Health inequity, treatment compliance, and health literacy at the local level: theoretical and practical aspects

The relation between the social status and various aspects of mental issues has been of interest for both doctors and researchers since long ago; the findings from a lot of research have demonstrated the meaningfulness of social status in understanding mental diseases and disability. The epidemiological research projects conducted all over the world have shown an inverse relation between mental issues and the social class. There has been consistent data obtained suggesting that mental disturbances are more common for the lower social class (Meltzer et al, 1995). At the same time, lately there have been discovered other channels of the significant impact that inequity has on health. In particular, it has been shown that chronic stresses related to the dissatisfaction with one’s socio-economic status may result in neuro-endocrine and psychological functional alterations thus contributing to the disease likelihood. It has already become a common opinion that a longer feeling of fear, uncertainty, low self-esteem, social isolation, inability to make decisions and be in charge of the situation both at home and at work impact health seriously: this may cause depression, increase susceptibility to communicable diseases, diabetes, high blood cholesterol, and cardio-vascular issues. Low socio-economic position, therefore, impacts health directly through deprivation and financial hardships, and through the subjective vision of one’s “unequal” position in the society and the related judgment, relations, experiences. When studying the influence that the socio-economic status has on health focus should be kept on both the objective and subjective socio-economic status. Therefore, there is an undoubted connection between the financial status and health, which can be seen both from the scientific-theoretical viewpoint, and at the level of common sense (Падиарова, А. Б., 2009).

Many researchers state that low socio-economic status is associated with high prevalence of mood disorders (Dohrenwend et al, 1992). There was also a suggestion that belonging to a particular social class will influence the nature of psychopathological symptomatology in depression. Patients demonstrating symptoms of somatized and anxiety disorders more often belong to a lower social class. At the same time cognitive symptoms were more often detected in patients from a higher class. The severity of depression in adults, related to financial issues, may depend on age. Mirowsky и Ross (2001) found that it goes down as the age goes up. Financial troubles and poor marital relationships are significant factors contributing to the risk of depression onset and its chronic course (Patel et al, 2002). Just like depression, poverty is typically chronic in its nature, so it usually needs focus both from caregivers and from decision makers.

If compared to the general population people who attempt suicide more often belong to the social groups where social instability and poverty are typical.

Gunnell et al. (1995) investigated the relation between suicide, parasuicidal behavior, and socio-economic issues. They identified a connection between suicide and parasuicidal behavior, while negative socio-economic factor offered nearly complete explanation. Besides, these murders and suicides more often happen in densely populated poor areas (Kennedy et al, 1999). Crawford and Prince (1999) also support these findings. They noticed an increase in the suicide rate among young unemployed men living under severe social deprivation. It also true that the frequency of cocaine or opiate overdose cases is associated with poverty (Marzuk et al, 1997).

Both unemployed men and women demonstrate a higher level of alcohol or substance dependency in case they belong to the unemployed. The social class is a risk factor of death due to alcohol abuse, which is also related to such structural social factors as poverty, disadvantage position and the social class. The rate of alcohol-induced death is higher among men involved in physical labor than among clerks, yet the relative index will depend on the age. Men aged 25–39 and involved in common non-qualified physical labor demonstrate a death rate 10–20 times higher than representatives of the middle class, while among those aged 55–64 the same index is only 2,5–4 times higher if compared to those who are involved in a type of labor requiring special skills (Harrison & Gardiner, 1999).

The relation between the lower socio-economic status and personality disorders is far from being well-investigated. Low family income and insufficient living conditions are prognostic factors for crime among adolescents and adults (based on official and survey data). However, the connection between poverty and crime is a complex and a continuous one. The interrelation between impetuosity and the neighborhood in connection to criminal activity show that impetuosity is higher among residents of poor areas rather than among those residing in better-off ones (Lynam et al, 2000). A Cambridge research into the development of minor delinquency produced data stating that unstable employment at the age of 18 was an important independent predictor of previous conviction history among young men aged 21–25 (Farrington, 1995).

The growing number of researches into the relation between poverty and health indicates that low income combined with unfavorable demographic factors and insufficient external support causes stress and life crisis, which serve risk factors for children and may trigger mental disturbances in them. Children from the poorest families show a 3 times higher rate of mental disturbances than children from more prosperous families. Poverty and disadvantaged social status have strongest connection with insufficient skills in children and their poor academic performance (Duncan & Brooks-Gunn, 1997).

Kaplan G. A. et al, (2001), after studying the socio-economic status in childhood and the cognitive functioning in adulthood, concluded that a higher socio-economic status in childhood and a higher level of education determine a higher level of cognitive functioning in the period of maturity, while both mothers and fathers, independently, contribute to the development of creative cognitive functioning in their children and their cognitive capacity at older age. Obviously, a better socio-economic status in parents and a higher level of education in children may improve cognitive functioning and reduce the risk of dementia at a later stage of life.

