Stress perception: A pathway from socio-economic status to health

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Stress perception: A pathway from socio-economic status to health

Kateryna Maltseva,

Candidate of Sciences in Philosophy (2003), PhD in Anthropology (2010); Associate Professor at the Sociology Department of the Faculty of Social Sciences and Social Technologies, National University of «Kyiv-Mohyla Academy» (8/5, Voloska St., block 4, room 213, Kyiv, 04655); Affiliated Research Scientist at the University of Connecticut (USA)

КАТЕРИНА МАЛЬЦЕВА

Сприйняття стресу: шлях від соціально-економічного статусу до стану здоров'я stress health condition medical sociology

Дослідження стресу є важливим напрямом у медичній соціології. Психосоціальний стрес пов'язаний з несприятливими наслідками для фізіологічних систем і може залишати свої відголоски в організмі в довготривалій перспективі. Соціально-економічний статус своєю чергою впливає на ймовірність зіткнення зі стресором і на те, як індивід зможе побороти наслідки цього зіткнення. Існують рясні систематичні докази як щодо впливу стресу на стан здоров'я, так і щодо складних взаємозв'язків між соціально-економічним становищем, стресом і його наслідками для здоров'я. Завдяки серії відкриттів у біомедичній сфері впродовж останніх десятиліть наше розуміння процесу стресу стало значно більш комплексним, а механізми впливу психосоціального стресу на здоров'я увиразнилися в дослідницькій літературі. Інтеграція цих знахідок із царини біології, генетики й медицини в соціологічні, антропологічні та соціально-епідеміологічні дослідження стресу змінила те, як ця дослідницька ніша в соціальних науках концептуалізує та вимірює стрес, а також те, як розцінюється роль, що її людське суспільство та його структури відіграють у патернах захворюваності, старіння та смертності. Хоча зв'язок між стресом та станом здоров'я вивчений добре, порівняно мало уваги приділяється питанню сукупності взаємозв'язків між соціально-економічним статусом, процесом стресу та його наслідками для здоров'я. Кількісне дослідження, проведене авторкою в Києві (п = 902) протягом 2020-2021 років на основі онлайн-анкетування, розглядало зв'язки між соціально-економічним статусом та стресом у контексті наслідків для здоров'я. Зокрема, збиралися дані для перевірки таких гіпотез: а) стрес чинить вплив на суб'єктивну оцінку здоров'я та самопочуття індивіда; б) соціально-економічний статус індивіда теж впливає на суб'єктивну оцінку його/її здоров'я та самопочуття; в) у індивідів з нижчим соціально-економічним статусом поточний рівень стресу (згідно з їхніми оцінками) вищий; г) індивіди, які в дитинстві мали нижчий соціально-економічний статус, у момент збирання даних під час пандемії коронавірусу характеризуються вищим рівнем сприйняття стресу, ніж ті, чий соціально-економічний статус у дитинстві був вищим; д) наявність хронічних захворювань у дорослому віці посилює вплив стресу.

Ключові слова: стрес, соціально-економічний статус, суб'єктивне здоров'я, наслідки для здоров'я, причинні механізми, кількісні методи

ЕКАТЕРИНА МАЛЬЦЕВА

Восприятие стресса: путь от социально-экономического статуса к состоянию здоровья

Исследование стресса является важным направлением в медицинской социологии. Психосоциальный стресс связан с неблагоприятными последствиями для физиологических систем и может оставлять свои отголоски в организме в долгосрочной перспективе. В свою очередь, социально-экономический статус влияет на вероятность столкновения со стрессором и на то, как индивид сможет побороть последствия этого столкновения. Существуют обширные систематические доказательства как относительно влияния стресса на состояние здоровья, так и касательно сложных взаимосвязей между социально-экономическим положением, стрессом и его последствиями для здоровья. Благодаря серии открытий в биомедицинской сфере в течение последних десятилетий наше понимание процесса стресса стало гораздо более комплексным, а механизмы влияния психосоциального стресса на здоровье более четко отображаются в исследовательской литературе. Интеграция этих новых открытий из области биологии, генетики и медицины в социологические, антропологические и социально-эпидемиологические исследования стресса изменила то, как эта исследовательская ниша концептуализирует и измеряет стресс, а также то, как расценивается роль, которую человеческое общество и его структуры играют в паттернах заболеваемости, старения и смертности. Хотя связь между стрессом и состоянием здоровья изучена хорошо, сравнительно мало внимания уделяется вопросу совокупности связей между социально-экономическим статусом, процессом стресса и его последствиями для здоровья. Количественное исследование, проведенное автором в Киеве (п = 902) в течение 2020-2021 годов на основе онлайн-анкетирования, рассматривало связи между социально-экономическим статусом и стрессом в контексте последствий для здоровья. Собирались, в частности, данные для проверки следующих гипотез:

