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Social Science & Medicine 49 (1999) 831845

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Understanding social variation in cardiovascular risk


factors in women and men: the advantage of theoretically
based measures
M. Bartley a,*, A. Sacker a, D. Firth b, R. Fitzpatrick b
a

Department of Epidemiology and Public Health, University College London, 119 Torrington Place, London WC1E 6BT, UK
b
Nueld College, Oxford, UK

Abstract
Many studies have attempted to understand observed social variations in cardiovascular disease in terms of sets
of intermediate or confounding risk factors. Tests of these models have tended to produce inconsistent evidence.
This paper examines the relationships to cardiovascular risk factors or two theoretically based measures of social
position. It shows that the strength of the relationships between social position and cardiovascular risk factors
varies according to the denition of social position which is used: there is a closer relationship between most health
behaviours and the Cambridge scale, an indicator of `general social advantage and lifestyle', whereas the Erikson
Goldthorpe schema, which is based on employment relations and conditions, is more strongly related to work
control and breathlessness. The implications of these ndings for understanding the conicting evidence in other
studies of health inequalities are then discussed. The paper concludes that inconsistencies between studies may be in
part due to unexamined dierences between the conceptual bases of the measures of social position they use,
combined with a failure to make explicit the hypothetical mechanisms of eect. If neither the conceptual basis of the
measure of social position, nor the links between social position and health outcome tested in each study are clear,
inconsistencies between studies will be dicult to interpret, making policy recommendations highly
problematic. # 1999 Published by Elsevier Science Ltd. All rights reserved.
Keywords: Social inequality; Health related behaviour; Cardiovascular risk factors; Social classication scales

Introduction
Studies of social variation in cardiovascular disease
have used a variety of measures of social position. In
most cases, the theoretical basis for these measures is
discussed only briey or not at all. While social variation is found regardless of the measure used

* Corresponding author. Tel.: 0171-391-1707; fax: 0171-8130242.


E-mail address: mel@public.health.ucl.ac.uk (M. Bartley)

(Gregorio et al., 1997; Marmot et al., 1997), adjustment for potential confounders and mediating factors
have tended to produce inconsistent evidence. This
paper investigates the relation to cardiovascular risk
factors of two validated measures of social position,
one based on employment relations: the Erikson
Goldthorpe schema; and the other based on general
social advantage and lifestyle: the Cambridge scale. It
describes the relationship of these measures of social
position to cardiovascular risk factors and goes on to
examine the implications of this nding to understanding the conicting evidence in other studies of health

0277-9536/99/$ - see front matter # 1999 Published by Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 1 9 2 - 6

832

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

inequalities. The paper asks: might we move further


towards understanding the causal pathways between
social circumstances and health if we distinguish dierent dimensions of inequality, use validated measures of
these, and include in our causal models only those
mediating or confounding factors justied by explicit
hypothetical pathways?
At present, studies of social variation in cardiovascular disease tend to dene social position in a number
of dierent ways, and include adjustment for a variety
of confounders such as health behaviours and physiological risk factors (Bruce et al., 1993; Mackenbach,
1992; Pocock et al., 1987; Power and Matthews, 1997;
Stronks et al., 1997b; Wannamethee and Shaper,
1997). There is relatively little discussion of the degree
of consistency between the size of the social eects in
studies which use dierent measures of social position,
or of variation between studies in the eect of adjustment for confounders. A result of this is that it is dicult to be clear about the nature of the evidence on
either the degree or the causes of health inequality for
purposes of policy discussion. Simple questions such as
`how great is the eect of social inequality on heart
disease' and `what are the best policies for reducing
this?' therefore receive vague answers.
The inconsistencies in denition and use of measures
of social position have recently been discussed by
Krieger and colleagues (Krieger and Fee, 1994, 1996;
Krieger et al., 1997). Krieger and her colleagues
suggest that the concept of `social class' be used to
refer to the underlying structure of industrialised societies, in which many social and economic characteristics such as employment conditions, levels of pay,
housing quality and prestige tend to vary together.
They point out, for example, that the term `socio-economic status', which is used very widely in the US and
UK literature to refer to social position, is itself a confusion of at least two concepts: economic circumstances (income and wealth) and prestige (status).
Although empirically related, these dimensions of
inequality are distinct, and further understanding of
the processes by which social variations in health
occur will not advance as long as investigators use
measures which conate them: ``understanding socioeconomic inequalities in health requires . . .conceptual
clarity abut what socio-economic parameters we are
measuring and why'' (Krieger et al., 1997, p. 344).
In this paper we suggest that researchers in health
inequality need to take two steps. The rst is to
acknowledge that social inequality has several dimensions and to adopt distinct measures of these (Krieger
et al., 1997). The second is to state more clearly the
nature of aetiological hypotheses which link specic
dimensions of social position and circumstances to
health. Instead of adopting the policy of indiscriminate
measurement of social position combined with multiple

simultaneous statistical adjustment which treats a number of more or less generally agreed variables as confounders, researchers need to consider the reason for
each adjustment and interpret the dierences between
models including each set in the light of such aetiological hypotheses (MacIntyre, 1997).
The traditional method of measuring the relationship between social position and health has been to
use classications of individuals into groups (social
classes or socio-economic groups) based on their occupations and, in the case of women without paid
employment, the occupation of husbands or male partners. In public health and epidemiology in the UK, the
classication used has been the Registrar Generals'
(RG). The criteria on which this classication is based
have never been made explicit, and no validation work
has been undertaken. There are at present two theoretically based measures of social position in common
use in the UK which operationalise dierent dimensions of inequality. The rst of these is the Erikson
Goldthorpe class schema (EG), described by its originators as a measure of the nature of employment relations and conditions (Erikson and Goldthorpe,
1993). This has already been shown to be related to
mortality in working-age men (Bartley et al., 1996;
Fitzpatrick et al., 1997), and is the basis for the new
social classication to be used in the census of 2001
(Rose and O'Reilly, 1997). The other is the Cambridge
scale (CS), described as a measure of shared lifestyle
based on general social and material advantage
(Blackburn and Marsh, 1991; Prandy, 1990; Stewart et
al., 1980) integrating concepts of both class and status
(Marsh and Blackburn, 1992, pp. 187189) and reecting ``the. . .choice of people with whom to interact
socially on an equal basis'' (Blackburn and Prandy,
1997, p. 502). In this paper the term `EG class' is
used to refer to an individual's social position based
on employment relations and conditions (EG
schema): it does not imply that we assume the measure
represents a more fundamental aspect of social stratication than the Cambridge scale. To measure a more
directly `material' dimension of social inequality, we
have also included in our analysis a commonly used
measure of material disadvantage: lack of ownership
of homes and cars.
Using these measures, we can compare the extent to
which behavioural and physiological risk factors are
related to shared lifestyle and cultural advantage independently of their relationships to working conditions
and material disadvantage. All results are presented
for men and women separately because it is known
that the relationships of risk factors to disease are not
the same in men and women (Barrett Connor, 1997).
Multivariate analysis is used to establish the independent relationship of each measure of socio-economic
position to each risk factor. We then discuss the impli-

