Compared to whom? Subjective social status, self-rated health, and referent group sensitivity in a diverse US sample
Introduction
Social status is a multidimensional concept whose measurement has been the topic of much debate. Scholars have suggested that social status indicators are comprised of different types of measures, some assessing actual economic resources and others capturing prestige-related characteristics (Krieger et al., 1997, Oakes and Rossi, 2003, Wilkinson, 1997). Health status has been found to be strongly associated with economic measures such as household income or wealth as well as with rank-related indicators such as occupational prestige (Lynch and Kaplan, 2000, Wilkinson, 1997). More recently, a growing number of studies has also indicated that subjective social status (SSS)—how people perceive their position in the social hierarchy—is significantly associated with health status, independently of objective economic indicators (Adler et al., 2000, Ostrove et al., 2000).
The association between SSS and health has been quite consistent when the outcome is a global self-rated health measure. Self-related health is considered a robust indicator of physical health status and a strong predictor of subsequent mortality (Idler and Benyamini, 1997, Singh-Manoux et al., 2006), although several validation studies have found racial/ethnic differences in self-rated health perceptions among various cultural groups both within the US. (Borrell & Dallo, 2008; McGee et al., 1999, Ren and Amick, 1996) and in other countries (Agyemang et al., 2006, Jylhä et al., 1998). While some questions have emerged regarding the use of self-rated health as a health indicator across cultures, higher SSS has been consistently found to be significantly associated with better self-rated health in several different population sub-groups, including White healthy women (Adler et al., 2000), White and Chinese-American pregnant women (Ostrove et al., 2000), British civil servants (Singh-Manoux, Adler, & Marmot, 2003), Hispanic adults in Texas (Franzini & Fernandez-Esquer, 2006), rural Chinese residents (Yip & Adler, 2005), and Taiwanese senior citizens (Hu, Adler, Goldman, Weinstein, & Seeman, 2005). In some cases, SSS has been shown to have a stronger association with health than objective social status (OSS) measures. In a national sample of American adults, a multivariable analysis of cross-sectional data showed that SSS was a stronger independent predictor of self-rated health than traditional economic indicators (Operario, Adler, & Williams, 2004), while the longitudinal Whitehall-II study of British civil servants found that SSS was a better predictor of health status over time than income or education (Singh-Manoux, Marmot, & Adler, 2005).
It has been suggested that SSS captures the averaging of standard status indicators. While the measure is associated with psychological factors such as negative affect, it is thought that these factors mediate, rather than confound, the relationship between SSS and health (Operario et al., 2004, Singh-Manoux et al., 2003). Similarly, the measure of self-rated health is correlated with psychological factors, yet it is still considered a strong indicator of subsequent morbidity and mortality. Although SSS and self-rated health are both subjective measures, previous research has concluded that their association is not driven by common method bias.
Since psychological factors are hypothesized as being significant mediators in the pathway of how SSS may affect one’s health status, research has begun to explore the mechanisms underlying this relationship. Discussions on the psychological processes involved in the social status-health relationship have tended to focus on the relative deprivation perceived by people who are lower on the social hierarchy (Baum et al., 1999, Wilkinson, 1999) which may affect health via stress-related processes (Kubzansky and Kawachi, 2000, Wilkinson, 1999). Evidence suggests that the negative psychological effects associated with low social status—such as chronic stress, anxiety, and negative emotions—can lead to the adoption of harmful coping behaviors such as smoking and drug use and can trigger a number of harmful physiological changes that can increase the risk of coronary heart disease, depression, the common cold, and a number of other conditions (Adler et al., 2000, Baum et al., 1999, Schnittker and McLeod, 2005).
However, it remains unclear whether the relationship between SSS and health status is consistent across populations, specifically among racial/ethnic minority groups. Relevant studies with large samples either have ignored race/ethnicity entirely or controlled for it in analyses. The few studies that have focused on racial/ethnic differences in the relationship between SSS and health have been with small samples and have generally yielded insignificant results for Blacks and mixed results for Hispanics. In models adjusting for OSS indicators, no significant relationship was found between SSS and self-rated health among Black and Hispanic pregnant women (Ostrove et al., 2000) or Black men (Adler et al., 2008). However, Franzini and Fernandez-Esquer (2006) did find that SSS was significantly associated with self-rated health among low-income Hispanic adults in Texas.
