McLeod, Erving & Caputo (2014)
McLeod, Erving & Caputo (2014)
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In this chapter, we review social psychologi- Social psychological theories and concepts
cal research on health inequalities across the must be central to any such analysis. As a group,
WKUHH FHQWUDO GLPHQVLRQV RI VWUDWL¿FDWLRQ LQ WKH they draw attention to the processes that connect
United States: socioeconomic position, race, macro dimensions of inequality to psychological
and gender.1 Much health research is motivated and bodily experiences. They direct us to con-
by the straightforward, and seemingly reason- sider how the structure and content of proximate
able, assumption that social disadvantages pro- environments influence the distribution of mate-
duce health disadvantages. However, patterns rial resources, the nature and quality of interper-
of health inequality are not always consistent sonal interactions, and the construction of sym-
with this assumption. Women’s health is not uni- bolic meanings. These proximate processes set
formly worse than men’s despite their relative in motion physiological and emotional responses
social disadvantage; the same is true in the com- that are the ultimate determinants of physical
parison of racial minorities with majority whites. and psychological well-being (Kiecolt-Glaser
Even in the case of socioeconomic position, for et al. 2002). Although others have made the point
which consistent health inequalities have been that proximate processes tell us how inequalities
observed, the association varies by outcome and “get under the skin” (Taylor et al. 1997), their
over the life course. These empirical complexi- accounts emphasize categories of proximate en-
ties call for a rich and nuanced analysis that looks vironmental experiences (e.g., interpersonal re-
beyond the distribution of material resources to lationships) rather than the social psychological
consider how group statuses affect interpersonal processes those categories represent. We empha-
interactions and the emergent meanings of objec- size the latter, as it is these processes that tell us
tive life circumstances. how, why, and under what circumstances social
disadvantage diminishes physical and psycho-
1
logical well-being.
Research on health inequalities encompasses other di-
mensions of stratification such as immigrant status and We begin with a brief description of health in-
sexual identity (Alegria et al. 2008; Cho et al. 2004; equalities, followed by a review of key factors
Saewyc 2011). Because the social psychological argu- that have been proposed to explain them. We
ments that are invoked are similar, we emphasize these begin with factors associated with the stress pro-
three key dimensions of stratification here.
cess framework because they have dominated
sociological research on health inequalities for
J. D. McLeod (
) · C. Erving · J. Caputo many years: stress exposures, residential envi-
Department of Sociology, Indiana University, Ballantine
ronments, psychological dispositions, and social
Hall 744, 1020 E. Kirkwood Avenue, Bloomington,
IN 47405, USA relationships. We then turn to two other explana-
e-mail: [email protected] tory factors—health behaviors and health care
J. D. McLeod et al. (eds.), Handbook of the Social Psychology of Inequality, Handbooks of Sociology and 715
Social Research, DOI 10.1007/978-94-017-9002-4_28, © Springer Sciences+Business Media Dordrecht 2014
716 J. D. McLeod et al.
interactions—that draw from other frameworks. also are sicker and stay sick longer than people
We close with a discussion of the role of social in higher socioeconomic positions (Herd et al.
comparisons in health inequalities. For each 2007), in part, because they are less likely to
factor, our central orienting question is: How can seek care and, when they do, receive lower qual-
social psychological theories and concepts help ity care (Fiscella et al. 2000). At the most basic
us understand its role in health inequalities?2 level, these patterns demonstrate that the effects
of socioeconomic inequality on health are the re-
sult not only of the profound material depriva-
Basic Patterns tions experienced by people who occupy the very
lowest status positions but also of symbolic pro-
Socioeconomic Position3 cesses through which people come to understand
their place in the world.
The basic findings in research on socioeco- This simple description of socioeconomic
nomic inequalities in physical health are well- inequalities in health overlooks important varia-
established and seemingly robust to historical tions across outcomes and over the life course.
and geographic variation, at least in the western Health inequalities are larger for some health
industrialized world. People who occupy lower outcomes (e.g., heart disease mortality) than for
socioeconomic positions as indexed by income, others (e.g., hypertension; Dow and Rehkopf
education, and occupational prestige have worse 2010), with no obvious explanation. Health in-
physical and mental health than people who oc- equalities also vary over the life course. For
cupy higher socioeconomic positions (see also physical health, they are largest in infancy and
Milkie et al., this volume). As a general rule, midlife, and smaller in childhood, adolescence,
socioeconomic inequality in health holds across young adulthood, and at older ages (Adler and
the full continuum—what is often referred to Rehkopf 2008). The patterns for mental health
as the health gradient (Adler et al. 1994; Brave- are less consistent, although this may be a func-
man et al. 2010). It is not just that people who tion of how socioeconomic position is measured.
are poor, who have not graduated from high Schieman (2003) reported that worsening finan-
school, and who work in unskilled positions have cial conditions are more strongly associated with
worse health than everyone else. Rather, people anger in younger adults than in older adults (see
who occupy any given position on the socio- also Mirowsky and Ross 2001). In contrast, the
economic scale have worse health than those in association of education with depression appears
positions above and better health than those in to grow stronger with age (Miech and Shanahan
positions below, with some leveling of the curve 2000), perhaps reflecting the association of edu-
at the highest status levels (House and Williams cation with chronicity of disorder (Miech et al.
2000). People in lower socioeconomic positions 2005).
2
Our review is necessarily selective. Literally thousands
of studies of health inequalities have been published just Race4
in the past decade, many of which offer some social psy-
chological insight. To keep our review manageable, we By virtually every indicator, U.S. blacks (or Afri-
focus primarily on studies that explicitly invoke social
can Americans) have worse physical health than
psychological theories and concepts. Even within this nar-
row group of studies, space limitations prevent us from U.S. whites. Blacks report worse health on sub-
including all relevant citations. jective measures such as self-rated health (Cum-
3 The terms “social class,” “socioeconomic status,” and
“socioeconomic position” are defined and used in various
ways by health researchers. Of the three, the term socio- 4
We follow Williams et al. (2010) in using race to refer
economic position is the broadest. We use it here to avoid to racial and ethnic categories, both because the boundar-
an unnecessary and unproductive alliance between our ar- ies between the two concepts are fuzzy and for the sake
guments and any more specific conceptualization. of parsimony.
