Health Inequalities
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In this chapter, we review social psychologi-
cal research on health inequalities across the
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United States: socioeconomic position, race,
and gender.1 Much health research is motivated
by the straightforward, and seemingly reason-
able, assumption that social disadvantages pro-
duce health disadvantages. However, patterns
of health inequality are not always consistent
with this assumption. Women’s health is not uni-
formly worse than men’s despite their relative
social disadvantage; the same is true in the com-
parison of racial minorities with majority whites.
Even in the case of socioeconomic position, for
which consistent health inequalities have been
observed, the association varies by outcome and
over the life course. These empirical complexi-
ties call for a rich and nuanced analysis that looks
beyond the distribution of material resources to
consider how group statuses affect interpersonal
interactions and the emergent meanings of objec-
tive life circumstances.
1
Research on health inequalities encompasses other di-
mensions of stratification such as immigrant status and
sexual identity (Alegria et al. 2008; Cho et al. 2004;
Saewyc 2011). Because the social psychological argu-
ments that are invoked are similar, we emphasize these
three key dimensions of stratification here.
J. D. McLeod (
) · C. Erving · J. Caputo many years: stress exposures, residential envi-
Department of Sociology, Indiana University, Ballantine
Hall 744, 1020 E. Kirkwood Avenue, Bloomington,
IN 47405, USA
e-mail: jmcleod@indiana.edu
J. D. McLeod et al. (eds.), Handbook of the Social Psychology of Inequality, Handbooks of Sociology and
Social Research, DOI 10.1007/978-94-017-9002-4_28, © Springer Sciences+Business Media Dordrecht 2014
Social psychological theories and concepts
must be central to any such analysis. As a group,
they draw attention to the processes that connect
macro dimensions of inequality to psychological
and bodily experiences. They direct us to con-
sider how the structure and content of proximate
environments influence the distribution of mate-
rial resources, the nature and quality of interper-
sonal interactions, and the construction of sym-
bolic meanings. These proximate processes set
in motion physiological and emotional responses
that are the ultimate determinants of physical
and psychological well-being (Kiecolt-Glaser
et al. 2002). Although others have made the point
that proximate processes tell us how inequalities
“get under the skin” (Taylor et al. 1997), their
accounts emphasize categories of proximate en-
vironmental experiences (e.g., interpersonal re-
lationships) rather than the social psychological
processes those categories represent. We empha-
size the latter, as it is these processes that tell us
how, why, and under what circumstances social
disadvantage diminishes physical and psycho-
logical well-being.
We begin with a brief description of health in-
equalities, followed by a review of key factors
that have been proposed to explain them. We
begin with factors associated with the stress pro-
cess framework because they have dominated
sociological research on health inequalities for
ronments, psychological dispositions, and social
relationships. We then turn to two other explana-
tory factors—health behaviors and health care
715
716
interactions—that draw from other frameworks.
We close with a discussion of the role of social
comparisons in health inequalities. For each
factor, our central orienting question is: How can
social psychological theories and concepts help
us understand its role in health inequalities?2
Basic Patterns
Socioeconomic Position3
The basic findings in research on socioeco-
nomic inequalities in physical health are well-
established and seemingly robust to historical
and geographic variation, at least in the western
industrialized world. People who occupy lower
socioeconomic positions as indexed by income,
education, and occupational prestige have worse
physical and mental health than people who oc-
cupy higher socioeconomic positions (see also
Milkie et al., this volume). As a general rule,
socioeconomic inequality in health holds across
the full continuum—what is often referred to
as the health gradient (Adler et al. 1994; Brave-
man et al. 2010). It is not just that people who
are poor, who have not graduated from high
school, and who work in unskilled positions have
worse health than everyone else. Rather, people
who occupy any given position on the socio-
economic scale have worse health than those in
positions above and better health than those in
positions below, with some leveling of the curve
at the highest status levels (House and Williams
2000). People in lower socioeconomic positions
2
Our review is necessarily selective. Literally thousands
of studies of health inequalities have been published just
in the past decade, many of which offer some social psy-
chological insight. To keep our review manageable, we
focus primarily on studies that explicitly invoke social
psychological theories and concepts. Even within this nar-
row group of studies, space limitations prevent us from
including all relevant citations.
3 The terms “social class,” “socioeconomic status,” and
“socioeconomic position” are defined and used in various
ways by health researchers. Of the three, the term socio-
economic position is the broadest. We use it here to avoid
an unnecessary and unproductive alliance between our ar-
guments and any more specific conceptualization.
J. D. McLeod et al.
also are sicker and stay sick longer than people
in higher socioeconomic positions (Herd et al.
2007), in part, because they are less likely to
seek care and, when they do, receive lower qual-
ity care (Fiscella et al. 2000). At the most basic
level, these patterns demonstrate that the effects
of socioeconomic inequality on health are the re-
sult not only of the profound material depriva-
tions experienced by people who occupy the very
lowest status positions but also of symbolic pro-
cesses through which people come to understand
their place in the world.
This simple description of socioeconomic
inequalities in health overlooks important varia-
tions across outcomes and over the life course.
Health inequalities are larger for some health
outcomes (e.g., heart disease mortality) than for
others (e.g., hypertension; Dow and Rehkopf
2010), with no obvious explanation. Health in-
equalities also vary over the life course. For
physical health, they are largest in infancy and
midlife, and smaller in childhood, adolescence,
young adulthood, and at older ages (Adler and
Rehkopf 2008). The patterns for mental health
are less consistent, although this may be a func-
tion of how socioeconomic position is measured.
Schieman (2003) reported that worsening finan-
cial conditions are more strongly associated with
anger in younger adults than in older adults (see
also Mirowsky and Ross 2001). In contrast, the
association of education with depression appears
to grow stronger with age (Miech and Shanahan
2000), perhaps reflecting the association of edu-
cation with chronicity of disorder (Miech et al.
2005).
Race4
By virtually every indicator, U.S. blacks (or Afri-
can Americans) have worse physical health than
U.S. whites. Blacks report worse health on sub-
jective measures such as self-rated health (Cum-
4
We follow Williams et al. (2010) in using race to refer
to racial and ethnic categories, both because the boundar-
ies between the two concepts are fuzzy and for the sake
of parsimony.
28 Health Inequalities
mings and Jackson 2008), as well as on more
objective measures such as counts of chronic
health conditions (Hayward et al. 2000). Blacks
experience earlier onset of major health problems
than whites, their health problems are more se-
vere, and their health declines more rapidly with
age than the health of whites (Hertz et al. 2005;
Kelley-Moore and Ferraro 2004; Shuey and
Willson 2008). Although blacks have lower cur-
rent and lifetime rates of major depression than
whites (a finding that extends to other psychiatric
disorders), their episodes last longer and are more
severe (Williams et al. 2007). Racial differences
in socioeconomic position contribute to racial in-
equalities in health but they do not fully explain
them; at each socioeconomic level, blacks have
worse health than whites (Williams 2005).
Studies of other minority groups complicate
our understanding of whether and how social
disadvantage produces poor health. Although
Asian Americans are racial minorities in the U.S.,
they have better health than whites on average
(Frisbie et al. 2001; Takeuchi et al. 2007). How-
ever, there is significant variation across Asian
American groups that maps closely onto their
socioeconomic profiles. Chinese, Japanese, and
Filipino immigrants tend to be highly educated
and experience better physical and mental health
than U.S.-born Whites, whereas poorly-educated
refugees from Southeast Asian nations such as
Vietnam and Laos generally experience poorer
physical health (Frisbie et al. 2001). Importantly,
the health of Asian Americans declines with lon-
ger time of residence in the U.S. (Frisbie et al.
2001; Takeuchi et al. 2007), pointing to a role for
meaning-based explanations.
Despite lower average socioeconomic posi-
tion, Latinos have similar, and sometimes better,
health profiles than whites, a pattern that is re-
ferred to as the “epidemiologic paradox” (Fran-
zini et al. 2001; Markides and Coreil 1986). As
for Asian Americans, Latino health declines with
the length of time immigrants have spent in the
United States (Alegría et al. 2007; Cho et al.
2004). Patterns of Latino health also vary with
country of origin but not necessarily with socio-
economic position. For example, Cubans experi-
ence better health than Puerto Ricans (Alegría
717
et al. 2007), which is consistent with their rela-
tive socioeconomic positions, but Mexicans ex-
perience better health than Puerto Ricans, which
is not. Although less well-studied, American
Indians and Alaskan Natives have poor health
relative to whites, with relatively high mortal-
ity rates for alcohol abuse, tuberculosis, diabe-
tes, unintentional injuries, homicide, and suicide
(Indian Health Service 2011).