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

cations of the results for research using multiple


measures of social position and circumstances in the
investigation of cardiovascular disease aetiology.
Data and methods
Sample
The data were taken from the 1993 Health Survey
for England (HSFE). The sampling procedure for the
HSFE was designed to achieve a representative sample
of approximately 17,000 adults over 16 years living in
private households. Survey interviews were attempted
with all adults in each selected household. The sample
considered here were men aged 2064 and women
aged 2059 years who were in paid employment
(n=8444). This age range was chosen because it
includes the ages at which men and women are most
likely to be employed: the ocial retirement age in the
UK being 65 years for men and 60 years for women.
Analysis of physiological measures was carried out on
all participants. Sample members who had pre-existing
heart disease or related diagnoses were excluded from
the analyses of all other risk factors, in case the presence of disease was itself acting as a determinant of
behaviour. In all, 714 individuals were excluded
because they had been diagnosed with heart disease or
diabetes, or they were being treated for hypertension.
This left 4137 men and 3593 women with sucient
data for this investigation.
Measurement of risk variables
Three categories of risk variables were considered.
These were behavioural factors (diet, smoking, drinking and sport participation), physiological risk factors
(hypertension, obesity, central obesity and breathlessness) and psycho-social factors (perception of social
support and work variety and control). A poor diet
was dened as one where the individual failed to adopt
at least three dietary habits consistent with government
recommendations. These habits were
.
.
.
.
.
.
.
.

eating wholemeal or granary bread


eating high-bre breakfast cereal
drinking semi-skimmed or skimmed milk
using soft margarine or other low-fat spreads
using oil not hard fat or lard for frying
reduced salt intake
eating fruit at least once every day
eating vegetables or salad at least once every day

Smoking was categorised into those who were current


smokers and those who were not. This is a more
simple measure than that used in many aetiological

833

studies, but is consistently shown to be the measure


most strongly associated with social position cross-sectionally (Bennet et al., 1995; Marmot et al., 1991;
Woodward et al., 1992), and to be the most powerfully
predictive of cardiovascular mortality (Prescott et al.,
1998; Tunstall et al., 1997). Alcohol consumption was
assessed in both men and women by comparing those
who were `light drinkers' (between 1 and 2.5 units per
day) on a regular basis (more than ve times a week)
with those who did not drink. This level of consumption has been adopted in the light of evidence that
light regular alcohol consumption is associated with
lower levels of heart disease (Marmot and Brunner,
1991; Royal College of Physicians et al., 1995) and
that those who rarely drink and those who binge drink
have an increased risk of heart disease compared to
the regular light drinkers (Marmot et al., 1981). The
nal behavioural characteristic was participation in
sport. Those who participated in at least one session
lasting 30 minutes or more per week were compared
with those who failed to take part in any exercise.
Hypertension was considered to be present where
either systolic blood pressure exceeded 159 mmHg or
diastolic pressure exceeded 94 mmHg, or where a participant was on medication for high blood pressure.
Men and women were classied as obese if their Body
Mass Index (BMI) (weight in kilograms/height in
metres2) exceeded 30. Central obesity was dened as
waist circumference divided by hip circumference; if
this was 0.95 or more for men and 0.85 or more for
women, the participant was assessed as centrally obese.
Breathlessness was graded according to the MRC respiratory questionnaire: participants were classied as
breathless if they had been coded with levels 1 (short
of breath when hurrying on level ground or walking
up a slight hill) or 2 (short of breath when walking at
own pace on level ground or at the same pace as
people of one's own age).
Measures of perceived social support, work control,
and work variety were derived by dichotomising scores
on composite variables for each of these. The composite variables were summed scores from questionnaire
items relating to the three constructs. Social support
was assessed by the responses to seven items on the
quality of the relationship with family and friends such
as the amount of acceptance, encouragement, love and
care provided by people known to the participant.
Work control was assessed from the answers to two
items about decision latitude and work variety from
four items about the amount of initiative, repetition
and opportunities for learning new skills in the workplace. The dichotomised scores separated those with
low levels of control, variety and social support from
those with moderate or high levels. Low levels of control, variety and social support were identied for
24%, 40% and 15% of the population respectively.

834

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

Measurement of social position


The EriksonGoldthorpe schema was developed as
part of a comparative study of social mobility patterns
in industrial societies (Erikson and Goldthorpe, 1997).
A similarly based measure has been used in the work
of the European Union's working group on Socioeconomic Inequality in Health (Cavelaars et al., 1998b;
Kunst, 1997; Mackenbach et al., 1997). The schema
distinguishes between those who are employers or
employees, perform manual or non-manual work, and
have a service versus labour form of employment contract. A service contract is characterised as one of
trust, with higher levels of autonomy and job security,
with the possibility of advancement through a clear
career structure. A labour contract is one where supervision is tighter, and motivation to work is gained
through the exchange of wages for set amounts of
work. Levels of job security are lower, and there is no
career structure.
The Cambridge scale is based on the analysis of
friendship and marriage choices, judged to be the most
accurate indication of perceived and experienced social
distance between members of dierent occupations.
Originally, respondents to surveys were asked the occupations of ve friends (more recently the occupations
of wives have also been used), and the number of
times each pair of occupations cited each other was
treated as a measure of social distance. These values
were entered into a multi-dimensional scaling analysis,
yielding one major factor: the score of each occupation
on this factor is the Cambridge score. The advantages
of the method, in the eyes of its originators, is that it
does not force individuals into discrete groups
(``classes''), is based on concrete social experience, and
forms a clear hierarchy.
Traditionally, measures of social position in women
have relied on the partner's occupation (the conventional approach) although, more recently, it has been
considered more appropriate to classify women by
their own occupation (the individual approach). In the
analysis presented here, employment relations and conditions are measured by the EriksonGoldthorpe (E
G) schema using the individual approach, on the
grounds that there is little plausibility in an aetiological
pathway between an individual's risk behaviour and
their partner's employment conditions. Where women
were in employment at the time of the survey their E
G class was allocated on the basis of their present occupation, and where they were out of the labour force
it was allocated on the basis of their most recent occupation. A six-category EG system (Erikson and
Goldthorpe, 1997) was adopted. These categories are
dened as: the higher professional class comprising
those in higher professional and administrative occupations, together with proprietors and managers of

