Class is the missing link in health equity strategies

Evidence consistently demonstrates that people from less advantaged backgrounds suffer poorer health, for longer, and die younger than their wealthier peers.

Inequalities have been documented as early as a century ago. The picture looks very similar today, in every country around the world.

Higher rates of chronic diseases and worse mental health abound for these individuals compared to those from higher social classes. Contributing factors include limited access to healthcare, poorer quality housing, less healthy lifestyle options and increased stress levels associated with lower socio-economic status (SES).

‘Class’ in society refers to a group of people who share a similar SES, typically determined by factors like wealth, income, occupation, education and social networks; it’s a way of dividing people based on their relative economic position within a society.

The concept of social class might muster images of 18th century English gentlemen, but class has been present throughout history. Ancient civilisations like Egypt exhibited a clear hierarchy that existed between the elite, common people and slaves.

In 1958, in his book Nation of Immigrants, John F Kennedy mused: ‘One of America’s characteristics has always been the lack of a rigid class structure.’ The 35th US president might have found himself disappointed with the impact of class on health outcomes in modern-day America.

In 2023, a study of American women found that that higher SES predisposes to better pregnancy outcomes, even when controlled for confounding factors such as ethnicity and underlying baseline health status. Women from the wealthiest percentile were less likely to develop complications including gestational hypertension, preeclampsia, eclampsia, gestational diabetes and preterm birth.

Low SES also impacts the economic and health value gained from drugs and medicines.

Research consistently shows that SES significantly impacts treatment adherence, with individuals from lower socio-economic backgrounds exhibiting lower adherence rates.  Limited access to healthcare, cost of medication and lack of health literacy are often associated with poorer treatment adherence.

Despite the overwhelming evidence linking lower SES with poorer health outcomes, why does addressing class remain so stubborn and unsexy? Addressing this significant marker of health outcomes is a complex and unsatisfying task for many who attempt to level the playing field.

Class is considered a sensitive and complex issue, with no single, clear definition of what the term constitutes, making it hard to identify and tackle inequalities based on SES.

This is especially true when compared to protected characteristics like race or gender, which are legally recognised and easier to pinpoint; additionally, people may not readily disclose their class background, contributing to the challenge of understanding and addressing class disparities.

Pioneering researchers might wish to take an intersectional lens to health inequities to improve the quality of programmes designed to progress outcomes. Analyses can be included within research to adjust for confounding factors, including ethnicity, pre-existing conditions, smoking status, obesity, illicit drug use and insurance type. Research like this can provide a stronger steer on interventions that will improve people’s health in a disease area.

In clinical trials, SES is collected by asking participants questions about their income, education level and occupation, allowing researchers to understand how different socio-economic groups are represented in the study and to analyse potential impacts of SES on health outcomes and treatment response.

Currently different studies use varying methods to measure SES, making comparisons and conclusions difficult to draw that might support the broader development of services and care. Improving the rigour and standardisation of data collection on class will improve this.

Multi-stakeholder programmes often need to include elements that tackle a broad range of factors for communities. The highly successful 2016 ‘Healthy Neighborhood Initiative’ in South Central Los Angeles can act as inspiration.

Interventions included: hiring and training local residents as community health workers to provide assistance navigating the healthcare system; establishing mobile health clinics, partnering with charities to address food insecurity; offering financial literacy workshops; implementing green spaces, and delivering tailored education programmes for young people.

The area saw a significant rise in preventive healthcare utilisation among low-SES residents, measured positive changes in dietary patterns, physical activity levels and smoking cessation rates within the community and overall observed narrowing of health gaps between low-SES areas and higher-income communities in key health metrics.

With the sustainability of community-led initiatives in danger beyond the initial grant periods, the life sciences sector might look to expand its support for multi-stakeholder initiatives and expand their impact in communities where treatments are designed to deliver value.

A focus on class might be complex, but the potential for reducing health inequities is vast. It’s time we worked harder to include it.