Ann. N.Y. Acad. Sci. ISSN 0077-8923

ANNALS OF THE NEW YORK ACADEMY OF SCIENCES Issue: The Biology of Disadvantage

Are psychosocial factors mediators of socioeconomic status and health connections? A progress report and blueprint for the future

Karen A. Matthews,1 Linda C. Gallo,2 and Shelley E. Taylor3 1University of Pittsburgh, Pittsburgh, PA. 2San Diego State University, San Diego, CA. 3University of California at Los Angeles, Los Angeles, CA Address for correspondence: Karen A. Matthews, Ph.D., Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213. [email protected]

The association between socioeconomic status (SES) and physical health is robust. Yet, the psychosocial mediators of SES-health association have been studied in relatively few investigations. In this chapter, we summarize and critique the recent literature regarding negative emotions and cognitions, psychological stress, and resources as potential pathways connecting SES and physical health. We discuss the psychosocial origins of the SES-health links and outline how psychosocial factors may lead to persistently low SES. Weconclude that psychosocial resources may play a critical mediating role, and the origins of the SES-health connection are apparent in childhood. Weoffer a blueprint for future research, which we hope contributes to a better understanding of how SES gets under the skin across the life span.

Keywords: socioeconomic status; emotions; stress; resources; development

health. From a psychosocial perspective, the lead- Introduction ing candidate pathways are the frequency and in- It is well established that socioeconomic status (SES) tensity of exposure to stress and related emotional is a strong correlate of health across the lifespan. responses. As shown in Figure 1, low SES environ- Those who are less educated, earn less income, or ments are thought to be associated with greater ex- hold less prestigious occupations are at greater risk posure to frequent and intense harmful or threaten- for a wide variety of diseases and premature death ing situations and to fewer rewarding or potentially (chapters 3 and 4, this volume).1 By and large these beneficial situations (Arrow A). Indeed, studies relationships are sustained in men and women, in show that individuals with lower SES encounter diverse ethnic groups, and in children and young, more frequent negative life events and chronic stres- middle-aged, and elderly adults. The associations sors3,4 and interpret even ambiguous events as more are graded, such that with every decrease in SES, stressful,5,6 relative to those with higher SES. Ex- there is increasing risk, although extreme poverty posure to chronic and acute stressors, in turn, has can be particularly health-damaging. A variety of adirectnegativeimpactonemotionalexperiences factors may account for the health effects of low (Arrow B). However, studies that account for ini- SES, including exposure to environmental toxins; tial differences in stress exposure suggest that at employment in jobs that have a high risk of injury every level of stress, individuals with lower SES re- or disability; lack of health insurance or access to port more emotional distress than those with higher high quality and preventative health care; poor nu- SES.3,7 trition; and adverse health behaviors, such as smok- Why might individual residing in low SES envi- ing, excessive alcohol intake, and physical inactivity. ronments be more reactive to stress? Our frame- These factors do not work individually but are likely work suggests that low SES individuals maintain to accumulate in low SES environments.2 a smaller bank of resources—tangible, interper- This chapter focuses on psychosocial factors that sonal, and intrapersonal—to deal with stressful may serve as pathways connecting low SES and poor events compared to their higher SES counterparts

doi: 10.1111/j.1749-6632.2009.05332.x 146 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Figure 1. The reserve capacity model for the dynamic associations among environments of low socioeconomic status (SES), stressful experiences, psychosocial resources, emotion and cognition, and biological and behavioral pathways predicting morbidity and mortality over time. Dashed lines depict possible reciprocal influences. Arrow A depicts the direct influence of SES on exposure to stressful experiences. Arrow B indicates the direct impact of stressful experiences on emotion and cognition. Arrow E shows the effects of stress on intermediate pathways hypothesized to affect health outcomes. Arrow C shows that socioeconomic environments condition and shape the bank of resources (i.e., the reserve capacity) available to manage stress. Arrow D shows that the reserve capacity represents a potential moderator of the association between stress and cognitive–emotional factors. Arrow E indicates the direct impact of cognitive–emotional factors on intermediate pathways and Arrow F on intermediate pathways to illness and death. HPA: hypothalamic-pituitary-adrenocortical axis; SAM: sympathetic adrenal-medullary axis.

(Arrow C).8 Resources tend to occur in aggregate, row E). According to this model, elevated negative or be absent in the aggregate, suggesting the exis- emotions and cognitions and reduced positive emo- tence of a generic protective influence or resource tions and cognitions then lead to intermediate phys- bank.9 Borrowing a concept from the aging litera- iologicalpathways(ArrowE)andeventuallytopoor ture, we label this reserve capacity. Reserve capacity health (Arrow F). Finally, this model takes a life- to deal with stressful environments may be dimin- course perspective in that the processes it proposes ished in circumstances of low SES for two reasons: are thought to start early in life and may also lead to (a) low-SES individuals are exposed to more sit- lowering of SES over time (dashed lines). uations that require they use their resources and Ten years ago there were few studies testing these (b) low-SES environments prevent the development proposed relationships. In fact, through 2001, we and replenishment of resources to be kept in reserve. found only seven articles that simultaneously ex- Indeed, having few resources exacerbates the effects amined SES, cognitive or emotional factors, and a of stressful events on outcomes such as depression.10 physical health outcome defined broadly (this re- Furthermore, once an individual has been exposed view did not include stress as a mediator).8 These to stress, resources tend to deteriorate, leaving indi- studies, taken together, did not provide conclusive vidualsmorevulnerabletofuturestrains(arrowD; evidence for the mediating role of negative emo- e.g., Ref. 11). Hence, having fewer stress-dampening tions. The major objectives of the current chapter resources, which are further reduced by more stress are (1) to summarize and critique the recent litera- exposures, individuals of low SES are likely to show ture regarding negative emotions and cognitions, greater responsiveness when faced with stress (Ar- psychological stress, and resources as pathways

