress. High levels of stress can cause coronary heart disease (CHD). 

The stress hypothesis

People with low SES experience more stress than people with high SES. The effects of stress are poor health. For each age category there are a number of examples of the type of stress that these people can experience:

• Childhood: family instability, unhealthy food, less educational opportunities.
• Adolescence: family aspiration, smoking, exposure to other people's smoking, leaving school with poor qualifications, experiencing unemployment or low-paid and insecure jobs. 
• Maturity: working in hazardous conditions, financial insecurity, periods of unemployment, low levels of control over work or personal life, negative social interactions.
• The elderly: no or small occupational pension, inadequate heating and food.

The greater the income inequality within a country, the worse the health within that country. The greater the inequality in wealth within a society, the lower the levels of social cohesion and social capital (the feelings of social cohesion, solidarity and trust in one's neighbors). A low social capital is associated with feelings of dissatisfaction and distrust. This is stressful and is confirmed by several studies. There is a relationship between social capital and social support. A large number of positive social relationships and few conflictual ones may buffer individuals against the adverse effects of the stress associated with low economic resources. A poor social support system may increase risk for disease. 

Work status and stress

Despite all the laws of today, it is inevitable that some jobs involve more risk of accidents or illness than others.

Some types of work have a character that causes more stress for employees.

On average, work factors associated with more alcohol consumption are job alienation, job stress, inconsistent social controls and a work culture of drinking. Furthermore, long work hours, lack of control and poor social support have been associated with higher tabacco consumption.

The Strain Model, developed by Karasek and Theorell, describes how different factors of the work environment contributes to stress and illness. 

The following three factors are included in the model:

1. The demands of the job.
2. The degree of freedom to make descisions about how best to cope with these demands (job autonomy).
3. The degree of available social support. 

These factors together determine the degree of work stress that the employee experiences. Stress-related diseases can be predicted as well.

Research shows that experiencing high demands and little autonomy, little social support has a negative impact on the health of the employee. The employee feels stressed and is at risk of illness. If an employee has high demands, but a lot of autonomy, this results in less stress.

Siegrist and colleagues (1990) have devised a different theory about work stress, but this is less known. If a high effort is rewarded with a high reward, this is acceptable. If a high effort is rewarded with a low reward, this leads to emotional stress and negative health effects. This theory has received some support.

An example of a combined risk is the work-home spillover phenomenon. This means that after work the responsibilities also continue at home. For men, the amount of (work) stress experienced is often a direct function of their working environment. The so-called work-home spillover theory often occurs in women. For women, it often applies that when they come home from work, a household job is still waiting for them at home. As a result, they often do not experience the self-confidence at work that men do get from their work.

Unemployment

Being unemployed has negative health effects, such as greater risk of heart attacks and strokes. The impact is especially large for people with little financial security.

What is the link between minority status and health?

People from an ethnic minority group often have relatively poor health. The most important issue when explaining this is that a disproportionate number of them also occupy low socio-economic groups. Before suggesting that being in an ethnic minority alone influences health, the effects of these socio-economic factors need to be excluded. For valid research results you have to compare disease rates between people in ethnic minorities and people from the majority population matched for income or other markers of SES. 

Differential health behaviours

The differences can also be explained by differences in behavior. In Britain for example, men of African and Asian descent sometimes consume more alcohol than other men with similar SES and age. As a result, these men are more likely to develop an alcohol related illness.

Stress

A second explanation for the negative health of people belonging to a minority group focuses on the psychosocial aspect. People belonging to an ethnic minority group experience more stressors than majority populations, due to specific stressors such as discrimination, racial intimidation and adaptation to a new culture.

Accessing health care

Research shows that black residents of the United States are less likely to be examined, operated, or treated than white residents. The number of people who die per disease is also higher for black people than for white people. In Britain this difference is also there, but not for ethnic background, but for SES. Unfortunately, it is often the minorities that are at most risk for illness or mental health problems.

In areas in the UK, where many ethnic minorities are of Asian descent, there are usually few women who work. Traditionally, it is not very common for Asian women to have such a function. This prevents many women in those areas from seeking help.

What is the link between gender and health?

In general, men have a shorter life expectancy than women. Despite this, men judge their own health higher than women and are less likely to seek help. 

If you look at what kind of diseases men and women get, men are less likely to suffer from acute diseases. Women suffer more often from a number of symptoms and also suffer longer from the symptoms than men, but in the end they are less likely to have a real chronic disease than men. In countries where industry is emerging, these differences are often smaller or even vice versa.

Biological differences

Women are more resistant to infectious diseases. Estrogen inhibits the development of CHD because it prevents blood clotting and it reduces cholesterol. The role of testosterone in men has changed over the years. High levels of testosterone are associated with low levels of HDL cholesterol (the so-called 'good cholesterol').

For men, the response to stress situations is greater, or at least different, than in women. This results in an increased risk of CHD. The question is whether this greater stress response can be attributed to biological or social and contextual aspects. Perhaps it is because men are more likely to end up in situations that would also cause such a major stress response in women. In controlled research situations, where men and women are exposed to the same stressors, there are usually hardly any differences to be found.

Behavioral differences

When they have a choice, women eat healthier than men. They are more inclined to eat the recommended daily amount of fruit and vegetables and pay more attention to what kind of food contains a lot of fat. More men than women engage in health-threatening behaviors such as smoking, drinking a lot of alcohol, not wearing seatbelts in the car, driving while they have drunk alcohol and not going to the doctor for a check-up.

However, there is an area where men are much healthier than women: men get much more exercise. Often this has to do with 'masculinity'.
Inequalities in power between the sexes can also have a negative impact on women's health, for example having unwanted sex is associated with inconsistent condom use.

Economic and social factors

In the UK, 30% of women are unemployed and the women who do have a job, on average, have jobs with less prestige and status and a lower salary.

Men drive more cars, certainly because women with a low SES have relatively less driver's license or a car. As a result, more women live in social isolation than men. As women get older, they live more often alone (as a widow) than men. This last point is probably related to the longer life expectancy of women. Women are also more vulnerable to a bad or broken social network than men.