We all hope for a long, healthy and fulfilling life with the opportunity to develop

inequality series ( )

Class of 2002:
our particular talents. Yet our chances are unequal, and vary depending on our social class. In the first of four sociological perspectives on inequality, Sarah Earle argues that, while we do need to develop an individualised, clientcentred approach, we must also be aware of how wider socioeconomic and cultural factors influence our practice.

an unequal future
I
Some of the most damning evidence was published in 1980 in The Black Report (Townsend et al, 1982), which showed that individuals in social classes V and VI (equivalent to classes 5, 6 and 7 in the NS-SEC) were more likely to have accidents, become ill, and die prematurely compared with those in classes I and II. The Acheson Report (Acheson, 1998) confirmed these findings and provided further evidence of a widening of class inequalities in health. The White Paper, Saving Lives: Our Healthier Nation (DoH, 1999a), established targets for the four priority areas of coronary heart disease and stroke, cancer, injury prevention a meritocracy and suicide, recognising the describes a society in c o n s i d e r a b l e which social rewards extent of inequalare allocated ity throughout Britain. The risk according to talent of heart disease but evidence suggests is, for example, that social rewards more than double for individuals vary considerably in the lowest according to social employment sectors (even after class. controlling for risk factors such as obesity and smoking) and rates of depression are twice as high for those who are unemployed, compared to those who are in paid employment (DoH, 1999a). Since the educational explosion of the 1950s and 60s, education has been regarded as one of the ways in which societies can become fairer and more meritocratic. However, a meritocracy describes a society in which social rewards are

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nequality is considered to be one of the universal features of all human societies. However, it is not equally distributed. Some theorists would argue that inequality is an integral, and even desirable, aspect of society whereas others would suggest that it is produced by the socio-economic organisation of society which unfairly advantages one group over another. Sociologists commonly use the term social stratification to describe the stable structures of inequality between groups that persist across different generations within any given society. The term social class is used to describe the type of stratification that exists within a modern indusTable 1 The National Statistics Socio-economic trialised society, such as Classification Britain. Although sociol1. Higher managerial & professional occupations ogists disagree on how, 1.1 Large employers & higher managerial exactly, social class occupations should be measured and 1.2 Higher professional occupations defined, in general 2. Lower managerial & professional occupations terms social class refers 3. Intermediate occupations both to material circum4. Small employers & own account workers 5. Lower supervisory & technical occupations stances - a persons 6. Semi routine occupations income and wealth - as 7. Routine occupations well as social status - a 8. Never worked & long-term unemployed persons social wealth and prestige. Since 1991, social class has been measured using the National Statistics Socio-economic Classification (NS-SEC). In the most commonly used version, there are eight classes, the first of which is sub-divided (see table if you 1). The NS-SEC considers an individuals occupa want to reach out beyond the clinic tion, as well as their employment status. believe the NHS should eradicate In 1946 the NHS was established to eradicate health inequalities inequalities in health in Britain. However, the exis see a link between communication tence of class inequalities soon became clear. and lifestyle

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allocated according to talent but evidence suggests that social rewards vary considerably according to social class. Table 2 Academic attainment in Year 11 by Parents Occupation in 2000
5+ GCSE grades A*-C Higher professional Lower professional Intermediate Lower Supervisory Routine 74 61 51 36 29 8+ GCSE grades A*-C 60 46 33 22 17 None reported

