Background
One of the most urgent challenges before us today is the inability to close the health gap between people at the top and in the bottom of the social hierarchy. Irrespective of whether one refers to differences by income, education, status or class, those of privilege tend to be healthier and live longer, while a disproportionately large burden of disease is concentrated amongst the most disadvantaged groups [
1]. Persisting social inequalities in health and the existence of a clear gradient in both mortality and morbidity have put social mobility in the spotlight for scholars as well as policy makers, both as a potential source of the inequality [
2] and as a strategy to reduce it [
3].
When speaking of social mobility, a differentiation is usually made between mobility within and between generations. Contrasting to
intergenerational social mobility which refer to people’s social position relative to that of their parents,
intragenerational social mobility (which is the focus of the present study), pertain to the movements people make across the social order throughout their own adult lifetime. The existence of a hierarchical separation between strata in society is thus essential for mobility processes to occur; as pointed out by Beller and Hout “social mobility would not matter in a society in which there was no inequality” ([
4], p. 20). In a society where inequalities are prominent, it has been suggested that high levels of social mobility are desirable as it would signal an equality in life-chances and opportunity [
5]. In addition, if people’s ability to move were not to be constrained by factors that are beyond their control some would argue that inequalities may indeed be tragic but not unfair [
2]. It is partly based on this idea that social mobility has received attention from researchers and policy-makers alike.
In sociology where the focus on social mobility is large it tends to be seen as a population level indicator of the extent to which societies distributes opportunity justly [
6]. Similarly, in social epidemiological research it is usually viewed as a process that constrains social inequalities in health since the health of mobile people tends to fall in between the class that they leave and the one which they join [
7‐
9]. Nevertheless, although theories exist, comparatively little emphasis have been placed on empirically examining the health implications of social mobility at the individual level [
10].
Theories on intragenerational social mobility and health
Three partially contrasting although not mutually exclusive explanations as to the health effects of intragenerational social class mobility (henceforth referred to as social mobility) can be found in the literature [
11]. For clarity and to contrast with the empirical hypothesizes which we aim to test, we will refer to the three explanations below as theories.
First,
the dissociative theory, which originates from the work of Sorokin [
12], suggests that mobility in general and upward mobility in particular are stressful experiences with implications in their own right. By forcing people to leave the milieu in which they feel most comfortable and thus contributing to feelings of exclusion, loneliness and isolation, mobility is by Sorokin ([
12], p. 522–523) seen as a source for psychological strain and distress. The dissociative theory was partly a response to the large amount of people who saw themselves moving upward in the social hierachy post World War II [
13]. As a result, although this theory is centered around the belief that any type of class transition would be demanding, Sorokin put a lot of emphasis on negative and life changing implications of upward mobility ([
12], p. 508–510).
The second principal idea,
falling from grace, emphasizes the direction of mobility by claiming that it is primarily downward movements that are harmful [
11]. Downward social mobility may be indicated by a vertical change in occupation, e.g. moving from a professional job with good pay and high status to “merely” a white collar, or even a manual position [
14]. Falling from grace, as described by Newman [
15], thus signifies this experience, emphasizing how people who move downwards ‘had it and then they lost it’. According to her, when downward mobility is involuntary, people are often stranded between two personas, forced out of the former comfortable, fulfilling and autonomous life, and simultaneously unable to accept the new lower status identity. They tend to be subject to self-blame, anger and distress, trying desperately to hold on to a prior way of life. Similar to the dissociative theory, falling from grace suggests that mobility is a negative experience in itself with effects that can neither be attributed to nor alleviated by the new (lower) status position. Rather, this theory states that downward mobility creates enduring effects in terms of insecurity, powerlessness and resentment ([
15], p. 83–90). Conditions which can be expected to have negative consequences for health.
Third and last is the
acculturation theory, which stresses processes of resocialization. In contrast to the two above, this theory [
16] emphasizes human’s ability to absorb and interact with our surroundings, thus claiming that mobile individuals have little problems maneuvering class transitions [
11]. Rather than being influenced by the movement itself, this theory posits that mobile people’s health is primarily a result of being in different social contexts. However, because these individuals are believed to be adaptive (a neccessity to reasure acceptance and integration in their new environment), their health is assumed to be more strongly affected by the conditions in the class which they join than by that of the class which they leave [
16, p. 294].
