Monday, 28 December 2015

An example of qualitative work?

I promised to give an example of what I thought might be one approach to doing qualitative research on health inequality in an unfamiliar culture.
This came from merely a conversation I once had with someone from Hong Kong who insisted there was no such thing as social class there. Social class is a property of the industrial structure, and I don't know anything about industrial structure in Hong Kong so I could not argue with this. So if one wanted to do research on health inequality there, how to proceed?
I decided to try asking about social status. Using my understanding of caste systems (from undergraduate days) I zeroed in on some questions about co-mensality and intermarriage. I started with intermarriage and did not (as it turned out) have to go any further.
"Lets say you had a daughter and she told you she had fallen in love and wanted to marry", I proposed to my friend. "What sort of guy would you be hoping she would want to marry?"
"Well", he replied, "of course he would need to be Chinese" (my friend is Chinese).
I said "OK, but would there be anything else about the potential husband that you and your wife would really prefer?"
My friend thought for a few minutes. At last he said
"Oh! You mean colour! Yes, of course, I understand".
So here we have an example of a discovery about a social status hierarchy. I had previously had no idea whatever that, within the Chinese community in Hong Kong (which I had realised was of high status and pretty endogamous), there were additional gradations of colour.
But if I had not already had a lot of ideas at the back of my mind, ideas that arise from reading theories about social inequality of different types, I would not have (1) been aware of the difference between class and status (2) had any idea of how to ask questions that might elicit relevant responses for the discovery of status systems.
I later discovered, partly by talking to experts and partly by reading additional literature, that within the African-American population there is well known to be a so called "pigmentocracy" in which those of darker skin colour have a lower status. This can be shown to even have associations with health. That indicates to me that the colour hierarchy is a very profound and stable phenomenon that "gets under the skin".
Since becoming aware of this phenomenon I have learned about its effects on the lives of several friends. This is anecdotal stuff of course. But if I had not been taught about the criteria for caste membership, I would never have even begun to realise that "pigmentocracy" existed at all, certainly not in Hong Kong.
The point being that without asking questions informed by social theory, a basic feature of social inequality might have been totally missed by qualitative work.

Tuesday, 15 December 2015

Are health inequalities less marked during "youth"?

Someone tweeted me a question about the famous (some years ago) "Health Equalization in Youth" hypothesis and I said it would take more than 140 characters to reply. So here it is in a few more characters

For a start it is called "Health Equalization" because health inequalities are very marked in the perinatal (not neonatal) period and in infancy. But between around 14 and 18 (depending on what paper you are reading,sometimes it goes higher) years of age it seems that health inequality is indeed lower than after around age 30. It does depend on how you measure health, however. Social class differences in average height, for example, are just as great in "youth" as earlier or later in the life course (or they were last time I looked). Class differences in, for example, louse infestation are also large. It is in mortality that we really see the smaller health gap.

Well, not many people, thank goodness, die during adolescence (this is changing now, but it was true in the 1980s and 1990s). At this time, cancers were one of the more common (not common really, just more common than heart disease which was the biggest killer in the adult population) causes of death in adolescents and cancers do not generally have a big social gradient. Apart from lung cancer, and this is unknown in young people. Leukaemia, for example, did not at this time have much of one as far as I remember.

The importance of the idea, however, was in the light some authors thought it shone on how health inequality in adulthood emerges. If, they argued, inequality in health according to the social class of one's parents was low in adolescence, but inequality according to one's own occupational class then emerged strongly by age 35 or so, maybe this tells us something about it. Perhaps it is that there are unhealthy adolescents scattered through the population at random, regardless of their parents social class. During youth, the deaths of these unhealthy adolescents will not, therefore, show a health gradient. What causes inequality in mortality later on in the life course is that the unhealthy ones (who were going to die anyway) could only get the lousiest, worst paid and most hazardous jobs? So although it looks like low pay and job hazards cause early mortality, actually it is poor health which causes both early mortality and having a lousy job. I know this sounds ridiculous, but that is what the argument was and why it got so much air-time.

