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Explaining the link between socioeconomic status and health Ostry, Aleck S. Feb 28, 1999

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)lGentre for Health Servicesand Policy ResearchHealth Policy Research UnitDiscussion Paper SeriesOF BRITISH COLUMBIAExplaining the Link betweenSocioeconomic Status and HealthAleck Osûry, M.4., M.Sc.HPRU 99zt2D February,1999THE UNIVERSITYThe Centre for Health Services and Policy Research was established by the Board ofGovernors of the University of British Columbia in December 1990. It was officiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas of health policy, health services research,population health, and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach to research, and topromoting wide dissemination and discussion of research results, in these areas. TheCentre aims to contribute to the improvement of population health by being responsive tothe research needs of those responsible for health policy. To this end, it provides aresearch resource for graduate students; develops and facilitates access to health andhealth care databases; sponsors seminars, workshops, conferences and policyconsultations; and distributes Discussion Papers, Research Reports and publicationreprints resulting from the research programs of Centre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of (pre-publication) work of Centre faculty, staff and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated within revised versions of these papers. The analyses and interpretations, andany erïors in the papers, are those of the listed authors, The Centre does not review oredit the papers before they are released.A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.Explaining the Link betweenSocioeconomic Status and HealthAleck Ostry, M.4., M.Sc.February 1999Centre for Health Services and Policy Research429 - 2194 Health Sciences MallUniversity of British ColumbiaVancouver, BCY6T tZ3AcknowledgementsI would like to acknowledge the financial support from the Institute of Work and Health(Toronto) and CPHI for this project.Introduction:The Black Repofi, published in Britain in 1980, confirmed the basic obseruation, madehundreds of years ago, that the socio-economic position of individuals is inversely associatedwith their health. Britain has historically lead the way in research on socio-economrcconditions and health, in part because accurate data sets linking occupation and health statushave been available for over one hundred vears.Since the Black Report's publication, research on socio-economic inequalities and health hasburgeoned in other countries as well as Britain partly due to the recognition that, in modemeconomies, some of the major remaining differences in health outcomes may be due to socio-economic factors. As well, sophisticated data systems have been developed that allow foraccurate measures and analyses of the relationships between economy and health. Over thepast two decades evidence linking socio-economic status and health has been obtained inmany nations and at levels of sophistication not possible prior to the publication of the BlackReport.In its review of the evidence, the Black Report divided possible explanations for thepersistence of health inequalities across social class into "4 categones: artefactualexplanations; natural and social selection; materialislstructuralist explanations; andcultural/behavioural explanations" (McINtyre p.727 .) Nearly 20 years after the Black Report,newer studies have produced evidence which has modified and reduced the importance ofsome of these categories of explanation and added a new category, the particularistexplanation.The purpose of this paper is to descnbe the various pathways which have been advanced toexplain the links between SES and health and the way they have evolved since publication ofthe Black Report. This will be accomplished by reviewing the evidence most often used tojustify these explanations. With this approach a picture of the pathways debate will bepresented and, the feasability of using emerging datasets to explicitly test pathway hypotheseswill be explored.This paper is divided into 5 sections. In the first section, the Black Report is briefly reviewed,Sections 2, and 3 review the evidence for, respectively, a "psychosocial" and a neo-materialistpathways. In section 4 the most recent studies of income inequality and social capital arereviewed in terms of their implications for the pathways debate. In the final section somethoughts are offered on future research directions.1. Black Report:At each stage in the investigative history of the effects of SES on health artefactualexplanations emerge. In 1980, the Black Report postulated that problems in the way theRegistrar General in Britian classified occupations over time (in particular shifts ofoccupations into different social class categories) may have produced a spurious relationshipbetween class and health. The natural/social selection explanation in the report is one of illnessdriven social drift such that people with poor health drift towards lower SES (i.e. ill-healthleads to low