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

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.

3. CONTENTS
SOCIAL STRATIFICATION ESSENTIALS
 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.”

5. HISTORY
In ancient times the societies could be divided into 2 groups.
HAVES
Were 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
BASED ON
WEALTH, JOB
AND
EDUCATION

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

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

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

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

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.
So the categories were originally based on political ideology

12. GLOBAL STRATIFICATION - TODAY
Global stratification categories today are high- , middle-, and low-income countries.
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
1. Social stratification is socially defined as a property of a
society rather than individuals in that society.
2. Social stratification is reproduced from generation to
generation.
3. Social stratification is universal (found in every society) but
variable (differs across time and place).
4. Social stratification involves not just quantitative inequality
but qualitative beliefs and attitudes about social status.

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

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.

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)

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

18. TYPES OF SOCIAL STRATIFICATION
OPEN CLOSED

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

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

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)

24. STRATIFICATION SYSTEM
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.

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)

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.

28. SOCIO ECONOMIC SCALES
 Several methods or scales have been proposed for classifying
different populations by socioeconomic status in India.
6. Kuppuswamy scale 1976
7. Shrivastava scale 1978.
8. Bharadwaj scale 2001
1. Rahudkar scale 1960
2. B G prasad 1961
3. Udai Pareek scale 1964
4. Jalota Scale 1970
5. 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
7. Farm power
8. Material possessions
9. Family

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

31. BG Prasad’s Classification
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. 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

34. KUPPUSWAMY REVISED SCALE

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.

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:
1. Marital status
2. Retired/employed status
3. Educational attainment
4. Occupational prestige.

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.

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.

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.
 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.

44. THE DOWNWARD DRIFT HYPOTHESIS
“A low social class position can have a negative effect on health”
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 CARE 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
“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”)
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.”

48. SOCIO ECONOMIC STATUSAND DENTAL HEALTH
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]

50. DENTAL CARIES
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. 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]**

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]

54. PERIODONTAL DISEASES
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 ]

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
[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]

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**
 Also 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
ATTITUDEOFUNDERPRIVILEGEDTOWARDHEALTHCARE
1. Castration complex
2. Contradiction of common sense
3. Coming in crowds
4. Last ditch effort
5. If it hurts, you are a quack
6. Unclean or dirty feeling
7. Clinic built there not here
8. Cold professional attitude
9. Pain threshold
10. Complication of unknown
11. Pills don’t work
12. Appointments not important
13. Teeth lost anyhow
14. Traditions

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.

60. THE SOCIALCLASS 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
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63. THANK YOU