Socioeconomic status and health: The role of subjective social status☆
Introduction
Socioeconomic inequalities in health are a key public health problem (Siegrist & Marmot, 2004). People of higher socioeconomic status (SES) live longer, enjoy better health, and suffer less from disability, while those of lower SES die younger and suffer a greater burden of disease and disability (Dalstra et al., 2005, Huisman et al., 2005, Mackenbach et al., 1997, Marmot et al., 1997, Marmot et al., 1978, Minkler et al., 2006). In many cases the associations between SES and health outcomes take the form of a gradient – the higher the SES the better the health (Adler et al., 1994, Marmot, 2006). Many different explanations for socioeconomic gradients in health have been proposed, but the causal pathways through which SES determines health in such an orderly way, are not well established (Adler et al., 1994, Steptoe and Marmot, 2002). Nevertheless, the existence of socioeconomic gradients in health suggests that causal processes do not operate only below a certain threshold through an impact of poverty, instead it points to a generic effect of SES on the health of all people. One mechanism for such a generic effect could be subjective social status through its impact on stress or other pathways.
Subjective social status (SSS) refers to “the individual's perception of his own position in the social hierarchy” (Jackman & Jackman, 1973) and relates to objective SES inasmuch as the socioeconomic resources people possess form the basis for their judgements about their social standing in a given society or community. Although people might use non-economic criteria (e.g. prestige) to make judgements about their own social status (Singh-Manoux, Adler, & Marmot, 2003) and identify to a variable extent with their objective socioeconomic situation, it is the objective indicators of SES that can be expected to constitute the basis of SSS. Current research, in line with these speculations, has suggested that SSS “reflects the cognitive averaging of standard markers of socioeconomic situation” (Singh-Manoux et al., 2003).
Until recently epidemiological research has relied on objective dimensions of SES, such as education and occupational class. SSS has only recently been used to explore health and health inequalities (Ostrove, Adler, Kuppermann, & Washington, 2000). This paper examines SSS as a health correlate and explores its role as a potential mediator of the associations between objective indicators of SES (education, occupational class, and wealth) and health. The exploration of SSS as a health correlate is expected to add an element of social meaningfulness to the association between SES and health (Nock & Rossi, 1979) by incorporating people's assessments of their experiences of deprivation and perceptions of own social status. Moreover, it should be noted that this paper is of added value as it focuses on later stages of the life-course where evidence on the size and patterns of health inequalities is still ambiguous (Chandola, Ferrie, Sacker, & Marmot, 2007).
Evidence on SSS as a correlate of health in old age is scarce, with only one such study identified in our literature review (Hu, Adler, Goldman, Weinstein, & Seeman, 2005). Nevertheless, an increasing body of research, mostly cross-sectional, indicates that SSS (measured as a ladder score) relates over and above objective SES markers to self-rated health (Franzini and Fernandez-Esquer, 2006, Hu et al., 2005, Operario et al., 2004, Ostrove et al., 2000, Singh-Manoux et al., 2005), mental health (Franzini and Fernandez-Esquer, 2006, Singh-Manoux et al., 2005), heart rate and sleep latency (Adler, Epel, Castellazzo, & Ickovics, 2000), cortisol levels (Wright & Steptoe, 2005), and dental outcomes (Sanders, Slade, Turrell, Spencer, & Marcenes, 2006). Also, there is evidence that SSS relates to adolescent health (Goodman et al., 2001, Goodman et al., 2003). In contrast, research has shown that SSS is not related at all to body mass index, sleep quality, and resting systolic blood pressure in women (Adler et al., 2000), angina and respiratory illness in women (Singh-Manoux et al., 2003), and difficulties in activities of daily living (Hu et al., 2005). Also, studies have shown that adjusting for objective indicators of SES attenuates the associations of SSS with perceptions of physical health (Franzini & Fernandez-Esquer, 2006), diabetes, self-rated health, and depression in both sexes, and angina and respiratory illness in men (Singh-Manoux et al., 2003).
As this paper aims at exploring the role of SSS for health as comprehensively as possible, it uses three objective SES indicators: education, occupational class, and wealth, along with SSS. The use of multiple indicators of SES accounts for both common and differential effects of the various SES dimensions on health and provides insights into their interrelationships, which are relevant for health over and above direct causal associations (Blane, 1995, Krieger et al., 1997, Lahelma et al., 2004, Singh-Manoux et al., 2002). Unlike most studies we are able to include wealth as a measure of material inequalities. We consider this to be a major advantage of our study as wealth is a marker of SES that indicates command over assets and material resources, reflects accumulated advantage and future economic prospects, and lies in the core of material inequalities in health (Oliver and Shapiro, 1995, Ostrove et al., 1999). Moreover, the inclusion of wealth adds value to this study as, unlike education and occupational class, it reflects contemporary SES and therefore is a more appropriate measure for use in older adults.
