Religious & Philosophical

Access to psycho-social resources and health: exploratory findings from a survey of the French population

Access to psycho-social resources and health: exploratory findings from a survey of the French population
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  Access to psycho-social resources and health:exploratory findings from a survey of the Frenchpopulation FLORENCE JUSOT* Eurisco-LEGOS, Universite´  Paris-Dauphine; and Associate Researcher, Research and Information Institute forHealth Economics, (IRDES), Paris, France MICHEL GRIGNON Departments of Economics and Health, Aging, and Society; Center for Health Economics and Policy Analysis(CHEPA), McMaster University, Hamilton, Ontario; and Associate Researcher, Research and InformationInstitute for Health Economics (IRDES), Paris, France PAUL DOURGNON Research and Information Institute for Health Economics (IRDES), Paris, France Abstract:  We study the psycho-socialdeterminants of self-assessed health inordertoexplainsocialinequalitiesinhealthinFrance.Weuseauniquegeneralpopulationsurvey to assess the respective impact on self-assessed health status of subjectiveperceptions of social capital, social support, and sense of control, controlling forstandardsocio-demographicfactors(SES,income,education,age,andgender).Thesurvey is unique in that it provides a variety of measures of self-perceived psycho-social resources (trust and civic engagement, social support, sense of control, andself-esteem). We find empirical support for the link between the subjectiveperception of psycho-social resources and health. Sense of control at work is themost important correlate of health status after income. Other important ones arecivic engagement and social support. To a lesser extent, sense of being lower in thesocial hierarchy is associated with poorer health status. On the contrary, relativedeprivation does not affect health in our survey. Since access to psycho-socialresources is not equally distributed in the population, these findings suggest thatpsycho-social factors can partially explain of social inequalities in health in France. *Corresponding author: Florence Jusot, Eurisco-LEGOS, Universite ´ Paris-Dauphine, Paris, France;IRDES (Research and Information Institute for Health Economics), 10 rue Vauvenargues, 75018 Paris,France. Email: jusot@irdes.frMichel Grignon conceived the study, designed the questions and co-wrote the first draft of the paper;Florence Jusot worked on the study design, ran the statistical analyses, and wrote a first draft of the paper;PaulDourgnonparticipatedthestudydesign,supervisedfieldwork,andhelpedwiththeanalysesandwriting.This study has benefited from a grant from CNRS-MiRe-INSERM, which provided the funds for theworkshops on the measurement of individual access to psycho-social resources in a general populationsurvey. IRDES funded the inclusion of the question in the SPS survey, allowing us to test the impacton self-assessed health. Our warmest thanks go to the participants to the workshops held in Paris (LisaBerkman, Basile Chaix, Pierre Chauvin, Sarah Curtis, Mariel Droomers, Christine Eibner, Anne Ellaway,Alexis Ferrand, Pierre-Yves Geoffard, Fre ´de ´rique Houzeaux, Myriam Khlat, Maria de Koninck, AnnetteLeclerc, Isabelle Parizot, Dominique Polton, S.V. Subramanian, Jean-Pierre Worms). We also would liketo thank our colleagues in the Polinomics Group at McMaster University and participants to the GlobalSocial Capital network at Berkeley. All remaining errors are ours. 365 Health Economics, Policy and Law (2008),  3:  365–391 ª  Cambridge University Press 2008 doi:10.1017/S1744133108004556  1. Introduction This study explores the statistical associations between social status, psycho-social resources (social capital, social network, and sense of control), and indi-vidual health, and compares them with associations between health and materialresources (income, education, occupation), within the theoretical framework of the production function of health developed by Evans  et al.  (1994).The production function of health approach distinguishes three broad cat-egories of determinants of health: genetic, physical environment, and socialenvironment. Within the latter category of social environment, material andpsycho-social effects can be distinguished (Stoddart, 1995). The former includesthe material effects of housing, health care, nutrition, and work environment onthe health of individuals; the latter includes the impact on health of the leveland quality of social support (network an individual can mobilize), socialcapital (trust in the community, civic involvement), and the sense of controlindividuals have on their life at home or at work (measured directly or as theperceived position of the individual in her/his reference group). Both materialand psycho-social resources influence health directly (so-called biological path-way) or indirectly, through their impact on health-related behaviours (Evans et al. , 1994). For example, it has been demonstrated that a lower sense of con-trol increases stress and, as a result, the risk of coronary heart disease (Marmot,2004) or that community social capital is a potentially powerful inhibitor of smoking behaviour (Brown  et al  ., 2006). In this exploratory study we do notattempt to separate these pathways and we are content with comparing theimpact of material and psycho-social resources on health. As detailed below,this first step will allow us to focus our analyses on the correlation betweenhealth status and a restricted set of psycho-social resources, future researchbeing centered on testing various causal pathways.Whereas material resources were seen as the main determinant of individualhealth and its unequal distribution across social strata, two observed factshave cast doubt on this conception (Stoddart, 1995). First, social inequalitiesin health still exist in welfare states, where access to health care is independentfrom ability to pay. Second, social inequalities in health follow a gradient ratherthan a two-tier divide and material resources cannot fully explain why upper-middle-class individuals are in better health than lower-middle-class ones,since most live in proper houses and are not subject to detrimental workingconditions. Even though this latter point is disputed in Pearce and Davey Smith(2003), based on the idea that early childhood living conditions have a lastingimpact on adult health and that current lower-middle-class individualslikely spent their childhood in working-class families, the idea that materialdeterminants may not explain all social health inequalities, and, as a result,that other important determinants of unequal health distribution across socialstrata exist, is now largely admitted (Marmot and Wilkinson, 2005; Berkman 366  F L O R E N C E J U S O T E T A L  .  