SOCIAL STRATIFICATION

Basics of social stratification including history, concepts and social mobility. How social stratification affects oral health with evidence from literature.

1. 1 SOCIAL STRATIFICATION SEMINAR - 9

2. PROLOGUE A HAT’S JOURNEY……… In the early 1800s, hats were worn by those in high positions of society, with both wealth and power. There was a time when a hat can show people your place in society and dictate the level of respect you deserved. 2

3. CONTENTS SOCIAL STRATIFICATION ESSENTIALS 3 Definition History Principles Theories Types Social mobility SOCIO ECONOMIC STATUS SCALES Pareek Scale The Hollingshead B G Prasad’s Classification Kuppuswamy Classification The Wealth Index IMPACT OF SOCIO ECONOMIC STATUS ON HEALTH The Downward Drift Hypothesis Inverse Care Law The Black Report The Statistics Of SES In INDIA SES And Dentistry

4. DEFINITION “Society’s categorization of its people into rankings of socioeconomic tiers based on factors like wealth , income , social status , occupation and power .” 4

5. HISTORY In ancient times the societies could be divided into 2 groups. 5 HAVES W ere the upper classes, generally consisting of rulers, nobles, and priests. HAVE NOTS Made up mostly of merchants, artisans, and peasants In every ancient civilization, there was a large slave class at the bottom of the social structure

6. EGYPTIAN SOCIAL PYRAMID 6 BASED ON WEALTH, JOB AND EDUCATION

7. INDIAN CASTE SYSTEM Based on Karma (Work) and Dharma (Duty) 7

8. EUROPEAN FEUDAL PYRAMID Based on Aristocracy, politics and power Exchange of land for military services 8

9. PYRAMID OF CAPITALISM M eans of production and distribution are owned by private organizations. M ajority of the people are employed by the capitalists and they receive wages for the work that they do. 9

10. GLOBAL STRATIFICATION Social stratification on a global scale. Where social stratification draws attention to inequalities between smaller groups of people, global stratification draws attention to inequalities among all the countries 10

11. THREE WORLD MODEL Americans used three categories to stratify nations: first-, second- , and third-world. The First World included the U.S. and other capitalist nations. The Second World was made up of Communist nations. The Third World was everyone else. 11 So the categories were originally based on political ideology

12. GLOBAL STRATIFICATION - TODAY Global stratification categories today are high- , middle-, and low-income countries. 12 HIGH-INCOME COUNTRIES Approximately 25% of the nations in the world, hold most of the world's wealth. Three examples are the United States, the United Kingdom, and Japan MIDDLE-INCOME COUNTRIES The largest proportion of the world's nations - about 42% - falls into the middle-income category have average income and a standard of living . India, Egypt, and Mexico are examples of middle-income countries LOW INCOME COUNTRIES This is third category is which constitute people living with limited resources e.g. Bangladesh, Pakistan and Afghanistan etc

13. PRINCIPLES Social stratification is socially defined as a property of a society rather than individuals in that society. Social stratification is reproduced from generation to generation. Social stratification is universal (found in every society) but variable (differs across time and place). Social stratification involves not just quantitative inequality but qualitative beliefs and attitudes about social status. 13

14. THEORIES OF SOCIO ECONOMIC STATUS FUNCTIONALIST THEORY CONFLICT THEORY BY KARL MARX CONFLICT THEORY BY MAX WEBER 14

15. If all the positions that have to be filled in a society were equally important and everyone were equally capable of doing their jobs, there would be no need of stratification. But this is not the case . Some tasks are clearly more necessary than others , and some require a great deal more talent and training . Functionalist Theory ( Kingley Davis and Wilbert Moore) Social inequality is viewed as both necessary and constructive. 15

16. Stratification is the result of the struggle among people for scarce rewards and it persists in society because the “haves” are determined (exploiters) and equipped to preserve their advantage by dominating and exploiting the “have not's” (exploited). Class conflict over material privilege and power; those who own the means of production (capitalists or bourgeoisie) and those who sell their labour (worker or proletariat) Conflict Theory (Karl Marx) 16

17. People are motivated by self interest. Group conflict is a basic ingredient of society Those who do not have property can defend their interests less well than those who have property Economic institutions are of fundamental importance in shaping the rest of society Those in power promote ideas and values that help them maintain their dominance Conflict Theory (Max Weber) Only when exploitation becomes extremely obvious will the powerless show their dominance. 17

18. TYPES OF SOCIAL STRATIFICATION OPEN CLOSED 18

19. 19 Positions are awarded on the basis of merit, and rank is tied to individual achievements. Status is said to be achieved depending on what the individual accomplishes and what he can do by his own efforts. It provides people with an equal chance to succeed. OPEN SYSTEM (CLASS SYSTEM)