I remember talking at a meeting to some people from a support group for people with chronic kidney disease. One the the conference speakers had put this idea forward. The people with kidney disease were very amused. They asked if anyone had the slightest idea what it was like, and how silly the idea was that people like them would be selected into things like mining, building work and ship building. They were looking forward to telling all their friends about the ludicrous academics who thought building workers have high mortality because they already suffered as children from diseases like kidney failure.

One thing you have to remember, especially in today's economic environment, is that the statistics on mortality that were being used did not include people with permanent disability who had no stable occupations at all. You could only be included in the statistics on health inequality if you had an occupation which defined your social class. So people who had chronic illness from childhood that prevented them from working were excluded altogether. And this was also in the days before people with chronic illnesses were being forced into various types of low paid work. So in fact, people in hard jobs were selected at the beginning of their working lives for good health. This has been called the "healthy worker effect". But that is another story.

As it was, at the time, there were quite a few people, including policy-makers, who for quite some time believed that health inequality was due to this process whereby sick people were recruited into tough jobs. It was called "direct selection".

The most important papers were written by Patrick West & colleagues:

West, P.  Health inequalities in the early years: Is there equalisation in youth? Soc Sci Med 1997 (44(6)) pp 833-858

West, P. Macintyre, S. Annandale, E. Hunt, K.  Social-class and health in youth - findings from the west of scotland 20-07 study. Soc Sci Med 1990 (30(6)) pp 665-673

and David Blane & colleagues:

Blane, D. Bartley, M. Smith, G D. Filakti, H. Bethune, A. Harding, S.
 Social patterning of medical mortality in youth and early adulthood. Soc Sci Med  1994 (39(3)) pp 361-366

Monday, 5 October 2015

Beware of "Resilience"

Why has resilience become such a big buzzword in social science and even in social epidemiology? In 2003 or thereabouts a group of us formed a research network on "Resilience and Capability" funded by the ESRC. Even at that early point there was quite a story attached. It took them ages to decide whether to fund us or not, and this turned out to be because, naively, we had not in our wildest imaginings realised what the topic was supposed to cover. The "call" had come out in 2002 just after 9/11 and was meant to attract proposals dealing with civil defense. The kind of resilience the funders were interested in was how cities, for example, might be prepared to resist the effects of terrorism.Our group's theory expert was Ingrid Schoon and our methods expert Amanda Sacker. They had been developing a model of "Risk and Resilience over the Life Course" in a previous project. Ingrid wrote a book Risk and Resilience which is highly recommended. We did have 2 project leaders, Rich Mitchell and Sarah Curtis, who, as geographers, knew about urban processes. We were accused by ESRC of not being sufficiently interested in work and employment despite the group including Stephen Stansfeld, one of the world leaders in the social psychology of work. Our expert on later life was David Blane, who, like Stephen, has a medical training and is interested in biological processes of resilience and vulnerability. And our public health leader was Margaret Whitehead. I told someone the other day that I felt like an impresario in Hollywood putting together an irresistible cast for a movie. And it was indeed a fantastic group, supported also by people like Dick Wiggins and Danny Dorliing. As we later found out, the ESRC despite their original plan, just could not resist it.

Anyway the point of this is that in 2002-3 Resilience in terms of a human characteristic was not on anyone's radar, or at least not powerful people with money. Sometime shortly after the end of the research network, Michael Marmot pointed out to me that "everyone was talking about Resilience". And at a similar time, Capability started to be a big word in social epidemiology as well. In the Network, we all read Amartya Sen's work on it and used his ideas to guide that bit of the work. My own rather basic idea was that over the life course people who passed through "resilience-promoting environments" in their family, neighbourhood, school and work, had strengthened levels of capabilities to "live a life they have cause to value" in Sen's words. For example, one way we tested this was to see whether people who had experienced more warm relationships with their parents (fathers were just as important as mothers) had a more "securely attached" way of looking at the world. They did, and this seemed to also help the securely attached people to reach the higher levels of the Civil Service in their career. But secure attachment was not important for everyone, and this is a vital point. It only made a difference to people who had also not had an elite type of education.

