Elsevier

Social Science & Medicine

Volume 53, Issue 6, September 2001, Pages 817-830
Social Science & Medicine

Does class matter? SES and psychosocial health among Hungarian adolescents

https://doi.org/10.1016/S0277-9536(00)00379-8Get rights and content

Abstract

Previous research finds a significant relationship between socioeconomic inequalities and health status; individuals with lower income, education, and occupational prestige have and report more health problems. Interestingly, this relationship is not consistent across the life cycle; health differences among adolescents across socioeconomic groups are not as clearly defined. Using data (n=1039) on adolescents from southern Hungary, we examine the role of socioeconomic differences in predicting psychosocial health. We argue that this investigation is of particular importance in a post-communist system where the general perception of SES is undergoing significant transformation. Findings show that ‘classical’ SES (socioeconomic status) indicators (manual/nonmanual occupational status) were not significant predictors of psychosocial health in this sample of Hungarian adolescents. While parents’ employment status as a ‘objective’ SES indicator had limited effect, SES self-assessment, as a subjective SES variable, proved to be a strong predictor of adolescents’ psychosocial health. We discuss the implications of these findings for the broader SES–health literature with specific attention paid to the impact these relationships may have for adolescent and young adult development in a post-communist country like Hungary.

Introduction

Considerable research indicates that socioeconomic inequalities have profound effects on health status and health behavior (Anderson & Armstead, 1995; Haan, Kaplan, & Syme, 1989; Link & Phelan, 1995; Marmot, et al., 1991; Marmot, Ruff, Bumpass, Shipley, & Marks, 1997; National Center for Health Statistics, 1998; Wilkinson, 1997). In both the United States and Europe, empirical studies find higher morbidity and mortality rates among persons with lower education, income, and prestige occupations (Adler, Boyce, Chesney, Folkman, & Syme, 1993; Marmot et al., 1997; Pappas, Queen, Hadden & Fischer, 1993; Power, 1994). Interestingly, the relationship between inequality and health status does not appear consistent across the life cycle. While the socioeconomic status (SES) and health relationship is well established in adulthood and infancy, the relationship is not as clearly defined in adolescent and young adult populations (Dutton, 1985).

We already know that adolescence is an important period of developmental transition. It is characterized by a number of significant biological, psychological and social changes. This time of transition is a period of upheaval during which parental influence is decreasing while at the same time the quest for personal autonomy is increasing (Sebald, 1992). In addition to these changes, as youth make efforts to develop independent lifestyles and habits, these lifestyle changes potentially impact both their health and life chances (Cotterell, 1996; National Research Council, 1993). Compared to adults or children, most adolescent studies find few significant differences by social class in morbidity and mortality rates (Macintyre & West, 1991; Rahkonen & Lahelma, 1992; West, Macintyre, Annandale, & Hunt, 1990). In an extensive literature review, West (1997) suggested that youth (12–19 years of age) might be experiencing a period of “relative SES equality” with respect to their health. He concludes that youth, particularly during their secondary education years, exhibit fewer health differences than at any other point in the life cycle. These findings are explained by what is referred to as a ‘process of equalization’ whereby the defining features of youth (school, peers, and youth culture) cut across those associated with social class (family, home, and neighborhood). He argues that the net effect of this association is to create a reversal of social class differences from those experienced during childhood (West, 1997). While equalization is not entirely uniform across all health outcomes, it appears as though class gradients among adolescents are not as apparent as in other stages of the life cycle.

Clearly, conflicting evidence exists regarding the exact role of SES in determining adolescent health outcomes, and it is within this research tradition that the current paper examines the SES–health relationship among a sample of Hungarian adolescents. The primary aims of the current study are two-fold. One, based on the findings of earlier work exploring the class gradients in adolescent health, our study attempts to further define the general role of SES in predicting adolescent physical and mental health outcomes. Two, unlike many earlier studies, the current study looks at the role SES in predicting health outcomes by using multiple indicators of SES: mother and father's education and occupation, as well as an adolescent's self-assessment of their current SES. The current sample of Hungarian adolescents adds to the growing list of empirical investigations which attempt to explore the complicated weave between SES indicators, sociodemographic characteristics, and psychosocial outcomes for adolescents in a variety of social structural settings.