There is also scant research empirically documenting the extent to which the relationship between SSS and health might be sensitive to the referent group used for social comparison. Most public health studies examining SSS have used a more distal referent when asking respondents how they rate themselves within the social hierarchy. Typically, research has explored the relationship between SSS and health by using the referent group of others “in [our] society” (Ostrove et al., 2000, Singh-Manoux et al., 2003) or by asking respondents to indicate the occupational group (e.g., manager, foreman) or social class (e.g., lower class, working class, middle class) of which they consider themselves to be a member (Macleod et al., 2005, Veenstra, 2005). While most public health studies examining SSS have used a more distal referent group for SSS measures, social psychologists have suggested that referent choice may be situational and comprise of more proximal referents. According to this line of research, referent choice is likely to vary with the respondents’ personal characteristics, including group identification, demographic characteristics, and performance-related abilities (Wood & Taylor, 1991). Specifically, individuals in low status groups, such as racial/ethnic minorities, may be more likely to make comparisons with referents in their own group or to other low status groups (Leach and Smith, 2006, Suls and Wills, 1991), although the evidence in this area has not been entirely consistent (Guimond, 2006, Kulik and Ambrose, 1992, Leach and Smith, 2006). People may also prefer to make temporal comparisons, evaluating their present circumstances to themselves or others in the past (Guimond, 2006, Suls and Wills, 1991).
Referent salience is important because SSS ratings by racial/ethnic group appear to be differentially sensitive to the referent group used in the comparison. In a multiethnic sample, Blacks and Hispanics were both more likely than Whites to perceive their income level to be lower than their friends and relatives, while only Blacks were more likely than Whites to consider their incomes lower than the national norm and those with the same education (Stiles & Kaplan, 2004). Among Cherokee and White Appalachian youth, Whites surprisingly rated their SSS lower than Cherokee youth when compared to the national norm, but when the referent was their peer group, White youth rated their peer SSS higher than Cherokee youth did (Brown et al., 2008).
With few exceptions, there has been little empirical analysis assessing the health impact of comparing oneself to one referent group over another. Siahpush et al. (2006) reported that, after adjusting for objective economic measures, SSS with the referent group of “others in your local area” was significantly associated with smoking status among Australians in a metropolitan sample. Analyses from a national Canadian survey found that SSS with the referent group “parents at the same age” was not significantly related to self-rated health, yet using the more distal referent of “other Canadians” for social comparison yielded a significant association between SSS and health in adjusted models (Dunn, Veenstra, & Ross, 2006). However, for the temporal comparison, this Canadian study asked whether, in general, “people your age are financially better off…as their parents at the same age” rather than specifically asking respondents about their own status compared to their own parents, a measurement limitation the authors note as possibly affecting their findings (Dunn et al., 2006). In their study of low-income Hispanic adults, Franzini and Fernandez-Esquer (2006) asked participants to whom they were comparing themselves when they responded to their SSS survey question. Nearly half the sample reported using the referent group of Mexicans in the US, while others compared themselves to people in the US/Anglos and to Mexicans in Mexico. While SSS was significantly related to self-rated health in this study, analyses assessing the relationship between SSS comparisons to alternative referent groups and health status were not reported (Franzini & Fernandez-Esquer, 2006).
In this paper, we aim to provide a greater understanding of whether the relationship between SSS and self-rated health is sensitive to the referent group used for social comparison as well as to the race/ethnicity of the respondent. We surveyed a national sample of American adults who provided their SSS ratings, by comparing themselves to the following referent groups: others in American society, others of their same race/ethnicity, their neighbors, and their parents when they were their age. We assessed the relationship between SSS with these alternative reference groups and self-rated health and hypothesized that the magnitude of the relationship between SSS and self-rated health would be strongest when respondents used more proximal referents, e.g., others of the same race/ethnicity or neighbors. Additionally, we hypothesized that there would be significant racial/ethnic differences in the relationship between SSS and self-rated health, particularly when using the distal referent group of others in American society.
Section snippets
Data collection
Data for this study are from the ConsumerStyles and HealthStyles annual surveys conducted by Porter Novelli using the Synovate, Inc. consumer mail panel. In May–June 2007, a stratified random sample of 20,000 individuals was selected from the panel and mailed the ConsumerStyles survey. The sample was stratified on region, household income, population density, age, and household size and oversampled for low-income and minority participants. A total of 11,758 people completed the 2007
Results
Table 1 presents the descriptive characteristics of the entire sample and the bivariate analyses for these characteristics by self-rated health. Among survey respondents, 15.3% reported that they would describe their health as poor or fair. Income, education, home ownership, marital status, and age were all significantly associated with poor/fair health (p < 0.05). There were no differences by race/ethnicity or gender in the percentage of respondents who reported poor/fair health. The
Discussion
In light of the current gap in the literature, this paper sought to explore whether the relationship between SSS and self-rated health was sensitive to the referent group used for social comparison. Results from the multivariable logistic regression models and subsequent likelihood ratio tests indicate that an SSS measure using the more distal referent group, others in American society, appears to have a stronger association with self-rated health than measures using other referent groups and
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SVS is supported by the National Institutes of Health Career Development Award (NHLBI 1K25 HL081275).