PUBLIC HEALTH

The Role of Public Health in Health and Social Care

The Role of Public Health in Health and Social Care

Introduction

Socioeconomic inequalities in health have been observed persistently over the course of human history. These differences are manifest across individuals, communities, and societies, and recent analyses suggest that for the most part they have increased over the past century, and even in the past few decades (Marmot et al. 1987; Pappas et al. 1993; Preston and Haines 1991). The nature and size of these inequalities make them arguably the major problem of population and public health in America and many other societies for reasons that will become clearer below. Hence, socioeconomic inequalities in health have increasingly become a focus of health policy (Department of Health and Human Services 1990) as well as health research.

We still do not well and consensually understand, however, why socioeconomic inequalities in health exist and persist, nor what policies are most likely and necessary to reduce these inequalities. In seeking such understanding, research has increasingly focused on socioeconomic differentials in health at the level of communities and societies as well as at the level of individuals. Yet, there has been little integration of our substantial knowledge of the relationship between individual-level socioeconomic position and health with our growing understanding of the relationship between community-level socioeconomic position and health. Thus, this chapter seeks to focus on: (1) what we have learned from studies of socioeconomic inequalities in health at the levels of individuals, communities, and societies, (2) whether and how the information from such multiple levels of analysis helps us to understand better the nature and explanations for socioeconomic inequalities in health at all levels, and (3) how social and health policy might address socioeconomic inequalities in health.

A comprehensive review of the literature on individual- and family-level socioeconomic inequalities in health is beyond the scope of this or any single chapter or paper of moderate length. There are, however, sources that have reviewed much of the literature, and we will refer readers to these while highlighting only the major theories, findings, and issues relevant to our discussion. We will first summarize major findings of individual- and family-level research on socioeconomic differentials in health, so that our later discussion of community-level research will indicate: (1) how findings from research on individual- and family-level socioeconomic position might inform research and theory at the level of communities or societies on socioeconomic differentials in health, and (2) how multilevel research on socioeconomic differentials in health may answer some of the questions that have previously been left unanswered in individual- and family-level research.

The Relation of Individual- And Family-Level Socioeconomic Position to Health: Major Findings and Issues

A large body of research, well-reviewed elsewhere (Adler et al. 1994; Antonovsky 1967; Feinstein 1993; Kaplan and Keil 1993; Krieger and Fee 1994; Marmot et al. 1987; Townsend and Davidson 1982; Williams 1990; Williams and Collins 1995), has documented the higher rates and risk of mortality and morbidity from most causes, as well as of functional limitations, among ...