In addition, to our knowledge, there are no studies that have explored these interrelationships among adolescents in a post-communist country like Hungary. As social structures begin to transform with the shifting Hungarian economic system, class has taken on new meaning. Despite the fact that since the 1960s Hungary has been more economically successful than many of its Eastern European neighbors, the mortality and morbidity rates have increased (Cockerham, 1999). Moreover, high socioeconomic gradients in health status have persisted for decades even though the communist state declared itself the guarantor of equality and equity (Csaszi, 1990). Since 1990, with the development of a market economy, Hungarians face increasing socioeconomic differences between classes, and unemployment has become a new phenomenon to consider. Thus, while some empirical evidence suggests social class gradients exist among Hungarian adults’ health (Kopp, Skrabski, & Szedmák, 1995), no research has investigated whether those same health inequalities can be found among the current generation of post-communist adolescents.

Health is a complex concept and, as a result, the measurement of health status assumes several forms (Ware, 1986). Conceptually and practically, an important feature of health is its multidimensionality. The WHO defines health as a state of complex physical, mental, and social well being, and not merely the absence of disease or infirmity (World Health Organization, 1946). Although the WHO definition has been criticized, it emphasizes that the most important feature of health is its multidimensional nature (Piko, 1999). Engel (1977) postulated that the classical biomedical model does not suffice in providing a basis for understanding the determinants and consequences of disease. Humans should be viewed as complex systems, with biological, psychological, and social dimensions all taken into account in order to obtain an accurate picture of one's health. This approach certainly reflects the biopsychosocial model of health and illness and, as evidenced over the last century, psychosocial factors continue to play an increasingly important role in understanding health and illness (Link & Phelan, 1995).

In addition, measurements of adolescent psychosocial health are particularly relevant to consider here for two reasons. One, most adolescents and young adults are free of serious physical illness, yet they experience and report considerable psychosomatic and psychological distress symptomatology (Piko, Barabas, & Boda, 1997). Psychosocial factors may play a decisive role in these complaints. Therefore, if we are interested in detecting whether or not there are social inequalities among adolescent health, the frequency of psychosomatic and psychosocial symptom reporting seems to be an appropriate set of health indicators to be examining. In fact, social inequalities in psychosocial health might suggest that inequalities are not really absent during this stage of the life cycle, rather they are less prominent in morbidity statistics. Two, adolescents undergo major biological and psychosocial changes which have a profound influence on their psychosocial health and health risk behaviors (Mechanic, 1991). Since psychosocial health problems may have major implications for adult morbidity and mortality, factors impacting adolescent's psychosocial well being should receive investigative priority.

The present study examines self-perceived health, psychological well being, and psychosomatic symptoms, which together are indicators of psychosocial health. Despite the fact that psychosocial processes play an important role in all of these self-reported health issues, they represent different types of health indicators. Psychosomatic symptomatology reflects the physical bodily complaints resulting from somatization of psychosocial processes (Katon, Kleinman, & Rosen, 1982). Psychosomatic health problems such as sleep disorders, back pain, tension headaches, and chronic fatigue are quite common in both general and adolescent populations (Mays, Chinn, & Ho, 1992; Piko et al., 1997). Notably, adolescents are at high risk for serious headaches and chronic fatigue (Linet, Stewart, Celentano, Ziegler, & Spreecher, 1989). Besides these problems, back pain and sleeping disorders were reported as frequent symptoms in a recent study of Hungarian students (Piko et al., 1997). These symptoms generally were found to be good indicators of adolescents’ increased introspectiveness and symptom reporting (Hansell & Mechanic, 1985).

Self-perceived health is a global assessment which focuses on general health rather than specific dimensions of health (Donavan, Frankel, & Eyles, 1993). Although self-perceived health is a subjective assessment, it is very much related to objective health indicators such as physical symptomatology and mortality (Barsky, Cleary, & Klerman, 1992; Idler & Benyamini, 1997). Subjectivity, however, might actually be a strength since it reflects personal views of health and illness, unlike many other measures (Krause & Jay, 1994). This, of course, has special significance for adolescents who tend to focus on making sense of body experiences that impact their health perceptions (Mechanic & Hansell, 1989). Research indicates that young persons, in the absence of chronic health conditions, are more likely to use psychosocial health problems rather than physical assessments as a way of framing their health perceptions than are adults (Krause & Jay, 1994). The self-perception of health is an active process of adolescent development involving cognitive and emotional strategies for understanding self.