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 147 Psychosocial mediators and their origins Matthews et al. connecting SES and physical health; (2) to discuss chosocial factors, and results are summarized in the psychosocial origins of the SES-health links; Table 1. and (3) to outline the psychosocial factors may lead to persistent low SES. Suggestions for future Studies examining stress as a psychosocial research are offered throughout the mediating pathway chapter. A number of researchers have suggested that the association between SES and health may, in part, re- Review of new literature on psychosocial flect the psychosocial pathway of “stress.”12–14 This pathways assertion is based on a large body of indirect research The criteria for articles to be in the review were in- connecting SES to various types of stress on the clusion of (1) a measure of SES (with title search one hand (e.g., Refs. 4,15–19), and connecting stress words SES, social status, socioeconomic position, with health and disease processes on the other hand education (not patient education), income, occu- (for reviews, see Refs. 20,21). The community, work, pation, occupational status, disparity, inequality, and home environments that individuals with low gradient); (2) an objective physical health outcome SES inhabit are often characterized by frequent and (with search keywords CVD, CHD, atherosclerosis, repeated challenges and negative events, potentiat- hypertension, blood pressure, diabetes, metabolic ing physiological and behavioral dysregulation that, syndrome, asthma, cancer, infectious disease, HIV, in turn, increases the risk of negative health out- and mortality); and (3) a candidate psychosocial comes.22,23 Our review uncovered nine studies that factor (negative emotions/attitudinal factors, with had examined a measure of stress as a possible ex- search keywords anxiety, depression, hostility, anger, planatory mechanism in SES-health gradients.24–32 negative emotions, emotional factors; intraper- Specific health outcomes varied across studies, with sonal and interpersonal resources, with search key- four examining mortality,26–28,32 one examining in- words mastery, perceived control, optimism, self- cident stroke,24 three examining the metabolic syn- esteem, social support, social competence, social drome or metabolic functioning,29–31 and one study integration, social network, and resources; and en- focusing on subclinical coronary artery disease.25 vironmental stress, with search keywords stress, dis- Most of the studies examined either life events24,29,32 crimination, life events, and coping). The final cri- or perceived stress,25,26,28,31 one study used five dif- terion was the use of statistical methods that would ferent stress measures,27 and one focused on stress- permit an evaluation of mediation. We did not in- ful aspects of the early environment.30 Five stud- clude papers that focused only on general self-rated ies found little or no evidence for a mediating health due to the very subjective nature of these role of stress.24,25,28,29,31 In fact, three studies re- measures and their overlap with psychosocial path- ported no significant relationship between SES and ways of interest (e.g., negative emotions). Moreover, stress25,29,31 and one found that individuals with we did not include papers that focused exclusively higher SES reported more stress.28 On the other on individual health risk factors (e.g., obesity, car- hand, van Oort et al.32 found that accounting for diovascular reactivity, immune functioning, health variability in life events (simultaneous with locus of behaviors). PsychINFO, PsychArticles, and Medline control) led to a 21 to 48% reduction in the excess were searched and results were limited to articles mortality risk attributed to low versus high edu- published in English, between 1990 and 2008, in cation. Much of the effect of these factors in that peer-reviewed journals. One thousand and ninety- study appeared to be indirect, via pathways from seven articles were obtained in the search. After material factors, to psychosocial factors, to mor- scanning titles for potential relevance, 53 abstracts tality. Khang and Kim26 found an 11% reduction were further examined; 23 met criteria and were not in the excess mortality risk for low versus high previously discussed by Gallo and Matthews.8 Sev- income (16% reduction in models not control- eral additional articles were identified via inquiries ling for baseline health) with simultaneous control to colleagues, or from scanning reference lists, for for depression and perceived stress. Lantz et al.27 a total of 27 studies. Data on each study’s design, showed that statistical control for five measures of population sampled, measurement of SES and psy- stress led to a 35 and 45% reduction in the excess

148 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins mortality risk for lower income groups relative to the In updating our prior review,8 we identified 12 highest income group, with life events appearing to studies that examined emotional factors as possi- have the greatest explanatory role. Finally, Lehman ble explanatory mechanisms in the association be- et al.30 found that a risky, early family environment tween SES and health.24–26,29,30,44–50 These studies represented part of a significant, indirect pathway were widely varied with respect to emotional in- from SES to poorer metabolic functioning. dicator/s and health outcomes. Three studies iden- Several additional studies focused specifically on tified little or no support for a mediating role of the contribution of “job strain” to socioeconomic emotional factors, and specifically, depression and health disparities.33–36 Job strain is often defined as anxiety in the association between SES and CHD a combination of job high demands and low levels incidence,46,50 and positive and negative emotional of control in the work environment, and is associ- styles in the association between SES and vulnera- ated with elevated CVD risk, particularly in men.37 bility to infectious illness.44 In contrast, Avendano Marmot and colleagues36 found that job control ex- et al.24 found that control for depression reduced plained about 64 and 51% of the excess risk for CHD the association between income and education with (self-reported) associated with low versus high oc- incident stroke by approximately 23 and 30%, re- cupational class, in men and women, respectively, spectively. Moreover, two studies identified support enrolled in the Whitehall study. In a case control for aggregate negative emotions as a pathway in study of CHD in women, statistical control for job the association between SES and the metabolic syn- strain reduced the excess risk associated with lower drome.29,30 Schnittker et al.49 showed that neuroti- occupational grade relative to the highest grade by cism (i.e., a trait-like propensity to frequently expe- 8–14%.34 Of the components of job strain, percep- rience negative emotions) and depression explained tions of control seemed to be the more important 15 and 37%, and 26 and 16% of the association of factor in explaining the occupational grade-CHD income and education, respectively, with the aggre- gradient. In the same sample, accounting for job gate number of self-reported chronic health condi- strain combined with social risk factors (e.g.,low tions. Nabi et al.48 found relatively strong evidence support) reduced the excess CHD risk for low ed- for a mediating role of hostile personality traits in ucation by 57%.33 In contrast, Kuper et al.35 found the association between SES and mortality in men no evidence that job stress contributed to the asso- (with 28–29% attenuation in SES effects after statis- ciation between education and stroke risk. Impor- tical control for hostile personality traits), but very tantly, job strain can be conceptualized as a type of little explanatory role for personality of any type in chronic stress, but it is also closely related to SES, explaining mortality risk in women. Gallo et al.25 since individuals with lower SES are more likely to showed that controlling for depression and anxi- hold jobs that are higher in demands and, particu- ety attenuated the association between education larly, lower in control. Thus, whether job strain rep- and aortic calcification (an indicator of atheroscle- resents an independent stress pathway from low SES rosis) by 5 and 16%, respectively, in a sample of to health, or whether it represents one of the toxic healthy women. Hostility and anger did not relate components of low SES itself, is unclear (e.g,38). to atherosclerosis and were not tested as mediators in this study. The contributing role of emotional factors is Studies examining emotional factors more difficult to ascertain in the remaining stud- as a mediating pathway ies because multiple mediators were considered si- High levels of negative emotions, such as depression, multaneously. Khang et al.26 found that concurrent anxiety, and anger, are a common correlate of stress control for depression and perceived stress reduced that have been related to health outcomes (partic- the association between SES and mortality by 11%; ularly CVD) in substantial prior research.39–42 In Maty et al. 47 found that control for depression along addition, individuals with lower SES are at greater with many other risk factors (e.g., baseline health, risk for negative emotions and emotional disorders health behaviors) reduced the excess diabetes risk as- relative to those with higher SES.8,43 Therefore, these sociated with lower education by 47%; and Gorman variables may represent another psychosocial path- et al.45 found that, after controlling for social and way contributing to SES-health gradients. demographic factors, accounting for depression and

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 149 Psychosocial mediators and their origins Matthews et al.

Table 1. Research addressing the whether psychosocial factors mediate the association between socioeconomic status (SES) and objective health outcomes Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Alter 3138 patients Prospective, Income Social support (if Mortality Age, sex, race Higher income Social support − et al. hospitalized 2 years f/u participants significantly assessment (54) for lived alone and predicted lower was quite myocardial if they had mortality risk, at limited. infarction, “someone to 30 days and at Short- mean age talk to about 2 years f/u. follow-up 64 years, private feelings Adjustment for 30% women and personal social support had decisions”) very little effect on HRs for income. Avendano 2524 men and Prospective, Education Depression Incident stroke Age, sex, race Education and Additional ± et al. women 12 years f/u Income (Validated income related analyses (24) form the measure) significantly and showed that EPESE Social Integration inversely with adjustment study, aged (Validated stroke risk. A for conven- 65 and older measure) reverse pattern was tional risk Stressful life observed in factors events persons aged 75 reduced the and older. After effect of adjusting for race, education inclusion of by 22% and depression and of income social integration by 43%. attenuated the HR for income and education by 23% and 30% and 37% and 27%, respectively. Adjustment for life events had little effect on SES- stroke relationship. Adjustment for all psychosocial factors reduced HRs by about 50%. Bosma 2462 Prospective, Education Perceived control Mortality Age, sex, Lower education and Additional + et al. participants 6-year f/u Occupation (Dutch version baseline occupation analyses (57) from the Income of Rotter’s health predicted higher showed that Dutch Locus of mortality risk, low SES in GLOBE Control Scale) whereas income adulthood study, 50% did not relate predicted men, significantly to adverse average age mortality. changes in 51 years Statistical control control for control perceptions perceptions across the reduced the 6-year education AMRs follow-up. by 54–57%, occupation AMRs by 41 to 50%, and income AMRs by 37 to 65%. Continued.

