Tuesday, 30 December 2014

Problems for measuring social inequality in illness (not mortality)

Inspired by a Twitter exchange with some medical colleagues here is a re-cap of a paper that we published many years ago now on some of the problems that can arise when you try to get an accurate measure of social inequality in ill-health.

The overall term for these in medical sociology is "Illness Behaviour". You can divide this general idea up into 4 more concrete categories

1. The lay referral network. Almost everyone has one of these. It is the bunch of people you talk to when you have a health worry. "Do you think I should take the day off work?" "Should I take vitamins?" "Should I go to the GP/casualty?" "Do I need to call an ambulance?" are some of the questions that family and friends might be asked. We know that people with a more biologically knowledgeable lay referral network are less likely to turn up at A&E unless they really need to. They are also more likely to get medical advice when they do really need it. But there are also more subtle effects. Women whose lay networks are made up more of friends consult less often, those whose networks are more dominated by family consult more often. You get 2 guesses why this might be, answers to @melb4886.

2. The demands of everyday life. People with more arduous jobs will need to seek care (and get themselves defined as "ill") at a level of symptoms that might not affect people in other kinds of jobs. If you are a roofer with vertigo you will feel "ill", if you are a librarian with vertigo you will probably not. So there will be biases in our measures of inequality in this kind of condition. There are plenty of other examples of this, and they have most intriguing implications for measuring social class differences in mortality but I won't go into that just now.

3. The sick role. Some groups of people need to be defined as ill in order to legitimately be excused certain kinds of role obligations (my favorite is "Not tonight, Josephine"). An academic (in my younger days) would not have to get a medical diagnosis and sick certificate in order to work at home for a day with a headache, period pains or a hangover.In some studies this results in people in middle class type jobs appearing to have less illness (and a lower consultation rate) than people in more routine types of jobs. When measuring social differences in consultation, you need to keep in mind that doctors are gatekeepers of the sick role, i.e. legitimate non-performance of various obligations. This varies with the type of obligation, and with its observability and the intensity with which it is policed. This kind of thing is pretty variable in place and time. For example, at UCL for some years now, after 12 days' sickness absence you get called for a disciplinary meeting even with a doctors' certificate. The the role of GPs in signing people off for long term sickness has totally changed in the UK in the past 5 years or so.

4. Quality of the Doctor-Patient relationship. GPs who know their patients and communicate will with them will tend to understand about illness behaviour. Although Phil Strong and others wrote about the ways in which many GPs (and other doctors) communicated less well with working class than middle class patients. In fact, looking back at the classical work on illness behaviour, we probably might not agree with all of it today. It was thought that a good GP screened for high blood pressure for example, on an opportunistic basis, and treated it. This would mean more people would tell a survey that they "had an illness". If GPs took more care of their middle class patients on the other hand this would produce a bias in the class specific rates of reported hypertension.I am not sure everyone is so keen on this kind of screening today, as there is little evidence of long term effectiveness. You could say the same of hypercholesterolaemia. I suspect an example everyone would still agree with would be high blood sugar. Although I have not seen much up to date evidence on this, I would not be surprised if screening surveys showed that more working class people had undiagnosed type 2 diabetes than middle class people.

You can see from these very quick examples that illness behaviour -produced bias does not all go in the same direction. Some factors will make inequalities in illness look bigger than they are and some will make them look smaller. When David Blane, Chris Power and I gave this paper to the RSS about 20 years ago, Derek Cook commented that we had "opened a can of worms that no one wants to think about".

Monday, 15 December 2014

Can we bring sanity into academic work?

A couple of tweets I sent today may have annoyed some people. They were only meant to suggest that we might be able to organize ourselves as academic Departments (or other types of "cost center") in a slightly more rational way. For example, what is the relative contribution to the Departmental budget of (1) 7 hours of admin and academic time spent revising expense forms that result in the saving of £5 versus (2) admin staff being able to deal more promptly with research applications so that deadlines are not missed. You need to take into account of course that the £5 is a bird in the hand whereas the application may fail. But it is worth thinking about. Admittedly, this very idea is an acceptance of the commercialization of the university that many people so hate (I do too). But since we are not succeeding in fighting commercialization all that well, trying to deal with it openly might save some gray hairs. The other reason I suggest this approach is that it was my experience that in fact university managers (both senior administrators and academics turned manager) absolutely hate it when you do this. It seems to take away some of their latitude for bullying made possible by ever shifting goalposts.

