Abstract

INTRODUCTION

In the 1970s, in view of the economic processes that led to the rapid growth of income inequality and new forms of social exclusion, social scientists sought to formulate operationalization models for the concept of social class that could be used in empirical research aimed at accurate documentation of these phenomena. ⁹9 . Kawachi I, Kennedy BP. The health of nations. New York: The New Press; 2002. ^{, 20}20 . Singer P. Dominação e desigualdade: estrutura de classes e repartição de renda no Brasil. Rio de Janeiro: Editora Paz e Terra; 1981. ^{, 26}26 . Wilkinson RG. Unhealthy Societes. London: Routledge; 1996. DOI:10.4324/9780203421680
https://doi.org/10.4324/9780203421680... ^{, 27}27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978.

The operationalization of the concept of social class has gained prominence in Latin America and has led many researchers to develop operationalization models for use in empirical research in the field of health care. ¹1 . Barros MBA. A utilização do conceito de classe social nos estudos dos perfis epidemiológicos: uma proposta. Rev Saude Publica . 1986;20(4):269-73. DOI:10.1590/S0034-89101986000400001
https://doi.org/10.1590/S0034-8910198600... ^{, 11}11 . Lombardi C, Bronfman M, Facchini LA, Victora CG, Barros FC, Beria JU, et al. Operacionalização do conceito de classe social em estudos epidemiológicos. Rev Saude Publica . 1988;22(4):253-65. DOI:10.1590/S0034-89101988000400001
https://doi.org/10.1590/S0034-8910198800... However, in the 90s, conceptual and methodological difficulties decreased interest in the topic. ²¹21 . Solla JJSP. Problemas e limites da utilização do conceito de classe social em investigações epidemiológicas: uma revisão critica da literatura. Cad Saude Publica . 1996;12(2):207-16. DOI:10.1590/S0102-311X1996000200009
https://doi.org/10.1590/S0102-311X199600...

Social dynamics has itself reestablished the importance of social class analysis. Factors such as globalization, increase in risk situations due to the erosion of welfare protection and restrictions imposed on social policies such as job security, minimum wages, social security, universal health systems, and others eventually reintroduced concern on social inequalities. In the last decade, an interest in the study of social determinants and formulation of public policies that can effectively decrease social inequalities in health reopened the discussion on the use of social class concepts as one of the key elements in the process of social reproduction.

Despite the general improvement in health status in high- and middle-income nations and the increase in public and private spending on health, social inequalities have apparently not decreased.

Social class is a key category for studies on social determinants of health-disease processes, considering that health risks tend to accumulate at different rates according to social class and position in the social structure. The better the class position in the social scheme, the greater the likelihood that class members will enjoy longer and healthier lives. ²²22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600... On the other hand, socially disadvantaged groups in the social structure face a disproportionate burden of injuries, illnesses, and death compared with better positioned groups. ²2 . Blacksher CE. Healthcare disparities: the salience of social class. Cam Q Healthc Ethics . 2008;17(2):143-53. DOI:10.1017/S0963180108080171
https://doi.org/10.1017/S096318010808017...

Undeniably, class position determines many aspects of material life by defining access to and possession of material resources, everyday life activities, and vulnerability to numerous determinants of health and disease. Furthermore, class position influences the perception of health problems and the search for solutions.

This article aims to highlight the relevance of the concept of class to epidemiological studies. It analyzes differences between social stratification (functionalist approach) and class structure (comprehensive or dialectic approach), discusses the theoretical density of empirical health research concepts, lists the main operationalization models available, and indicates the limitations and scopes of the empirical use of the concept in health research.

ARGUMENTS IN FAVOR OF THE USE OF SOCIAL CLASS CONCEPTS IN EMPIRICAL RESEARCH

The sociologists Wright and Goldthorpe developed the most renowned conceptual and operationalization models of social class in contemporary sociology for use in empirical research. ¹⁸18 . Santos JAF. Efeitos de classe na desigualdade racial no Brasil. Dados. 2005;48(1):21-65. DOI:10.1590/S0011-52582005000100003

According to Wright, ²⁹29 . Wright EO. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. DOI:10.1017/CBO9780511488900
https://doi.org/10.1017/CBO9780511488900... perhaps the most important issue in contemporary sociological research, for which class analysis can provide relevant answers, is related to inequalities in opportunity and material living standards. According to him, almost all current sociological schools of thought have explored class analysis, although the concepts may be different in each of these traditions of thought.

Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. emphasizes the need for empirical research as a valuable resource to explain social phenomena and argues that quantitative research may be useful outside the tradition of functionalist sociology. He also claims that the Marxist theory can generate real world propositions that can be studied empirically using both quantitative and qualitative approaches.