Psychological well being has always been an important focus for mental health research and its gauging of adolescent psychosocial health. Measures of well being usually reflect actual mood or self-esteem and are often capable of assessing levels of psychological distress. Thus, these measures are often viewed as indicators of self-reported mental health symptomatology (Mechanic & Hansell, 1989).

Three sociodemographic factors are included in the analysis between SES and psychosocial health in adolescence: age, gender and the type of school. Health problems have been influenced by gender across all age groups (Verbrugge, 1985). However, the direction and magnitude of gender differences in health vary according to particular symptoms or conditions present during specific phases of the life cycle. In most countries, the mortality rates of men and women differ; with a greater proportion of men reporting serious illness. Beyond the biological/genetic factors, there are substantial differences in health behaviors influenced by gender roles (Verbrugge, 1985). While men appear to engage in more risky behaviors, such as smoking or drinking, women are more likely to exhibit preventive behaviors such as health screenings (Waldron, 1991). On the contrary, self-assessments of health consistently find that men evaluate their health more positively than do women (Anson, Paran, Neumann, & Chernichovsky, 1993). Although a significant number of males have physical symptoms and conditions, women tend to report more psychosomatic and distress symptoms (Piko et al., 1997; Macintyre, Hunt, & Sweeting, 1996). Because of age and gender differences in psychosocial health, an appropriate adjustment for these sociodemographics is important to the present study. Besides these sociodemographic factors, type of school is also controlled for, as the three forms of secondary school in Hungary represent a system of hierarchy based on demands, teaching quality and educational success (Piko, 2000).

Prior research indicates that social class gradients in adolescents’ health may be influenced by measurements of both health and social class (West, 1988). A variety of health indicators from subjective assessments to more objective physical measures related to mortality data have been applied. Although biases in indicators of self-reported health might contribute to the differences or lack of differences observed, self-perceived health, and self-reported mental and physical health symptomatology have been argued to be important in explicating the health–SES gradient among adolescents (West et al., 1990; Gore, Aseltine, & Colton, 1992; Wells, Deykin, & Klerman, 1985).

Additionally, while social class is a complex concept, inadequate measurement may be attributed to the lack of observable class differentials in adolescent health. The major indicators of social class (SES) such as education, income or occupation are substantially intercorrelated in most populations, though they may have differential influences in varying instances (Liberatos, Link, & Kelsey, 1988). All these findings provide important evidentiary support for the assumption that while there may be no consequent social class differences in health among adolescents, there may be differences in those factors preceding socioeconomic health differences in adult life. These latent variables include lifestyle factors, as well as cognitive or other psychosocial processes (Tuinstra, Grotthoff, van den Heavel, & Post, 1996).

Historically, one of the major studies setting the agenda for subsequent research on health inequalities was the Black report. The report argued for four possible explanations of health inequalities: material circumstances, artifactual effects, behavioral–cultural factors and social selection (Department of Health and Social Security, 1980). Research over the past decade has examined a number of potential pathways through which SES influences one's health (work environments, stress, health behaviors and other psychosocial variables) (Haan et al., 1989). One frequent theme to emerge from this body of research has been SES differences in behavioral risk factors such as smoking, alcohol consumption or diet, accounting for the strong relationship between SES and poor health (Koivusilta, Rimpelä, & Rimpelä, 1998). Another approach identifies socioeconomic or material factors (i.e., deprived access to car, medical care, food, public transportation or health knowledge) as the source of poor health (Eachus et al., 1996). Research also emphasizes SES differences in exposures to noxious social and physical environments leading to higher rates of morbidity and mortality in lower SES groups (Fitzpatrick & LaGory, 2000; Jenkins, 1983). Yet there are still other views that propose personal or social characteristics of individuals are important to remaining in poverty, thus strengthening the SES link to health (Stronks, van Mheen, Looman, & Mackenbach, 1996).

