Full text of DOI:10.1006/pmed.2000.0751

Preventive Medicine 31, 691–701 (2000)
doi:10.1006/pmed.2000.0751, available online at http://www.idealibrary.com on
Trends in Social Class Inequalities in Health Status, Health-Related
Behaviors, and Health Services Utilization in a Southern
European Urban Area (1983–1994)
Carme Borrell,*,1 Montserrat Rue,† M. Isabel Pasar´ın,* Izabella Rohlfs,* J osep Ferrando,*
and Esteve Fernandez‡
*Institut Municipal de Salut Pu´blica de Barcelona; †Fundacio´ Parc Taulı´, Sabadell; and
‡Institut Universitari de Salut Pu´blica de Catalunya
to be ta k en in to a ccou n t by p olicy-m a k er s a n d p u blic
Ba ckgr ou n d . Th e objective of th is stu d y w a s to d e-
scr ibe th e evolu tion of socia l cla ss in equ a lities in Ba r -
celon a (Sp a in ) r esid en ts in p er ceived h ea lth sta tu s,
h ea lth -r ela ted beh a vior s, a n d u tiliza tion of h ea lth ser -
vices betw een 1983 a n d 1994.
h ea lth w or k er s.
P r ess
᭧ 2000 Am er ica n Hea lth F ou n d a tion a n d Aca d em ic
Key Wor d s: in equ a lities in h ea lth ; socia l cla ss; h ea lth
in ter view su r vey; tim e tr en d s.
Meth od s. Th e in for m a tion w a s obta in ed fr om th e
Hea lth In ter view Su r veys con d u cted in 1983, 1986,
1992, a n d 1994 in Ba r celon a . In th is stu d y w e in clu d ed
n on in stitu tion a lized p eop le a ges Ͼ14 yea r s. Socia l
cla ss w a s obta in ed fr om th e Sp a n ish a d a p ta tion of th e
Br itish Registr a r Gen er a l cla ssifica tion . We stu d ied
h ea lth sta tu s, h ea lth -r ela ted beh a vior s, a n d h ea lth ser -
vices u tiliza tion va r ia bles. Age-a d ju sted p er cen ta ges
a n d th e r ela tive in d ex of in equ a lity w er e obta in ed .
Resu lts. Of th e h ea lth sta tu s va r ia bles, h a vin g been
INTRODUCTION
Social structure is an important determinant of popu-
lation health status. It has been reported in some Euro-
pean countries that social class inequalities in health
have widened in recent years because health has im-
proved more in advantaged social classes than in disad-
vantaged ones [1,2]. In southern European countries
and mainly in urban areas the study of socioeconomic
con fin ed to bed a n d a cu te r estr iction of a ctivity in th e inequalities in health is very recent [3].
2 w eek s p r ior to th e in ter view sh ow ed a n in cr ea se in
in equ a lities by socia l cla ss in 1994. Th e p a tter n of
ch r on ic con d ition s by socia l cla ss in m en d id n ot
ch a n ge betw een 1983 a n d 1994. Wom en h a d a h igh er
p r eva len ce of ch r on ic con d ition s a n d th e in equ a lities
a m on g socia l cla sses h a d in cr ea sed . In m en th er e w er e
n o socia l cla ss in equ a lities in sm ok in g in 1983. In 1992
a n d 1994 sm ok in g w a s m or e p r eva len t in m en of socia l
cla sses IV a n d V. In w om en , sm ok in g w a s m or e p r eva -
len t in socia l cla sses I a n d II in 1983 th a n in socia l
cla sses IV a n d V, som eth in g th a t h a d ch a n ged by 1994.
La ck of u su a l p h ysica l a ctivity in m en w a s a lw a ys m or e
p r eva len t in socia l cla sses I a n d II, a n d th is d iffer en ce
in cr ea sed sin ce m or e p eop le of a d va n ta ged cla sses
m oved in to in a ctivity. Hea lth ser vices u tiliza tion
sh ow ed n o in equ a lities in th e yea r s stu d ied .
Barcelona is the second largest city in Spain, with
1,650,000 inhabitants, located in the Northeast of the
country in the Autonomous Community of Catalonia.
In the mid-1980s, Catalonia and Barcelona underwent
a change in production processes, which introduced
greater job flexibility due to improved communications.
Certain important demographic changes should be
mentioned. First is the aging of the population, due to
higher life expectancy and decreasing fertility rates.