28 Health Inequalities 717
mings and Jackson 2008), as well as on more et al. 2007), which is consistent with their rela-
objective measures such as counts of chronic tive socioeconomic positions, but Mexicans ex-
health conditions (Hayward et al. 2000). Blacks perience better health than Puerto Ricans, which
experience earlier onset of major health problems is not. Although less well-studied, American
than whites, their health problems are more se- Indians and Alaskan Natives have poor health
vere, and their health declines more rapidly with relative to whites, with relatively high mortal-
age than the health of whites (Hertz et al. 2005; ity rates for alcohol abuse, tuberculosis, diabe-
Kelley-Moore and Ferraro 2004; Shuey and tes, unintentional injuries, homicide, and suicide
Willson 2008). Although blacks have lower cur- (Indian Health Service 2011).
rent and lifetime rates of major depression than
whites (a finding that extends to other psychiatric
disorders), their episodes last longer and are more Gender
severe (Williams et al. 2007). Racial differences
in socioeconomic position contribute to racial in- With respect to physical health, women report
equalities in health but they do not fully explain poorer health and have higher rates of disability
them; at each socioeconomic level, blacks have than men but they live longer (Read and Gorman
worse health than whites (Williams 2005). 2011; Verbrugge 1985). Although this basic con-
Studies of other minority groups complicate clusion seems secure, life course research intro-
our understanding of whether and how social duces complexity. For example, the male disad-
disadvantage produces poor health. Although vantage in heart disease now appears to be small-
Asian Americans are racial minorities in the U.S., er than previously thought (McKinlay 1996) and
they have better health than whites on average decreases at older ages (Verbrugge and Wingard
(Frisbie et al. 2001; Takeuchi et al. 2007). How- 1987). Women’s disadvantage in self-rated health
ever, there is significant variation across Asian also declines with age, perhaps as men develop
American groups that maps closely onto their more life-threatening illnesses, but their disad-
socioeconomic profiles. Chinese, Japanese, and vantage in functional disability increases (Gor-
Filipino immigrants tend to be highly educated man and Read 2006).
and experience better physical and mental health With respect to mental health, scholars have
than U.S.-born Whites, whereas poorly-educated long documented higher rates of depression and
refugees from Southeast Asian nations such as higher levels of depressive symptoms in women
Vietnam and Laos generally experience poorer as compared to men (Rosenfield 1999), leading
physical health (Frisbie et al. 2001). Importantly, to the conclusion that women have worse mental
the health of Asian Americans declines with lon- health. However, more recent evidence suggests
ger time of residence in the U.S. (Frisbie et al. that the differences may reflect gendered norms
2001; Takeuchi et al. 2007), pointing to a role for of emotional expression: women report more
meaning-based explanations. symptoms of internalizing distress while men
Despite lower average socioeconomic posi- report more symptoms of externalizing distress,
tion, Latinos have similar, and sometimes better, such as alcohol and substance abuse (Rosenfield
health profiles than whites, a pattern that is re- 1999).
ferred to as the “epidemiologic paradox” (Fran- Research across these three dimensions of in-
zini et al. 2001; Markides and Coreil 1986). As equality confirms that social disadvantages often,
for Asian Americans, Latino health declines with but not always, translate into health disadvantag-
the length of time immigrants have spent in the es. The associations of socioeconomic position
United States (Alegría et al. 2007; Cho et al. and gender with health vary by outcome and over
2004). Patterns of Latino health also vary with the life course. Some racial minority groups have
country of origin but not necessarily with socio- poorer health than whites (e.g., Blacks) whereas
economic position. For example, Cubans experi- others do not (e.g., Latinos). Social psychologi-
ence better health than Puerto Ricans (Alegría cal theories help us understand these patterns by
718 J. D. McLeod et al.
identifying the processes through which social We organize our review with reference to six
disadvantage produces health disadvantages, and major classes of explanatory factors that have
the contingencies that govern them. been identified as most central in previous re-
views (Adler and Stewart 2010; House and Wil-
liams 2000; Matthews et al. 2010): stress expo-
Explaining the Patterns sures; residential environments; psychological
dispositions; social relations; health behaviors;
As House and Williams (2000) note, inequality and health care interactions. For each, we high-
influences health through many different path- light the complementary contributions of mate-
ways. Virtually all known behavioral, psychoso- rial and subjective explanations. We then review
cial, and environmental health risk factors vary research on social comparisons and health, which
across positions in systems of inequality (see underlies interest in relative deprivation, equity,
also Lynch et al. 2000). Thus, the goal of health and illness interpretations. We begin with fac-
inequalities research is not to determine wheth- tors associated with the stress process because of
er specific risk factors contribute but why. Two their long dominance in health research and their
broad types of processes have been proposed: (1) especially close alliance with social psychology.
those that involve the differential distribution of
material deprivations and resources and (2) those
that involve non-material or “psychosocial” fac- Stress Exposures
tors. The former emphasize objective life condi-
tions associated with lower status positions that According to the stress-exposure explanation,
place people at risk of poor health, such as ex- people in socially disadvantaged positions expe-
posure to health-damaging physical and social rience poorer health because they are exposed to
environments. The latter emphasize subjective more stressors and have fewer resources (intra-
experiences that arise at the intersection of the psychic, interpersonal, and material) for coping
social and the psychological, often conceptual- with them (Schwartz and Meyer 2010; Thoits
ized as stress exposures, psychological disposi- 2010). Chronic and intense stressors have been
tions, social relationships, and health behaviors. hypothesized to play an especially strong role
Social psychology aligns naturally with the in health inequalities (Turner et al. 1995). This
analysis of psychosocial factors. Yet, it would be explanation draws implicitly from the social
a mistake to remove all consideration of material structure and personality framework within so-
life conditions from social psychological inquiry. ciological social psychology (House 1981; Wil-
Material deprivation can affect health through liams 1990), which traces the effects of macro-
social psychological processes, such as when structures and processes on individuals through
economic deprivation affects the perceived level the “smaller structures and patterns of intimate
of financial stress. As well, psychosocial factors interpersonal interaction or communication”
can have material implications, such as when (House 1981; p. 540) that constitute people’s
the quality of social relationships affects access day-to-day lives. Most sociological research on
to other health-promoting resources (Kawachi stress measures objective stress exposures, such
et al. 2010). For these reasons, we set aside re- as job loss; in contrast, most psychological re-
cent debate over the relative primacy of material search measures “subjective” stress exposures by
and psychosocial factors in health inequalities taking into account respondents’ perceptions of
(see Carpiano et al. 2008 for a review) in favor the stressfulness of the experience (e.g., severity,
of a focus on the social psychological processes threat, and the like).
that link material realities to psychosocial fac- Studies have evaluated both general and spe-
tors. These processes occur in proximate envi- cific forms of the stress exposure explanation.
ronments that structure daily life and give life Tests of the general form use global measures
meaning. of stress exposure—sums of life events, chronic
28 Health Inequalities 719
stressors, lifetime traumatic experiences, and/or Together, these studies demonstrate that gen-
of overall stress burden (Turner et al. 1995)—to eral stress exposure is one pathway through
evaluate whether stress exposures account for which social disadvantage increases the risk of
health inequalities. Results are mixed. People poor health, especially for race. Research on spe-
with low levels of income, education, and who cific stressors adds depth to this conclusion by
work in less prestigious occupations experience pinpointing the stress exposures that are most
a relatively high burden of chronic and severe closely linked to specific dimensions of inequali-
stressors, but these stress exposures do not fully ty. This research investigates differences in stress
account for their poorer physical and mental exposure across social groups as well as the ef-
health (see Matthews et al. 2010 for a review). fects of specific stressors on health within social
The same holds for gender. For example, Denton groups.
et al. (2004) found that women’s poorer general Specific Stressors: Socioeconomic Position.