Gender
With respect to physical health, women report
poorer health and have higher rates of disability
than men but they live longer (Read and Gorman
2011; Verbrugge 1985). Although this basic con-
clusion seems secure, life course research intro-
duces complexity. For example, the male disad-
vantage in heart disease now appears to be small-
er than previously thought (McKinlay 1996) and
decreases at older ages (Verbrugge and Wingard
1987). Women’s disadvantage in self-rated health
also declines with age, perhaps as men develop
more life-threatening illnesses, but their disad-
vantage in functional disability increases (Gor-
man and Read 2006).
With respect to mental health, scholars have
long documented higher rates of depression and
higher levels of depressive symptoms in women
as compared to men (Rosenfield 1999), leading
to the conclusion that women have worse mental
health. However, more recent evidence suggests
that the differences may reflect gendered norms
of emotional expression: women report more
symptoms of internalizing distress while men
report more symptoms of externalizing distress,
such as alcohol and substance abuse (Rosenfield
1999).
Research across these three dimensions of in-
equality confirms that social disadvantages often,
but not always, translate into health disadvantag-
es. The associations of socioeconomic position
and gender with health vary by outcome and over
the life course. Some racial minority groups have
poorer health than whites (e.g., Blacks) whereas
others do not (e.g., Latinos). Social psychologi-
cal theories help us understand these patterns by
718
identifying the processes through which social
disadvantage produces health disadvantages, and
the contingencies that govern them.
Explaining the Patterns
As House and Williams (2000) note, inequality
influences health through many different path-
ways. Virtually all known behavioral, psychoso-
cial, and environmental health risk factors vary
across positions in systems of inequality (see
also Lynch et al. 2000). Thus, the goal of health
inequalities research is not to determine wheth-
er specific risk factors contribute but why. Two
broad types of processes have been proposed: (1)
those that involve the differential distribution of
material deprivations and resources and (2) those
that involve non-material or “psychosocial” fac-
tors. The former emphasize objective life condi-
tions associated with lower status positions that
place people at risk of poor health, such as ex-
posure to health-damaging physical and social
environments. The latter emphasize subjective
experiences that arise at the intersection of the
social and the psychological, often conceptual-
ized as stress exposures, psychological disposi-
tions, social relationships, and health behaviors.
Social psychology aligns naturally with the
analysis of psychosocial factors. Yet, it would be
a mistake to remove all consideration of material
life conditions from social psychological inquiry.
Material deprivation can affect health through
social psychological processes, such as when
economic deprivation affects the perceived level
of financial stress. As well, psychosocial factors
can have material implications, such as when
the quality of social relationships affects access
to other health-promoting resources (Kawachi
et al. 2010). For these reasons, we set aside re-
cent debate over the relative primacy of material
and psychosocial factors in health inequalities
(see Carpiano et al. 2008 for a review) in favor
of a focus on the social psychological processes
that link material realities to psychosocial fac-
tors. These processes occur in proximate envi-
ronments that structure daily life and give life
meaning.
J. D. McLeod et al.
We organize our review with reference to six
major classes of explanatory factors that have
been identified as most central in previous re-
views (Adler and Stewart 2010; House and Wil-
liams 2000; Matthews et al. 2010): stress expo-
sures; residential environments; psychological
dispositions; social relations; health behaviors;
and health care interactions. For each, we high-
light the complementary contributions of mate-
rial and subjective explanations. We then review
research on social comparisons and health, which
underlies interest in relative deprivation, equity,
and illness interpretations. We begin with fac-
tors associated with the stress process because of
their long dominance in health research and their
especially close alliance with social psychology.
Stress Exposures
According to the stress-exposure explanation,
people in socially disadvantaged positions expe-
rience poorer health because they are exposed to
more stressors and have fewer resources (intra-
psychic, interpersonal, and material) for coping
with them (Schwartz and Meyer 2010; Thoits
2010). Chronic and intense stressors have been
hypothesized to play an especially strong role
in health inequalities (Turner et al. 1995). This
explanation draws implicitly from the social
structure and personality framework within so-
ciological social psychology (House 1981; Wil-
liams 1990), which traces the effects of macro-
structures and processes on individuals through
the “smaller structures and patterns of intimate
interpersonal interaction or communication”
(House 1981; p. 540) that constitute people’s
day-to-day lives. Most sociological research on
stress measures objective stress exposures, such
as job loss; in contrast, most psychological re-
search measures “subjective” stress exposures by
taking into account respondents’ perceptions of
the stressfulness of the experience (e.g., severity,
threat, and the like).
Studies have evaluated both general and spe-
cific forms of the stress exposure explanation.
Tests of the general form use global measures
of stress exposure—sums of life events, chronic
28 Health Inequalities
stressors, lifetime traumatic experiences, and/or
of overall stress burden (Turner et al. 1995)—to
evaluate whether stress exposures account for
health inequalities. Results are mixed. People
with low levels of income, education, and who
work in less prestigious occupations experience
a relatively high burden of chronic and severe
stressors, but these stress exposures do not fully
account for their poorer physical and mental
health (see Matthews et al. 2010 for a review).
The same holds for gender. For example, Denton
et al. (2004) found that women’s poorer general
physical health is not explained by differences
in their structural positions, lifestyle, or experi-
ences of stress. Evidence for the role of stress
exposures in racial inequalities in health appears
more solid (Williams et al. 1997). Blacks and
U.S.-born Latinos report higher levels of stress
exposure than whites and foreign-born Latinos
(Sternthal et al. 2010; see Hatch and Dohren-
wend 2007 for a review) and the differences in
stress exposure account for roughly half of the
differences in self-rated health, chronic illnesses,
and depressive symptoms (Sternthal et al. 2010).
Research on general stress exposures has been
extended with life course concepts, especially
the notion of cumulative exposures (Elder et al.
1996). Early life socioeconomic disadvantages
appear to set into motion cascades of negative
experiences with profound health consequences
(McLeod and Almazan 2003; Wadsworth 1997).
Low socioeconomic position during childhood is
related to risk factors for the prevalence of adult
disease (e.g. Lynch et al. 1997), mortality (Davey
Smith et al. 1998; Hayward and Gorman 2004),
self-rated health, and physical symptoms (Power
et al. 1998), independent of adult life conditions
(e.g., Kuh et al. 2002; although see Hayward and
Gorman 2004). Childhood disadvantage also
has been implicated in race differences in health
among adults (Warner and Hayward 2006). For
example, evidence supports Geronimus’ “weath-
ering hypothesis,” which proposes that African
Americans experience earlier health deterioration
due to the cumulative impact of repeated experi-
ences of social or economic adversity (Geroni-
mus et al. 2006).
719
Together, these studies demonstrate that gen-
eral stress exposure is one pathway through
which social disadvantage increases the risk of
poor health, especially for race. Research on spe-
cific stressors adds depth to this conclusion by
pinpointing the stress exposures that are most
closely linked to specific dimensions of inequali-
ty. This research investigates differences in stress
exposure across social groups as well as the ef-
fects of specific stressors on health within social
groups.
Specific Stressors: Socioeconomic Position.
Economic experiences and work environments
have received sustained attention in research
on socioeconomic differences in health. People
with low levels of income are at disproportionate
risk of food insecurity and financial stress (e.g.,
Bickel et al. 1999; Broussard 2010). People with
low levels of education encounter less favorable
job conditions (Warren et al. 2004) and more fi-
nancial difficulties (Stronks et al. 1998). The psy-
chosocial work environment also varies across
occupations in ways that matter for health. For
example, jobs that involve a combination of high
demands and low control are associated with in-
creased risk of cardiovascular disease (Karasek
and Theorell 1990), as are jobs that involve high
effort and low reward (Theorell 2000). Economic
and occupational stressors extend into other life
domains, increasing family and marital conflict
and, in turn, threatening health (e.g., Frone 2000;
Grzywacz 2000).
While these results are consistent with the
assumption that social disadvantage increases
stress exposure, some research on socioeconomic
position finds the opposite. Studies of the “stress
of higher status” find that people in higher-status
occupations report more work-family conflict,
longer hours, and more work demands than peo-
ple in lower-status occupations (Schieman et al.
2006). Similarly, people with high levels of edu-
cation report greater exposure to daily stressors
than people with low levels of education (Grzy-
wacz et al. 2004). Additional results from the lat-
ter study suggest that the apparent disadvantage
among people with high levels of education may
be more illusory than real: although they report
more stressors, the stressors they report are less
720
severe (based on both objective and subjective
ratings) and less strongly associated with health
(Grzywacz et al. 2004). More studies of stress
exposure that take into account the qualities of
events and how objective life conditions are in-
terpreted may help resolve these inconsistencies
(McLeod 2012).