Second, there has been a shift of the immigration pat-
tern: immigration is now from developing countries
(mainly those of North Africa) while formerly it was
from other regions of Spain. The population of Barce-
lona City is declining and its suburban areas are grow-
ing. Finally, the composition of households has changed:
there are more households with one person (generally
elderly) and more households of nuclear families sup-
porting young people who, due to the difficulty of finding
a stable job, delay emancipation [4–6].
Con clu sion . Th e ch a n gin g p a tter n a ccor d in g to socia l
cla ss of sm ok in g a n d p h ysica l a ctivity p r a ctice n eed s
1
To whom reprint requests should be addressed at Institut Munici-
As a large city, Barcelona has important socioeco-
nomic inequalities in health at both geographical and
pal de Salut Pu´blica de Barcelona, Pl. Lesseps 1, 08023 Barcelona,
Spain. Fax: ϩ34 93 2173197. E-mail: cborrell@imsb.bcn.es.
691
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692
BORRELL ET AL.
individual levels. The inner city area has excess mortal- Health Status, Health-Related Behaviors, and
ity and morbidity, compared with the rest of the city
[7–11]. These geographical inequalities in mortality in-
creased between 1983 and 1994, mainly due to causes
affecting the poorer populations (AIDS and drug over-
dose) in deprived neighborhoods [12].
Although inequalities in health were described with
data from health interview surveys [13,14], to date no
systematic description of time trends in social class
inequalities in health-related variables exists. Thus,
the objective of this study was to describe the evolution
of social class inequalities in Barcelona residents in
perceived health status, health-related behaviors, and
utilization of health services between 1983 and 1994,
using data from four population Health Interview
Surveys.
Health Services Utilization Variables
Although the four surveys followed a similar method-
ology, some differences exist and we studied only the
variables that could be compared across the four sur-
veys. Health status variables were: (a) If confined to
bed in the 2 weeks prior to the interview due to health
problems; (b) Presence of at least one chronic condition
from a list of common illnesses (this list had 29 condi-
tions in 1983, 34 in 1986, 21 in 1992, and 16 in 1994);
(c) Perceived health status—this variable was obtained
for the years 1986, 1992, and 1994. For analysis pur-
poses, answers were grouped into two categories: “good
health” (good and very good health in 1986 and 1992
and excellent, very good, and good health in 1994) and
“poor health” (regular, poor, or very poor health in 1986
and 1992; poor and very poor health in 1994). In 1986
this question was answered by people older than 15
years; (d) Acute restriction of activity—limitation of
activity in the 2 weeks prior to the interview due to
limitation of principal activity (working, studying, etc.)
or habitual activity (spare time activities). This also
includes people who were confined to bed.
Health-related behavior variables were: (a) Smok-
ing—people who smoked daily one or more cigarettes
at the time of the survey were considered as current
smokers; (b) Lack of usual physical activity, which re-
fers to the physical activity usually undertaken, there-
fore including activity at work. People whose activity
was catalogued as none (seated most of the day) are
included. In 1986 these variables were considered for
people older than 15 years.
METHODOLOGY
Design, Study Population, and Sources of
Information
The information was obtained from the Health Inter-
view Surveys conducted in 1983 [15], 1986 [16], 1992
[17], and 1994 [18], in Barcelona among the noninstitu-
tionalized population. The data were collected by per-
sonal interview over the first 6 months of 1983 and
over the entire year in 1986, 1992, and 1994 using a
questionnaire with similar methodology. Sample sizes
were 3,134 subjects in 1983, 7,907 in 1986, 5,004 in
1992, and 2,155 in 1994. Non-response rates ranged
from 7% in 1994 to 18% in 1983, while substitutions
were allowed in 1992 and 1994. All samples were stra-
tified, strata being districts in 1983, 1986, and 1994,
and groups of census tracts in 1992. In all surveys, the
sample were representative of age and sex for the total
population of Barcelona. In this study we included peo-
ple ages Ͼ14 years, the major characteristics of whom
are shown in Table 1.
The following two variables relating to utilization of
health services are reported for the years 1986, 1992,
and 1994: (a) having visited the doctor in the 2 weeks
prior to the interview; (b) having been hospitalized in
the year prior to the interview. Frequency of health
service use is presented by the two above-mentioned
levels of perceived health status in order to determine
the level of need.
