Original ResearchSocioeconomic gradients in cardiorespiratory disease and diabetes in the 1960s: Baseline findings from the GPO study
Introduction
In 1968 Antonovsky1 reviewed 35 studies of cardiovascular mortality and 21 studies of morbidity. He concluded that for diseases of the circulatory system, disease of the heart, arteriosclerotic and degenerative heart disease, and coronary heart disease (CHD) the evidence did not substantiate the widely held view that during the first half of the 20th century men in higher socioeconomic groups were more affected by cardiovascular disease than those lower down. The number of studies that reported direct class gradients was equal to the number that reported inverse class gradients and both were outnumbered by studies showing no clear gradient. The conclusions of Antonovsky's review were endorsed by a more recent review of well-characterized studies with standardized measures of disease prevalence or incidence, carried out in the UK or the USA, with initial recruitment up to and including 1960. With one exception, the studies showed either no association or a non-significant inverse association between socioeconomic position and disease prevalence or incidence.2
Currently, steep inverse socioeconomic gradients (higher status, lower morbidity) are observed for most major causes of morbidity and mortality in industrialized countries and, increasingly, in less developed countries.3, 4, 5, 6, 7 While the emergence of the socioeconomic gradient in cardiovascular disease among men in industrialized countries has been relatively well documented, less work has examined the socioeconomic gradient in cardiovascular risk factors among women, or diabetes and impaired glucose tolerance (IGT) in either sex. Determinants of the inverse socioeconomic gradient in respiratory disease, which affected both sexes,8 have similarly been relatively well documented among men,9 but not among women. There were no women in the first Whitehall study10 or the British Regional Heart study,11 the two studies that are the source of most of what is known about the development of socioeconomic gradients in cardiovascular disease in Britain. The only early UK study of cardiorespiratory disease to include a substantial proportion of women, the Renfrew and Paisley or Midspan study, was conducted in an urban area of Scotland with an unusually high level of socioeconomic deprivation.12
From 1661, when the first British postmark was introduced, the Post Office has been a national institution. During the 1960s the General Post Office (GPO) was a government department, part of the Civil Service. It had a monopoly of all mail, telegraph and telecommunications services in the UK and was one of its largest employers.13 Over a period spanning the end of 1966 to the beginning of 1967 a cohort of women and men employed by the GPO and aged 15–73 underwent a clinical examination. This cohort was recruited and surveyed under the aegis of Harry Keen, Donald Reid and Geoffrey Rose, who went on, shortly after (1968–1970), to recruit and survey the 19 000 men included in the first Whitehall study of white-collar civil servants. The GPO study was designed as a pilot for Whitehall I. However, possibly due to the untimely death of Patrick Hamilton, one of the investigators, the proximity of the studies, or the sufficiency of the data furnished by Whitehall I, data from the GPO study have never been published.
In this paper we report socioeconomic distributions of risk factors for cardiorespiratory disease and diabetes amongst women and men in the GPO study. Mortality follow-up is available for a 38-year period and will be reported in another paper.
Section snippets
Study sample
The target population for the GPO study was women and men of working age employed by the telecommunications arm of the GPO in central London in late 1966. Of the 4230 invited, 3345 women and men completed a short questionnaire and participated in a clinical examination, a response rate of 79%. Letters of invitation delivered to potential participants at their place of work contained a copy of the questionnaire which participants were asked to complete and bring with them to their clinical
Results
The distribution of sociodemographic factors among the 1251 women and 2094 men in the GPO study, and the distribution of cardiorespiratory symptoms and risk factors, are shown by sex in Table 1, Table 2, and by occupational grade in Table 3. The bimodal distribution of women by age reflects their absence from work during the childbearing and rearing years, and in later working life. Women were much less likely to be married than men and occupational grade was inversely associated with marriage
Discussion
Although intuitive, our occupational grade classification conforms to the expected pattern of higher car ownership and garden access among the higher-grade occupations for both sexes. Height, a marker of growth and socioeconomic position in childhood, as well as a marker of socioeconomic position in adulthood, also showed a steep occupational gradient in men. A strong inverse grade gradient was observed for bronchitis and a strong positive gradient in FEV1 in men, although smoking was less
Acknowledgements
The GPO study was supported by a grant to Donald Reid. The diabetes component of the study was funded by a grant to Harry Keen from the Chief Scientist Fund, Department of Health. J.E.F. is supported by the MRC (Grant number G8802774) and M.J.S. by a grant from the British Heart Foundation. We would like to thank David Leon for providing access to the original records of the study archived at the London School of Hygiene and Tropical Medicine and for his comments on an earlier draft of the
References (50)
Social class and the major cardiovascular diseases
J Chronic Dis
(1968)- et al.
Cardiorespiratory disease and diabetes among middle-aged male civil servants
Lancet
(1974) - et al.
Social class differences in ischaemic heart disease in British men
Lancet
(1987) - et al.
A cardiovascular survey of British postal workers
Lancet
(1966) Standardisation of observers in blood pressure measurement
Lancet
(1965)- et al.
A sphygmomanometer for epidemiologists
Lancet
(1964) - et al.
Coronary risk factors and socioeconomic status. The Oslo study
Lancet
(1976) - et al.
Coronary risk factors and socioeconomic status
Lancet
(1977) - et al.
Social class and serum-cholesterols
Lancet
(1970) - et al.
Blood pressure and social class
Public Health
(1981)
Social class and biological tests
Lancet
Coronary heart disease risk and impaired glucose tolerance: the Whitehall Study
Lancet
Life course exposure and later disease: a follow-up study based on medical examinations carried out in Glasgow University (1948–68)
Public Health
Socioeconomic differentials
Socioeconomic differentials in cancer among men
Int J Epidemiol
Socioeconomic differences in mortality in Britain and the United States
Am J Pub Health
Socioeconomic inequalities in cardiovascular disease mortality; an international study
Eur Heart J
Social inequality in mortality in Sao Paulo State, Brazil
Int J Epidemiol
Educational status, coronary heart disease, and coronary risk factor prevalence in a rural population of India
Br Med J
Chronic bronchitis: an introductory examination of existing data
Br Med J
Cardiorespiratory disease in men and women in urban Scotland: baseline characteristics of the Renfrew/Paisley (Midspan) study population
Scott Med J
Royal mail: the post office since 1840
Standardized questions on respiratory symptoms
Br Med J
The diagnosis of ischaemic heart pain and intermittent claudication in field surveys
Bull World Health Organ
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