Skip to main content
PMC home page
Journal of Epidemiology and Community Health logoLink to Journal of Epidemiology and Community Health
. 1999 Oct;53(10):603–611. doi: 10.1136/jech.53.10.603

An additional dimension to health inequalities: disease severity and socioeconomic position

J Eachus, P Chan, N Pearson, C Propper, S Davey
PMCID: PMC1756792  PMID: 10616672

Abstract

OBJECTIVE: To investigate the association between the severity of hip pain and disability, and a number of measures of socioeconomic position, using a range of individual and ecological socioeconomic indicators. DESIGN: Interviewer administered and self completed questionnaires on symptoms of pain and disability, general health and socioeconomic indicators, completed by people reporting hip pain in a cross sectional, postal, screening questionnaire. SETTING: 40 general practices from inner city, suburban and rural areas of south west England. PARTICIPANTS: 954 study participants who had reported hip pain in a postal questionnaire survey of 26,046 people aged 35 and over, selected using an age/sex stratified random probability sample. DATA: Individual indicators of socioeconomic position: social class based on occupation, maximum educational attainment, car ownership, gross household income, manual or non-manual occupation and living alone. Area level measures of socioeconomic position: Townsend scores for material deprivation at enumeration district level; urban or rural location based on the postcode of residence. Severity of hip disease, measured by the pain, disability and independence components of the New Zealand score for major joint replacement. Self reported comorbidity validated using general practice case notes and summary measures of general health. MAIN RESULTS: Increasing disease severity was strongly associated with increasing age and a variety of measures of general health, including comorbidity. The data provide considerable evidence for the systematic association of increased severity of hip disease with decreasing socioeconomic position. Measures of socioeconomic position that were systematically associated with increasing disease severity, standardised for age and sex, included educational attainment (relative index of inequality 1.95 (95% confidence intervals 1.29 to 2.62) and income (relative index of inequality 4.03 (95% confidence intervals 3.43 to 4.64). Those with access to a car (mean disease severity 15.5) had statistically significant lower severity of hip disease than those without (mean 17.5, p < 0.01). Similar results were found for access to higher or further education and living with others. For a given level of income, people with greater comorbidity had more severe hip pain and disability. The gradient in disease severity between rich and poor was steepest among those with the most comorbidity. CONCLUSIONS: People with lower socioeconomic position experience a greater severity of hip disease. The poorest sector of the population seem to be in double jeopardy: they not only experience a greater burden of chronic morbidity but also a greater severity of hip disease. This study has implications for health care provision, if the National Health Service is to live up to its principle of equal treatment for equal medical need.

 

