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Psychological and Sociological Concepts

Social contexts, ethical issues and inequalities in Health

The aim of this paper is to explore the relationship between social contexts and
ethical issues, mainly the implications for addressing inequalities in health status and
access to health care. Dimensions of inequality overlap and reinforce each other as
Graham (2004) asserts, but while researchers debate about what predisposes
certain social groups to health inequalities, most researchers choose to accept that
health inequalities are a result of a combination of pathways (Benzeval, 2014).
Certain key terms will be used in the proceeding paper, which include health status,
health inequalities, access to health care, and social inequalities.
Health Status has a range of varying definitions. One definition can be defined as
the impact of disease on patient function as reported by the patient or the quality
of life as experienced and perceived by the patient (Rumsfeld, Health Status and
Clinical Practice). Another definition of health status is that it is a holistic concept
that is determined by more than the presence or absence of any disease. It is often
summarised by life expectancy or self-assessed health status, and more broadly
includes measures of functioning, physical illness, and mental wellbeing (Australian
Institute of Health and Welfare, Health Status). It would seem then that health status
has a contextual relation to wellbeing as experienced by the individual, in addition to
it being a subjective measure of a certain quality of life. Regardless of the economic
status of a country, whether industrialised or poor, the World Health Organization
(WHO) reports that indigenous people living in those countries enjoy a lower health
status in comparison to the overall population (WHO, Indigenous peoples right to
health status).
The term health inequalities is usually used in the context of referring to differences
in the health of social groups who occupy disproportionate positions in society. In
other words, the term can be used to understand inequalities in the health of different
socioeconomic groups, where one group has an advantage over another and is
usually based on factors linked to their access to economic resources (Graham,
2004). In this context, health inequalities are linked to an individuals position on the
proverbial socioeconomic ladder. This means that socioeconomic positions of
individuals are based on social hierarchies usually built around factors of occupation,
education and income and will further predispose those individuals into falling within
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socio groups based on these factors. These factors will in turn influence their quality
of life and standards of living. The higher up the socioeconomic ladder, will often
mean that the individual will have increased access to certain resources based on
the fact that they have disposable income and for example, the freedom to choose a
better quality of health care. Graham (2004), moreover draws a distinction between
social inequalities and socioeconomic inequalities. The former usually refers to
ethnic inequalities in health, gender inequalities in health etcetera, while the latter
refers to the individuals place in the hierarchies built around education, income and
occupation. Furthermore, in the context of the UK, occupation is the single most
important measure of socioeconomic inequality.
Certain ethical questions can be posed, such as; should individuals of lower
socioeconomic status necessarily deserve fewer options when it comes to choosing
health care than say, an individual higher up the same ladder with an occupation
which affords greater financial rewards and associative benefits? After all, despite
the United States of America being a first world country, it is one of 86 countries
whose constitutions do not guarantee their citizens any kind of health protection
(Wheeler, 2013). While these sorts of questions potentially lead on to intriguing
ethical debates, it is not within the scope of this paper to provide answers to such
questions. Instead, the impetus of this paper is more focused on addressing social
contexts of the inequalities in health status and access to health care in
contemporary societies.
Now that a distinction has been drawn between social and socioeconomic
inequalities, where socioeconomic inequalities was briefly contextualised above with
reference to its impact on access to health care, it is necessary to examine social
inequalities in equal measure. A social determinant affecting inequality in health and
associative access to health care one highlighted as sometimes being the single
most important obstacle is one which WHO identifies as being tied to the gender
picture. The fact that men and women are different from each other, for example in
some cultures men wearing trousers and women wearing skirts, means that the
practice in and of itself does not favour one sex over the over. However, the
distinction that gender norms and values give rise to gender differences, in certain
cultures, has the distinct possibility of translating into gender inequalities where men
and women are viewed differently and are therefore treated disproportionately. The
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implications of these gender differences and inequalities mean that where there is a
difference in status among men and women, possibly giving more rights to one sex
over the other, within this context, could disproportionately affect their access to
health care (WHO, Why gender and health?).