For Wright, ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. there are several modes of determination, such as concepts or theoretical categories, and empirical phenomena, which can be organized into models. These models are schematic representations of the interactions between modes of determination in a given structural process. Moreover, these models can be viewed as symbolic maps or structured wholes used to mediate the knowledge of reality. In later work, Wright ²⁸28 . Wright EO. The debate on classes. London: Verso; 1989. returned to this topic, using Bhaskar formulations to emphasize the importance of empirical research. Bhaskar had established an epistemological position that was intermediate between naive realism and idealism and had proposed a distinction between three domains of reality, namely the real, the actual, and the empirical, and these corresponded to three ontological categories, namely mechanisms, events, and experiences, respectively. Mechanisms generate events, and together with specific conditions of perception and observation, create experiences. Therefore, theories are regarded as preconditions to understand empirical regularities and reveal the importance given to the formulation and operationalization of concepts.

Wright restates his goal to formulate a class structure concept that can be used in the analysis of microsocial processes, i.e., processes applicable to the study of everyday life. The operationalization model is designed so as to comprehend class structure, which is a real mechanism that exists independently of the theory used to study it.

Goldthorpe and Marshall ⁶6 . Goldthorpe J, Marshall G. The promising future of class analysis: a response to recent critiques. Sociology . 1992;26(3):381-400. DOI:10.1177/0038038592026003002
https://doi.org/10.1177/0038038592026003... start from a Weberian conception of social class, and stress the importance of class analysis in the study of the relationship between class structure and social mobility, social inequalities, and social action. For these authors, class analysis is a research program that can perfectly incorporate distinct sociological theories.

Class conditions affect material interests, life experiences, and the capacity for collective action. It allows access to productive resources and shapes work and consumption experiences, leading to second-order effects on health, attitudes, tastes, etc. ¹⁸18 . Santos JAF. Efeitos de classe na desigualdade racial no Brasil. Dados. 2005;48(1):21-65. DOI:10.1590/S0011-52582005000100003 Clearly, social inequalities cannot be reduced to class inequalities, but class relations play a decisive role in the modulation of other forms of inequality such as ethnic and gender inequalities. ¹⁹19 . Santos JAF. Uma classificação socioeconômica para o Brasil. Rev Bras Ci Soc. 2005;20(58):27-46. DOI:10.1590/S0102-69092005000200002
https://doi.org/10.1590/S0102-6909200500...

It is precisely in this perspective that class concepts can be useful in epidemiological studies, in which one attempts to explain the social inequalities and identify the effects that class position can have on different health-disease aspects at the population level.

DIFFERENT SOCIOLOGICAL APPROACHES IN CLASS ANALYSIS: STRATIFICATION VS. CLASS STRUCTURE

All forms of social class analysis can potentially contribute to a better understanding of the microsocial and macrosocial processes involved in the production of social inequalities. ³⁰30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16. Social inequalities can be studied in attributive or relational terms, focusing predominantly on attribute distributions or structural processes of social reproduction. ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046...

Many class analysis theorists make distinctions between stratification and structure concepts, reserving the term stratification to approaches that identify classes on the basis of attribute distribution and material conditions and defining the boundaries of the strata more or less arbitrarily or through statistical measures of distribution. That way, the class concept would correspond to a cluster of economic and social attributes. The terminology used in stratification models usually differentiates between upper, middle, and lower classes in line with the method of cluster construction and on the basis of the position of individuals in a rank of continuous values. From a theoretical standpoint, these approaches are most useful for descriptive purposes. ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 13}13 . Muntaner C, Borrell C, Vanroelen C, Chung H, Benach J, Kim IH, et al. Employment relations, social class and health: a review and analysis of conceptual and measurement alternatives. Soc Sci Med. 2010;71(12):2130-40. DOI:10.1016/j.socscimed.2010.09.038
https://doi.org/10.1016/j.socscimed.2010... ^{, 30}30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16.

A variant of the stratification concept is the classification based on occupational clustering. This type of class analysis is based on Durkheim’s concept of labor division. The occupational groupings correspond to certain lifestyles, consumption practices, group associations to fight for common interests, and subjective perceptions, among others. The classification is based on the identification of “units of occupation”, i.e., a set of technically similar activities institutionalized in the labor market through trade unions or associations. The classification is also based on the requirement of certain licenses or credentials (titles), skills, and other characteristics. ⁸8 . Grusky D, Galescu G. Foundations of a neo-Durkheimian class analysis. In: Wrigth EO, editors. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. In this sense, the choice of occupational groups as a classification category would have more explanatory power compared with variables such as income, education, wealth, and material possessions.