Specific Stressors: Race. Studies of racial
minority health emphasize discrimination as a
specific stressor linked to poor health. In these
studies, discrimination is conceptualized as a
multi-level phenomenon, encompassing institu-
tional discrimination, personal discrimination,
and internalized racism (Williams and Moham-
med 2009). In this section, we review research
on personal discrimination because it aligns
most closely with the stress exposure explana-
tion. Institutional discrimination operates in part
through race differences in socioeconomic posi-
tion which, as noted, explain some but not all of
racial health inequalities. Institutional discrimi-
nation is also evident in racial residential segre-
gation (Takeuchi et al. 2010), a health risk that
we discuss in the section that follows.
Measures of personal discrimination include
major discriminatory acts (e.g., being denied a
job because of one’s race), day-to-day experienc-
es of discrimination or micro-aggressions (e.g.,
being treated with disrespect; Sue et al. 2007),
and anticipated experiences of discrimination
or heightened vigilance. Individual discrimina-
tion is an important determinant of health among
racial minorities. For example, among racial mi-
nority adults, experiences of major discrimina-
tion are associated with poorer self-rated health,
higher blood pressure, cardiovascular disease,
and psychological distress (see reviews by Har-
rell et al. 2003; Williams et al. 2003). Micro-ag-
gressions are associated with both internalizing
and externalizing emotions among Asian Ameri-
can adults (Wang et al. 2011) and with depressive
and somatic symptoms among Latino and Asian
American adolescents (Huynh 2012). Despite
the strong association of personal discrimination
with health within racial minority populations,
discrimination does not consistently account for
racial differences in physical and mental health
(e.g., Kessler et al. 1999; Williams et al. 1997).
J. D. McLeod et al.
This is especially true in studies that measure
discrimination with reports of “unfair treatment”
because those reports do not differ by race (e.g.,
Kessler et al. 1999). Discrimination provides a
stronger explanation in studies that ask respon-
dents directly about racial discrimination (Krieg-
er 2012). Thus, studies that use more refined
measures that incorporate the perceived basis for
the discrimination and the context in which it oc-
curs may yield more consistent results.
Among racial minorities, perceptions of dis-
crimination and the effects of discrimination on
health appear to be contingent on identities and
beliefs. African Americans whose racial iden-
tities are central to their sense of self and who
believe that other groups hold negative attitudes
toward African Americans report higher levels
of perceived discrimination than other African
Americans (Sellers et al. 2003, 2006). At the
same time, the negative effects of discrimina-
tion on mental health are dampened by the belief
that the public holds one’s group in low regard
(Sellers et al. 2006) and by having a strong racial
identity (Mossakowski 2003; Sellers et al. 2003;
although see Yip et al. 2008), although evidence
for the latter is more mixed (Pascoe and Richman
2009).
Specific Stressors: Gender. Research on
gender-specific stressors draws primarily from
research on gendered social roles. This research
has waned in recent years, perhaps because pat-
terns of gender-based health inequality are less
straightforward and because scholarship on gen-
der has shifted away from a role-based concep-
tualization (Courtenay 2000). During the 1980s
and 1990s, scholars established that women’s
disadvantaged positions in the family and labor
market contributed to women’s higher levels
of distress and lower levels of self-rated health
compared to men (e.g., Aneshensel et al. 1981;
Ross and Bird 1994; Thoits 1986). Interestingly,
these studies also pointed to men’s potential vul-
nerability to changing gender roles in the family,
and found that men whose wives work or earn
more than them may have poorer mental health
compared to those in households with a more
traditional division of labor (Glass and Fujimoto
1994; Rosenfield 1992).
28 Health Inequalities
Subsequent research extended these basic
findings with evidence that the meaning of so-
cial roles and, therefore, their stressfulness var-
ies by gender. For example, Simon (1995) found
that employment has different meanings for
married male and female parents, with women
feeling guilty about the time work may take
away from their families and men seeing work
as bolstering their family roles. This difference
in role meanings contributes to women’s greater
distress. Similarly, women encounter more stress
in association with parenthood because they con-
tinue to have greater responsibility for parenting
activities such as finding childcare (Ross and
Mirowsky 1988; Simon 1992). Gendered expec-
tations for emotion work also produce gender dif-
ferences in vulnerability to stress. For example,
Kessler and McLeod (1984) found that women’s
greater psychological vulnerability to stressful
life events lies in the events that occur to network
members, which may reflect the expectation that
women shoulder the burden of maintaining inter-
personal relationships (although see Aneshensel
et al. 1991).
Research on specific stressors extends re-
search on general stressors by acknowledging
that certain stressors may be more closely tied to
some forms of inequality than to others. In that
way, it offers a more nuanced conceptualization
of proximate environments that brings stress re-
search into conversation with more general social
psychological concepts, such as social roles and
discrimination. The most promising research has
sought to incorporate subjective interpretations
of stressors (i.e., perceived severity, perceived
discrimination, the meanings of social roles),
which strengthens the stress process framework’s
alliance with symbolic interactionism (McLeod
2012).
Residential Environments
Exposure to harmful residential environments is
socially patterned to the disadvantage of people
in lower socioeconomic positions and racial mi-
norities. The poor and racial minorities are more
likely to live near environmentally hazardous
721
facilities and are more likely to be exposed to
environmental toxins and air pollutants (Brulle
and Pellow 2006). Although direct evidence is
scarce (Adler and Stewart 2010), these differen-
tial exposures seem likely to contribute to health
inequalities. How much they contribute is uncer-
tain as some evidence indicates that physical en-
vironments contribute only about 5% to prema-
ture mortality (McGinnis et al. 2002).
Sociological studies of health inequalities
have devoted more attention to the social char-
acteristics of residential environments than to
their physical risks. Disadvantaged residential
environments are often, although not always,
conceptualized as stress exposures. Although
their effects on health are amenable to social psy-
chological explanation, social psychology is ref-
erenced only infrequently in this literature. (See
Quillian, this volume for further discussion.)
Since the early 2000s, research on socioeco-
nomic health inequalities has turned to the ques-
tion of whether neighborhood-level socioeco-
nomic disadvantage and residential segregation
contribute to socioeconomic health inequalities
(see Pickett and Pearl 2001, and Robert et al.
2010 for reviews). These neighborhood condi-
tions are thought to affect health because they are
associated with material living conditions (e.g.,
access to health care, exposure to violence, hous-
ing quality) as well as social environments (e.g.,
social cohesion, behavioral norms; Diez-Roux
and Mair 2010). Neighborhood characteristics
appear to have significant but modest associa-
tions with physical and mental health indepen-
dent of individual-level socioeconomic position
(Robert et al. 2010). However, they do not ex-
plain the associations of socioeconomic position
with health. Instead, socioeconomic position in-
teracts with neighborhood characteristics when
predicting health outcomes. For example, stress-
ful daily events have stronger effects on mood
for women who live in neighborhoods that they
regard as unsafe and in which residents do not
engage in mutually supportive activities than for
women who live in better neighborhoods (Caspi
et al. 1987). More generally, living in deprived
neighborhoods heightens the associations of
722
other stressors with physical and mental health
(Cutrona et al. 2006).
As noted in the previous section, studies of ra-
cial health inequalities treat racial residential seg-
regation as an indicator of institutional discrimi-
nation. Consistent with this conceptualization,
neighborhood characteristics explain a signifi-
cant proportion of the effects of race on hyperten-
sion, obesity, self-rated health, and other health-
related outcomes (e.g., Cagney et al. 2005; More-
noff et al. 2007; Robert and Lee 2002). African
Americans who live in segregated neighborhoods
also have a much higher risk of mortality than
African Americans who live in areas of low seg-
regation in both childhood and adulthood (e.g.,
LaVeist 1993; Takeuchi et al. 2010). However,
Mexican Americans and Asian Americans who
live in segregated neighborhoods report better
health than their counterparts who live in inte-
grated neighborhoods (e.g., Gee 2002; Patel et al.
2003). Scholars speculate that, for some racial
groups, residential segregation increases access
to immigrant enclaves, ethnic social networks,
and supportive social relations that promote,
rather than damage, health (Takeuchi et al. 2010).
In sum, research supports the conclusion
that the characteristics of areas of residence
make only a modest contribution to explaining
socioeconomic health inequalities. Residential
characteristics contribute more to explaining
racial health inequalities although the patterns
are not straightforward. Research on the health-
promoting features of segregated neighborhoods
suggests that the quality of relationships within
neighborhoods may matter more for health than
their objective characteristics—a possibility that
emphasizes the centrality of social psychology to
research on the environmental determinants of
health.
Psychological Dispositions
People’s positions in systems of inequality influ-
ence not only their exposure to stress and harmful
environments, but also their psychological dispo-
sitions. Research on stress evaluates differences
in dispositions with reference to the concept of
J. D. McLeod et al.
coping. Studies of coping investigate the possi-
bility that people in socially disadvantaged posi-
tions have fewer resources to cope with stressors,
which renders them more vulnerable to health
problems when stressors occur (Williams et al.
2010; see Thoits 1995 for a review). However,
psychological dispositions are important for
health beyond their role as coping resources, as
we outline below.
