Socioeconomic health disparities revisited: coping flexibility enhances health-related quality of life for individuals low in socioeconomic status

Socioeconomic disparities in health-related quality of life (HRQoL) are a pressing issue in many countries, especially developing countries with huge wealth gaps [1]. Stress has been identified as one of the primary pathways through which low socioeconomic status (SES) influences HRQoL [2]. However, some emerging studies have shown that not every individual with a low SES level experiences poor health [3‐5]. Hence, the ability to cope effectively with stress may be a psychological resource that is particularly relevant to low SES individuals with scant socioeconomic resources [6]. Although some coping studies have examined the effect of SES on health [7, 8], the interplay of SES, coping and HRQoL is not well understood. The present study seeks to address this important but unexplored issue by examining whether coping flexibility mitigates the adverse effects of low SES on HRQoL in India, a developing country with a steep inequality in wealth distribution.

Coping refers to the thoughts and/or behaviour used to manage the demands of a stressful event [9]. These efforts typically aim at directly managing the stressor (i.e., primary approach coping), altering the individual’s stress-related thoughts and behaviour (i.e., secondary approach coping) or stress avoidance (i.e., avoidant coping) [10]. The transactional theory of coping postulates that different stressors have distinct demands, and thus coping flexibility is adaptive [11]. An individual with high coping flexibility tends to adopt primary approach strategies (e.g., problem solving) to handle controllable stressors and secondary approach strategies (e.g., relaxation) to handle uncontrollable stressors [12].

Although a growing body of studies have indicated that flexible coping fosters well-being [13, 14], other studies have similarly shown the adaptiveness of an (inflexible) active coping style [15, 16] We propose that an active coping style may be more beneficial for individuals with a high SES because they are endowed with abundant psychosocial resources, whereas a flexible coping style may be more beneficial for those with a low SES because they have deficient resources. Our proposition stems from the social stress theory, which postulates that individuals lower in SES face numerous and largely uncontrollable stressful experiences but lack the external resources necessary to handle their heightened stress levels [17]. Therefore, an intrapsychic approach that emphasises adjusting one’s self and flexibility may be particularly adaptive for these individuals in terms of stress management [18].

Our proposition is also supported by some resource-based theories of stress. For instance, the reserve capacity model states that individuals lower in SES experience a disproportionate disease burden, partly because psychosocial resources are less accessible to them [19]. When present in abundance, such resources may promote resilience and alleviate resource depletion. Resilience studies have indicated that trauma survivors with initially higher levels of psychosocial resources report better health outcomes over time [20, 21]. Given its association with well-being in highly stressful situations [22], coping flexibility may foster resilience in low SES individuals who experience heightened stress levels.

In summary, the present study aims to test two theory-driven hypotheses. First, the inner-resource hypothesis puts forward that coping flexibility may moderate the positive association between subjective SES and HRQoL. Within the low SES group, individuals who display higher levels of coping flexibility may report a better HRQoL than others who display less flexibility. Although we use objective SES to classify participants, we also include subjective SES as a major study variable, as previous studies have indicated that it reliably influences psychological processes and health independently of objective SES [23, 24]. Second, the stress-buffering hypothesis proposes that coping flexibility is more beneficial to individuals who experience higher (vs. lower) levels of life stress. Of the individuals experiencing high stress levels, those who are more flexible in coping may experience a higher HRQoL than their counterparts who are less flexible in coping.

This study examines the hypothesised beneficial role of coping flexibility on socioeconomic inequalities in terms of HRQoL. Three key new findings emerge. First, compared with those higher in the SES strata, individuals with a lower subjective SES tend to be more flexible and vary their use of coping strategies according to the perceived controllability of stressful situations. Coping studies have shown that individuals differ in how rigid or flexible they are when deploying coping strategies [36, 37]. Our study is important in that it shows that such individual differences in coping flexibility may be related to one’s socioeconomic environment. This finding can be explained by social class theory of agency [38], according to which individuals have different models of agency that pertain to their normative beliefs about action. Individuals from higher SES strata are endowed with ample socioeconomic resources, resulting in a greater sense of personal control and a tendency to use primary approach strategies to directly tackle problems during stressful encounters. In contrast, individuals with a low SES place value on acceptance and adjustment and thus may tend to be more flexible when deploying different strategies to handle diverse stressors with varying extents of controllability [39] These individuals’ scant resources prohibit them from addressing every problem using primary approach strategies, and an inflexible deployment of primary approach strategies may elicit resource depletion for these individuals.

