Sociologists define social class as the grouping of people by occupations. The different positions represent different levels of power, influence and money1, 2. In the UK society was divided into 5 main groups of classes however the Office of National Statistics (ONS) produced a new socio-economic classification in 2001 (Table 1)3, 4.
Up to 2001
Table 1- Classification of Social class4
The Black Report and the Acheson Report
In August 1980 the Department of Health (DOH) published the Black Report, also known as the Working Group on Inequalities in Health. The Report showed the extent to which ill-health and death are unequally distributed among the population of Britain, and suggested that these inequalities have been widening rather than decreasing since the formation of the National Health Service (NHS) in 19485. The Report concluded that these inequalities were not caused due to failings in the NHS, but because of many other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work. In consequence, the Report recommended a wide strategy of social policy measures to reduce inequalities in health; however these recommendations were ignored not implemented 6. In 1998 The Acheson Report, also known as the Independent Inquiry into Inequalities in Health Report was published, this was 18 years after the Black Report, both reports showed similarities in their finding. The Acheson report showed a widening gap between different social groups (Figure 1)7.
Figure 1-Number of deaths per 1000 by all causes for men aged 20-64 between 1991-19937
The report also noted that, while social determinants (Figure 2) affect people’s health across their lives, the early years are a particularly important stage of life, where poor socio economic circumstances have lasting effects. The Report recommended policies and interventions to reduce inequalities in access to the determinants of good health among parents, particularly mothers and children8, 9.
The Main Determinants of Health
Figure 2- The Main Determinants of Health10
The Situation in the UK- Income and Poverty
The main point that both the Black and Acheson report identified was the association between poverty, social class and health inequalities. This applied to all aspects of health including life expectancy, infant mortality and general level of health8.
Poverty isolates people, reducing their ability to engage in social and community life. In a study comparing the poorest and richest fifth of households, poorer children had fewer opportunities for activities and socialising. Poverty is measured by looking at the low-income threshold. This is 60% of the median UK income 4, 11.
In 2007/08, 13½ million people in the UK (Table 2) were living in households below the low-income threshold, an increase of 1 ½ million compared with the 2004/05 figures. This is around a fifth (22%) of the population. The number of people on low incomes is lower than it was during the early 1990s but is much greater than in the early 1980s11, 12.
Number of people
Table 2- Distribution of people living below the poverty line in the UK, 13.5 million of the total population of approx 61 million13
Health of the UK Population- Link between Poverty and Health
The health of people in the more wealthy areas of the UK is better than those living in the deprived areas. Those people living in poorer communities die younger and experience poorer physical and mental health throughout their life than those living in wealthier communities12, 13.
There is a link between life expectancy at birth and social class in the UK. Those from social class I and II have a higher life expectancy at birth than those from social class IV and V .Professional men are expected to live to around 80 years and unskilled manual men to 72.7 years and for women, the figures are 85.1 and 78.1 years (Figure 3)14
Figure 3- Life expectancy of men and women at birth by social class UK, 1992-200515
This can be linked to death by major diseases in the UK, those from social class IV and V have a higher death rate compared to those form social class I and II (Figure 4).14, 15.
Figure 4- Major causes of death 2003: Death rate for men aged 25-64 are 50-100% higher among those from manual backgrounds compared to those form non-manual backgrounds4, 12, 13.
Infant Mortality in the UK
The general association between poverty and health can be seen by looking at different diseases and mortality rates in the UK however one area which shows this association very clearly is child health. This is measured by looking at the rate of infant mortality. Infant mortality rate is the number of deaths of infants per 1000 live births16.
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There were 9,954 infant deaths overall in the period 2006-08, giving an overall infant mortality rate of 4.8 deaths per 1,000 live births (Table 3). Of those with a valid socio-economic group (8,709), the rate was 4.7 deaths per 1,000. Out of the 8,709 deaths in this category, 43% of these deaths (3,744) were in the Routine and Manual (R&M) Social group, giving a rate of 5.4 deaths per 1,000 live births in this group 17, 18.