Examining the health impact of intragenerational social mobility
In contemporary research the association between intragenerational social mobility and health is broadly examined through two different analytical approaches. The first is based on comparing health outcomes between groups generated by a priori or data driven development of discrete intragenerational mobility trajectories (e.g. stable high/low and upward/downward movements). Studies using these methodologies have for example found that mobile people have a higher risk of all-cause mortality compared to non-mobile individuals [
17] or to the stable in the highest class [
18,
19]. Similarly, a downwardly mobile trajectory has been found to be more detrimental for mental health than being stable [
20], and improvements in occupational prestige across mid-life has been linked to a more favorable health development [
21]. Altogether, these studies point to mobility being potentially important for health. Whether this is due to the movement itself or a result of people having faced different social norms and expected behaviors in the alternating class contexts is, however, difficult to infer.
Corresponding to Sorokin’s idea that mobility is a stressful experience, the second approach complements the first by attempting to disentangle and examine the health impact of the movement per se. In order to do this, the effect of
moving between two classes has to be separated from those of
belonging to them over time, something which studies using the above-mentioned trajectory methods cannot do [
22]. This challenge arises because at a given point in time, a class will logically incorporate both those that have been permanently residing there as well as those that have entered it through mobility. The fact you are never without a class, but either have or have not experienced mobility, is the core of this problem and the issue that needs to be resolved in order to capture an effect of change. To date, by being the only method which allows for a differentiation between mobile and non-mobile individuals within each strata [
23], Sobel’s Diagonal Reference Model (DRM) [
24] is the most appropriate method to capture the effect of mobility. The utilization of DRM is fairly uncommon in research overall, with Houle [
11] being one of the few who have applied it with regard to health. In his study on white men born in the late 1930’s and who graduated from high school in Wisconsin (US) in 1957, the author examined whether intragenerational social mobility was associated with psychological distress. His results did not favor either the dissociative nor falling from grace theories, but indicated the health of mobile people may be the result of an acculturation processes to the current class [
11].
A life course perspective to social mobility and health
The participants of the present study were born in Luleå, a middle sized industrial town in the north of Sweden in 1965 [
25]. They came to grow up in a time with occupational instability, facing relatively high levels of youth unemployment around the time of labor market entry in the mid to late 1980s, and then a subsequent economic recession in the early 1990s. For the present cohort, class was measured in 1995 and 2007, with these people having reached age 30 and 42, respectively. At the time we start assessing their mobility, Sweden was recovering from a severe economic crisis [
26]. The years to follow were, however, characterized by a steady increase in, for example gross domestic product (GDP), employment rates and disposable incomes which means that during the study period Sweden overall was fairly prosperous [
27,
28].
From a life course perspective, the highest degree of mobility often come about early in the career. Adolescence and young adulthood are periods of transition with mobility being common but where a class position may be difficult to establish as ongoing military service or post-secondary education usually keep people from entering the labor market. For those who do work, however, their occupation is generally not permanent and if people are to reach high up in the social hierarchy, it is most often not until mid-adulthood that they do so. As indicated by both life course epidemiological and intergenerational social mobility research, people’s social origin is still often strongly predictive of later social positions [
4] as well as of health [
29].
People usually reach “occupational maturity” at some point between age 30 and 40 years [
30], but for cohorts such as ours, the outset of their careers may have made occupational stability occur somewhat later than what is normally the case [
31]. In addition, Sweden is a comparably fluid country [
30] where generous unemployment benefits and universal access to public childcare facilities may support class movements in mid-life [
6,
32]. Mobility within our sample could therefore be potentially high, although it is possible that these circumstances also allows for class transitions to be a more normative and less harmful experience. Nevertheless, the health impact of social mobility is examined at a life period during which people are often in the midst of handling multiple roles, demands and expectations, circumstances which may make them particularly sensitive to unexpected life changes [
33]. Consequently, although resilience and plasticity have also been put forward as characteristics of people in mid-adulthood [
34] we believe that in the context of our study mobility in itself could be important for health.
Within the present study intragenerational social mobility is examined with regard to self-reported functional somatic symptoms (FSS), which pertain to a clustering of physical complaints in the absence of an underlying organic disease [
35]. Exposure to chronic stress and sustained states of negative affect is thought to increase the risk of FSS [
36] and rising stress levels have indeed been shown to precede an increase in FSS [
37]. Since Sorokin [
12] theorized that class transitions could be linked to health via stress and strain, FSS may be a suitable health outcome to study in relation with social mobility.