We aimed to explore more thoroughly than previously the associations of SSS with both self-perceived and clinical measures of health. Non-clinical measures have been chosen on account of their importance as determinants of quality of life and people's experiences of it. The selected clinical measures are risk factors for cardiovascular disease, and their inclusion is intended to establish whether SSS is involved in pathogenic processes related to cardiovascular outcomes.
Recent evidence suggests that there are gender differences in coronary heart disease and the distribution of related risk factors (i.e. hypertension and diabetes) (Dalstra et al., 2005, Thurston et al., 2005) and that different SES dimensions might relate in a differential way to men's and women's health outcomes (Sacker, Firth, Fitzpatrick, Lynch, & Bartley, 2000). For this reason we have undertaken gender-specific analyses.
The aims of this paper are to examine: (a) the associations between SSS and self-perceived and clinical health measures, (b) whether these associations remain significant after adjustment for objective indicators of SES (wealth, occupational class and education), and (c) the influence SSS might exert on the associations of objective SES markers (education, occupational class and wealth) with the selected health outcomes.
Section snippets
Sample, design and participants
Cross-sectional data from the second wave (2004–2005) of the English Longitudinal Study of Ageing (ELSA) were used. ELSA is a multidisciplinary study of ageing and the social, psychological, economic, and health factors that relate to it. The sample was drawn from 3 years of the annual cross-sectional Health Survey for England (HSE) (1998, 1999 and 2001), which each year is organized around a different health theme. The HSE annual samples are representative of the English population living in
Results
The distribution of SSS was normal and unimodal (Fig. 1). The full range of score distribution (1–10) was observed in both men and women. The mean SSS value for the entire sample was 5.88 (95% CI: 5.84, 5.93), while the median and mode coincided on the sixth rung. Both men and women thought of their social status as being slightly higher than the midpoint of the distribution, but men tended to report higher SSS (mean = 5.95, 95% CI: 5.89, 6.01) than women (mean = 5.82, 95% CI: 5.77, 5.88)
Discussion
This paper has explored the associations between SSS and health outcomes in a national sample of non-institutionalised people aged 52 or over in England. It has also examined whether SSS mediated the associations between objective SES indicators and health outcomes. It was found that SSS was significantly related to the examined health outcomes and that these relationships could only partially be accounted for by either sociodemographic characteristics such as age and marital status or the
References (41)
- et al.
The association of subjective social status and health in low-income Mexican-origin individuals in Texas
Social Science & Medicine
(2006) - et al.
Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations
Lancet
(2005) - et al.
Socioeconomic inequalities in morbidity and mortality in western Europe
Lancet
(1997) - et al.
Contribution of job control and other risk factors to social variations in coronary heart disease incidence
Lancet
(1997) - et al.
Health inequalities and the psychosocial environment – two scientific challenges
Social Science & Medicine
(2004) - et al.
Subjective social status: its determinants and its association with measures of ill-health in the Whitehall II study
Social Science & Medicine
(2003) - et al.
Subjective socioeconomic position, gender and cortisol responses to waking in an elderly population
Psychoneuroendocrinology
(2005) - et al.
Socioeconomic-status and health – the challenge of the gradient
American Psychologist
(1994) - et al.
Relationship of subjective and objective social status with psychological and physiological functioning: preliminary data in healthy white women
Health Psychology
(2000) - et al.
Metabolic syndrome – a new world-wide definition. A consensus statement from the International Diabetes Federation
Diabetic Medicine
(2006)
Standards of medical care in diabetes-2006
Diabetes Care
Social determinants of health – socioeconomic status, social class, and ethnicity
American Journal of Public Health
Social inequalities in self reported health in early old age: follow-up of prospective cohort study
British Medical Journal
Methodology
Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries
International Journal of Epidemiology
Impact of objective and subjective social status on obesity in a biracial cohort of adolescents
Obesity Research
Adolescents' perceptions of social status: development and evaluation of a new indicator
Pediatrics
Quality control of blood, saliva and urine analytes
The socioeconomic status of older adults: how should we measure it in studies of health inequalities?
Journal of Epidemiology & Community Health
Relationship between subjective social status and measures of health in older Taiwanese persons
Journal of the American Geriatrics Society
Cited by (0)
- ☆
The data were made available through the UK Data Archive. English Longitudinal Study of Ageing (ELSA) was developed by a team of researchers based at University College London, the Institute of Fiscal Studies and the National Centre for Social Research. The funding is provided by the National Institute on Aging in the United States (grants 2RO1AG7644-01A1 and 2RO1AG017644) and a consortium of UK government departments coordinated by the Office for National Statistics. JN and MM are supported by the ESRC through its funding of the project ‘Inequalities in health in an ageing population: patterns, causes and consequences’ (RES-000-23-0590). MM is supported by a Medical Research Council Research Professorship. The developers and funders of ELSA and the Archive do not bear any responsibility for the analyses or interpretations presented here.