Social class and health inequalities – does capital make the difference?
The persistence of health inequalities is one of the greatest concerns in public health [1, 2]. The term health inequality generically refers to differences in the health of individuals or groups [3]. What is particularly disquieting is first that these inequalities in health have been widening and second that interventions aimed at tackling this “wicked” problem have not been able to stop this trend [4].
Social-epidemiological explanations of health inequalities traditionally take the existence of social inequality as a given. They ignore the fundamental questions of why social inequality exists anyhow and why it is so persistent [5]. Moreover, these traditional social-epidemiological explanations are based on a rather static and unidirectional view of the association between socio-economic status and health. Recently, more dynamic models have been proposed as ways of rethinking the causal relationship between social class and health [4]. For example, The Netherlands Institute for Social Research (SCP) proposed a capital-based model in explaining the differences within the Netherland population, which draws on Pierre Bourdieu’s theory of class and processes of cultural distinction [6, 7].
Bourdieu argued that people from varying social positions differ from one another with regard to their possession of three forms of capital: social, cultural, and economic capital [8, 9]. Each of these forms of capital is considered as a resource; and according to Bourdieu these resources are interrelated and reflect class positions: the diverging power of various groups in the social hierarchy. In his view the cultural hegemony of the upper classes (as shown in their habitus: life styles, manners, tastes, preferences and ideas) was essential in reproducing the existing social hierarchy over generations, with the educational system performing a key role in this process.
SCP developed a theoretical model that builds on the Bourdieu’s capital notions, but also includes the idea of ‘life chances’ as developed by Weber and his followers; the importance of individual heterogeneity as stressed by Pareto; and notions derived from social network theory [10-13]. This model distinguishes four types of capital and incorporates elements of health status, thus linking to the wider debate on socio-economic health differences. Social capital refers to networks for social and instrumental support, cultural capital to differences in language, communication, preferences, etc. and economic capital to levels of education, income, wealth and occupational status. Person capital relates to ‘embodied’ differences: people’s physical and mental health, and their appearance (attractiveness). The various forms of capital theoretically determine people’s life chances, and their impact and causal order for life chances may vary over the life course (e.g. education may be more important for young people, health among the elderly). Segmentation theoretically occurs when there is multiple correspondence of the social hierarchies on each of these four types of capital. Based on latent class analysis of variables indicating the sub-dimensions of all forms of capital, SCP concluded that the current Dutch population may be divided into six capital groups. The main juxtaposition is between the established upper echelon (which has lots of each subtype of capital) and the precariat (which typically has low education, limited income and wealth, joblessness; small networks for social support and professional advancement; few digital skills, low language proficiency and little participation in high-brow culture; and low health (both physical and mental) and attractiveness. In between these two social classes are the ‘privileged younger people’, the ‘employed middle echelon’, ‘the comfortable retirees’ and the ‘insecure workers’. The total capital of the insecure workers and the precariat lags far behind the resources of the other four groups.
The notion of capital applied in that study implies that the various forms can increase or decrease over the life course (e.g. building social networks as working adults results in more social capital, but this typically is in decline after retirement, when people’s networks become smaller as they lose job contacts and elderly friends and relatives die). In addition to such processes of (dis)accrual, the various forms of capital theoretically are convertible: for instance, cultural capital (e.g. high proficiency in English language) may be useful in obtaining a decent job, which can result in a higher income; and this may allow people to extend their networks (e.g. by being able to participate in social activities), or improve their health or appearance (buying healthier food or representative clothes). The model also presumes agency: people may actively invest or disinvest in the various forms of capital (buying a house or gambling away one’s wealth, pursuing a healthy life style or eating junk food); and this is likely to affect their remaining life chances.
Most research does not regard health as a separate form of capital (see however [14]), and this is a theoretical advancement of the current project. There are, however, some studies that investigate the relationship between health and economic, social and cultural capital. Evidence suggested that economic capital could influence health status both directly and indirectly through health-related lifestyles and behaviours [15, 16]. However, the majority of this research did not discriminate economic capital from the narrower concept of socio-economic status, which is typically a combination of income, occupational status and educational attainment whereas economic capital is broader. Social capital affects health status as social connectedness, social participation, associational activity, and social support are associated with health outcomes [17-19]. Although only limited attention has been paid to cultural capital in health research thus far, e.g. Mackenbach identifies cultural capital as a promising approach to explain health inequalities [2, 20-22].
The vast body of evidence in explaining health inequalities from a capital perspective leads to discussion on social conditions being the fundamental cause, but the theoretical consideration of the interaction between different forms of capital is still in its infancy. In this regard, the proposed longitudinal studies offer interesting possibilities to realise the full potential of interactions between different forms of capital as key processes in the social reproduction of health inequalities. [23]. Moreover, pioneering researchers in this area confirmed the importance of simultaneously including measurements of the different forms of capital [24, 25].
In this attempt to advance beyond the detection of causal links and association to a framework, we further integrated the capital-based model by drawing on the research output from SCP and consequently considering the four forms of capital. We will distinguish four types of capital at the micro level: social capital, cultural capital, economic capital, and person capital in particular (Figure 1). Cultural capital refers to the shared tastes and preferences, attitudes, language use, consumption patterns and so on, which are linked to the membership of a social class [19]. Economic capital is the asset that can be (directly or indirectly) converted into money and may be institutionalized in the form of property rights. This includes all kinds of material and non-material resources (for example, education, occupation, or income) that could be used to acquire or maintain other capital. Person capital refers to 'body-specific' characteristics that people can derive from social advantages or disadvantages. It is noteworthy that two types of person capital are distinguished here: health-related person capital (i.e. health status, disease status and age) and non-health related person capital (i.e. someone’s personality). Finally, social capital relates to relationships with other people: the number of people who support, their resources, the willingness or obligation to help, the position that one occupies in networks and the structure of networks.
The overall aim of the proposed project is therefore to explore the degree to which differences in availability of capital contribute to the health inequalities. We aim to understand the dynamics of health inequalities by simultaneously considering and modelling indicators of each form of capital. Further, different types of interplay between the capitals will be examined in order to realise the full potential of the current approach.