Social stratification and health

Social stratification refers to the hierarchical arrangement of individuals and groups in society based on socioeconomic factors such as wealth, income, education, and occupation. Understanding social stratification is essential for recognizing how social position influences health behaviors, access to healthcare, disease risk, and overall well-being. The socioeconomic gradient in health demonstrates that health disparities exist not only between the rich and poor but across all levels of the social hierarchy, with each step down in socioeconomic status associated with worse health outcomes.

This article covers the measurement and dimensions of social class, patterns of social mobility, types of poverty, and the relationship between social stratification and health outcomes. For more information on these topics, also see "Social determinants of health” in "Health care system" and "Demographic transition" in "Population health".

The meritocratic triad ^[1]

The meritocratic triad provides a framework for measuring an individual's socioeconomic status (SES) using three key indicators that tend to be correlated but can vary independently.

• Education level
  • Highest degree or credential obtained
  • Years of schooling completed
  • Influences cognitive skills, health literacy, and employment opportunities
• Occupation
  • Type of work performed
  • Occupational prestige or social standing
  • Distinguishes between manual labor, skilled trades, and professional positions
• Income
  • Individual or household earnings
  • Wealth and assets
  • Determines purchasing power and access to resources

Social class indices

• Definition: numerical scores that combine multiple indicators of socioeconomic position to classify individuals into social strata
• Multiple class index: combines all three components of the meritocratic triad to provide a comprehensive assessment of social position
  • Helps account for inconsistencies when different indicators conflict
  • More reliable than single-indicator measures

Status consistency and inconsistency

• Status consistency (status congruence)
  • Occurs when an individual's education, occupation, and income are all aligned at similar levels
  • Example: A physician with advanced education (high), professional occupation (high prestige), and high income (high)
• Status inconsistency (status incongruence)
  • Occurs when different status indicators are misaligned
  • Example: A PhD graduate working as a taxi driver (high education, low occupational prestige, low income)
  • Example: A successful entrepreneur with limited formal education (low education, high income)
  • Status inconsistency can create psychological stress and social ambiguity

Social stratification is multidimensional and encompasses more than just economic resources.

Power, privilege, and prestige

• Power
  • The ability to influence others and control resources
  • Can be formal (political office, managerial authority) or informal (social influence, expertise)
  • Unequally distributed across social positions
• Privilege
  • Unearned advantages conferred by social position
  • Often invisible to those who possess it
  • Examples: access to quality education, social networks, the benefit of the doubt in interactions
• Prestige
  • Social honor, respect, or esteem accorded to a position or occupation
  • Occupations are ranked by prestige (e.g., physicians and scientists typically rank high)
  • May not always correlate perfectly with income

Cultural capital and social capital

• Cultural capital ^[2]
  • Non-financial social assets, including education, cultural knowledge, language skills, and manners
  • Forms
    • Embodied (personal attributes, speech patterns, cultural knowledge)
    • Objectified (cultural goods, books, art)
    • Institutionalized (educational credentials, degrees)
  • Facilitates navigation of social institutions (schools, workplaces, healthcare systems)
  • Transmitted from parents to children, perpetuating advantage
• Social capital ^[3]
  • Networks of relationships and social connections
  • Provides access to information, opportunities, and resources
  • Unequally distributed across social classes
  • Bridging capital (connections across groups) vs. bonding capital (connections within groups)

Social reproduction

• Definition: the process by which social inequality is perpetuated across generations
• Mechanisms
  • Children of wealthy families inherit advantages (e.g., financial resources, educational opportunities, social connections)
  • Children of poor families face structural barriers (e.g., underfunded schools, limited access to enrichment activities, fewer role models)
  • Cultural and social capital are transmitted intergenerationally
  • Educational systems may reinforce rather than reduce inequality
• Challenges the ideal of meritocracy by showing that social position is not solely based on individual merit

Social mobility refers to movement between social class positions, either within an individual's lifetime or across generations.