SES). The third explanation, the materialislstructuralist, has a "hard" and a"soft" interpretation according to Mclntyre (1997).The "hard" version states that "physical, material conditions of life which are deterrnined byoccupational class positron, produce class gradients in health and death, and that relativedeprivation in income and wealth produces relative deprivation in health and longevity"(Mclntrye 1997, p.728). This assumes that different positions in the socio-economic hierarchyare associated with material life conditions which impact health. The "soft" version expandsthe scope of these life conditions to include things like working conditions, particularly thedegree of job security, levels of job satisfaction, and physical and mental stressors encounteredat work opening the possibility that psychosocial factors associated with a person's place inthe socio-economic hierarchy, as well as material factors might directly affect health status.The cultural/behavioural pathway was also expressed in soft and hard versions. In the hardversion health differences between classes are explained in terms of individual behaviours andlifestyles. The soft version locates individual behaviour within a class context recognizing thatthey may be social constructed.The Black Report's artefactual explanation has been completely laid to rest because, since itspublication, dozens of studies using measures other than the Registrar General's occupationalclassification sÇheme have shown consistent inverse relationships between class and health.Thus, the relationship cannot be due to the particular measure of social class used. As well, re-analyses of data in the repoft using "adjusted" versions of the Registrar General'sclassification did not alter the results.The plausibility of the social selection hypothesis has been reduced due to the use oflongitudinal study designg. And, many studies have shown that "bad" behaviour and lifestylehave an SES context so that evidence of upstream material antecedants of poor lifestyleincreasingly undermines the "hard" naturaVsocial selection explanation (REFS). It isincreasingly difficult, therefore, to view the cultural/behvaioural hypothesis is isolation from amateri alis lstructurali st framework.The only entirely new explanation of the link between SES and health articulated sincepublication of the report is called the particularist hypothesis. Briefly, this explanation raisesthe possibility that associations between SES and health may not be a universal phenomenonbut may depend on the particular situation in a country, state, or city. Complex historical andcultural factors may operate in different ways in different societies producing a set ofrelationships between SES and health which are dependant on the circumstances particular toa culture and a time (Lynch et al, unpublished). While this is an important view of how SESand health may be linked, because it is peripheral to the cunent competing explanations (neo-material and psychosocial) it is not considered further in this report.The last two decades of research has seen the building of a strong empirical base linkingpsychosocial factors and health which has "tipped the balance" from a strictly materialistexplanation (the "hard" version of the materialislstructuralist explanation in the Black Report)towards a mixed explanation embodying both psychosocial and material components (the"soft" version of the materialist/structuralist explanation in the Black Report). In order tounderstand the present "pathways debate" the psychosocial and neo-material poles of thiscontinuum wiil be described next.Before proceeding it should be emphasizedthat, as far as I know, a specific and purelypsychosocial or purely neo-material pathway have yet to be hypothesized and tested. In otherwords, those on the continuum who are closer to the neo-material pole do not exclude thepossibility of psychosocial elements in the pathway between SES and health and those whoare closer to the psychosocial pole similarly do not exclude material elements in theexplanation. Instead researchers in the field articulate these pathways at afairly broad level ofgenerulization which leaves room for inter-twined explanations. This must be kept in mindwhen reading the next two sections in which these pathways are discussed in isolation fromeach other.2. Psychosocial PathwayThere are five key bodies of evidence that point to a psychosocial link between socio-economic and health status. First, basic physiological research on humans and animals,pioneered by Seyles in the 1930s, demonstrates that the experience of stress producesmeasureable biochemical and hormonal responses (Seyles L93?). Seyles and others haveshown that physiological damage can occur in animals and humans if the normal response tostressors, fight or flight, is blocked. Such a situation, leading to sustained low level exposureto stressors, activates the PAH axis promoting release of catabolic agents which have beenshown to compromise immune functioning. This work demonstrates the existence of aphysiological pathway between psychosocial conditions of life, measured in terms of a balancebetween