Ключевые слова: стресс, социально-экономический статус, субъективное здоровье, последствия для здоровья, причинные механизмы, количественные методы

KATERYNA MALTSEVA

Stress perception: A pathway from socio-economic status to health

Stress research is an important area in medical sociology. Psychosocial stress accounts for negative health outcomes across various physiological systems and can have far-reaching consequences for the organism's health. Socio-economic status, in its turn, influences the likelihood of stress exposure and how its consequences will be addressed. All in all, there is ample systematic evidence in support of complex associations between socio-economic status, stress and health outcomes. Following a series of discoveries in the biomedical sphere, our understanding of stress became considerably more complex, and the causal mechanisms of this process have become more prominent in research literature over the last few decades. Integration of this new data from biology, genetics and medicine into sociological, anthropological and socio-epidemiological research of stress has changed not only how this research niche conceptualizes and measures stress but also how the role that the society and social structures play in patterned distribution of disease, aging and mortality is understood. Although the link between stress and health is well studied, the mechanisms linking socio-economic status, the stress process and health outcomes have received rather less attention. An online quantitative study (n = 902) carried out in Kyiv during 2020-2021 focused on the question of the SES-stress link in the context of health outcomes. Specifically, the study tested the following propositions: (a) stress affects self-rated health and wellness of individuals; (b) current SES affects individual self-rated health and wellness; (c) individuals from low SES categories face higher current perceived stress levels compared to individuals from higher SES categories; (d) individuals who report having low SES in childhood have higher perceived stress levels during the COVID-19 pandemic compared to their counterparts whose familial socio-economic status was higher when they were children; and (e) having chronic conditions exacerbates individual stress levels.

Every day our bodies and brains adapt to changing situations regardless of our perceptions of these situations as «stressful» [Schieman, 2019]. These adaptations may include instances when we do not get our usual amount of sleep, when we exceed or reduce the amount of social interaction that is typical for us, when we are stuck in a loud crowd, etc. What exactly is «stress» and «stressor» as conceptualized by those medical sociologists and social epidemiologists studying the effects of society on human physiology? And more importantly, what kinds of stress are noxious for human health?

The concept of stress has changed considerably over the past 50 years and, in consequence, our understanding of stress biology has expanded and become more nu- anced [Cole, 2010; Epel et al., 2018; McEwen, 2019]. Prior to the formulation of the stress process theory the concept of «stress» was primarily understood as an extraordinary and dangerous event that was bound to cause harm to one's health and bring about the onset of disease, thus branding it as deleterious and inherently maladaptive. However, contemporary socio-epidemiological literature views stress as a continuous adaptive process during which an individual scans the environment and adapts to its changes while actively resisting the negative impact of stress and learning to cope with and anticipate the future challenges [Kiecolt-Glaser, Renna, Shrout, & Madison, 2020; McEwen & Akil, 2020; Turner et al., 2020]. Furthermore, owing to several decades of biological and medical research into stress and immune response, stress is no longer conceptualized as a dramatic, irregular experience with an unequivocally destructive potential for health but as an adaptive process of monitoring one's (social and natural) environment, which occurs regularly and in which an individual takes an active role in resisting stress and acquiring skills for more effective coping [Cohen, Murphy, & Prather, 2019; Hughes, Steffen, & Thayer, 2018; McEwen & Akil, 2020].

In general terms, the stress dynamics includes the interaction of the external factors (elements of the situation that acts as a stressor, which in an individual's perception translates into his/her experience of tension of different degrees, varying from a slight discomfort to a potential health or life threat) and internal factors (that are the physiological reactions and biomarkers of stressful experiences). Since the extent to which a situation is perceived as stressful varies from person to person depending on their psychological constitution, cultural heritage and characteristics of life trajectory, the cognitive (evaluative) component of the mechanics of stress is of great importance to studying the impact of stress on health [Christensen et al., 2019; Cundiff, Boylan, & Muscatell, 2020; Kiecolt-Glaser et al., 2020; McLeod, 2012; Segerstrom & O'Connor, 2012]. That is why stress perception is an essential component of the presently prevalent theoretical model of stress process.