150 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Bosma 3888 men and Prospective, Composite of Control beliefs: Incident CHD Sex, age, Low SES was + et al. women 5-year f/u education, General self (myocardial traditional associated (58) from the occupation, efficacy and infarction risk factors with a 45% Groningen income Mastery and higher rate of Longitudi- (validated congestive heart disease nal scales) heart (prior to Aging failure) risk-factor Study, adjustment). 57 years and Inclusion of older control beliefs reduced the HR by 29%, after control for traditional risk factors. Chaix 498 Prospective, Income Support from CHD None Low income Marriage and ± et al. participants 10 year f/u Income family and Incidence 10 years social (55) from the change friends CHD before support Swedish Neighborhood Mortality retirement from friends “Men born support predicted and family in 1914” increased were not study CHD and found to be mortality risk. protective. Income The authors change was speculate not predictive. that neigh- Lower income borhood related to less support neighborhood may gain support, but importance not support in older from friends ages, given and family. social After control network for risk changes factors, associated neighborhood with support led to retirement. an additional 7and8% decrease in the income effect on CHD incidence and mortality, respectively. 16% and 14% of the risk for low income in CHD and mortality that was explained by risk factors was attributable to neighborhood support. Continued.

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 151 Psychosocial mediators and their origins Matthews et al.

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Cohen 95 men and 98 Cross sectional Subjective SES Positive and Infection, Immunity to Neither income Volunteer − et al. women, (MacArthur negative mood signs and the virus as nor education sample is a (44) aged 21 to ladder (adjective symptoms assessed by related to limitation of 55 years, measure). checklist of the pre- illness. Lower the research. volunteer Education administered common challenge subjective SES Additional sample Income on each of cold, and antibody predicted a analyses 14-days clinical titer, age, higher risk for suggested preceding the illness, after BMI, race, developing a that poorer experiment). exposure to sex, cold. The sleep Mastery, virus. virus-type, association duration optimism, and season between and self-esteem, of exposure. subjective SES efficiency purpose in life, and colds associated and remained with lesser extraversion statistically subjective (all validated significant in status might measures) analyses contribute controlling for to observed negative findings. emotional, style, positive emotional style, self-esteem, mastery, purpose, optimism, extraversion, and all of these variables exam- ined in a single model. Gallo 145 healthy Cross- Educational Reserve Capacity Risk factors Age, meno- Education Limitations ± et al. Latinas Sectional Attainment – composite of that pausal showed a include (59) (primary perceived comprise status significant, convenience Mexican- social support, the inverse sample, American) optimism, self metabolic relationship cross (mean age esteem, and syndrome with most sectional 47 years) perceived components of design, and recruited control the metabolic the fact that from health (validated syndrome, and some risk clinics along measures used women with factors were the for all lower SES also available California– constructs) reported lower only in a Mexico psychosocial subset of border resources. partici- Approximately pants. 1/3 of the Range of relationship SES was between SEP restricted and waist was (sample was due to an low indirect effect income). through psycho- social resources (P for indirect effect < .05). Continued.

152 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Gallo 308 women Prospective Educational Hostility, anger, Calcification Age A significant linear Control for ± et al. from the Attainment depression, of the trend was observed individual (25) Healthy anxiety, social coronary in the association traditional Women support, job arteries and between education risk factors Study, satisfaction, aortic valve, and coronary and also had a average age perceived stress measured aortic calcification small impact 67 years old, (all validated by electron (P <.05). Education on the 90% non- measures) beam also showed a magnitude of Hispanic computed positive association the white tomography with hostility, association depression (P < between .10), anxiety, and an education inverse association aortic with social support. calcification. Coronary No risk factor calcification did not met statistical relate to criteria for psychosocial risk mediation. factors. Only depression and anxiety related to aortic calcification, and were tested as mediators. Regression coefficients for the education trend for aortic calcification were reduced by 5% with control for depression and 16% with control for anxiety. Gorman 29,816 US Cross- Education Social support Self-reported Age Working status was Limitations ± &Siva- adults sectional Family (1-item) hyperten- Ethnicity related to include the ganes 25 years and income to Social integration sion Nativity self-reported self-reported (45) older, from poverty Depression (Age only hypertension, physical the 2001 ratio (validated for social whereas education health National Working measure) and and income did not outcome, Health status Life Satisfaction emotional predict this cross- Interview (1-item) factors) outcome. In sectional Survey Happiness in age-adjusted (only) framework, past 30 days models, greater use of 1-item (1-item) emotional support measures or and integration, life non-validated satisfaction, and assessments happiness related to of some lower hypertension psychosocial risk, and depression constructs, related to higher testing risk. Control for emotional social factors had factors little impact on SES together with effects. Additional health control for both behaviors, health behaviors and and lack of emotional factors consistent further reduced the SES effects. OR for unemployed versus employed by approximately 24%. Continued.

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 153 Psychosocial mediators and their origins Matthews et al.

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Khang 5437 Prospective Income Marital status Mortality Age, gender, Income showed In compari- ± & participants 5-year f/u Feelings of urbaniza- an inverse son, control Kim(26) from depression/ tion of association for health Korean sadness residence, with mortality behaviors NHANES past year number of risk. Control and study (1-item) family for biological Perceived stress members, psychosocial risk factors past year baseline factors created created a (1-item) health status a 11.2% 14.3 and reduction in 15.3%, RR for the low respective, income group reduction in compared to RR. the high income group (16.5% change in RR in models that did not control for baseline health). Kittleson 1131 male Prospective, Childhood Depression Incident CHD CVD risk Risk of CHD on Self-report of − et al. medical median f/u SES (father’s (incidence of (myocardial factors, in or before age diagnosed (46) students 40 years occupation) clinical infarction, some 50 was higher depression from the depression, sudden analyses with low SES. may be a Johns assessed via death, HR was largely limitation, Hopkins self-report) angina unchanged given the Precursors pectoris, with control sample. Study chronic for depression. IHD, other coronary disease requiring bypass or percuta- neous interven- tion) before age 50. Kuper 47,942 women Prospective, Education Job demands, job Incident stroke Age Lower education Age of − et al. from the average f/u control, and significantly participants (35) Women’s 11 years social support predicted was Lifestyle at work higher stroke relatively and Health (validated risk. Work young to Cohort measures) characteristics examine Study General social did not relate stroke, and (Sweden), support significantly to only 200 aged 30 to stroke risk, incident 50 yrs whereas lower cases were general observed. support related to higher risk. Adjustment for support and work characteristics had very little effect on the education and stroke association. Continued.