Among psychological dispositions, two di-
mensions of the self-concept—self-esteem and
mastery—have received most attention from so-
ciologists (see Callero, this volume). Self-esteem
refers to an overall evaluation of one’s worth
or value. The association of socioeconomic po-
sition with self-esteem increases with age, at
least through mid-adulthood. In Rosenberg and
Pearlin’s (1978) foundational study, parents’ oc-
cupational prestige was unrelated to self-esteem
for young children (ages 8–11), weakly related
to self-esteem for older adolescents, and strongly
related to self-esteem for adults. The same age-
graded pattern has been confirmed and extended
in other studies, with evidence that the associa-
tion begins to decline after age 60 (Twenge and
Campbell 2002). Women also report lower self-
esteem than men, with the difference emerging in
late adolescence (Kling et al. 1999). In contrast,
race differences in self-esteem are not consistent
with the hypothesis that social disadvantage di-
minishes feelings of self-worth. Rather, African
Americans report higher self-esteem than whites
who, in turn, report higher self-esteem than Lati-
nos and Asian Americans (Gray-Little and Haf-
dahl 2000; Twenge and Crocker 2002).5
Self-esteem is positively associated with self-
reported health (McDonough 2000) and nega-
5
Several explanations have been proposed for the rela-
tively high self-esteem observed among African Ameri-
cans: that members of disadvantaged groups tend to com-
pare themselves to similarly disadvantaged others; that
they attribute failures or rejection to prejudice; that they
devalue domains in which their group show relatively
poor achievement; and that they hold positive group iden-
tities that protect self-esteem (see Twenge and Crocker
2002 for a review). However, why Latinos and Asian
Americans report low self-esteem relative to whites and
blacks, despite presumably having access to these same
cognitive coping strategies, remains unclear.
28 Health Inequalities
tively associated with reports of illness (Anto-
nucci and Jackson 1983). It predicts mortality
prospectively (Forthofer et al. 2001) and is nega-
tively associated with depressive symptoms and
psychological distress (Pearlin et al. 1981). Self-
esteem appears to promote health by fostering
healthy social relationships and by encouraging
healthy behaviors (McGee and Williams 2000;
Stinson et al. 2008; although see Gerrard et al.
2000). Despite its promise as an explanation for
socioeconomic and gender health inequalities,
however, it does not explain them in statistical
models (McDonough 2000; Schnittker 2004).
Possibly, self-esteem is more important for ex-
plaining group differences in response to stress
than for explaining health inequalities per se.
The second dimension of the self-concept,
mastery, refers to the extent to which people
perceive themselves as in control of forces that
importantly affect their lives. Mastery is rooted
in objective conditions of power and depen-
dency that vary across social hierarchies. As
noted in the section on stress, people who are
in socially disadvantaged positions are dispro-
portionately exposed to adversities that dimin-
ish control. High status also carries opportuni-
ties and positive life experiences that enhance
sense of control through “social conditioning”
(Weeden and Grusky 2005) and learning gener-
alization (Kohn and Schooler 1983). As a result,
people who occupy higher positions in social hi-
erarchies have higher average levels of mastery
(e.g., Pearlin et al. 1981; Ross and Mirowsky
1992). High mastery is associated with bet-
ter physical and mental health, longevity, and
fewer activity limitations (Kiecolt et al. 2009;
McDonough 2000; Mirowsky and Ross 1989).
Mastery contributes importantly to explaining
differences in physical and mental health by
socioeconomic status, gender, and race (e.g.,
Denton et al. 2004; Pudrovska et al. 2005; Ross
and Mirowsky 1989; Turner et al. 2004). Mas-
tery also moderates the effects of stressors on
health, encourages healthy behaviors, and pro-
motes recovery from illness (Pudrovska et al.
2005; Schwarzer and Fuchs 1995), suggesting
its relevance to understanding group differences
in vulnerability to stress.
723
Research in health psychology extends the
study of psychological dispositions to encompass
negative emotions, including depression, anxiety,
hostility, and anger (see Foy et al., this volume).
People who occupy socially-disadvantaged posi-
tions, whether based on socioeconomic position,
race, or gender, report higher levels of negative
emotions than people who occupy socially-ad-
vantaged positions. In turn, negative emotions
have been linked to poor health in prior research,
and especially to the risk of poor immunological
functioning and cardiovascular disease (Kiecolt-
Glaser et al. 2002; Matthews et al. 2010).
Psychological dispositions represent an addi-
tional pathway through which inequality affects
health. Although often treated as coping resourc-
es by stress researchers, mastery and negative
emotions also have direct effects on health that
contribute to health inequalities. Their contribu-
tion demonstrates that the meanings associated
with social disadvantage profoundly influence
bodily functioning.
Social Relationships
Social relationships can promote positive health
behaviors, facilitate social control against nega-
tive health behaviors, foster a sense of meaning
and purpose in life, serve as standards for social
comparison, and improve an array of physiologi-
cal processes (Umberson and Montez 2010). At
the same time, social relationships carry costs.
They can be sources of stress as well as comfort,
and they may encourage risk-taking behaviors,
especially among youth (Mirowsky and Ross
2003; Ennett et al. 2006). Social relationships
also convey values, and material and informa-
tional resources that matter for health. As Cook
(this volume) notes, because people’s social
networks tend to be populated by similar others
(McPherson et al. 2001), social group member-
ships shape the social resources to which people
have access and the values they hold.
Most sociological research on health concep-
tualizes social relationships with reference to the
concepts of social support and social integration.
Social support refers to “the functions performed
724
for the individual by significant others” (Thoits
1995; p. 64), including instrumental, informa-
tional, and/or emotional assistance. Social inte-
gration refers to the “overall level of involvement
with informal social relationships,” including
marriage and membership in formal organiza-
tions (Umberson and Montez 2010; p. S54).
Among dimensions of social support, per-
ceived emotional support is most strongly associ-
ated with health. People who have intimate, con-
fiding relationships with others, and who feel that
they are loved and cared for, report better health
and experience fewer damaging effects of stress
(Thoits 2011). Access to social support is socially
patterned, although not always to the disadvan-
tage of lower status groups. People in lower
socioeconomic positions report smaller confi-
dant networks and lower levels of social sup-
port than people in higher socioeconomic posi-
tions (McPherson et al. 2006; Turner and Marino
1994). Similarly, blacks report smaller confidant
networks than whites (McPherson et al. 2006)
and lesser involvement in “balanced” exchanges
of emotional support (exchanges in which both
partners give and receive support; Sarkisian and
Gerstel 2004). However, blacks also report more
church-based support than whites (Krause 2002)
and, especially for women, are more likely to be
involved in giving and receiving practical support
(e.g. household help, transportation help, child
care; Sarkisian and Gerstel 2004). Indeed, in
general, women report larger confidant networks
than men and higher levels of support (McPher-
son et al. 2006; Turner and Marino 1994).
Perhaps because social disadvantage does not
correlate neatly with social support, evidence
suggests that social support does not explain
health inequalities. Specifically, social support
contributes little to explaining socioeconomic
and race differences in depressive symptoms
(Kiecolt et al. 2008), and it suppresses the associ-
ation between gender and depression (Turner and
Marino 1994). Instead, the limited existing evi-
dence suggests that social support interacts with
indicators of social disadvantage when predicting
health (Matthews et al. 2010). For example, kin
support significantly reduces the likelihood of
J. D. McLeod et al.
mental disorder for African Americans, but not
for whites (Kiecolt et al. 2008).
Social integration is a second type of social
resource of interest to stress researchers. It is typi-
cally measured by participation in major social
roles, such as marriage or employment, member-
ship in social organizations, such as churches or
voluntary groups, or frequency of social interac-
tion with friends and relatives. Each of these di-
mensions of social integration strongly predicts
physical and mental health (Berkman and Syme
1979; see Berkman et al. 2000 for a review). For
example, on average, married persons report bet-
ter physical and mental health and have lower
mortality rates than persons who are not mar-
ried (e.g., Berkman and Syme 1979; Hughes and
Waite 2009), and organizational and religious par-
ticipation are associated with better health (e.g.,
Hummer et al. 1999; Piliavin and Siegl 2007).
Social integration varies with socioeconomic
position and race in ways that suggest its potential
as a mediator of health inequalities. People who
occupy lower socioeconomic positions and racial
minorities are less likely than people who occupy
higher socioeconomic positions and whites to be
married and employed (Martin 2006). They are
also more likely to change residences frequently,
and to live in communities characterized by so-
cial disorder and weak social bonds (Massey and
Denton 1993; Wilson 1987). Blacks are less like-
ly than whites to participate in voluntary social
organizations, with the exception of churches and
neighborhood organizations, although the race
difference is declining in more recent cohorts
(Miner and Tolnay 1998).
Yet, as was true for social support, social in-
tegration does not explain health inequalities.
