Objective and subjective social class gradients for substance use among Mexican adolescents☆
Introduction
Low socioeconomic status has been consistently associated with poor health outcomes among children, particularly those living in poverty during early childhood (Duncan and Brooks-Gunn, 1997, Evans and Kim, 2007, Walker et al., 2007). A similar social class “gradient” has been found in many studies of adults in a range of health domains (Adler and Rehkopf, 2008, Marmot and Wilkinson, 2006, Sapolsky, 2005). In contrast, no consistent pattern has been shown between socioeconomic status (SES) and health outcomes during adolescence across key domains such as respiratory health, smoking, obesity, mental health, and asthma (Starfield et al., 2002, Torsheim et al., 2004, West, 1997, West and Sweeting, 2004).
There are several possible explanations for divergent findings regarding the SES–health relationship among adolescents. First, different indicators of SES (e.g. family income, parental education, parental occupational grade) may exert varying effects on the same outcome; research with adults has shown different associations of components of SES and heath outcomes (Braveman et al., 2005). Second, few studies on adolescents have included youth-specific indicators of social class. While family and parental SES are useful for younger children, they may be less applicable for adolescents since they do not fully capture the dynamic nature of adolescents' educational attainment, the economic status of adolescents who are employed outside of the home or adolescents' sense of relative social standing among their peers. These subjective dimensions of class have been shown to help explain health-related outcomes beyond the effects of simple objective indicators of SES in both adults and adolescents (Adler et al., 2000, Goodman et al., 2003, Goodman et al., 2001, Singh-Manoux et al., 2005). However, research has primarily been done in high-income countries, and findings may not be entirely generalizable to adolescents from less developed countries, like Mexico. As Brown et al. found, adolescents from different socio-cultural contexts may use different criteria when ranking their social position (Brown et al., 2008). The extent to which there are similarities in findings between Mexico and high-income countries like the U.S. will shed light on the cultural specificity of these processes.
The central goal of the present study is to extend inquiry regarding the social gradient in adolescent health to a wider economic and cultural context. Utilizing two subjective social status (SSS) scales for adolescents previously used only in the U.S., our study examines the association between objective and subjective dimensions of SES and substance use among a large sample of Mexican adolescents living in very low-income urban communities. Below we review the recent empirical research on SSS and its relationship to health in high-income countries; the small but growing literature on substance use among Mexican youth, and, finally; the potential relevance of SSS for explaining patterns of substance use in an urban Mexican context.
Social class is a reflection of social, economic, political and cultural status within a given social hierarchy. Its association with health outcomes involves not only differential access to material resources but also social processes associated with social position (Adler & Newman, 2002). The social gradient in adolescent health has largely been explored using objective indicators of the socioeconomic components of parents' social class, such as income, education, or occupation, which serve as proxy measures of access to goods and services. Several recent studies have also investigated adolescents' perceptions of their relative subjective social status (SSS)—using scales modeled after those used in adults—and found the ladders to be valuable in explaining adolescents' health status even after taking into account objective indicators of parental social class (Glendinning et al., 1992, Goodman et al., 2001, Goodman et al., 2000).
Similar to the measurements for SSS in adults, the youth-specific indicators involve two “ladders:” one representing broader society, and the other representing one's immediate community; adolescents are asked to rank themselves on these ladders. Thus, this assessment process invites them to tap into their emerging self-concept of social stratification within the context of two reference populations (Brown et al., 2008, Goodman et al., 2001, Gruenewald et al., 2006).
Considered as a whole, the existing literature on adolescent social class and health suggests that SSS captures unique aspects of social standing and appears useful in predicting health-related outcomes beyond objective indicators of social class; several patterns emerge in the literature (see Table 1 for a review of the literature on adolescent SSS). First, adolescent SSS—both community and societal—is significantly associated with psychological, physical, behavioral and physiological indicators of health. Second, each SSS scale, defined by a given reference population (e.g. society, peer community), represents a unique social hierarchy. While both SSS ladders have been found to be associated with health-related outcomes independent of objective indicators of SES, community SSS is more strongly related to health-related outcomes than is society SSS. Third, important group differences, in terms of age, race/ethnicity, SES and sex, exist in the SSS–health relationship among adolescents. For example, in the U.S., Native American youth ranked themselves higher than did their White American peers on a society SSS ladder, even though their poverty level was higher. This suggests that they simultaneously considered their local social comparison with others from their reservations and territories while ranking themselves in reference to the general society.