Confused, strict and full of violence upbringing as well as lack of control and poor child-parent attachment will aggravate the poverty effect and worsen other structural factors, when it comes to minor delinquency. A Cambridge research into the evolution of minor criminals poverty was taken as one of the most important predictors for delinquency (Farrington, 1995). It was also shown that, in view of mother’s education and behavior in early childhood, poverty also affected academic performance and delinquency (Pagani et al, 1999). Eyler and Behnke (1999), after studying the effects of most common psychoactive substances in children (on their first and second years of life) who were subjected to that in the prenatal period, concluded that the children living in poverty demonstrated obviously aggravated effects of those substances.

The materials of the WHO show that social inequities may also have an impact on the level of vulnerability to environmental risks and the severity of these risks” impact on health. There have been 4 of such mechanisms demonstrated:

?Mechanism 1. Social determinants correlate with the quality of the environment. Socially disadvantaged groups often live and work under poorer environmental conditions if compared to the general population.

?Mechanism 2. The levels of impact are in a certain dependency on the factors related to social inequity (such as level of knowledge and type of behavior in terms of health). Therefore in case of similar environment disadvantaged groups may be subject to a more intense impact than the population in general.

?Mechanism 3. Factors related to social inequities (such as health status and biological susceptibility) affect the dependency “impact – response”. Given the same level of impact, disadvantaged groups may reveal a higher level of vulnerability to unfavorable consequences for health, e.g. due to synergy of various risk factors.

?Mechanism 4. Social inequities have a direct impact on the end results related to health, which may reveal itself through both environmental and non-environmental mechanisms. However, under similar dependency parameters of “impact – response” disadvantaged groups may reveal a higher level of vulnerability to unfavorable consequences for health due to poorer access to the respective services and reduced capacity to cope with the negative effects. The absolute scale of the consequences can also be higher in disadvantaged groups because of higher prevalence of previously existing health issues (Whitehead and Dahlgren, 2008).

According to most researches representatives of lower socio-economic groups stand a higher vulnerability to negative environmental factors (Braubach M, Fairburn J., 2010; Bolte G, Tamburlini G, Kohlhuber M., 2010).

Gender features of health inequity and the family role

Research conducted all over the world show that gender is another important factor determining health inequity.

The feature typical of Russia is an extremely high death rate among men and an unprecedented gap between the life expectancy among men and women (12–14 years).

This attracts more attention to men’s health in modern Russia, which overshadows the fact that, according to medical statistics and opinion polls, women have been consistently showing higher rates of health issues.

The lower status of health in Russian women – not only compared to Russian men yet also to women in other countries – is also seen from the calculations of the healthy life expectancy. According to the data provided by the leading Russian demographers the huge gap in the healthy life expectancy of the 20-year olds (both Russian men and women) and their Western counterparts (13 years), in men is due to a higher level of death rate (especially in the working age), and in women – due to a lower health status (mostly in the older age) (Масленникова Г. Я., Оганов Р. Г., 2002, 2004).

Actually, the so-called gender paradox, which could be expressed as “women become ill more often while men die earlier”, which is a global tendency, typical of civilized countries at least, has always been of interest to researchers. For a long time this gender paradox has been explained by medical statistics, supporting the fact that men typically suffer from fatal illnesses and fall prey to illnesses that do not reveal well expressed symptomatology; as for women – they typically suffer from acute and chronic, even though less severe conditions.

Thus, a number of empirical research projects have shown a significant variability in the scale, and sometimes in the patterns of gender-bound health differences at various stages of life cycle, as well as within different health indicators.

According to the theory of unequal impact, women demonstrate a higher level of ill health due to their restricted access to material and public resources that would save health, and because of increased stress accounted for by their gender and family role.

If compared to men women hold different positions: they are more often unemployed, get employment in other areas, and in general they have to enjoy lower income. There are also some gender differences in behavior stereotypes as men are more prone to smoking, alcohol abuse and unbalanced diet, while women are less active physically.

It has also been proven empirically that women carry a heavier burden of responsibility in fulfilling their social roles. Theу also possess a smaller psychological resource required to cope with stresses. In particular, women have a lower awareness of control over life circumstances. At the same time women, if compared to men, have various sources of obtaining some social support.

According to the second approach – vulnerability difference – women demonstrate more health issues as they respond differently (compared to men) to financial, behavioral and socio-psychological circumstances that develop health.

Thus, empirical data shows that full-time employment along with taking care of the family, as well as social support are more important health predictors for women rather than for men.