Studies of socioeconomic, race, and gender dif-
ferences in health often control for social role
occupancy (e.g., marital status, employment
status), providing implicit evidence that social
integration does not account for health inequali-
ties. Gorman and Sivaganesan (2007) provide
direct evidence in their finding that social inte-
gration—as measured by frequency of talking or
interacting with friends, neighbors, and family, as
well as by church participation—does not medi-
ate socioeconomic disparities in self-rated health
28 Health Inequalities
and hypertension. Kiecolt et al. (2008) report that
church attendance does not account for race dif-
ferences in rates of mental disorder. Indeed, the
African American health disadvantage would be
even larger if not for high rates of religious par-
ticipation (Oates and Goode 2013).
Instead, there is consistent evidence that so-
cial integration interacts with gender and race
when predicting health. African Americans ex-
perience greater health benefits than whites from
marriage (Liu and Umberson 2008) and religious
participation (Krause 2002) but reap fewer health
benefits from being employed (Farmer and Fer-
raro 2005) and volunteering (Hinterlong 2006).
While marriage is beneficial for both genders,
men accrue more health benefits from marriage
than do women, a finding that has been attributed
to women’s control of their husbands’ health be-
haviors (Berkman and Breslow 1983; Umberson
1992). Women also appear to derive fewer health
benefits from employment than men (Pugliesi
1995; Thoits 1986), because the jobs they hold
are less self-directed and lower-paying and be-
cause their employment is seen as threatening to
family roles.
In sum, social support and social integration
powerfully shape health but they do not consis-
tently explain health inequalities. The contingent
nature of their associations with health reveals
limitations in the concepts themselves. As we
noted at the beginning of this section, social re-
lationships matter for reasons other than the sup-
port and behavioral control they provide (see
Berkman 2000 and Umberson and Montez 2010
for a review).
For that reason, some health scholars have
turned to analyzing social relations through the
broader lens of social capital (see Cook, this vol-
ume). Some scholars follow Coleman’s (1988)
definition, which emphasizes trust, norms of rec-
iprocity, and mutual aid “which act as resources
for individuals and facilitate collective action”
(Kawachi and Berkman 2000, p. 175). Accord-
ing to this definition, social capital encourages
the sharing of material resources and informa-
tion, the development of relationships involving
obligation and reciprocation, and the cultiva-
tion of effective norms and sanctions (Coleman
725
1988). Other scholars prefer Bourdieu’s (1985)
definition, “the aggregate of actual or potential
resources linked to possession of a durable net-
work” (p. 248), because it opens opportunities to
consider the negative side of social relations for
health. Both conceptualizations link macro-social
inequalities to health through patterned variation
in the structure and content of social networks.
The most common application of social capi-
tal to health is in research on neighborhood dis-
advantage. Scholars in this area posit that social
networks in disadvantaged neighborhoods are
less cohesive and efficacious than networks in ad-
vantaged neighborhoods (Sampson et al. 2002).
As a result, residents of disadvantaged neighbor-
hoods are less able to engage in collective action
(e.g., mobilizing to prevent a hospital closure),
enforce positive norms (e.g., against underage
drinking), provide mutual aid, and disseminate
information (see Quillian, this volume).6 Advo-
cates for a more Bourdieuian approach to social
capital challenge the assumption that cohesive
networks necessarily promote health and note
that, depending on their composition and norms,
cohesive networks can damage health (Carpiano
2007). Networks can enforce negative (e.g., drug
use) as well as positive norms and networks with
dense reciprocal exchange systems can impose
excessive obligations that create stress for their
members (Henley et al. 2005).
Empirical evidence for the association of
neighborhood-level social capital with health
varies by outcome. In these studies, social capi-
6 A related argument has been presented in research on
income inequality. In a small sample of OECD countries,
Wilkinson (1992) documented a negative correlation
between income inequality and life expectancy that ap-
peared to be independent of absolute levels of income.
One explanation given for the association was that income
inequality erodes social bonds and diminishes social co-
hesion. Research by Kawachi et al. is consistent with this
explanation in that state-level income inequality is nega-
tively associated with levels of trust, and levels of trust
are strongly associated with age-adjusted mortality (e.g.,
Kawachi et al. 1997, 1999). However, the basic associa-
tion has been challenged by studies that incorporate more
comprehensive controls, fixed effects models, or multi-
level models (e.g., Beckfield 2004; McLeod et al. 2004;
Sturm and Gresenz 2002), calling the social cohesion ar-
gument into question.
726
tal is operationalized as perceived social cohe-
sion, perceived trust, reciprocal exchanges be-
tween neighbors, and the like. These features of
neighborhoods have consistently been found to
predict lower levels of depression but the results
for physical health are mixed (see Diez-Roux and
Mair 2010 for a review). In addition, even the re-
sults for depression can be challenged because
the studies rely on cross-sectional data and sin-
gle-source data collection (i.e., data on outcomes
and neighborhood characteristics are reported by
the same person), which means that the possibil-
ity of non-random sorting of residents into resi-
dential areas cannot be eliminated. Thus, it is not
clear whether causal claims for the role of neigh-
borhood social capital in health are justified.
What is perhaps most surprising about re-
search on social capital and health is its weak
grounding in social psychological theory. De-
spite a strong intellectual connection between re-
search on social capital and social psychological
theories of exchange, the latter theories are virtu-
ally absent from research on health. Studies make
little or no reference to research on how the struc-
ture of social networks affects the patterns and
frequency of exchange, or on the development of
relational cohesion in exchange networks (Thye
and Kalkhoff, this volume). Instead, studies of
social capital and health draw primarily from
theories of social disorganization from criminol-
ogy (e.g., Browning and Cagney 2002). Social
psychological theories could be used to forge a
connection between the Coleman and Bourdieui-
an branches of social capital research and to add
precision to the general claim that social disad-
vantage diminishes social cohesion. (Others have
offered comparable suggestions for research on
social networks and social support; see Lin and
Peek 1999).
Social disadvantage matters for health beyond
its association with stressors and resources. We
turn now to two additional explanatory factors:
health behaviors and health care interactions.
Health Behaviors
Research both within and outside of sociology
emphasizes the importance of health behaviors
J. D. McLeod et al.
as proximate causes of health inequalities. One
reason that members of disadvantaged groups
experience less favorable health outcomes is that
they engage in less healthy behaviors. For exam-
ple, persons with lower income and fewer years
of education are more likely to smoke, be over-
weight, are less likely to exercise, and consume
more alcoholic beverages than persons with
higher socioeconomic position (see Adler and
Stewart 2010 for a review). Scholars also find
race differences in health behaviors, although
the patterns are more complex and depend on the
behavior and racial group examined. Dubowitz
et al. (2011) found that whites consume more
fruits and vegetables and are less likely to be sed-
entary than African and Mexican Americans, but
are more likely to smoke than Mexican Ameri-
cans. With respect to gender differences in health
behaviors, women engage in more preventive and
fewer risky behaviors compared to men, and men
are more likely to drink and smoke, experience
accidental injuries, eat less healthy foods, and
are less likely to seek care for health problems
(Denton et al. 2004; Read and Gorman 2011).
However, men are also more likely than women
to exercise (Read and Gorman 2011). Health be-
haviors appear to explain a modest, but signifi-
cant, proportion of patterned variation in morbid-
ity and mortality (Lantz et al. 1998), suggesting
the importance of understanding their origins.
Most theories of health behaviors rely on
value-expectancy models of behavior, i.e., that
people will adopt health-protective behaviors if
they anticipate the personal benefits from the be-
havior will outweigh the costs (see DiClemente
et al. 2011 for an overview of health behavior
theories). In essence, these theories posit that ac-
tors engage in a rational calculus when deciding
whether to adopt and maintain specific health
behaviors. Theories vary in how they conceptu-
alize the factors that contribute to the calculus.
The theory of planned behavior emphasizes at-
titudes toward health behaviors, perceived be-
havioral norms, perceived behavioral control,
and behavioral intent (Ajzen and Madden 1986).
The health behavior model emphasizes perceived
threat of ill health (affected in turn by perceived
severity of the condition and perceived vulner-
ability), the expected net gain of the behavior,
28 Health Inequalities
and the presence of cues to action (Rosenstock
et al. 1988). Social cognitive theory emphasizes
knowledge, perceived self-efficacy, outcome ex-
pectations, and goal formation (Bandura 2004).
These differences aside, all health behavior theo-
ries are social psychological at their core inas-
much as they see health behaviors as arising from
the interaction of person and environment.
Surprisingly, despite evidence that health be-
haviors are associated with social structural con-
ditions, little research has evaluated how those
conditions affect the proximate factors on which
theories of health behavior focus: knowledge, at-
titudes, perceived norms, etc. (Glanz and Bishop
2010). We review three processes through which
social disadvantage may influence health be-
haviors. These processes complement dominant
theories of health behavior by highlighting their
social psychological underpinnings.
