Socioeconomic Status and Health Outcome

The social structure and personality perspective provides a theoretical and analytical framework for understanding the persistent association between race/ethnicity and socioeconomic status and health outcomes. Current social and epidemiological research suggests that health behaviors, stress, and environments are critical links between social structure and health status. These psychological and psychosocial factors are linked more strongly to health status than is medical care and are related to a greater degree systematically to socioeconomic status. The social distributions of these factors represent the patterned response of social groups to the conditions imposed on them by social structure. Accordingly, the elimination of inequalities in health status ultimately may require changes not only in psychological factors or health care delivery, but also socioeconomic conditions. More research is needed that will identify the critical features of socioeconomic status which determine health, delineate the mechanisms and processes whereby social stratification produces diseases, and specify the psychological and interpersonal processes that can intensify or mitigate the effects of social structure.There has been a large and expanding literature that looks at the systematic links between the health statuses characteristics of African Americans but the results have been inconsistent. Much of these studies have included an effort to test a conflict theory to account for the disparities and over representation of black Americans in the states mortality rates statistics when compared to that of whites. Some researchers have looked at the epidemiology in the United States in the last forty years and have come to believe that the primary, if not the outstanding predictor of illness and mortality differentials among individuals in virtually all regions are socio-economic status.These relations between socio-economic characteristics and health are believed to be heavily based on occupational status – in the long term – and income status – in the short-medium term. Several extensive analysis of racial, ethnic, gender and socio-economic characteristics in health status which focuses largely on how to reduce inequalities have been undertaken in recent years.

Studies from the literature on health status, not only describes the nature and extent of these disparities in health but also out- lines strategies for dealing with them. It is also important to note, however, that the recommendations of these studies, has primarily been focused on the development of health professionals, health education and health promotion strategies. None of the recommendations in these studies directly address the structural element of health inequality in our American society. A report on health status of minority groups (DHHS 2002) for example, is typical of a growing tendency among some health authorities to use evidence linking psychosocial factors with health in order to blame the victims for their failure to follow healthier lifestyles. It is important to note, however, that less is mentioned, in these reports about variability and other health outcomes within the racial/ethnic and poverty population, especially the African American population. Neither, is the variability within gender in the poverty population mentioned. Some studies for example, questioned why the United States has the highest infant mortality rates among developed countries, and why does the United States have a much higher infant mortality rate than countries with comparable living standards. Researchers believe that since the United States spends more than other countries, the United States should rate higher than the others by the indices of health outcomes such as life expectancy, and infant mortality. But on the contrary, the infant mortality rate in the United States is higher than the average among developed countries, at 7.2 deaths per 1,000 live births in 2004, compared to an average of about 5.0. According to a recent Harvard Public Health annual report, for the first time in 40 years, the infant mortality in the U.S. has increased, with seven out of every 1,000 children born in America dying within their first year of life. According to the National Center for Health Statistics, in 1997, the mortality rate (per 1,000 live births) for infants born to African American mothers was 13.7% compared to 6.0% for Caucasian mothers. Infant mortality among the 50 states and the District of Columbia for African American range from a high of 20.8% in Nebraska to a low of 9.1% in Massachusetts. Some researchers like Nevarro (1976); Sterling (1978) have questioned the evidence linking lifestyle factors to health outcomes. Nevarro for example, contends that the focus on life style is merely a ploy to divert attention away from the maldistribution of political and economic power in society.