In a 2013 report aimed at improving public health and compiled for local authorities
within the United Kingdom, nine key areas were identified in terms of improving
health and reducing health inequalities. These areas cover the local authoritys
statutory duties towards the following nine areas: Children and young peoples
services, supporting schools, helping people find jobs and stay in work, active and
safe travel planning, providing warmer and safer homes, access to green and open
spaces which include sports and leisure services, helping to develop strong
communities, wellbeing and resilience, effective public protection and regulatory
services and dood special planning to improve health. (The Kings Fund, 2013).
What the statutory duties imposed on local authorities in the UK indicate, is an
initiative which highlights the need to tackle key aspects of health equity and the
inequalities in health between varying socioeconomic groups. The remainder of this
paper will take a closer look at the social contexts, ethical issues and inequalities in
health. This will be achieved by, in the next section, looking at social and cultural
environments and how certain factors within these environments, affect the quality of
interaction between professionals and patients.
The quality of interaction between the patient and healthcare professional, will
ultimately be influenced by a number of factors within the social and cultural
environment in which the healthcare takes place. This section of the paper will
explore the quality of interaction between healthcare professionals and patients as
influenced by socio and cultural environmental factors respectively. Under socioenvironmental factors, three determinants will be explored, namely patient access
and distribution of healthcare, the quality of the healthcare provided and the job
satisfaction of healthcare workers. Lastly, language as a cultural environmental
factor, will briefly be explored as pertaining to the quality of interaction between
professional and patient.
The distribution of health, otherwise known as health outcomes, has been
documented by researchers under three categories, namely gender, social class and
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ethnicity. These three categories have been briefly referenced and contextualised at
the outset of this paper. In terms of gender, the aspect of gender inequality was
highlighted as giving disproportionate rights to one sex over the other. WHO further
highlighted this as potentially being the single most important obstacle, albeit in
terms of access to healthcare? As far as environmental determinants are concerned,
gender would more accurately be categorised as socio-cultural in nature. Gender
however can also contribute to access to health services where gender norms place
an embargo on women driving. In certain cultures for example, it is forbidden for
women to drive and in terms of access to healthcare this would in turn affect their
own as well as those dependant on them for care. Regarding social class or
socioeconomic factors, it was established that income, occupation and education
affected the distribution and access to healthcare. Lastly, in terms of ethnicity, WHO
identified indigenous people, regardless as to whether they existed in industrialised
or poor countries, as having a comparatively lower health statuses compared to the
overall population.
When there is diversity in healthcare practice over a broad scale of patient
demographics, given the absence of proper leadership and team working, this
potentially creates a variation in care standards which can negatively impact quality
and safety. Through clinical governance, efforts have been made to create a practice
culture, focusing on meeting patient needs and being accountable for the standard of
patient care provided. This in turn provides accountability to the public. For example,
one of the three essential features incorporated into the core competencies of the
GP training curriculum of the UKs National Health Service, is that of attitudinal
features. What the attitudinal features centre around are values, feelings and ethics
and the impact this will have on patient care between the practitioner and the patient.
Specifically, this could include the practitioner admitting when an error has occurred
and apologising for failings in the delivery of care (Royal College of General
Practitioners, 2010).
Staff wellbeing has to do with care infrastructure and demands on staffing, where
healthcare staff report high demands on their time, which in turn has a negative
causal relationship between staff delivery and patient care and affects the perceived
quality of that service delivery (both from the professionals perspective and from the
patient). The outcome of the 2012 study suggests that for a good patient experience,
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there needs to be enhanced staff wellbeing. The higher the demand on the staff, the
more stress they experience which is coupled with exhaustion and a decrease in job
satisfaction. Contextually, to use one example from the study surrounding the area of
elderly care, in this specific setting, staff members were found to have poor relational
care and failing to connect with individual elderly patients (National Institute for
Health Research, 2012).