Social Class
Social class data were obtained from the Spanish
adaptation of the British Registrar General classifica-
tion [19]. Class I includes managerial and senior techni-
Data Analysis
Sampling weights derived from the sample design
cal staff and free professionals; class II includes inter- were used in the analysis of each survey. In order to
mediate occupations and managers in commerce; class compare the different variables among social classes,
III consists of skilled non manual workers; class IV age-adjusted percentages and their 95% confidence in-
contains skilled (IVa) and partly skilled (IVb) manual tervals (95% CI) (direct standardization) were calcu-
workers; and class V includes unskilled manual work- lated [20]. The reference population was that of Barce-
ers. Women and other people (e.g., students) with no lona for the year 1988. All analyses have been
paid job and those unemployed were assigned the social performed separately for male and female subjects.
class of the head of the household, with the exception
As a summary measure for socioeconomic inequality
of those who had previously worked, who were classified in health the relative index of inequality (RII) was ob-
according to their last occupation. For analysis pur- tained by means of logistic regression. The dependent
poses classes are grouped into classes I–II, class III, variables were health status, health-related behaviors,
and classes IV–V.
and health services utilization, as described above. The

TRENDS IN SOCIAL CLASS INEQUALITIES IN HEALTH
693
TABLE 1
Demographic Variables in the Four Health Interview Surveys (Percentages)a
Male
Female
1983
1986
1992
1994
1983
1986
1992
1994
N ϭ 835
N ϭ 2545
N ϭ 2014
N ϭ 821
N ϭ 1010
N ϭ 2958
N ϭ 2286
N ϭ 1051
Age group (years)
15–24
25–34
35–44
45–54
17.4
14.1
16.6
20.9
15.2
15.8
20.2
15.0
17.0
16.2
16.9
14.7
20.1
17.7
15.3
12.5
15.4
19.1
19.4
16.7
16.2
13.0
15.1
19.6
16.0
13.3
16.2
16.0
18.2
20.2
18.5
15.1
16.2
15.7
14.8
19.6
17.5
15.2
14.3
13.9
16.9
22.2
16.8
14.0
15.6
15.1
13.9
24.6
55–64
Ն65
Employment status
Worker
Housewife
Unemployed
Student
59.4
—
8.7
11.5
17.0
2.0
56.8
—
9.3
12.7
17.8
3.1
53.1
—
7.5
13.1
22.3
3.9
51.5
—
10.7
13.5
21.0
3.0
24.5
39.6
4.7
9.3
17.0
4.1
27.5
40.5
4.5
11.6
13.7
1.9
27.2
39.4
5.5
11.8
14.2
1.8
33.3
35.3
5.8
11.3
10.9
3.1
Retired
Other
Missing data
Social class
I–II
III
IV–V
1.4
0.4
0.1
0.2
1.0
0.4
0.1
0.4
21.0
24.6
53.6
0.8
24.9
28.1
41.8
5.3
27.1
23.4
40.5
9.0
27.9
26.9
43.5
1.7
14.9
22.6
54.3
8.2
22.9
24.5
44.4
8.2
21.7
22.5
46.7
9.0
24.0
24.0
47.7
4.4
Missing data
a
Male and female, ages Ͼ14 years, Barcelona, 1983–1994.
independent variables were social class and age. Social higher prevalence of chronic conditions and the inequal-
class categories (I–II, III, IV–V) were assigned a value ities among social classes had increased. Differences
between 0 and 1, which represents the relative position
of the central subject of the class. The RII is the odds
ratio obtained and it expresses the risk for those at the
bottom of the social hierarchy compared with those at
the top. This is a measure of total impact because it
takes into account the effect of social class and also the
size of the groups that are compared and has been used
extensively in the study of social inequalities in
health [21].
among classes widened between 1983 (RII: 1.36, 95%CI:
0.75–2.47) and 1994 (RII: 2.85, 95%CI: 1.65–4.93). Poor
perceived health status was more common in social
classes IV–V and in women. Inequalities were more
important and stable in women (RII greater than 4 in
all 3 years) than in men (RII: 2.67 in 1986 and 3.38 in
1994) (Table 2 and Fig. 1).