Table 1
Distribution of social position variables in sample from the
Health Survey for England

Maximum n
Age in years
EG class (%)
Higher professional
Lower professional
Routine non-manual
Self-employed
Skilled manual
Non-skilled manual
Cambridge scale
Mean
S.D.
Use of car (%)
Owner occupier (%)

Men

Women

4534
2064

3910
2059

21
19
6
15
23
17

10
23
26
6
6
19

40
18
92
83

42
17
90
82

large rms; the lower professional class, consisting of


lower professionals and administrators, higher technicians, managers of small rms and non-manual
supervisors; routine non-manual employees and service
workers; the self-employed, including small proprietors
and farmers; skilled manual workers, lower grade technicians and manual supervisors; and non-skilled manual workers (semi-skilled and unskilled) and
agricultural workers.
The Cambridge scale is used to operationalise general aspects of social advantage and lifestyle which
aect the extent to which members of dierent occupations associate together on the basis of equality.
Men's and women's occupations are rated separately.
The approach taken here was to consider the general
social advantage and lifestyle of an individual (and any
eect this might have on behaviour) as emanating
from both his/her own and his/her partner's occupation (Marshall et al., 1995). Hence the dominant
approach was adopted. Under this system, each individual was allocated the higher of their own or their
partner's Cambridge score if married or cohabiting.
Single persons living alone or as members of larger
household groups were allocated a score on the basis
of their own occupation. The dominant Cambridge
scores were ranked into sextiles for presentation of the
comparison with the six-category EG system.
However, in the statistical analyses, the household
Cambridge score is conceptualised as representing a
continuum of social advantage and is therefore treated
as an interval scale.
Material circumstances
Material circumstances were measured according to

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

835

housing tenure and car ownership: owning outright or


having a mortgage, and owning at least one car, were
regarded as more advantageous. The least advantaged
group were those renting their homes and not having
access to a car in the household.
Table 1 shows the distribution of the Erikson
Goldthorpe classes, the household Cambridge score,
and ownership of cars and homes amongst the men
and women in the survey.
Statistical analyses
When reporting the prevalence of risk factors in
men and women in dierent social positions, age
adjustment was carried out using the direct standardisation method, using all working-age men and women
in HSFE as the standard population. Multivariate statistical analyses were performed using the logistic regression option of SPSS for WINDOWS. In these
multivariate analyses the potential confounding eects
of age were taken account of by entering linear and
quadratic terms for age in the models (if related to the
outcome variable) before entering the predictor variables of interest. The sample population for the analyses has been described above. We have not analysed
social variation separately for either women or men in
dierent family types. It has been shown in our previous work (Bartley et al., 1999) that the presence or
absence of children, marital status, and attachment to
the labour force made no dierence to the strength of
the social gradient in health.
The EG schema is a categorical measure whereas
the Cambridge scale is continuous. There is a possibility of bias when comparing the two measures due to
the dierent degrees of freedom required when entering
them into models. When assessing the statistical signicance of dierences found among the six EG classes,
two dierent probability values were therefore calculated from the reduction in w 2, these corresponding to
the standard test on 5 degrees of freedom (df) and to a
more liberal test on 1 degree of freedom. The 5 df test
is a relatively insensitive instrument for detecting the
kind of monotone gradient across the EG classes that
might be expected. For example, those in non-skilled
manual occupations may have poorer physiological
proles (lung function or blood pressure for example)
than those in other occupations due to their harsher
working environment. The 1 df version, in eect
measures the signicance of a linear gradient across
the EG classes, with each class being implicitly
assigned a numeric value on the basis of the data. In
the example just quoted, if physiological factors are related to non-skilled manual work, then the 1 df test
operates as if non-skilled manual occupations were
given one value and all other occupations another.
Note that the 1 df test is slightly over-sensitive because

Fig. 1. Distribution of Cambridge scale with Erikson


Goldthrope class for men and women of working age.

the P value is calculated as if numeric values for the


EG classes were xed in advance (that is, we explicitly predicted the poorer physiological status on the
non-skilled manual workers); but it provides an approximate basis for informal comparison with the corresponding test of a gradient across CS scores. If the 1
df test is signicant but the 5 df test is not, we can
reasonably conclude that the model concerned is suggestive of a relationship with EG class, but that the
evidence is not very strong.
Results
Relationships of social position measures to risk factors
Fig. 1 shows that there is a high degree of overlap
between an individual's social position measured
according to the EG class schema or the Cambridge
scale (Spearman rank correlation coecient = 0.75).
Nevertheless, there is a substantial minority who are
discordant on the two measures. For both men and
women, there was substantial agreement at the two
ends of the scales but less agreement in the middle.
Individuals in routine non-manual and self-employed
occupations were categorised across the full range of
the CS. Men in routine non-manual work enjoyed a
higher level of general social advantage, on average,
than self-employed men. This pattern was not repeated
for women. Self-employed women had a higher level
of general social advantage, on average, than women
in routine non-manual occupations. This may be
because the ratio of men in higher routine non-manual
occupations to lower routine non-manual occupations
was twice the size of that found for women.
Tables 2 and 3 show the relationship between the
measures of social position and material circumstances and the risk factors for men and women, respectively. For men, the EriksonGoldthorpe schema,
the Cambridge scale, and the material measures were
signicantly related to most of the behavioural, phys-

% Breathless

% Centrally obese

% Obese

Physiological
% Hypertensive

% Low work variety

% Low work control

Psychosocial
% Low social support

% No sport

% Regular light drinkers

% Smokers

Behavioural
% Poor diet

EG class
Cambridge sextile
7.78
7.85
23.28
22.96
4.18
3.14
53.38
50.21
13.58
11.67
8.24
8.49
19.90
18.98
12.82
11.63
12.38
11.20
18.01
16.62
9.04
8.72

