Psychosocial Resources and the SES‐Health Relationship

INTRODUCTION

What explains the robust SES gradient with respect to all‐cause mortality and health outcomes? How does social class get under the skin so that it adversely affects basic bodily processes and the likelihood of illness? Plausible pathways include the differential practice of health habits, differential availability and use of health services, the cumulative adverse effects of chronic stress, and the inability to meet chronic stress with resources that may help to diffuse its psychological and biological impact. 1 Our analysis focuses on this last pathway, arguing that the availability of psychosocial resources varies by social class, and the effectiveness of those resources for moderating stress may vary by SES as well. We begin by identifying the resources that have been shown to be distributed by SES, to most effectively moderate the effects of stress, to ameliorate the effects of ill health, or all three. Four psychosocial resources meet these criteria: a sense of personal control, optimism, social support, and ways of coping. To varying degrees, these resources seem to be distributed by SES and are associated with health outcomes. As such, they may partially mediate the relation between SES and health; they clearly moderate the SES and health relationship; and, taken together, they present a portrait of the type of person who may best be able to combat the health risks of SES‐related chronic stress.

PERSONAL CONTROL

Personal control, also known as a sense of personal mastery, reflects individuals’ beliefs regarding the extent to which they are able to control or influence their outcomes. Many theorists have emphasized the importance of perceptions of personal control or mastery and suggested that this desire is a fundamental need of human beings. 2, 3 A variety of instruments assess control‐related beliefs, b with Pearlin and Schooler’s 4“Personal Mastery Scale,” the most widely used measure in health research.

Studies have shown a positive association between SES (e.g., higher income and/or education) and belief in personal control. 5–9 Similar patterns of association are seen for related constructs such as personal mastery 10–12 and self‐efficacy, 10 and lower SES has also been associated with greater powerlessness and anomie. 6, 13 Social class differences in personal control beliefs may also be importantly influenced by characteristics of the environmental settings that are likely to be inhabited by different social classes. For example, Kohn and Schooler found that work setting characteristics such as environmental complexity and contingency (i.e., control over the process of one’s work) can promote the development and persistence of stronger personal agency/control beliefs, 14 and studies of the effects of downward mobility with respect to employment status highlight the negative impact of such experiences on personal control and efficacy beliefs. 10, 12

Evidence linking control beliefs to health is mixed, with evidence for both more positive and more negative health outcomes associated with stronger perceptions of personal control. Some studies show a relation between a higher sense of control and better psychological health, 15 as well as better physical health outcomes, including lower incidence of CHD, 16 better self‐rated health and functional status, 17, 18 and lower mortality risk. 17, 18 However, control beliefs can be associated with poorer health outcomes under certain circumstances, 19, 20 especially when expectations for control are high but opportunities to exercise it are constrained. 20–22 Both animal and human studies have found the highest levels of reactivity (that is, increasing cardiovascular or neuroendocrine activity or reduction in immune function) in situations marked by incongruity between expectations for control and situational uncontrollability or difficulty in controlling outcomes. 23–26 The relation between the Type A behavior pattern and increased risk for heart disease may also be an example of such links. Type As have been shown to have a strong need for control, 27 to persist in attempts for control in laboratory situations, 27, 28 and to exhibit greater physiologic reactivity in the face of uncontrollable situations. 29 Such persistence, in the face of external realities that limit or prevent actual control over outcomes, along with its accompanying physiological reactivity, may contribute to Type As’ increased risk for CHD. Personal control beliefs, however, may also contribute to CHD risk independent of Type A behavior. The presence of stronger personal mastery beliefs, for example, has been found to be associated with greater coronary atherosclerosis independent of other known risk factors. 19 To the extent that such strong mastery beliefs promote unrealistic expectations for control, they may be associated with patterns of physiological arousal that promote the development of atherosclerosis.

Socioeconomic status may also moderate the association between control beliefs and health outcomes. Using data from three national samples, Lachman and Weaver 11 found significant interactions of control beliefs with both education and income in relation to health and well‐being. Specifically, although beliefs in personal control were associated with more positive health outcomes in all SES groups, the differences in health outcomes associated with stronger versus weaker control beliefs were greater at lower levels of education and income. Among those with less education or income, those with strong control beliefs reported health outcomes comparable to those seen in higher SES groups for self‐rated health, acute physical symptoms, depressive symptoms, and life satisfaction. Continued focus on the antecedents of control beliefs, their distribution by SES, and their relation to health outcomes, is clearly justified by the current evidence.