Tobacco and alcohol consumption are more meaningful health determinants for men while overweight and low physical activity affects women more. While maturing educated girls create smaller and healthier families. The survival rate in their children is higher, and they stand a higher chance of getting education, if compared to children born to less educated mothers (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).

The research conducted in Russia has shown that in women the meaningful determinants of physical functioning include the level of education, awareness of personal responsibility for health, as well as a possibility to spend some time taking care of oneself, while men’s physical condition depends more on a balanced diet and preventive measures. Men’s physical health is especially vulnerable to external impacts at a certain stage of their lives, the pre-retirement decade, to be exact (51–60 years. Gender differences are especially obvious in the health developing mechanisms when analyzing the levels of realized welfare (Назарова И. Б., 2007; Русинова Н. Л., Браун Дж., 1997; Журавлева И. В., 1999, 2006; Русинова Н. Л., Панова Л. В. Сафронов В. В., 2007).

In important issue in healthcare is getting assistance by women in many countries. There is significant evidence showing that women are subject to gender-bound restrictions in terms of getting access to medical assistance, which is true in particular for women from the poorest groups. The obstacles they have to face include lack of culturally adjusted types of assistance, shortage of resources, transportation troubles, suppression, and sometimes even a ban imposed by husband or other family members. Lack of public funding for healthcare affects men as well, yet in view of a limited family budget women’s healthcare needs do not enjoy priority.

Similar issues remain in relation to identification and measuring abuse, family violence, and sexual abuse. The life expectancy of an American woman will depend on ethnic factors: white women live an average of 82,2 years, while for black women this index is 75,5. The infant death rate (per 1,000 births) among the black population is 13,6, among Chinese the infant death rate in America is only 3,5. The maternal mortality among black women over 35 is 71,0 per 100,000 labors, while among white women it is only 11,4. Hite women have a higher rate of breast cancer; however the survival rate within 5 years following treatment in black women is 15 % lower because the tumor in them is detected at later stages. Latin American women have a cervical carcinoma rate that is double of the rate among white women, and their death rate from this issue is 40 % higher. American Indians get antenatal assistance in 69 % of cases while American Japanese – in 90 % of cases. The HIV and AIDS prevalence (per 100,000 women) is 2,3 among the white, 11,8 among Latin Americans, and 50,0 – among the black population. The death rate for infants born to white mothers with no special education is twice higher if compared to white mothers with a degree in higher education (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).

Males also have some specific features contributing to the development of health inequities. For instance, men’s mental health is significantly due to the position they have in the society.

It is interesting to note though that the relation between men’s mental health and the key markers of their social position – education and financial welfare – is inverse. While a high level of prosperity has a positive effect on men’s mental well-being, their mental health clearly deteriorates along with their education level.

As for women, their realized welfare is largely determined by behavioral factors, mental issues faced in the family environment, and the capacity of their psychological resources allowing them to cope with stress (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).

A number of research projects carried out in Western Europe stress the importance of family in shaping a certain level of health inequity. The parents” resources alone already have an impact on young children’s life quality and create inequity between children from prosperous and poor families. First, the parents” economic capacity determines where and how the family will live. There is a difference if children live in a small rented apartment located in a disadvantaged urban area or in a large house with a garden in a fashionable neighborhood (Meulemann, 1990). Empirical findings show that different life quality among children from poor and prosperous families does not just matter in itself yet it also serves precondition for further inequities. The level of recognition that children enjoy among their friends depends on their toys, sport gear, pets, fashionable clothes, opportunity to travel, pocket money, the configuration of their own computer (Szydlik, M., 2004).

At the same time already in the earliest childhood the parents” resources set important milestones for the entire biography and for the position in the social inequity structure. The parents” choice of the residential area has a direct impact on their children’s first friends” social position. Peers, in turn, have a significant impact on children’s and adolescents” secondary socialization – they either increase or suppress the interest in education and culture. This means that parents, be that deliberately or not, through the social groups of their children’s first friends set the framework for the common and desired standards in education, about which their children learn from their closest environment. Of course, it is also important that the residence determines the choice of school and the level of education in the child’s school friends.

The parents” impact on their children’s education can hardly be overestimated. Education determines the opportunities in life. The individual education has a decisive influence on income, choice of profession, prestige, career, employment opportunities, working conditions, match between the professional background and employment, property, retirement benefit, choice of partner, health and life expectancy. This is why education is a central measure for social stratification. The one with the best education shall get the highest score in all the above-mentioned areas. Each year of school or professional training adds around 6 % to the salary. Better educated people will have less trouble finding an employment and they are fired more seldom. Those with a University degree stand a better chance to find an employment within their area of training (Szydlik М., 1996).