The approaches by Weber and Marx analyze classes as a result of structural social relations, i.e., the position of individuals in the class structure is inherent to institutionalized social relations and does not correspond to grading on a scale. In these approaches, classes are qualitatively distinct groups.

Weber ⁴4 . Breen R. Foundations of a neo-Weberian class analysis. In: Wrigth EO, editors. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. ^{, 7}7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 30}30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16. believes that the market is the main determinant of economic and social opportunities for individuals. Labor market relations define the class structure, whereas other social relations, which distinguish individuals on the basis of educational credentials, ethnicity, gender, and religion, define the hierarchy of status.

Weber ⁴4 . Breen R. Foundations of a neo-Weberian class analysis. In: Wrigth EO, editors. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. ^{, 7}7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 30}30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16. suggested that four basic classes can be empirically identified in Western capitalist societies. The first distinction is between those who own the means of production and those who do not. The second division depends on the property type and the service type offered in the market. The resulting scheme comprises entrepreneurs (major owners of the means of production), the small bourgeoisie (smallholders), workers with academic credentials, and individuals whose only asset is their own labor. These positions in the class structure are added to those arising from status hierarchies and can shape the social structure, which determines the set of economic and social opportunities for the class occupants.

In the Marxist tradition of class analysis, the mechanisms of domination and economic exploitation are considered to be the main determinants of the resulting social structure. Exploitative relations establish a bond of mutual dependence between the exploiters and the exploited, which is the basis of class relations. Exploitative relations are fundamental to the social reproduction process, determining not only the position of individuals in the production process but also the rules of product distribution and consumption patterns. Therefore, the social relations of production comprise the sum of the rights and authorities that individuals have on the basis of their form of participation in the productive process. ¹⁴14 . Muntaner C, Borrell C, Solá J, Marí-Dell’Olmo M, Chung H, Rodriguez-Sanz M, et al. Class relations and all causa mortality: a test of Wright’s social class scheme using the Barcelona 2000 Health Interview Study. Inter J Health Ser. 2011;41(3):431-58. DOI:10.2190/HS.41.3.c
https://doi.org/10.2190/HS.41.3.c... ^{, 29}29 . Wright EO. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. DOI:10.1017/CBO9780511488900
https://doi.org/10.1017/CBO9780511488900... ^{, 30}30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16.

Bourdieu ³3 . Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 1989. disagrees with the Weberian formulation by considering that status differences are manifestations of class positions and, from the structural standpoint, are not derived from these positions. He believes that the social world can be described as a space constructed by principles of differentiation and distribution in which agents are defined by their relative positions in that space.

The social field or space can be described as a multidimensional space of positions defined according to a set of coordinates. In the first dimension, the positions are defined by the volume of economic and cultural capital of the agents; in the second dimension, they are defined by the composition of capital (relative weight of each type of capital); in the third dimension, they are defined by the trajectories followed by the agents according to the stability or change in capital volume and composition that they experiment over time. ²⁵25 . Weininger EB. Foundations of Pierre Bourdier’s class analysis. In: Wrigth EO, editor. Approaches to class analysis. Cambridge: Cambridge University Press; 2005.

Bourdieu postulated an intrinsic and necessary relationship between class location and habitus, which is a set of socially established provisions that the agents incorporate as a result of the experience of belonging to a certain class. The relationship between habitus and everyday practices configures lifestyles that, in turn, constitute social collectives or status groups differentiated by the symbolic boundaries between the different positions in the class structure occupied by the agents. ²⁵25 . Weininger EB. Foundations of Pierre Bourdier’s class analysis. In: Wrigth EO, editor. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. Based on the positions of agents in the social space, it is possible to delineate classes, i.e., sets of agents who occupy similar positions and who, when subjected to similar material limitations, must share similar interests, attitudes, and social practices. ³3 . Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 1989.

In health research, class position is a key element in determining access to social resources that are available for promotion, protection, and recovery of health. Class relations have direct and indirect consequences on health. Relations between classes and health outcomes are mediated by complex mechanisms of differential exposure to stressors, control and autonomy in labor processes, participation in wealth distribution, consumption patterns, behaviors, symbolic elaborations, and other social processes present in everyday life. ²³23 . Vanroelen C, Levecque K, Moors G, Louckx F. Linking credentialed skills, social class, working conditions and self-reported health: a focus on health inequality –generating mechanisms. Sociol Health Iln. 2010;32(6):948-64. DOI:10.1111/j.1467-9566.2010.01260.x
https://doi.org/10.1111/j.1467-9566.2010... ^{, 24}24 . Veentra G. Social space, social class and Bourdieu: healyh inequalities in Britsh Columbia, Canada. Health Place . 2007;13(1):14-31. DOI:10.1016/j.healthplace.2005.09.011
https://doi.org/10.1016/j.healthplace.20...