Increasingly, references have been made to the relationship between personal characteristics and SES differences in health, such as internal/external control, self-efficacy, coherence, hardiness or coping style (Elstad, 1998). There is some evidence that lower SES persons perceive themselves as less in control of external events, and that such beliefs are associated with poorer health (Rodin, 1996; Brunner, 1997). It might be assumed that these measures represent important cognitive assessments of social processes, thus adopting the psychosocial perspective of social inequalities in health (Elstad, 1998). Two possible explanations for this status health link can be argued. First, beliefs and attitudes vary by SES strata, or second, the cognitive evaluation of people influenced by their personality and intrapsychic processes can have a profound impact on attitudes and beliefs. Research by Kopp, Skrabski, and Szedmák (1995) supports the importance of psychosocial processes in understanding the relationship between SES and health. This study argues that the relationship between the general health status of Hungarian adults and their level of socioeconomic deprivation is a function of the severity of their life dissatisfaction and depressive symptomatology. As such, people must learn how to cope with the changing social, psychological and economic structures, including the ever-widening gap between the social class and developing unemployment.

Our review of the current literature suggests a complex model for understanding the social inequalities in health among Hungarian adolescents. While studies from Western European countries (West, 1997; Rahkonen & Lahelma, 1992) have shown that socioeconomic differences in youth are negligible when using ‘classical’ socioeconomic indicators (e.g., parents’ education, occupational class, etc.), explanations of the psychosocial perspectives on health inequalities suggest that the subjective evaluation of one's own socioeconomic circumstances (i.e., SES self-assessment), as a cognitive process may have more of an impact on health than more objective SES indicators. The use of subjective class assessments in understanding the class–health relationship have a long history (Runciman, 1966). As previous research suggests, even children and adolescents are aware of social inequalities and thus capable of accurately assessing the concomitant unequal chances that they bring (Bugard, Cheyne, & Jahoda, 1989). Prior research among Hungarian adolescents finds that SES self-assessment reflects the socioeconomic situation of the adolescent's family regardless of their parents’ education and occupational class (Piko, 1996). Findings, however, do not show consistency between the objective and subjective SES indicators, though children of self-employed and highly qualified parents (i.e., those with successful market positions in the new market economy) tended to evaluate themselves mostly as upper and upper-middle class.

There are several arguments for introducing subjective SES assessment into models investigating the SES and health link among Hungarian adolescents. First, status beliefs, or the relative evaluation of one's material resources, are an important part of the larger processes by which inequality in society is achieved (Ridgeway, Boyle, Kuipers, & Robinson, 1998). While adolescents’ health inequality is generally not a class-based problem, the SES self-assessment seems to be a capable indicator of adolescents’ status beliefs of their relative social deprivation and life chances and relationship with psychosocial health. Second, one possible explanation of the relative SES equality in adolescents’ health, is that in a postmodernist view, biography is individualized and identity is not referenced by class but by the consumer culture (Featherstone, 1991; West, 1997). Individualization, however, also means that a standard biography becomes the chosen biography of most people, regardless of their social status (Beck, Giddens, & Lash, 1994). This time of transition in Eastern European culture moves closer towards an increasing level of individualization and consumerism, particularly in Hungary, where the influx of Western consumer preferences have been present since the late 1960s (Cockerham, 1999). Third, studies of Hungarian youth support the idea that a consumer culture has become dominant among youth (Gabor & Balog, 1995). Thus, SES self-assessment might reflect more of how adolescents can actually realize their life chances and lifestyle choices that are generated by certain desired consumer tastes.

Based on empirical evidence and the arguments above regarding the relative SES equality in adolescents’ health in highly developed countries, we believe that ‘classical’ or objective social class indicators will play a limited role in predicting adolescents’ psychosocial health even in a post-communist country like Hungary. For this reason, we argue that SES self-assessment, expressing the cognitive perception of one's own relative socioeconomic circumstances, should play a significant role in influencing adolescents’ psychosocial health. Specifically, we hypothesize that even after controlling for sociodemographic differences, the overall effect of social class indicators on psychosocial health should disappear, except for SES self-assessment. Furthermore, we argue that this subjective SES and psychosocial health link may be an important latent association influencing health into adulthood through a variety of difficult to detect cognitive and psychosomatic processes.