Number of Deaths
Infant Mortality Rate
Table 3- Infant deaths and mortality: babies born in 2006-200819
Poverty and Infant Mortality
Infant death rates among both those from manual backgrounds (social class 1-4) and those from non-manual backgrounds, (social class 5-8) have fallen by around a fifth over the last decade but the gap between them has not reduced. Infant deaths are still 50% more common among poor children in lower social groups (manual backgrounds) than among those from non-manual backgrounds. In the lower social groups infant mortality is 20% higher than the average 4.8 per 1,000 (Figure 5)20, 21, 22.http://www.poverty.org.uk/21/a.png
Figure 5- Annual number of deaths per 1000 live births between 1997-2007, it also shows the social class of the infants4, 15.
When looking at different regions of the UK; it is clear that there is a significant difference in infant death rates. The rate of infant deaths in the West Midlands is one-and-a-half times more than that in the South East (Figure 6)23, 24, 25.http://www.poverty.org.uk/21/b.png
Figure 6- Graph showing how the number of infant deaths per 1000 live births varies by region (West midlands, Yorkshire and the Humber, North West, Northern Ireland, East Midlands, North East, London, Scotland, Wales, South West, East, South East) 4,24.
Infant death by region also has an association with poverty. The region with the highest proportion of households below the average income is the North East and West Midlands and it is the West midlands which has the highest infant death rate. The regions with the lowest portion of households below the average income, is the East and South East and it is the South East with the lowest number of infant deaths (Figure 7) 26, 27, 28.
Figure 7- Graph showing low-income households by region (North East, West midlands, Wales, North West, Yorkshire and the Humber, East Midlands, Scotland, South West, Northern Ireland, East, South East)4, 15, 27
There are many conditions that cause infant death. The leading causes of infant death include congenital abnormalities, Sudden Infant Death Syndrome (SIDS), problems related to complications of pregnancy, and infant respiratory distress syndrome (Table 4)19, 29.
Cause of Death
Number of Deaths
Immaturity related conditions
Asphyxia, anoxia or trauma (intrapartum)
Infant respiratory distress syndrome
Other specific conditions
Sudden infant deaths
Table 4- Infant deaths by cause of death: babies born in 200811, 15, 19
Other Risk Factors Increasing Infant Mortality
There are other risk factors which increase the rate of infant deaths. These factors are associated with income and poverty. The main three factors are low birth weight, smoking during pregnancy and ethnicity27.
Low birth weight
Babies’ birth weights are key indicators of the outcome of pregnancy, even though there can be considerable differences between the health and well-being of babies born at the same stage of pregnancy. Babies born with a low birth weight are at greatest risk of having immediate and long-term health problems. The smallest babies are the most likely to die in the first weeks and months of life. Babies born to parents from manual backgrounds (Social class 5-8) tend to be more likely to have low birth weight than those born to parents form non-manual social backgrounds (Social class 1-4) these differences continue throughout the decade (Figure 8)31.
Figure 8- Graph shows the proportion of babies born each year who are classed as having low birth weight (less than 2.5 kilograms, 5 ½ lbs), between 1996-2006. It also shows the social class of the infants4.
Smoking during pregnancy
Smoking in pregnancy causes devastating outcomes; these are increased risk of miscarriage, still birth and death. If parents continue to smoke after pregnancy, there is an increased rate of sudden infant death syndrome32.
In the UK in 2006, 33% of mothers from social class 5-8 (manual) smoked throughout pregnancy compared with only 22% of mothers from social class 1-4 (non manual) (Figure 9) 33.
Figure 9- Smoking prevelance overall and by social class. England 1998-2006 34
Exposure to passive smoking during pregnancy is associated with still birth, death and increase risk of lower respiratory tract infection in infants. One study found that in households where both parents smoke, young children have a 72 per cent increased risk of respiratory illnesses35.