12.32
10.20
4.63
4.71
9.86
14.57
13.35
11.73
13.30
12.76
16.26
14.34
8.12
8.68

Lower professional
2

6.64
5.50
18.01
16.05
3.61
3.60
48.28
49.79

Higher professional
1

10.75
14.75
10.35
14.11
26.15
23.53
15.59
10.38

14.26
14.66
25.69
17.01
43.57
29.05

13.11
9.49
27.04
23.84
2.21
2.62
61.08
60.00

Routine non-manual
3

12.63
14.88
15.02
12.26
24.16
21.44
13.27
11.98

14.80
13.46
6.51
18.28
31.07
35.89

11.63
13.63
29.65
28.66
1.79
4.38
65.38
59.69

Self-employed
4

14.08
12.60
13.27
15.81
22.24
24.53
11.89
12.84

14.67
14.77
23.47
23.40
34.80
36.48

13.42
12.82
32.67
36.56
2.03
1.35
61.89
64.15

Skilled manual
5

Table 2
Age adjusted proportions in EG classes, Cambridge sextiles and deprivation indices of risk factors for heart disease in men

16.07
18.65
12.85
12.85
23.06
25.12
14.52
14.82

20.22
23.11
48.55
39.69
68.57
60.22

14.26
16.62
36.95
38.62
2.22
1.63
64.27
65.02

Non-skilled
6

13.63
13.70
12.76
12.79
19.62
19.96
9.76
10.54

13.39
13.74
16.55
16.94
28.66
29.43

9.34
10.21
23.49
25.24
2.98
3.04
55.60
56.57

Owner occupied
Car

14.44
14.13
15.36
15.51
24.50
25.18
17.34
16.33

20.65
22.59
27.41
33.84
44.21
51.71

20.08
19.59
45.38
47.12
2.97
1.76
67.62
67.74

Rented home
No car

836
M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

% Breathless

% Centrally obese

% Obese

Physiological
% Hypertensive

% Low work variety

% Low work control

Psychosocial
% Low social support

% No sport

% Regular light drinkers

% Smokers

Behavioural
% Poor diet

EG class
Cambridge sextile
4.36
6.43
20.19
24.53
6.52
5.73
54.95
55.95
7.73
7.48
10.66
21.65
22.15
40.11
9.08
7.20
11.72
8.28
7.89
5.62
14.60
13.41

8.41
8.26
3.97
11.93
13.31
23.29
7.16
9.64
12.38
10.58
8.72
8.38
10.03
13.96

Lower professional
2

1.67
2.27
19.25
15.37
7.45
8.15
52.12
51.46

Higher professional
1

8.83
8.29
12.97
13.43
8.94
9.53
18.89
17.48

11.15
12.13
38.24
25.11
62.57
43.06

7.76
5.27
48.95
24.48
4.13
3.17
59.48
58.46

Routine non-manual
3

6.34
7.74
14.98
16.10
14.57
9.32
18.27
20.56

8.84
8.52
3.59
24.45
50.04
53.91

8.84
7.31
29.05
27.96
4.23
2.86
63.50
62.29

Self-employed
4

10.58
8.54
15.82
16.44
15.23
14.58
18.08
18.95

12.13
13.26
34.00
41.35
55.85
66.26

9.64
10.58
36.78
33.34
1.82
4.92
64.11
63.73

Skilled manual
5

Table 3
Age adjusted proportions in EG classes, Cambridge sextiles and deprivation indices of risk factors for heart disease in women

10.12
10.54
21.04
21.34
18.41
18.34
23.16
23.19

14.43
14.06
49.83
45.63
79.63
76.83

12.67
13.04
39.68
41.66
3.09
2.83
69.82
68.64

Non-skilled
6

8.72
8.68
12.86
13.54
9.98
10.55
16.06
16.72

9.31
9.81
26.69
27.11
47.27
47.84

5.98
6.75
23.81
25.11
4.65
4.85
58.54
59.06

Owner occupied
Car

9.21
9.80
22.47
23.22
18.74
18.19
25.81
26.57

16.96
18.68
31.05
31.45
58.61
61.70

13.70
12.44
43.05
45.54
5.17
3.16
65.91
66.80

Rented home
No car

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845


837

838

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

iological and psychosocial risks for heart disease:


generally, risks were higher in those with less favourable employment conditions and lower levels of general social advantage and material living standards.
Exceptions were that neither EG class nor cars and
tenure were related to obesity or high blood pressure, the CS score was not related to obesity, and
cars and tenure were not related to regular light
drinking.
The social gradient for diet, smoking, social support,
hypertension and central obesity appear steeper based
on the CS score of the household than on the EG
classes of individuals. However, in most cases there
was not a smooth increase over the Cambridge sextiles
in the proportion of men aected by the risk factors.
An example of this can be seen in the proportion of
men protected by regular light alcohol consumption in
the Cambridge sextiles. This suggests that more than
one aspect of social position may be related to drinking behaviour. The unique contribution from each
measure of social circumstances to an understanding
of the distribution of the risk factors for heart disease
will be returned to again later.
Work control and variety did not show a steady gradient across the EG classes (Table 2). Here there was
a clear contrast between the dimensions of employment
conditions and general social advantage. The prevalence of low work control rose from 4.6% in EG
class 1 (higher professional and managers in large
rms) to almost 26% in routine non manual workers.
Not surprisingly, far fewer self-employed men reported
low work control. More surprisingly, only 23.5% of
skilled manual men reported low work control, a
slightly lower prevalence of low control to that found
among non-manual men with routine jobs. Unskilled
manual workers were almost twice as likely as routine
non-manuals to report low work control. In contrast,
work control was more smoothly graded up the scale
of general social advantage. A similar pattern was seen
for work variety. It is of note that self-employed men
may have control over their work but they do not
have the same amount of variety in their work as the
professional men. The self-employed are also more
likely to report having a poor diet, smoking and taking
little exercise. Thus the potential protective eects of
work control in this group (a psychosocial risk factor)
are combined with higher levels of risk derived from
behavioural factors.
The relationships between car and home ownership
and the various outcomes were remarkably similar.
This could not be attributed to the characteristics of
those individuals who were without a car and in rented
accommodation. The only exceptions were for work
control and variety where steeper gradients were found
for car ownership than for home ownership. It may be
that this was due to reverse causation. Ill-health may