specific stressors (such as psychological demand) and factors which moderate theirimpact (such as social support and control) and biochemlcal processes which may be healthdamaging.Second, the linear gradient observed between individual level socio-economic position andmortality, across almost all diseases, indicates that "the association of SES occurs at everylevel of the SES hierarchy, not simply below the threshold of poverty" (Adler et al. 1994).The "challenge of the gradient" is to explain how SES affects health at levels well above thepoverty line. This challenge, according to Mclntyre "has tended to focus attention onpsychosocial mechanisms mediating social position and health, and on possibleneuroendocrine, immunological, and other pathways by which such psychosocial mechanismsmight operate". (Mclntyre 1997, 131).Third, numerous investigations over the past 40 years have demonstrated the links betweenstress and coronary heart disease (CFD). In particular, over 50 epidemiological studies haveshown that stress at work, measured usually in terms of an imbalance between psychologicaldemands and the resources to cope with these, is consistently associated with elevated CHDmorbidity and mortality (Landsbergis 1994). This research has attempted to identify thespecific psychosocial conditions associated with elevated CHD morbidity and mortality,Cónsistently, low social support obtained at work in combination with lack of control andhigh levels of psychological demand are associated with adverse health outcomes.This CHD research has shown that lack of control at work is usually the single best predictorof adverse health outcomes. As well, a number studies in non-work arena's of life also showthat a high perception of control is positively related to health outcomes (Syme 1991;Thompson and Spacapan 1991) (From some people are healty p 165). This work, mainly withCHD outcomes, has moved the psychosocial pathway discussion away from a generalemphasis on "psychosocial conditions" to one focused on the importance of control and to alesser extent social support and psychological demand.A fourth type of evidence in support of a psychosocial pathway comes from investigations ofanimal models. Work undertaken by Sapolsky using free-range baboons in Keny a shows thatposition in the baboon social hierarchy has direct and measurable physiological andbiochemical stress responses (Sapolsky l9??). For example, dominant males can "turn off' thephysiological reponse to stress more rapidly after the stressful event passes than subordinatemales. Top males exhibit better stress coping mechanisms than subordinate males. Whilesocial suppoft appears to be important among the baboons, the amount of control, asevidenced by rank in the troop, is the single most important predictor of stress andphysiological change. These models show that there is a relationship between social positionand stress.Seyles work demonstrated a plausible physiological pathway between stress and disease. TheCHD and stress work has identified the components of stress exposure (specific psychosocialconditions) in people's lives which effect health. Occupational epidemiology and Sapolsky'swork with baboons has identified control as the most important psychosocial variable. Aswell, many studies have shown that the levels of these psychosocial conditions, particularlycontrol, vary according to position in an occupational or socio-economic hierarchy Marmot etal, 1991). Thus, specific psychosocial factors which are implicated in the production of stressat work, vary across the socio-economic hierarchy and have a powerful impact on health.The fifth type of evidence which points to a psychosocial explanation comes from Wilkinson'scrops-national investigations using both absolute income and income distribution. In his earlierwork using average national income he demonstrated a diminishing return in life-expectancyamong developed nations as average national income increased. He found that for countriesearning above 5,000 dollars GNP per capita there was little relationship between absolutematerial deprivation and life-expectancy. These results mean that although richer individualswithin nations tend to have better health status than poorer people (and that this gradient willbe continuous across the income hierarchy) richer countries will not necessarily havepopulations with better health status than poorer ones. This means that, for developed nations,"mortality is related more closely to relative income within countries than to differences inabsolute incomes between them" And, "the contrast in the strength of the relation within andbetween societies would make sense if mortality in rich countries were influenced more byrelative income than by absolute material standards" (Wilkinson 1997,592).a¡IliWilkinson further refined this work by investigating the relationship between incomedistribution within developed nations and life-expectancy. While health outcomes were notrelated to the absolute incomes of nations he showed that countries with a more "egalitarian"income distribution had better mortality and life-expectancy outcomes. This result, againreinforces