Adolescence is a life stage marked by increased risk of tobacco smoking, excessive alcohol consumption, and illicit drug use (Kulig, 2005, Sánchez-Zamorano, 2007). These three risk behaviors during adolescence are associated with immediate health hazards, including depression, interpersonal violence, motor vehicle accidents, drowning, risky sexual behaviors, suicidal behavior and more frequent use of health services (Arillo-Santillán et al., 2005, Kulig, 2005). Continuous and long-term use of these substances can result in morbidity and early mortality in adulthood (Aarons et al., 1999, Services, 1997).
A sizable body of research conducted in the U.S. and Western Europe has investigated the association between “objective,” parent-reported SES and substance use among adolescents, with mixed results. The preponderance of studies have found that higher SES, measured objectively, is associated with lower rates of substance use in adolescents (Bloomfield et al., 2006, Fothergill and Ensminger, 2006, Goodman and Huang, 2002, Hanson and Chen, 2007, Lemstra et al., 2008, van Oers et al., 1999, Starfield et al., 2002, Tyas and Pederson, 1998, West et al., 2007). Other studies, however, have not confirmed these associations (Tuinstra, Groothoff, van den Heuvel, & Post, 1998). One U.S. study found that low SES adolescents, as measured by parental income, reported more cigarette use compared to adolescents of high SES (West et al., 2007). In contrast, another U.S. study found that high SES adolescents, defined as those with greater financial resources and family social status, reported more cigarette, alcohol and drug use compared to low SES adolescents (Hanson & Chen, 2007).
Only two studies to our knowledge have examined the relationship between adolescents' own ratings of their social status and their use of substances. In a U.S.-based study, higher community SSS (defined as within school) was associated with a lower prevalence of smoking among adolescents, in both cross-sectional and longitudinal analyses, even after controlling for objective SES (Finkelstein, Kubzansky, & Goodman, 2006). A study of Hungarian adolescents found that those who ranked their families as having higher SES had higher rates of substance use, after adjustment for their parents' report of objective SES indicators (Piko & Fitzpatrick, 2007).
In Mexico, as in many other Latin American countries, adolescent cigarette smoking, alcohol consumption, and illicit substance use are all on the rise (Arillo-Santillán et al., 2005, Benjet et al., 2007, Bird et al., 2006, Felix-Ortiz et al., 2001, Lotrean et al., 2005, Medina-Mora et al., 2003, Monteiro, 2007, Villalobos and Rojas, 2007). According to a 2002 national survey, 15.7% of poor urban Mexican adolescents ages 12–21 had ever smoked cigarettes and 8.6% currently consumed alcohol (Urquieta, Hernandez-Avila, & Hernandez, 2006). The latest national estimate of illicit drug use of young people living in urban Mexico, from the same 2002 survey, reported that 5.4% of males and 1.5% of females, ages 12–34, reported using illicit drugs (Villatoro et al., 2002). Although reported drug use among adolescents remains low in Mexico, drug use is increasing with the rise in drug trafficking, particularly in the northern states which border the U.S. and lie on major drug trafficking routes (Bucardo et al., 2005).