Several decades ago those social scientists who initiated the research on stress in medical sociology started emphasizing the impracticality of exploring stress process without including its interpretative aspect [Lazarus & Folkman, 1984; McLeod, 2012; Pearlin, 1989; Reynolds & Turner, 2008]. Stressful elements can be part of one's factual environment/situation, or one's evaluation of the environment/situation, or one's reaction to an environment/situation -- first and foremost, emotional and physiological responses [Segerstrom & O'Connor, 2012]. Therefore, perception of stress, or subjective stress, is a parameter that matters if we intend to explain causal relationships between stress and health, as well as variation in the ensuing health outcomes.

Another important aspect of conceptualizing the links between stress and health -- which is, by implication, part and parcel of measuring stress in stress research -- takes into consideration at least three factors such as stress exposure, stressful situation evaluation and stress response [McLeod, 2012; Pearlin, 1989; Schieman, 2019], as well as distinguishing between them. Ignoring this aspect potentially leads to equating stress exposure with stress response and even extending stress-related health outcomes to all instances of stress exposure. However, in actuality not all stressful events have the same impact on people, and individuals vary among themselves with respect to their stress resistance and resilience [McEwen, 2019]. At this juncture, it is worth pointing out that socio-economic status (SES), in its turn, influences the likelihood of stress exposure and how its consequences will be perceived, evaluated and addressed [Mullainathan & Shafir, 2013]. It is also worth noting that inequality per se can have different forms in different countries [Lopez-Roldan & Fachelli, 2021], thus shaping patterns of stress exposure and interpretation of stress experience across different cultural contexts.

There are different kinds of stressors; their effect can be of short and long duration, e.g. they can be acute or chronic. Chronic stressors are particularly important for social research as they are often inextricably connected to the social fabric and also very impactful. Moreover, the effects of chronic stressors in health tend to accumulate and generate cascading consequences. Embedded into the structure of social roles, cultural prescriptive norms, social statuses and hierarchies, chronic stressors are part of the daily routines that is often left unnoticed (and unprocessed) by cultural community members who go through it day by day [Schieman, 2019]. The impact of chronic stressors on health has received much research attention, but the mechanisms by which the «wear-and-tear» attributable to the allostatic load occurs are still not fully understood [Goldstein & McEwen, 2002]. Once again, one's SES is a characteristic that likely determines the presence of chronic stressors in one's life, as well as their nature, amount and severity. For example, compared to high SES, low SES is associated with the risks of sexual, physical and psychological abuse, childhood trauma, neglect and other forms of early childhood adversity that have been systematically shown to affect health in adult years [Fogelman & Canli, 2019; Miller, Chen, & Parker, 2011].

Social gradient in health (an inverse relationship between socio-economic status and morbidity/mortality) has been documented virtually in every community where it has been studied [Lea et al., 2021]. There are a number of theoretical explanations of health inequalities, and the effects of SES in health outcomes are well studied. Although they focus on different aspects of SES and place different emphasis on the timing of impactful events, most researchers concur that the direction of gradual changes in health with the decrease in social standing is universally supported by empirical data. Thus, a gradual decrease in health with the reduction of status in the social hierarchy is an important feature in the context of how the society and its structures can influence human physiology.

A Ukrainian study on stress perception, SES and health (Kyiv, May 2020 -- February 2021)

The data analysis was performed in IBM SPSS Statistics 25.0 [IBM SPSS Statistics for Windows, 2017] and Microsoft Excel. After data cleaning and reliability checking the next step in the analysis was to create scales and calculate additive indices that would be then used in the regression analysis to explore causal links between socio-demographic characteristics, on the one hand, and stress and health measures (both objective and perceptual), on the other. Correlations among all indices are presented in Table 2.

Table 2 Correlation of indices: Stress Perception Index [Cohen et al., 1983], Depression Index (BDI-I) [Beck et al., 1961], and Flourishing Index [Diener et al., 2010]

Figure 1 and Figure 2 supply context for the present findings with regard to the social determinants of health: the graphs represent the gradients in health that are typically of interest to health researchers addressing similar questions. Both self-rated health and subjective experience of wellness show a distribution of averaged scores that privilege higher SES groups. This finding is consistent with major socio- epidemiological findings in Europe and North America.

