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Another point of view (see page 565)
Macleod and Davey Smith state that the aim of their paper is to critically examine the role of psychosocial factors in health.1 Unfortunately, what could have been an interesting discussion is compromised by the authors implicit assumption that there is a single pathway linking social position to health. The authors seem to equate parsimonious causal analysis with a narrow, reductionistic perspective, subsequently devoting most of their paper to a discussion of “psychosocial versus material explanation”, while ignoring evidence showing multiple pathways linking social position to health.2,3
This commentary widens the debate by considering three issues:
(1) PSYCHOSOCIAL VARIABLES: DEFINITION AND THEIR IMPORTANCE TO HEALTH
Psychosocial variables encompass two categories of variables. The first consists of psychological attributes like hostility, depression, hopelessness, etc, which exist at the individual level, and are likely to be a result of the process of socialisation. The second category is more structural in nature, work conditions for example. These two categories work synergistically at the individual level, as can be seen from social support at work, which is a function of both work conditions and personal social interaction skills. Although the authors start out with a similar definition of psychosocial variables, in fact they interpret them rather narrowly as being the way in which “poor people feel about their poverty”. This restrictive view of psychosocial variables negates the importance of the ubiquitous association between social disadvantage and a host of psychosocial variables in the developed world. We still know very little about the mechanisms that create and sustain this link, and when in the lifecourse this link is established.
In considering the importance of psychosocial variables to health Macleod and Davey Smith create a false dichotomy between “objective disease” and “misery”. They themselves acknowledge “misery” to be a legitimate public health issue, particularly in …