154 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Lantz 3,617 men and Prospective, Education Five measures of Mortality Age,sex,race, Income related Inclusion of ± et al. women 8-years f/u Income stress: financial baseline significantly to financial (27) from the stress, parental health mortality, after stress is Americans’ stress, marital/ controlling for problematic Changing domestic education, given Lives survey, relationship whereas conceptual 25–65 years, stress, lifetime education did overlap with 90% non- events, and life not relate to income. Hispanic events past mortality risk white 3years. beyond the Administered effects of at baseline and income. In at a 3-year f/u. models that included SES and all stress measures, only wave 1-assessed total life events related to mortality risk. HRs for the lowest and middle income groups relative to highest income group were reduced by 45% and 35%, respectively, but remained statistically significant. Lehman 3255 Cross Childhood Early family Metabolic None reported Structural Additional + et al. participants Sectional SES environment Functioning equation analyses in (30) from (composite (7 item scale (fasting models showed separate CARDIA, of mother’s measuring glucose, a significant sex/race aged 33 to and father’s factors such as insulin, LDL direct path from groups 45 years, education) abuse, and HDL- SES to found poor 44% male, Adult SES supervision, cholesterol, metabolic model fit for 45% black, (composite chaos, and triglyc- functioning, black men, 55% white of subjective feeling loved erides) and significant and SES, and cared for) indirect paths variations in measured Summary from SES to the model with the psychosocial risky family among MacArthur measure of environment, to other ladder depression, psychosocial groups. measure, hostility factors, to income, and (validated metabolic education) scales), and functioning. social contacts Additional (supportive pathways were and identified from unsupportive) childhood SES to adult SES to psychosocial functioning. Adult SES did not relate directly to metabolic functioning. Continued.

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 155 Psychosocial mediators and their origins Matthews et al.

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Liu et al. 4,049 Prospective, Education Social Mortality Gender Age Education related In compari- + (56) participants 4-year f/u Participation Ethnicity significantly to son, health (42% (attends any Marital mortality. About behaviors women; activities or Status 83% of this effect explained Mean age none) was indirect, via about 9% of 68.19 years) Emotional influences of the from the Support (2 education on relationship Taiwan item measure) baseline health between Survey of status, social education Health and factors, and health and Living behaviors. Social mortality. Status of the participation and Elderly emotional support related significantly to mortality, and accounted for about 26% of the indirect effect (P <.01). Macleod 5232 men, 35 Prospective, Occupation of Perceived stress Mortality Age Risk All SES indicators Additional − et al. to 64 years, 25 years participant (Reeder Stress factors were associated analyses (28) recruited follow up and father Inventory) (smoking, significantly with showed that from Area Job satisfaction drinking, all-cause higher SES various deprivation blood mortality. was companies Education pressure, Adjusting for associated in Scotland Height cholesterol, stress and job with greater Car access BMI, satisfaction had stress Subjective fitness) little or no impact perceptions. occupa- on the magnitude The validity tional of the RR of the status associated with Reeder low SES, after inventory is control of risk unknown. factors. Marmot 7372 men and Prospective, Occupational Job Control CHD Smoking, Lower occupational Self report of + et al. women 5yearf/u grade (decision Incidence serum status was CHD and (36) from authority/skill (self- cholesterol, associated with inclusion of Whitehall II discretion) reported: BMI, hyper- higher incident angina (a Social support angina tension, and CHD risk in men subjective (validated pectoris physical and women. In endpoint) measure) from the activity, men, adjustment are Rose ques- height. for job control and limitations tionnaire, social support of the report of reduced the OR current severe, for low versus high study. Oc- prolonged grade by 64% and cupational chest pain, 14%, respectively. grade trends or report of In women, were doctor- adjustment for job relatively diagnosed control reduced weak. angina or the OR for the myocardial occupation effect infarction) by 51%, whereas control for social support increased the magnitude of the occupation effect. Continued.

156 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Matthews 401 women Prospective, Education Negative Incident Structural Education ± et al. from the 12-years emotions metabolic equation showed no (29) Healthy follow-up (depression syndrome models (SEM) association Women’s symptoms, showed that with stress Study trait anxiety, SES had a and (Pittsburgh, trait anger). significant including PA), 42–50 Reserve Capacity indirect stress in at study (optimism, pathway to SEMs did entry, social support, metabolic not >90% non- self-esteem). syndrome significantly Hispanic Stressful life through alter the white events reserve factor All validated capacity and loadings or measures. negative paths emotions, and among SES, a significant reserve direct pathway capacity, to metabolic negative syndrome. emotions, Indirect and the pathways from metabolic SES to negative syndrome. emotions through reserve capacity, and from reserve capacity to metabolic syndrome through negative emotions, were also significant. Maty 6147 men and Prospective, Education Depression Incident Age, gender, Only education The indirect ± et al. women 43 years f/u Income diabetes race, marital related effect of SES (47) from the Occupation status significantly through Alameda and depression County consistently to cannot be Study incident determined diabetes. With due to si- control for multaneous behavioral risk control for factors, body multiple composition risk factors. (BMI, waist), blood pressure, insurance status, access to care, and depression, the excess incident diabetes risk associated with lower education was reduced by nearly 47%. Continued.

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 157 Psychosocial mediators and their origins Matthews et al.

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Nabi et al. 14 445 Prospective, Father’s social Type A behavior Mortality Age, sex, Results for men: Evidence ± (48) participants 12.7 years class pattern marital Father’s social concerning from the f/u Education (Validated status, class did not the validity French Occupa- measure) alcohol, relate to of the GAZEL tional grade, Hostility smoking, mortality, Grossarth- study Income (Validated BMI. Also, whereas Maticek and (employees Measure) depression education, Eysenck of France’s Personality types in analyses occupational personality national gas (Grossarth- involving grade, and type and Maticek and personality. income were measure is electricity Eysenck- inversely, mixed. In companies), Personality- significantly the current aged 39–54 Stress- associated with study, at Inventory) mortality. In alphas for enrollment analyses adjusting some scales for personality were <.70. factors, neurotic hostility attenuated SES effects by 28–29%, ‘CHD-prone’ by 13–16%, and ‘antisocial’ by 12–22%. Adjustment for ‘ambivalent’ personality type attenuated SES effects by only 3–5%. With adjustment for all personality characteristics, SES effects were reduced by 28 to 34%. Results for women: Father’s social class and income were significantly, inversely associated with mortality, whereas occupation and education were not. Controlling for TABP reduced the SES effects by 3–11%. Controlling for CHD-prone personality type and ‘healthy’ personality increased the magnitude of SES effects. Continued.

158 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Prescott 5801 Cross- Educational Perceived Stress Metabolic Age and sex All SES indicators Behavioral − et al. participants Sectional attainment (single item) syndrome (in sex- were inversely factors (31) (57% Occupation Vital exhaustion index combined related to the (smoking, women), Income (17-item models) metabolic alcohol, aged measure of syndrome. physical 20–97 years depression and Education was activity) from the fatigue) most strongly were also Copen- Social integration related and was tested as hagen City (3 items, used in further mediators, Heart Study examined analyses. and did not separately) Control for account for psychosocial associations factors had between little to no education impact on the and MS association prevalence. between education and MS prevalence. Schnittker Americans’ Cross- Income Mastery (3 items Total number Age At wave 1, higher The use of ± (49) Changing Sectional Education from Pearlin’s of self- Sex income and self-report Lives Study, scale) reported Race education assessments Waves 1-III Self Esteem (3 chronic predicted fewer and (1986– items from conditions chronic inclusion of 1994) Rosenberg’s in past year conditions. subjective (3,617 scale) (arthritis, With control conditions participants Depression lung for self-esteem, is a at Wave 1) (11-item disease, hy- mastery, limitation of version of pertension, neuroticism, the current CESD) heart and study. The Neuroticism disease, depression, the cross (5-item scale) diabetes, coefficients for sectional cancer, foot low income framework problems, (relative to and brief loss of urine highest measures of beyond income) were some psy- one’s reduced by chological control) 13%, 12%, factors are 15%, and 37%, additional respectively, limitations. and the coefficients for low education (relative to highest education) were reduced by 5%, 4%, 26%, and 16% respectively. Effects of (baseline) psychological factors and their mediating roles were diminished at subsequent waves of assessment. Continued.

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 159 Psychosocial mediators and their origins Matthews et al.

