ArticlesInequalities in self-rated health: explanations from different stages of life
Introduction
Understanding of the causes of inequalities in health has progressed1, 2 but still too little is known about the relative importance of different explanations. Research has expanded on the four main explanations presented in the Black Report3 (artefact, selection, lifestyle, and material circumstances), to emphasise distribution, accessibility, and quality of medical care,2, 4 factors early in life,5 psychosocial factors,6 and social cohesion.7 Collectively, this research suggests that explanations vary by sex and lifestage and for different causes of mortality and morbidity.8
Evidence on long-term and cumulative influences on inequalities is sparse, primarily because few studies take account of lifetime circumstances or duration of exposure to particular risk factors. An exception is Power and colleagues' investigation of inequalities in early adulthood, based on the 1958 British birth cohort.9 They showed that an accumulation of diverse factors from birth to age 23 years contributed to subsequent inequalities. An analysis of the cohort at age 33 years provided further support for this conclusion, but focused mainly on the role of health-related social mobility, with limited representation of lifetime risks.10 The need for a detailed investigation of specific influences was recognised. We aimed to provide such a detailed analysis of the 1958 birth cohort to provide explanations for inequalities in self-rated health at age 33 years. We assessed whether factors identified in relation to inequalities at age 23 years9 remained important 10 years later. We also investigated the contribution of additional explanatory factors between ages 23 years and 33 years.
During these 10 years, many factors are likely to have had an impact on health. This period is one of transition, in which many individuals in the UK complete their education, gain employment, leave the family home, and start their own family. We selected factors known to have adverse health effects as potential explanations for health inequalities. By taking into account more specific factors, we were able to extend previous investigations of inequality in this cohort.
Section snippets
Methods
The 1958 British birth cohort includes all children born in England, Wales, and Scotland from March 3 to 9, 1958. The original Perinatal Mortality Study recorded information on 17414 (98%) births, with follow-up surveys at ages 7 years, 11 years, 16 years, 23 years, and 33 years (11405 people were interviewed in 1991: 5606 men and 5799 women).11 In general, the people remaining in the study were representative of the original sample.9, 11 We assessed response biases specifically for the study
Results
We found a significant social gradient in poor health by age 23 years, ranging from 5·3% of men in social classes I and II to 10·5% in classes IV and V; for women, the range was from 5·2% to 13·9%. The gradient persisted to age 33 years, ranging from 8·5% in men in classes I and II to 17·7% in classes IV and V; and in women from 9·4% to 18·8% (table 1).
Odds ratios previously calculated for poor health for participants in classes IV and V relative to classes I and II at age 23 years, adjusted
Discussion
For this cohort, we have previously established that social gradients in poor health exist in early adulthood; these gradients remain constant from ages 23 years to 33 years, and seem to be explained by lifetime socioeconomic circumstances.9, 10, 15 Previous analyses did not assess the specific life-course factors that might explain inequalities at age 33 years or show whether factors identified in relation to health inequalities at age 23 years would be relevant to inequalities 10 years later
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