Several studies on the variability on health outcomes and health status by Diez-Roux et al. (1995); James (1993); Sorlie, Backlund, and Keller (1995); Williams et al. (1997) suggest that some health outcomes appear to vary by race/ethnicity, gender and, within race/ethnicity, by nativity status and geography. On the variability of health relation-ships between socioeconomic characteristics and race, ethnicity and gender on health outcome, some studies for instance, Smith et al. (1998); Geronimus (2000); Brown et al. (2000); Epstein (2003) suggests, that health differences and health outcomes within race/ethnicity can be modified by regional influences and community conditions; the very conditions that conceptualize and structure these relationships of health outcomes. It is suggested by some researchers for example, James (1993); Backlund and Keller (1995); Williams et al. (1997) that the magnitude of the effect of socio-economic position on at least some health outcomes appears to vary by race/ethnicity and gender
and within race and ethnicity and gender by nativity status. These studies suggests, that analyses of national or state data sets that average across different types of black or poor communities may conceal striking variation in excess mortality among these communities. Although, the health significance of discrimination has been assessed in a number of studies, it is only recently that researchers have been able to identify both structural and subjective pathways from discrimination to health. These relationships in health status can be modified by the regional influences and community conditions that contextualize and structure these relation- ships. Recent scholar-ship suggests caution in assuming that socioeconomic position influences black Americans’ health as steeply as that of other populations. James (1994) for example, believed that in certain regions of the United States middle-class African Americans suffer a greater pre-valence of cardiovascular disease than do middle-class whites even when both have similar socio-
economic status. Geronimus (1994, 1996) believed that African American women of reproductive age experience more health detoriation, or “weathering,” than their white counterparts. Researchers in multiple disciplines (Rogers 1979; Flegg 1982; Le Grand 1987; Waldmann 1992; Kawachi and Kennedy 1997; Kawachi, Kennedy, and Lochner 1997; Ross se al. 2000) have documented a relationship between income inequalities as aggregate measures of health outcome. The Income Inequality on Health hypotheses on morbidity and mortality has been criticized in some studies. For example, Judge (1995); Judge, Mulligan, and Benzavel (1998); Mellor and Milyo (2001) as not been sensitive to time periods examined, and the specific causes of mortality examined and the inclusion of controls for other population characteristics. Conrad (1997) observed that in recent years there has been a shift from the sociology of medical practice and organization that focus on the physician and physician work, to a more general concern how health and illness are dealt with in our society. This shift has broadened the conceptualization of the relationship between sociology and medicine. In Conrad’s view, this shift has encouraged researchers to examine problems such as the social causation of illness. Other researchers like Syme and Barkman (1976); Williams (1990); Turner, Wheaton and Llyod (1995); La Veist (1996); Brown et al. (2000); Finch, Kelody, and Vega (2000); Taylor and Turner (2002) have studied and examine the economic basis of medical services and social organizations including racial and ethnic, gender and socioeconomic backgrounds.

These disparities in health status, on racial, ethnic, gender and socio-economic characteristics have been documented by the U.S. Department of Health and Social Services study as representing clear significant public health problems which are threatening on going efforts to improve the nation’s health. Smedly, Stith and Nelson (2002) believed that these disparities in health status are significant problems both to the individuals who seek care, and all members of society. These disparities in health status same health plan. For example, the study found African-American children were more likely to need ER care but less likely to see an asthma specialist than their White counter-parts, even when controlled in the same health plan. The underlying reasons for health disparities are complicated, but many of the factors that matters can be identified, and have been identified by social researchers. These disparities should never be allowed to exist in a society that prides itself on equal opportunity. Harvard School of Public Study (2002), researchers analyzing national Medicare data on the quality of care in managed care plans, have found that black enrollees received poorer quality of care than white enrollees.

Studies after studies tell a troubling story about racial differences in sickness and health. In nearly all statistical comparisons, the losing score goes to African American, although the death and disease numbers for American Indian or Native Alaskans and Hispanic Americans also show a similar gap against the comparatively robust health of European Americans. The researchers looked at four important measures of clinical quality; breast cancer screening, use of beta-blockers after heart attack, eye examinations for patients with diabetes and follow-up after hospitalization for mental illness, and found that African Americans were less likely to receive each of them. The study found that Breast cancer screening among the study participants was done for 62.9 percent of black enrollees compared to 70.9 percent for whites. Eye exams were given to 43.6 percent of African American patients with diabetes compared to 50.4 percent for Whites. Eye exams were given to 43.6 percent of African American patience with diabetes compared to 50.4 percent for whites with the same condition. When beta-blockers were administered after a heart attack, the study found 64.1 percent of black Americans compared to 73.8 percent for whites were administered with beta-blockers. The same study found after a follow up after hospitalization for mental illness was performed for 32.2 percent of African Americans compared to 54 percent for whites. A study by the Institute for Public Policy & Social Research and Institute for Health Care Studies at Michigan State University (2002) found wide discrepancies in the health care received by whites and by members of minority groups in this country. Some of the elements of racial gap were found in Breast cancer screenings; Heart disease; and Diabetes. The study found 71 percent of white patients got Breast cancer screenings compared to 63 percent of African American patients did. For Heart disease, the study found that for every 100 white patients who had a procedure to clear an artery, only 74 African American patients did. As for Diabetes, the study found that African American patients are over three-and-a-half times more likely to have a limb amputated. According to the Michigan State University (2002) study, there is clear evidence that disparities in quality exist even among similarly insured individuals and even among individuals. Many causes of the differential in the health status between race/ethnicity, gender and socioeconomic characteristics has been attributed to different patterns of education, economic success and employment, as well as different access to the goods, resources, and privileges available within the larger society (Ross 2000; Brown et al. 2000; Browning and Cagney 2002).