physical health is not explained by differences Economic experiences and work environments
in their structural positions, lifestyle, or experi- have received sustained attention in research
ences of stress. Evidence for the role of stress on socioeconomic differences in health. People
exposures in racial inequalities in health appears with low levels of income are at disproportionate
more solid (Williams et al. 1997). Blacks and risk of food insecurity and financial stress (e.g.,
U.S.-born Latinos report higher levels of stress Bickel et al. 1999; Broussard 2010). People with
exposure than whites and foreign-born Latinos low levels of education encounter less favorable
(Sternthal et al. 2010; see Hatch and Dohren- job conditions (Warren et al. 2004) and more fi-
wend 2007 for a review) and the differences in nancial difficulties (Stronks et al. 1998). The psy-
stress exposure account for roughly half of the chosocial work environment also varies across
differences in self-rated health, chronic illnesses, occupations in ways that matter for health. For
and depressive symptoms (Sternthal et al. 2010). example, jobs that involve a combination of high
Research on general stress exposures has been demands and low control are associated with in-
extended with life course concepts, especially creased risk of cardiovascular disease (Karasek
the notion of cumulative exposures (Elder et al. and Theorell 1990), as are jobs that involve high
1996). Early life socioeconomic disadvantages effort and low reward (Theorell 2000). Economic
appear to set into motion cascades of negative and occupational stressors extend into other life
experiences with profound health consequences domains, increasing family and marital conflict
(McLeod and Almazan 2003; Wadsworth 1997). and, in turn, threatening health (e.g., Frone 2000;
Low socioeconomic position during childhood is Grzywacz 2000).
related to risk factors for the prevalence of adult While these results are consistent with the
disease (e.g. Lynch et al. 1997), mortality (Davey assumption that social disadvantage increases
Smith et al. 1998; Hayward and Gorman 2004), stress exposure, some research on socioeconomic
self-rated health, and physical symptoms (Power position finds the opposite. Studies of the “stress
et al. 1998), independent of adult life conditions of higher status” find that people in higher-status
(e.g., Kuh et al. 2002; although see Hayward and occupations report more work-family conflict,
Gorman 2004). Childhood disadvantage also longer hours, and more work demands than peo-
has been implicated in race differences in health ple in lower-status occupations (Schieman et al.
among adults (Warner and Hayward 2006). For 2006). Similarly, people with high levels of edu-
example, evidence supports Geronimus’ “weath- cation report greater exposure to daily stressors
ering hypothesis,” which proposes that African than people with low levels of education (Grzy-
Americans experience earlier health deterioration wacz et al. 2004). Additional results from the lat-
due to the cumulative impact of repeated experi- ter study suggest that the apparent disadvantage
ences of social or economic adversity (Geroni- among people with high levels of education may
mus et al. 2006). be more illusory than real: although they report
more stressors, the stressors they report are less
720 J. D. McLeod et al.
severe (based on both objective and subjective This is especially true in studies that measure
ratings) and less strongly associated with health discrimination with reports of “unfair treatment”
(Grzywacz et al. 2004). More studies of stress because those reports do not differ by race (e.g.,
exposure that take into account the qualities of Kessler et al. 1999). Discrimination provides a
events and how objective life conditions are in- stronger explanation in studies that ask respon-
terpreted may help resolve these inconsistencies dents directly about racial discrimination (Krieg-
(McLeod 2012). er 2012). Thus, studies that use more refined
Specific Stressors: Race. Studies of racial measures that incorporate the perceived basis for
minority health emphasize discrimination as a the discrimination and the context in which it oc-
specific stressor linked to poor health. In these curs may yield more consistent results.
studies, discrimination is conceptualized as a Among racial minorities, perceptions of dis-
multi-level phenomenon, encompassing institu- crimination and the effects of discrimination on
tional discrimination, personal discrimination, health appear to be contingent on identities and
and internalized racism (Williams and Moham- beliefs. African Americans whose racial iden-
med 2009). In this section, we review research tities are central to their sense of self and who
on personal discrimination because it aligns believe that other groups hold negative attitudes
most closely with the stress exposure explana- toward African Americans report higher levels
tion. Institutional discrimination operates in part of perceived discrimination than other African
through race differences in socioeconomic posi- Americans (Sellers et al. 2003, 2006). At the
tion which, as noted, explain some but not all of same time, the negative effects of discrimina-
racial health inequalities. Institutional discrimi- tion on mental health are dampened by the belief
nation is also evident in racial residential segre- that the public holds one’s group in low regard
gation (Takeuchi et al. 2010), a health risk that (Sellers et al. 2006) and by having a strong racial
we discuss in the section that follows. identity (Mossakowski 2003; Sellers et al. 2003;
Measures of personal discrimination include although see Yip et al. 2008), although evidence
major discriminatory acts (e.g., being denied a for the latter is more mixed (Pascoe and Richman
job because of one’s race), day-to-day experienc- 2009).
es of discrimination or micro-aggressions (e.g., Specific Stressors: Gender. Research on
being treated with disrespect; Sue et al. 2007), gender-specific stressors draws primarily from
and anticipated experiences of discrimination research on gendered social roles. This research
or heightened vigilance. Individual discrimina- has waned in recent years, perhaps because pat-
tion is an important determinant of health among terns of gender-based health inequality are less
racial minorities. For example, among racial mi- straightforward and because scholarship on gen-
nority adults, experiences of major discrimina- der has shifted away from a role-based concep-
tion are associated with poorer self-rated health, tualization (Courtenay 2000). During the 1980s
higher blood pressure, cardiovascular disease, and 1990s, scholars established that women’s
and psychological distress (see reviews by Har- disadvantaged positions in the family and labor
rell et al. 2003; Williams et al. 2003). Micro-ag- market contributed to women’s higher levels
gressions are associated with both internalizing of distress and lower levels of self-rated health
and externalizing emotions among Asian Ameri- compared to men (e.g., Aneshensel et al. 1981;
can adults (Wang et al. 2011) and with depressive Ross and Bird 1994; Thoits 1986). Interestingly,
and somatic symptoms among Latino and Asian these studies also pointed to men’s potential vul-
American adolescents (Huynh 2012). Despite nerability to changing gender roles in the family,
the strong association of personal discrimination and found that men whose wives work or earn
with health within racial minority populations, more than them may have poorer mental health
discrimination does not consistently account for compared to those in households with a more
racial differences in physical and mental health traditional division of labor (Glass and Fujimoto
(e.g., Kessler et al. 1999; Williams et al. 1997). 1994; Rosenfield 1992).
28 Health Inequalities 721
Subsequent research extended these basic facilities and are more likely to be exposed to
findings with evidence that the meaning of so- environmental toxins and air pollutants (Brulle
cial roles and, therefore, their stressfulness var- and Pellow 2006). Although direct evidence is
ies by gender. For example, Simon (1995) found scarce (Adler and Stewart 2010), these differen-
that employment has different meanings for tial exposures seem likely to contribute to health
married male and female parents, with women inequalities. How much they contribute is uncer-
feeling guilty about the time work may take tain as some evidence indicates that physical en-
away from their families and men seeing work vironments contribute only about 5% to prema-
as bolstering their family roles. This difference ture mortality (McGinnis et al. 2002).
in role meanings contributes to women’s greater Sociological studies of health inequalities
distress. Similarly, women encounter more stress have devoted more attention to the social char-
in association with parenthood because they con- acteristics of residential environments than to
tinue to have greater responsibility for parenting their physical risks. Disadvantaged residential
activities such as finding childcare (Ross and environments are often, although not always,
Mirowsky 1988; Simon 1992). Gendered expec- conceptualized as stress exposures. Although
tations for emotion work also produce gender dif- their effects on health are amenable to social psy-
ferences in vulnerability to stress. For example, chological explanation, social psychology is ref-
Kessler and McLeod (1984) found that women’s erenced only infrequently in this literature. (See
greater psychological vulnerability to stressful Quillian, this volume for further discussion.)