In the public health literature, three main approaches to the social class concept have been observed: stratification according to economic or social variables, social class according to the Marxist approach, or social class according to the conception of Bourdieu. ³3 . Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 1989. In social epidemiology studies, the use of social stratification is more frequent, wherein the socioeconomic position is indicated by several variables without any explicit reference to the theoretical model or the sociological school of thought. Although less common, there are examples of relational approaches to class structures. ¹³13 . Muntaner C, Borrell C, Vanroelen C, Chung H, Benach J, Kim IH, et al. Employment relations, social class and health: a review and analysis of conceptual and measurement alternatives. Soc Sci Med. 2010;71(12):2130-40. DOI:10.1016/j.socscimed.2010.09.038
https://doi.org/10.1016/j.socscimed.2010...

EXPLANATORY POTENTIAL OF THE SOCIAL CLASS CONCEPT

Although social stratification measures are very useful in describing and predicting the distribution of events and health problems, they have been less suitable to explain the social mechanisms that determine the position of social agents in the different gradients analyzed. Therefore, these measures have contributed little to the understanding of the social determinants of the health-disease processes.

The relational concepts of class, in any of their theoretical approaches, have greater explanatory potential. Studies show that stratification and class structure capture various aspects of social inequality in health and are not completely similar to each other.

Analyses based on social stratification are more consistent with the notion that health behaviors depend fundamentally on knowledge of the risks and benefits associated with particular courses of action. The explanations derived from relational approaches establish a connection between socioeconomic behaviors and circumstances, considering that behaviors of individual agents are determined by structural conditions. In the Weberian version, the explanatory emphasis is placed on the idea of different opportunities associated with different forms of agent participation in the market. ¹⁰10 . Lindbladh E, Lyttkens CH, Hanson BS, Östergren P, Isacsson SO, Lindgren B. An economic and sociological interpretation of social differrences in health-related behaviours and encounter as a guide to social epidemiology. Soc Sci Med. 1996;43(12):1817-27. DOI:10.1016/S0277-9536(96)00087-1
https://doi.org/10.1016/S0277-9536(96)00...

In the Marxist version and in Bourdieu’s perspective, ³3 . Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 1989. the material and symbolic conditions inherent to social relations and related to the agent’s position in the social structure or social space are determinants of attitudes, preferences, resources, courses of action, and, consequently, health outcomes. Social classes exert pervasive psychological effects on their members, shaping the way individuals construct their social environment and behavior in relation to others. ¹⁵15 . Piff PK, Kraus MW, Cote S, Cheng BH, Keltner D. Having less, giving more: the influence of social class on prosocial behaviors. J Pers Soc Psychol. 2010; 99(5):771-84. DOI:10.1037/a0020092
https://doi.org/10.1037/a0020092...

The notion of habitus is useful to overcome the macro-micro and objective-subjective dualities in the analysis of class and its impact on health because it mediates social structure (macrosocial organization) and the behavior of groups or individuals (micro-organization). On the other hand, by connecting the economic capital (material conditions) with the social and cultural capital, the subjective-objective duality in the analysis of social phenomena in everyday life is overcome. ³3 . Bourdieu P. O poder simbólico. Rio de Janeiro: Bertrand Brasil; 1989.

The explanatory capacity of class concepts in health research can be demonstrated by their interaction with predictors such as age, gender, and ethnicity, all of which are modified or subsumed by social class determinants.

Social classes explain how social inequalities are generated and are the basis for the distribution of social determinants of health, such as income, working conditions, and access to health services. The relational concepts have a potentially greater explanatory power and higher theoretical density in health-related empirical analyses compared with conventional approaches focused on social stratification. ¹²12 . Muntaner C, Borrell C, Solá J, Marí-Dell’Olmo M, Chung H, Rodríguez-Sanz M, et al. Capitalists, manangers, profissionals and mortality: findings from the Barcelona social class and all cause mortality longitudinal study. Scand J Public Health . 2009;37(8):826-38. DOI:10.1177/1403494809346870
https://doi.org/10.1177/1403494809346870...

Class analysis can be useful in explaining disparities in health status and epidemiological profile as well as in explaining distinct patterns of access and use of health services and resources in general.