For men there were no social class inequalities in
smoking in 1983 (RII: 1.09, 95%CI: 0.64–1.86); in 1992
and 1994, however, smoking was more prevalent in men
of social classes IV–V. For women, smoking was more
prevalent in social classes I–II in 1983 (29.4%) than in
social classes IV–V (17.8%), but this changed in 1994
(19.9% of social classes I–II and 20.5% of classes IV–V).
The RII was 0.29 (95%CI: 0.15–0.56) in 1983 and 0.77
(95%CI: 0.42–1.44) in 1994 (Table 2 and Fig. 2).
Lack of usual physical activity in men was always
more prevalent in social classes I–II, and this difference
increased since more people of advantaged classes
moved into inactivity. RII were always different from
1, being 0.45 in 1986, 0.30 in 1992, and 0.29 in 1994. No
clear pattern emerged for women (Table 2 and Fig. 2).
Health services utilization showed no inequalities
when perceived health was good, except among women
in 1992, where social classes IV–V had more visits to
a doctor (RII: 2.6). In 1994, subjects in classes I and II
RESULTS
Of the health status variables, having been confined
to bed in the 2 weeks prior to the interview showed an
increase in inequalities by social class in 1994. In 1983
it was more prevalent among men of classes I–II (10%)
and among women of class III (12.6%), whereas in 1994
it was more prevalent among men (7.2%) and women
(10.4%) of classes IV–V, compared to 2.5% of men and
7.0% of women of classes I–II (Table 2). The RII changed
from being lower than 1 to 6.24 (95%CI: 1.60–24.3) in
men and 2.63 (95%CI: 1.05–6.58) in women (Fig. 1). A
similar pattern was apparent for acute restriction of
activity (Table 2 and Fig. 1).
Declaring at least one chronic condition was more
prevalent in men of social classes IV–V, but the pattern
did not change between 1983 and 1994. Women had a had been hospitalized in a greater proportion, although

TABLE 2
Perceived Health and Health-Related Behaviors by Social Class (Age Standardized Percentages and 95% Confidence Intervals) and Relative Index of Inequality
(RII and 95% confidence intervals)a
Male
Female
1983
1986
1992
1994
1983
1986
1992
1994
Health Status
Bed past 2 weeks
Social classes I–II
Social class III
Social classes IV–V
RII
10.0 (4.9–15.1)
5.5 (2.3–8.8)
6.7 (4.3–9.1)
0.76 (0.28–2.1)
3.3 (1.8–4.7)
2.0 (0.09–3.0)
3.5 (2.4–4.6)
4.9 (3.0–6.8)
5.8 (3.5–8.0)
4.9 (3.4–6.5)
2.5 (0.05–4.5)
3.9 (0.09–6.9)
7.2 (4.3–10.1)
7.6 (2.9–12.3)
12.6 (8.4–16.8)
7.2 (5.0–9.5)
4.9 (3.2–6.7)
3.8 (2.2–5.4)
5.7 (4.4–7.0)
4.2 (2.5–5.9)
7.7 (4.9–10.5)
6.5 (4.9–8.1)
7.0 (3.8–10.2)
4.2 (1.6–6.8)
10.4 (7.4–13.4)
1.39 (0.57–3.77)
0.96 (0.44–2.09) 6.24 (1.60–24.3) 0.51 (0.22–1.23)
1.35 (0.70–2.62)
1.35 (0.67–2.72) 2.63 (1.05–6.58)
Acute restriction of activity
Social classes I–II