life events lies in the events that occur to network Since the early 2000s, research on socioeco-
members, which may reflect the expectation that nomic health inequalities has turned to the ques-
women shoulder the burden of maintaining inter- tion of whether neighborhood-level socioeco-
personal relationships (although see Aneshensel nomic disadvantage and residential segregation
et al. 1991). contribute to socioeconomic health inequalities
Research on specific stressors extends re- (see Pickett and Pearl 2001, and Robert et al.
search on general stressors by acknowledging 2010 for reviews). These neighborhood condi-
that certain stressors may be more closely tied to tions are thought to affect health because they are
some forms of inequality than to others. In that associated with material living conditions (e.g.,
way, it offers a more nuanced conceptualization access to health care, exposure to violence, hous-
of proximate environments that brings stress re- ing quality) as well as social environments (e.g.,
search into conversation with more general social social cohesion, behavioral norms; Diez-Roux
psychological concepts, such as social roles and and Mair 2010). Neighborhood characteristics
discrimination. The most promising research has appear to have significant but modest associa-
sought to incorporate subjective interpretations tions with physical and mental health indepen-
of stressors (i.e., perceived severity, perceived dent of individual-level socioeconomic position
discrimination, the meanings of social roles), (Robert et al. 2010). However, they do not ex-
which strengthens the stress process framework’s plain the associations of socioeconomic position
alliance with symbolic interactionism (McLeod with health. Instead, socioeconomic position in-
2012). teracts with neighborhood characteristics when
predicting health outcomes. For example, stress-
ful daily events have stronger effects on mood
Residential Environments for women who live in neighborhoods that they
regard as unsafe and in which residents do not
Exposure to harmful residential environments is engage in mutually supportive activities than for
socially patterned to the disadvantage of people women who live in better neighborhoods (Caspi
in lower socioeconomic positions and racial mi- et al. 1987). More generally, living in deprived
norities. The poor and racial minorities are more neighborhoods heightens the associations of
likely to live near environmentally hazardous
722 J. D. McLeod et al.
other stressors with physical and mental health coping. Studies of coping investigate the possi-
(Cutrona et al. 2006). bility that people in socially disadvantaged posi-
As noted in the previous section, studies of ra- tions have fewer resources to cope with stressors,
cial health inequalities treat racial residential seg- which renders them more vulnerable to health
regation as an indicator of institutional discrimi- problems when stressors occur (Williams et al.
nation. Consistent with this conceptualization, 2010; see Thoits 1995 for a review). However,
neighborhood characteristics explain a signifi- psychological dispositions are important for
cant proportion of the effects of race on hyperten- health beyond their role as coping resources, as
sion, obesity, self-rated health, and other health- we outline below.
related outcomes (e.g., Cagney et al. 2005; More- Among psychological dispositions, two di-
noff et al. 2007; Robert and Lee 2002). African mensions of the self-concept—self-esteem and
Americans who live in segregated neighborhoods mastery—have received most attention from so-
also have a much higher risk of mortality than ciologists (see Callero, this volume). Self-esteem
African Americans who live in areas of low seg- refers to an overall evaluation of one’s worth
regation in both childhood and adulthood (e.g., or value. The association of socioeconomic po-
LaVeist 1993; Takeuchi et al. 2010). However, sition with self-esteem increases with age, at
Mexican Americans and Asian Americans who least through mid-adulthood. In Rosenberg and
live in segregated neighborhoods report better Pearlin’s (1978) foundational study, parents’ oc-
health than their counterparts who live in inte- cupational prestige was unrelated to self-esteem
grated neighborhoods (e.g., Gee 2002; Patel et al. for young children (ages 8–11), weakly related
2003). Scholars speculate that, for some racial to self-esteem for older adolescents, and strongly
groups, residential segregation increases access related to self-esteem for adults. The same age-
to immigrant enclaves, ethnic social networks, graded pattern has been confirmed and extended
and supportive social relations that promote, in other studies, with evidence that the associa-
rather than damage, health (Takeuchi et al. 2010). tion begins to decline after age 60 (Twenge and
In sum, research supports the conclusion Campbell 2002). Women also report lower self-
that the characteristics of areas of residence esteem than men, with the difference emerging in
make only a modest contribution to explaining late adolescence (Kling et al. 1999). In contrast,
socioeconomic health inequalities. Residential race differences in self-esteem are not consistent
characteristics contribute more to explaining with the hypothesis that social disadvantage di-
racial health inequalities although the patterns minishes feelings of self-worth. Rather, African
are not straightforward. Research on the health- Americans report higher self-esteem than whites
promoting features of segregated neighborhoods who, in turn, report higher self-esteem than Lati-
suggests that the quality of relationships within nos and Asian Americans (Gray-Little and Haf-
neighborhoods may matter more for health than dahl 2000; Twenge and Crocker 2002).5
their objective characteristics—a possibility that Self-esteem is positively associated with self-
emphasizes the centrality of social psychology to reported health (McDonough 2000) and nega-
research on the environmental determinants of
health. 5
Several explanations have been proposed for the rela-
tively high self-esteem observed among African Ameri-
cans: that members of disadvantaged groups tend to com-
Psychological Dispositions pare themselves to similarly disadvantaged others; that
they attribute failures or rejection to prejudice; that they
devalue domains in which their group show relatively
People’s positions in systems of inequality influ- poor achievement; and that they hold positive group iden-
ence not only their exposure to stress and harmful tities that protect self-esteem (see Twenge and Crocker
environments, but also their psychological dispo- 2002 for a review). However, why Latinos and Asian
Americans report low self-esteem relative to whites and
sitions. Research on stress evaluates differences blacks, despite presumably having access to these same
in dispositions with reference to the concept of cognitive coping strategies, remains unclear.
28 Health Inequalities 723
tively associated with reports of illness (Anto- Research in health psychology extends the
nucci and Jackson 1983). It predicts mortality study of psychological dispositions to encompass
prospectively (Forthofer et al. 2001) and is nega- negative emotions, including depression, anxiety,
tively associated with depressive symptoms and hostility, and anger (see Foy et al., this volume).
psychological distress (Pearlin et al. 1981). Self- People who occupy socially-disadvantaged posi-
esteem appears to promote health by fostering tions, whether based on socioeconomic position,
healthy social relationships and by encouraging race, or gender, report higher levels of negative
healthy behaviors (McGee and Williams 2000; emotions than people who occupy socially-ad-
Stinson et al. 2008; although see Gerrard et al. vantaged positions. In turn, negative emotions
2000). Despite its promise as an explanation for have been linked to poor health in prior research,
socioeconomic and gender health inequalities, and especially to the risk of poor immunological
however, it does not explain them in statistical functioning and cardiovascular disease (Kiecolt-
models (McDonough 2000; Schnittker 2004). Glaser et al. 2002; Matthews et al. 2010).
