Descripción de las principales clases utilizadas en la solución

2.2.2.1 Childhood SEP and health care utilisation

In this thesis, childhood social class will be used as a measure of childhood socioeconomic position (SEP). A limited amount of research has investigated the associations between childhood SEP and adult health management or health care utilisation.

There are a small number of studies assessing the association between SEP and health care utilisation in childhood (which might influence health care utilisation in later life);

however, results are mixed. A cross-sectional study using data from the 1999 Health Survey for England (Saxena et al., 2002) found no association between social class and the use of health care services (including GP services and access to hospital services either as an inpatient or outpatient) in a sample of children and young adults (up to the age of 20). Although this study lacks a longitudinal approach, it reflects the lack of relationship between childhood social class and health care utilisation which may or may not transfer into adulthood.

One study reported an association between childhood SEP and hospital admissions. The longitudinal study, which followed children for the first 10 years of life, using linked routine data, reported that children from a lower social class were more likely to be admitted to hospital and remain an inpatient for more days than children from the highest social class, after adjusting for factors relating to childbirth and maternal health (Petrou &

Kupek, 2005). This study suggests that a link between social class and health care utilisation is apparent in childhood, hence it is possible that this association could persist into adulthood but early exposure to professional health care services may also influence later health management approaches. Furthermore, evidence was found for the effect of SEP in childhood on children’s attendance to preventive health care services and health professional consultation. In a study of N=68,366 children, low SEP was associated with a lower likelihood of consulting a professional in families where children were not attending preventive health care services, which included general health check-ups and immunisations (Martensson et al., 2012).

Childhood SEP has also been associated with health care utilisation in adulthood, although the evidence is limited. In a retrospective study of participants who grew up in a deprived area of the UK, those who lived in rented accommodation as a child (this was used as a marker of social disadvantage), visited their GP more often in adulthood (Lindsay, 2009); this study suggested that this association might operate through lower

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health locus of control, in that those from a lower SEP felt as they had lower personal control over their health. However, this study did not consider social mobility throughout the life course and only included childhood SEP as a predictor of health management, without considering the possible pathways.

2.2.2.2 Pathways between childhood SEP and adult health management

Childhood SEP could be associated with adult health management through many of the other adult health and social factors shown in Figure 2.1. As the literature is vast, a selection of recent studies and systematic reviews will be discussed below to illustrate these associations.

2.2.2.2.1 Socioeconomic pathways

There is strong evidence for associations between childhood and adulthood SEP (as represented by education and adult social class in Figure 2.1). For example, findings from the NCDS showed that coming from a family with a higher household income as a child was associated with socioeconomic advantage in adulthood, as indicated by higher educational attainment, even after adjusting for parental education (Case et al., 2005), demonstrating the role of childhood environment in predicting socioeconomic outcomes in adulthood. These results have been supported by other research, including research from NSHD (Kuh, Power, Blane, & Bartley, 2004) and from another longitudinal study (the Midspan family study) that reported that individuals whose father was from a manual working class had lower levels of education themselves (Hart, Mcconnachie, Upton, &

Watt, 2008).

2.2.2.2.2 Health related pathways

Childhood SEP is often described in the literature as a predictor of health in adulthood which in turn could influence health management. There are a number of health-related pathways that might contribute to an association between childhood SEP and health management in adulthood. (It is worth noting that research from the 20th century predominantly uses father’s occupational grade to capture childhood SEP.) As presented in a model of the pathways between childhood and adulthood health in Kuh et al. (2004), childhood social class influences adulthood social class (both directly and indirectly via educational attainment) (discussed further in section 2.3.1) and the socioeconomic environment in adulthood affects health outcomes through adult health behaviours and underlying biological mechanisms; in addition, childhood SEP may affect adult health through its influence on childhood growth, development and the initiation of health behaviours.

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The literature consistently reports associations between childhood SEP and adult health, in terms of adult cardiometabolic and cardiovascular disease (Brunner, Shipley, Blane, Davey Smith, & Marmot, 1999; Clark, DesMeules, Luo, Duncan, & Wielgosz, 2009; Howe et al., 2010; Jones et al., 2015), obesity (Hart et al., 2008; Power et al., 2005a), lung function and respiratory disease (Galobardes, Lynch, & Davey Smith, 2004; Mann et al., 1992; Ramsay, Whincup, Lennon, Morris, & Wannamethee, 2011) and certain cancers (Davey Smith, Hart, Blane, & Hole, 1998; Galobardes et al., 2004). Childhood SEP has also been associated with adult self-rated health. Case et al. (2005) also reported that a more disadvantaged childhood social class was associated with a higher likelihood of being in poor or fair health at age 42 and that accounting for father’s social class and educational attainment explained nearly 20% of the variance in a multiply adjusted model of life course predictors of adult health in the NCDS.