the idea that relative income matters more than absolute income. Wilkinsonconcluded that "a shift in emphasis from absolute to relative standards indicates a fall in theimportance of the direct physical effects of material circumstances relative to psychosocialinfluences. The social consequences of people's differing circumstances in terms of stress,self-esteem, and social relations may now be one of the most important influences on health"(Wilkinson 1992).Wilkinson's work cross-nationally, and the existence of the smooth gradient within nations,provide evidence that material conditions in developed countries may be less important thanoriginally conceived of in the Black Report's "soft" materialislstructuralist explanation. Atthe same time Seyles work and the CHD/stress research underlined the importance ofpsychosocial factors by showing the linkages between them and socio-economic position aswell as the biochemical pathways through which these factors might impact health.This work as well as evidence from CHD and animal research has elevated the importance of apsychosocial explanation relative to a material one and specifically identified "perception ofcontrol" as the single most important psychosocial mediator of the relationship between socialposition and health. The evidence outlined leads to a generalized understanding of thepsychosocial pathway as a coherent story based on an accretion of good evidence for majorelements in the pathway.However, the extent to which the psychosocial pathway is separate from any materialistpathway remains unclear. This may be partly because the psychosocial pathway is usuallyexpressed as a highly plausible explanation at a fairly broad level of generalization. In otherwords, the psychosocial pathway appears not to be reducable to one or several specifichypotheses. Before advancing this discussiondevelopment of the neo-materialist pathway.3. Neomaterialist:further it is necessary to review theNeo-materialists evolved from the "hard" version of the materialislstructuralist explanation inthe Black Report. The neo-materialists viewpoint, unlike its progenitor, acknowledges thatpsychosocial factors may be important, but claims that these must be ultimately rooted inmaterial circumstances. Material conditions are "upstream" from psychosocial conditions. Theways in which people perceive, cope with, and ultimately react to stressors is socially andmaterially determined so that focus on psychosocial conditions themselves runs the risk ofmissing the real cause and mis-directing remedial action. (The neo-materialist explanation isessentially Marxist and determinist with little opening for "agency',.)The argument that psychosocial conditions may be embedded within material ones hasempincal support as many studies have shown that jobs held by persons of lower socio-economlc status tend to have worse psychosocial work conditions than those held by theirsocial "betters". In other words, there is usually a link between socio-economic position andpsychosocial work conditions.But, even if this link is present, how do neo-materialists explain why or how materialconditions might effect psyChosocial work conditions at the top and middle levels of the SEShierarchy? In other words, how do they deal with the challenge of the gradient andWilkinson's work on the primacy of relative versus absolute income? The strategy has been tocall for better conceptualization and measures of SES which are "fine grained" enough tocapture the material circumstances which presumably lie behind the SES/hrealth relationshipobserved at the middle and upper levels of the SES hierarchy.Even though basic material factors such as sewers, clean water, and basic nutrition are largelyavailable to all people in developed countries, there may be aclditional neo-material factorswhich could improve health but remained unmeasured (Davey Smith et al, 1990; Blane et al,1997; Mclntyre et al, 1998). Neo-materialist conditions may be such things as gradations inhousing quality and type versus the traditional materialist conception of housing simply asadequate sheiter. Or, instead of measuring diet roughly in terms of caloric intake' assessmentsof quality such as whether the diet is balanced and rich in fruit and vitamins may be a betterindicator of relative deprivation (Lynch et al, unpublished). The underlying assumption is thatabsolute material deprivation is present but has not been studied in the right way with the righttools.Several studies of areal deprivation, mainly in the IIK, show that there may be neo-materialfeatures of neighbourhoods and communities which exert an effect on health, even afteraccounting for individual-level SES effects (Blane et aL, 1997; Blaxter 1990; Davey Smith etal, 1990; Mclntyre et al, 1993). Similar results have been found in the United States with theAlameda Counrry Study in California (Haan et al 1987). One of the best of theseinvestigations, conducted in Glasgow by Mclntyre (1993), identified neo-material factors suchas quality and quantity of local transit, number of recreational facilities, density of shoppingfacilities, availability of "healthy" food at reasonable prices, and