Tracing the social gradient in the health of Canadians: primary and secondary determinants
Introduction
Health status is directly related to social status. This fact is referred to as the social gradient in health. Numerous efforts have been made to explain social gradient in health. One of the first efforts in this regard, and arguably the most influential, was the health field concept (Lalonde, 1974). The health field concept linked the macro structures of social and physical environments, including the nature of, and access to, the health care system with the micro factors of lifestyle and biology. It constituted an important conceptual breakthrough insofar as it emphasized the fact that access to health care services, particularly physician and hospital services, was not a primary determinant of population health status. Despite this advance, in its original application, the health field concept has been criticized for reinforcing the view that individual lifestyles contribute disproportionately to health (Crawford, 1977; Bolaria, 1988). This view lends credence to policies which focus upon individual level health solutions rather than more effective collective level solutions.
Subsequent revisions to the health field concept have attempted to redress this imbalance. Evans and Stoddart (1990), for example, have emphasized the role of various inequalities rooted in Canadian social structure in determining health status. While both macro variables such as socioeconomic status and micro variables such as stressors and coping mechanisms are recognized as important determinants of health status, their interaction and relative importance are in need of further examination. This study contributes to that objective. We contend that the social gradient in health status may be attributed, in part, to the intervening effects of secondary determinants, such as stressors, control, self-esteem, social support, and social involvement.
The first general perspective proposed to account for social inequalities in health best explains absolute health inequalities between socioeconomic status groups. This perspective is expressed in a number of theories, including the theory of culture and behavior, health selection, general susceptibility, and various Marxist theories.
The theory of culture and behavior emphasizes micro-level factors such as the health risks of smoking, excessive alcohol intake, and poor nutrition (Macintrye, 1997). Health selection theory maintains that poor health results in lower socio-economic status because less healthy individuals tend to drift into lower social positions (Marmot, Kogevinas, & Elston, 1987; Mackenbach, Van de Mheen, & Stronks, 1994). General susceptibility theory, on the other hand, maintains that members of lower social classes experience worse health by virtue of their social positions (Wilkinson, 1994). Finally, Marxist theories explain absolute inequalities in health in terms of class inequality. Whereas the hard version considers only the physical hardships associated with class position, soft versions account for psychosocial aspects of material inequality (Macintrye, 1997). Marxist explanations of health inequalities are only recently shifting toward the soft version in order to account for the gradient aspect of social inequalities in health. This is due to the fact that it has been difficult for Marxist analysts to paint health inequalities within the middle and upper social strata as indicative of absolute material deprivation.
The second approach addresses psychosocial pathways between social status and health status. It attempts to explain gradations of health within the middle and upper social status strata using social causation theory and life course theory. Social causation theory identifies social position as a determinant of health and focuses upon factors not readily accessed within other theories (Dahl, 1994; Kaplan, 1996; Mackenbach, 1992; Dahl, 1991; Williams & Collins, 1995; Grayson, 1993; Syme, 1991; Daly, Duncan, Kaplan, & Lynch, 1998; Mustard & Frohlich, 1995; Krieger & Fee, 1994; Bobak, Pikhart, Hertzman, Rose, & Marmot, 1998). Life course theory combines elements of health selection and social causation theory. From the perspective of life course theory, social structural conditions may prompt individuals to respond with psychosocial orientations and health behaviors that are differentially arranged to contribute to health inequalities (Lynch & Kaplan, 1999). Blane (1999) explains social advantages in life as cumulative. From this perspective good health status is one of the advantages indicating past social position.
The theories summarized above fail to account for the social gradient in health by explicating the role of psychosocial mechanisms as mediators between stressors and health. A number of other studies, however, have proposed models to account for this possibility. For example, Susser, Watson, and Heppier (1985) examined psychosocial pathways from social status to health status. They suggested that lower social status individuals, given comparable stress levels, suffer greater distress as a result of poorer coping abilities. Although they did not address the issue of control, they did note that social support has varying degrees of buffering effects upon health outcomes in the face of stress. Ascertaining whether social support precedes, mediates, or antecedes health disorder, however, is important with respect to operationalizing support.
Addressing this point, Pearlin and Aneshensel (1989) advance a model that explicitly outlined the inter-relationships between stressors, health, and the psychosocial mediators of coping and social support. In their model social support is viewed as having four functions: preventing, managing, changing the meaning, and managing the symptoms of the stressful situation. Pearlin and Aneshensel, however, do not address the issue of control as a mediator. Williams and Collins (1995) consider the possibility that control over daily life activities determines the consequences of stress for health. They argue that control is shaped by position within the socioeconomic hierarchy. McCubbin (1997) also considers this issue by inquiring whether control and social support are separate coping mechanisms. It is interesting to note that the notion of social support and control as complementary, yet complexly intertwined, mediators of stress levels has emerged only recently.
Section snippets
Review of literature
In this study, we consider socioeconomic and demographic variables as subsets of the primary determinants of health (Fig. 1). Employment status, household income, and education denote position in the socioeconomic hierarchy. Researchers typically rely upon only one or two of these indicators. However, each measure equates with an element of socioeconomic status, not with socioeconomic status itself. In the end, aspects of each indicator have varying implications for health as well as for
Data and methods
We use the method of path analysis to test our hypothesis of the order of the relationship amongst primary determinants, secondary determinants, and health (Fig. 1). Researchers find path analysis useful when their task is to “test a theory about the causal order among a set of variables” (Klem, 1997, p. 65). The arrows of a path model illustrate the predictive ordering of hypothesized relations, such as “A causes B and B causes C”. In path analysis, the value of exogenous variable “A”, much
Results
An examination of the zero-order correlation matrix points to the strength of the relationships within the various health status measures, primary determinants, and secondary determinants (Table 3). For instance, of the three health measures considered, self-reported health and physical health have the strongest relationship (0.470). Although the relationship is moderate, it does indicate that a high degree of self-reported health is somewhat related to a high score on the physical health
Discussion
This analysis addressed the question of whether the social gradient in health is a function of a social gradient in secondary health determinants. Specifically, we tested the hypothesis that a social hierarchy of health status exists owing to a corresponding social hierarchy in secondary determinants via a stressor index. This hypothesis is challenged in that not all of the primary determinants have significant direct and indirect effects upon particular secondary determinants and health
Conclusions and recommendations
This study adds to others’ findings regarding the existence of a social gradient in health. There is no doubt that such a gradient exists, nor any doubt that a social gradient in key secondary determinants of health exists. We refer specifically to stressors, control, self-esteem, and social support as secondary determinants of health. This study utilized path analysis methodology to test a particular hypothesis regarding the direction of these relationships, specifically that socioeconomic and
Acknowledgments
We would like to thank Bernard Schissel and Peter Li for carefully reading previous versions of this manuscript, and sharing their valuable expertise. We are also grateful to Carl D’Arcy of Applied Research Psychiatry for his thoughtful advice throughout the research process.
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