Kaplan G. People and places: contrasting perspectives on the association between social class and health. International Journal of Health Services 1996; 26 507-19

This paper reflects on two ways of explaining why lower social classes have worse health outcomes. One is looking for behavioral, biologic and physiologic pathways, focussing on the individual. What about group characteristics, which can only be measured at the population level? These group properties of the environment in which people live may exert independent effects on health. This study looked at residence in a poverty area of Alameda County, California, as being a risk factor for poor health, independent of factors such as smoking, alcohol consumption, obesity, depression, social networks, employment status, income, race, etc. The more deteriorated the census tracts in which people lived, the worse their health. This persisted even after adjusting for the usual risk factors. Looked at another way, what were the characteristics of those residing in areas of high mortality? They were likely to have low education, obese, be isolated with little emotional or tangible support, sedentary, a victim of crime, have low income, inadequate food, be a current smoker, and be unable to fill prescriptions for medicines. Individuals who reported high demands being made on them, and who had few resources were 10 times more likely to live in high mortality areas than in low mortality areas. These findings are consistent with others demonstrating the role of neighborhood and community factors in health outcomes. 

Abstract

While a substantial body of evidence demonstrates a strong association between socioeconomic variables and health outcomes, most analyses conceptualize socioeconomic status as an individual characteristic. This article argues for an expanded view that focuses on the relationship between social class and characteristics of the neighborhood and communities in which people live, and illustrates how these characteristics can provide some new directions for research relating class and health. Using the Alameda County Study, the author presents three analyses that support this view. They indicate that socioenvironmental characteristics of areas are importantly related to the mortality experience of individuals, independent of characteristics of the individuals, and that personal and socioenvironmental risk factors cluster together in areas of low income and high mortality. Studying the balance of demands and resources in areas may help to unravel some of the pathways that link social class and health.

Keywords

• behavioral factors
• community
• health inequalities
• income
• income inequality
• medical care
• mental illness
• mortality
• neighborhoods
• poverty
• psychosocial factors
• race
• relative deprivation
• social class
• social cohesion
• socioeconomic status
• unemployment