Social class III
Social classes IV–V
RII
—
—
—
5.1 (3.3–6.9)
3.8 (2.4–5.3)
5.8 (4.4–7.2)
9.6 (7.0–12.3)
9.1 (6.3–11.9)
9.9 (7.7–12.0)
4.5 (1.8–7.3)
8.3 (4.2–12.3)
13.1 (9.2–17.0)
—
—
—
8.0 (5.6–10.4)
6.4 (4.4–8.5)
9.4 (7.7–11.1)
1.48 (0.86–2.52)
10.8 (7.8–13.8)
11.7 (8.4–15.1)
13.1 (10.8–15.4)
1.34 (0.80–2.5)
12.4 (8.1–16.8)
10.6 (6.2–15.0)
16.9 (13.1–20.6)
2.08 (1.03–4.21)
1.49 (0.74–2.97) 1.08 (0.60–1.93) 5.63 (2.12–14.9)
Chronic conditions
Social classes I–II
Social class III
Social classes IV–V
RII
52.9 (41.7–64.3) 52.7 (46.8–58.7)
58.4 (47.5–69.3) 55.9 (50.4–61.4)
64.2 (56.7–71.6) 56.8 (52.3–61.3)
2.35 (1.31–4.20) 1.33 (0.96–1.85)
46.7 (40.8–52.5) 46.4 (37.6–52.2) 65.1 (46.3–83.9) 62.9 (56.3–69.5)
44.1 (38.0–50.2) 54.1 (43.7–64.5) 72.0 (58.8–85.3) 66.8 (60.0–73.6)
50.2 (45.3–55.1) 55.2 (47.5–63.0) 70.6 (63.6–77.7) 72.7 (68.0–77.3)
1.39 (0.96–2.02) 2.15 (1.21–3.80) 1.36 (0.75–2.47) 2.08 (1.49–2.90)
62.2 (54.3–70.1)
67.2 (59.3–75.0)
71.2 (66.1–76.3)
2.15 (1.47–3.14)
59.2 (49.3–69.1)
58.3 (47.1–69.6)
69.9 (62.5–77.2)
2.85 (1.65–4.93)
Poor health status
Social classes I–II
Social class III
Social classes IV–V
RII
—
—
—
15.1 (11.7–18.5)
16.8 (13.6–20.1)
23.4 (20.3–26.5)
2.67 (1.74–4.09)
13.6 (10.4–16.8) 13.1 (8.4–17.8)
11.1 (7.9–14.3) 18.5 (12.3–24.8)
22.5 (19.2–25.8) 23.1 (18.2–27.9)
3.24 (1.98–5.32) 3.38 (1.68–6.79)
—
—
—
21.2 (16.8–25.7)
24.8 (20.3–29.3)
37.8 (34.4–41.3)
4.58 (3.19–6.57)
18.4 (13.8–23.1)
20.4 (15.6–25.1)
32.3 (28.9–35.7)
4.65 (2.98–7.25)
18.9 (13.1–24.8)
26.7 (18.6–34.6)
34.6 (29.5–39.6)
4.35 (2.39–7.89)
Health-related behaviors
Smoking
Social classes I–II
Social class III
Social classes IV–V
RII
53.8 (42.6–64.9) 43.4 (37.9–48.9)
53.9 (43.5–64.2) 48.5 (43.0–54.1)
55.4 (48.1–62.6) 49.6 (44.8–54.5)
1.09 (0.64–1.86) 1.30 (0.94–1.81)
40.3 (34.8–45.8) 38.7 (30.4–47.0) 29.4 (20.8–37.9) 20.1 (16.6–23.7)
42.5 (36.5–48.6) 37.8 (29.5–46.0) 23.4 (17.5–29.3) 18.0 (15.1–20.9)
50.0 (45.0–55.1) 43.1 (35.7–50.5) 17.8 (13.8–21.8) 18.6 (15.9–21.2)
1.91 (1.34–2.73) 1.19 (0.69–2.04) 0.29 (0.15–0.56) 0.76 (0.51–1.15)
25.9 (21.8–30.0)
24.0 (20.0–28.0)
22.6 (19.3–25.8)
0.55 (0.36–0.83)
19.9 (14.5–25.2)
24.3 (18.7–29.8)
20.5 (15.9–25.1)
0.77 (0.42–1.44)
Lack of usual physical
activity
Social classes I–II
Social class III
Social classes IV–V
RII
—
—
—
40.5 (35.0–46.0)
40.8 (35.7–45.9)
28.3 (24.8–31.9)
0.45 (0.32–0.64)
40.4 (35.0–45.9) 50.2 (40.9–59.5)
35.2 (29.7–40.7) 49.5 (39.8–59.3)
24.4 (20.9–27.8) 31.2 (25.2–37.2)
0.30 (0.20–0.43) 0.29 (0.17–0.49)
—
—
—
23.8 (19.1–28.4)
31.6 (27.1–36.1)
24.6 (21.7–27.5)
1.04 (0.73–1.47)
23.5 (18.8–28.2)
25.7 (21.1–30.4)
18.3 (15.7–21.0)
0.59 (0.39–0.89)
30.4 (23.0–37.8)
42.3 (33.3–51.2)
26.5 (21.9–31.2)
0.65 (0.39–1.09)
a
Male and female, ages Ͼ14 years, Barcelona, 1983–1994.