Types of social mobility

Vertical mobility

• Definition: movement up or down the social hierarchy
• Upward mobility: movement to a higher social class
  • Example: a factory worker's child becomes a physician through education
  • Facilitated by education, economic growth, and a changing occupational structure
• Downward mobility: movement to a lower social class
  • Example: middle-class manager loses job and becomes unable to find comparable employment
  • Can result from economic recession, health crises, or structural changes in the economy

Horizontal mobility

• Definition: a change in occupation or position without a significant change in social class
• Example: teacher switching to social worker (similar education requirements, prestige, and income)
• Example: moving from one company to another in the same role
• Does not involve a significant change in overall socioeconomic position

Intragenerational mobility

• Definition: social mobility within one person's lifetime
• Example: an individual starts a career in a low-wage service job, obtains a college degree while working, and advances to a professional position
• Reflects individual trajectory and the opportunities available during one's working life

Intergenerational mobility

• Definition: a change in social position between parents and their children
• Example: child of a janitor becomes an engineer
• Example: a child of a business owner experiences downward mobility to a working-class position
• High intergenerational mobility: children's outcomes are not strongly determined by parents' position
• Low intergenerational mobility: children tend to remain in the same social class as their parents

Factors affecting social mobility

Meritocracy

• Definition: a system in which social position is determined by individual merit, talent, and effort rather than by inherited status or privilege
• Ideal characteristics
  • Equal opportunity for all individuals
  • Achievement based on ability and hard work
  • Education is the primary pathway to advancement
• Reality
  • Structural barriers often limit true meritocracy
  • Family background, social capital, and cultural capital create unequal starting points
  • Discrimination based on race, gender, and other factors restricts opportunities
• Despite imperfect implementation, meritocratic ideals shape educational policies and social programs

Structural barriers to mobility

• Economic inequality: the growing gap between the rich and the poor reduces mobility opportunities
• Educational inequality: unequal school funding and resources limit opportunities for children from low-SES families
• Neighborhood effects: residential segregation concentrates disadvantage
• Labor market changes: decline in middle-skill jobs reduces pathways to the middle class
• Discrimination: bias based on race, ethnicity, gender, or other characteristics

Absolute poverty

• Definition: inability to afford basic necessities required for survival
• Basic necessities include:
  • Food and clean water
  • Shelter and clothing
  • Sanitation
  • Healthcare
• Context: primarily used to measure poverty in developing nations, but exists in developed countries
• Represents extreme material deprivation that threatens health and survival

Relative poverty

• Definition: income or resources significantly below the societal median or average
• Common threshold: less than 60% of the median household income
• Characteristics
  • Context-dependent (varies by country and time period)
  • Reflects the inability to afford the standard of living considered normal in a given society
  • A more relevant measure in developed nations
• Consequences: social exclusion and limited participation in mainstream society

Social exclusion

• Definition: systematic disadvantage and marginalization from social, economic, and political opportunities
• Manifestations
  • Limited access to quality education
  • Difficulty obtaining stable employment
  • Restricted access to healthcare
  • Geographic isolation in disadvantaged neighborhoods
  • Exclusion from social networks and civic participation
• Spatial dimension: often concentrated in specific geographic areas
  • Residential segregation by income and race
  • Concentration of poverty in certain neighborhoods
  • Limited access to resources (quality schools, healthy food, safe spaces)
• Creates barriers to social mobility and perpetuates intergenerational poverty

Overview

• Definition: a stepwise relationship between socioeconomic position and health outcomes across all levels of the social hierarchy
• Key characteristics
  • Not simply "poor vs. rich" but a gradient across all SES levels
  • Each step down in SES is associated with incrementally worse health outcomes.
  • Each step up in SES is associated with incrementally better health outcomes.
  • Observed for mortality, morbidity, and health behaviors

Lower socioeconomic status consistently predicts higher disease risk, disability, and mortality.

Disease distribution by social class

The socioeconomic gradient is evident across a wide range of health conditions.

The gradient is most pronounced for preventable chronic diseases, where behavioral and environmental factors play major roles.

Theories explaining the SES-health gradient

Causation hypothesis (social causation) ^[4]

• Core premise: Low socioeconomic status causes poor health through multiple pathways.
• Mechanisms
  • Material deprivation: inability to afford healthcare, nutritious food, safe housing, and health-promoting resources
  • Adverse working conditions: more hazardous occupations, greater physical demands, less job control, and job insecurity
  • Adverse living conditions: substandard housing, neighborhood violence, environmental pollution, noise
  • Psychosocial stress: financial strain, discrimination, lack of control, chronic uncertainty
  • Health behaviors: higher rates of smoking, excessive alcohol consumption, physical inactivity, poor diet
  • Limited healthcare access: lack of insurance, geographic barriers, provider shortages, discrimination in care
  • Lower health literacy: less understanding of disease prevention and management
• Evidence: Robust evidence from longitudinal studies showing SES predicts subsequent health outcomes.