SOCIAL SUPPORT

Social support refers to the types of help that people receive from others, and it is generally classified into two (sometimes three) major categories: emotional and instrumental (and sometimes informational) support. Emotional support refers to the things that people do that make a person feel loved and cared for and that bolster a sense of self‐worth (e.g., talking over a problem, providing encouragement/positive feedback); such support frequently takes the form of nontangible types of assistance. By contrast, instrumental support refers to the various types of tangible help that others may provide (e.g., help with child care/housekeeping, provision of transportation or money). Informational support (sometimes included within the instrumental support category) refers to the help that others may offer through the provision of information.

Investigators have chiefly explored three types of measures of social support. The first is network measures, namely whether people are involved in relationships and groups, and if so, which ones and how many. That is, are people married; do they have children; do they have friends; and are they members of formal and informal community, religious, and interest groups? The second approach assesses social support, that is, people’s perceptions that there are others available to them who might provide emotional or instrumental support. The third approach investigates how satisfied people are with the support that they receive from others.

Social support has been found to vary positively with socioeconomic status in studies in the United States, 53–55 England, 8 and Sweden. 56 This pattern is true for both emotional and instrumental support and for both men and women (though the differences appear to be somewhat greater for men. 8 Notably, however, the actual size of the observed variations is relatively small. 8

The strongest associations between social support (particularly emotional support) and health outcomes are seen in relation to psychological well‐being. A large literature documents lower risk for depression and for psychological distress more generally for those who enjoy greater social support (for review see 57). Relationships to physical health outcomes have also been documented. Much of this research has used measures of social integration, such as network size, rather than social support, and found consistent relations to all‐cause mortality and extant disease (e.g., 58, 59, for reviews). There is also evidence linking both emotional and instrumental support to less extensive development of coronary atherosclerosis 60, 61 and to better survival post‐myocardial infarction, 62, 63 and post‐stroke. 64 More generally, evidence suggests that emotional support is protective with respect to physical function. 65 The effects of instrumental support, however, appear to be more mixed with higher levels of such support associated with greater disability in some cases 66 (for review, see 67).

Studies also show that emotional support in particular affects both psychological and physical health outcomes in children. Children exposed to deficient nurturing are at increased risk for depression 68, 69 and suicidal ideation. 70 Children born to mothers who lacked family support are at increased risk for low birth weight 71 and childhood exposure to less responsive parenting has been related to increased risk for childhood illness 72 and substance abuse among adolescents. 73, 74

A growing body of evidence links social support to physiological regulatory processes. Among children, presence of a supportive caregiver has been shown to lower HPA responses to maternal separation (as indexed by salivary cortisol levels). 75 For adults, social support has likewise been found to predict lower levels of HPA (hypothalamic‐pituitary‐adrenal) and SNS (sympathetic nervous system) activity in laboratory‐based challenge paradigms as well as community settings. 76 Evidence also links social support to lower risk of decline in CD4 T cell counts among HIV‐infected men. 77

To date, social conflict has been a relatively neglected aspect of social relationships in research on SES, social relationships, and health. Social conflict refers to the various types of negative social interaction that may occur within social relationships (e.g., arguments, criticism, hostility, unwanted demands) and may include physical violence. Available data suggest that lower SES is associated with higher levels of social conflict for adults, 78 and evidence also suggests that lower SES is associated with more troubled peer relations among adolescents. 79 Research also suggests that certain social stressors may be more prevalent in lower SES environments (e.g., residential crowding, fear of crime, financial strain); these stressors are associated with lower perceived support 80–83 and may contribute to reductions in reported levels of social support because they foster a distrust of others. 84 However, high levels of support have been found within certain ethnic enclaves (e.g., see 85–87).

A modest research literature indicates that greater social conflict is associated with greater psychological distress 78, 88 (for review, see 67). Significantly, the impact of social conflict on psychological distress levels is greater among those living in more crowded homes, 83 an effect that appears to be partially mediated by reductions in perceptions of control. 89

Relationships between social conflict and physical health outcomes have received little research attention to date. However, in both children and adults exposed to social conflict, patterns of heightened physiological reactivity are found, suggesting possible links to poorer health outcomes. Preschoolers exposed to videotapes of angry adult interactions exhibit increases in heart rate and blood pressure. 90 Research also demonstrates relationships between childhood exposure to conflict and/or physical violence and increased risks for depression, 91, 92 headaches and stomachaches, 93 and increased risk of mortality. 94 Increased levels of reported stressors in both day‐care and family environments (some reflecting social stressors) have also been related to increased incidence of respiratory illness (though specific measures of family conflict were not related to illness). 95 Studies of adults report relationships between social conflict and greater physiologic arousal both with respect to blood pressure 96, 97 and neuroendocrine activity. 98

Unlike control and optimism, for which there are generally preferred measures of the concepts, social support enjoys no preferred measure, and so the lack of a gold standard for assessing social support has impeded progress. Nonetheless, social support, social conflict, and the balance between them may be important moderators of the SES and health relationship.