F IG. 1. Relative index of inequality and 95% confidence interval of health status. Male and female, Ͼ14 years, Barcelona, 1983–1994.

F IG. 2. Relative index of inequality and 95% confidence interval of health-related behaviors. Male and female, Ͼ14 years, Barcelona, 1983–1994.

TRENDS IN SOCIAL CLASS INEQUALITIES IN HEALTH
697
the difference was not statistically significant (Table 3 no differences were found in the limitation of activity
and Fig. 3).
according to social class in the 1987 National Health
Interview Survey, whereas data from the 1993 survey
revealed that among people with poor perceived health,
advantaged social classes more often declared some
type of limitation [23].
In 1986 there were no differences by social class in
visiting the doctor among people with poor perceived
health (RII for men was 1.28, 95%CI: 0.56–2.97, and for
women 1.13 with a 95%CI: 0.59–2.17); in 1994 women of
classes I and II had visited the doctor more. Men of
advantaged classes were hospitalized more frequently
in 1986 (RII: 0.43, 95%CI: 0.13–1.42), while the pattern
changed in 1994 (RII: 1.5, 95%CI: 0.29–7.67). There
was no clear pattern of hospitalization by social class
in women with poor health status (Table 3 and Fig. 3).
A poor perceived health status and the presence of
chronic conditions showed a social class pattern of ine-
qualities in the four surveys. Such inequalities were
increased in women for chronic conditions and in men
for perceived health status. In Finland, some studies
that analyzed the evolution of inequalities in perceived
health status by educational level in the 1980s and
1990s found a decrease in inequalities in men and no
trend in women [24,25]. In Spain inequalities in per-
ceived health status by social class were more im-
portant in men and women of older ages compared with
young people, and were greater in 1987 than in 1993
[23]. Although the list of chronic conditions was not
exactly the same in the four surveys, it is important to
emphasize the increase in inequalities in women. Fu-
ture studies, incorporating gender perspective, are
needed to further analyze the evolution by social class
of the different or selected chronic conditions. In Spain
inequalities have been reported by educational level for
some chronic conditions (bronchitis, hypertension, and
diabetes) and these widened between 1987 and 1993
[26].
DISCUSSION
Perceived Health Status
In this series of four health interview surveys no
differences according to social class in the restriction
of activity were found until 1992, but in 1994 a social
pattern was apparent. An explanation could be the fact
that in 1994 the estimates had larger variability be-
cause of a smaller sample size. The analysis of data
from the 2000 Barcelona Health Interview Survey will
provide valuable information to confirm or disprove
that pattern.
Other studies have found a different pattern of the
evolution of the limitation of activity by social class. In
Finland between 1964 and 1987 social class inequalities
in longstanding illness had diminished [22]. In Spain
Despite the stability of social class inequalities in
perceived health status, we have recently reported a
TABLE 3
Health Services Utilization by Social Class and Perceived Health Status (Age Standardized Percentages and 95% Confidence Intervals)
and Relative Index of Inequality (RII and 95% Confidence Intervals)a
Male
1992
Female
1992
1986
1994
1986
1994
Good perceived health status
Visit to doctor last 2 weeks
Social classes I–II
Social class III
Social classes IV–V
RII
11.4 (8.1–14.7)