Some studies for example, McCord and Freeman (1990); Wilson and Daly (1997); Geronimus, Bound, and Waidman (1999) show African Americans in high- poverty urban areas face extremely disadvantageous mortality schedules through old age in comparisons with national averages, with African American residents of more affluent communities. Recasting socioeconomic characteristics in life cycle terms allows researchers to have a more cogent framework of the possible pathways by which racial differences in health arise. The basic point in this paper is that these mechanisms can combine to affect racial differences in health in myriad ways. How best can we understand the significance of race/ethnicity, gender and socioeconomic characteristics in our health care system? To understand the sociological significance of racial/ethnic, gender and socioeconomic inequalities in our American health care system we have to turn our attention to the significance and genius of Emile Durkheim’s study of Suicide (1897) which explain what appears as a highly individual and personal phenomenon in terms of social structure and social processes. From Durkheim’s empirical study of suicide we learn that variations in suicide rates for example, gender, religion, and geographic location are not reduced to individual characteristics, but are understood as social rates and the product of broader influences exerted within the social system, that is, aspect of social structure. While still overlooked in epidemiological thinking, social system influences such as government policies, organizational practices and provider behaviors may account for as much of the variation in health and/or illness statistics as – if not more than environmental influences, or even the attributes and life styles of individuals.

Moreover, these social system influences offer the greatest promise for effective interventions designed to improve the health of the populations. This paper argues that the social structure and social processes and the broader influences exerted within the social system may influence the degree of exposure to adverse racial/ethnic, gender and socioeconomic circumstances. These social structure and social processes thus, contribute in transforming the meaning of those circumstances in affecting health care inequality in our American society. Both logic and evidence suggests two guiding assumptions. One assumption is that the corollaries and consequences of racism include greater exposure to a variety of social stressor. A significant portion of documented inequalities in health arises, directly or indirectly, from differences in exposure to stress. One study on the environment and stress by Epstein (2003) suggests that unsafe neighborhoods, inaccessible recreation facilities and weak social networks will be associated with many measures of environmental stress which in return will result to variations in health outcome statistics and health risks. Although, the health significance of discrimination has been assessed in a number of studies; the social stress factor to exposure to health risk has never been tested effectively and cannot be measured empirically. Studies suggest that, within the context of health outcomes, race is fundamentally a measure of exposure to health risks. There is a substantial consensus that racial discrimination account for an important part of the variability of health outcomes as evident in studies by La Vest (1996); Brown et al. (2000) and Epstein (2003).

The ability to control everyday life circumstances, stress, social ties, diet and health-risk behaviors, the nature of work and the work environment, and the availability of health care are all as a result of those socioeconomic stratification as indicated by Garber (1989); Behrman et al. (1991); and Feinstein (1993).There has been very little evidence in the literature so far, to support those generalizations with empirical evidence. However, evidences from researchers Ferraro (1989); Bengston (1978) and Kraus (1978) suggests African Americans are most likely than whites to experience poorer health and differential in health outcome for both subjective health and reported disability even after controlling for education, financial strains and income. This article on race, ethnicity, gender and socioeconomic differences argues that African Americans at all socioeconomic levels may pay a higher price in stress-related disease than whites in similar socioeconomic levels; that inequality on health status can be explained on other factors besides socioeconomic status. Although, inequality based on race and gender may have shifted out of the economic, sphere, this article argues that inequality in race and gender is still present in other settings. This racial inequality and racism is predicted to continue to affect health through stress associated with other minority status. The goal of this article is to explore what degree of inequality in health status can be explained when socioeconomic status is controlled. For example, Wilner et al. (1962);Mason (1968);Froberg et al. (1971); Hamburg et al. (1973); Haan, Kaplan and Camacho (1987); Diez-Roux et al. (1995); Smith et al. (1998); Brown et al. (2000); Geronimus (2000); and Epstein (2003) demonstrate that environmental features such as residing in a poverty area affect health independently of individual characteristics and behaviors. Those studies found that the high levels of psychological distress among African Americans is a function of African Americans being exposed to higher levels of stressful events, and not to an escalated response to equal stressor. The link between stress and illness in humans has been well documented by Casell (1970); Kessler (1979), specifically, essential hyper-tension (Brod (1971) and asthma and upper respiratory infections (Kass 1997; Fullilove 1999).