This result (which I am using here as I worked on this paper myself, in contrast to the vast majority of papers from the Network, as I was really the kind of administrator who helped to make sure the bills got paid and everyone had enough sandwiches at the Network meetings) highlighted a couple of important issues. The first was that resilience is only important in the presence of adversity. We had quite a lot of discussion about this, and Ingrid distinguished several different definitions of resilience, of which this was the one we adopted. I thought it was important to distinguish it from just any kind of beneficial experience over the life course. I was worried: how could we distinguish between a resilience factor and the simple fact that people who experience only 2 adversities will do better than those who experience 3? This is the well known  "accumulation" model in life course research. We didn't want to do just more of that (although it was not quite such a cliche in 2003).

So if someone has experienced poverty in childhood and a stressful job, they will tend to have worse mental and physical health than someone who only had poverty in childhood.But does this make a financially secure childhood a resilience factor?  No, it is only a resilience factor if it is more important to people who have stressful jobs than it is to those with better jobs. It is what is called an interactive rather than an additive relationship. Lets say childhood poverty and job stress each take a score of 1. In an accumulative relationship between the 2 factors, the risk of mental ill-health (lets say) would be 0% in someone with a secure childhood and a nice job,  50% in someone with either a secure childhood or a nice job and 100% with a poor childhood and a stressful job. If childhood financial security is a resilience factor someone with a stressful job but a secure childhood would have a zero risk of mental ill-health.

Accumulative relationship


Not stressful

Childhood financial security is a resilience factor


Not stressful

The second point of debate within the Network was the role of childhood experiences and parenting. The paper I worked on just happened to include data on childhood experiences. But I confess that I also have a bit of a bee in my bonnet about this kind of thing. Ingrid was not having any of that! I remember her phoning me on my mobile in the middle of Marylebone High Street to straighten out some of my ideas. Similarly, Margaret was very concerned that resilience was being used as a sop or a fig leaf, as some of the people from the WHO that she was working with had feared. Ingrid and our colleague Jenny Head were concerned about "parent-blaming". They were quite clear that resilience could be fostered at any time in the life course by the right kind of environment: school, workplace, neighbourhood for example.

One implication of this kind of thinking for policy is that a resilience-promoting environment is in fact most important for people with the most adversities in the rest of their lives. It is the total opposite of what tends to happen in real life. A good school is most important for children with families suffering the effects of low income, or parental ill health, or substandard housing. Facilities for maintaining a social support network such as free efficient public transport (we used the example of the Croydon Tram) are most important for people with mobility problems for whatever reason. The accessible low-loading feature of the tram wouldn't make much difference to people who had cars, or could hop on and off of classic buses, but a huge difference to those with prams, in wheelchairs etc.

What turned out against our expectations not to increase resilience in the face of such adversities as poverty and the onset of chronic disease was the provision of services in the short term. David Blane, Gopal Netuveli and Zoe Hildon  found that older people whose health began to be affected tended to maintain good mental health if they had strong, long standing social networks. The key to this seems to have been that they were enabled to maintain a firm identity that did not revolve around the illness or disability. For example someone who developed arthritis would not become "the arthritic lady" but "our community festival organizer Barbara who has developed arthritis". Joining a patient support type group did not have the same effect. Margaret Whitehead and Krysia Canvin found, alarmingly, that even Sure Start Centers were sometimes shunned by the poorest mothers for fear that social services would remove their children.

How common was resilience in our studies? Using various different sources of data we concluded that in the face of a major adverse even such as the loss of a loved one, unemployment or the onset of a serious illness around 20% of people could "bounce back" fairly quickly. It is much harder to talk in this kind of way about resilience in the face of life long adversities.Because, as already pointed out, once an individual gets started on an adverse life course, the way social institutions work is not to try and provide "springboards" to remedy the problem, but to pile one adversity on top of another.

