Research published in the Journal of the American Medical Association sheds new light on a long-standing health policy problem: what is the relationship between socio-economic status and health outcomes and to what extent is that relationship due to differences in health behaviors. (JAMA Article) The research examined almost 10,000 civil servants in Great Britain over a 24 year period of time. The primary outcome was mortality and the behaviors included smoking, drinking, diet and exercise. Unlike many previous studies this one followed the behaviors over a lengthy period of time as opposed to a single point.
With the exception of alcohol consumption, there were more unhealthy behaviors in the lower socio-economic groups at the start of the study and over its entire length. Alcohol is a somewhat complex case, as moderate use may actually be associated with lower mortality than no use or heavy use. The lower socio-economic classes were more abstinent than higher ones. The authors concluded that unhealthy behaviors accounted for as much as 70-90% of the differences in mortality. This seems logical. Why the lower groups engaged in more unhealthy behavior is not specifically explored in the study but an accompanying editorial suggests it is due to differential stress. That is a hypothesis that is easily testable and not currently supported by research.
It is possible that this line of research has ignored another possible relationship; that poor health behaviors contribute to a low socio-economic position and to stress, and that poor health behaviors result from not having enough sense or incentives to take care of one’s self. An example would be smoking, which is very expensive and for a low-wage worker would use a significant portion of take-home pay. Everyone knows smoking is bad at this point. Poor health behaviors undoubtedly lead to worse health status and that can make it harder for a person to find and keep better paying jobs which might improve their standard of living. In the United States a confounding factor for this research might be access to health care; this should not be a concern in Great Britain, which basically has free, universal health care. It would also be interesting to see more specific examination of aspects of socio-economic status, such as poverty and education, and their connection with poor health behaviors.
From a public policy perspective, certainly in the United States there are few incentives for those in lower socio-economic strata to change unhealthy behaviors. They get access to almost free health care through Medicaid, whether they smoke, drink or have poor diet and exercise habits. Limiting access to health care or increasing the cost might help change those behaviors. The same is true for welfare and food stamp programs. Research generally shows that without strong financial incentives, people won’t change their behavior. To improve the health of those in lower socio-economic groups, we probably need to take a much harder line on the acceptability of their health behaviors.