contribute to men ceasing to drive and also to their


employment in less physically arduous jobs such as
routine non-manual clerical work.
Table 3 shows similar patterns of relationships for
women. The CS and EG classes were signicantly
related to all the behavioural, physiological and psychosocial outcomes except hypertension. Material circumstances were related to all outcomes except
regular light drinking and hypertension. The proportions of men and women reporting behaviours
and perceptions which may place them at risk for
heart disease can be directly compared. Consistent
with the higher levels of heart disease in men than
women, men were more at risk than women of engaging in risk behaviours. Men's diets were poorer than
women's across the whole social spectrum. Rates of
smoking cigarettes were similar for men and women
except at the extremes of the CS scale where men
smoked more than women. The majority of people in
the survey did no sport, but women were less likely
to do so than men. The social gradient in regular
light drinking was steeper for women than men, with
women in positions of advantage more likely to be
protected than their male counterparts. The ndings
for the physiological and psychosocial risks were
more mixed. Fewer women were hypertensive or centrally obese, but more had a high BMI, despite their
better diets. Men's perception of their social support
network was poorer than women's. However, their
working environment was seen in a more positive
light with men reporting higher levels of control and
variety at work than women.
In women, social gradients were stronger using the
CS than the EG schema for smoking, drinking,
hypertension and obesity. Social support showed a
similar gradient to that seen in men. More surprisingly, perhaps, so did work control and variety: the
EG schema appeared to provide additional information about work control and variety in women as
it did in men. Control and variety in routine nonmanual occupations were lower than in skilled manual work. A very high proportion of women in nonskilled manual work, approaching 80%, reported low
variety.
As for men, the dierences in risk factor prevalence
between those with and without access to cars was
very similar to that between owner occupiers and those
in rented accommodation. However, cars and tenure
were more discriminating of work control and variety
in men than in women: for example 27% of women
with a car and 31.4% without reported low work control whereas the dierence for men was 16.5% versus
27.1%. Moreover, for women, there was no additional
risk of low work control and variety associated with
the lack of a car compared with the association with
housing tenure.

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

Relative importance of employment relations and


conditions and general social advantage
Univariate results show statistically signicant relationships between almost all of the behavioural,
physiological and psychosocial risks and social position
using the Cambridge scale, the EriksonGoldthorpe
schema, and cars and tenure amongst men and
women. Based on the chi-square statistic, CS appeared
more strongly related to the behavioural measures and
the EG scheme was more strongly related to the
work characteristics. The steeper social gradients using
the CS could have been artefactual to the method of
examining the odds ratio between the most advantaged
and the least advantaged possible (100 CS units) and
comparing this to the unequal groups provided by the
EG classication. Following the comparative strategy
adopted in Marmot et al. (1997), all three of the socioeconomic position variables were entered into multivariate models with each of the risk factors as the outcome. The chi-squared measures and P values are
reported for each variable when it has been entered
last into a model.
Table 4 shows the univariate and multivariate outcomes for men. After general social advantage and
cars and tenure were entered into the model, the dierences in odds ratios between EG classes for most risk
factors were greatly reduced. The odds ratios for
sports participation, work control and variety, and
breathlessness, although attenuated, remained high and
were still statistically signicant. The odds ratios for
social support and central obesity were reduced to
values of little substantive value and no statistical signicance. In contrast, although the odds ratios for
light drinking were no longer statistically signicant in
the multivariate case using the 5 df test, their values
were unaected by controlling for CS and cars and
tenure. When the chi-squared tests were repeated on
the basis of one degree of freedom, so as not to disadvantage the EG schema, then there was some weak
support for the relationship between light drinking and
the EG.
The odds ratios associated with non-ownership of
cars and homes were, by contrast, considerably less
reduced by simultaneous adjustment for Cambridge
score and EG class and remained signicant in all
cases except for central obesity. The odds for work
control and variety suered greater attenuation than
for the other outcomes but lack of the use of a car was
still independently related to control and variety.
Adjustment for material disadvantage and EG class
only explained away two of the ten signicant relationships of general social advantage to risk factors: those
for breathlessness and frequent light drinking. The
independent eect of CS was largely unaected in the
case of low social support, high blood pressure and

839

central obesity. Odds ratios for the other risk factors


were attenuated but remained statistically and substantively signicant.
The results of the univariate and multivariate analyses for women are shown in Table 5. General social
advantage (CS) was signicantly related to all but
hypertension in univariate analysis: after adjustment
for employment conditions and material circumstances,
CS relationships with social support and breathlessness
were greatly reduced and no longer statistically signicant (see Table 5). Other odds ratios were less severely
attenuated and remained statistically signicant. As in
men, work control, variety and breathlessness showed
an attenuated but statistically signicant relationship
with EG class. There was some weak evidence
suggesting that EG class was still independently related to a poor diet, sports participation, light drinking
and central obesity. The eects of E-G class on smoking, social support and obesity were no longer of substantive or statistical importance once other measures
of social position were included in the model.
Consistent with the small dierences in prevalence seen
in Table 2, cars and tenure were not related to work
control or variety in women after adjustment (in contrast to what was found for men). All other relationships were attenuated but only sports participation was
no longer of statistical signicance.
Discussion
In the 1993 Health Survey for England we have
shown that measures of social position which are explicitly based on dierent theoretical approaches to social
stratication are not related in the same way to dierent risk factors for cardiovascular disease. In many
cases, risk factors have independent relationships to
more than one dimension of inequality. Shared lifestyle
associated with dierential social advantage was
strongly related in the expected mannerhigher levels
of advantage associated with lower levels of riskto
most of the behavioural and psycho-social risk factors,
and this relationship was not an artefact of the co-variation of this measure with employment conditions or
material disadvantage. Material disadvantage was also
independently related to the majority of the risk factors. Social class based on employment relations and
conditions was independently related to work control,
work variety and breathlessness even when the most
conservative method, with 5 df, was used, and to the
majority of risk factors using the weaker criterion of a
single degree of freedom.
The use of distinct measures of dierent dimensions
of social position and circumstances allows us to
acknowledge that social inequality is a complex and
multi-faceted phenomenon, and to begin to operatio-

