Family Practice Advance Access originally published online on December 7, 2006
Family Practice 2007 24(1):7-10; doi:10.1093/fampra/cml064
Socio-economic position and the use of preventive health care in older British women: a cross-sectional study using data from the British Women's Heart and Health Study cohort
a Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR
b Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
Correspondence to Rita Patel, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK; Email: Rita.Patel{at}bristol.ac.uk
Received 16 March 2006; Accepted 25 October 2006.
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Abstract |
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Background. Socio-economic inequalities in health may be due to differential uptake of preventive and therapeutic medical services.
Objectives. To examine socio-economic position and self-reported use of six preventive services in a cohort of older British women.
Methods. Women randomly selected from general practice age/sex registers in 23 towns were examined from 1998 to 2001. Of all, 3652 women aged 62–83 years completed a questionnaire in 2003 assessing preventive service use.
Results. Women from manual social classes were less likely to have recent flu vaccinations [odds ratio (OR) 0.85, 95% confidence interval (CI) 0.74, 0.98] and dental (OR 0.42, 95% CI 0.36, 0.49), eye (OR 0.77, 95% CI 0.67, 0.88) or chiropody examinations (OR 0.88, 95% CI 0.77, 1.01). Manual social class was not related to having recent blood pressure or cholesterol checks.
Conclusions. Among older British women, preventive services for cardiovascular disease are not socially patterned. However, those from lower socio-economic groups are less likely to have recent flu vaccinations and dental, eye and chiropody examinations.
Keywords. Preventive health services, socio-economic position, women.
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Introduction |
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The association between socio-economic position (SEP) and health outcomes has been well documented and interventions to reduce these inequalities (by improving the health of the less affluent groups) are important to UK health policy.1,2 Socio-economic inequalities in health may be due to differential uptake of preventive and therapeutic medical services; the so-called ‘inverse care law’.3 We examined the relationship between SEP and use of six preventive services in a cohort of British women aged 62–83 years.
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Methods |
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The British Women's Heart and Health Study4 includes 4286 women, aged 60–79 years (60% of those invited), randomly selected from age/sex registers in general practices in 23 British towns who returned a baseline questionnaire between 1999 and 2001. This cohort has a social class distribution comparable to the 1991 and 2001 census.5 The questionnaire elicited the longest held occupation of the woman and her husband. These were classified according to the UK Registrar General's Classification [six categories; I (professional) through V (unskilled manual), with the middle category split into skilled non-manual (III nm) and skilled manual (III m)] and head of household social class was defined on the basis of whether the woman or her spouse's occupational social class was the higher. Cardiovascular disease (CVD) and diabetes at baseline were defined as those with either self-report of a doctor diagnosis or medical record evidence of the condition.
A follow-up questionnaire was sent in 2003 to 4108 surviving women, now aged 62–83 years, and 3677 (90%) responded. Participants were asked if they had ever had the following: a blood pressure (BP) check, blood cholesterol check, flu vaccination, dental examination, eye examination or foot care from a chiropodist/podiatrist and the year of the most recent check for each. We defined a recent check as anyone reporting a visit in either 2002 or 2003, those who reported a check but gave no date were coded as not having had a recent check.
We used multiple logistic regression to assess the effect of social class on preventive service use, with adjustment for potential confounding factors. In the main analysis social class was examined as a dichotomy (manual versus non-manual). In additional analyses the use of preventive services across all six social class categories was assessed. In all analysis robust standard errors were used, allowing for potential non-independence between women from the same town, to calculate confidence intervals (CIs) and P-values.
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Results |
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Of the 3677 women who completed the follow-up questionnaire, 3652 (99.3%) gave responses to the questions on preventive health behaviours. Women from manual compared to non-manual social classes were less likely to have had a recent flu vaccination, dental examination, eye examination or chiropody examination (Table 1). Manual social class was not related to having a recent BP or cholesterol check. These associations remained after adjustment for potential confounding factors. When associations were examined across all categories of occupational social class, they were broadly consistent with the findings where social class was dichotomized into manual versus non-manual social classes (Table 2). Notably, there were strong linear associations across all social class categories for decreasing odds of recent dental and eye examinations with poorer social class. When these associations were re-examined, only in those aged 65 years and older (the age group at which GP payments are increased and flu vaccinations are recommended) they were essentially unaltered.
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Of the 3652 women included in the analysis, 565 had a diagnosis of CVD at baseline, and of these, 463 (82.1%) had a recent BP check and 321 (56.8%) a cholesterol check. In this subgroup, the age-adjusted odds ratio (OR) of manual versus non-manual social class was 0.92 (95% CI 0.60, 1.42) for BP check and 0.92 (95% CI 0.65, 1.30) for blood cholesterol check; these findings were essentially unchanged with full adjustment.
Among the 170 women with diabetes at baseline, 146 (85.9%) reported a BP check, 118 (69.0%) a cholesterol check, 133 (78.2%) a flu vaccination, 134 (78.4%) an eye examination and 109 (64.9%) a chiropody examination recently. There were no associations of social class with BP, cholesterol or chiropody examination in this group (point estimates of ORs being 0.98–1.01). There appeared to be a reduced odds of eye examination among diabetic women from manual social classes, 0.81 (95% CI 0.38, 1.75), and by contrast increased odds of having a flu vaccination, 1.32 (95% CI 0.62, 2.81).