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Thurston 6265, Prospective, Educational Depressive and Incident CHD Age, gender, In fully adjusted The authors − et al. 25–74 years, 15.1 years attainment anxious race/ models, also tested (50) 46% men, f/u symptoms ethnicity, education moderation, from (Validated marital related and found NHANES I measure) status, significantly to no and smoking CHD significant follow-up status, incidence. education studies leisure time Depressive by physical symptoms depression activity, accounted for or anxiety alcohol use, 4.8% and interaction BMI, anxious effect in diabetes, symptoms relation to hyperten- < 1% of the incident sion education CHD. effect in fully adjusted models. Van Oort 3979 men and Prospective, Education Life events (9 Mortality Age, gender Education Additional + et al. women, 7 years f/u possible) predicted analyses (32) aged 15–74, Long lasting mortality. showed that from the difficulties Coping, the inde- GLOBE Emotional chronic stress, pendent study, the support Active and support effect of Netherlands and avoiding were not psychoso- coping styles considered cial factors Locus of control further as was mediators, due relatively to a lack of small (0 to consistent 11%), but association in part, with education material and mortality. factors With control (insurance, for life events financial and locus of difficulties, control, the housing) HRs for the had an lower indirect role education in the groups association compared to between the highest education education and group were mortality reduced by 21 through psy- to 48%. chosocial factors (10% to 48% of all variance was explained by these indirect effects). Continued.

160 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins

Table 1. Continued Indicator/s of Population/ Indicator/s of Psychosocial Health Study Source Design SES Variable/s Outcomes Controls Results Comments Evidencea

Wamala 292 CHD Case-Control Education Job strain CHD Age Education related In compari- + et al. patients and (validated significantly and son, control (33) 292 age- measure) inversely to CHD for matched Social isolation risk, and control behavioral controls (all Capacity for for psychosocial factors women, coping factors reduced reduced the 65 years and this association education younger) by 57%. effect by 48%. The design is a limitation, given the possible influence of recall and survivor biases. Wamala 200 CHD Case-Control Occupation Job strain CHD Age Women with lower The case + et al. patients and (validated occupational control (34) 212 age- measure) status had design is a matched significantly limitation controls (all higher CHD risk. of the study, employed Adjustment for given the women, job stress possible 65 years and reduced the influence of younger) excess risk of recall and semi/unskilled survivor versus biases. professional workers by 14%, and other groups by 8% to 14%. The linear trend for occupational class remained significant. aEvidence for a meditational role of psychosocial factors in the SES-health association. Rated as “−”iflittleorno support, “±” if mixed or limited support “+” if clear support. health behaviors reduced the excess (self-reported) distributed across the SES spectrum, and therefore, hypertension risk associated with not working by these variables have been proposed as another pos- approximately 24%. sible explanatory pathway.8,51 Weidentified 17 studies that examined the contri- bution of one or more psychosocial resource vari- Studies examining psychosocial resources ables to the association between SES and physical as a mediating or moderating pathway , , , , , , , health. Ten studies24 25 31 33 35 36 45 54–56 focused ex- Finally, we examined studies that evaluated the me- plicitly on the independent contribution of social diating role of social resources, such as social sup- factors (e.g., social support, integration). Of these, port or integration, and psychological resources, four studies found no evidence that social support or such as self-esteem and mastery, in the associa- integration contributed to SES-gradients in health tion between SES and health. Such factors have outcomes including mortality,54 self-reported hy- been related to health in prior research, although pertension,45 incident stroke,35 and the metabolic more evidence supports their roles in psychologi- syndrome.31 Moreover, in the study by Gallo et al.,25 cal than in physical health outcomes.51–53 Likewise, social support did not relate to the outcome of levels of psychosocial resources are inconsistently subclinical atherosclerosis, and, was not tested as a

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 161 Psychosocial mediators and their origins Matthews et al. mediator. In contrast to these null findings, Aven- and vulnerability to infectious illness. In contrast, dano et al.24 found that statistical control for social Matthews et al.29 found that educational attain- integration led to a 37 and 27% reduction in ex- ment related to incident metabolic syndrome risk cess stroke risk associated with low education and both directly, and indirectly, via pathways from low income, respectively. Liu et al.56 showed that most SES, to lower reserve capacity (aggregate of social (83%) of the association between education and support, self-esteem, and optimism), to higher neg- mortality occurred indirectly through a variety of ative emotions, to the metabolic syndrome. Simi- pathways, and moreover, that social resources ac- larly, Gallo et al.59 found that lower SES related to counted for approximately 26% of this indirect ef- waist circumference (a primary factor underlying fect. In a study by Marmot et al.,36 accounting for the metabolic syndrome) in part through an as- social support reduced the excess CHD risk asso- sociation with reserve capacity (aggregate of social ciated with a low occupational grade by approxi- support, self-esteem, mastery, and optimism). mately 14% in men, but control for support actually strengthened the occupational effect in women. An- Conclusions other study showed that neighborhood social sup- Our review of the literature examining psychoso- port reduced the excess risk of CHD incidence and cial mediating pathways leads to two clear conclu- CHD mortality experienced by individuals with low sions. First, despite widespread discussion of the income by 16 and 14%, respectively.55 However, possible roles of psychosocial factors in SES-health support from friends and family was not related disparities, evidence is insufficient to draw strong to mortality and was not tested as a mediator conclusions about the hypothesized relationships. in this study. Finally, as noted earlier, a study by Second, the limited existing literature has produced Wamala et al.33 found that simultaneous control mixed findings. In general, the evidence seems least for job strain and social isolation reduced the ex- supportive of stress as a mediational pathway, even cess risk associated with low versus high education thoughexposuretostressisbelievedtobeaprimary by 54%. explanation for the association between low SES and Four studies examined intra-personal resources poor health.12–14,60 The one exception may be job as mediating pathways. In one study, accounting strain, which appears to be promising. The role for variations in locus of control reduced the SES- of psychosocial resources, and particularly intra- mortality associations by 37–57%.57 General con- personal resources, such as control, mastery, and trol beliefs also contributed significantly to ex- self-esteem, seems clearer. Because the empirical plaining the association between SES and incident base is still rather small, it is difficult to ascertain dif- CHD,58 with statistical control for these factors re- ferences in study results due to differences in pop- ducing the excess CHD risk for low SES by nearly ulations, health outcomes, or SES marker. Finally, 30%. As noted earlier, simultaneous statistical con- no studies have found that psychosocial resources trol for locus of control and life events reduced the moderate the effects of stress on health, a proposed excess mortality risk of less educated participants pathway in the reserve capacity model, although few by 21–48% in a study by van Oort et al.32 Finally, studies have tested a moderator role. At this point, Schnittker et al.49 found that accounting for mastery resources appear to play a role of direct mediation, reduced the association between income and edu- as opposed to moderation. Overall, additional, and cation and total number of chronic conditions by carefully designed research is needed to better test 12% and 4%, respectively, and self-esteem reduced psychosocial factors as possible mediating mecha- the income and education associations by 13% and nisms or moderating factors. Later we discuss spe- 5%. cific limitations of the literature and directions for Finally, three studies examined the aggregate in- future research to continue to evaluate psychosocial fluence of psychosocial resources in explaining SES explanations for health disparities. health disparities. Cohen et al.44 found no evidence that psychosocial factors including positive and neg- Limitations of the literature ative emotional style, self-esteem, mastery, purpose in life, optimism, and extraversion contributed to As noted, a primary limitation of the literature is the explaining the association between subjective SES small number of studies that have directly addressed