Possibly, self-esteem is more important for ex- Psychological dispositions represent an addi-
plaining group differences in response to stress tional pathway through which inequality affects
than for explaining health inequalities per se. health. Although often treated as coping resourc-
The second dimension of the self-concept, es by stress researchers, mastery and negative
mastery, refers to the extent to which people emotions also have direct effects on health that
perceive themselves as in control of forces that contribute to health inequalities. Their contribu-
importantly affect their lives. Mastery is rooted tion demonstrates that the meanings associated
in objective conditions of power and depen- with social disadvantage profoundly influence
dency that vary across social hierarchies. As bodily functioning.
noted in the section on stress, people who are
in socially disadvantaged positions are dispro-
portionately exposed to adversities that dimin- Social Relationships
ish control. High status also carries opportuni-
ties and positive life experiences that enhance Social relationships can promote positive health
sense of control through “social conditioning” behaviors, facilitate social control against nega-
(Weeden and Grusky 2005) and learning gener- tive health behaviors, foster a sense of meaning
alization (Kohn and Schooler 1983). As a result, and purpose in life, serve as standards for social
people who occupy higher positions in social hi- comparison, and improve an array of physiologi-
erarchies have higher average levels of mastery cal processes (Umberson and Montez 2010). At
(e.g., Pearlin et al. 1981; Ross and Mirowsky the same time, social relationships carry costs.
1992). High mastery is associated with bet- They can be sources of stress as well as comfort,
ter physical and mental health, longevity, and and they may encourage risk-taking behaviors,
fewer activity limitations (Kiecolt et al. 2009; especially among youth (Mirowsky and Ross
McDonough 2000; Mirowsky and Ross 1989). 2003; Ennett et al. 2006). Social relationships
Mastery contributes importantly to explaining also convey values, and material and informa-
differences in physical and mental health by tional resources that matter for health. As Cook
socioeconomic status, gender, and race (e.g., (this volume) notes, because people’s social
Denton et al. 2004; Pudrovska et al. 2005; Ross networks tend to be populated by similar others
and Mirowsky 1989; Turner et al. 2004). Mas- (McPherson et al. 2001), social group member-
tery also moderates the effects of stressors on ships shape the social resources to which people
health, encourages healthy behaviors, and pro- have access and the values they hold.
motes recovery from illness (Pudrovska et al. Most sociological research on health concep-
2005; Schwarzer and Fuchs 1995), suggesting tualizes social relationships with reference to the
its relevance to understanding group differences concepts of social support and social integration.
in vulnerability to stress. Social support refers to “the functions performed
724 J. D. McLeod et al.
for the individual by significant others” (Thoits mental disorder for African Americans, but not
1995; p. 64), including instrumental, informa- for whites (Kiecolt et al. 2008).
tional, and/or emotional assistance. Social inte- Social integration is a second type of social
gration refers to the “overall level of involvement resource of interest to stress researchers. It is typi-
with informal social relationships,” including cally measured by participation in major social
marriage and membership in formal organiza- roles, such as marriage or employment, member-
tions (Umberson and Montez 2010; p. S54). ship in social organizations, such as churches or
Among dimensions of social support, per- voluntary groups, or frequency of social interac-
ceived emotional support is most strongly associ- tion with friends and relatives. Each of these di-
ated with health. People who have intimate, con- mensions of social integration strongly predicts
fiding relationships with others, and who feel that physical and mental health (Berkman and Syme
they are loved and cared for, report better health 1979; see Berkman et al. 2000 for a review). For
and experience fewer damaging effects of stress example, on average, married persons report bet-
(Thoits 2011). Access to social support is socially ter physical and mental health and have lower
patterned, although not always to the disadvan- mortality rates than persons who are not mar-
tage of lower status groups. People in lower ried (e.g., Berkman and Syme 1979; Hughes and
socioeconomic positions report smaller confi- Waite 2009), and organizational and religious par-
dant networks and lower levels of social sup- ticipation are associated with better health (e.g.,
port than people in higher socioeconomic posi- Hummer et al. 1999; Piliavin and Siegl 2007).
tions (McPherson et al. 2006; Turner and Marino Social integration varies with socioeconomic
1994). Similarly, blacks report smaller confidant position and race in ways that suggest its potential
networks than whites (McPherson et al. 2006) as a mediator of health inequalities. People who
and lesser involvement in “balanced” exchanges occupy lower socioeconomic positions and racial
of emotional support (exchanges in which both minorities are less likely than people who occupy
partners give and receive support; Sarkisian and higher socioeconomic positions and whites to be
Gerstel 2004). However, blacks also report more married and employed (Martin 2006). They are
church-based support than whites (Krause 2002) also more likely to change residences frequently,
and, especially for women, are more likely to be and to live in communities characterized by so-
involved in giving and receiving practical support cial disorder and weak social bonds (Massey and
(e.g. household help, transportation help, child Denton 1993; Wilson 1987). Blacks are less like-
care; Sarkisian and Gerstel 2004). Indeed, in ly than whites to participate in voluntary social
general, women report larger confidant networks organizations, with the exception of churches and
than men and higher levels of support (McPher- neighborhood organizations, although the race
son et al. 2006; Turner and Marino 1994). difference is declining in more recent cohorts
Perhaps because social disadvantage does not (Miner and Tolnay 1998).
correlate neatly with social support, evidence Yet, as was true for social support, social in-
suggests that social support does not explain tegration does not explain health inequalities.
health inequalities. Specifically, social support Studies of socioeconomic, race, and gender dif-
contributes little to explaining socioeconomic ferences in health often control for social role
and race differences in depressive symptoms occupancy (e.g., marital status, employment
(Kiecolt et al. 2008), and it suppresses the associ- status), providing implicit evidence that social
ation between gender and depression (Turner and integration does not account for health inequali-
Marino 1994). Instead, the limited existing evi- ties. Gorman and Sivaganesan (2007) provide
dence suggests that social support interacts with direct evidence in their finding that social inte-
indicators of social disadvantage when predicting gration—as measured by frequency of talking or
health (Matthews et al. 2010). For example, kin interacting with friends, neighbors, and family, as
support significantly reduces the likelihood of well as by church participation—does not medi-
ate socioeconomic disparities in self-rated health
28 Health Inequalities 725
and hypertension. Kiecolt et al. (2008) report that 1988). Other scholars prefer Bourdieu’s (1985)
church attendance does not account for race dif- definition, “the aggregate of actual or potential
ferences in rates of mental disorder. Indeed, the resources linked to possession of a durable net-
African American health disadvantage would be work” (p. 248), because it opens opportunities to
even larger if not for high rates of religious par- consider the negative side of social relations for
ticipation (Oates and Goode 2013). health. Both conceptualizations link macro-social
Instead, there is consistent evidence that so- inequalities to health through patterned variation
cial integration interacts with gender and race in the structure and content of social networks.
when predicting health. African Americans ex- The most common application of social capi-
perience greater health benefits than whites from tal to health is in research on neighborhood dis-
marriage (Liu and Umberson 2008) and religious advantage. Scholars in this area posit that social
participation (Krause 2002) but reap fewer health networks in disadvantaged neighborhoods are
benefits from being employed (Farmer and Fer- less cohesive and efficacious than networks in ad-
raro 2005) and volunteering (Hinterlong 2006). vantaged neighborhoods (Sampson et al. 2002).
