Socioeconomic determinants of health : a matter of economic or social capital?

Background: There is currently a growing interest in the role of social structures, social conditions and social relationships in explaining patterns of population health, as well as the need to connect individual health outcomes to their socio-economic context. This thesis contributes to this young, but fast growing field by analyzing the role of social and economic conditions in determining health.

Aim: To study the socioeconomic determinants of health by focusing on the relevance of economic and social capital.

Methods: The thesis comprises four studies, three of which are based on cross-sectional data from the National Public Health Survey 2006 (N= 56,889) and 2009 (N= 51,414) (Study II, III and IV) and one based on longitudinal data from the Swedish Survey of Living Conditions (ULF) panel study from the years 1981–1997 (N= 3,780) (Study I). While Study I and II analyzed associations between measures of economic capital and health outcomes, Study III focused on associations between measures of social capital and health outcomes. Finally, in Study IV independent associations, and interactions, of a lack of economic capital and social capital on health outcomes were analyzed. Low economic capital (i.e. economic hardships) was measured by low household income and self-reported financial stress (inability to meet expenses and a lack of cash reserves). Social capital was measured on the individual level by social participation, interpersonal (horizontal) and institutional (vertical) trust. Health outcomes included self-rated health, psychological health (severe anxiety, GHQ-12, anti-depressant medication), physical health (musculoskeletal disorders) and health behaviors (harmful alcohol consumption).

Results: In Study I, based on longitudinal data, a dose-response effect on women‟s health was observed with an increasing score of cumulative exposure to financial stress, but not for low income. The results for men were more inconclusive. Cumulative exposure to financial stress seemed to affect men‟s self-rated health, while exposure to low income seemed to affect men‟s psychological distress, and neither exposure to low income nor financial stress seemed to affect men‟s musculoskeletal disorders. In Study II, financial stress (but not low income) was significantly associated with both women‟s and men‟s mental health problems (all indicators). Additionally, a graded association was found between mental health problems and levels of economic hardships (as measured by a combined economic hardships measure capturing both self-reported financial stress and low income). In Study III, low social capital (as measured by institutional trust in ten main welfare institutions in Sweden) was associated with increased likelihood of harmful alcohol consumption. Furthermore, a graded association was found between harmful alcohol consumption and levels of institutional trust. In Study IV, a measure of economic hardships (including both self-reported financial stress and low income) and low social capital (i.e., low interpersonal and institutional/political trust and low social participation) were significantly associated with men‟s and women‟s poor health status, with only a few exceptions. Furthermore, statistically significant interaction effects measured as a synergy index were observed between economic hardships and all different types of social capital. Gender differences in health outcomes related to low economic and social capital were analyzed in all studies. However, only very small gender differences were revealed throughout the studies with the exception of Study I where financial stress was consistently associated with poor health outcomes for women, but not for men.

Conclusions: This thesis adds to the scientific evidence that economic and social capital at the individual level are multifaceted concepts independently connected to poor health outcomes, both physical and mental. However, when combined they seem to be associated with a further increased magnitude of poorer health. Hence, the social and the economic determinants should not be considered as exclusive and separate in relation to health. Policy initiatives minimizing the extent to which individuals perceive themselves as excluded in several dimensions in society, e.g., by channeling resources at improving the economic conditions under which people live and encouraging social connectedness and social cohesion, are desirable.

List of scientific papers

I. Ahnquist J, Fredlund P, Wamala SP. Is cumulative exposure to economic hardships more hazardous to women's health than men's? A 16-year follow-up study of the Swedish Survey of Living Conditions. J Epidemiol Community Health. 2007, 61(4):331-336.
https://doi.org/10.1136/jech.2006.049395

II. Ahnquist J, Wamala SP. Economic hardships and mental health problems in Sweden. The Swedish National Public Health Survey 2009. BMC Public Health. 2011, 11:788.
https://doi.org/10.1186/1471-2458-11-788

III. Ahnquist J, Lindstrom M, Wamala SP. Institutional trust and alcohol consumption in Sweden: the Swedish National Public Health Survey 2006. BMC Public Health. 2008, 8:283.
https://doi.org/10.1186/1471-2458-8-283

IV. Ahnquist J, Lindstrom M, Wamala SP. Social determinants of health – a matter of social or economic capital? Interaction effects of socioeconomic factors and social capital on mental health disorders. [Submitted]