In 2006, 21% of non smoking pregnant women were exposed to the smoke of someone else usually a partner, throughout their pregnancy.
Also 40% of mothers aged under 20 smoked throughout pregnancy compared with 13% of mothers aged 35 and over 33, 34.
There are large differences in the infant mortality rates of ethnic groups in the UK, for babies born in 2005. Asian and Black ethnic groups accounted for over 11% of live births and 17% of infant deaths.
Babies in the Pakistani and Caribbean groups had particularly high infant mortality rates, 9.6 and 9.8 deaths per 1,000 live births this was double the rate in the White British group of 4.5 deaths per 1,000 live births (Table 5)36
Number of deaths
Infant mortality rate
Bangladeshi (Asian/Asian British)
Indian (Asian/Asian British)
Pakistani (Asian/Asian British)
African (Black/Black British)
Caribbean (Black/Black British)
All other ethnic groups
Total Number of deaths
Table 5- Infant deaths and infant mortality rates by ethnic group of babies born in 2005 11, 27, 30,
Mortality in the Pakistani group was high throughout the first year of life whilst mortality in the Caribbean group was especially high in the first month of life.
Half of all infant deaths in the Pakistani group were due to congenital anomalies, compared with only a quarter of deaths in the White British group.
There is a general trend between income of ethnic groups and infant mortality rates. Those groups that have a high infant mortality rate such as the Pakistani and African groups tend to live in low income households compared to white groups (Figure 10)25,30,.
Figure 10-Graph showing how the proportion of people living in low-income households varies by different ethnic groups4, 15, 30,
Conclusion- Policies in place to address the issues
It can be seen that health inequalities are present in the UK and therefore the Government has put in place many programmes and policies to tackle this problem.
Tackling Health Inequalities-A Programme for Action
The “Tacking Health Inequalities: A Programme for Action” was launched in July 2003 by the Secretary of State for Health, its aim is to meet the government’s targets to reduce the health gap on infant mortality and life expectancy by 2010.
The Programme has a clear strategy to work on the following four delivery themes:
Supporting families, mothers and children
Engaging Communities and Individuals
Preventing Illness and providing effective treatment and care
Addressing the underlying determinants of health37
National Service Framework for Children, Young People and Maternity Services
The National Service Framework for Children, Young People and Maternity Services
(Children’s National Service Framework) is a 10 year programme aiming to improve children’s health, social care and promote high quality health care for women and their families. The standards set by this framework require services to:
Promote healthy lifestyles.
Tackle health inequalities
Ensure that pregnant women receive high quality care throughout their pregnancy38
Infant Mortality National Support Team
The Infant Mortality National Support Team (IMNST) was launched in autumn 2008. It supports the 43 areas with the highest infant mortality rate in the routine and manual group. The IMNST has 4 main aims (Figure.11)39.
Figure 11- The aims of The Infant Mortality National Support Team39.
Tackling health inequalities is a top priority for the Government and the main focus is on narrowing the health gap between disadvantaged groups, communities and the rest of the country and on improving health overall. The policies, programmes and strategies in place are helping to reduce the health gap however there is a long way to go before there is significant change in health inequalities. This can be seen by looking at one of the Health Inequalities Public Service Agreement (PSA) targets (Box 1) and the progression of this target40.
PSA Target on Infant Mortality
By 2010 to reduce by at least 10% the gap in mortality between routine and manual groups and the population as a whole.
Box 1- PSA target on reducing mortality in the UK by 10% by 201040.
There is a decrease of infant mortality amongst the routine and manual groups however to narrow the gap by at least 10% by 2010 is still a challenge (Table 6)41.
Table 6- Percentage gap in mortality between routine and manual groups and the population as a whole41.
This shows that the Government needs to do more to reduce health inequalities by concentrating on wider social determinants of health.
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