20. CLOSED SYSTEM (CASTE SYSTEM) Status is ascribed and determined at birth and people are locked into their parent’s social position. Ascribed characteristics determine social position, and individuals opportunities are limited accordingly. It is a rigid system. People are born into and spend their entire lives within a caste with little chance of leaving it 20

21. SOCIAL MOBILITY “The movement of an individual or group within a stratification that changes the individual’s or group’s status in society.” INDICATORS - POWER - WEALTH - PRESTIGE 21

22. TYPES OF SOCIAL MOBILITY Its of two Types • Horizontal mobility refers to movement within a social class or stratum. • Vertical mobility refers to the movement between social classes or strata. There are two kinds of vertical mobility: • Intragenerational mobility (within a person’s lifetime ) • Intergenerational mobility (several generations of one family) 22

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24. STRATIFICATION SYSTEM 24 Historically, four basic system of stratification can be distinguished: 1. Slavery - slavery is an extreme form of inequality, in which certain people are owned as property by others 2. Caste - A caste system is a social system in which ones social status is given for life. Caste system is a closed system . A person is born into a caste and remains there for life 3. Estates - were part of European feudalism wealthy and powerful families that ruled the country and owned the land 4. Class

25. CLASS SYSTEM Segment of society whose members hold similar amounts of resources and share values, norms and an identifiable lifestyle. Ownership of wealth together with occupation are chief bases of class differences. Classes differ from earlier forms of stratification in four main respects. 1 . Class system are fluid . 2 . Class positions are in some part achieved. 3. Class is economically based. 4 . Class system are large scale and impersonal. 25

26. Upper Class have great wealth, often going back for many generations; are recognized by reputation and lifestyle; have an influence on the society’s basic economic and political structures. Upper Middle Class is made up of successful business and professional people and their families; Have a college education, own property and have money savings; live comfortably in exclusive areas TYPICAL OF CLASS SYSTEM (FICHTER) 26

27. Lower- Middle Class shares many characteristics with the upper middle class but they have not been able to achieve the same lifestyle because of economic or educational shortcomings; usually high school or vocational education graduates with modest incomes; less professionals, clerical, and sales workers. Working Class is made up of factory works and other blue-collar workers. Lower Class are people at the bottom of the economic ladder. They have little in the way of education or occupational skills and are consequently either unemployed or underemployed. 27

28. SOCIO ECONOMIC SCALES Several methods or scales have been proposed for classifying different populations by socioeconomic status in India . 28 6 . Kuppuswamy scale 1976 7 . Shrivastava scale 1978. 8 . Bharadwaj scale 2001 Rahudkar scale 1960 B G prasad 1961 Udai Pareek scale 1964 Jalota Scale 1970 Pareek & Kulshrestha scale 1972

29. SOCIO-ECONOMIC STATUS SCALE (RURAL) By Udai Pareek (1964) 1. Caste 2. Occupation of head of family 3. Education of head of family 4. Level of social participation of the head of the family 5. Land holding 6. Housing 29 7. Farm power 8 . Material possessions 9 . Family

30. Five SES Categories Upper Upper Middle Lower Middle Upper Lower Lower 30

31. BG Prasad’s Classification 31 Based on per capita income of family CPI Index : A comprehensive measure used for estimation of price changes in a basket of goods and services representative of consumption expenditure in an economy is called consumer price index

32. 32 Modified BG prasad scale (proposed updating for January 2017). Both rural and urban community Based on per capita monthly income of the family. Simple to calculate

33. KUPPUSWAMY’S SCALE - 1976 33

34. KUPPUSWAMY REVISED SCALE 34

35. 35 ( Shaikh Z, Pathak R. Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9 .)

36. THE WEALTH INDEX The NFHS-3 wealth index is based on the following 33 assets and housing characteristics and is a composite measure of a household's cumulative living standard . The wealth index is calculated using easy-to- collect data on a household's ownership of selected assets, such as televisions and bicycles; materials used for housing construction; and types of water access and sanitation facilities. 36

37. The Hollingshead Four Factor SES SCALE The Hollingshead Four Factor Index of Socioeconomic Status is a survey designed to measure social status of an individual based on four domains: Marital status Retired/employed status Educational attainment Occupational prestige. 37

38. IMPACT OF SOCIO ECONOMIC STATUS ON HEALTH Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally are rooted in poor socio- economic conditions. Poverty is both a cause and a consequence of poor health. 38