162 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins psychosocial pathways contributing to SES-health ited potential to clearly elucidate the roles of psy- gradients. For example, although stress is frequently chosocial factors. For example, it is typical for epi- mentioned as a pathway linking SES with health, demiological studies to include blocks of variables in very few studies have examined this hypothesis ex- analyses that attempt to “explain” SES-health gra- plicitly. Thus, a primary recommendation is that re- dients. Often, these combinations of variables are searchers should take advantage of available datasets not clearly conceptually related and moreover, the collected on a national or local level to better test me- practice leads to an inability to determine the spe- diational hypotheses. More studies are needed ex- cific contributions of psychosocial factors as unique amining all types of psychosocial mediators—stress, from other influences. This approach also results in negative emotions, and resource variables, as well as missed opportunities to identify theoretically mean- the exploratory pathways discussed further. ingful indirect pathways. For instance, the study by A limitation the literature that is available is Gorman and colleagues45 simultaneously examined the use of self-reported health outcomes in some the contribution of depression and health behav- cases.45,47,49,61 This is problematic for a num- iors to SES-disparities in (self-reported) hyperten- ber of reasons. First, asking participants to report sion prevalence. This approach disallows evaluation physician-based diagnoses introduces biases related of the independent impact of depression; in addi- to access to medical care, because discrepancies in tion, the influence of depression on hypertension access to quality health care are a well known fac- risk may occur indirectly in part, via associations tor contributing to health disparities.62,63 Thus, the with health behaviors such as smoking and physical link between SES and health outcomes may be at- activity.67 Similarly, Chaix et al.55 report the addi- tenuated when self-reported diagnoses are assessed, tional reduction in the SES–CHD association with given confounding of prevalence and awareness, es- control for social support after accounting for other pecially among people with low SES who are less risk factors, but it is probable that, in part, support likely to come into regular contact with the medical exerts effects on distal endpoints via proximal in- system, or who may receive fewer diagnostic tests by fluences on clinical and behavioral risk factors. A nature of inadequate insurance, etc. Furthermore, better strategy would be to perform path analyses even assuming equivalent healthcare, individuals that can accommodate multi-step links among psy- with lower SES (particularly lower education) may chosocial and other types of mediating mechanisms have difficulty in accurately answering questions (e.g., Refs. 32,59). Optimally, structural equation about their health status, due to the link between modelingcanbeusedtotestconceptuallydriven SES and health literacy.64 The resulting increased er- hypotheses concerning direct and indirect pathways ror variance can attenuate power to identify direct of interest (for example, Refs. 29,30; for further dis- or indirect pathways from SES to health. The use cussion, see Ref. 1). In addition to considering alter- of self-reported measures is also problematic when native analytic strategies, it is recommended that re- more subjective indexes of illness are administered. searchers report more complete information about For example, the assessment of total chronic condi- the results of tests for mediation. A number of stud- tions used in the study by Schnittker49 asked about ies concluded that there was “little” or “no” evidence the presence of a number of health problems that re- for mediation based on the fact that SES effects re- quire a judgment call on the part of the respondent. mained statistically significant after statistical con- Giventhewell-knownassociationsbetweennegative trol for psychosocial pathways. However, in general, emotionality and distress with somatic symptoms– the contribution of psychosocial factors (and any sometimes in the absence of objective underlying single pathway) to SES-health gradients is likely to disease65,66–including subjective outcomes such as be small. Because these factors certainly represent these may lead to biased estimates of the possible only one of many relevant mechanisms account- roles of psychosocial factors. Thus, additional stud- ing for the link between SES and health, even minor ies that include objective endpoints (e.g., mortality, contributions in terms of variance explained may be or objectively measured indications of disease) in informative and meaningful on a population level. particular are needed. Finally, a further analytic limitation of the available A further shortcoming of the available literature literature is the failure to consider non-linearity in is the reliance on statistical techniques with lim- the associations among SES, psychosocial pathways,

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 163 Psychosocial mediators and their origins Matthews et al. and health. That is, psychosocial factors could po- ethnic minority status, a better strategy would be to tentially have a greater impact at certain levels of consider their joint impact. In support of this as- SES than at others, or different psychosocial factors sertion, some studies reviewed here showed that the may be important for determining health of lower link between SES and health largely dissipated with versus higher SES individuals. control for other demographic characteristics, and Another limitation is the quality of measurement. in particular, race and ethnicity (e.g., Ref. 24). In Large studies are needed to understand and isolate addition, it is possible that SES and ethnic minority the many contributing factors. However, the trade- status may operate in a synergistic manner, requir- off of large, nationally based studies is that they ing tests of interaction effects. Specifically, individu- often include very limited measures of psychosocial als with low SES who are also ethnic minorities may functioning. For example, several studies evaluated be at especially high given the added impact of dis- in the current review used single-item measures of crimination and other unique stressors, or, ethnic stress and other psychosocial constructs,26,31 or ad- minority groups may experience “diminishing re- ministered brief measures with unknown psycho- turns” on health with higher SES, for example, due metric properties.28 Even in cases where more com- to factors such as racism in the workplace, “glass- plete measures were included, generally only one ceilings,” or residential segregation, when compared type of stress (e.g., life events) was examined. Yet, with non-Hispanic whites.72–74 In addition, the the association between SES and stress is complex, association between SES and health is frequently and a multi-dimensional assessment of stress may observed to be attenuated in studies of Hispanics be necessary to fully understand status-based dif- and in immigrants. These trends may reflect im- ferences that contribute to health.68 For example, a migration patterns, or they may indicate resilience prior study showed that lower SES was associated to the health implications of low SES as a conse- with the experience of fewer, but more severe, daily- quence of health-protective behavioral or social fac- life hassles.69 Another study suggested that stressor tors.73,75 Inasmuch as the SES-related distribution domain, severity, timing, and perceived risk influ- of stress and other psychosocial factors differs ac- enced the nature of the relationship between SES cording to race/ethnicity,76 their roles in explain- and stress.70 Further, over time, consistent expo- ing SES-health gradients may differ across ethnic sure to disadvantage may lead to stress habitua- groups. tion,71 attenuating related appraisals in some in- dividuals. Studies that include multiple measures of Psychosocial origins of SES-health stress and other psychosocial variables27 may allow connections across the life span a clearer understanding of the roles that these fac- tors have in SES-health gradients. Moreover, studies This chapter has reviewed the psychosocial path- that include a smaller number of participants but ways connecting SES and health. The populations examine psychosocial experiences at a more refined under study were all adults. Yet, we know that SES level (e.g., via approaches of ecological momen- in childhood is associated with some indices of , , tary assessment)4 19 69 represent important comple- adult health, especially mortality from hemorrhagic ments to large, epidemiological studies, which have stroke and stomach cancer, and prevalent cardio- the advantage of adequate power to examine rela- vascular disease.77,78 Although there are a number tively rare objective health outcomes (e.g., mortality, of methodological deficiencies in this literature that stroke). Likewise, since psychosocial factors could preclude strong conclusions (Cohen et al. this vol- contribute differentially to disparities based on di- ume), the body of evidence does suggest the low verse socioeconomic indicators, optimally, more SES in childhood confers risk in adulthood. Fur- than one measure of SES would be examined. thermore, among children and adolescents, there Population diversity is another important con- are strong associations between parental SES and sideration when evaluating the nature of SES-health indicators of health status, e.g. severity of asthma, disparities, and identifying psychosocial and other physical limitations due to health, and physical inac- contributing pathways. Although SES and ethnic tivity.79 These findings suggest that the SES-health disparities are often considered separately, given the connections begin early in life and have long-lasting closely confounded nature of socioeconomic and health effects. We next review what has been learned