Education as Socialization. Several theories
of health behavior posit that behaviors are a func-
tion, in part, of information, motivation (shaped
by attitudes and social norms), and perceived
ability to enact the behavior successfully. Struc-
turally-oriented theories of health inequalities,
including the fundamental cause theory (Link
and Phelan1995) assert that people who occupy
positions of social disadvantage engage in less
healthy behaviors because they have less access
to knowledge and information than their more
advantaged counterparts (Link and Phelan 1995).
In complement, as we discussed in the section on
mastery, social disadvantage also erodes actual
and perceived control over their life circumstanc-
es, thereby diminishing motivation and agency
(see also the discussion of social ecological mod-
els of health behavior in DiClemente et al. 2011).
Mirowsky and Ross (2005) assert that at root,
knowledge, information-seeking, and agency
have their origins in formal education, which is
highly correlated with other forms of social dis-
advantage.
Education yields specific content knowledge,
but it also encourages the development of gen-
eral skills that that can be applied to a range
of life problems. In formal schooling, people
learn how to think critically, to communicate,
to analyze problems, and to implement plans.
727
As people move into higher levels of education,
they encounter and master increasingly complex
problems. As a result, they develop a sense of
efficacy that prepares them for a wide range of
life challenges. People who succeed in school
also display habits and attitudes, such as commit-
ment, trustworthiness, and motivation that allow
them to tackle difficult circumstances with con-
fidence.7 In Mirowsky and Ross’s (2005) words,
“(e)ducation encourages and helps individuals
to assemble a set of habits and ways that are not
necessarily related except as effective means to-
ward health.” (p. 7). Ample empirical evidence
supports the strong role of education in shaping
health behaviors (e.g., Ross and Wu 1995).
Although health behaviors are undoubtedly a
function of knowledge and skills, they also have
a habitual character that is under-recognized by
theories of health behavior and which may be
better explained with reference to socialization
and identity processes, to which we now turn.
Informal Socialization. Traditional socializa-
tion theories are concerned with how people
“acquire social competence by learning the
norms, values, beliefs, attitudes, language char-
acteristics, and roles appropriate to their social
groups” (Lutfey and Mortimer 2003, p. 183).
Socialization arguments are especially promi-
nent in research on neighborhood characteris-
tics and health. In his analysis of neighborhood
decline and isolation, Wilson (1987) argued
that residents of racially and economically
segregated neighborhoods develop unique sub-
cultures and tolerances for risky behavior. Fol-
lowing the concept of “collective socialization”
(Mayer and Jencks 1989), disadvantaged neigh-
borhoods may also lack positive role models,
contributing to patterns of risky health behavior
(Boardman et al. 2001). Consistent with these
speculations, low neighborhood SES and social
disorganization are associated with risky sexual
7 Although there is some debate over how much these
habits and attitudes are products of success in formal
educational settings, research on the role of non-cognitive
traits in educational success demonstrates that teachers
differentially reward students based on trustworthiness,
dependability, and the like (Farkas 2003).
728
behaviors among adolescents (Ramirez-Valles
et al. 1998), drug use among adults (Boardman
et al. 2001), and less knowledge about health
and fewer preventive health behaviors (Cubbin
and Winkleby 2005). Scholars have also noted
that norms about food consumption in some
ethnic neighborhoods may contribute to more
healthy dietary behaviors in these groups (Lee
and Cubbin 2002).8
Traditional theories of socialization of health
behaviors stress how people learn to conform
to societal expectations (see Mortimer and
McLaughlin, this volume). Contemporary theo-
ries of socialization have shifted emphasis to
the negotiation, sharing, and creation of culture
in interaction (see Corsaro and Fingerson 2003,
for a review). These theories stress habitual,
taken-for-granted routines that guide action and
the use of cultural knowledge and skills to enact
behavior (see Carpiano et al. 2008 for a review).
Along these lines, Cockerham (2005) proposes
a theory of health lifestyles that draws on Bour-
dieu (1984) to link social positions to socializa-
tion processes and life experiences that, together
with objective life chances, shape dispositions
to act, health practices, and health lifestyles.
According to Cockerham’s theory, group differ-
ences in health behaviors are a function not only
of social learning but of habitual ways of acting
that reflect what people perceive as possible in
their given life circumstances. In an application
of his theory, Cockerham et al. (2006) explained
the heavy drinking among men in the former So-
viet Union as a habitual behavior supported by
strong cultural norms rather than as a function of
distress.
8
Socialization arguments have been extended to un-
derstanding why immigrant health deteriorates with the
length of time spent in the U.S. (Lara et al. 2005). The
major theoretical framework that has been used to un-
derstand this observation is the negative acculturation
hypothesis (also referred to as “unhealthy assimilation”).
The negative acculturation hypothesis asserts that the
health advantage of immigrants declines as they begin to
acculturate to American society and adopt the unhealthy
lifestyles of their U.S. counterparts (Hunt et al. 2004; Lara
et al. 2005; Schwartz et al. 2010).
J. D. McLeod et al.
In sum, socialization theories emphasize the
processes through which health behaviors are
learned or become habitual within social groups.
They remind us that health inequalities derive
not only from differences in the material cir-
cumstances of life, but also from differences in
values and meanings. The next set of theories to
which we turn, on identity processes, move one
step beyond to conceptualize health behaviors as
expressions of valued identities.
Identity Processes. Identity theories shift em-
phasis away from learned knowledge and habits
toward identity work as a key determinant of
health behavior. In the most explicit application of
identity theory to health, Oyserman et al. (2007)
present an identity-based motivation model in
which health behaviors, such as not smoking,
exercising, or eating healthy food, are concep-
tualized as social identity infused habits. Their
theory draws on social identity theory (Tajfel and
Turner 1986) which proposes that people use so-
cial categories and attributes that describe groups
to define themselves, and that these social identi-
ties motivate group comparisons and behaviors
that favor groups to which they belong. Oyser-
man et al. apply the theory to understanding why
people engage in specific health behaviors, such
as eating the same kinds of things as others in
their in-groups, and also why healthier behav-
iors are chosen more often by persons of higher
status. In their words, “if groups compete over
a self-defining characteristic, all things being
equal, higher resource groups are likely to have
an advantage in claiming valued characteristics
as in-group identifying” (p. 1012). Consistent
with that statement, their research revealed that
socioeconomically disadvantaged college stu-
dents viewed health promotion as a characteristic
of the white, middle class and not as part of their
in-group identity. It is not just that they believed
themselves unable to afford or enact healthy be-
haviors, but that they did not see those behaviors
as part of who they were (see also Cockerham
2005).
Similar arguments have been made for race
and gender. Harvey and Afful (2011) examined
the relationships among perceived racial typical-
ity of health behaviors, the importance of the be-
28 Health Inequalities
haviors, engagement in the behaviors, and racial
identity in a small sample of black Americans.
They found that viewing a behavior as more or
less typical of blacks was an important deter-
minant of the degree to which the behavior was
valued and practiced by respondents. Moreover,
the association between racial typicality and en-
gagement in health behaviors was stronger for
respondents who endorsed racial identities and
ideologies that emphasize the distinctiveness of
blacks from other groups.
Through their relevance for health behaviors,
racial identities may also help us understand the
better health outcomes observed for socioeco-
nomically disadvantaged minority groups. For
example, research on Latino health suggests that
the better health outcomes observed in some
Latino groups are attributable, in part, to eating
healthier food (Ayala et al. 2008). Food choices
are one means of expressing ethnic identities,
suggesting the potential of identities to explain
patterns of health behaviors that favor disadvan-
taged groups (Devine et al. 1999).
Gender identities are also expressed through
health-promoting or health-risky behaviors
(Courtenay 2000). Cultural beliefs about mascu-
linity suggest that men are the more powerful or
robust sex. Following from this, men are more
likely than women to engage in health risk-tak-
ing behaviors and are less likely to seek health
care when they are ill (Addis and Mahalik 2003).
Seeking help is consistent with portraying a fem-
inine self but contradicts dominant constructions
of the masculine self (Courtenay 2000; Nathan-
son 1977; Verbrugge 1985). Extending this basic
insight further, men who endorse dominant norms
of masculinity are less likely to adopt healthy be-
haviors and more likely to engage in risky behav-
iors than men who endorse less traditional norms
(e.g., Eisler 1995; O’Neil et al. 1995). In other
words, men express masculine identities by em-
bracing risk, which ultimately damages health.
As a group, identity processes emphasize the
role of identities as standards for behavior and as
sources of meaning. According to studies in this
area, normative health behaviors differ across
729
groups not only because of differences in shared
values—the emphasis of socialization theories—
but also because group members use health be-
haviors as a way to express valued identities.