community crime rates whichclearly differentiated neighbourhoods with the best compared to the worst mortality rates inthe city.These studies demonstrate the existence of neighbourhoodlevel contêxtual effects on healthwhich may have a neo-material basis and have resulted in calls for investigations into themicro-ecology of every day life in order to better define these conditions. In order to developsuch studies, "a starting point would be an effort devoted to understanding the ways in whichsocio-economic factors structure the everyday lives of people, and the resultant connectionswith health and quality of life, Such an approach would focus on the everyday texture ofpeople's lives and how that texture is involved in patterns of behavior, social contact,personality, and feelings. Such an understanding would clarify how socioeconomic factors getinside the body and, perhaps more importantly, might suggest new areas of intervention"(Kaplan 1995,211).Investigations of this type cry out for new types of data sets and methods. It may be difficult,with current data systems to gather data systematically at the micro-level as envisioned byneo-materialists. Newer types of health investigations using, income inequality, social capital,and neighborhood level inequality analyses may be useful in this regard, These are reviewednext.4. Recent Studies of Income Inequality and Social CapitalAs already mentioned, Wilkinson's ground-breaking work on income inequality across nationsshowed that income distribution is related to health. This work has been extended by Kaplanand Lynch in the United States who have investigated patterns of income inequality acrossstates and metropolitan areas in relation to overall mortality rates (Kaplan et al,1996; Lynchet al. 1998). As, with Wilkinson's cross-national work, strong correlations were foundbetween income distribution at both the state and MSA levels and mortality after controllingfor median state income. In these analyses correlations between median state income andmortality were -0.28 compared to correlations of 4.62 between state income inequality andmortality. As in Wilkinson's cross-national work, a measure of relative income was strongerthan absolute level income.A study by Fiscella and Franks with similar methods was negative. They suggested thatpositive findings from ecological studies were due to confounding by individual income andthat income inequality measures were capturing compositional effect of individual income onmortality (Fiscella and Franks , 1997). (This is the same criticism raised by Gravelle (1998)),Parlly in order to deal with this criticism two studies were conducted controlling for individualor household income (Kennedy et al, 1998; Daly et al, 1998). Both show that aftercontrolling for both state median income and individual income, income inequality at the statelevel predicts self-rated health (Kennedy) and mortality @aly). These studies indicate thatcontextual effects of income inequality, beyond the effect due to an individual's position in the10SES hierarchy, are present. In other words, "something" about the social fabric ofcommunities. over and above the effects which occur at the individual level, "matter" forhealth, a conclusion reached in most of the investigations of areal-deprivation reviewed in theprevious section.These contextual effects can be explained in neo-material or psychosocial terms. For the neo-materialist, inequitable income distributions are likely associated with a set of economic,political, institutional, and social conditions that reflect systematic under-investment in human,physical, health, and social infrastructure. Kaplan has produced evidence showing that incomeinequality at the state level is correlated with a number of population-level measures of socialcaptial such as unemployment rate, proportion of the population with no health insurance,proportion of the population unable to work because of disability, per-capita expenditure onpersonal protection, and proportion of the state population with no high school education(Kaplan et al, 1996).The psychosocial explanation arising from these income inequality studies is twofold. First, incommunities with inequitable income distribution, levels of stress may be higher than thosewith egalitarian distributions. The exact mechanism of this process is unclear. It is possiblethat the perception of place in the social hierarchy will be different for the same groups incommunities with different income distributions. This might mean, for example, that peoplewithin communities with an inequitable income distribution would have lower perceptions ofcontrol, and higher levels of stress and disease, than for people in similar groups incommunities with equitable income distribution.And, second, perceptions of relative rank and social distance between groups may bemediated by reduced social cohesion (social capital). Societies with greater income inequalityalso have lower social cohesion, as measured by levels of trust and social connectedness andthat perceptions of unfairness, lack of personal connection within social networks, andreduced quality of personal relationships