Why should health psychologists care about socioeconomic status?
Karen A. Matthews, Ph.D.
Low education associated with:
• high BP• high cholesterol• high insulin• high 2-hour glucose• ever smoker• low consumption alcohol• physical inactivity• high BMI• history of hysterectomy*• taking medications for chronic conditions*
*ineligible
Matthews et al., Am J Epidemiol. 129: 1132-1144, 1989.
Low education associated with:
• not discussing anger• high (trait) anger• high anger-in• high depression symptoms• low social support • high pessimism
Matthews et al. , Am J Epidemiol. 129: 1132-1144, 1989.
Why should we care about SES?
Selection of study populationsUnderstand limits of generalizability of findingsEvaluation of psychosocial processes that may
mediate or moderate associations between SES and health
Designing targeted interventions on health-damaging processes associated with poor health
Matthews KA: Health Psychology 8:641-648, 1989.
Questions:
1. What is the definition of SES and how is it measured?
2. What are the relationships between SES and health? When does the association start in the life span?
3. Why is SES related to health?
4. What can be done?
Socioeconomic Status: One’s social position linked to both access to resources and prestige in a social hierarchy.
Common Measures: • Education• Occupational rank• IncomeOther Measures:• Wealth (savings, material resources)• Subjective rank• Childhood SES• Income loss/gain
Median Net Worth in 1991 by Monthly Household Income Quintiles for Whites, Blacks, and Hispanics
Household Income White Black Hispanic
All $44,408 $4,604 $5,345
Lowest Quintile $10,257 $1 $645
Second Quintile $25,602 $3,299 $3,182
Third Quintile $33,503 $7,987 $7,150
Fourth Quintile $52,767 $20,547 $19,413
Highest Quintile $129,394 $54,449 $67,435
Eller TJ: Household wealth and asset ownership; 1991. US Bureau of Census, Current Population Reports, P70-34. Washington, D.C.: US GPO, 1994.
Measures can be taken at an individual, neighborhood,
or national Level
Davey-Smith, et al. BMJ. 1992, 304:431-434.
All-Cause Mortality by IncomeNLMS, 25+ years
SMR (O/E)
Rogot, et al. 1992
0
20
40
60
80
100
120
140
White Male Af-Am Male WhiteFemale
Af-AmFemale
<$50005-9,99910-14,99915-19,99920-24,99925-49,999>50,000
Association of CHD among Black and White Women aged 45-54 by State in 1994 against
Race-Specific Educational Attainment
Percent of not-a-high-school graduate
CH
D m
orta
lity
(41
0-41
4, 4
29.2
) am
ong
wom
en a
ged
45-
54 (
/100
,000
)
J Womens Health Gend Based Med, 2000; 9: 545-558
Race black white
Chronic Conditions More Prevalent Among Those with <12 Year of Education
NHS, 1989: 65 + years
Arthritis Gout Intervertebral disc dis.
Gastritis Kidney dis. Indigestion
Cerebrovascular dis. Hardening of the arteries Varicose veins
Bunions Psoriasis Visual impairment
Diverticulitis Constipation Goiter
Chronic bronchitis Asthma Hay fever
Cataracts Hearing impairment Speech impairment
Diabetes Anemias Migraine
Chronic Sinusitis Emphysema Abd. Hernia
Abs. Of extremities Paralysis Deformity or orth. Impairment Ulcer
Neuralgia/Neuritis Kidney trouble Ischemic heart dis. Other heart dis. Hypertension
Series 10, No. 129
Odds Ratio of Life Time Psychiatric Disorders from National Comorbidity
Study Comparing Those < 19K and > 70K
1
1.4
1.8
2.2
2.6
Affective Disorder
AnxietyDisorder
SubstanceAbuse
AntisocialPersonality
3 Disorders
Kessler, Arch Gen Psychiatry, 1994
Explanations for SES-Health Link
• Poor health causes lowering of SES• Poverty is all that matters• Poor quality health care• Toxic environments • Low intelligence• Adverse health behaviors• High stress environments • Low resources
Risk of Subsequent Income Loss (<$25K) in Depressed (> 16 CES-D) Compared
with Non-depressed Participantsin CARDIA (N=2781)
OR (95% CI) P
White Men 2.4 (1.0 – 5.5) 0.05
White Women 2.2 (1.0 – 4.6) 0.05
African American Men 3.1 (1.5 – 6.6) 0.003
African American Women 1.8 (1.0 – 3.3) 0.05
Whooley et al., Annals of Internal Medicine, in press
Psychol Bull 128:295-329, 2002
0
3
6
9
12
15
18
1 2 3 4 5
Any limiting chronic condition
Asthma prevalence
Ear disease
Injury
Physical inactivity
Prevalence of Health Problems in Children
SES (lowest to highest)
Per
cen
tag
e
Is the association between educational attainment and adult health due in part to poor health in childhood limiting achievement?