OPERATIONALIZATION MODELS OF SOCIAL CLASS

In addition to the two models embodied in the sociological literature and proposed by Goldthorpe ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... and Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. , other models have been reviewed, such as the one proposed by Singer ²⁰20 . Singer P. Dominação e desigualdade: estrutura de classes e repartição de renda no Brasil. Rio de Janeiro: Editora Paz e Terra; 1981. and adapted by Barros ¹1 . Barros MBA. A utilização do conceito de classe social nos estudos dos perfis epidemiológicos: uma proposta. Rev Saude Publica . 1986;20(4):269-73. DOI:10.1590/S0034-89101986000400001
https://doi.org/10.1590/S0034-8910198600... for health research and the one developed by Bronfman and Tuirán ⁵5 . Bronfman M, Tuirán RA. La desigualdade social ante la muerte: clases sociales y mortalidade en la ni-ez. Cuad Med Soc. 1984;29/30:53-75. and adapted by Lombardi et al. ¹¹11 . Lombardi C, Bronfman M, Facchini LA, Victora CG, Barros FC, Beria JU, et al. Operacionalização do conceito de classe social em estudos epidemiológicos. Rev Saude Publica . 1988;22(4):253-65. DOI:10.1590/S0034-89101988000400001
https://doi.org/10.1590/S0034-8910198800...

The model developed by Goldthorpe ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... is extensively used for the empirical analyses of social class, particularly in sociological research on social mobility. From the theoretical point of view, this model agrees with the Weberian conception of social class and seeks to establish the classification of individuals based on different characteristics of integration in the labor market. The scheme is constructed after considering, at a first level, the situation in the market, i.e., by grouping occupations that are similar in terms of employment conditions, source and level of income, financial security, and career prospects. A second level of differentiation takes into account the labor situation with regard to the position within the authority hierarchy and the level of control over the labor process. A third level of differentiation corresponds to employment, which considers the type of contract, number of employees, and other factors. ⁴4 . Breen R. Foundations of a neo-Weberian class analysis. In: Wrigth EO, editors. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. ^{, 7}7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 17}17 . Regidor E. La clasificacion de clase social de Goldthorpe: marco de referencia para La propuesta de medición de La clase social Del grupo de trabajo de La Sociedad Espa-ola de Epidemiologia. Rev Esp Salud Publica. 2001;75(1):13-22. DOI:10.1590/S1135-57272001000100003
https://doi.org/10.1590/S1135-5727200100... ^{, 18}18 . Santos JAF. Efeitos de classe na desigualdade racial no Brasil. Dados. 2005;48(1):21-65. DOI:10.1590/S0011-52582005000100003 The resulting scheme defines three categories and seven classes ( Table 1 ).

It is possible to adopt a summarized structure containing four classes: service class (I + II), intermediate classes (IIIa + V), manual workers (IIIb + VI + VII), and petite bourgeoisie (IV).

The Spanish Society of Epidemiology ¹⁷17 . Regidor E. La clasificacion de clase social de Goldthorpe: marco de referencia para La propuesta de medición de La clase social Del grupo de trabajo de La Sociedad Espa-ola de Epidemiologia. Rev Esp Salud Publica. 2001;75(1):13-22. DOI:10.1590/S1135-57272001000100003
https://doi.org/10.1590/S1135-5727200100... has adapted this model for use in health research and proposed a scheme with five classes ( Table 2 ).

Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. started from Poulantzas’s formulation, ¹⁶16 . Poulantzas N. As clases sociais no capitalismo de hoje. Rio de Janeiro. Editora Zahar, 1978. which considers three determination axes for classes: economic, political, and ideological. The economic axis is defined by its polarity in the relation of exploitation and the distinction between productive and unproductive labor. In both the political and ideological axes, distinctions are made on the basis of the concepts of domination and subordination. A theoretical-methodological difficulty, i.e., the conceptualization and operationalization of productive and unproductive labor as well as the empirical observation that more than 85% of the economically active North American population had been categorized as proletariat, led Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. to develop an alternative proposal within the framework of the Marxist theory of class analysis.

Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. identified three distinct locations in the class structure, derived from exploitation relations in the capitalist production system: the bourgeoisie (investment controls, accumulation processes, means of production, and employed workforce), the proletariat (no control over the means of production), and the petite bourgeoisie (investment control over the means of production but no control over the workforce). He also proposed three other locations, which are considered contradictory, in order to solve the “middle class problem” in modern societies. He also claims the existence of contradictory locations between the proletariat and the bourgeoisie (occupations with varying degrees of control over the means of production exercised by waged employees), between the proletariat and the petite bourgeoisie (semiautonomous employees), and between the petite bourgeoisie and the bourgeoisie (small employers).

Reviewing his proposition, Wright ²⁸28 . Wright EO. The debate on classes. London: Verso; 1989. ^{, 29}29 . Wright EO. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. DOI:10.1017/CBO9780511488900
https://doi.org/10.1017/CBO9780511488900... reformulated his model and put greater emphasis on the concept of exploitation. In this perspective, the unequal distribution of the means of production constitutes the material basis for the exploitation system and capitalist accumulation. The social relations of production determine social class configurations, and fundamental disparity occurs between owners and non-owners of the means of production. Among the owners, he proposes stratification into bourgeoisie, small employers, and petite bourgeoisie according to the number of employees.