Social drift hypothesis (health selection) ^[5]

• Core premise: poor health causes downward social mobility and/or prevents upward mobility
• Mechanisms
  • Direct effects of illness
    • Chronic disease leads to job loss or the inability to work
    • Illness expenses deplete savings and assets
    • Disability limits educational attainment
  • Indirect effects
    • Childhood illness disrupts education
    • Mental illness impairs social functioning and employment
    • Stigma of illness reduces opportunities
• Example: individual with serious mental illness (e.g., schizophrenia) loses a job, depletes savings, becomes homeless, and experiences downward mobility
• Example: child with a chronic illness misses school, falls behind academically, and has fewer opportunities for educational advancement
• Evidence: some evidence for selection effects, particularly for severe mental illness and disability, but effects are generally smaller than causation effects

Synthesis

• Most evidence supports the causation hypothesis as the primary explanation.
• Health selection (drift) does occur, but accounts for a smaller proportion of the SES-health gradient.
• Both processes likely operate simultaneously in a reciprocal relationship.
• Cumulative disadvantage: Low SES causes poor health, which in turn reinforces low SES, creating a cycle.

Mechanisms linking SES to health ^[6]

Multiple interconnected pathways explain how social position influences health. These pathways interact and compound over the life course, creating cumulative health advantages or disadvantages.

Material pathways

• Access to resources: income, wealth, health insurance
• Quality of housing and neighborhood environment
• Ability to afford healthcare, medications, and health-promoting goods

Psychosocial pathways

• Chronic stress from financial strain and uncertainty
• Sense of control over life circumstances
• Exposure to discrimination and stigma
• Social support and social integration

Behavioral pathways

• Health behaviors: smoking status, diet, physical activity, alcohol use
• Health literacy and knowledge
• Adherence to medical recommendations
• Use of preventive services

Healthcare access pathways

• Insurance coverage and ability to pay
• Geographic proximity to providers and facilities
• Quality of care received
• Patient-provider communication and trust

Early life and developmental pathways

• Maternal health and prenatal environment
• Childhood nutrition and healthcare
• Educational quality and cognitive development
• Adverse childhood experiences

Health disparities

• Definition: differences in health outcomes among different population groups due to social, economic, and environmental disadvantages
• Manifestations by social class
  • Higher mortality rates in lower SES groups
  • Greater burden of chronic disease
  • Earlier onset of illness
  • More severe disease progression
  • Shorter life expectancy (can differ by 10-15 years between the highest and lowest SES groups) ^[7]
• Intersectionality: SES interacts with race, ethnicity, gender, and other identities to create compounding disadvantage.

Health care disparities ^[8]

• Definition: differences in access to, quality of, and outcomes from healthcare among different population groups
• Access barriers for low-SES populations:
  • Lack of health insurance or underinsurance
  • Inability to afford co-payments, deductibles, and medications
  • Limited transportation to healthcare facilities
  • Fewer providers in low-income neighborhoods
  • Long wait times and difficulty getting appointments
  • Language barriers and a lack of interpretation services
• Quality disparities
  • Shorter appointment times
  • Less patient-centered communication
  • Lower rates of recommended preventive services
  • Delayed or missed diagnoses
  • Less access to specialists and advanced treatments
  • Implicit bias affecting clinical decision-making
• Consequences: Even when access is achieved, quality of care may differ, contributing to worse outcomes.

Addressing disparities

Reducing health and healthcare disparities requires multilevel interventions.

• Individual level: health education, care coordination, patient navigation
• Provider level: cultural competence training, implicit bias awareness, communication skills
• Healthcare system level: expanding insurance coverage, increasing safety-net services, addressing workforce shortages
• Community level: improving neighborhood conditions, increasing economic opportunities, strengthening social support
• Policy level: addressing income inequality, strengthening social safety net programs, and reforming education and housing policy