Aim and hypothesizes
The purpose of the present study is to examine whether intragenerational social mobility in mid-life is associated with higher levels of FSS, above and beyond an impact of prior and current class. Based on the dissociative, falling from grace and acculturation theories we formulated four hypothesizes which are then tested using Diagonal Reference Models – a method which is suitable because it allows us to compare the health of people that reported being in the same class between two time points (non-mobile) to the health of those who experienced a change in social class (mobile).
First, as the dissociative theory suggests that any type of mobility may be a source for distress we hypothesize that:
Hypothesis 1. Mobile individuals report higher levels of FSS than do non-mobile individuals.
Second and more precisely, the dissociative theory posits that upward mobility could be particularly stressful, as to why we also hypothesize that:
Hypothesis 2. Upwardly mobile individuals report higher levels of FSS than do non-mobile individuals.
Third, falling from grace proposes that it is primarily downward mobility may result in chronic stress and strain, we therefore hypothesize that:
Hypothesis 3. Downwardly mobile individuals report higher levels of FSS than do non-mobile individuals.
Fourth, distinct from and challenging both the dissociative and falling from grace theories, the acculturation theory suggests that the health of mobile people is primarily the result of being in different strata and that current class is particularly influential. Consequently, our last hypothesis is that:
Hypothesis 4. Current class is more important for FSS than prior class in both upwardly and downwardly mobile individuals.
Discussion
The purpose of the present study was to examine whether class transitions across a twelve year period during mid-life, i.e. intragenerational social mobility, have health implications, over and above the effect of prior and current class. Following in the footsteps of Houle [
11] the dissociative, falling from grace and acculturation theories were empirically analyzed using a novel method. Taken together, the study did not find unanimous support for any of the four hypotheses tested. Compared to immobility, neither overall mobility (hypothesis 1) nor upward movements (hypothesis 2) predicted higher FSS levels, thus contradicting Sorokin’s dissociative theory. Instead, after controlling for potential confounders as well as prior and current class, upward mobility was associated with lower levels of FSS. In contrast also to falling from grace (hypothesis 3), downward mobility was not strongly related to FSS at age 42. In addition, since prior class seemed to be somewhat more important for FSS than current class for both upwardly and downwardly mobile people, neither was the acculturation theory supported (hypothesis 4).
Sorokin’s [
12] elaborations on how changes between class contexts should not be easily coped with but rather a very stressful experience do not seem to fit in the context of the present study. The reasons as to why mobility overall was found to have limited effects might be because up- and downward movements are, in fact, different experiences that should perhaps not be clustered together. Although Sorokin also emphasized the negative consequences of upward movements, conversely, it seemed as if people born in Northern Sweden in 1965 might experience better health as a result of upward mobility. Even after controlling for potential confounders such class of origin, which has known implications for both later health [
50] and adult social positions [
4], this finding persisted. Maybe the result is due to an improvement in the absolute material standard of living, or perhaps the reasons are more psychological and linked to a strengthened self-image. Goldthorpe found some support for the latter notion when British middle-aged men were asked to describe their mobility experience: “(…) in accounting for the work-life advancements of which they were so overwhelming aware, they clearly wished to represent this as being primarily their own achievements” ([
51], p. 234). In contrast to this idea, however, neither Hadjar and Samuel [
52] nor Marshall and Firth [
53] has found an upward trajectory to be associated with higher life satisfaction/well-being.
According to Newman [
15], downward mobility should be a source for negative affect and psychological distress. However, when examined with regard to self-reported functional somatic symptoms in this study, the implications of such movements, over and above the importance of prior and current class, appeared small. Notwithstanding that downward mobility is probably a disruptive life event in some way, especially if involuntary, Hout and DiPrete [
6] suggest that its negative effects may be partially alleviated. Generous and universal social security systems could potentially remove some desperation when downward mobility is at risk (e.g. in times of downsizing, job insecurities/displacements and unemployment) and consequently function as a buffer. As such, in the context of the present study it is possible that downward mobility simply does not act on health as described by Newman [
15].