Section snippets

Study population

Data were collected in 1996 from students enrolled in the secondary schools of Szeged, southern Hungary. This representative sample, consisting of 1200 students, was stratified by gender and school type. In Hungary, there are three types of secondary schools. A grammar school (4 years) provides a general certificate of education for those wanting to go to a university or college (roughly corresponds to US high school). A secondary modern school (4–5 years) provides both a general certificate of

Results

Table 1 presents a detailed sociodemographic, socioeconomic, and health profile of the Hungarian adolescent sample. The majority of adolescents perceived their own health as good (58.5%) with moderately high scores on the psychological well-being scale (Mean=12.1; SD=4.0) and somewhat lower scores on the psychosomatic symptoms scale (Mean=6.8; SD=4.0). Most of the students considered themselves middle class (60.3%), 5% reported being lower class, and only 1% of the adolescents said they

Discussion

The focus of our analyses was detecting possible relationships between SES indicators and psychosocial health, i. e., psychological well being, self-perceived health and psychosomatic symptomatology among a sample of Hungarian adolescents. Based on our earlier discussion, we hypothesized that ‘classical’ or objective social class indicators were not likely to play a very important role in predicting adolescents’ psychosocial health, even in a post-communist country like Hungary. On the

Acknowledgements

This research was supported by the OTKA F 017968 research grant of the National Research Fund, Hungary. The authors thank Darlene Wright for her helpful comments regarding the manuscript. An earlier version of this paper was presented at the 2000 American Sociological Association Meetings in Washington, DC.

References (70)

  • D Mechanic

    Adolescents at risk

    Journal of Adolescent Health

    (1991)
  • O Rahkonen et al.

    Gender, social class and illness among young people

    Social Science & Medicine

    (1992)
  • I Waldron

    Patterns and causes of gender differences in smoking

    Social Science & Medicine

    (1991)
  • P West

    Inequalities? Social class differentials in health in British youth

    Social Science & Medicine

    (1988)
  • P West

    Health inequalities in the early yearsIs there equalisation in youth?

    Social Science & Medicine

    (1997)
  • N.E Adler et al.

    Socioeconomic inequalities in healthNo easy solution

    JAMA

    (1993)
  • N.B Anderson et al.

    Toward understanding the association of socioeconomic status and healthA new challenge for the biopsychosocial approach

    Psychosomatic Medicine

    (1995)
  • M Bartley

    Unemployment and ill healthUnderstanding the relationship

    Journal of Epidemiology and Community Health

    (1994)
  • U Beck et al.

    Reflexive modernization

    (1994)
  • W.D Berry

    Understanding regression assumptions. Sage university paper series on quantitative applications in the social sciences. (pp. 07–92)

    (1993)
  • E Brunner

    Stress and biology of inequality

    British Medical Journal

    (1997)
  • P Bugard et al.

    Children's representation of economic inequalityA replication

    British Journal of Developmental Psychology

    (1989)
  • W.C Cockerham

    Health and social change in Russia and Eastern Europe

    (1999)
  • J Cotterell

    Social networks and social influences in adolescence

    (1996)
  • G.D Davey Smith et al.

    Education and occupational social classWhich is the more important indicator of mortality risk?

    Journal of Epidemiology and Community Health

    (1998)
  • Department of Health and Social Security. (1980). Inequalities in health: Report of a working group. London:...
  • J.L Donavan et al.

    Assessing the need for health status measures

    Journal of Epidemiology and Community Health

    (1993)
  • D.B Dutton

    Socioeconomic status and children's health

    Medical Care

    (1985)
  • J Eachus et al.

    Deprivation and cause specific morbidityEvidence from the Somerset and Avon Survey of Health

    British Medical Journal

    (1996)
  • J.I Elstad

    The psycho-social perspective on social inequalities in health

    Sociology of Health and Illness

    (1998)
  • G.L Engel

    The need for a new medical modelA challenge for biomedicine

    Science

    (1977)
  • M Featherstone

    Consumer culture and postmodernism

    (1991)
  • K.M Fitzpatrick et al.

    Unhealthy placesThe ecology of risk in the urban landscape

    (2000)
  • K Gabor et al.

    The impact of consumer culture on Eastern and Central European youth

    Education

    (1995)
  • S Gore et al.

    Social structure, life stress and depressive symptoms in a high school-aged population

    Journal of Health and Social Behavior

    (1992)
  • Cited by (0)

    View full text