Several recent studies on SES and substance use among Mexican youth suggest that SES may be an important risk factor for adolescent substance use (Benjet et al., 2007, Gutié et al., 2004, Reddy-Jacobs et al., 2006). The complex associations between SES and adolescent substance use found in the US and Western Europe are also found in Mexico. Two studies found that higher SES, measured objectively, is associated with lower rates of substance use among adolescents in Mexico (Benjet et al., 2007, Borges et al., 2007). Another recent study from Mexico, among low SES Mexican teens from disadvantaged urban areas, reported that higher SES was associated with higher rates of drinking and sexual activity (Gutierrez, Bertozzi, Conde-Glez, & Sanchez-Aleman, 2006). While substance use among Mexican adolescents is a growing health concern, the risk factors associated with substance use are still poorly understood (Arillo-Santillán et al., 2005).
The purpose of our present study is to extend the current literature on the association between SSS and reported adolescent substance use in several key ways. First, results from this study will fill a critical research gap by examining how two different SSS gradients (community and society) relate to multiple substance use behaviors in a large sample of adolescents. Second, our findings will test whether adolescent SSS relates to health risks in a broader context, outside of the U.S. The findings may provide insights into influences in health of recently immigrated Mexican-American adolescents, as they have characteristics in common with our sample in Mexico. Finally, this study focuses on adolescents within an extremely restricted range of SES in Mexico allowing us to examine SSS across what could be considered to be a socioeconomically homogenous population. In this way, the study will also contribute to a better understanding of the impact of relative (rather than absolute) deprivation on the social gradient in adolescent health. Based on the small existing literature, we hypothesize that adolescents who perceive themselves to be higher in SSS (society and community) would be less likely to report substance use.
Section snippets
Procedure (study design and sampling)
The cross-sectional analyses reported in this paper use data gathered in 2004 for the evaluation of a poverty alleviation program in Mexico. All data were collected using an audio-computer assisted self-interview system, supplemented with a socioeconomic household questionnaire.1 The survey included 157 urban (defined as having 50,000 to 1 million inhabitants) towns in seven states in Mexico. Households were
Results
The prevalence of current smoking in the sample was 16.8%, alcohol consumption was 30.2%, and drug use was 4.6%. Males were more likely than females to smoke, drink or take drugs, as were older adolescents, those who dropped out of school or those whose parents had an alcohol problem (Table 2). Tobacco and alcohol use were both positively correlated with community SSS and household expenditures and negatively correlated with society SSS. Drug use was not significantly correlated with any
Discussion
In our study of low SES Mexican adolescents, we found that the SSS ladders for community and society were differentially related to adolescents' use of substances. Adolescents who perceived themselves as higher in social status in reference to their peers (community SSS) reported more smoking and drinking. These findings are consistent with what we found using objective SES measures. In contrast, adolescents who perceived their families as higher in social status in reference to others in
Limitations
Several limitations of the present study should be noted. First, the assessment of risk behaviors was broad, e.g. “non-current users” of tobacco and alcohol included both those who had never used these substances, and those who no longer used them and “current users” included all adolescents who have ever tried a drug without distinguishing between regular, occasional and experimental use. This artificial dichotomization of a behavior that occurs on a continuum likely served to attenuate the
Conclusions
This study provided us with the opportunity to examine the associations between social class and substance use among an extremely poor sample of adolescents from Mexico, a middle-income country undergoing an epidemiologic transition in which chronic illnesses are replacing infectious diseases as the primary causes of morbidity and mortality. Consistent with studies conducted in high-income countries, this study found that adolescents with higher perceived social status of their family within
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The authors thank Paul Gertler and Alan Hubbard at the University of California, Berkeley, Aurora Franco, Ryo Shiba, Francisco Papaqui, Gustavo Olaiz, Lynnette Neufeld and Stefano Bertozzi at the Instituto Nacional de Salud Publica in Mexico, and Rogelio Gomez-Hermosillo, Concepcion Steta and Iliana Yaschine of the Oportunidades program; thanks also to the nurses who collected the data. For financial support, the authors acknowledge the Oportunidades program, National Institutes of Child Health and Human Development (PIs: Gertler/Bertozzi), the Fogarty International Center at NIH (PI: Fernald), and the John D. and Catherine T. MacArthur Foundation “Research Network on Socioeconomic Status and Health” (PI: Fernald) for funding this research.