Can subjective and objective socioeconomic status explain minority health disparities in Israel?☆
Introduction
Gaps in health between various sub-populations have been reported consistently over the years in many societies and much research has gone into understanding what stands behind these inequalities or disparities. These gaps may be due to biology, environment, behavior, healthcare and social factors (Adler and Rehkopf, 2008, Braveman, 2006). Understanding the causes of these disparities may help to improve the health of deprived populations.
One major and consistent cause of health disparities is socioeconomic status (SES) and the association between health and SES is well documented and has been found in almost every nation that has been studied (Adler and Ostrove, 1999, Banks et al., 2006, Lokshin and Ravallion, 2008, Singh-Manoux et al., 2007). However, the mechanism by which SES influences health is far from understood.
Most of the studies on SES and health use measures of social status such as income, education and employment, which represent the available resources the individual has at his/her disposal (Banks et al., 2006, Dowd and Zajacova, 2007). Wilkinson (1999) suggested that it is not just the absolute income level that influences health but the psychosocial impact of low social class, the larger the inequalities in the society the larger the psychosocial impact of low social class. Lately studies have shown that the effect of social status on health may depend also on the individual's perception of his/her relative placement in the social hierarchy, the later being a more general and subjective measure of social status (SSS).
Since the development of a scale to measure SSS (Adler, Epel, Castellazzo, & Ickovics, 2000) much research has looked at the association between SSS and various health measures such as self-reported health (Adler et al., 2008, Franzini and Fernandez-Esquer, 2006, Singh-Manoux et al., 2005), mental health and physical health (Franzini and Fernandez-Esquer, 2006, Singh-Manoux et al., 2005), self-reported diseases (Singh-Manoux, Adler, & Marmot, 2003), and depression (Adler et al., 2008, Singh-Manoux et al., 2003). SSS seems to be strongly associated with health even after controlling for the objective socioeconomic measures such as income, education and employment. This suggests that the psychological perception the individual has of his/her position in society may be more important in influencing health than the actual employment, income and education he or she has (Adler et al., 2000, Goodman et al., 2003, Hu et al., 2005, Ostrove et al., 2000, Singh-Manoux et al., 2003, Singh-Manoux et al., 2005).
Most of the studies regarding SSS and health have compared different ethnic groups within the USA (Franzini and Fernandez-Esquer, 2006, Ostrove et al., 2000). Other studies have looked at European and Asian populations (Hu et al., 2005, Kopp et al., 2004). Although in most studies a similar picture emerges, the relationship between SSS, SES and health may differ in various ethnic groups (Adler et al., 2008). For example, SSS was associated with self-reported health in White and Chinese Americans after adjusting for the objective indicators of SES, but not in Latinas and African Americans, where only education and income were significant predictors of self-reported health (Ostrove et al., 2000).
Israel seems to be a good setting to further investigate the relationship between SSS, SES and health because of the multi-cultural and multi-ethnic character of its population, its social and economic western lifestyle, a highly developed national healthcare system and a universal national health insurance to which all the population is entitled. In 2006, 7,053,700 citizens resided in Israel. The Israeli population consists of three major population groups, Jews born in Israel or residing in Israel most of their life; immigrants who during the last two decades are mainly from the former Soviet Union (fSU) and Arab citizens. During 1990–2006 a large immigration wave from the fSU arrived in Israel, including 937,100 immigrants (13.3% of the population in 2006) (Central Bureau of Statistics, 2005). About 55% of the immigrants arrived during the first 5 years of the immigration wave and about 14% of them arrived in Israel since 2000 (Central Bureau of Statistics, 2005). The immigrants are entitled to all national services on immigration, including healthcare services. Immigrants differ in their culture and language from non-immigrant Jews. Studies have reported lower levels of self-reported health among these immigrants (Baron-Epel & Kaplan, 2001). In addition, self-reported disease prevalence rates were reported to be high among the fSU immigrants compared to western countries (Gad, Nurit, Ada, & Yitzhak, 2002).
Arabs living within the state of Israel comprised 19.8% of the population in 2006 (about 1.4 million people) and are also entitled to all national services provided by the state. Arabs and Jews differ in religion, culture, and language. The mortality and morbidity of the Arab population is higher than the Jewish population and life expectancy is lower (Israel Center for Disease Control, 2005). Arabs also have higher levels of emotional distress and lower self-appraisal of mental health (Levav et al., 2007). The Arabs are mostly segregated in their living areas, only a small percentage live in mixed towns or cities, and more Arab communities are rural. Arabs in Israel are largely an underprivileged minority with a history of disadvantage in income, education and employment (Okun & Friedlander, 2005).
The objectives of this study were to examine the relationship between self-reported health status and objective and subjective socioeconomic measures in a multicultural population and to asses to what extent do subjective and objective socioeconomic measures explain the disparities in self-reported health between the two minority groups, Arabs and fSU immigrants, and the majority of non-immigrant Jews in Israel.
Section snippets
The sample
This is a cross sectional study, based on a random sample of the Israeli population aged 35–65 years performed during the January and February of 2006. This age group was chosen so as to represent people that are part of the work force, not including students or retired individuals.
Two random samples of telephone numbers were drawn from a computerized list of subscribers to the national telephone company: one including only Arab subscribers and one including the Jewish majority. Most Israeli
Results
The characteristics of the three population groups are described in Table 1. Arabs were the youngest population group, with the highest percent of married individuals and the lowest socioeconomic status (highest percent of low income, low education and unemployment). Immigrants had the highest percent of non-married individuals, the highest levels of education and the percentage of low income was higher than among non-immigrants Jews but lower than among Arabs. There was a significant
Discussion
Both minorities in Israel (Arabs and immigrants from the fSU) report worse physical and mental health compared to the Jewish majority (except for physical health among immigrant men). This can be corroborated with more objective reports (Israel Center for Disease Control, 2005). These two minority groups are of lower socioeconomic status compared to the Jewish majority population, so that these disparities are expected (Adler and Ostrove, 1999, Banks et al., 2006, Lokshin and Ravallion, 2008,
Conclusions
The disparities in health between the minorities and the majority population in Israel may be explained to a certain extent by subjective and objective measures of SES but it seems there are still additional factors causing these disparities which need to be identified, mainly among women. SSS explains the disparities in health mainly among immigrants and less so among Arabs.
Acknowledgment
The authors thank Nancy Adler for helpful discussions.
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Funding: The study was founded by a grant from The Israel National Institute for Health Policy and Health Services Research.