I have learned a great deal from the Project Manager of our ESRC center (ICLS). To spare her blushes I will call her PM. To the horror of many of the older center members, PM insists that we evaluate all of our initiatives. When we organize a meeting we ask attendees to say how helpful it has been, for example. Our first attempt to organize a Summer School was so poorly evaluated by our students that we spared ourselves the effort of doing it again. PM's track record of building up seminar series and other forms of science communication is, basically, fantastic. So much as we sometimes disliked it, we usually took her advice.

PM has an MBA. Now, once again, I would not be regarded by those who know me as the kind of person who would thrive in a Business School. But one thing I think they teach you to do is the 'business plan' (another detested phrase). At the moment, I have this idea that Departments could formulate business plans, which could be totally transparent. It would consist, at the simplest level, of figuring out a budget for our work by adding up the amount that comes in from teaching, research and the "QE". Does teaching bring in enough to pay the wages and overheads of everyone with a HEFC post? If so, then they can be left in peace when not teaching to concentrate on intellectual work, which may well result in some additional funds via the QE when it results in good publications. But the main contributors to the QE will be academics who teach less and put more effort into writing. The QE accruing to the Department must be enough to cover this cost.

Then there is research money. Well, first of all it needs to be understood that not all research money is equal. Research Council money covers (in theory) 80% of the total cost of the work including rent, building maintenance, heat, lights, water and so on. Universities are free to set the level of these costs. At top places it can be as much as £55,000 per year per full time post (no matter what the post holder is paid). So the lead applicant on a RC grant is bringing in, lets say to be moderate, 0.8*£35,000 per post (including a proportion added to her own time buy-out so if she spends 20% time on the project it is 0.8*£7,000). There are other funding bodies like drug companies who pay "100% overheads". Then there are the charities and foundations like Wellcome and Cancer Research UK. Many charities, not unreasonably, say that their benefactors do not expect their donations to be used to run the fabric of the universities and will not pay "overheads" at all. So although this money may buy out some academic time from teaching, it will not pay the running costs for the replacement person, nor for any additional staff needed for the project.

But all this can be calculated. What seems to me increasingly important nowadays is that there is more money out there to do a type of market research for government bodies. I am not sure what "overheads" are paid by, e.g. National Institute of Health Research. But deciding to apply for these research contracts throws another factor into the mix. The work still requires skill and effort, but is less likely to address the kinds of intellectual questions that will get papers that add to the QE. I have heard rumours that this kind of work is going spare and the funding bodies have trouble commissioning it. Should academic departments go for it? To me it would depend on a rational calculation. The money gained may pay for staff and their notional running costs, and thus help to retain people on short contracts, whose wages are not covered by other grants, QE money or teaching money. The ideal state would be to have enough coming in from the latter 3 sources that everyone can keep going by doing more classical types of academic work. But if this has not been achieved then people may need to turn their hands to less glamorous toil.

None of this is an different to what any small business has to do. The first priority needs to go to the tasks that bring in the most money. Unfortunate as this may be, it is not the fault of those who manage Departments (or other cost centres), who can be totally transparent about the whole thing. This would actually mean that everyone in the Department would be able to take joint responsibility for a common effort.

Sunday, 22 June 2014

How sociology was destroyed in the 1980s

I have had some interesting twitter exchange about why sociology has split into the 'qual' and 'quant' camps, and also lost a lot of its theoretical strengths. I do have a theory about this but no idea if anyone else agrees, or even remember that long ago.

My memory of the 1980s is that people I knew who were sophisticated social theorists felt themselves to be under attack. The writings of Durkheim on the importance of social solidarity, and of Marx on how economy and society are related, became increasingly criticised. These ideas, at least in the version my colleagues taught them, were not obscure or hard to understand if well described. They were highly relevant to helping students and other understand the world they were living in. But somehow we got pressurized into teaching more obscure versions such as Althusser and Foucault. The other side of that deal was that we no longer had to be able to test the ideas empirically so the skills of data analysis atrophied. Everything then became more and more a matter of opinion or debate (but debate with astonishingly little demand for scholarship such as actually knowing what was happening in society). I believe this was called 'post-modernism'. Then there was the rejection of 'grand theory', so we all lost the idea that sociology could try to explain anything at all.

I should say here that I never actually managed to get a teaching job as a sociologist, and went from being a printworker, to a computing assistant, to being a kind of epidemiology researcher. So none of this actually happened to me and I am reliant on other people's accounts. But in the middle of all this I did a PhD on the sociology of science and technology and witnessed one of the most exciting new social theories, Actor-Network Theory, being totally crucified by American Big-Science interests. I mention this partly so that people don't just think  am a 'quantophrenic' or whatever Robert Dingwall might fear! My dismay is not about the disappearance of statistics but about the decline of the kind of scholarship that brings theory together with data, quantitative or qualitative. And weakness in theory is just as important here as weakness in methods.