Children’sHealth
Children’sEducation
Duration & Quality
Adult Health
Risk
Parental Education
Low education of mother associated with:
• Low birth weight in Whites, Blacks, American Indians or Alaska Natives, not Hispanics
• Teenage births in all groups
• No prenatal care during first trimester in all groups
Health, United States, 1998, with Socioeconomic Status and Health Chartbook
Relationships between SES in Childhood and Health at 26 years: Dunedin Birth Cohort
SES
Adult health Child Adult Social Origin
Physical:
BMI
Waist/hip ratio
SBP
V02 max
Dental:
Tooth cleanliness
Dental caries > 4
Mental:
Major depression
Alcohol dependency
Tobacco dependency Lancet 2002; 360:1640-1645
Variations in Age-26 Health Outcomes as a Function of Alcohol Dependence and Waist:Hip Ratio
0
5
10
15
20
25
30
High Downwardmobility
Upwardmobility
Low76
78
80
82
84
High Downwardmobility
Upwardmobility
Low
% Alcohol Dependence Mean Waist:Hip Ratio
Lancet 360:1640-1645, 2002
Adjusted Hazard Ratios for Low Relative to High SES for CVD Mortality
in Alameda County Study
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Haz
ard
Rat
io
ChildhoodSES
Education Occupation Income
Beebe-Dimmer: Am J Epidemiol 159:481-490, 2004.
Only in America…
The Reserve Capacity Model
Low SES
Access to
resources
Position in
social
hierarchy
Risk for
atherosclerosis
and
CHD
Threat of
or actual
loss/harm
Potential
for or
actual benefit/
gain
Reserve
Capacity
Tangible
Interpersonal
Intrapersonal
Negative
emotion and
cognition
Positive
emotion and
cognition
TimeC
A
B
D
E
Gallo & Matthews. Psychol Bull 129:10-51, 2003.
Reserve
Capacity
Tangible
Interpersonal
Intrapersonal
What is Reserve Capacity?Resource bank containing:
• Tangible, e.g., financial and material goods.
• Interpersonal, e.g., availability of social support, positive relationships.
• Intrapersonal, e.g., cognitive and social skill, sense of mastery, positive expectations.
Confronting Adversity
• Fewer resources associated with greater susceptibility to negative effects of adversity.
• Experiencing the negative effects of adversity leads to further depletion of resources or to not adding further to the resource bank.
Correlations between SES Indices, Ethnicity, and Life Events Categories among Children
Life Events Category Income Assets Ethnicity:
Black=1 White=0
Discrete, Negative, Independent
-.16* -.30**** .30****
Discrete, Ambiguous, Independent
-.29*** -.25*** .38****
Chronic, Negative, Independent -.17** -.24*** .10
Negative, Non-Independent -.17** -.24*** .21**
Positive, Non-Independent -.02 -.02 .02
Total -.28*** -.34**** .34****
J Ped Psychol 27:575-583, 2002
Negative Interpretations as a Potential Factor in SES-Health Link• Low SES persons grow up in
unpredictable, stressful environments.
• This may lead to a propensity toward interpreting the world as a threatening place that requires constant vigilance.
• Thus, low SES persons may interpret a wide range of stimuli, including ambiguous ones, as potentially threatening.
Negative Outcome:• A popular girl walks up to you and asks why you didn’t
attend her party last night. You hadn’t known there was a party. This girl tells you that she told another classmate of yours to tell you about the party
Ambiguous Outcome:• You are shopping and a clerk asks to take your back pack and count the clothing
articles that you will try on. The security guard and clerk chat and the clerk asks if you would like to keep anything. You say no and start toward the door. The clerk puts your articles back on the rack and stops abruptly, asking the guard where you are.
How do you think it happened that this person…?How would you feel in that situation?
Correlations among SES, Interpretations and Cynical Attitudes SES & Negative
Interpretations SES & Anger
Negative Interpretations &
Cynicism
Ambiguous 1
Ambiguous 2
-.31*
-.29*
-.32*
-.41**
.35**
.40**
Negative 1
Negative 2
-.14
-.20
-.16
-.20
.16
.17
Chen & Matthews, 2001.
*p < .05**p < .01
Mean SBP among Adolescents with Negative Interpretation Scores
SB
P
123
124
125
126
127
128
no one parents otherrelatives
friends schoolpersonnel
Mean Night Time Heart Rate
67
68
69
70
71
72
1 2 3 4
Quartile of Negative Interpretation Scores
HR
Mean Ambulatory SBP by Neighborhood Percent of Poverty
122
123
124
125
126
127
128
129
130
131
Low SES Medium SES High SES
SB
P
What can be done?
• Direct effects on SES thru enhanced education, job training, redistributions of income
• Indirect effects on pathways:
• Health behaviors
• Sense of purpose and commitment
• Stress exposure and coping
Summary
1. SES is a multi-dimensional construct
2. SES is strongly correlated with health
3. SES associations begin early in life
4. Many reasons why
5. Plausible psychological connections
6. Things can be done.