164 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins about the psychosocial origins of the SES-health tion and discipline style. These parenting practices, connections. in turn, are posited to lead to children’s inability to learn how to regulate negative emotions and to develop a sense of security with and attachment to Early family environment important figures in their lives. Emotional dsyregu- From the psychosocial perspective, an obvious po- lation and insecurity in childhood may lead to mis- tential contributor to the pattern of psychosocial trust of others, poor social and coping skills, and risk associated with low SES in adulthood is the feelings of depression, anxiety, and anger. To the quality of the early family environment. Relevant extent that marital conflict leads to marital dissolu- family characteristics include overt family conflict, tion, then the family also declines in SES, with the manifested in recurrent episodes of anger and ag- consequent additional stress of financial insecurity gression, and deficient nurturing, especially family and insufficient resources. Indeed, adults who expe- relationships that are cold and unsupportive or ne- rience parental divorce in childhood are less likely glectful. Families with these characteristics are con- to attend college, more likely to be unemployed and ceptualized as “risky” because they may leave their on welfare, and less likely to have sufficient finan- children vulnerable to a wide array of emotional and cial resources than their counterparts raised in in- physical disorders.80 Specifically, risky families fail tact families. They also have more problems in rela- to provide children with the experiences they need tionships with parents and siblings, and in forming to develop effective socioemotional skills.80 Instead, and maintaining other intimate relations, including offspring from risky families exhibit a propensity to marriage.90 experience and display chronic negative affect and Low SES and a risky family environment, includ- have difficulty developing or maintaining support- ing those marred by marital conflict, in turn, have ive social networks.81 Consistent with the allostatic been related to the intermediate pathways such as load model,82 these effects can contribute to the ex- outlined in Figure 1. A harsh family environment has , perience of chronic or recurring stress, which, in in- been tied to poor health behaviors,80 91 high levels of , teraction with genetic predispositions and acquired depression, hostility, and anxiety,80 81 elevated au- risks, such as poor health habits, lead to accumulat- tonomic and cortisol responses to threatening cir- ing damage to biological systems. Ultimately, these cumstances (e.g., Ref. 92), and poor health (e.g., processes can lead to the increased health risks asso- Ref. 83). Research shows that marital dissolution ciated with low childhood SES and an adverse early specifically leads to greater risk for physical health family environment. problems in adolescence, including substance abuse Risky families are more likely to emerge in low SES and sexual promiscuity,90 and maternal-marital dis- than high SES families. In both longitudinal and ret- satisfaction is associated with adolescent offspring’s rospective studies, low SES has been related to all of poor physical health 5 years later.93 Interestingly in the “risky family characteristics,” including familial an analysis of middle and high school students, ado- conflict, neglect, and cold, non-nurturant behav- lescents from high conflict intact families had more ior.2,80,83 Low SES children are at heightened risk physical symptoms than adolescents from low con- for physical mistreatment or abuse84,85 and expo- flict divorced families.94 Finally, parental divorce in sure to family violence,86 and they are at greater risk childhood is associated with early mortality among , of being in family relationships lacking in warmth men.91 95 and support (e.g., Ref. 87). Both sustained poverty Three investigations have explicitly tested the and decline into poverty move parenting into more risky families model in the Coronary Artery Risk harsh, punitive, irritable, inconsistent, and coercive Development in Young Adults (CARDIA) study, directions.2,84,88 an epidemiological investigation of risk factors A model complementary to and consistent with for atherosclerosis and hypertension in young and the risky family model emphasizes the role of mar- middle-aged black and white adults. In year 15 of ital conflict and dissolution, specifically. Troxel and CARDIA, 3225 participants completed measures of Matthews89 suggest that marital conflict leads to childhood SES, early family environment, and adult decreased monitoring of children, less expressed psychosocial functioning, a latent factor assessed warmth and affection, and changes in communica- by depression, hostility, and positive and negative

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 165 Psychosocial mediators and their origins Matthews et al. social contacts.30 Themodelwasthentestedusing educational degree, may be employed but passed these measures in relation to metabolic functioning, over for career advancement, thereby earning lower C-reactive protein, an inflammatory marker, and incomes, when compared to individuals who are high blood pressure. Structural equation modeling low in negative emotions and high in positive emo- showed that low childhood SES was associated with tions. Indeed, data from CARDIA show that among a harsh family environment, which, in turn, was re- employed individuals, those who had elevated de- lated to the latent factor composed of negative affect pressive symptoms lost substantial annual income and inadequate social support. Results showed that over the next 5 years.98 the latent factor was related to poor metabolic func- A more direct way that low parental SES may tioning in the full sample, although the fit was better impact the SES of offspring concerns the educa- for white women and men, and black women, than it tional environments associated with low SES com- was for black men. A similar model characterized the munities. Children from low income families have relationships between a harsh family environment a lower sense of being connected to their schools, and elevations in C-reactive protein96 and preva- have less qualified teachers, and have parents who lence of high blood pressure and blood pressure arelessinvolvedinschoolactivities.2 Females from increases across 5 years (this model did not include lower SES families are more likely to be pregnant as social support).97 Unlike the evidence for metabolic teenagers, thus reducing the likelihood of complet- functioning, the model fit the blood pressure data ing high school or attending college. in all four CARDIA subsamples of white and black Low income children also experience less cogni- men and women. tive stimulation and enrichment at home than do It is clear, however, that not all the variance in re- higher income children. In a provocative study by lations between childhood SES and health outcomes Hart and Risley,99 parent-child verbalizations were can be explained through a pathway implicating a observed monthly from 6 months to 3 years of age risky early family environment. In the blood pres- among 42 families that were defined by occupational sure study, for example, there was a significant di- status (welfare, lower/middle, and professional fam- rect path from low childhood SES to blood pressure, ilies). Lower SES children heard fewer words and independent of the relation to early family environ- proportionally more orders or commands and fewer ment and the psychosocial variables.97 Thus, a risky positive comments, relative to higher SES children. early family environment is best conceived of as one These differences occurred even when the child was of several potential pathways by which low SES in preverbal at age 9 months to a year: infants from childhood contributes to adverse health outcomes the welfare families heard about 500 words, whereas in adulthood. infants from professional families heard about 1500 words during the observation session. Similar find- ingshavebeenreportedbyothers.100,101 The differ- Intergenerational transmission of SES encesinspeechproductionobservedbyHartand Developed democratic countries offer their citizens Risley99 were strongly correlated with higher child- the promise of improvement in standard of living hood scores in vocabulary and linguistic complexity with hard work and adequate preparation. Yet, in more generally (see also Ref. 102). Thus, lower SES general, in the United States and in other developed children are less prepared to succeed in formal edu- countries, low SES families produce by and large cational environments. children who grow up to be low SES adults and high In consequence, it is not surprising that children’s SES families produce children who grow up to be academic achievement is correlated with family in- high SES adults. Why should low SES be persistent come103 and that the effects may be cumulative over across generations? childhood. In the NICHD Early Child Care Network In part, this channeling of low SES across gener- study,104 the longer that a child lived in poverty from ations may reflect the fact that a harsh early family the ages of birth to 9 the more likely the child was environment leads to poor psychosocial function- to have behavioral problems and low cognitive per- ing in offspring. Individuals who are high in neg- formance. Being poor later in childhood tended to ative emotions and low in positive emotions may be more detrimental than early poverty in this sam- lack the coping skills necessary to attain a higher ple.84 Consistent with the importance of parenting

