Elsevier

Social Science & Medicine

Volume 61, Issue 9, November 2005, Pages 1916-1929
Social Science & Medicine

Is subjective social status a more important determinant of health than objective social status? Evidence from a prospective observational study of Scottish men

https://doi.org/10.1016/j.socscimed.2005.04.009Get rights and content

Abstract

Both subjective and objective measures of lower social position have been shown to be associated with poorer health. A psychosocial, as opposed to material, aetiology of health inequalities predicts that subjective social status should be a stronger determinant of health than objective social position. In a workplace based prospective study of 5232 Scottish men recruited in the early 1970s and followed up for 25 years we examined the association between objective and subjective indices of social position, perceived psychological stress, cardiovascular disease risk factors and subsequent health. Lower social position, whether indexed by more objective or more subjective measures, was consistently associated with an adverse profile of established disease risk factors. Perceived stress showed the opposite association. The main subjective social position measure used was based on individual perceptions of workplace status (as well as their actual occupation, men were asked whether they saw themselves as “employees”, “foremen”, or “managers”). Compared to foremen, employees had a small and imprecisely estimated increased risk of all cause mortality, whereas managers had a more marked decreased risk. The strongest predictors of increased mortality were father's manual as opposed to non-manual occupation; lack of car access and shorter stature, (an indicator of material deprivation in childhood). In the fully adjusted analyses, perceived work-place status was only weakly associated with mortality. In this population it appears that objective material circumstances, particularly in early life, are a more important determinant of health than perceptions of relative status. Conversely, higher perceived stress was not associated with poorer health, presumably because, in this population, higher stress was not associated with material disadvantage. Together these findings suggest that, rather than targeting perceptions of disadvantage and associated negative emotions, interventions to reduce health inequalities should aim to reduce objective material disadvantage, particularly that experienced in early life.

Section snippets

Social position and health

For much of the 20th Century, and especially over the past 25 years, epidemiological research has focused on the relation between social position and health (Davey Smith, 1997). In one sense, this relation appears straightforward. Poorer health is associated with social disadvantage. In the UK at least, this has been true for most overall health indicators since the 19th century (Chadwick, 1965; Stevenson, 1923; Logan, 1954; Black, Morris, Smith, & Townsend, 1980; Davey Smith, Gunnell, &

Study population

The current investigation is based on a cohort of 5232 men aged 35–64 years (mean age 48) recruited from 27 workplaces in Scotland between 1970 and 1973. The workplaces were chosen to provide a sample of the occupational spectrum of the male working population. They included engineering, manufacturing and petrochemical plants; a publishing house, civil service departments; administrative and professional divisions from British Rail; legal and dental offices; architectural institutes and banks (

Results

In general, disadvantageous social position was associated with an unfavourable profile of disease risk factors whatever the measure of social position used (Table 1). The exceptions to this rule were plasma cholesterol, perceived stress, and job satisfaction where advantageous social position was associated with an adverse risk profile. Nine hundred and six men described themselves as “managers”, 459 as “foremen” and 3867 as “employees”. Foremen reported higher stress than employees and only

Health and social position

Social disadvantage was associated with poorer health (as indexed by all cause mortality) in this population, whatever the measure of social position used. Having a father in a manual occupation was the strongest predictor of poorer health. Other strong predictors were height and car access. Workplace status, current occupation, educational status and area of residence were all strongly associated with health in age-adjusted analyses. Adjustment for health behaviours and physiological risk

Acknowledgements

The work of Victor Hawthorne, Charles Gillis, David Hole and Pauline MacKinnon has provided us with the data required for this analysis. A grant within phase two of the Economic and Social Research Councils, Health Variations research programme allowed linkage to hospital admission data. JM is supported by a Career Scientist fellowship from the Department of Health. All views expressed are those of the authors and not necessarily of the Department of Health.

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