Help-Seeking as a Specific Type of Health
Behavior. As research on gender and health
behavior highlights, help-seeking can be con-
ceptualized as a health behavior subject to the
same explanations outlined above. Whether or
not people seek formal treatment for illness has
implications for the severity and chronicity of
disease. Early theories of help-seeking drew
primarily from dominant theories of health be-
haviors to assert that people make decisions
about whether or not to seek formal treatment
based on their beliefs about treatment and actu-
al/perceived access to care. According to these
theories, if people who experience social disad-
vantage are less likely to seek treatment, it is
because they are less informed about treatment,
less likely to believe in its efficacy, and less able
to access it (Andersen 1995).
While research supports these theories, they
are limited in that they rely on the assumption
that help-seeking decisions are made by indi-
vidual, rational actors. Pescosolido (1992) re-
jects that assumption and proposes an alternative
theory that grounds help-seeking decisions in
social networks that give meaning to illness ex-
periences. These networks—composed of family
and friends, the broader community, the treat-
ment system, and social service agencies (includ-
ing churches, police, support groups)—serve as
sources of information as well as of behavioral
regulation (both formal and informal) that shape
people’s pathways of care. What members of the
network know, how they define the problem, and
how they evaluate the likely efficacy and ap-
propriateness of alternative responses become
important determinants of whether the person
takes action, is coerced into care, or “muddles
through” the illness episode (Pescosolido 2011).
While the broad sweep of the theory has pre-
vented a full empirical evaluation, its embedded
claims offer ample opportunity for social psycho-
logical research.
730
Health Care Interactions
Inequities in clinical care contribute important-
ly to health inequalities (Starfield et al. 2012).
While some of the inequities reflect differences
in help-seeking and differential access to care,
some reflect differences in quality of care re-
ceived. As gatekeepers to medical treatments,
health care providers have substantial control
over the quality of care their patients receive. By
implication, providers’ beliefs about the compe-
tence and worth of their patients are important
determinants of the quality of care they receive.
Those beliefs can be understood as status pro-
cesses: processes through which individuals,
groups, or objects are ranked as superior or infe-
rior according to a shared standard of social value
(Ridgeway and Nakagawa, this volume)
One of the most consistent findings in re-
search on health care is that people in lower so-
cioeconomic positions and racial minorities re-
ceive lower quality care independent of income,
insurance, and disease severity (Fiscella et al.
2000). In other words, it is not just that people in
lower socioeconomic positions have less access
to health care but also that the care they receive
is of poorer quality. One explanation for the asso-
ciation of socioeconomic position and race with
the quality of care is that physicians make dif-
ferential attributions about patients’ motivations
and abilities based on their social characteristics
(Franks and Fiscella 2002).
Consistent with this explanation, Lutfey and
Freese (2005) found that physicians more often
interpreted the noncompliance of diabetes pa-
tients from lower socioeconomic groups with
reference to psychological attributes. There are
many external reasons why lower status patients
had a difficult time following a treatment regi-
men: it cost them more in time and money to get
to appointments on a regular basis, they were
less able to afford the test strips for glucometers
so they were less able to tightly monitor their
glucose levels, they had to fill their prescrip-
tions at the hospital pharmacy which was not
convenient and so they were more likely to let
their prescriptions lapse. However, physicians
tended to attribute the problems they had fol-
J. D. McLeod et al.
lowing regimens to lower motivation, lower
cognitive ability, and lower ability to maintain
a more complex (and also more effective) dia-
betes regimen. Although Lutfey and Freese did
not present evidence on this point and are care-
ful not to draw the inference, it seems likely that
differential attributions of competence would
affect physician recommendations for future
regimen design.
Along the same lines, van Ryn and Burke
(2000) observed that black cardiac rehabilitation
patients were perceived less positively than white
patients by their physicians: they were less likely
to be rated as low risk for substance abuse and
noncompliance, half as likely to be rated as de-
siring an active lifestyle, and were rated as less
intelligent. In their review of relevant research,
van Ryn et al. (2011) conclude that white clini-
cians hold negative implicit racial biases and
explicit racial stereotypes that influence clini-
cal decision-making. Comparable evidence is
available for gender biases in clinical decision-
making for certain conditions, such as coronary
heart disease. In simulated medical encounters
involving male and female patients with com-
parable presenting complaints, physicians were
more certain of coronary heart disease diagnoses
for men than women, asked men more questions
about smoking, gave men more lifestyle advice,
and prescribed men more medications (Arber
et al. 2006; Lutfey et al. 2010).
Judgments of competence and worth also
influence diagnostic decisions and the care that
follows from them. For example, psychiatric re-
searchers have established that psychiatrists over-
diagnose schizophrenia in black men and under-
diagnose depression and anxiety (see Neighbors
1997 for a review). Although the precise reasons
for the over-diagnosis of schizophrenia have not
been identified, it appears to reflect, in part, the
tendency of clinicians to interpret certain specific
symptoms (e.g., inappropriate affect) as signs of
mental illness for blacks more than for whites
(Neighbors et al. 2003).
In sum, research on patient-provider interac-
tions illustrates the social psychological under-
pinnings of the differential distribution of mate-
rial advantage. High quality medical care is a re-
28 Health Inequalities
source that people of higher status can claim but
it is a resource that does not derive exclusively
from material advantage. Inequality involves a
hierarchy of status that parallels hierarchies of
material advantage and that amplifies those ad-
vantages.
Social Comparisons
Status processes involve social comparisons
that influence how people evaluate their relative
worth and value. Research on health inequali-
ties invokes other types of social comparisons,
as well, as evident in research on relative social
standing, equity, and illness interpretations.
Relative Social Standing. Research on relative
social standing and health draws on the concept
of relative deprivation. Relative deprivation re-
fers to a discrepancy between what one expects
to receive and what one obtains. In their research
on psychosocial factors and health, Marmot et al.
(1998) operationalized relative deprivation with
a measure of “perceived inequality”: respon-
dents’ perceptions that they were disadvantaged
relative to others at home, in the family, at work,
and in their neighborhoods. They found that per-
ceptions of relative inequality contributed im-
portantly to explaining socioeconomic inequali-
ties in health, a finding that has been replicated
in other studies (e.g., Eibner and Evans 2005;
Pham-Kanter 2009). Although direct evidence is
limited, relative deprivation is thought to affect
health through its association with negative emo-
tions such as anger, frustration, and hostility and
the associations of those emotions with health-
compromising behaviors and diminished physi-
ological functioning (Kubzansky and Kawachi
2000).
Studies of subjective social status report simi-
lar results. In these studies, respondents are asked
to place themselves on a ladder to indicate where
they stand relative to others in their neighbor-
hoods, communities, or countries. Like measures
of relative deprivation, subjective status ratings
contribute to explaining the association of objec-
tive social status with health (e.g., Adler et al.
2000; Ostrove et al. 2000); indeed, they are some-
731
times more strongly associated with health than
are objective measures (e.g., Adler et al. 2000;
Singh-Manoux et al. 2003). Low subjective sta-
tus is associated with physiological indicators of
stress and with negative emotions (Adler et al.
2000; Wright and Steptoe 2005), consistent with
the hypothesis that the stresses inherent in low
status positions account for their associations
with poor health (Sapolsky 2005). Although
well-studied with respect to socioeconomic posi-
tion, the concept of relative social standing has
received little attention in research on race and
gender.
Equity and Justice. Theories of equity and
justice emphasize the psychological outcomes
of comparing one’s own inputs and outcomes to
those of others and are most often referenced in
research on mental health. Equity theory predicts
that people will experience distress upon perceiv-
ing an inequity to themselves or others, that is,
from either under-benefitting or over-benefitting
(Hegtvedt and Isom, this volume; Homans [1961]
1974; Walster et al. 1978). According to equity
theory, under-benefitting produces anger or re-
sentment while over-benefitting produces guilt
(Homans [1961] 1974; Stets 2003). Experimen-
tal studies generally support these predictions, al-
though evidence is stronger for the effects of un-
der-benefitting than over-benefitting (e.g., Austin
and Walster 1974; Hegtvedt 1990). Inasmuch as
people in lower status groups are more likely to
under-benefit, they are more likely to experience
negative emotions. Negative emotions, in turn,
set into motion health-damaging physiologi-
cal and psychological processes (Kiecolt-Glaser
et al. 2002). For example, Simon and Lively
(2010) found that women’s higher reports of de-
pression were attributable to their higher reports
of anger. The authors infer that the anger and rage
resulting from perceived inequity lead to long-
term mental health decrements.
