Socioeconomic status and health: Youth development and neomaterialist and psychosocial mechanisms

https://doi.org/10.1016/j.socscimed.2007.07.018Get rights and content

Abstract

There is substantial debate in the field of epidemiology over the theoretical underpinnings of socioeconomic status (SES)–disease mechanisms in the developed world. In particular, it has been debated whether psychosocial mechanisms are important in understanding these relationships, compared with material influences. Within an interdisciplinary context, this review synthesizes the youth development and resilience literatures in examination of this hypothesis.

This review provides evidence that both classes of mechanisms are critical to understanding and addressing SES–disease mechanisms over the lifecourse. Research findings demonstrating the effects of these classes of factors point to the complicated and dynamic nature of how SES may impact disease. In the epidemiologic literature, investigators predominantly consider the cumulative impact of biological insults over time. A developmental perspective, however, provides evidence of the importance of psychosocial influences early in life on socioeconomic and health trajectories over the lifecourse.

Future epidemiologic research should consider cumulative and developmental influences of early adversity—both psychosocial and material—on later health. This perspective may be particularly relevant to appropriately evaluating the impact of selection and causation in research on SES and disease and will also hopefully provide clarity to this ongoing theoretical debate.

Introduction

Socioeconomic status (SES) is so predictive of health that it has been referred to as a “fundamental cause” of disease (Link & Phelan, 1995). It is consistently related to most adverse health outcomes. However, the mechanisms through which SES influences these outcomes are unclear. One debate regarding the nature of the relationship between SES and disease in economically developed countries has involved neomaterialist vs. psychosocial explanations.

The neomaterialist position is that the effects of SES are due to the material structures of society and that the relationship between SES and disease outcomes can be understood as a function of the distribution of material risk factors and thus patterns of exposure to adverse conditions. Neomaterialism thus offers insights about how adverse material conditions are overrepresented among and even intentionally distributed to persons at the bottom of the socioeconomic distribution. In short, neomaterialism is about a society's macrostructures that determine the distribution of resources. While in theoretical discussions, neomaterialists argue that psychosocial explanations may be subsumed within neomaterial ones, repeated articles have dismissed stress and other psychosocial factors as possible explanatory factors in SES–disease relationships. Thus, though the neomaterialist argument allows that both material and psychosocial factors might mediate associations between SES and disease outcomes, in the practice of research, neomaterial and material influences end up being conflated and considered interchangeably. Those arguing for neomaterial explanations in explaining SES–disease relationships argue generally against the power of psychosocial influences in favor of material explanations (Macleod & Davey Smith, 2005; Macleod, Davey Smith, Metcalfe, & Hart, 2005; Macleod & Smith, 2004; Macleod et al., 2001; Metcalfe, Smith, Macleod, & Hart, 2007).

The psychosocial position suggests that the influence of SES on health may involve social and psychological factors that impact on subsequent health and health behaviors. To illustrate, a material perspective might consider how a lack of material opportunity might lead to exposure to air pollution, infection with Helicobacter pylori, or physically dangerous conditions at work or at home, which jeopardize health. A psychosocial approach might consider how the lack of material opportunity might lead to a lack of hope and consequently depression or hostility, jobs that lead to feeling a lack of control over tasks at work, or adverse psychological conditions at work or at home, which jeopardize health, directly or through health compromising behaviors.

Theoretical and empirical consideration of how material and psychosocial influences affect health outcomes may help to think more creatively about interventions to reduce disparities.

Light might be shed on this issue by referencing work done in the field of youth development. The youth development literature is firmly grounded in a lifecourse perspective, which is important given that SES is considered to have effects on health throughout the lifecourse. In addition to separately addressing the influences of material and psychosocial factors on health, the youth development literature addresses how material conditions such as overcrowding or pollution might influence social or psychological factors such as depression or hostility and subsequently health, or how psychological or social factors might influence academic success or other lifecourse-relevant outcomes. Relevant for this perspective and also debated among researchers are whether or not there are critical developmental periods in SES–disease relationships or whether adversity influences health through cumulative exposure. Nonetheless, experts generally agree that both material and psychosocial factors are important (Shonkoff & Phillips, 2000), depending in part on the outcome but also proving true because of the complexity of how social factors influence human biology. Interestingly, there appears to be far greater consensus about this among those who study youth development than those who focus their attention on adult exposures and disease outcomes.