39. MAIN EFFECTS OF POVERTY MALNUTRITION Malnutrition is the most common effect of poverty is malnutrition . This is especially seen in children of poor families. People living in poverty rarely have access to highly nutritious foods . 39

40. 40 HEALTH One of the most severe effects of poverty are the health effects that are almost always present. Diseases are very common in people living in poverty because they lack the resources to maintain a healthy living environment

41. EDUCATION Education is largely affected by poverty. Many people living in poverty are unable to attend school from a very early age. 41 Among the effects of poverty includes its impact on the economy of the country. Mainly, the number of people living in poverty influences employment rates heavily. Without an education, people are unlikely to find a paying job. ECONOMY

42. SOCIAL EFFECTS Many people living in poverty are homeless, which puts them on the streets. There is also a connection between poverty and crime. When people are unemployed and homeless and have nothing and no money to buy necessities, they may be forced to turn to theft in order to survive. 42

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44. THE DOWNWARD DRIFT HYPOTHESIS “A low social class position can have a negative effect on health” 44 But, poor health can also lead to a fall in social class position (the “Downward Drift” hypothesis) e.g. people who become alcoholics or drug addicts, people who cannot work because of bad health etc can fall into poverty.

45. JULIAN TUDOR – INVERSE C ARE LAW Why ? Because of barriers to access: Financial barriers e.g. unable to pay, cannot afford to take time off from work to see the doctor Geographic barriers e.g. too far to travel Cultural barriers 45 “People who need health services the most are the least likely to get them”

46. THE BLACK REPORT In 1947-48, the British Government established the NHS (National Health Service) and made access to medical services equal for all social classes. However, the social class gradient continues to persist in Britain (documented by the “Black Report”) 46 Can equal access to medical services eliminate the social class gradient? Thus proving that good health depends on more than just access to medical services

47. THE SOCIAL CLASS GRADIENT IN HEALTH It is NOT a statistical artifact: “No matter how “social class” is measured, the relationship between low social class and low health status is found in every country where health statistics are collected.” 47

48. SOCIO ECONOMIC STATUS AND DENTAL HEALTH 48 TOOTH LOSS DENTAL CARIES PERIODONTAL DISEASE ORAL CANCER UTILIZATION OF SERVICES

49. TOOTH LOSS Gilbert GH et al., 2003 Florida dental care study African Americans and persons of lower SES reported more dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them . [ Gilbert GH, Shelton BJ. Social determinants of tooth loss. Health Services Res 2003;38:1843–62 ] 49

50. DENTAL CARIES 50 Disease of poverty or deprivation Klein – lower SES – higher value for D & M, lower values of F. [ Klein.H , Palmer C.E.and Knutson J.W.; Studies on Dental Caries. I. Dental Status and Dental Needs of Elementary School Children ,The Journal of the American Dental Association and The Dental Cosmos , Volume 25 , Issue 10 , 1703 - 1705 ]

51. 51 Higher levels of parental education, in particular maternal education, may be associated with reduced risk of dental caries in preschool children. Keiko Tanaka- 2012 (Japan) [ Tanaka, Keiko,Miyake , Yoshihiro, Sasaki, Satoshi Hirota , Yoshio, Socioeconomic status and risk of dental caries in Japanese preschool children: the Osaka Maternal and Child Health Study ,Journal of Public Health Dentistry. Summer2013, Vol. 73 Issue 3, p217-223. 7p.]

52. Dutta 1965 * School going children of Calcutta Higher caries prevalence – lower class [ Dutta A. A study on prevalence of periodontal disease and dental caries amongst the school going children in Calcutta. J Indian Dent Assoc 1965; 37 : 367 ]* Kuriakose S et al., 1999** Pre-school children Ulloor Panchayat , Trivandrum, Kerala SES have a negative correlation with caries [S Kuriakose et al. Caries Prevalence and Its Relation to Socio-Economic Status and Oral Hygiene Practices in 600 Pre-School Children of Kerala-India, J Indian Soc Pedod Prev Dent 17 (3), 97-100. 9 1999 ]** 52

53. Sogi GM et al., 2002 2007 children of 13 to 14 years age Davangere town Dental caries experience and oral hygiene status of children - strongly correlated to socio-economic status. [ Sogi G.M.Bhaskar D.J , Dental caries and Oral Hygiene Status of school children inDavangere related to their Socio - Economic levels : AnEpidemiological study. Indian Soc Pedo Prev Dent December (2002) 20 (4) : 152-157] 53

54. PERIODONTAL DISEASES 54 Taani DQ et al., 2002 (Jordan ) Study conducted in 12-15 yr olds Low to moderate SES -( 347 public schools) High SES -(347 private schools) Public schools – increased bleeding on brushing & calculus - increased mean plaque & gingival scores - increased DMFT scores Private schools – low missing & high filled teeth surfaces [ TAANI, DQ. Relationship of socioeconomic background to oral hygiene, gingival status, and dental caries in children. Quintessence International. 33, 3, 195-198, Mar. 2002. ISSN: 00336572.]