Smoker

Non-light drinker

n
Univariate
3850
3851
3856
Cambridge scale
Odds ratio/unit change
1.021
1.024
1.013
Odds ratio/100 units
7.92
10.49
3.67
w2
47.55
125.40
5.88
P (df=1)
< 0.0001 < 0.0001
0.02
EG schema
Higher professional
1.00
1.00
1.00
Lower professional
1.20
1.48
1.14
Routine non-manual
2.31
1.88
1.17
Self-employed
1.91
2.05
2.06
Skilled manual
2.12
2.42
2.93
Non-skilled manual
2.22
2.90
1.71
w2
36.18
97.54
14.50
P (df=5)
< 0.0001 < 0.0001
0.01
Deprivation indicators
No car
1.31
1.83
1.39
Rented accommodation
2.05
2.36
0.84
w2
42.06
135.75
0.77
P (df=2)
< 0.0001 < 0.0001
0.68
Multivariate
Cambridge scale
Odds ratio/unit change
1.015
1.014
1.001
Odds ratio/100 units
4.44
4.14
1.09
w2
11.67
21.99
0.01
P (df=1)
0.0006 < 0.0001
0.90
EG schema
Higher professional
1.00
1.00
1.00
Lower professional
1.00
1.24
1.14
Routine non-manual
1.65
1.32
1.43
Self-employed
1.28
1.41
2.07
Skilled manual
1.25
1.44
2.90
Non-skilled manual
1.12
1.45
1.71
w2
6.23
6.89
8.80
P (df=5)
0.28
0.23
0.12
P (df=1)
0.01
0.009
0.003
Deprivation indicators
No car
1.15
1.58
1.24
Rented accommodation
1.87
2.11
0.75
w2
27.64
90.68
1.04
P (df=2)
< 0.0001 < 0.0001
0.60

Poor diet
3831
1.017
5.58
42.47
< 0.0001
1.00
1.24
1.43
1.47
1.36
2.03
23.70
0.0002
1.46
1.54
25.65
< 0.0001
1.017
5.42
19.31
< 0.0001
1.00
1.02
0.99
0.94
0.77
1.01
5.25
0.39
0.02
1.30
1.39
13.44
0.001

1.015
4.44
59.95
< 0.0001
1.00
1.29
1.68
2.23
1.85
2.19
77.31
< 0.0001
1.42
1.54
35.36
< 0.0001
1.006
1.80
4.62
0.03
1.00
1.20
1.44
1.92
1.50
1.65
24.98
0.0001
< 0.0001
1.31
1.42
20.85
< 0.0001

1.35
1.15
7.41
0.02

1.00
2.10
7.67
1.30
5.35
15.41
298.76
< 0.0001
< 0.0001

1.012
3.16
9.22
0.002

1.98
1.51
51.92
< 0.0001

1.00
2.37
9.81
1.73
7.81
24.35
579.22
< 0.0001

1.045
84.77
285.22
< 0.0001

3803

1.45
1.29
16.84
0.0002

1.00
2.16
6.39
3.55
3.63
15.26
316.52
< 0.0001
< 0.0001

1.011
3.03
12.67
0.0004

1.93
1.68
75.77
< 0.0001

1.00
2.47
8.19
4.71
5.33
24.03
670.76
< 0.0001

1.042
62.18
366.48
< 0.0001

3780

0.99
0.96
0.12
0.94

1.00
0.84
0.65
0.71
0.73
0.83
4.93
0.42
0.03

1.011
3.03
7.24
0.007

1.06
1.13
0.98
0.61

1.00
0.93
0.79
0.92
1.03
1.24
4.90
0.43

1.008
2.14
7.32
0.007

3732

Low social support Low control Low variety High BP

3855

No sport

Table 4
Age-adjusted odds ratios for risk factors for heart disease in men by EG schema, Cambridge scale and deprivation indicators

1.21
1.14
2.83
0.24

1.00
0.89
0.62
1.03
0.84
0.77
6.35
0.27
0.01

1.005
1.72
2.09
0.15

1.20
1.16
3.17
0.20

1.00
0.95
0.71
1.20
1.02
0.98
5.31
0.38

1.004
1.45
2.06
0.15

4143

Obese

1.15
1.13
2.23
0.33

1.00
1.11
1.32
1.33
1.07
1.02
5.80
0.33
0.02

1.014
4.06
16.27
0.0001

1.30
1.28
8.84
0.01

1.00
1.28
1.80
1.85
1.69
1.75
28.79
< 0.0001

1.016
4.71
19.14
< 0.0001

3757

1.13
1.77
22.23
< 0.0001

1.00
1.12
2.00
1.59
1.32
1.57
11.62
0.04
0.0007

1.005
1.62
1.39
0.24

1.23
1.92
32.58
< 0.0001

1.00
1.21
2.31
1.87
1.66
2.15
31.32
< 0.0001

1.013
3.78
22.53
< 0.0001

4222

Central obesity Breathless

840
M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

Smoker
3418
1.013
3.78
16.50
< 0.0001
1.00
0.81
1.25
0.93
1.32
1.68
19.84
0.001
1.61
1.72
32.32
< 0.0001
1.006
1.82
1.56
0.21
1.00
0.77
1.08
0.79
0.99
1.10
5.47
0.36
0.02
1.49
1.61
22.23
< 0.0001

3438
1.013
3.82
42.18
< 0.0001
1.00
1.15
1.36
1.31
1.58
2.14
41.66
< 0.0001
1.30
1.29
15.71
0.0004
1.008
2.20
7.24
0.007
1.00
1.05
1.13
1.08
1.17
1.47
6.63
0.25
0.01
1.19
1.16
5.47
0.06