And to return to the beginning, my guess is that this all began in the 1980s attack on sociology which produced a kind of stand-off in which sociologists (implicitly) promised not to say anything important in return for getting away with being obscure and vague. That original generation realized what was happening but felt powerless to change it. Problem is that their students really don't know any different.

Wednesday, 26 March 2014

The trouble with "Socio Economic Status"

It is dismaying to notice how this term and its abbreviation "SES" is returning to reports and discussions of research in health inequality. I thought we had done away with it at least outside the USA, and adopted "Socio Economic Position" (SEP). The virtue of SEP is that it is a very general term, referring to social class, social status, income and material circumstances. As these measures of life circumstances are often used pretty indiscriminately in research studies, if you want to do some kind of review paper, you often have to use the measure that is present in each paper. But as Nancy Krieger and colleagues pointed out many years ago now, if we are going to get serious about explaining as opposed to describing health inequality, we need to be more precise about what our input variable actually is. Because no one imagines that income, wealth, social status or occupational social class come along and bonk anyone over the head resulting in disease or mortality. If you think about it for one second, you realise that there are always 'proximal' factors like environmental conditions, housing quality, work conditions, psychosocial stresses or health behaviours that do the business for health. But different dimensions of inequality can be shown to have different relationships to these different proximal factors. Social status is most strongly related to the behavioural patterns at the present time (this will not necessarily be the same at all times in all places). Occupational class has the strongest relationship to working conditions. Income is the strongest determinant of housing. And even the income-housing link is different in different countries according to housing policies, for example in Denmark housing is not as segregated as in the UK.

Neither is it useful to talk about "high" and "low" SES (or SEP for that matter). Yes, income can be high or low, but that needs to be explicit before we can make sense of the mediating factors. Social status can also be high or low if we are thinking in terms of caste-like phenomena where members of certain occupations or groups defined in terms of religion, language or skin colour tend to avoid each other's company. Here again, if you think clearly you can imagine how such discrimination might well act according to stress pathways as described by Wilkinson and Pickett. Caste groups in Hindu societies also adopt different behaviours such as diet. A person wishing to pass as a member of a higher caste will need to change these behaviours, and this is what we find in relation to smoking and social mobility. These are real examples of the Black Report's "cultural-behavioural" explanations, that make sense in sociological terms. So one could think in terms of low income or low status if that is what one's explanatory hypothesis for a certain aspect of health inequality entails. But "low" and "high" are of little use as general blanket terms. We know that members of certain ethnic groups such as Catholics in Northern Ireland and The Netherlands, or people or Irish or Caribbean descent  in England for example, tend to have suffered historical discrimination and as a result have lower incomes and also worse health than Protestant or Anglo-European groups. But we do not use the blanket terms "higher" or "lower ethnicity" to refer to this. It is clearer to use  "more" or "less advantaged" as the more general term.

Recently there has also been a return to using education as a measure of SEP. This makes things even more confusing. As important as education is in the life-course factors that determine what kind of conditions and attitudes a person will have in adult life, it is not in itself a dimension of social position. It is a very strong indicator of where someone will end up (and their resultant exposures). In fact, if policy were so organised that people who started off in a less advantaged social position as children were given extra attention at school, population health might be greatly improved. But even this would not eliminate social inequality which arises from the structure of occupations and the income distribution. We will soon be able to see whether the increasing proportion of graduates who end up in low paid (income) and insecure (employment conditions) jobs will change the relationship between education and health.

The use of education as a measure of social position does give us a hint, however, of the thinking that creeps into research on health inequality. As pointed out by Gordon Marshall (even longer ago than Krieger et al.'s seminal work), there is a sneaky eugenic argument that lurks beneath the use of terms like "lower" and "higher" SES. This is that people with superior personal characteristics have better health. So their success at school, their more advantaged occupations,  their higher income and their better health are in fact all consequences of this underlying superiority. The enthusiasm in epidemiology for genetics gives further strength to this kind of thinking. People in "low social positions" tend to smoke? Well, what do you expect, they are not bright enough to figure out the dangers (by the way, what evidence we have points strongly in the opposite direction, that there is no link between social position however measured and the desire to stop smoking).

I do not actually believe that many social epidemiology researchers mean to make this kind of argument. After all, we would put ourselves out of business pretty quickly. There is no point to public health if everything is determined genetically.