55. Jagadeesan M et al., 2000 Study was conducted in Rural women of Pondicherry Concluded that illiteracy – significant risk factor for periodontal disease. [ Jagadeesan M, Rotli S, Danabalan M. Oral Health Status and Risk Factors for Dental and Periodontal Diseases Among Rural Women in Pondicherry.Indian J Community Med 2000;25:31-31 ] 55

56. Countries where the study was undertaken were classified according to level of development and income as defined by the World Bank Oral cancer risk associated with low SES is significant and related to lifestyle risk factors Conway DI et al ORAL CANCER [Conway DI, Petticrew M, Marlborough H, Berthiller J, Hashibe M, Macpherson LM. Socioeconomic inequalities and oral cancer risk: a systematic review and meta-analysis of case–control studies. Int J Cancer2008; 122:2811–2819] 56

57. 57 Thankappan K et.al* Found significance of social status and tobacco use and oral cancer in Kerala India They suggested that since tobacco use has been reported to be higher among the poor and less educated people [ Thankappan K R & Thresia CU.Tobacco use & social status in Kerala.Indian J Med Res. 2007 Oct;126(4):300-8 .]* Ramanathan ** A lso found most of the oral sub mucous fibrosis cases from India were also of low socioeconomic groups . [ Ramanathan K . OSMF - an alternative hypothesis as to its causes Med J Malaysia 1981;36:243-45 ]**

58. TRITHART 1968 ATTITUDE OF UNDERPRIVILEGED TOWARD HEALTH CARE Castration complex Contradiction of common sense Coming in crowds Last ditch effort If it hurts, you are a quack Unclean or dirty feeling Clinic built there not here Cold professional attitude Pain threshold Complication of unknown Pills don’t work Appointments not important Teeth lost anyhow Traditions 58

59. CONCLUSION Although many societies worldwide have made great strides toward more equality between The “haves” and the “have-nots in terms of the standard of living and life chances. Still there are large gaps between the wealthiest and the poorest within a nation and between the wealthiest and poorest nations of the world . Poverty is not an accident like slavery and apartheid ; it is man-made and can only be removed by the actions of human beings. 59

60. 60 THE SOCIAL CLASS GRADIENT IN HEALTH It is NOT a statistical artifact: No matter how “social class” is measured, the relationship between low social class and low health status is found in every country where health statistics are collected

61. REFERENCES 1) Grusky , David B. (2011). “Theories of stratification and inequalities” In Ritzer , George and J. Michael Ryan. The Concise Encyclopedia of Sociology. Wiley-Blackwell. pp. 622–624. Retrieved 23 June 2014 . 2) Park. Social sciences and health. In: Park. Social & preventive medicine. 2005. 23 rd ed.506-518 . 3) Mishra D & Singh HP. Kuppuswamy’s socioeconomic status scalr . –a revision. Ind J Pediatrics 2003 ; 70: 273-4. 4)Gilbert GH et al. Social determinants of tooth loss. Health Serv Res. 2003 Dec;38(6 Pt 2):1843-62. 5)Sanders AE et al. Social inequality in perceived oral health among adults in Australia. Aust N Z J Public Health. 2004 Apr;28(2):159-66. 6) Mahalakshmi Y et al. Estimation and comparison of significant caries index and the pattern of sugar consumption among 12 yr old school going children of two different socio economic strata. IJDR 2004 ; 15(1): 20-23. 61

62. 62 7) Shaikh Z, Pathak R. Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9. 8) Shah N. Impact of socio demographic variables, oral hygiene practices and oral habits on periodontal health status of Indian elderly: a community based study. IJDR 2003; 14(4): 289-297. 9) Hashibe M . Socioeconomic status, lifestyle factors and oral premalignant lesions.Oral Oncol . 2003 Oct;39(7):664-71 . 10) NancyE.AdlerandKatherine Newman. Inequality in education, income, and occupation exacerbates the gaps between the health “haves” and “have-nots.” ©2009 HOPE– ThePeople -to-People Health Foundation, Inc. 11) Agarwal AK. Social classification: The Need to Update in the present Scenario. IJCM; Jan –Mar; vol 33: Number 1

63. THANK YOU 63