Language barriers in terms of cultural-environmental factors affecting quality of
patient/healthcare professional interaction, language barriers will briefly be
discussed. In particular, language barriers which affect access to healthcare as
experienced by migrants and asylum seekers within the UK. Quantitative evidence,
although limited, suggests that notwithstanding the mental and physical impact of
war which some asylum seekers settling in the UK have experienced from their own
countries, language barriers attribute to reduced access to health on the following
levels: inadequate information, unfamiliarity with the healthcare systems in the UK,
insufficient support in interpreting and translating for people with limited English
fluency, confusion around entitlement, and cultural insensitivity of some front line
care providers. Even something as seemingly unimportant as regional accents, could
create a barrier for the migrant in understanding the healthcare practitioner and
therefore have a negative impact on health delivery. Quantitative information from
these studies also revealed that certain risk factors for maternal mortality also
increased and was particularly high among mothers of African-Caribbean and
Pakistani ethnicity (Jayaweera, 2014).
In the next section of the paper we will focus on Role and impact of social
inequalities around; health beliefs, lifestyle and risk, class, gender, culture and
ethnicity, ageing, family and poverty, in view of the social contexts of inequalities of
health, the impact and role around the following determinants will be described and
discussed: health beliefs, lifestyle and risk, class, gender, culture and ethnicity,
ageing, family and poverty.
While looking at culture and ethnicity, within the context of health in the United
Kingdom, studies have shown that black and minority ethnic (BME) groups are
disadvantaged to the extent that they are far more likely to live in poverty, with an
income of less than 60 per cent of the median household income, compared to that
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of white British people. What the implications of these statistics reveal, is that when it
comes to health, these BME groups are more likely to be affected by ill health (and
be affected earlier) than white British people by comparison. This evidence draws on
socioeconomic inequalities which impact these minority groups, but what it also
draws on are determinants linked to access to healthcare, which the reports also
indicate are linked to barriers facing BME groups (Institute of Race Relations,
Poverty Statistics). Continuing with the topic of ethnicity, earlier in this paper,
attention was also drawn to studies which highlighted the plight of asylum seekers
and immigrants where BME groups were shown to be more susceptible to maternal
mortality which faces mothers during childbirth. Given these examples, it is worth
drawing attention to a point which was noted at the outset of this paper, which is that
dimensions of inequality overlap and reinforce each other. The interconnectedness
of these inequalities are all the more evident and can be shown to overlap culture,
ethnicity, family and poverty.
Ethnicity is linked to health beliefs. Ethnic diversity can lead to issues of ethnic
inequality which will directly impact health and the delivery of healthcare. It was
noted earlier that cultural insensitivity of some front line health workers towards
migrants and asylum seekers, were reported in studies. Taking a closer look at
health beliefs and the religious views which drive these beliefs, it is worth exploring
the social contexts of certain health beliefs which may include, blood transfusion and
organ transplantation, termination of pregnancy, contraception and circumcision.