Non-owners of the means of production correspond to waged workers whose location can be created from two axes: domination/subordination relations in the production process and the possession of qualifications or expertise. Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. ^{, 28}28 . Wright EO. The debate on classes. London: Verso; 1989. considers that domination relations are also constitutive of the accumulation process because waged workers with domination positions act as delegates of capitalists and guarantors of the process of appropriation of the surplus value in addition to taking a portion of the surplus value through their wages. The possession of educational credentials or expertise distinguishes part of the waged workers because of their scarcity in the labor market. This is a mechanism that also allows these workers to be an appropriate part of the surplus value. Therefore, a scheme with 12 classes defined by the combination of the three axes would be possible ( Table 3 ).

Santos ¹⁸18 . Santos JAF. Efeitos de classe na desigualdade racial no Brasil. Dados. 2005;48(1):21-65. DOI:10.1590/S0011-52582005000100003 used this classification to define social classes in the Brazilian population using data from the National Research by Household Sampling (NRHS), and he showed the possibility of operationalization with Brazilian data.

In Brazil, two operationalization models have been used in health research. One was developed by Singer ²⁰20 . Singer P. Dominação e desigualdade: estrutura de classes e repartição de renda no Brasil. Rio de Janeiro: Editora Paz e Terra; 1981. to study the distribution of income in Brazil and adapted by Barros ¹1 . Barros MBA. A utilização do conceito de classe social nos estudos dos perfis epidemiológicos: uma proposta. Rev Saude Publica . 1986;20(4):269-73. DOI:10.1590/S0034-89101986000400001
https://doi.org/10.1590/S0034-8910198600... for household health surveys, while the other was developed by Bronfman & Tuirán ⁵5 . Bronfman M, Tuirán RA. La desigualdade social ante la muerte: clases sociales y mortalidade en la ni-ez. Cuad Med Soc. 1984;29/30:53-75. for demographic studies and was adapted by Lombardi et al ¹¹11 . Lombardi C, Bronfman M, Facchini LA, Victora CG, Barros FC, Beria JU, et al. Operacionalização do conceito de classe social em estudos epidemiológicos. Rev Saude Publica . 1988;22(4):253-65. DOI:10.1590/S0034-89101988000400001
https://doi.org/10.1590/S0034-8910198800... for use in epidemiological research.

Singer ²⁰20 . Singer P. Dominação e desigualdade: estrutura de classes e repartição de renda no Brasil. Rio de Janeiro: Editora Paz e Terra; 1981. formulated a class operationalization model from data available in the demographic census and the NRHS. He proposed a scheme of five classes defined on the basis of the occupied position, income level, activity sector, and occupation. Moreover, he considered the existence of two strata for the bourgeoisie: the entrepreneurial bourgeoisie, formed by legal owners of productive enterprises, and the managerial bourgeoisie, composed of executives and technicians in charge of corporate administration and administrators of the State apparatus (public administration, universities, foundations, research agencies, and others).

The petite bourgeoisie comprises the self-employed and small employers. The proletariat is a group of waged workers from all sectors of the economy, with the exception of those from the managerial bourgeoisie. Finally, individuals with precarious positions in the labor market, such as rural migrants, squatters, independent workers without a business, the unemployed, and the disabled, form the subproletariat. The operationalization strategy adopted by Barros ¹1 . Barros MBA. A utilização do conceito de classe social nos estudos dos perfis epidemiológicos: uma proposta. Rev Saude Publica . 1986;20(4):269-73. DOI:10.1590/S0034-89101986000400001
https://doi.org/10.1590/S0034-8910198600... as an adaptation of the proposal by Singer is presented in Table 4 .

Bronfman & Tuirán ⁵5 . Bronfman M, Tuirán RA. La desigualdade social ante la muerte: clases sociales y mortalidade en la ni-ez. Cuad Med Soc. 1984;29/30:53-75. developed an operationalization model for the Encuesta Nacional Demográfica de Mexico (National Demographic Survey of Mexico). The first dimension of the classification is the place or position in the production system (activity status, occupational position, sector and branch of activity, occupation, and number of employees). The second dimension is ownership of the means of production. The third dimension is the role in the social organization of labor (schooling and skills), and the fourth dimension is participation in wealth (salary and other income sources). From the combination of these dimensions, the authors arrive at a model of six classes: bourgeoisie, new petite bourgeoisie, traditional petite bourgeoisie, atypical proletariat, typical proletariat, and sub-proletariat ⁵5 . Bronfman M, Tuirán RA. La desigualdade social ante la muerte: clases sociales y mortalidade en la ni-ez. Cuad Med Soc. 1984;29/30:53-75. ( Table 5 ).