COPING STRATEGIES

Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events. Two general coping strategies have been distinguished: problem‐solving strategies are efforts to do something active to alleviate stressful circumstances, whereas emotion‐focused strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. Research indicates that people use both types of strategies to combat most stressful events. 99 The predominance of one type of strategy over another is determined, in part, by personal style (e.g., some people cope more actively than others) and also by the type of stressful event. For example, people typically employ problem‐focused coping to deal with potentially controllable problems such as work‐related problems and family‐related problems, whereas stressors perceived as less controllable, such as certain kinds of physical health problems, prompt more emotion‐focused coping.

An additional distinction that is often made in the coping literature is between active and avoidant coping strategies. Active coping strategies are either behavioral or psychological responses designed to change the nature of the stressor itself or how one thinks about it, whereas avoidant coping strategies lead people into activities (such as alcohol use) or mental states (such as withdrawal) that keep them from directly addressing stressful events. Generally speaking, active coping strategies, whether behavioral or emotional, are thought to be better ways to deal with stressful events, and avoidant coping strategies appear to be psychological risk factors or markers for adverse responses to stressful life events. 100

Broad distinctions, such as problem‐solving versus emotion‐focused, or active versus avoidant, have only limited utility for understanding coping, and so research on coping and its measurement has evolved to address a variety of more specific coping strategies. A variety of idiosyncratic coping measures exist, but in recent years, researchers have typically used one of two instruments: the Ways of Coping measure 99 or the COPE. 39

In terms of the SES‐health relation, coping style may be a psychosocial resource that is farther downstream than those thus far reviewed. That is, coping methods may be, in part, the result of expectations of control, an optimistic or pessimistic way of thinking, and the degree to which one has social support available. This is not to say that coping strategy is unimportant or epiphenomenal in the SES‐health relation, but rather that it may be somewhat farther along on the psychosocial chain as a mediator. Consequently, and not surprisingly, the evidence for the relation of coping strategies to SES is rather meager. Only preliminary evidence has found avoidant coping to be higher as SES decreases. 101

Both the COPE and the Ways of Coping scales have been reliably tied to psychological distress, such that active coping strategies appear reliably to produce better emotional adjustment to chronically stressful events than do avoidant coping strategies. In terms of physical health outcomes, an active versus avoidant coping strategy has been associated with better immune status in HIV‐seropositive men, 102, 103 in individuals infected with herpes simplex virus, 104 and in men with immunologically‐mediated infertility. 105 Use of denial following serostatus notification was associated with more rapid disease progression in HIV‐seropositive gay men. 106 Active coping with disease was associated with fewer recurrences and longer survival from melanoma. 107 Avoidance coping was associated with lower numbers of T cells and reduced NK cytotoxity among law school students. 49

In summary, it appears as if coping strategies may be part of a mediational chain from SES to health risk, but exactly the ways in which they are affected by or reflect SES, and the point at which they affect health, requires further exploration.

OTHER PSYCHOSOCIAL RESOURCES

We reviewed several other psychosocial resources as candidate mediators or moderators of the SES‐health gradient. One resource that does not appear to contribute to the SES‐health relation is self‐esteem. There is little evidence that self‐esteem varies by SES or that it is associated reliably with health outcomes. 108 There does seem to be some role for high self‐esteem in successful coping with stressful events and in recovery from illnesses (see 109), but these beneficial outcomes do not appear to be SES‐distributed.

Also deserving of consideration are psychosocial resources that may facilitate longevity and good health at the upper ends of the SES‐health gradient, which include vitality and vigor and purpose in life. Relative to the resources already discussed, fewer studies have explored the potentially protective effects of these resources, but preliminary research is promising. For example, vitality may be modestly correlated with SES 110d and, on the health side, vitality is associated with fewer chronic physical health conditions, 111 fewer symptoms among people with HIV infection, 112 and fewer symptoms for those with chronic fatigue syndrome. 113 However, measures of vitality do not distinguish between physical and psychological forms, and, therefore, endorsement of exhaustion may represent feelings of physical exertion in the context of poor health or psychological demands in the context of poor coping. 114 Despite these reservations, the potential protective functions of positive states merits additional consideration.