Tuesday, 11 August 2015

Do more meritocratic societies have higher health inequality?

The impressive and influential programme of research comparing health inequality in different nations by Prof Mackenbach's team at Erasmus University has produced disappointing results for those of us who think stronger welfare institutions would lead to lower health inequality. I am not going to give a load of URLs to all their papers here, but almost 20 years ago they showed that inequality in mortality was at least as high in Sweden as in, for example, England and Wales. Since then, subsequent studies have looked at changes in inequalities in mortality (and other outcomes, but mortality is the one that seems the most reliable). And while these have not changed much in the Mediterranean, unequal nations and have actually fallen in neo-Liberal Britain, they have risen most in the Nordic nations. So not only did the Nordic nations always have a level of health inequality at least as great as others, but they have experienced more adverse trends.

One explanation that Prof Mackenbach came up with was in a paper subtitled "Now its Personal". In this paper he suggested that maybe the greater social mobility in the nations with stronger welfare states and less unequal income distributions was the answer to this puzzle. Maybe in the more mobile, meritocratic nations, the people who end up in the worst, lowest paid lowest status jobs are those with personal characteristics that have held them back, for example, in education. So no matter where a person begins their life, the less intelligent and conscientious (for example) they are, the more likely they are to end up in a socio-economically less advantaged position. And because of their personal failings, these people are also hypothesised to be less able to understand and implement messages about risky health behaviour. So the causal link is not between socio-economic circumstances and health at all. On the contrary, it is personal characteristics that 'cause' both social position and (via their link with health behaviours) health.

When discussing this with a Swedish epidemiology colleague, he said it can't be true. Sweden has very high social mobility so it should have very high health inequality. My colleague is a clinical epidemiologist and not familiar with the Erasmus work, which has actually shown just that. But I thought OK lets have a look at some other nations.

So I have put together a little graph that takes its measure of health inequality from a recent paper by Prof Mackenbach's group, and its measure of social mobility from an OECD paper on this topic that got a lot of media attention in 2010. By luck, both data sources deal with roughly similar time periods. The measure of social mobility is called "income elasticity" which is the strength of the correlation between fathers' and sons' (usually) incomes. I high elasticity means these are "sticky" (at least that is how I think about it), fathers' incomes have a lot of influence so social mobility is low. And vice versa. And here is what it shows.

The linear correlation is -0.66, which is quite high as my vague memory of these things goes.

So what does everyone think? I don't like the implications of this, but neither do I agree with selective reporting of one's findings. This is a very, very quick and dirty exercise. But it would be really interesting to see what other reckon to it.

Thursday, 30 April 2015


Some time ago now our research group were funded by ESRC to create a network on "Capability and Resilience". Interest in resilience has actually grown since that project ended ages ago (2006 or thereabouts). Our old website persists (type Capability and Resilience into Google) but the link to the list of published papers via the ESRC website is broken. So here are the URLs for at least some of them. It was an amusing story how e got the contract. Apparently (it was not long after 9/11) the ESRC actually wanted research on civil defense type things. We had one referee who complained "These people are just the same old mafia and whatever they say they are going to do they will just do more research on health inequality". If you read the bookleet "Beating the Odds" (available free, just type that into Google) you can judge for yourself.

Ingrid Schoon's book "Risk and Resilience: Adaptations to Changing Times" was our guide.

Examining Resilience of Quality of Life in the Face of Health-Related and Psychosocial Adversity at Older Ages:

Understanding adversity and resilience at older ages

Mental health and resilience at older ages: bouncing back after adversity in the British Household Panel Survey (sorry this is still paywalled)

Quality of life in older ages

Resilience at older ages: the importance of social relations and
implications for policy.