This paper is divided into two sections. In the first section, I review the youth development literature on children living in Western/developed nations and provide evidence that: (1) childhood SES influences exposure to material conditions that influence health—a traditional (neo)material approach; (2) low SES adversely influences material conditions that adversely influences cognitive and psychosocial development, which impacts health, and (3) low SES adversely influences the psychosocial environment, with developmental and biological consequences. However, to demonstrate the independent influence of psychosocial factors, I present the literature of: (4) the health consequences of the early psychosocial environment, independent of the per se influence of material conditions—a traditionally psychosocial perspective. My intent is to be integrative and illustrative, to demonstrate the importance of each of these classes of mechanisms based on consistent themes in the literature, rather than totally comprehensive, given the voluminous literatures. In Section 2, I highlight the need for additional research, with the proposed framework in mind, given the limitations of existing research.

Though the neomaterialist/psychosocial debate has centered on the types of mechanistic influences of such aggregate, macro-level variables as social inequality and social capital, this article will not address the question as to whether there is credible evidence for psychosocial influences on disease at the macro level. Pertinent research, however, could involve consideration of such factors, e.g., such as changing social norms and beliefs that led to the acceptability of substantial rises in salaries of a few at the top of the economic distribution in the context of modest economic gains or declines for the rest of the population. It may also be relevant to determine more generally what macro-level factors influence culture, values and people's attitudes which lead to the acceptance of lack of material opportunities for those of low SES. Relevant to this, there is a sizeable and growing literature about the influence of culture and acculturation on population health. This perhaps involves revisiting in part the historical Marxian–Weberian debate on material structures vs. culture. Further research and theoretical work will need to address in depth the critiques of current macro-level variables under debate and other possible ways to examine this debate.

Section snippets

Methods

This could not be a comprehensive review of all aspects of the literature examined, due in part to the interdisciplinary nature of the paper. As such, the goal was to determine a means of summarizing opinion of the youth development field in the developed world and from that point of consensus, find literature to address how early material and psychosocial exposures, as well as their joint influences, begin to influence physical health early in the lifecourse. Particular attention was given to

Childhood SES influences exposure to material conditions which influence health

Krieger writes of the importance of understanding how SES is embodied, or how cumulative disadvantage materializes biologically (Krieger, 2005). This research has generally sought to determine how childhood SES and adult SES independently affect health. It is important to consider cohort effects and lifecourse approaches in understanding SES–disease relationships. In childhood, numerous material risk factors and their health impacts have been examined. These include overcrowding (Goodman &

II. More research, particularly longitudinal research, accounting for early youth development, is needed

There is a great need for additional research in this area. There is great difficulty in demonstrating childhood SES-related exposures and proximal health outcomes given that children living in the developed world are generally healthy. Most data are cross-sectional or limited to relatively short time periods in the lifecourse. A major limitation of this research and the reason this is a much understudied area of research is the difficulty, intensity, and expense of collecting data over the

Conclusion

Researchers have debated whether psychosocial mechanisms have any importance in understanding SES–disease relationships. Evidence in the youth development literature points to the importance of both material and psychosocial explanations in understanding how SES influences disease. Conditions early in life that influence early patterning of emotional regulation may influence disease trajectories directly through a variety of biological mechanisms and indirectly through material trajectories.

Acknowledgments

The author thanks the Robert Wood Johnson Foundation's Health & Society Scholars Program for its financial support. I would also like to thank several of the RWJ HSS faculty and scholars at the University of California for their helpful comments on this manuscript.

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