A good predictor
Recently published government statistics (DfES, 2001) suggest that social class is a good predictor of educational and occupational success. For example, statistics show that academic attainment - at all levels - is strongly related to social class and that young people whose parents are classified at Levels 1 and 2 are most likely to succeed (see table 2). Statistics also show that the number of 16 year olds not in education, training or employment varies considerably according to social class. For example, in 2000 only 2 per cent of 16 year olds with parents in NS-SEC 1 were not in education, training or employment, compared with 11 per cent of those in NS-SEC 7. There have been many competing explanations put forward to explain the persistence of class inequalities in health and education and, although explanations based on natural selection or innate intelligence have been popular in the past, materialist and cultural explanations are currently two of the most influential. Materialist and structural explanations focus on the material causes of inequality, such as living and working conditions, which are often seen as arising from the social structure the way in which society is organised. The poorest in society are seen to lack the material resources required to sustain health and achieve educational and occupational success. For example, within the context of health it is widely accepted that individuals with lower incomes tend to pay more for their food because they cannot physically Speech and access larger (usually out of town) retail outlets which language sell food more cheaply than local shops (DoH, 1999b). therapists The inverse care law also disadvantages those in lower socio-economic groups as statistics suggest that those have an living in the most deprived areas have the worst access important role to good quality health care services (see table 3). to play in Within the context of education, children from poorer socio-economic backgrounds are seen to lack the tackling and material resources they need to succeed. They are, for reducing example, more likely to live in overcrowded conditions, more likely to have a poor diet and will have inequalities in higher rates of illness, accident and disease; all of health and which impact upon childrens educational careers. education Children from poorer backgrounds are also more likely to have paid employment and more domestic responsibilities than children from more affluent backgrounds and are, therefore, less likely to stay on at school (DoH, 1999b). Cultural theories explain class inequalities in health and education by referring to the social processes that create cultural differences in attitudes and behaviour. With respect to health, the emphasis is often on lifestyle and risky health behaviours. Indeed, some sociologists believe that lifestyle is now the most important predictor of inequalities in health (see Crompton, 1993). Individuals from lower social classes are seen to engage in health behaviours that are not conducive to health. For example, they are more likely to smoke, and consume a diet that is high in fats and refined sugars (DoH, 1999a). With respect to education, children from poorer backgrounds are seen to lack the appropriate environment that is needed to foster educational success. For example, children from less affluent backgrounds are the least likely to have access to constructive forms of play, and will have poorer access to books, newspapers and the internet (see table 4).

2 2 3 4 7

Adapted from: (DfES, 2001).

Table 3 Cancer survival rates in affluent and deprived areas

Likelihood of surviving for 5 years (%) Affluent area Deprived area Mouth cancer Breast cancer Rectal cancer Skin cancer 55 79 41 81 44 72 35 75

Source: ONS (1999).

Table 4 Access to the internet by household

Social class Professional Intermediate Skilled non-manual Skilled manual Partly skilled Unskilled Source: ONS (2001). % of household with access 78 65 52 37 33 27

Table 5 Tackling inequality and social exclusion - some examples of good practice
The HANEN programme family-focused programmes for children and parents, for example It Takes Two to Talk, an intervention programme for parents and the You Make the Difference Parent-Child Interaction Programme. These programmes are especially suitable for children and families who are socially, geographically and economically disadvantaged (see www.hanen.org). Self-help and support groups such as those provided by Headway (www.headway.org.uk); Speakability (www.speakability.org.uk); and Sense (www.sense.org.uk). Sure Start programme in Keighley, Yorkshire a one-stop shop, including speech and language therapy, is being established to provide local support to a deprived community. Sure Start programme at Leigh Park, Havant toy libraries, reading schemes, play schemes and an outreach speech and language therapy service are planned.

Important role
Defining and measuring social class is a complex process and some of the key issues and debates have been highlighted here. However, it is clear that there is a strong relationship between social class and inequality; this has been recognised by Government, and strategies to combat inequalities in health and education have been implemented. Speech and language therapists have an important role to play in tackling and reducing inequalities in health and education and they are increasingly being expected to either coordinate or participate in multi-professional initiatives such as Sure Start (see www.surestart.gov.uk). Two of the most common problems for therapists (and other health professionals) are those of attendance and compliance, which often strongly correlate to class divi-

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..resources...resources...
sions. In response to this, some areas are addressing waiting list problems by refusing to accept clients after one missed appointment, regardless that this serves to perpetuate inequality and social exclusion. Under such circumstances, other methods of service provision may be more effective, for example, drop-in sessions, outreach services or comprehensive home programmes. Some of the ways in which therapists, and others, are working to tackle inequality can be found in table 5. There is no easy solution to reducing class inequalities in health and education and, although it is important for therapists to develop an individualised and client-centred approach to care, it is also important for the therapist to be aware of the wider socio-economic and cultural factors that affect practice. Dr Sarah Earle is Lecturer in Health Studies at University College Northampton. Address for Correspondence: Centre for Healthcare Education, Boughton Green Road, Northampton, NN2 7AL, e-mail: sarah.earle@northampton.ac.uk, tel. 01604 735 500.