After reviewing numerous studies, Turner (1966); Hocking (1970), those studies predict that environmental stress, particularly if it is extreme, may result in psychological disability. Andersen, Mullner and Cornelius (1987) for instance, note that black Americans have poorer health than whites as measured by death, chronic disease.There are several theoretical perspectives that are relevant to gain an understanding of how neighborhood environment factors contribute to health risk factors. Deprivation, both economic and social, is one such theory as indicated by Carstairs and Morris (1989); Levitan (1993); Krieger (1994); Gordon (1995) and Link (1995). Individuals who are poor, and are socially and economically deprived lack access to necessary goods and services. Research in the area of environmental stress indicates that stressors are created by and differentially distributed within and between neighborhoods in urban settings. Graig (1993) and Evans, Hygge and Bullinger (1995) for example, characterization of the urban physical and social environments as “urban press” is one characteristic that is relevant for the study of stress caused by neighborhood settings. Urban Press for instance is conceptualize as housing violations, vacant housing, household crowding, rates of aggravated crimes and per capita crime rate. The purpose of this research is to further a better understanding of the relationship between health status, race, ethnicity, gender, and socioeconomic background to help to eliminate those disparities and to add to the existing knowledge of health care status between race/ethnicity, gender and socioeconomic back-ground. Because of the limited research on disadvantaged neighborhood structure and diseases of adulthood and the lack of clear standards for assessing household and neighbor-hood on health outcome and health status differentials, this article has instead focus on the existence of a relationship or the lack of a relationship between socioeconomic characteristics such as race/ethnicity, and gender to determine the underlying factors responsible of health care inequality. The reason for the observed health differentials between African Americans and whites; and the observed differentials in health status between genders is not entirely clear.

One of the most compelling arguments traces both morbidity and mortality experiences of African Americans and Whites, and between genders to differences in socioeconomic statutes. Studies that have addressed socio- economic determinants of health believed that individuals with more education and income are in a better health for instance Antonovsky (1967); Syme and Berkman (1981) and Victor (1989). Many causes of these differentials have been highlighted in the literature. Markides and Mindel (1987) argued that by citing the common conjecture that health differences between African Americans and whites would disappear if socioeconomic differences were eradicated. Similarly, other researchers like Jackson (1988) suggests that health differences between black Americans and whites are rarely observed when age, sex and socioeconomic status are controlled. The concept of race in examining health has a thorny legacy. Until recently, race was thought to identify homogeneous groups linked by a common biological inheritance (Krieger et al. 1993; Williams 1997). Different disease experiences across racial and ethnic groups were interpreted solely as the result of different genetic constitutions. It is difficult to overstate the role that race plays in patterning our life fortunes in American society. Childhood poverty, marginal employment, inadequate education, low income, and segregated living conditions are more likely to be features of African Americans’ lives (Farley 1984; Massey and Denton 1993; Jargowsky 1994). These features of socioeconomic stratification are what some studies have termed the fundamental social causes of disease (Link and Phelan 1995; 1996).There “Fundamental Causes” theory posits that social and economic inequalities in morbidity and mortality have persisted over historical time—and will continue to persist – because people with access to more social and economic resources are always better able to avoid health, even if the nature of those risks change over time. Despite the prominence of Link and Phelan’s theory and its inherent challenge to mainstream epidemiological, public health, and social science research, the core empirical fact the theory is designed to explain has not been well established by Link and Phelan or others. The question is, thus having socioeconomic inequalities in morbidity and mortality remained essentially constant over time?


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