Thursday, 6 February 2014

University pay: why the bosses are confident

Today we are on strike. Some union members have suggested we should do something active rather than just stay away and not work. As an arthritic retired academic I remember the social media  and decided to do this instead.

I think the bosses have a reason to be confident about keeping academic pay so low. When I worked on labour markets in the 1980s there was this idea about the "dual labour market2. I have heard less about it recently but I think academe is increasingly one of these. There is a shrinking "core group" of workers and a growing penumbra or reserve army around it.

Why are university chiefs not more worried about being able to recruit top people at a time when global competitiveness is stronger than ever? I think the solution they have found is simple. There is something called the "labour market adjustment" that allows people they want a lot (including managers) to be paid more or less anything. Need to recruit a top economist? OK, you can offer a competitive wage. But the poor bloody infantry of people to teach English or social sciences, it seems, will do it for far less.

Most academic jobs are done for a "component wage", that is, a wage that will not support a family on its own. Someone asked me the other day "Why are all our students (of social epidemiology) women"? This is because a discipline that focuses on preventing disease as opposed to treating it does simply not pay enough to live on, certainly not in London. Another colleague pointed out that most of her colleagues who had already had children were married to bankers, that is the only way they could do it.

So lets not be too hopeful that university staff will soon be paid a wage that reflects their training.

Friday, 3 January 2014

Is life-course research a political cop-out?

Now, there is something controversial for me to say, of all people. But a couple of thing recently have made me think. First of all there was a book, a really interesting one that I wold actually recommend to life course researchers called "Biological Consequences of Socio-economic Inequalities" (BCSI)edited by Barbara Wolfe and colleagues: https://www.russellsage.org/publications/biological-consequences-socioeconomic-inequalities

We noticed that the editorial group was made up to psychologists and economists. When I read the various chapters of the edited collection I was surprised to find hardly anything about how health inequality is 'endogenous'. This idea is often put forward by economists and as far as I understand it, it means that health inequality is a result of individual characteristics that sort people destined for poor health into less advantaged social and economic circumstances. At one time, my (highly valued) economics colleagues seemed to think these characteristics were genetic. A position rather similar to that of Boris Johnson's Margaret Thatcher Memorial Lecture (or whatever it was). I do not think they meant congenital diseases (or at least not once we had finished discussing how rare such diseases are). Rather it seemed that there was an idea about individual preferences that arose from the genes (what a social epidemiologist would call 'indirect selection' rather than 'direct selection'). A preference for hard work and self denial, for example, would tend to result in both good health and high income.

In the last few years it has become increasingly unlikely that 'genetics' would be able to explain such highly complex characteristics as preferences with any precision. So I wondered if that was one reason for the remarkable consensus between the psychologists and the economists who edited and wrote the chapters for BCSI. Instead, the theory being put forward was based around early life experiences and their consequences for later health. The idea is that early adverse experiences 'get under the skin' by a number of biological pathways: by influencing inflammatory responses, immune responses and, most exciting of all to some people, by 'epigenetic' mechanisms.

The epigenetic mechanism, as I understand it (again) is the way in which the environment (by which people mean everything from the next door cells to the neighbourhood) 'tells' certain genes whether or not to turn on the proteins for which they can act as a template. A gene which doesn't do anything much in most children, for example, may, in abused children, become 'myelinated' and turn on a protein that has a harmful effect. Furthermore, it seems that once this change to the workings of the gene has happened, it  not only persists throughout life but even may be passed on to the next generation. So for example, the fact that the children of smokers are known to be far more likely to smoke themselves. Child abuse seems to be similarly 'hereditary' (though I never heard anyone suggest that this was epigenetic).

I am sure people can see where this kind of thing is going. Instead of blaming the individual for their poverty and poor health, we can just blame their parents! There is indeed a lot of evidence in the tradition of 'family stress theory' research to show that, not surprisingly, people find it harder to be 'good parents' under conditions of poverty. The problem is, there are such powerful inter-relations between material adversity, psycho-social adversity and poor health right across life. A person whose childhood was marked by low parental wages and poor housing will have started off with higher exposure to factors that produce inflammation (frequent infections for example) . They may well have done worse in school due to difficulties in studying. So they have a high risk to find themselves in a hazardous occupation and poor housing in their own adult lives. Until these different exposures are isolated from each other and from the child's relationships to its parents we should not jump to conclusions.

Ironically, it would rightly be impossible to do trial-like studies of such processes because no one would randomise children into poverty. But a better idea might be to randomise disadvantaged adolescents into a carefully supported school experience, with free healthy meals and warm, quiet study areas supplied. Even that sounds rather unethical though, when you think about it. How could one justify not providing the intervention to the control group?