Back to pen and paper

Do you need to record statistical information as you go? Developed for teachers, the AsPen may have applications for speech and language therapists. A traditional ballpoint pen, it also incorporates a barcode reader in the cap storing information for later transfer onto a computer. www.aspenonline.co.uk

Be alert
A system to protect people who have hidden medical conditions and allergies in the event of an emergency is reaching out to a wider audience. MedicAlerts body-worn bracelets or necklets, now available in different styles, are supported by a 24 hour emergency telephone service. Freephone 0800 581 420, www.medicalert.org.uk.

Deaf awareness
Bright new posters with BSL greetings signs and fingerspelling provide a focal point for BSL and Deaf Awareness. In addition, four wipe-clean mats cover greetings, questions, family and feelings respectively. A2 poster, 9.99 inc p+p Set of A4 Poster/Mats with separate guidance notes 8.99 inc p+p From The Forest Bookshop Warehouse, fax 01594 833446, www.ForestBooks.com Deaf Awareness and Sign Language Resources, see www.deafsign.com.

Bilingual resources
Urdu and Punjabi versions of the Afasic Glossary sheets and the Afasic leaflet Lost for Words have been developed as part of a Scottish Executive funded project to support bilingual children with speech and language impairments. The new year will see the launch of Punjabi and Urdu Fireman Sam and Dennis the Menace videos as a resource for speech and language therapists and teachers working with parents to support first language development. Details: Afasicscot@aol.com, tel. 01382 666560.

References
Acheson, D. (1998) Independent Inquiry into Inequalities in Health: A Report. London: Stationery Office. Crompton, R. (1993) Class and Stratification: An Introduction to Current Debates. Cambridge: Polity Press. Department for Education and Skills (2001) Youth Cohort Study: The Activities and Experiences of 16 year olds: England and Wales 2000. http://www.dfes.gov.uk/statistics/DB/SFR/ [Accessed 26 April 02]. Department of Health (1999a) Saving Lives: Our Healthier Nation. [Cmnd 4386]. London: The Stationery Office. Department of Health (1999b) Reducing Health Inequalities: An Action Report. London: The Stationery Office. Office for National Statistics (1999) Cancer Survival Trends in England & Wales 1971-1995. Deprivation and NHS Region. London: The Stationery Office. Office for National Statistics (2001) National Statistics Omnibus Survey. London: The Stationery Office. Townsend, P., Davidson, N. & Whitehead, M. (1988) Inequalities in Health. The Black Report/The Health Divide. London: Penguin.

Speech not babel

Text-to-speech software continues to improve in quality. The new Windows based Babel-Infovox Desktop offers full control of voice parameters such as volume, pitch and intonation, has a variable reading speed, and allows users to change the pronunciation of a word. Text can be read sentence by sentence or spelled out character by character. www.infovox.se

The Grid
Sensory software has released The Grid, a program that can be used as a predictive on-screen keyboard or as a communication aid with synthetic and pre-recorded speech, symbols and pictures and text. Autumn 2002 catalogue, tel. 01684 578868, www.sensorysoftware.com.

Therapy for deaf children

Three different versions of the parent booklet Speech and language therapy for deaf children are available to cover Scotland, Northern Ireland and England and Wales. Copies from the NDCS Freephone helpline, tel/text 0808 800 8880, open Mon-Fri, 10am-5pm.

Source database
A resource centre to meet the information needs of those working in health, disability and development worldwide has opened in London. The majority of materials on the on-line Source database are relevant to developing countries and not recorded elsewhere. Tel. 020 7242 9789 (ext. 8698), www.asksource.info.

Reflections
Does our caseload management style perpetuate or reduce health inequality? Do we facilitate access to services and resources? Do we recognise our role in tackling social exclusion?

Small sips
People with dysphagia who need to take small swallows to reduce their aspiration risk may benefit from a new type of cup. The PROVALE cup offers liquid, including some thickened drinks, by the teaspoon (5cc), has ample nose clearance to minimise head tilt and a broad base to reduce tipping and spilling. www.ReliantMedicalProducts.com

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002