Full Text

The Full Text of this article is available as a PDF (93.5 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Blaxter M. Evidence on inequality in health from a national survey. Lancet. 1987 Jul 4;2(8549):30–33. doi: 10.1016/s0140-6736(87)93062-5. [DOI] [PubMed] [Google Scholar]
  2. Croft P., Coggon D., Cruddas M., Cooper C. Osteoarthritis of the hip: an occupational disease in farmers. BMJ. 1992 May 16;304(6837):1269–1272. doi: 10.1136/bmj.304.6837.1269. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Davey Smith G., Hart C., Hole D., MacKinnon P., Gillis C., Watt G., Blane D., Hawthorne V. Education and occupational social class: which is the more important indicator of mortality risk? J Epidemiol Community Health. 1998 Mar;52(3):153–160. doi: 10.1136/jech.52.3.153. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Eachus J., Williams M., Chan P., Smith G. D., Grainge M., Donovan J., Frankel S. Deprivation and cause specific morbidity: evidence from the Somerset and Avon survey of health. BMJ. 1996 Feb 3;312(7026):287–292. doi: 10.1136/bmj.312.7026.287. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Felson D. T. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev. 1988;10:1–28. doi: 10.1093/oxfordjournals.epirev.a036019. [DOI] [PubMed] [Google Scholar]
  6. Frankel S., Eachus J., Pearson N., Greenwood R., Chan P., Peters T. J., Donovan J., Smith G. D., Dieppe P. Population requirement for primary hip-replacement surgery: a cross-sectional study. Lancet. 1999 Apr 17;353(9161):1304–1309. doi: 10.1016/S0140-6736(98)06451-4. [DOI] [PubMed] [Google Scholar]
  7. Hadorn D. C., Holmes A. C. The New Zealand priority criteria project. Part 1: Overview. BMJ. 1997 Jan 11;314(7074):131–134. doi: 10.1136/bmj.314.7074.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Hannan M. T., Anderson J. J., Pincus T., Felson D. T. Educational attainment and osteoarthritis: differential associations with radiographic changes and symptom reporting. J Clin Epidemiol. 1992 Feb;45(2):139–147. doi: 10.1016/0895-4356(92)90006-9. [DOI] [PubMed] [Google Scholar]
  9. Harris W. H. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737–755. [PubMed] [Google Scholar]
  10. Haynes R. M., Bentham C. G. The effects of accessibility on general practitioner consultations, out-patient attendances and in-patient admissions in Norfolk, England. Soc Sci Med. 1982;16(5):561–569. doi: 10.1016/0277-9536(82)90309-4. [DOI] [PubMed] [Google Scholar]
  11. Heliövaara M., Aromaa A., Klaukka T., Knekt P., Joukamaa M., Impivaara O. Reliability and validity of interview data on chronic diseases. The Mini-Finland Health Survey. J Clin Epidemiol. 1993 Feb;46(2):181–191. doi: 10.1016/0895-4356(93)90056-7. [DOI] [PubMed] [Google Scholar]
  12. Helmert U., Shea S. Social inequalities and health status in western Germany. Public Health. 1994 Sep;108(5):341–356. doi: 10.1016/s0033-3506(05)80070-8. [DOI] [PubMed] [Google Scholar]
  13. Lequesne M. Indices of severity and disease activity for osteoarthritis. Semin Arthritis Rheum. 1991 Jun;20(6 Suppl 2):48–54. doi: 10.1016/0049-0172(91)90027-w. [DOI] [PubMed] [Google Scholar]
  14. Mackenbach J. P., Looman C. W., van der Meer J. B. Differences in the misreporting of chronic conditions, by level of education: the effect on inequalities in prevalence rates. Am J Public Health. 1996 May;86(5):706–711. doi: 10.2105/ajph.86.5.706. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Marmot M. G., Smith G. D., Stansfeld S., Patel C., North F., Head J., White I., Brunner E., Feeney A. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991 Jun 8;337(8754):1387–1393. doi: 10.1016/0140-6736(91)93068-k. [DOI] [PubMed] [Google Scholar]
  16. Mays N., Keen J. The NHS's 50 anniversary. Will the fudge on equity sustain the NHS into the next millennium? BMJ. 1998 Jul 4;317(7150):66–69. doi: 10.1136/bmj.317.7150.66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. O'Donnell O., Propper C. Equity and the distribution of UK National Health Service resources. J Health Econ. 1991 May;10(1):1–19. doi: 10.1016/0167-6296(91)90014-e. [DOI] [PubMed] [Google Scholar]
  18. Payne N., Saul C. Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality. BMJ. 1997 Jan 25;314(7076):257–261. doi: 10.1136/bmj.314.7076.257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Peters T. J., Eachus J. I. Achieving equal probability of selection under various random sampling strategies. Paediatr Perinat Epidemiol. 1995 Apr;9(2):219–224. doi: 10.1111/j.1365-3016.1995.tb00135.x. [DOI] [PubMed] [Google Scholar]
  20. Phillimore P., Beattie A., Townsend P. Widening inequality of health in northern England, 1981-91. BMJ. 1994 Apr 30;308(6937):1125–1128. doi: 10.1136/bmj.308.6937.1125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Pincus T., Callahan L. F., Burkhauser R. V. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis. 1987;40(9):865–874. doi: 10.1016/0021-9681(87)90186-x. [DOI] [PubMed] [Google Scholar]
  22. Regidor E., Navarro P., Dominguez V., Rodriguez C. Inequalities in income and long-term disability in Spain: analysis of recent hypotheses using cross sectional study based on individual data. BMJ. 1997 Nov 1;315(7116):1130–1135. doi: 10.1136/bmj.315.7116.1130. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Roussou E., Kennedy L. G., Garrett S., Calin A. Socioeconomic status in ankylosing spondylitis: relationship between occupation and disease activity. J Rheumatol. 1997 May;24(5):908–911. [PubMed] [Google Scholar]
  24. Schrijvers C. T., Stronks K., van de Mheen D. H., Coebergh J. W., Mackenbach J. P. Validation of cancer prevalence data from a postal survey by comparison with cancer registry records. Am J Epidemiol. 1994 Feb 15;139(4):408–414. doi: 10.1093/oxfordjournals.aje.a117013. [DOI] [PubMed] [Google Scholar]
  25. Smith G. D., Hart C., Watt G., Hole D., Hawthorne V. Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley Study. J Epidemiol Community Health. 1998 Jun;52(6):399–405. doi: 10.1136/jech.52.6.399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Smith G. D., Morris J. N., Shaw M. The independent inquiry into inequalities in health is welcome, but its recommendations are too cautious and vague. BMJ. 1998 Nov 28;317(7171):1465–1466. doi: 10.1136/bmj.317.7171.1465. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Stansfeld S. A., Marmot M. G. Social class and minor psychiatric disorder in British Civil Servants: a validated screening survey using the General Health Questionnaire. Psychol Med. 1992 Aug;22(3):739–749. doi: 10.1017/s0033291700038186. [DOI] [PubMed] [Google Scholar]
  28. Wagstaff A., Paci P., van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med. 1991;33(5):545–557. doi: 10.1016/0277-9536(91)90212-u. [DOI] [PubMed] [Google Scholar]
  29. Wagstaff A., Van Doorslaer E. Measuring inequalities in health in the presence of multiple-category morbidity indicators. Health Econ. 1994 Jul-Aug;3(4):281–289. doi: 10.1002/hec.4730030409. [DOI] [PubMed] [Google Scholar]
  30. Watt I. S., Franks A. J., Sheldon T. A. Health and health care of rural populations in the UK: is it better or worse? J Epidemiol Community Health. 1994 Feb;48(1):16–21. doi: 10.1136/jech.48.1.16. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of Epidemiology and Community Health are provided here courtesy of BMJ Publishing Group

RESOURCES