increase the sense of social distance between peopleleading to reduced perceptions of control, increased stress, and adverse health effects. Worktlby Kawachi in the United States has shown that income inequality measured at the state levelis associated with lower membership in community and social groups and lower levels of trust(Kawachi et al, 1997) This work shows that social cohesion, measured in terms of individual-level "trust" and "connectedness" does vary by income inequality. Other-measures of socialcohesion, particularly crime rates, have been sho',¿n to vary by income inequality too(Wilkinson et al, 1998).The neo-materialists use the social cohesion (social capital) explanation in a different way.They accept that social capital may mediate between income inequality and health but arguethat social capital, as currently conceptualized, is over-reliant on measures of individualpsychological attributes such as trust and perception of fairness. The neo-materialists arguefor development of social capital measures at the population level. Thus, high incomeinequality is a symptom of mal-distribution of social resources. Higher income inequality areaswill likely provide "less support for public education, affordable housing, good roads;environmental protection; have a less unionised workforce leading to higher concentration oflow paying jobs and poor working conditions; few infectious disease control programs;inferior choice and greater expense for food; fewer public health campaigns about smokjngand exercise; higher concentrations of cigarette and alcohol advertising; fewer opportunitiesfor recreation; and be more likely to tolerate racial, gender, sexuality and disabilitydiscrimination" (Lynch et al, unpublished).This argument fits with the neo-materialist focus on the development of different and morefinely graded SES measures. In the context of recent income inequality and social capitalresearch, this focus explicitly argues for re-conceptualizing social capital in population ratherthan individual terms.5. How to solve the pathways problem?As stated earlier, the pathways debate is a continuum with neo-material and psychosocialpoles' Most advocates of a psychosocial pathway understand that there may be a socialT2context within which this pathway operates and most neo-materialist know psychosocialpathways will be important in mediating material effects. The broad level at which both"pathways" are articulated means that specific hypotheses for one versus the other pathwayare not made explicit. Within the context of the latest income inequality research, thepathways debate is usually reduced to an assessment of whether or not observed relationshipsbetween SES and health are due to relative or absolute differences in income.Framed this way, evidence for absolute effects supports a neo-material view and evidence forrelative effects supports a psychosocial view. (This is simplistic as some mix of absolute andrelative effects can be interpreted, and often is, as support for both pathways). Themethodological thrust in this research is to move to more sensitive health outcome measures(morbidity vs mortality; age and cause-specific mortality vs overall mortality) more sensitiveincome and social capital measures and smaller areas of geographic analysis. Such anapproach makes sense as a way of gathering greater evidence for the relationship beteweeninequality and health but it is unlikely to produce a "knock-out" blow for either pathway.This is partly because of methodological problems. For example, as we move to smaller levelsof geographic analysis communities become more homogeneous so that the strength of anyincome distribution effects will be diminished. Problems of the stability of outcome measuresalso arise in small area analyses, particularly if we move to age and cause specific morbiditymeasures. While these methodological problems will undoubtedly be overcome (after firstanswering the expected artefactual explanations which always seem to arise withmethodolgical advances in SES/health research) we will be left, when the research is in, withsome mix of absolute and relative effects of income inequality which may be very useful interms of the ongoing project documenting the scope and level at which SES effects health butleave us no further head in terms of the pathways debate.In order to move the pathways debate forward a conceptual advance is first needed. There area number of conceptual weaknesses in the pathways debate that remain concealed as long asthese are articulated at a general level. As soon as one attempts to develop specific hypothesesT3difficulties arise. The choice is to leave these pathways alone at the broad level at which theyare currently expressed or to develop a more specific series of hypotheses.Neo-materialists should develop both a plausible theory and realistic measures and data sets tooperationalize these. The notion that unmeasured fine gradations in material conditions(operating presumably at the individual and community level) lie upstream of psychosocialconditions cannot be maintained indefinetly particularly within the context of the recent andmore