0.83
0.96
2.22
0.33

1.00
2.74
13.33
1.09
10.49
19.30
334.38
< 0.0001
< 0.0001

1.007
2.03
3.94
0.05

1.12
1.24
6.79
0.03

1.00
2.94
15.45
1.29
13.25
24.93
545.00
< 0.0001

1.035
31.82
211.51
< 0.0001

3388

1.10
1.04
0.73
0.70

1.00
1.57
8.46
5.43
5.41
15.43
377.49
< 0.0001
< 0.0001

1.012
3.22
12.88
0.0003

1.46
1.40
29.47
< 0.0001

1.00
1.78
10.77
7.07
8.13
25.00
765.32
< 0.0001

1.045
80.64
404.02
< 0.0001

3357

1.12
1.01
0.24
0.89

1.00
1.10
1.19
0.87
1.60
1.45
4.13
0.53
0.04

0.998
0.79
0.19
0.66

1.18
1.04
0.66
0.72

1.00
1.07
1.14
0.82
1.49
1.35
4.89
0.43

1.003
1.35
0.67
0.41

3243

Non light drinker No sport Low social support Low control Low variety High BP

n
Univariate
3436
3433
3436
Cambridge scale
Odds ratio/unit change
1.032
1.026
1.021
Odds ratio/100 units
24.29
13.46
8.08
w2
61.85
123.71
21.11
P (df=1)
< 0.0001 < 0.0001 < 0.0001
EG schema
Higher professional
1.00
1.00
1.00
Lower professional
2.12
1.13
1.07
Routine non-manual
4.12
1.51
1.77
Self-employed
4.63
1.65
1.85
Skilled manual
4.99
2.44
3.84
Non-skilled manual
7.02
2.83
2.62
w2
57.00
84.64
20.44
P (df=5)
< 0.0001 < 0.0001
0.001
Deprivation indicators
No car
1.29
1.89
1.51
Rented accommodation
2.21
2.01
0.93
w2
34.63
104.75
1.57
P (df=2)
< 0.0001 < 0.0001
0.46
Multivariate
Cambridge scale
Odds ratio/unit change
1.019
1.019
1.014
Odds ratio/100 units
6.89
6.82
3.94
w2
10.30
31.84
4.59
P (df=1)
0.001
< 0.0001
0.03
EG schema
Higher professional
1.00
1.00
1.00
Lower professional
1.66
0.94
0.96
Routine non-manual
2.70
1.00
1.31
Self-employed
2.84
1.03
1.71
Skilled manual
2.36
1.20
2.43
Non-skilled manual
2.74
1.12
1.54
w2
10.44
2.10
5.16
P (df=5)
0.06
0.83
0.40
P (df=1)
0.001
0.15
0.02
Deprivation indicators
No car
1.09
1.64
1.26
Rented accommodation
1.86
1.75
0.80
w2
17.51
60.08
1.09
P (df=2)
0.0002 < 0.0001
0.58

Poor diet

Table 5
Age-adjusted odds ratios for risk factors for heart disease in women by EG schema, Cambridge scale and deprivation indicators

1.40
1.63
26.07
< 0.0001

1.00
1.01
0.86
1.04
0.85
1.04
2.96
0.71
0.09

1.015
4.31
12.57
0.0004

1.57
1.84
45.88
< 0.0001

1.00
1.16
1.21
1.49
1.52
2.19
30.80
< 0.0001

1.019
6.49
43.73
< 0.0001

3556

Obese

1.32
1.54
12.97
0.002

1.00
0.78
0.72
1.10
1.14
1.24
12.29
0.03
0.0005

1.013
3.78
7.79
0.005

1.53
1.87
30.57
< 0.0001

1.00
0.89
0.99
1.52
1.92
2.40
51.60
< 0.0001

1.023
9.97
47.41
< 0.0001

3259

1.39
1.55
26.97
< 0.0001

1.00
1.48
1.84
1.76
1.56
1.99
11.55
0.04
0.0007

1.003
1.35
0.71
0.40

1.47
1.66
39.35
< 0.0001

1.00
1.54
2.00
1.91
1.85
2.61
33.65
< 0.0001

1.012
3.42
24.10
< 0.0001

3742

Central obesity Breathless

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845


841

842

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

nalise some of these dimensions. There is no reason to


believe that the same aspect of inequality is at issue for
all health outcomes, or for all social groups. For
example, in this paper `general advantage and lifestyle'
has been attributed not to the individual but to the
couple, by the use of the `dominance' method, taking
the highest score of two co-habiting partners, when
allocating a Cambridge score. The rationale for this
was that health-related attitudes and behaviour would
be more inuenced by shared than individual elements
of lifestyle. In contrast, it makes more sense to allocate
social class based on employment relations and conditions on the basis of the present or past occupation
of each individual, and use this as a measure of the
contribution of work related risks. These distinctions
are particularly useful in the analysis of health inequalities in women (Bartley et al., 1999).
One implication of these results is that studies
attempting to investigate pathways between social position and health might easily obtain contradictory ndings due to their choice of indicators of social position.
At present we have, in use in health studies, measures
of social position based on any of the following: `generalised social advantage and lifestyle' (Chandola,
1998), employment relations (Bartley et al., 1996;
Cavelaars et al., 1998b; Mackenbach et al., 1997), education (Cavelaars et al., 1998a; Elo and Preston, 1996;
House et al., 1994), income (Kaufman et al., 1998), occupational skill (Drever and Whitehead, 1997), `general
standing in the community' (Fox and Goldblatt, 1982)
and other prestige measures (Gregorio et al., 1997).
Should we necessarily assume that the intervening processes are the same? If the 'component causes'1
(Rothman, 1986) relating dierent dimensions of social
inequality to dierent health outcomes are not the
same, then measuring social position according to one
dimension and adjusting for intervening variables
appropriate for the pathways involved in another will
give a misleading picture of the processes at work. In
the analysis presented in this paper, when using a
measure based on employment relations and conditions
(EG class) rather than general social advantage
(Cambridge score), no relationship between social position and high blood pressure was observed in men.
Yet further contradictory results were obtained by
using cars and tenure. Light drinking was not related
to this measure of material circumstances although
social inequality was demonstrated using the other two
measures.
The interpretation of results will depend on identifying the aetiological pathways between aspects of social
position and circumstances and ill-health (Wohlfarth,
1
We are grateful to an anonymous referee for pointing this
out.