NHS staff are required to be trained and cognisant of the fact that Jehovah
Witnesses (a small Christian sect) deem it unacceptable for one of their own to
undergo a blood transfusion and organ transplantation. In this cultural-religious
setting, these health beliefs could impede the first priority of a physician, which in an
emergency situation, is to save a life. Should the life of a child of a Jehovah Witness
be in peril, and the parent refuse a life-saving blood transfusion or an organ
transplant for their child, it is possible to have the child made a ward of the court to
give the court the right to make that decision. Abortion or termination of pregnancies
is something which is strongly opposed in certain religions. Healthcare professionals
need to be aware that it is ethically not acceptable to impose their own beliefs or
views on these patients who hold such health beliefs. Another example of a religious
group who hold health beliefs is that of Roman Catholics who are strongly opposed
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to contraception. Roman Catholics do not permit barrier methods of contraception

which include condoms, hormonal contraception or IUCDs. When it comes to
circumcision, which forms part of some faiths such as Judaism and Islam, there is
sometimes some ethical concern among doctors that the child cannot give informed
consent to the procedure and especially if the procedure is performed for nonmedical reasons outside of the NHS, the risk of potential complications
(Patient.co.uk. Ethnic Matters). These few factors which were briefly discussed, not
only pertain to health beliefs, but potentially also to lifestyle and risk. Since the term
belief is also meant to include religious and philosophical belief, it should technically
also affect ones life choices and the risks which accompany these life choices. The
protected characteristics of the Equality Act which was brought into force in 2010,
brings together a number of existing laws with the aim of making Britain a fairer
society. These specific protected characteristics are protected by law and include
age, disability, gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion and belief, sex and lastly sexual orientation (Equality and
Human Rights Commission, Private and Public Sector Guidance).
Despite legislative protection, many ethnic minority groups still experience social and
health inequalities imposed by their own religious leaders and families, while being
citizens of or resident in the United Kingdom. An example of one such cultural and
religious context, specifically where culture and religion overlaps with a lifestyle risk
and at the same time being in conflict with legislative protection, is that of female
genital mutilation (FGM). FGM is a procedure which intentionally alters or causes
injury to the female genital organs for non-medical reasons. Unlike circumcision in
boys or men, there is reportedly no health benefit for either girls or women. It is a
practice which is mostly carried out on young girls between infancy and the age of
fifteen and carries severe health complications and risks which include severe
bleeding, later potentially developing cysts, problems urinating, infertility,
complications in childbirth and potentially and increased risk in infant deaths at birth.
It is a procedure which is not carried out by NHS staff, but instead by traditional
circumcisers (WHO. Female genital mutilation). Despite protection afforded to
individuals living in the UK, FGM practices still occur within minority groups. With
enough education and awareness, the impact of health inequalities like FGM has
received enough attention to warrant 330,000 of funding in 2014 to help address
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the problem. Internationally, combined efforts have also received similar

endorsement (Department for Communities and Local Government, Funding to
prevent female genital mutilation and forced marriage).
Another social inequality determinant which merits reference and one which is
incidentally also protected by the Equality Act of 2010, is that of age. When buying
goods or using services, the Equality Act includes protective provisions which cover
direct discrimination, indirect discrimination and harassment related to age. The aim
is to provide older people with equal rights as that afforded to a younger person,
whether this may be with regards to gaining access to a gym or a nightclub, buying
goods or simply protecting the older person from offences jokes or remarks.
Social inequalities also pertain to class. Otherwise known as the great class divide,
the term ties in economic status and a related social hierarchy, which already
referenced earlier in this paper, includes occupation, education and income. The
increasing social class divide has been an issue observed by government and local
authorities. The NHS for example, which draws its statistics from the Kings Fund
research studies, observes health among the social classes in the UK and purports
that the so-called middle class is making more informed health decisions and
refraining from certain negative health habits which the lower socio-economic
classes are failing to implement. The data further suggests that negative health
habits such as smoking, sedentary lifestyle and excess alcohol consumption, which
can lead to disease and early death, is more likely to be practiced by social groups
lower down the social ladder. The more educated a person was, the more likely they
were to have better financial resources and the more likely to also engage in a
healthier lifestyle (Hope, 2012).
In conclusion, this paper has successfully explored social contexts addressing
inequalities in health status and access to health care. In addition, it has managed to
establish that socioeconomic positions of individuals are based on social hierarchies
usually built around factors of occupation, education and income. While the scope of
this paper was not to provide answers to ethical questions around social and health
inequalities, it managed to establish certain principles, for example that ethnicity is
linked to health beliefs, that the quality of interaction between professional and

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patient is influenced by factors such as the quality of the healthcare, staff wellbeing
and language barriers and that class inequalities are directly linked to lifestyle habits.
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