profound progress in the psychosocial "camp". The invisible neo-material hand must bemade more visible in the pathways debate.As long as neo-materialists remain in the conceptual closet, this is a problem. For example,one could argue that recent results from the Whitehall study, in which SES was controlled andan effect on health was observed for control, clinch victory for the psychosocial pathway(Bosma et al, 1997). But, neo-materialists can insist that fine-grained material factors,unmeasured in the Whitehall study, may still, lie upstream framing these psychosocial effects.To properly test these pathway proponents must be able to say what these conditions are andhow they might frame psychosocial or (other, as yet unspecified) processes which impacthealth.While there are shortcomings with the basic conceptual frame for neo-materialists this is also aproblem for proponents of the psychosocial pathway. In terms of the recent incomeinequality/social capital debate, there are problems in the sole use of social capital measuresthat are based on individual psychological attributes. Use of such measures in isolationunhinges "civicness" and social cohesion from its social context. At the very least, particularlyas income distribution is a proxy for the distribution of social goods within any society,population and individual-based measures of social capital should be used together in studies.Recent preliminary results from Canadian income inequality studies underscore this last point.Income inequality is a proxy for the way in which resources are distributed in a society. In theUnited States where re-distributive mechanisms are relativelv weak and the economv ist+strong, income inequality may largely reflect the way in which the labour market distributesresources. However, in Canada, where re-distributive mechanisms are very strong, and inmany cases regionally organized, it is particularly important to investigate other social capitalmeasures at the population level in conjunction with income inequality.l)ReferencesAdler N, Boyce T, Chesney M, Cohen S, Folkman S, Kahn R., Syme L. (1994)Socioeconomic Status and Health the Challenge of the Gradient. 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American Jottrnal of Epidemiology 125(6):989-98, 1987.Haan, MN, Kaplan GA, Syme SL. 1989. Socioeconomic Status and Health: Old Observationsand New Thoughts. In Pathways to Health: The RoIe of Social Factors, eds. JP Bunker DSGomby, and BH Kehrer, 76-135. Menlo Park, California: Henry J. Kaiser Family Foundation.Kaplan GA, Pamuk ER, Lynch W, Cohen RD, Balfour IL. l996.Inequality in Income andMortality in the United States. British Medical Journal.3I2:9I9-L003.Kaplan G A. Where do Shared Pathways Lead? Some Reflections on a Research Agenda.Psychosomataic Medicine 57:208-212, 1995.Kaplan GA, Pamuk ER, Lynch JW, Cohen RD, Balfour JL. Inequality in Income andMortality in the United States: Analysis of Mortality and Potential Pathways. British MedicalJ ournal. 3 12:999 -1003, 1996.Kaplan GA. Socioeconomic Considerations in the Health of Urban Areas. Journal of UrbanHealth: Bulletin of the New York Academy of Medicine. T5(2):228-235,1998.l6Kawachi I,Kennedy BP, Lochner K, Prothrow-Smith D. Social Capital, Income Inequality,and Mortality. American Journal of Public Health 8l:L49I-99, 1997 .Lynch JW, Kaplan GA, Paruk ER et al. Income Inequality and Mortality in MetropolitanAreas in the United States, American Journal of Public Health. 1998.Lynch JW, Davey-Smith G, Kaplan GA, House J. Four Hypotheses Concerning theRelationship Between Income Inequality and Health. (unpublished manuscript submitted toBMJ, 1999)Marmot M, Smith GD, Stansfeld S, et al. L99I. Health Inequalities among British civilServants: The Whitehall II Study. Lancet 337: 1387-93.Mclntyre S, Maciver S, Soomans A. Area, Class and Health: Should we be Focusing onPlaces or People? Jouranl of Social Policy. 22(2):213-234,1993.Mclntyre S. The Black Report and Beyond What are the Issues? Social Science and Medicine.44(6):123-745, 1997.Mclntyre S, Ellaway A, Der G, Ford G, Hunt K. Do Housing Tenure and Car Access PredictHealth Because they are Simply Malkers of Income or Self-esteem? A Scottish Study. Journalof Epidemiology and Community Health. 52: 657-664,1998.pamuk ER, Heck KE, Lynch JW, Kaplan GA. Economic Inequality and Premature Mortalityin US Cities. Paper presented at: International Health Congress, Baltimore, MD, 1997'Preston SH. 1975. The Changing Relation between Mortality and the Level of EconomicDevelopme nt. P o p ul at i on Studie s. 29 : 23 I -248.Rodgers GB. IgTg.Income and Inequality as Determinants of Mortality: An InternationalCross section Analysis. Popttlation Studies' 33: 343-35I.Wilkinson R G. 1992. Income Distribution and Life Expectancy. British Medical Journal'304:165-168.Wilkinson R. Health Ineqalities: relative or absolute material standards?. BMJ, 314:59I-595,t997Wilkinson RG, Kawachi I, Kennedy BP. Mortality, the Social Environment, Crime andViolence. In: M. Bartley, D. Blane, G Dazvey-Smith (eds) The Sociology of HealthInequalities . P 19-39, Oxford:Blackwell, 1998.t7

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