Lastly, the acculturation theory claims that there are no effects of moving per se but rather that the health of mobile people is a result of being in different class contexts [
16]. In the present study we found that upward movements might be beneficial, but also that both prior and current class seem to take part in shaping the health of mobile people. As such, at a general level, our results seem to favor resocialization as a partial explanation as to how social mobility may impact on health, but more specifically, the findings were not in the expected direction. While acculturation holds that current class is to have a stronger impact than prior, the class weights in our study did not support such a notion. Instead, similar to the studies by Boyle, Norman and Popham [
8] as well as Claussen, Smits, Naess and Smith [
9], they indicated that both upwardly and downwardly mobile people may carry with them a socialization from the class circumstances from which they depart. Nevertheless, previous research suggests that the longer people stay in their current class, the more they come to resemble this group [
11]. Unfortunately, we had no information about the time people spent in the different class context, and the class weights in our study should therefore be interpreted with some caution. In spite of this shortcoming, however, the current study sheds light on the possibility that social mobility may impact on health through both acculturation and mobility effects.
Methodological considerations
Compared to standard approaches, Diagonal Reference Models [
45,
48] allowed us to analytically separate “being” in a certain class, from moving between them. Something which enabled us examine whether class transitions could have health implications, over and above the effects of prior and current class. However, although we have used the, to date, most appropriate method on prospective data shown to be representative of the same age cohort in Sweden overall [
25], the study is subject to several limitations.
First, there are some factors which we have been unable to adjust for, for example any personal characteristics. Similarly, it has not been possible to capture and account for the reasons as to why people change class, whether the job relocation was by choice or involuntary, or took place within or between organizations. Consequently, we might be overlooking potential selection mechanisms that could act as a partial explanation.
Second, although our analyses give no such indication (neither self-rated health nor any measure of FSS seemed to affect the results), we cannot completely disregard the possibility of health selection. However, the likelihood that health status has been selecting people into different hierarchical occupations across their life course is fairly low both within our particular cohort [
54] and in other contexts [
55]. As a result, even though the interpretation of our results is limited by the fact that we measure current class concurrently with FSS at age 42, the risk of reverse causality seems low.
Third, since only two time points in mid-adulthood are used to operationalize mobility, people could have experienced some class transitions during the twelve years in between measurements that we have been unable to capture [
56]. Most serious being the possibility that the people we define as immobile have in fact been mobile, but just ended up in the same class in 2007 and 1995. The extent of such a potential misclassification is, unfortunately, difficult to assess.
Fourth, the extent to which intragenerational social mobility is affected by time has, to date, received little theoretical and empirical attention. Whether the health implications of class transitions remain somewhat constant over the years or if they can be expected to decrease as people become more integrated in their new class is therefore unclear. Consequently, we do not know if, and in that case how our inability to account for the time spent in different classes affects the results, just that it is a limitation of the study. One the same note, the fairly high degree of mobility in our sample is a strength overall, but also suggests that people may not have reached “occupational maturity”. Our assessment of current class can therefore be seen only as a temporary endpoint to an overall mobility trajectory. Altogether, while our analytical approach offers new insights to the relationship between social mobility and health, it only provides a snapshot of and very limited insight as to the temporal variations of social mobility across the adult life course. Approaches such as ours should therefore be seen as complementary to strategies using more than two time points when modeling mobility.
Fifth and last, while we defined functional somatic symptoms as characterized by physical complaints in the absence somatic disease, we cannot ascertain that the measure is medically unexplained. Our operationalization is based on self-reported symptoms that have not been evaluated relative to a diagnosis. However, a recent systematic review and meta-analysis suggests that people with FSS rarely have a medical disorder to account for their symptoms [
57]. In addition, while we acknowledge the overall discussion about the nature and classification of FSS [
58] our assessment is similar to those used in population studies [
59].
Conclusion
By testing specific hypotheses derived from the dissociative, falling from grace, and acculturation theories, the present Swedish study examined whether intragenerational social mobility across 12 years in mid-adulthood could be linked to functional somatic symptoms. All in all, although our results provide limited support for any of the theories, the analyses indicate that upward movements in the class hierarchy could be potentially beneficial for stress-related health problems in mid-adulthood, while downward mobility seems to be of less importance for middle-age health complaints. The present study therefore adds new insight to the body of knowledge examining intragenerational social mobility on health, suggesting that while mobile people seem to be shaped by both their prior and current class context, perhaps there is also an effect of moving per se. As such, although our analytical approach needs to be complemented by similar studies performed in other contexts, future research examining mobility at more than two time points should be aware about the possibility that a detailed social mobility trajectory may include both acculturation processes and mobility effects.
Acknowledgements
We wish to thank all study participants.