Understanding the Association Between Socioeconomic Status and Physical Health: Do Negative Emotions Play a Role?

siavosh kaviani

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Abstract: Do Negative Emotions Play a Role?

In this article, the authors evaluate the possible roles of negative emotions and cognitions in the association between socioeconomic status (SES) and physical health, focusing on the outcomes of cardiovascular diseases and all-cause mortality. After reviewing the limited direct evidence, the authors examine indirect evidence showing that (a) SES relates to the targeted health outcomes, (b) SES relates to negative emotions and cognitions, and (c) negative emotions and cognitions related to the targeted health outcomes. The authors present a general framework for understanding the roles of cognitive-emotional factors, suggesting that low-SES environments are stressful and reduce individuals’ reserve capacity to manage stress, thereby increasing vulnerability to negative emotions and cognitions. The article concludes with suggestions for future research to better evaluate the proposed model.

Introduction:

Health disparities associated with socioeconomic status (SES) have existed for centuries (G. D. Smith, Carroll, Rankin, & Rowan, 1992) and have been recognized by researchers for many decades (Chapin, 1924; Warren & Sydenstricker, 1916). Recent research within the United States and other industrialized countries demonstrates that SES is associated with diverse health outcomes (Adler, Marmot, McEwen, & Stewart, 1999), and some evidence suggests that SES inequalities in mortality may even be widening (e.g., Drever, Whitehead, & Roden, 1996; Pappas, Queen, Hadden, & Fisher, 1993; Phillimore, Beattie, & Townsend, 1994). Despite the consistent pattern of these findings, the mechanisms that underlie the graded relationship between SES and health have not been clearly elucidated. In part, SES disparities in health are clearly due to differences in the distribution of basic resources such as health care, nutrition, and sanitary living environments (e.g., Antonovsky, 1967; see also Lynch, Smith, Kaplan, & House, 2000). This focus may be particularly important to explaining poor health in groups characterized by poverty, but the impact of SES on health is not only at the poverty line. Rather, health discrepancies have a monotonic relationship with SES, so that even relatively affluent groups exhibit worse health than their higher SES counterparts (e.g., Kitagawa & Hauser, 1973; Kraus, Borhani, & Franti, 1980). Thus, numerous interconnected factors appear to contribute to SES disparities in health, and researchers have therefore cast a wider net in attempting to explain the SES gradient.

One prominent explanation is that cognitive-emotional factors and disorders play a role in understanding how low SES results in risk for early death and disability (Adler et al., 1994; Kaplan & Keil, 1993; Matthews, 1989; Taylor, Repetti, & Seeman, 1997). Low-SES environments may kindle disproportionate levels of negative emotions and attitudes, and likewise, these variables may have deleterious effects on health. However, the literature has not been reviewed systematically to support or refute this hypothesis. In the current article, we evaluate the evidence for the tenet that cognitive-emotional factors may, in part, mediate the relationship between SES and health. First, we provide a brief overview of the conceptual issues important in examining socioeconomic and emotional factors. We then review the evidence that bears on the mediational hypothesis.

For mediation by cognitive-emotional factors to be tenable, the research must show (a) that SES relates to health; (b) that SES relates to negative emotions and cognitions; (c) that negative emotions and cognitions related to health; and finally (d) that when all factors are examined within a single methodological frame, the relationship between SES and health is attenuated if effects for negative cognitive-emotional factors are statistically controlled (Baron & Kenny, 1986). Unfortunately, few studies have evaluated these four criteria. The indirect evidence for mediation is more compelling, and we, therefore, discuss this research at length. Many detailed reviews concerning the associations between SES and health and between cognitive-emotional factors and health have been published recently. Rather than duplicate this work, we summarize and update it. We focus on cardiovascular diseases—the leading cause of mortality in the United States (American Heart Association, 2000)—and all-cause mortality because these outcomes have been examined with sufficient frequency and rigor to provide an estimate of the proposed Psychological Bulletin Copyright 2003 by the American Psychological Association, Inc. 2003, Vol. 129, No. 1, 10–51 0033-2909/03/$12.00 DOI: 10.1037/0033-2909.129.1.10 10 links and because SES gradients are particularly strong for these health outcomes (e.g., M. A. Gonzalez, Rodriguez, & Calero, 1998; Kaplan & Keil, 1993; Lynch et al., 2000). The associations between SES and cognitive-emotional factors have not been presented in any recent, enumerative reviews (but see the review of SES and psychiatric disorders by Kohn, Dohrenwend, & Mirotznik, 1998), and we, therefore, analyze this research in more detail. Following our review and critical analysis, we present a framework for understanding the pathways that may dynamically link SES, cognitive-emotional factors, and health. Finally, we conclude with recommendations for future research to better address the proposed mediation hypothesis.

Conclusion

Available evidence supports the plausibility of the hypothesis that the association between SES and health is mediated—at least in part—by cognitive-emotional factors. Cognitive–emotional factors may play a particularly salient role in the context of low reserve capacity, and we, therefore, recommend further studies that adopt a more integrative approach to examining the roles of psychosocial factors. Cognitive–emotional factors are only one potential influence to consider in unraveling the links between low SES and poor health. The challenge is to identify those factors susceptible to intervention to promote better health in the population and reduce the substantial health variability that exists according to SES. This review points to the importance of cognitive and emotional factors in the quest to reduce health inequalities.

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The Kavian Scientific Research Association (KSRA) is a non-profit research organization to provide research / educational services in December 2013. The members of the community had formed a virtual group on the Viber social network. The core of the Kavian Scientific Association was formed with these members as founders. These individuals, led by Professor Siavosh Kaviani, decided to launch a scientific / research association with an emphasis on education.

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