Factors which nurture geographical resilience in Britain: a mixed methods study (Paywalled but available through Research Gate)

Is economic adversity always a killer? Disadvantaged areas with relatively low mortality rates

Risk and Resilience in the Life Course: Implications for Interventions and Social Policies (£)

Socioeconomic Adversity, Educational Resilience, and Subsequent Levels of Adult Adaptation (£)

Educational resilience in later life:

Growing up in Poverty: The Role of Human Capability and Resilience

Competence in the face of adversity: the influence of early family environment and long-term consequences   (£)

The Social Ecology of Resiience (book)

I think that will do for now! Not exhaustive list.

Saturday, 17 January 2015

The real reasons for not sharing data

I said I would post something about my experiences of non-sharing of data and then forgot to do it. So here is a little story.

For 3 years or so I worked on the British Regional Heart Study (BRHS) as a clerical assistant. I coded quite a few bits of the questionnaires, including the social class codes (as I had 2 degrees in sociology this seemed to them like a logical thing to get me to do, which it was really). Eventually I decided I ought to go and try to get a PhD (long story, some other time). I had gotten really interested in epidemiology, could see a lot of scope for a medical sociologist to work in the area, and needed a 'credential'. As it happened, the BRHS had surveyed 300 men in each of 24 British towns in 1978-9, just before the economic crisis caused by Thatcher's policies. Several of these were heavily industrial towns, whose populations had experienced massive rises in unemployment. It was a natural experiment.

So off I went to Edinburgh university to study with Adrian Sinfield, as I wanted to study unemployment and health and Adrian was a world authority on unemployment. I had a study design in my head, based on one town, Dunfermline, where the BRHS had studied a sample of middle aged men, taking lots of biomarker measures as well as sketchy social information. My plan was to team up with experts from the Edinburgh University school of nursing, which was part of the social policy department (where Adrian was Professor). I would design a life event questionnaire and I hoped that a nursing Masters or PhD student (even in those days -- early 1980s -- nursing was a degree subject in Edinburgh). "we're not doing your bloody fieldwork for you!" was the response of the nurses, quite rightly. So I said OK you teach me to measure blood pressure and lung function and I will teach you about labour markets and life events and we can do it all together.

The next step was to get hold of the data for Dunfermline, which was in part a mining town that had experienced massive economic change, Adrian seemed rather dubious about this so we approached Margot Jefferys, my mentor when I did the MSc in Medical Sociology, who knew the Director of the BRHS, Gerry Shaper. Her response was not encouraging "You might try extreme flattery" she advised. In my innocence, I had absolutely no idea why everyone was acting so strangely about this. After all, I had worked on these data already. In fact in Dunfermline I even did the interviewing to fill in for one of the nurse fieldworkers who had broken a finger. So I had personally met most of the participants in the study in that town.

No way, said Shaper, the GP practice from which we drew our sample would not tolerate someone going back to their patients. I said, of course it would be up to the GPs to ask permission from their patients for me to get in touch with a small sub-sample. I would not be appearing out of the blue. Based on other experiences, I was pretty sure that a lot of people would be only too happy to talk about what had happened to their jobs. And the biological measures I planned to do were non-invasive, unlike some of the ones people had agreed to in the main study. I had wanted to take a much more qualitative approach and devote more time to listening to people's stories of the recession and their experiences. We already knew from the original study and some linked data from GP records and the NHS central statistics organisation that men who were unemployed were at greater risk of health problems. But what about those who later lost their jobs as a result of the 1980s recession? To this day there has never been such a perfect opportunity to do a study of this kind.

I  consider that protection of the privacy of research participants is of the very highest importance. Anyone who reveals personal information about someone who has consented to be in a study should be banned from human research for life. But 30 years after all this, I know much better now the real reasons for reluctance to share research data and it has nothing to do with protection of participants. I am reminded of a much more recent experience where a teacher obtained a small subset of study data (not BRHS) to use as an example for students. Once the course was finished, the study director demanded she give the data back and destroy her own copy, When I asked why, the director responded: "What if one of the student discovers something we have never seen?" This is a shameful attitude, but much closer to the real reason for reluctance to share data than crocodile tears about confidentiality.