Parents set important educational standards for their children. This is not only about the decisions concerning education itself but also about the general level of education in the family. The very first years of life lay the basis for future academic and professional success. The decisive role here is rather common – the financial capacity of the parents. Therefore, the family connections reproduce social inequity through the entire life. Especially impressive here is the connection of inter-generation solidarity and social inequity. Solidarity between generations is well expressed not only in relation to minor children who still reside with their parents. This goes on after the children leave the parental home. This solidarity continues for the entire life, thus constantly reproducing social inequity.

Parents from higher social groups create better conditions for their children not only in childhood and adolescence. When children become independent they still get support through regular money transfers, gifts, property and, finally, inheritance. This is how the support provided by the upper class to their children through their lives will enforce and even increase the social inequity. The youngster who had better chances due to the parents” resources will have obvious advantage in adulthood.

In general solidarity between generations is well expressed through all the social groups. However, bigger opportunities mean bigger support. Parents without significant resources can never provide such support. This is how families strengthen and increase social inequity. This enhances the chances of children whose parents hold higher social positions thus reducing the opportunities of children from poorer families. Here we must recognize the invaluable service done by the family and assist it in every way. However, an important public and political task is to reduce inequity based on parentage (Szydlik, M., 2004).

Role of education in health inequity

As stressed above, education is one of the major determinants of the economic inequity and its role is increasing year after year.

The public expenses on education make up about 60 % of the total national educational budget; the part covered by the population is about 30 %, with another 10 % coming from the employers. This ratio of public and non-public funding on education (60/40) is significantly different from what economically developed countries have where the population has a higher level of income in general and, which is equally important, where the differentiation in income is much lower, while the private funding from employers and sponsors is higher. For instance, in 2001 in the USA the public budget for education was 69,2 %, in Germany – 81,4 %, in Great Britain – 84,7 %, in Italy – 90,7 %, in Sweden – 96,8 %, in the Czech Republic – 90,6 %, in Slovakia – 97,1 %.

The crisis of public funding for education in Russia stimulates paid education and getting fee from the family for various services, which increases inequity in access to education. Selection is more and more based not on the aptitude criteria but on the applicants” parents” financial capacity. A survey conducted in 2005 by the Russian National Center for Public Opinion showed that half of the Russian population (55 %) cannot afford educational services that are paid, while 21 % of Russians can afford it in extreme cases only. Besides, attending an educational institution and graduating from it with the respective degree certificate does not mean having quality education. The growing density of education both in school and in universities is one of the factors for a certain reduction of its quality. This already contributes, and will contribute on, to the growth of inequity.

However, it is common knowledge that each extra year or education in Russia accounts for a nine-percent death rate reduction in men and a seven-percent death rate reduction in women, while those involved in mental work (especially leaders) demonstrate a higher survival rate than those involved in physical labor (Тапилина В. C., 2004). Researches carried out in St. Petersburg (Russia) showed significant differences in health status esteem depending on the level of education and financial deprivation – in the social groups with limited educational and economic resources the health status was lower (Русинова Н. Л., Браун Дж., 1997; Русинова Н. Л., Панова Л. В., 2003; 2005; Максимова Т. М., 2005; Назарова И. Б, 2007). Foreign authors, too, focused on the issue of social differentiation of health in our country. In order to support the facts mentioned it was shown that the level of financial hardships and education are important predictors of the perceived health (Bobak, Pikhart, Hertzman, Rose and Marmot, 1998; Bobak, Pikhart, Rose, Hertzman, and Michael Marmot, 2000; Carlson, 2000). These works also stated that one of the significant health status determinants is such an indicator of social well-being as the perceived control over the life circumstances.

The differences in education related, to a certain degree, to income differentiation, may also reveal themselves in the value and behavioral aspect of the way someone treats his/her own health. In particular, education is connected to the specificity of ordinary health conceptualization, the level of personal responsibility for one’s health status, and the differences in people’s awareness of health issues, healthy lifestyle, and medical care. People with a degree in higher education are usually involved in a wider network of interpersonal connections thus standing a better opportunity to get instrumental and emotional support. The level of education has also been repeatedly noticed to have relation to the differences in the prevalence of health destroying behavior patterns (Демьянова А. А., 2005; Cockerham, 2000; Pomerleau, Gilmore, McKee, Rose, and Haerpfer, 2004). For instance, in 1998 in the female part of the city 64 % of the respondents with a level of education below average referred to their health as poor or very poor, while among those with a higher degree of education the same response was obtained from 20 % only. As for men, about 58 % of St. Petersburg residents with no complete secondary education considered their health as unsatisfactory, while in the most educated segment the same response was given only in 10 % of cases. In the same year the share of respondents with poor health in the first (lowest) and the fourth (highest) income quartiles were: for women – 30 % and 13 %, and for men – 21 % and 4 % (Русинова Н. Л., Браун Дж., 1997, 1999; Rusinova and Brown, 2003).