Health selection in a 14-year follow-up study—A question of gendered discrimination?

Abstract

Health selection, as one of the several possible explanations for social inequities in health, has been receiving more attention recently but few researchers turn the issue into a question of discrimination. The aim of the study was to analyse the impact of health in young age for social position in adult age and to discuss health selection in terms of discrimination from a gender-theoretical perspective. A prospective cohort study was conducted, in which all pupils ($N=1083$) in the last year of compulsory school in a middle-sized municipality in northern Sweden were followed for 14 years. The response rate was high, with 96.6% still participating after 14 years. The data were collected through repeated comprehensive self-administered questionnaires as well as through teacher interviews and register data. Health selection was analysed in a multiple logistic regression model, with working-class position at age 30 as a dependent variable and different measures of health/health behaviour at age 16 and 21 as independent variables. Overall, the impact of early health/health behaviour on future socioeconomic position was small or non-existent. However, even after correction for possible mediating and moderating mechanisms, being overweight at age 16 and at age 21 was related to future working-class position among women only. Possible mediating mechanisms were feeling looked down upon, not being active in associations and not reading cultural/political events in daily newspapers. Early menarche together with early motherhood and low education could not explain the correlations. Our results indicate that overweight girls and young women are exposed to gendered discrimination which probably occurs in many arenas, based on the societal norms for female bodies in our society. There is a need to redirect research on health selection into gender research in order to further explore the subject as well as the possible mechanisms of gendered discrimination.

Introduction

Health selection, as one of several possible explanations for social inequities in health, has received more and more attention during the last few years (Chandola, Bartley, Sacker, Jenkinson, & Marmot, 2003; Elstad, 2001; Elstad & Krokstad, 2003; Goldman, 2001; Koskela, 1997; Joung, van de Mheen, Stronks, van Poppel, & Mackenback, 1998; McDonough & Amick III, 2001; Power, Matthews, & Manor, 1996; van de Mheen, Stronks, Looman, & Mackenback, 1998). The hypothesis of health selection implies that good health is crucial for attaining high social position, resulting in a pattern of social mobility where people with good health move up the social scale while people with poor health move down the scale.

In a review of the field, West (1991) criticises a dislike among social inequity researchers for the research field of health selection, as they tend to see no other mechanism behind the mobility than a Social Darwinist argument about social position being the result of personal genetic or biological attributes. Instead, West argues for redirection of research on health selection as a question of discrimination, where people with poor health are at risk of discrimination on the labour market and thus risk an increased tendency to drift down the social scale.

Since then, many articles on health selection refer to West's call for more research on the issue, although most of them neglect his main argument for this, namely, discrimination. The concept of discrimination needs to be seen as a social process, in which power is created along several axes (Hammarström & Ripper, 1999). People in power over others have the option to discriminate against others with less power, in relation to hierarchical social structures such as gender, class and race (Connell, 1987). Connell's theory of the gender order says that each society is characterised by a gender order in which a gendered distribution of power, resources, work and emotions is organised. Gender research has shown that most societies have a general pattern with local exceptions, characterised by male dominance and female subordination.

Postmodernism has brought with it a useful view of people as active agents in their lives (Burr, 1995). Postmodernism has also led to a view that meta-narratives of worldwide discrimination need to be replaced by local studies about how discrimination is produced, in interaction between social structures and the individual.

The importance of health at a young age for adult social position needs to be analysed in longitudinal studies of young people, starting at school before they have entered the labour market and following them until adult age. However, there is a lack of such long-term longitudinal studies. Besides, a major problem in most existing prospective studies is the high non-response rate, leading to under-representation of those with the most disadvantaged background (Novo, Hammarström, & Janlert, 1999). Goldman criticises researchers within the field of social inequities in health (2001) for having done a relatively poor job of defining and analysing health selection.

When analysing the discrimination hypothesis, possible mediating mechanisms between early health status and adult socioeconomic position could be related to problems in the psychosocial situation at school (classmate relations, the learning situation), poor parental contact, lack of control, feeling subordinated and excluded from social activities such as associations.

The aim of the study was to analyse the impact of health in young age for social position in adult age as well as to discuss health selection in terms of discrimination from a gender-theoretical perspective.