11.7 (8.7–14.8)
10.1 (7.7–12.5)
14.7 (11.0–18.4) 12.7 (7.7–17.8)
15.8 (11.7–19.9) 15.9 (10.0–22.0) 15.8 (11.3–20.3)
12.9 (10.1–15.7) 15.7 (10.8–20.5) 15.4 (12.5–18.3) 19.6 (16.2–23.0) 19.6 (14.6–24.6)
14.6 (10.5–18.8) 11.7 (7.9–15.4)
16.8 (11.0–22.6)
15.0 (10.4–19.7) 19.5 (11.6–27.4)
0.84 (0.47–1.53) 0.86 (0.50–1.51) 1.36 (0.61–3.06) 1.19 (0.72–1.99) 2.60 (1.51–4.47) 1.27 (0.62–2.61)
Hospitalization last year
Social classes I–II
Social class III
Social classes IV–V
RII
5.9 (3.5–8.4)
5.2 (3.1–7.2)
4.9 (3.2–6.7)
6.5 (4.1–8.9)
4.8 (2.6–7.0)
6.9 (4.8–9.1)
7.2 (3.4–11.1)
6.7 (2.6–10.7)
3.9 (1.6–6.2)
5.7 (3.5–8.4)
6.9 (3.7–10.0)
5.3 (3.6–7.0)
6.6 (3.9–9.3)
5.6 (2.8–8.4)
8.1 (5.9–10.3)
8.2 (4.3–12.1)
6.5 (1.9–11.2)
5.1 (2.5–7.6)
0.81 (0.35–1.88) 1.18 (0.52–2.64) 0.40 (0.11–1.42)
0.89 (0.42–1.92) 1.41 (0.66–2.99) 0.44 (0.14–1.38)
Poor perceived health
Visit to doctor last 2 weeks
Social classes I–II
Social class III
24.4 (10.6–38.1) 21.1 (7.0–35.1)
27.2 (16.7–37.8) 28.1 (9.2–47.0)
37.7 (9.1–66.4)
28.0 (17.2–38.8) 51.4 (30.3–72.5) 36.4 (17.2–55.5)
28.0 (12.5–43.4) 32.4 (22.4–42.3) 37.8 (24.4–51.2) 37.2 (15.5–58.9)
Social classes IV–V
RII
26.5 (18.6–34.4) 32.5 (23.3–41.8) 30.3 (16.1–44.5) 30.5 (24.8–36.3) 46.2 (36.9–55.4) 26.8 (17.8–35.8)
1.28 (0.56–2.97) 2.41 (0.94–6.17) 1.19 (0.33–4.23) 1.13 (0.59–2.17) 1.24 (0.58–2.62) 0.41 (0.15–1.14)
Hospitalization last year
Social classes I–II
Social class III
Social classes IV–V
RII
20.4 (7.1–33.7)
5.3 (1.5–9.1)
9.0 (4.4–13.7)
9.8 (3.5–16.1)
17.1 (1.3–34.0)
13.1 (7.4–18.8)
16.3 (0.08–31.8)
7.4 (0.01–15.1) 11.3 (5.3–17.4)
20.3 (7.5–33.1) 7.4 (4.9–10.0)
9.1 (2.2–15.9)
11.4 (1.3–21.5)
10.0 (3.4–16.6)
16.6 (11.3–21.9)
13.3 (3.0–23.5)
10.5 (0.0–21.0)
11.3 (4.3–18.3)
0.43 (0.13–1.42) 1.08 (0.35–3.39) 1.50 (0.29–7.67) 0.87 (0.31–2.49) 2.76 (0.85–9.00) 0.47 (0.11–1.91)
a
Male and female, ages Ͼ14 years, Barcelona 1986–1994.

F IG. 3. Relative index of inequality and 95% confidence interval of health services utilization by perceived health status. Male and female, Ͼ14 years, Barcelona, 1986–1994.

TRENDS IN SOCIAL CLASS INEQUALITIES IN HEALTH
699
pattern of widening inequalities in premature mortality activity. This may be explained by the fact that their
among the wards of Barcelona with low socioeconomic occupations are manual and also because the women
level in relation to the other wards. The increase in of these social classes do more housework than the
social inequalities in premature mortality was due to women of upper classes [43]. We have observed that
two main causes of death: AIDS and drug overdose. This lack of usual physical activity is more prevalent in ad-
has lead to increased inequalities in specific mortality vantaged classes. The differences are increasing, proba-
rates for the group of ages 15–44 years [12]. These bly due to the fact that in the industrialized society
findings show that mortality inequalities are increasing jobs are requiring less and less physical activity. As a
mainly due to the diseases affecting the marginal popu- result, physical activity is becoming more and more
lation. This is a hidden population, not traced in health part of leisure time [44]. We previously reported that
interview surveys (due to sample methodology) and leisure time physical activity was related to advantaged
may partly explain why social inequalities in perceived social class in both men and women [45]. Unfortunately,
health status are stable in Barcelona.
we are not able to study the evolution in leisure time
physical activity because it was measured in different
ways in the surveys.