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Discussion |
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Older women from manual social classes were less likely to have had a recent flu vaccination or to have recently received preventive services provided by agencies outside general practice (dental, eye and chiropody examinations), but social class was not associated with recent BP or cholesterol checks. Among women with diabetes, those from manual social classes appeared to be more likely to receive flu vaccinations, but this association was imprecise.
To our knowledge no previous study has examined the association of SEP with a range of preventive services supplied both in primary care and by other providers in the same study population. Findings for eye examinations similar to ours have been reported for British women and men aged 65 years and older,7 and for preventive dental care in different age groups.8–10 The lack of socio-economic differentials in CVD-preventive services are consistent with findings from younger populations11 and may reflect that CVD prevention in all adults has been the National Health Service policy for some decades.
We used self-report of uptake of prevention services. While BP and cholesterol assessment and flu vaccination would be recorded in medical records, it would be difficult to ascertain the uptake of other preventive services that we were interested in through any available record system. Our results would be subject to recall bias if error in self-reports differed by socio-economic group; it seems unlikely that this bias exists for some preventive services (e.g. dental services where we found an effect) but not others (e.g. cholesterol tests with no effect). Our study is in women only and less than 1% of the cohort is from minority ethnic groups.
Information on the availability and cost of preventive services is confusing and inconsistent12 and this may contribute to the socio-economic differentials. Policies regarding entitlement to free services vary by geographical location (e.g. dental services are free to over 60s in Wales but only free to those receiving benefits in England) and over time (the groups entitled to free flu vaccination changed in 2000 and eye examinations in 1999). For eye examinations and flu vaccinations, the provision of free or incentivized services does not eliminate differential uptake, and while cost may not be the primary factor determining uptake, it may explain some of the inequalities that we found in use of dental and foot examinations.
There is no evidence to suggest that those from lower socio-economic groups require less preventive care. On the contrary, the greater risk of CVD, diabetes and of dental problems in those from lower socio-economic groups would indicate a need for greater preventive care. Thus, our results highlight the need to promote all preventive services to those from lower socio-economic groups.
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Declaration |
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Funding: The British Women's Heart and Health Study is funded by the UK Department of Health and British Heart Foundation. DAL is funded by a UK Department of Health Career Scientist Award. The views expressed in this publication are those of the authors and not necessarily those of any of the funding bodies. The funding bodies have had no influence over the scientific work or its publication.
Ethical approval: The British Women's Heart and Health Study has received local and multi-centre research ethics committee approval in the UK. All the participants in the study gave informed consent.
Conflicts of interest: None.
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Acknowledgments |
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The British Women's Heart and Health Study is co-directed by Shah Ebrahim, Debbie Lawlor, Peter Whincup and Goya Wannamethee. We thank Carol Bedford, Alison Emerton, Nicola Frecknall, Karen Jones, Mark Taylor and Katherine Wornell for collecting and entering data, all the GPs and their staff who have supported data collection and the women who have participated in the study. Contributors: SE and DAL co-direct the British Women's Heart and Health Study. DAL and RP developed the idea for this paper. DAL undertook the main analyses. RP managed the study and wrote the first draft of the paper and all authors contributed to the final version. RP and DAL act as guarantors.
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Notes |
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Patel R, Lawlor D A, Ebrahim S. Socioeconomic position and the use of preventive health care in older British women: a cross-sectional study using data from the British Women's Heart and Health Study cohort. Family Practice 2007; 24: 7–10.
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References |
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1 Acheson D. (1998) Independent Inquiry into Inequalities in Health(The Stationery Office, London).
2 Department of Health. Saving Lives. Our Healthier Nation (1999) (The Stationery Office, London).
3 Hart JT. (1971) The inverse care law. Lancet 1:405–412.[CrossRef][Web of Science][Medline]
4 Lawlor DA, Bedford C, Taylor M, Ebrahim S. (2003) Geographical variation in cardiovascular disease, risk factors, and their control in older women: British Women's Heart and Health Study. J Epidemiol Community Health 57:134–140.
5 Shaper AG, Pocock SJ, Walker M, Cohen NM, Wale CJ, Thomson AG. (1981) British Regional Heart Study: cardiovascular risk factors in middle-aged men in 24 towns. Br Med J (Clin Res Ed) 283:179–186.
6 Adamson J, Lawlor DA, Ebrahim S. (2004) Chronic diseases, locomotor activity limitation and social participation in older women: cross-sectional survey of British Women's Heart and Health Study. Age Ageing 33:293–298.
7 van der Pols JC, Thompson JR, Bates CJ, et al. (1999) Is the frequency of having an eye test associated with socioeconomic factors? A national cross sectional study in British elderly. J Epidemiol Community Health 53:737–738.[Web of Science][Medline]
8 Eddie S and Davies JA. (1985) The effect of social class on attendance frequency and dental treatment received in the General Dental Service in Scotland. Br Dent J 159:370–372.[CrossRef][Web of Science][Medline]
9 Pavi E, Kay EJ, Stephen KW. (1995) The effect of social and personal factors on the utilisation of dental services in Glasgow, Scotland. Community Dent Health 12:208–215.[Medline]
10 Office of Population Censuses and Surveys. Living in Britain. Results from the 1995 General Household Survey (1997) (HMSO, London).
11 Atri J, Falshaw M, Livingstone A, Robson J. (1996) Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project. Br Med J 312:614–617.
12 Lorna Easterbrook. Your Rights to Health Care, Helping Older People Get the Best from the NHS (2005) (Age Concern Books, England).
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