The association between childhood SEP and adult health is likely to be explained by a number of alternative pathways. Results from NSHD also illustrated the need to consider different mechanisms contributing to the associations between childhood social class and adult health outcomes; Mishra, Black, Stafford, Cooper & Kuh (2014) reported that associations found between father’s social class and physical health (as measured by the physical functioning scale of the SF36,) at age 60-64 were explained by other adult health and social factors, including adult SEP, health and health behaviours.

There is a large body of literature describing the association between childhood socioeconomic circumstances and adult health behaviours (also shown in the chain of risk life course model (Kuh et al., 2004)), which may contribute to the pathway between childhood SEP and adult health management. There is consistent support for an association between manual childhood SEP and smoking in adulthood, particularly in women, in the Whitehall II British longitudinal study (Brunner et al., 1999), the Midspan family study (Hart et al., 2008) and in a cross-cohort study including both the NSHD and the NCDS (Power et al., 2005). Systematic reviews and large, national cohort studies have also presented evidence for associations between lower childhood SEP and lower levels of physical activity (Elhakeem, Cooper, Bann, & Hardy, 2015; Juneau, Benmarhnia, Poulin, Côté, & Potvin, 2015) and alcohol misuse (Gauffin, Hemmingsson,

& Hjern, 2013).

2.2.2.2.3 Summary

Whilst the literature gives a fairly comprehensive overview of the associations between childhood SEP and adult health, many of which can be used to infer the possible pathways between childhood SEP and health management in adulthood, there is a lack of literature considering the role of childhood socioeconomic circumstances in adults’

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approach to managing their health, particularly self-management and engagement with preventive health care. These gaps in the literature will be addressed by this thesis.

2.2.2.3 Childhood SEP and women’s health management

As one of the health challenges discussed in a later chapter (Chapter 5) is women’s response to symptoms in midlife, this section considers associations between childhood SEP and women’s experience and management of symptoms in midlife.

2.2.2.3.1 Childhood SEP and women’s management of symptoms in midlife

Childhood social class has been shown by one study to be associated with women’s management of the menopause. Lawlor, Davey Smith, & Ebrahim (2004) found that in a sample of N=4286 British women, selected from a variety of GP lists, those who reported a manual childhood social class were more likely to be currently taking or to have ever taken HRT, compared to women from higher social classes in childhood. These results were significant after adjusting for age, adult social class and other measures of women’s health in adulthood. However, this study did not account for symptomatology in midlife (the role of symptoms will be discussed further throughout this chapter), so it is unclear whether HRT use in this group was a result of more frequent or more bothersome symptoms or if it reflects a more medicalised approach to managing symptoms. Whilst the research on childhood exposures and management of women’s symptoms experienced in midlife and throughout the menopausal transition is minimal, there is currently an absence of research that considers the role of symptoms in mediating the associations between childhood exposures and management of symptoms in midlife.

2.2.2.3.2 Pathways between childhood SEP and women’s management symptoms in midlife

Women’s experience of symptoms in midlife could explain or contribute towards the pathway between childhood SEP and how women manage their health throughout the menopausal transition. Previous research has reported an association between father’s social class and women’s symptomatology in midlife. Women whose father had lower social class reported more severe symptoms (Mishra & Kuh, 2012), which may influence how women respond to their symptoms. Moreover, timing of the menopause has been associated with childhood socioeconomic circumstances. Women from a manual social class in childhood and those who reported indicators of childhood deprivation, such as having no bathroom, sharing a bedroom and having no access to a car, experienced a significantly earlier menopause than women from other social classes (Lawlor, Ebrahim,

& Davey Smith, 2003), although the difference was small (0.68 years). Further analysis reported that the association between childhood SEP and timing of the menopause was,

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in part, attenuated by adulthood health behaviours and BMI, indicating some of the pathways between childhood social class and women’s health outcomes in midlife. In the NSHD, women whose father had a manual social class were also more likely to have an earlier menopause (Hardy & Kuh, 2005), which is likely to be associated with women’s experience and management of the menopause. Furthermore, a range of indicators of childhood socioeconomic disadvantage were associated with the experience of more psychological symptoms in midlife in women (Kuh, Hardy, Rodgers, & Wadsworth, 2002) (these symptoms will be included in the analysis for this thesis). The experience of more symptoms is likely to be associated with subsequent management of symptoms, thus demonstrating a possible pathway between childhood social class and health management, particularly relevant to women.