1997). For example our data showed that smoking was


related to general social advantage but breathlessness
was related to EG class. Given these distinct patterns,
it seems unlikely that the gradient in breathlessness
between EG classes, which operationalise employment
conditions, can be entirely attributed to smoking.
Breathlessness and smoking were both related to the
measures of material deprivation, independent of EG
class and Cambridge score. This may indicate that
damp conditions in rented accommodation (a material
factor) contribute to breathlessness, in addition to occupational exposures (another material factor) and
smoking (a behavioural factor), and that the psychological impact of material deprivation (a psycho-social
factor) increases the likelihood of adopting smoking as
a coping strategy, even allowing for cultural dierences
between levels of social advantage.
The adoption of clearer denitions of dierent
dimensions of social inequality together with a more
explicit model of aetiological pathways has implications for the interpretation of previous studies of the
social determinants of cardiovascular risk. In dierent
studies, adjustment for risk factors results in various
degrees of attenuation of relationships between social
position and cardiovascular disease outcomes
(Lundberg, 1991; Suadicani et al., 1997; Woodward et
al., 1992). When reviewing these, it is important to
consider both the conceptual basis of the social position measure and the postulated model of the aetiological pathways involved (MacIntyre, 1997; Stronks et
al., 1997a). The results presented here do suggest that
relationships between social position and cardiovascular disease morbidity and mortality may be more substantially attenuated by behavioural variables when
social position is dened in terms of `culturally' based
measures likely to index dierences in prestige and associated lifestyles. At present, there are two commonly
used measures which may be taken either explicitly or
implicitly to index `culture': these are the UK
Registrar Generals' classication said to be based on
`general standing in the community', and education
(Bucher and Ragland, 1995; Winkleby et al., 1992;
Wohlfarth, 1997). If these are good indicators of
shared culture, and the pathway between social position so dened and cardiovascular disease is one
which mainly involves culturally determined health related behaviour, we would expect to see a large eect
of adjustment for behavioural risk factors in models
using them as the measure of inequality. If, on the
other hand, social position is measured according to
employment relations and conditions or material disadvantage, we might expect a lesser degree of attenuation
by adjustment for behavioural variables.
Examples are indeed to be found in the literature of
these contrasting eects. For example Woodward et al.
(1992) reported on coronary heart disease incidence

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

according to occupational social class (Registrar


General's denition), level of educational attainment,
and housing tenure. All of these were signicantly related to mortality before adjustment for behavioural
risk factors, but dierences according to educational
level were by far the most attenuated by adjustment
for risk factors in multivariate analysis. Brunner et al.
(1996) reported similar ndings in respect of brinogen: the relationships with civil service grade and housing tenure survived adjustment for behavioural risk
factors whereas that with education did not.
Dierences between income groups in the incidence of
acute myocardial infarction in Finnish men (Lynch et
al., 1996) and all-cause mortality in the Americans'
Changing Lives Survey (Lantz et al., 1998) were not
explained away by behavioural risk factors, while
dierences between educational groups were.
This kind of strategy does not enable us to determine whether cultural dierences in behaviour are the
`best' explanation of health inequality. However, it
does enable us to understand why studies in which
social position is operationalised in terms of, say,
income or employment conditions, may show weaker
attenuation of eect after adjustment for behavioural
factors than those using a measure based on general
social advantage, `general standing in the community'
or other similar more `culturally' based measures. If a
`cultural/behavioural hypothesis', which has been
suggested as an explanation for health inequalities in
the UK (Department of Health and Social Security,
1980) is tested using a measure of social position based
on employment conditions, we do not know whether
low or high risk behaviour is being promoted by the
work situation, or whether people in certain work situations contingently happen to share a `cultural' background which inuences their behaviour. Some studies
which have operationalised social position in terms of
employment relations and conditions (Lundberg, 1991;
Woodward et al., 1992) have shown less attenuation
by behaviour than those in which social position is
measured according to `general standing in the community' (Pocock et al., 1987). A similar argument
applies when investigating whether control and variety
at work are an important pathway between social position and cardiovascular disease. Relationships between
incident cardiovascular disease and a social position
measure based on shared culture and lifestyle (such as
the CS) have been shown to be strongly attenuated by
behavioural variables (Chandola, 1998), but they might
be little aected by adjustment for work control and
variety. What would be shown in these examples is
that risk behaviour is not as important a link in the
process relating employment relations to disease as
work control and variety, and that these latter factors
are not as important in the pathway between more
general `cultural' aspects of social advantage and dis-

843

ease. What we can expect from any variable in this


sort of model depends upon its theoretical basis, and
the interpretations of statistical adjustments depend on
the nature of the aetiological hypothesis being tested.
Adopting this kind of explanatory strategy helps us
to interpret the dierent eects of adjustment for behavioural risk factors found in the Whitehall I study
(which reports that only a moderate amount of the
social variance in cardiovascular disease status is
explained by behaviour) and British Regional Heart
Study (in which class dierences in cardiovascular
events are entirely accounted for by adjustment for
health behaviours) (Marmot et al., 1978; Pocock et al.,
1987). If we accept the 1981 denition of the conceptual basis of the Registrar General's social classes as
``general standing in the community'' and Civil Service
grade as a better indicator of conditions and relationships in the workplace, it becomes clearer how these
dierences may occur. The inclusion of health behaviour in a statistical model including a measure of
`general standing in the community' (a CS type
measure with a strong cultural component) will result
in considerable attenuation of the univariate relationship between class and health. On the other hand, in
models where the measure of social position is a better
indicator of employment relations and conditions, the
inclusion of work control and variety will have a
greater eect whereas the introduction of behavioural
variables will have a weaker eect. By using measures
of social position with dierent theoretical bases, studies are in fact testing dierent hypotheses. Rather
than passing over the contradictory results which accumulate in the literature without comment, these can
be used to improve understanding, possibly by somewhat more sensitive methods such as path analysis.
Conclusion
We have argued here for the importance of clear
denition of social position and explicit formulation of
hypothetical pathways between social circumstances
and disease. This is supported by the dierences shown
in the relationships of social position to risk factors
when dierent measures are used. Eorts to understand social variations in major diseases such as cardiovascular disease will be more fruitful when their
measures of social position and of intervening explanatory variables are dened in terms of an explicit theory; and when possible confounders are also clearly
distinguished from variables lying on the causal pathway.
It may be that we shall never reach a `full' understanding of social variations in health: however, many
researchers and policy makers not unreasonably wish
the standard of evidence to improve. Attempts to

844

M. Bartley et al. / Social Science & Medicine 49 (1999) 831845

assess the relative importance of dierent explanations


for health inequality have suered from the use of
measures of social position and methods of analysis
based on dierent models of social structure and of
social and biological processes. This paper has shown
that use of a culturally based measure of social position, a measure of material disadvantage, and a
measure of social class based on employment relations
and conditions yield dierent relationships to behavioural and psychosocial risk factors for cardiovascular
disease, and has discussed the ways in which knowledge of these dierences helps us to understand some
of the diculties in interpreting research on health
inequality. The results from multivariate analysis of
social factors in cardiovascular disease need to be
interpreted in the light of the denition of the variables
used and the hypothetical processes relating them.

Acknowledgements
This research was supported by Economic and
Social Research Council Health Variations Programme
grant no. L12825001 and Medical Research Council
grant no. G8802774

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