While marriage is beneficial for both genders, As a result, residents of disadvantaged neighbor-
men accrue more health benefits from marriage hoods are less able to engage in collective action
than do women, a finding that has been attributed (e.g., mobilizing to prevent a hospital closure),
to women’s control of their husbands’ health be- enforce positive norms (e.g., against underage
haviors (Berkman and Breslow 1983; Umberson drinking), provide mutual aid, and disseminate
1992). Women also appear to derive fewer health information (see Quillian, this volume).6 Advo-
benefits from employment than men (Pugliesi cates for a more Bourdieuian approach to social
1995; Thoits 1986), because the jobs they hold capital challenge the assumption that cohesive
are less self-directed and lower-paying and be- networks necessarily promote health and note
cause their employment is seen as threatening to that, depending on their composition and norms,
family roles. cohesive networks can damage health (Carpiano
In sum, social support and social integration 2007). Networks can enforce negative (e.g., drug
powerfully shape health but they do not consis- use) as well as positive norms and networks with
tently explain health inequalities. The contingent dense reciprocal exchange systems can impose
nature of their associations with health reveals excessive obligations that create stress for their
limitations in the concepts themselves. As we members (Henley et al. 2005).
noted at the beginning of this section, social re- Empirical evidence for the association of
lationships matter for reasons other than the sup- neighborhood-level social capital with health
port and behavioral control they provide (see varies by outcome. In these studies, social capi-
Berkman 2000 and Umberson and Montez 2010
for a review). 6 A related argument has been presented in research on
For that reason, some health scholars have income inequality. In a small sample of OECD countries,
turned to analyzing social relations through the Wilkinson (1992) documented a negative correlation
broader lens of social capital (see Cook, this vol- between income inequality and life expectancy that ap-
peared to be independent of absolute levels of income.
ume). Some scholars follow Coleman’s (1988) One explanation given for the association was that income
definition, which emphasizes trust, norms of rec- inequality erodes social bonds and diminishes social co-
iprocity, and mutual aid “which act as resources hesion. Research by Kawachi et al. is consistent with this
for individuals and facilitate collective action” explanation in that state-level income inequality is nega-
tively associated with levels of trust, and levels of trust
(Kawachi and Berkman 2000, p. 175). Accord- are strongly associated with age-adjusted mortality (e.g.,
ing to this definition, social capital encourages Kawachi et al. 1997, 1999). However, the basic associa-
the sharing of material resources and informa- tion has been challenged by studies that incorporate more
tion, the development of relationships involving comprehensive controls, fixed effects models, or multi-
level models (e.g., Beckfield 2004; McLeod et al. 2004;
obligation and reciprocation, and the cultiva- Sturm and Gresenz 2002), calling the social cohesion ar-
tion of effective norms and sanctions (Coleman gument into question.
726 J. D. McLeod et al.
tal is operationalized as perceived social cohe- as proximate causes of health inequalities. One
sion, perceived trust, reciprocal exchanges be- reason that members of disadvantaged groups
tween neighbors, and the like. These features of experience less favorable health outcomes is that
neighborhoods have consistently been found to they engage in less healthy behaviors. For exam-
predict lower levels of depression but the results ple, persons with lower income and fewer years
for physical health are mixed (see Diez-Roux and of education are more likely to smoke, be over-
Mair 2010 for a review). In addition, even the re- weight, are less likely to exercise, and consume
sults for depression can be challenged because more alcoholic beverages than persons with
the studies rely on cross-sectional data and sin- higher socioeconomic position (see Adler and
gle-source data collection (i.e., data on outcomes Stewart 2010 for a review). Scholars also find
and neighborhood characteristics are reported by race differences in health behaviors, although
the same person), which means that the possibil- the patterns are more complex and depend on the
ity of non-random sorting of residents into resi- behavior and racial group examined. Dubowitz
dential areas cannot be eliminated. Thus, it is not et al. (2011) found that whites consume more
clear whether causal claims for the role of neigh- fruits and vegetables and are less likely to be sed-
borhood social capital in health are justified. entary than African and Mexican Americans, but
What is perhaps most surprising about re- are more likely to smoke than Mexican Ameri-
search on social capital and health is its weak cans. With respect to gender differences in health
grounding in social psychological theory. De- behaviors, women engage in more preventive and
spite a strong intellectual connection between re- fewer risky behaviors compared to men, and men
search on social capital and social psychological are more likely to drink and smoke, experience
theories of exchange, the latter theories are virtu- accidental injuries, eat less healthy foods, and
ally absent from research on health. Studies make are less likely to seek care for health problems
little or no reference to research on how the struc- (Denton et al. 2004; Read and Gorman 2011).
ture of social networks affects the patterns and However, men are also more likely than women
frequency of exchange, or on the development of to exercise (Read and Gorman 2011). Health be-
relational cohesion in exchange networks (Thye haviors appear to explain a modest, but signifi-
and Kalkhoff, this volume). Instead, studies of cant, proportion of patterned variation in morbid-
social capital and health draw primarily from ity and mortality (Lantz et al. 1998), suggesting
theories of social disorganization from criminol- the importance of understanding their origins.
ogy (e.g., Browning and Cagney 2002). Social Most theories of health behaviors rely on
psychological theories could be used to forge a value-expectancy models of behavior, i.e., that
connection between the Coleman and Bourdieui- people will adopt health-protective behaviors if
an branches of social capital research and to add they anticipate the personal benefits from the be-
precision to the general claim that social disad- havior will outweigh the costs (see DiClemente
vantage diminishes social cohesion. (Others have et al. 2011 for an overview of health behavior
offered comparable suggestions for research on theories). In essence, these theories posit that ac-
social networks and social support; see Lin and tors engage in a rational calculus when deciding
Peek 1999). whether to adopt and maintain specific health
Social disadvantage matters for health beyond behaviors. Theories vary in how they conceptu-
its association with stressors and resources. We alize the factors that contribute to the calculus.
turn now to two additional explanatory factors: The theory of planned behavior emphasizes at-
health behaviors and health care interactions. titudes toward health behaviors, perceived be-
havioral norms, perceived behavioral control,
and behavioral intent (Ajzen and Madden 1986).