166 Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. Matthews et al. Psychosocial mediators and their origins practices, the link between income and child out- in part by perceptions of threat. Similarly, Chen comes was in part due to less positive parenting. et al.106 found that in children with asthma, lower There may also be structural impediments to up- family SES, as measured by home rental versus own- ward mobility that even highly motivated lower SES ership, was associated with heightened production children experience. For example, the lack of coun- of IL-5 and IL-13 and higher eosinophil counts, and seling about higher educational alternatives, the re- family SES was associated with higher chronic stress luctance to provide or to accept educational loans and perceived threat. Statistical mediation tests re- to families with no savings or no income, and the vealed that chronic stress and threat perception rep- lack of public transportation to travel the neces- resented statistically significant pathways between sary distances to search for and obtain good jobs family SES and immune processes. It is noteworthy would make advancement difficult. These impedi- that a similar emphasis on threat interpretation has ments undoubtedly vary widely by state and region. been the focus of studies on poor attachment and Finally, there are some data suggesting that edu- divorce: individuals from divorced families are more cation attainment and to a lesser extent earned in- vigilant to threat cues in contrast to those from intact come are heritable. For example, based on a nation- families who are more avoidant of threat cues.107,108 ally representative sample of full and half siblings Low brain serotonergic activity correlated with 28–35 years old, heritabilities due to a common ge- impulsivity and aggression comprises another can- netic factor were estimated to be 0.52 for education didate pathway connecting SES with health. Manuck and 0.12 for income, with environmental influences et al. have suggested that low brain serotonergic ac- due to a common shared environmental factor be- tivity predisposes to impulsive aggression in both ing.018 for education and 0.08 for income.105 These adult humans and primates.109 Their extensive re- analyses, while provocative, do not indicate what view of the literature documents that heightened heritable traits lead people to attain different lev- aggressiveness, whether indexed by violent criminal els of social status or which heritable traits might activity, lifetime history of aggression, or aggres- respond differently to life stressors correlated with sive behavior observed in a laboratory setting, is SES. associated with diminished or dysregulated central serotonergic activity (see also Ref. 110). These as- sociations are apparent using several measures of Promising future directions serotonergic function, including CSF 5-HIAA con- This chapter has concentrated on the role of centrations, neuroendocrine challenges, and re- three classes of psychosocial factors—stress, nega- sponsivity to serotonergic stimulation of frontal tive emotions, and resources—in relation to SES and brain regions thought to modulate aggressive be- health. There are several other psychosocial path- havior. Interestingly, the component of impulsivity ways at a different level of analysis that may inform that is most highly associated with brain serotoner- the links between SES and physical health. Chen and gic activity is the nonplanning component, which is Matthews5 suggest that low SES individuals may be also associated with SES.110 Diminished serotoner- more likely to perceive threat in ambiguous situa- gic function is associated with individual and neigh- tions in compared to high SES individuals facing borhood level measures of SES, adverse health be- the same ambiguous situation. Thus, low SES in- haviors, metabolic syndrome, and blood pressure dividualsnotonlyexperiencemoreobjectivestress in nonpsychiatric samples of middle-aged men and but also subjectively experience the same situation women (e.g., Refs. 111–114). as more stressful, a pattern of results consistent with As we gain understanding on the key psychosocial the reserve capacity model. Support for this per- variables that may connect SES to health, it will be spective has been obtained in a number of stud- helpful to chart fine-grained models of how brain ies of children and adolescents. For example, Chen function and volume may be related to health out- and Matthews5 found that the extent of children’s comes (see McEwan & Gianaros, this volume). For perceiving threat in ambiguous situations was cor- example, lower perceived SES is related to smaller related with parental SES based on education and hippocampal brain volume and greater amgydala occupation, and that the association between SES reactivity to threat cues as measured by functional and cardiovascular reactivity to stress was mediated magnetic resonance imaging (fMRFI) in several

Ann. N.Y. Acad. Sci. 1186 (2010) 146–173 c 2010 New York Academy of Sciences. 167 Psychosocial mediators and their origins Matthews et al. studies.115,116 Individual differences in impulsivity serotonegic function, but only among those with are related to greater activity in the bilateral ventral at least one short allele123 also suggesting that SES amgydala, parahippocampal gyrus, dorsal anterior may serve as a moderator of the phenotypic expres- cingulate gyrus, and bilateral caudate, and to lower sion of the genotype. Integrating evidence at the activity of the ventral prefrontal cortex and dorsal SES level with neural and genetic evidence, psycho- amygdale.117 Adults who report having harsh fam- logical data, and assessments of family environment ily upbringing, consistent with the risky families can provide richly detailed information regarding model,118 showed little amygdala reactivity to ob- exactly how these variables may inform an overar- serving fearful/angry faces and a strong positive as- ching model of the relations of childhood SES to sociation between amydala activation while labeling adult health outcomes. emotions in the face and activation of right ventral prefrontal cortex, suggesting a dysregulation in the Final comments neural systems involved in responses to emotional stimuli. In contrast, adults from nonrisky families We began this chapter with a framework regard- showed the expected amygdala reactivity to observ- ing how SES may impact health through the ing the faces and activation of right ventrolaterial emotional/cognitive sequalae of high levels of psy- prefrontal cortex while labeling emotions. Thus, chosocial stress, and how SES may reduce re- adults who grew up in risky families exhibit atypical sources or reserves for dealing with stress, due to responses to emotional stimuli that are evident at underdeveloped or overused reserves. This the neural level. framework—called the reserve capacity model— Identifying and integrating genetic risks may fur- has been tested empirically only a few times. The ther clarify the pathways connecting SES and health. literature review contained herein suggests that psy- For example, children who had physician-diagnosed chosocial resources may be important but not be- asthma were identified as high or low SES based cause they impact stress responses. Rather, they may on parent education and income.119 Genome-wide have a direct and mediating effect on health out- transcriptional profiles from T lymphocytes were comes. The surprising aspect of the review is how measured. Results showed that children with asthma much there is yet to be learned regarding the psy- from a low SES family showed overexpression of chosocial pathways connecting SES and health. In genes regulating inflammatory processes, includ- that regard, we have suggested a number of design ing those involved in chemokine activity, stress re- and measurement issues that need to be addressed sponses, and wound responses, compared to high in future research. We may be approaching the mea- SES children with asthma. Bioinformatic analysis surement of stress in too simplistic a manner, not suggested that decreased activity of CREB and NF- taking into account more micro- levels of analy- Y, and increased NF-␬B, transcriptional signaling sis and domains of stress relevant to different so- mediated theses effects. These pathways are known cial strata. Similarly, more fine grained analyses of to regulate catecholamine and inflammatory signal- psychosocial processes, such as sensitivity to threat, ing in immune cells. impulsivity, and correlated brain function, along Another example is from an analysis of the re- with measures of SES and health should be fruit- lation of the serotonin transporter gene to depres- ful. Even though much is yet to be learned, evidence sive symptoms.120 Among young adults with the does suggest that origins of SES-health connections s/s genotype, those who came from risky families can be traced to psychosocial processes in child- were at enhanced risk for depressive symptoms but hood. Children who are exposed to parental con- those who came from nurturant families were at flict, neglect, and cold, non-nurturant behavior in significantly reduced risk for depressive symptoms, the family are particularly likely to be at risk for relative to those with other genotypes (see also Ref- emotional dysregulation, sense of insecurity, and erences 121, 122). Thus, early environment impor- their physiologic sequaelae. This suggests that early tantly moderated the phenotypic expression of the interventions directed toward children and their genotype. Childhood SES and physical health was parents/guardians may not only impact well be- not examined in those studies. However, in another ing in childhood but have lasting health benefits sample, adult SES was associated with low brain into adulthood. Given the potential importance of

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