Lombardi et al ¹¹11 . Lombardi C, Bronfman M, Facchini LA, Victora CG, Barros FC, Beria JU, et al. Operacionalização do conceito de classe social em estudos epidemiológicos. Rev Saude Publica . 1988;22(4):253-65. DOI:10.1590/S0034-89101988000400001
https://doi.org/10.1590/S0034-8910198800... compared the class structure of the population of Pelotas, RS, as classified according to the model of Bronfman & Tuirán ⁵5 . Bronfman M, Tuirán RA. La desigualdade social ante la muerte: clases sociales y mortalidade en la ni-ez. Cuad Med Soc. 1984;29/30:53-75. and as classified according to that model used by Barros and observed that major discrepancies occurred in relation to: a) the reduction of the subproletariat as a result of the reclassification of agriculture and civil construction workers, skilled workers or administrative workers, as well as of the self-employed without a business but with specific skills; b) the increase of the proletariat as a result of the incorporation of the reclassified workers from the subproletariat; c) the reclassification of the managerial bourgeoisie as new petite bourgeoisie.

In general, these are the schemes that are currently available for the operationalization of class concept from a relational perspective. They are distinct from social stratifications based on the use of isolated socioeconomic variables or on the composition or synthesis of a set of socioeconomic variables.

LIMITATIONS AND SCOPES OF OPERATIONALIZATION MODELS

The operationalization process of any concept presents a number of conceptual, methodological, and technical challenges. In the case of a complex concept such as social class, these difficulties are even greater.

With regard to the conceptual dimension, the limitations noted by the authors or critics of these models are associated with three main problems: greater difficulty in operationalizing the political aspects of the concept rather than economic aspects, definition of the boundaries between the proletariat and the so-called “middle classes,” and difficulty in selecting empirical variables capable of describing the relational nature of certain processes to avoid reduction to mere stratification. ²²22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600...

With regard to the first problem stated above, there are critics who simply consider it impossible to operationalize social class concepts. They claim that it only makes sense as a theoretical tool in macrosocial analyses developed by Marx and as an explanatory category in historical materialism. Others acknowledge operationalization, but they believe that only the economic aspects of translation into empirical approaches are amenable. Authors such as Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. and Goldthorp ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... are of the opinion that economic and political aspects are inseparable, and they believe in the possibility of translating any theoretical concept into a series of mechanisms, events, and empirical experiences susceptible of being observed in reality. ²²22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600...

With regard to class definitions, problems arise in the conceptualization of the proletariat, in the configuration of middle classes, and in the definition of strata within the bourgeoisie. ²²22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600... Poulantzas ¹⁶16 . Poulantzas N. As clases sociais no capitalismo de hoje. Rio de Janeiro. Editora Zahar, 1978. proposed that only productive workers should be classified as workers. Goldthorpe ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... and Wright ²⁷27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. ^{, 28}28 . Wright EO. The debate on classes. London: Verso; 1989. classified waged workers who have no control over the labor process as proletariat, and found it difficult to empirically separate productive from unproductive labor. According to Wright ²⁸28 . Wright EO. The debate on classes. London: Verso; 1989. , authors’ views on the boundaries of the middle class vary considerably and include the denial of their existence, the definition as a relation between two polar classes, conceptualization as new phenomena not previously theorized in the tradition of Marxist sociology or comprehensive sociology, and the concept of contradictory locations formulated by Marx to solve the problem.

The third problem within the conceptual domain refers to the translation of certain analysis categories into empirical variables. Concepts such as appropriation of surplus value, autonomy and control over production, and educational qualifications and credentials present challenges in the identification and articulation of empirical variables capable of translating them adequately. ²²22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600...

From a methodological point of view, the main problems encountered are as follows: classification of population segments that are not included in the production process, classification of individuals or family groups, and specificities of particular social formations.

Various authors recognize the need to adjust the models to the characteristics of each social formation and the goals of the empirical research. All models presuppose the possibility of grouping individuals in more or less classes, depending on the object of the research. ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 22}22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600... ^{, 29}29 . Wright EO. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. DOI:10.1017/CBO9780511488900
https://doi.org/10.1017/CBO9780511488900...