Health Behaviors The health behavior model emphasizes perceived
threat of ill health (affected in turn by perceived
Research both within and outside of sociology severity of the condition and perceived vulner-
emphasizes the importance of health behaviors ability), the expected net gain of the behavior,
28 Health Inequalities 727
and the presence of cues to action (Rosenstock As people move into higher levels of education,
et al. 1988). Social cognitive theory emphasizes they encounter and master increasingly complex
knowledge, perceived self-efficacy, outcome ex- problems. As a result, they develop a sense of
pectations, and goal formation (Bandura 2004). efficacy that prepares them for a wide range of
These differences aside, all health behavior theo- life challenges. People who succeed in school
ries are social psychological at their core inas- also display habits and attitudes, such as commit-
much as they see health behaviors as arising from ment, trustworthiness, and motivation that allow
the interaction of person and environment. them to tackle difficult circumstances with con-
Surprisingly, despite evidence that health be- fidence.7 In Mirowsky and Ross’s (2005) words,
haviors are associated with social structural con- “(e)ducation encourages and helps individuals
ditions, little research has evaluated how those to assemble a set of habits and ways that are not
conditions affect the proximate factors on which necessarily related except as effective means to-
theories of health behavior focus: knowledge, at- ward health.” (p. 7). Ample empirical evidence
titudes, perceived norms, etc. (Glanz and Bishop supports the strong role of education in shaping
2010). We review three processes through which health behaviors (e.g., Ross and Wu 1995).
social disadvantage may influence health be- Although health behaviors are undoubtedly a
haviors. These processes complement dominant function of knowledge and skills, they also have
theories of health behavior by highlighting their a habitual character that is under-recognized by
social psychological underpinnings. theories of health behavior and which may be
Education as Socialization. Several theories better explained with reference to socialization
of health behavior posit that behaviors are a func- and identity processes, to which we now turn.
tion, in part, of information, motivation (shaped Informal Socialization. Traditional socializa-
by attitudes and social norms), and perceived tion theories are concerned with how people
ability to enact the behavior successfully. Struc- “acquire social competence by learning the
turally-oriented theories of health inequalities, norms, values, beliefs, attitudes, language char-
including the fundamental cause theory (Link acteristics, and roles appropriate to their social
and Phelan1995) assert that people who occupy groups” (Lutfey and Mortimer 2003, p. 183).
positions of social disadvantage engage in less Socialization arguments are especially promi-
healthy behaviors because they have less access nent in research on neighborhood characteris-
to knowledge and information than their more tics and health. In his analysis of neighborhood
advantaged counterparts (Link and Phelan 1995). decline and isolation, Wilson (1987) argued
In complement, as we discussed in the section on that residents of racially and economically
mastery, social disadvantage also erodes actual segregated neighborhoods develop unique sub-
and perceived control over their life circumstanc- cultures and tolerances for risky behavior. Fol-
es, thereby diminishing motivation and agency lowing the concept of “collective socialization”
(see also the discussion of social ecological mod- (Mayer and Jencks 1989), disadvantaged neigh-
els of health behavior in DiClemente et al. 2011). borhoods may also lack positive role models,
Mirowsky and Ross (2005) assert that at root, contributing to patterns of risky health behavior
knowledge, information-seeking, and agency (Boardman et al. 2001). Consistent with these
have their origins in formal education, which is speculations, low neighborhood SES and social
highly correlated with other forms of social dis- disorganization are associated with risky sexual
advantage.
Education yields specific content knowledge,
but it also encourages the development of gen- 7 Although there is some debate over how much these
eral skills that that can be applied to a range habits and attitudes are products of success in formal
of life problems. In formal schooling, people educational settings, research on the role of non-cognitive
traits in educational success demonstrates that teachers
learn how to think critically, to communicate, differentially reward students based on trustworthiness,
to analyze problems, and to implement plans. dependability, and the like (Farkas 2003).
728 J. D. McLeod et al.
haviors, engagement in the behaviors, and racial groups not only because of differences in shared
identity in a small sample of black Americans. values—the emphasis of socialization theories—
They found that viewing a behavior as more or but also because group members use health be-
less typical of blacks was an important deter- haviors as a way to express valued identities.
minant of the degree to which the behavior was Help-Seeking as a Specific Type of Health
valued and practiced by respondents. Moreover, Behavior. As research on gender and health
the association between racial typicality and en- behavior highlights, help-seeking can be con-
gagement in health behaviors was stronger for ceptualized as a health behavior subject to the
respondents who endorsed racial identities and same explanations outlined above. Whether or
ideologies that emphasize the distinctiveness of not people seek formal treatment for illness has
blacks from other groups. implications for the severity and chronicity of
Through their relevance for health behaviors, disease. Early theories of help-seeking drew
racial identities may also help us understand the primarily from dominant theories of health be-
better health outcomes observed for socioeco- haviors to assert that people make decisions
nomically disadvantaged minority groups. For about whether or not to seek formal treatment
example, research on Latino health suggests that based on their beliefs about treatment and actu-
the better health outcomes observed in some al/perceived access to care. According to these
Latino groups are attributable, in part, to eating theories, if people who experience social disad-
healthier food (Ayala et al. 2008). Food choices vantage are less likely to seek treatment, it is
are one means of expressing ethnic identities, because they are less informed about treatment,
suggesting the potential of identities to explain less likely to believe in its efficacy, and less able
patterns of health behaviors that favor disadvan- to access it (Andersen 1995).
taged groups (Devine et al. 1999). While research supports these theories, they
Gender identities are also expressed through are limited in that they rely on the assumption
health-promoting or health-risky behaviors that help-seeking decisions are made by indi-
(Courtenay 2000). Cultural beliefs about mascu- vidual, rational actors. Pescosolido (1992) re-
linity suggest that men are the more powerful or jects that assumption and proposes an alternative
robust sex. Following from this, men are more theory that grounds help-seeking decisions in
likely than women to engage in health risk-tak- social networks that give meaning to illness ex-
ing behaviors and are less likely to seek health periences. These networks—composed of family
care when they are ill (Addis and Mahalik 2003). and friends, the broader community, the treat-
Seeking help is consistent with portraying a fem- ment system, and social service agencies (includ-
inine self but contradicts dominant constructions ing churches, police, support groups)—serve as
of the masculine self (Courtenay 2000; Nathan- sources of information as well as of behavioral
son 1977; Verbrugge 1985). Extending this basic regulation (both formal and informal) that shape
insight further, men who endorse dominant norms people’s pathways of care. What members of the
of masculinity are less likely to adopt healthy be- network know, how they define the problem, and
haviors and more likely to engage in risky behav- how they evaluate the likely efficacy and ap-
iors than men who endorse less traditional norms propriateness of alternative responses become
(e.g., Eisler 1995; O’Neil et al. 1995). In other important determinants of whether the person
words, men express masculine identities by em- takes action, is coerced into care, or “muddles
bracing risk, which ultimately damages health. through” the illness episode (Pescosolido 2011).
As a group, identity processes emphasize the While the broad sweep of the theory has pre-
role of identities as standards for behavior and as vented a full empirical evaluation, its embedded
sources of meaning. According to studies in this claims offer ample opportunity for social psycho-
area, normative health behaviors differ across logical research.