Second, coping flexibility moderates the link between subjective SES and HRQoL. This result is consistent with those of previous studies, which have documented that psychological factors can act as a buffer against the adverse health effects of low SES. For example, positive reappraisal, a sense of purpose in life and perceived control are associated with better HRQoL in individuals from low SES backgrounds [3, 40, 41]. Individuals from this socioeconomic group are typically faced with frequent and uncontrollable stressors. Therefore, coping flexibility, which entails adapting oneself to the demands of stressful situations, is a highly useful psychological resource for low SES individuals.

Third, coping flexibility moderates the adverse effects of perceived stress on HRQoL. Dual process theory of coping postulates that flexible coping may be particularly useful in highly stressful situations, which often present individuals with varied and fluctuating demands [42]. Studies have identified SES and stress as risk factors that compromise HRQoL [43, 44]. The present study extends the literature by specifying that these risk factors are relevant only to individuals with a lower rather than higher level of coping flexibility. It is particularly noteworthy that among the participants who had higher coping flexibility, the group with low SES and high stress levels and the group with high SES and low stress levels tended to report comparable levels of HRQoL. Such novel results provide converging evidence for the beneficial role of coping flexibility for individuals from the low SES stratum.

The observed stress-buffering function of coping flexibility may have practical implications for the design of intervention programmes. Cognitive-behavioural stress management programmes traditionally focus on building specific skills such as relaxation and problem solving. However, individuals may not be able to apply these skills in a situation-appropriate manner. Thus, stress management programmes should also incorporate a ‘meta-skill’ of coping flexibility that involves teaching individuals how to differentiate stressful situations and deploy coping strategies that best match the specific demands of a situation. For example, a person low in SES may deploy more secondary approach coping in some situations to reserve resources for deploying primary approach coping to handle controllable stressors [45, 46]. Such coping flexibility fosters adaptation to the changing environment for individuals with deficient socioeconomic resources.

Before concluding, some limitations of the study should be noted. First, this study adopted a cross-sectional design and thus the direction of its effect is uncertain. Although coping flexibly may influence HRQoL, it is equally possible that the reverse also holds. Experimental or intervention designs are needed to establish causality. Second, although we observe socioeconomic differences in coping flexibility, it remains uncertain whether these differences are stable over time. Longitudinal studies may be needed to address this issue. Third, the present findings indicate that coping flexibility is a fit between participants’ reported strategies and perceived controllability over stressful events. However, it remains unclear whether the participants perceived that controllability would concur with other people’s judgement. Future studies should include third-party ratings of controllability. Finally, as all of the participants in the study were Indians, its findings should be generalised to other ethnic groups with caution, particularly as there may be cultural differences in areas of stress appraisal and context sensitivity [47, 48]. Notwithstanding these limitations, the present study provides some new evidence that socioeconomic differences in HRQoL may be moderated by psychological resource factors such as coping flexibility.

In summary, our findings suggest that coping flexibility may be a more crucial correlate of HRQoL than subjective SES and perceived stress. Coping flexibility may be particularly useful to low SES individuals as a psychological resource that can supplement material coping resources and help them to effectively mitigate stress. Furthermore, given that broader social policies and environments are often resistant or take a long time to change, an approach that focuses on enhancing psychological qualities such as coping flexibility may be an effective target point for decreasing socioeconomic health disparities. Future studies should continue to examine socioeconomic influences on coping in general and the construct of coping flexibility in particular.