Individuals not included directly in the production process, such as students and housewives, can be classified by their family relationships (class location mediated by family ties). Those individuals who are permanently excluded from the labor market can be grouped in the “oppressed” class, i.e., individuals excluded from the capitalist relations of production. ⁷7 . Goldthorpe J. Analysing social inequality: a critique of two recent contributions from economics and epidemiology. Eur Sociol Rev. 2010;26(6):731-44. DOI:10.1093/esr/jcp046
https://doi.org/10.1093/esr/jcp046... ^{, 27}27 . Wrigth EO. Class, crisis & the State. London: Verso; 1978. ^{, 30}30 . Wrigth EO. Understanding class: towards an integrated approach. New Left Rev. 2009; 60:101-16. These solutions are not equally satisfactory and may pose new problems when applied empirically.

Other important methodological problems are associated with the class trajectory of individuals or simply their current situation, e.g., assigning the most adequate trajectory to an individual with different insertions in the production process, either choosing a family member who will determine the classification of the group or create a classification structure based on the different insertions of its members, and addressing the class situation of women. ²⁹29 . Wright EO. Approaches to class analysis. Cambridge: Cambridge University Press; 2005. DOI:10.1017/CBO9780511488900
https://doi.org/10.1017/CBO9780511488900... These aspects depend on choices made by the researchers and will influence the final empirical results.

For statistical purposes, the operationalization models require large samples capable of providing a minimum number of individuals from all classes as well as databases with variables that are sufficient and appropriate to the construction of the proposed models. ¹³13 . Muntaner C, Borrell C, Vanroelen C, Chung H, Benach J, Kim IH, et al. Employment relations, social class and health: a review and analysis of conceptual and measurement alternatives. Soc Sci Med. 2010;71(12):2130-40. DOI:10.1016/j.socscimed.2010.09.038
https://doi.org/10.1016/j.socscimed.2010... ^{, 22}22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600... This is one of the aspects that hinders the widespread use of these operationalization models.

It is necessary to establish relatively arbitrary cutoffs for some of the variables used, such as the number of employees and income, even if fully convincing arguments for the values chosen are not available. ¹⁷17 . Regidor E. La clasificacion de clase social de Goldthorpe: marco de referencia para La propuesta de medición de La clase social Del grupo de trabajo de La Sociedad Espa-ola de Epidemiologia. Rev Esp Salud Publica. 2001;75(1):13-22. DOI:10.1590/S1135-57272001000100003
https://doi.org/10.1590/S1135-5727200100... ^{, 20}20 . Singer P. Dominação e desigualdade: estrutura de classes e repartição de renda no Brasil. Rio de Janeiro: Editora Paz e Terra; 1981.

The major problem may arise from the fact that social class is a distal determinant, the action of which is mediated by several more or less independent variables, and that its strength is relatively weakened after controlling these intervening variables in the regression models used in health research. ¹³13 . Muntaner C, Borrell C, Vanroelen C, Chung H, Benach J, Kim IH, et al. Employment relations, social class and health: a review and analysis of conceptual and measurement alternatives. Soc Sci Med. 2010;71(12):2130-40. DOI:10.1016/j.socscimed.2010.09.038
https://doi.org/10.1016/j.socscimed.2010... ^{, 17}17 . Regidor E. La clasificacion de clase social de Goldthorpe: marco de referencia para La propuesta de medición de La clase social Del grupo de trabajo de La Sociedad Espa-ola de Epidemiologia. Rev Esp Salud Publica. 2001;75(1):13-22. DOI:10.1590/S1135-57272001000100003
https://doi.org/10.1590/S1135-5727200100... ^{, 22}22 . Solla JJSP. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cad Saude Publica . 1996;12(3):329-37. DOI:10.1590/S0102-311X1996000300006
https://doi.org/10.1590/S0102-311X199600... Although regression models are useful tools, they are rudimentary instruments while dealing with the complexity of social reality. In these models, social classes are included as another independent variable, and the relations of determination and mediation between the social class and the other intervening variables are not included in the model.

Despite all the limitations listed above, operationalization of the concept of social class has a greater explanatory power because stratified analyses are fragmented. The more widespread use of these models will allow assessment of the extent to which this theoretical expectation can be confirmed as well as the accumulation of experiences and practical solutions.

FINAL CONSIDERATIONS

There are different theoretical perspectives and various operational models that can be used for the operationalization of social class concepts that can be used in empirical research.

From the theoretical point of view, all approaches are valuable for the study of social inequalities in health depending on the authors of the research. Therefore, none of the theories presented can be considered false, and all are useful to describe the phenomena; however, some theories have a greater explanatory power compared with others.

Conceptually, each of the models presented is consistent with the theoretical concept that underlies it, precluding the selection of one model over the others.

From an empirical point of view, it may be possible to differentiate the models at a later phase of the research, with the purpose of making empirical comparisons of the models presented.

References

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