Health Related Behaviors
Smoking habit diffuses within societies in four differ-
ent stages. In stage 1, smoking is an exceptional be-
havior and typical of advantaged classes. In stage 2
Health Services Utilization
We found almost no inequalities by social class in
smoking becomes more common, more in men of all health service utilization in our series of health inter-
social classes or advantaged classes. Women lag 10–20 view surveys. A number of studies carried out in Spain
years behind men and the habit is adopted by advan- in recent years have not found any socioeconomic ine-
taged classes. During stage 3, prevalence in men de- qualities with regard to visits or hospitalizations [46–
creases mainly in the upper classes, and women reach 48]. In earlier studies with data collected in the 1980s,
their peak. In stage 4, the habit declines and smoking however, differences by social class were evident when
becomes more prevalent in disadvantaged classes the level of need was taken into account, with persons
[27–29].
of disadvantaged classes and with poor self-perceived
The pattern of tobacco consumption varies among health consulting less [49,50].
countries. Northern European countries and other de-
One explanation of this change could be the imple-
veloped countries like the United States, Australia, and mentation in the late 1980s of the Spanish National
Canada are mainly in stage 4, where the prevalence of Health System with an almost universal coverage of
smokers is higher among disadvantaged social classes health care. The system is financed through taxation
and among those with lower education levels [24,28,30– of income, most health facilities are public, and access is
33]. In the United States, people with higher education universal and free [51]. This universalization facilitates
levels maintained high prevalence of smoking until the access to services for all social classes. Another relevant
1950s, after which prevalence became higher in groups issue is the broadening reforms in primary care that
with lower education levels [34]. In other countries this were initiated in 1984 following the principles of the
change occurred somewhat later [31]. In Finland it oc- Alma Ata Conference. The new Primary Health Care
curred among women during the 1970s [35]. In contrast, in Spain implies the construction of health care centers
southern European countries, including Spain, are in where professionals work in teams [52]. Nowadays the
an earlier stage, with the differences between social reform has different degrees of implementation in the
classes appearing in men, while the patterns are chang- different regions of Spain. In Barcelona it has only
ing in women, the habit becoming more common among reached 46% of the population [6]. Moreover, it is neces-
the disadvantaged classes [13,23,26,36,37,38]. We have sary to mention that the reform in the city of Barcelona
described how in Barcelona the change was taking place has been oriented to the reduction of social inequalities
among women in 1994 while in men the trend reversed in health, and thus the most deprived neighborhoods
a few years ago [39]. The analysis of smoking initiation received priority when the reform was implemented
rates in Catalonia also supports the hypothesis that we [53]. We believe that the reform of primary health care
are at the end of stage 3 of the tobacco epidemic [40]. increases the accessibility and diminishes the inequali-
People in advantaged classes usually undertake more ties in health services utilization by social class, but
leisure time physical activity, but less usual physical specific studies to address this question are still needed.
activity [41,42,32]. As usual physical activity is mainly
It should, however, be mentioned that in Barcelona
related to occupational physical activity among work- approximately 30% of the population have private
ers, and to activities of daily living among nonworkers health insurance in addition to the public one. This
(i.e., housework), it is reasonable to expect that persons double coverage is much more prevalent in people of
in disadvantaged social classes do more usual physical advantaged classes and is related to the existence of

700
BORRELL ET AL.
inequalities in other aspects of health care utilization
The analysis and monitoring of the evolution of ine-
such as preventive practices (preventive dental care, qualities in perceived health status, health-related be-
prevention of breast and cervical cancer, etc.) and in haviors, and the quality of health services should be a
some characteristics of the visits, i.e., waiting times matter of concern not only for social researchers and
[13,23,46,54,55]. However, in this study it was not possi- epidemiologists, but also for policy-makers. The chang-
ble to investigate such preventive practices, as they ing pattern by social class of health-related behaviors
were included only in the 1992 and 1994 health inter- needs to be taken into account by policy makers and
view surveys.
public health workers. This study indicates that actions
aimed at the prevention of smoking initiation among
women and men in deprived classes would have a major
beneficial effect. Finally, it is important to further ana-
lyze the potential impact of primary health care reform
on social class inequalities in health services accessibil-
ity and use.
Limitations
The four health interview surveys conducted in Bar-
celona exhibit certain differences that should be noted.
In 1983 the interviews were conducted in the first 6
months of the year, while in 1986, 1992, and 1994 the
interviews took place over the full year. In this study
we have compared those variables that were worded in
the same manner, although some minor changes had
been introduced, for example, in the question about
tobacco consumption or in the lists of chronic conditions.
Other questions were presented very differently (e.g.,
leisure time physical activity) and for this reason we
have not included them.
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