730 J. D. McLeod et al.
source that people of higher status can claim but times more strongly associated with health than
it is a resource that does not derive exclusively are objective measures (e.g., Adler et al. 2000;
from material advantage. Inequality involves a Singh-Manoux et al. 2003). Low subjective sta-
hierarchy of status that parallels hierarchies of tus is associated with physiological indicators of
material advantage and that amplifies those ad- stress and with negative emotions (Adler et al.
vantages. 2000; Wright and Steptoe 2005), consistent with
the hypothesis that the stresses inherent in low
status positions account for their associations
Social Comparisons with poor health (Sapolsky 2005). Although
well-studied with respect to socioeconomic posi-
Status processes involve social comparisons tion, the concept of relative social standing has
that influence how people evaluate their relative received little attention in research on race and
worth and value. Research on health inequali- gender.
ties invokes other types of social comparisons, Equity and Justice. Theories of equity and
as well, as evident in research on relative social justice emphasize the psychological outcomes
standing, equity, and illness interpretations. of comparing one’s own inputs and outcomes to
Relative Social Standing. Research on relative those of others and are most often referenced in
social standing and health draws on the concept research on mental health. Equity theory predicts
of relative deprivation. Relative deprivation re- that people will experience distress upon perceiv-
fers to a discrepancy between what one expects ing an inequity to themselves or others, that is,
to receive and what one obtains. In their research from either under-benefitting or over-benefitting
on psychosocial factors and health, Marmot et al. (Hegtvedt and Isom, this volume; Homans [1961]
(1998) operationalized relative deprivation with 1974; Walster et al. 1978). According to equity
a measure of “perceived inequality”: respon- theory, under-benefitting produces anger or re-
dents’ perceptions that they were disadvantaged sentment while over-benefitting produces guilt
relative to others at home, in the family, at work, (Homans [1961] 1974; Stets 2003). Experimen-
and in their neighborhoods. They found that per- tal studies generally support these predictions, al-
ceptions of relative inequality contributed im- though evidence is stronger for the effects of un-
portantly to explaining socioeconomic inequali- der-benefitting than over-benefitting (e.g., Austin
ties in health, a finding that has been replicated and Walster 1974; Hegtvedt 1990). Inasmuch as
in other studies (e.g., Eibner and Evans 2005; people in lower status groups are more likely to
Pham-Kanter 2009). Although direct evidence is under-benefit, they are more likely to experience
limited, relative deprivation is thought to affect negative emotions. Negative emotions, in turn,
health through its association with negative emo- set into motion health-damaging physiologi-
tions such as anger, frustration, and hostility and cal and psychological processes (Kiecolt-Glaser
the associations of those emotions with health- et al. 2002). For example, Simon and Lively
compromising behaviors and diminished physi- (2010) found that women’s higher reports of de-
ological functioning (Kubzansky and Kawachi pression were attributable to their higher reports
2000). of anger. The authors infer that the anger and rage
Studies of subjective social status report simi- resulting from perceived inequity lead to long-
lar results. In these studies, respondents are asked term mental health decrements.
to place themselves on a ladder to indicate where Similar findings appear in survey studies of
they stand relative to others in their neighbor- marital equity. Husbands and wives who per-
hoods, communities, or countries. Like measures ceive their relationships as equitable experience
of relative deprivation, subjective status ratings fewer depressive symptoms than those who per-
contribute to explaining the association of objec- ceive themselves as under-benefitting or over-
tive social status with health (e.g., Adler et al. benefitting (e.g., DeMaris et al. 2010; Lennon
2000; Ostrove et al. 2000); indeed, they are some- and Rosenfield 1994; Longmore and DeMaris
732 J. D. McLeod et al.
1997), although some studies report significant more basic way, by shaping the definition and in-
effects only for under-benefitting (Sprecher terpretation of physical and psychological expe-
2001; Voydanoff and Donnelly 1999). The asso- riences, and the manifestations of distress. In the
ciation of marital equity with mental health var- most systematic treatment of the former, Angel
ies with personal and social characteristics. It and Thoits (1987) assert that people construct
is stronger for women than for men (e.g., Glass interpretations of their physical and emotional
and Fujimoto 1994), for women who affirm experiences through comparisons with referent
more egalitarian gender ideologies (Voydanoff others. Conditions that might be considered in-
and Donnelly 1999), for people who believe that dicators of poor health in some groups may not
marriage is a sacrament (DeMaris et al. 2010), be given any significance in others. Differences
and for people with lower self-esteem (Long- in perceptions of physical experiences across
more and DeMaris 1997). The association also groups influence what we believe to be true
differs depending on the domain of life being about group differences in health by influencing
considered, with women being more sensi- expressions of illness, self-reports of health, and
tive to inequities in housework and men being treatment-seeking, all of which become incorpo-
more sensitive to inequities involving paid work rated into health statistics. For example, in his
(Glass and Fujimoto 1994; Sprecher 2001). Re- early research on health in “Regionsville,” Koos
search on the direct relationship between equity (1954) observed that, although lower back pain
and physical health is less common, although was quite common among lower-class women,
the association of emotions with physical health they did not consider it a sign of disease; in
(Kiecolt-Glaser et al. 2002) suggests the con- comparison with other women they knew and in
nection. the context of their physically demanding lives,
Research on social comparison processes lower back pain was considered normal for those
demonstrates that positions in systems of in- women and not worthy of mention in response to
equality influence health in part through percep- questions about health problems.
tions of relative deprivation, subjective social Referent comparisons also shape the physi-
status, and equity. Basic social psychological cal and psychological manifestations of distress.
research reveals that these perceptions do not fol- Kleinman (1977) presented evidence that Chi-
low automatically from objective life conditions nese patients with mental disorders were more
but, rather, are contingent on social contexts and likely than U.S. patients to experience somatic
on the availability of alternative explanations for symptoms; this same pattern has been observed
disadvantage. For example, among Latinos, the among Chinese patients in the United States
choice of reference groups differs depending on (Takeuchi et al. 2002). Kleinman attributed this
nativity, with foreign-born, Spanish-speaking pattern to the highly stigmatized nature of mental
Mexicans more likely to choose Mexicans in the illness in Chinese culture. Physiological symp-
U.S. as the reference group and U.S. born, Eng- toms are viewed as acceptable expressions of dis-
lish-speaking Mexicans more likely to choose tress whereas psychological symptoms are not.
people in the U.S. (including Anglos; Franzini A variant of this argument has been advanced
and Fernandez-Esquer 2006). This research re- to explain the higher rates of major depression
minds us that members of disadvantaged groups among whites as compared to blacks (and, cor-
may be able to maintain positive evaluations of respondingly, the higher rates of physical health
their situations even in the face of objective dis- problems among blacks as compared to whites).
advantage by selecting referent others who allow Mental illness is highly stigmatized in U.S. black
positive social comparisons and by adopting sal- culture (Anglin et al. 2006; Neighbors 1985),
utary interpretations for their life circumstances which may encourage physical, rather than psy-
(Diener and Fujita 1997). chological, expressions of distress.
Illness Interpretations. Social comparisons Arguments for the role of social compari-
are implicated in health inequalities in an even sons in group differences in the experience and
28 Health Inequalities 733
have devoted less attention to unexpected health the full set of conceptual tools that social psy-
patterns than to expected health inequalities. chology has to offer regarding the structure and
Our review illustrates that social relationships, content of proximate environments, as well as
identities, social comparisons, and the meanings how people construct meaning in interaction with
to which they give rise have the potential to ad- others.
vance research on those unexpected patterns and,
in the process, to reveal processes through which
people resist the health-damaging effects of so- References
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actional and cognitive processes that modify its health: Descriptions, causes, and mechanisms. Annual
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Adler, N. R., & Stewart, J. (2010). Health disparities
material realities, these theories emphasize that across the lifespan: Meaning, methods, and mecha-
inequality is a symbolic as well as distributional nisms. Annals of the New York Academy of Sciences,
phenomenon and that the meanings associated 1186, 5–23.
with disadvantaged statuses can both amplify and Adler, N. E., Boyce, T., Chesney, M. A., Cohen, S., Folk-
man, S., Kahn, R. L., et al. (1994). Socioeconomic
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