Figure 1. Social gradient in health by self-rated health (averaged scores)

Figure 2. Social gradient in health by wellness (averaged scores) Соціологія: теорія, методи, маркетинг, 2022, 2

According to the results of linear regression, the current familial SES had statistically significant effects on depression and flourishing measures (i.e. negative and positive sides of mental health spectrum), on both subjective health measures and perceived stress levels These and subsequent data are presented in Table 3.. Familial SES in a respondent's childhood had an influence on respondent's current SES (Я = 0.196, p < 0.000). A respondent's family's SES in childhood per se only influenced the levels of perceived stress (indicating a weak positive relationship). However, a decrease in SES during one's lifetime (computed as a difference between the indicators of the respondent's current familial SES and his/her SES in childhood, as embodied by a separate variable) had a statistically significant effect on the perceived stress and wellness by increasing the former and decreasing the latter. In absolute terms, this effect on perceived stress was more potent than that of the current SES. The decrease in SES during one's lifetime also showed an impact on metrics of depression and flourishing, suggesting a tendency towards mental health deterioration on both negative and positive sides of mental health spectrum. In this context, it is noteworthy that the impact of either of these SES variables on health-related measures exceeded that of the accessibility of medical care. These findings support the propositions expressed in the hypothetical propositions (a)-(d) and signal the importance of the link between low SES and stress as a meaningful pathway that impacts an individual's health.

Overall, the female respondents in the sample showed higher depression scores compared to their male counterparts; female gender also came out as a significant predictor of higher stress levels, lower flourishing scores and poorer subjective wellness, but the causal relationship was low in strength. This general finding is consistent with the results of nationally representative surveys in many industrialized, Western countries such as the USA and European welfare states.

Albeit self-rated health decreased with age, older respondents scored lower on stress and depression and had higher scores on flourishing compared to younger participants in the sample.

Having good friends contributed to one's resistance to depression, increase in flourishing and improvement of self-rated health scores in the sample. Furthermore, individuals who had a partner at the moment of data collection displayed lower scores of stress and depression, as well as higher scores of positive mental health compared to those who did not have a partner in their lives. The same statistical pattern was found for individuals with children, but the association was weaker.

Spending long hours on social media sites was conducive to increased levels of depression and stress. It also negatively affected flourishing (positive mental health) scores.

Table 3

The results of linear regression for SES and mental health variables

*p < 0.05; **p < 0.01; ***p < 0.001

A respondent's educational attainment had some effect on depression, yet the association was not the one of great strength. No other causal effects of education were found. Education level of the respondent's father had no effect on his/her health outcomes; however, the respondent's mother's higher educational attainment increased the likelihood of depressive symptoms and higher levels of perceived stress in the respondent.

Moreover, having parents who did care for the respondent's emotional needs in childhood had a series of causal connections with health outcome variables which were similar to the effects of higher SES -- although the association was of smaller magnitude. This is an important finding confirming that parents play a considerable role in forming the resource of health during one's childhood.

Individuals who reported leading a healthy lifestyle, particularly having good nutrition and getting enough sleep also mentioned having lower levels of perceived stress. Smoking had a reverse effect.

Chronic diseases had a negative effect on both measures of self-rated health but had no effect on perceived stress. Therefore, out of all five hypotheses this particular proposition (e) was not supported by the data; in the meantime, the data supported the remaining four hypotheses.

Conclusions and future directions

The study conducted in Kyiv (Ukraine) from May 2020 through February 2021 collected data regarding interrelations between an individual's socio-economic status, perceived stress and health.

The data supported most of the hypotheses (four out of five) formulated at the beginning of the study. First of all, perceived stress levels had a statistically significant effect on metrics of both self-rated health and wellness, decreasing both. The same effect was found for socio-economic status: low SES reduced self-rated health and wellness. In the sample, individuals with lower SES reported facing higher current stress levels during the COVID-19 pandemic. Individuals whose familial SES in childhood was low displayed a tendency to have higher perceived stress levels at the moment of data collection during the pandemic, as compared to their counterparts who belonged to higher SES categories as children.

The last hypothesis was not supported by the data: chronic conditions did not have an impact on perceived stress levels in the sample, although this negatively influenced both measures of self-rated health and wellness.

In contemporary sociological literature on social determinants of health, socio-economic status is typically interpreted as a macro-variable responsible for the variation in health, as well as the most potent predictor of physical and mental health outcomes in most communities that have been surveyed. The results of the present study are consistent with this tendency. The study also furnishes support for the role parental figures play in the formation of the health resource in childhood, suggesting that with respect to health-related behavior this avenue of social transmission should be explored more in-depth.

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