Similar findings appear in survey studies of
marital equity. Husbands and wives who per-
ceive their relationships as equitable experience
fewer depressive symptoms than those who per-
ceive themselves as under-benefitting or over-
benefitting (e.g., DeMaris et al. 2010; Lennon
and Rosenfield 1994; Longmore and DeMaris
732
1997), although some studies report significant
effects only for under-benefitting (Sprecher
2001; Voydanoff and Donnelly 1999). The asso-
ciation of marital equity with mental health var-
ies with personal and social characteristics. It
is stronger for women than for men (e.g., Glass
and Fujimoto 1994), for women who affirm
more egalitarian gender ideologies (Voydanoff
and Donnelly 1999), for people who believe that
marriage is a sacrament (DeMaris et al. 2010),
and for people with lower self-esteem (Long-
more and DeMaris 1997). The association also
differs depending on the domain of life being
considered, with women being more sensi-
tive to inequities in housework and men being
more sensitive to inequities involving paid work
(Glass and Fujimoto 1994; Sprecher 2001). Re-
search on the direct relationship between equity
and physical health is less common, although
the association of emotions with physical health
(Kiecolt-Glaser et al. 2002) suggests the con-
nection.
Research on social comparison processes
demonstrates that positions in systems of in-
equality influence health in part through percep-
tions of relative deprivation, subjective social
status, and equity. Basic social psychological
research reveals that these perceptions do not fol-
low automatically from objective life conditions
but, rather, are contingent on social contexts and
on the availability of alternative explanations for
disadvantage. For example, among Latinos, the
choice of reference groups differs depending on
nativity, with foreign-born, Spanish-speaking
Mexicans more likely to choose Mexicans in the
U.S. as the reference group and U.S. born, Eng-
lish-speaking Mexicans more likely to choose
people in the U.S. (including Anglos; Franzini
and Fernandez-Esquer 2006). This research re-
minds us that members of disadvantaged groups
may be able to maintain positive evaluations of
their situations even in the face of objective dis-
advantage by selecting referent others who allow
positive social comparisons and by adopting sal-
utary interpretations for their life circumstances
(Diener and Fujita 1997).
Illness Interpretations. Social comparisons
are implicated in health inequalities in an even
J. D. McLeod et al.
more basic way, by shaping the definition and in-
terpretation of physical and psychological expe-
riences, and the manifestations of distress. In the
most systematic treatment of the former, Angel
and Thoits (1987) assert that people construct
interpretations of their physical and emotional
experiences through comparisons with referent
others. Conditions that might be considered in-
dicators of poor health in some groups may not
be given any significance in others. Differences
in perceptions of physical experiences across
groups influence what we believe to be true
about group differences in health by influencing
expressions of illness, self-reports of health, and
treatment-seeking, all of which become incorpo-
rated into health statistics. For example, in his
early research on health in “Regionsville,” Koos
(1954) observed that, although lower back pain
was quite common among lower-class women,
they did not consider it a sign of disease; in
comparison with other women they knew and in
the context of their physically demanding lives,
lower back pain was considered normal for those
women and not worthy of mention in response to
questions about health problems.
Referent comparisons also shape the physi-
cal and psychological manifestations of distress.
Kleinman (1977) presented evidence that Chi-
nese patients with mental disorders were more
likely than U.S. patients to experience somatic
symptoms; this same pattern has been observed
among Chinese patients in the United States
(Takeuchi et al. 2002). Kleinman attributed this
pattern to the highly stigmatized nature of mental
illness in Chinese culture. Physiological symp-
toms are viewed as acceptable expressions of dis-
tress whereas psychological symptoms are not.
A variant of this argument has been advanced
to explain the higher rates of major depression
among whites as compared to blacks (and, cor-
respondingly, the higher rates of physical health
problems among blacks as compared to whites).
Mental illness is highly stigmatized in U.S. black
culture (Anglin et al. 2006; Neighbors 1985),
which may encourage physical, rather than psy-
chological, expressions of distress.
Arguments for the role of social compari-
sons in group differences in the experience and
28 Health Inequalities
expression of illness are an important corrective
to the dominant assumption that observed group
differences in mental and physical health are
“real.” They remind us that observed inequalities
in health are a function, in part, of group differ-
ences in the experience and expression of illness
rather than of objective experiences of disease.
Inasmuch as all illness experiences are filtered
through cultural repertoires, all knowledge about
group differences in health is socially construct-
ed. When professionals become involved in the
interpretation, the constructions become espe-
cially consequential. For example, McKinlay
(1996) demonstrates that coronary heart disease
(CHD) is under-diagnosed in women relative to
men, also in part because physicians believe that
women are less likely to experience CHD and are
therefore less likely to consider CHD as a diag-
nosis when women present with cardiac symp-
toms. The “fact” that women experience less
heart disease than men is perpetuated when the
flawed diagnoses are incorporated into medical
statistics. These statistics, in turn, feed back into
the quality of care women receive through their
influence on how research resources are distrib-
uted (i.e., more research on men’s CHD than on
women’s), reinforcing health inequalities.9 As for
the role of status processes in health care, the so-
cial construction of illness illustrates the social
psychological bases of material disadvantage.
9
While McKinlay (1996) identifies a disease that is
under-recognized in women, other scholars have high-
lighted the over-production of disease in women through
the medicalization of normal reproductive functions (e.g.,
pregnancy, childbirth, menstruation, menopause). By
treating common and ordinary aspects of women’s repro-
ductive lives as disease, the medical profession constructs
an understanding of women as “sicker” than men which,
in turn, affects women’s personal interpretations of their
reproductive lives and, presumably, their self-reports of
health (Conrad and Barker 2010; Riska 2003). In short,
professional understandings of disease influence personal
interpretations and the care that people receive in ways
that reinforce those understandings.
733
Conclusion
Health research identifies key pathways through
which inequality influences health: stress, resi-
dential environments, psychological disposi-
tions, social relations, health behaviors, and
health care interactions. As a general rule, people
who occupy disadvantaged social positions con-
front more stressful life conditions and do so with
relatively few material, social, and psychological
resources. Yet, a simple resource-based explana-
tion is insufficient to explain observed patterns
of health inequalities. Each of the pathways that
we discussed implicates objective life conditions
but also the meanings those conditions are given.
For example, people who occupy disadvantaged
social positions are exposed to more stressors,
but the effects of those stressors depend on how
they are interpreted (as in research on discrimina-
tion and health). Health behaviors are a function
of knowledge and resources, but also of habits
and identities. These processes occur in meso-
level social contexts, including the workplace,
families, neighborhoods, and social networks,
which bridge macro-structures of inequality with
bodily and psychological responses. These same
contexts hold the seeds of resistance, in the form
of social support, salutary identities, and social
comparisons that yield positive meanings.
Social psychological research on health dem-
onstrates the complementary contributions of re-
search on material life conditions and subjective
meanings, paralleling the more general comple-
mentarity of the social structure and personality
framework and symbolic interactionism. Where-
as the former encourages precise identification
of the proximate experiences that explain health
inequalities, the latter encourages analysis of the
interactional processes that produces those expe-
riences. A comprehensive analysis of health in-
equalities requires attention to both.
Meaning-based processes have unique poten-
tial to inform our understanding of unexpected
health patterns. As noted early in our chapter,
although socially disadvantaged groups often
experience poorer health than socially advan-
taged groups, their health disadvantages are not
uniform. As a general rule, health researchers
734
have devoted less attention to unexpected health
patterns than to expected health inequalities.
Our review illustrates that social relationships,
identities, social comparisons, and the meanings
to which they give rise have the potential to ad-
vance research on those unexpected patterns and,
in the process, to reveal processes through which
people resist the health-damaging effects of so-
cial disadvantage. More generally, social psycho-
logical theories emphasize the complexity of the
processes through which inequality affects the
structure and content of daily life, and the inter-
actional and cognitive processes that modify its
effects. While not denying the health relevance of
material realities, these theories emphasize that
inequality is a symbolic as well as distributional
phenomenon and that the meanings associated
with disadvantaged statuses can both amplify and
mitigate their effects on health.
We believe that health researchers have yet
to take advantage of the full potential of socio-
logical social psychology to analyze health in-
equalities. One reason may be the absence of a
comprehensive conceptual framework that in-
tegrates diverse social psychological traditions
and highlights their unique and complementary
contributions. Although many individual studies
incorporate specific social psychological theories
and concepts, few speak across traditions.
Any comprehensive social psychological
framework must meet several challenges. It
must account for objective conditions of social
disadvantage as well as the discrepancy between
those conditions and how they are perceived. It
must account not only for group differences in
health but also for heterogeneity within groups
(Schwartz and Meyer 2010). It must also account
for life course dynamics. Finally, a comprehen-
sive social psychological framework for the study
of health inequality must attend to how historical
and social contexts shape proximate experiences
of inequality. The specific structure and content
of processes that produce health inequalities will
vary by place and time, even though the basic
processes remain intact (Link and Phelan 1995).
The construction of such a framework is a
daunting challenge but a surmountable one. To
succeed, health researchers will have to draw on
J. D. McLeod et al.
the full set of conceptual tools that social psy-
chology has to offer regarding the structure and
content of proximate environments, as well as
how people construct meaning in interaction with
others.
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