and Kawachi, 2000). One avenue of research is therefore to test for psycho-social resources as candidates in explaining social health inequalities, that isto test the relationship between psycho-social factors and health, controllingfor other determinants of health, and then to measure social inequalities inaccess to these psycho-social resources. We follow a well-established methodo-logy in this literature on the association between utilization of psycho-socialresources and health and social health inequalities (see e.g. Lavis and Stoddart,2003): using a general population survey, we measure the correlation betweenperceived access to psycho-social resources and health at the individual level,controlling for gender, age, income, education, and socio-economic status(SES, in French, CSP, standing for  cate´  gorie socio-professionnelle ). In thisframework, age and gender account for biological determinants of health, andoccupation, income, and education account for ‘material’ factors of health,even though it could be argued that education incorporates some psycho-socialeffects as well. Behaviours  per se  (smoking, drinking, diet, and exercise) are notentered as controls in the regression, since psycho-social factors are conceivedof as determinants of health-related behaviours (poorer access to social capitalcould lead to smoking or poor diet). As mentioned above, this first analysis isconcerned with the relative magnitudes in the association between health andvarious measures of material and psycho-social resources. The causal pathways,including the effect of psycho-social resources on health-related behaviours, willbe tested in a further step.Therefore, our research question is: Does individual access to psycho-socialresources (support, social capital, sense of control) explain an important partof the variation in health across individuals and socio-economic statuses?We add to the literature in the following ways: To the best of our knowledge,this is the first time a study is conducted on this issue based on a general popula-tion survey representative of the French population. Lavis and Stoddart (2003),using data from the  World Values Survey  including France show that the impactof psycho-social factors on health varies with national context. Moreover,the  World Values Survey  (2007) indicates that the average level of access topsycho-social resources (measured as generalized trust and sense of control overone’s life in the 1999–2004 wave) is much lower in France (22% trust othersand the level of sense of control over life is at 6.5 on a 10-degree scale) than inGreat Britain (30% and 7.2), the US (36% and 8.0), or Sweden (66% and7.4). Last, Mackenbach  et al  . (1997) have shown that France has the highest levelof social inequalities in mortality among 11 European countries.Second, we use a unique dataset, representative of the general populationliving in France, comprising a descriptor of individual self-perceived health aswell as a complete set of measures of psycho-social factors at the individuallevel. Besides civic engagement, trust, and social support we add measures of the sense of control and the sense the individual has of his/her position in thesocial hierarchy. We are therefore in a position to assess the respective impacts Access to psycho-social resources and health 367  of access to these different types of psycho-social resources, whereas most pre-vious studies focused on one (social support, social capital, or position in thesocial hierarchy) only.The study is organised as follows: we start with a brief review of previousstudies. Section 3 describes our data and methods, Section 4 provides the resultsand Section 5 discusses and concludes. 2. Previous literature A recent literature review of the link between social capital (one measure of psycho-social resources) and health (Islam  et al  ., 2006) identifies two mainapproaches: the first one posits that what matters for health are the level andquality of psycho-social resources (e.g. civic engagement, trust, public services)available at the aggregate level; in such a conceptual framework social inequal-ities in health stem from the uneven distribution of socio-economic statusesacross geographic areas (Kawachi and Berkman, 2003, Veenstra  et al  ., 2005).The alternative view, to which this study belongs, is interested in the composi-tional effect and measures access to psycho-social resources at the individuallevel rather than the availability of these resources at the aggregate level. 1 Islam  et al  . (2006) identified nine published articles on the link between indi-vidual access to social capital and individual health. After this literature reviewwas published, Dunn  et al  . (2006) published a study analyzing self-assessedposition in the reference group and self-assessed health based on individual-levelCanadian data. We also identified Lavis and Stoddart (2003), not mentioned inIslam  et al  . (2006), and two studies linking social support and job-relateddemand to health in France (Paterniti  et al  . 2002, Melchior  et al  . 2003,both based on a longitudinal survey of employees of the state-owned powercompany, EDF). We present briefly the main findings of these 13 studies(studies are summarized in Table 1 according to country of observation, thevariables used to measure health, and the type of psycho-social resourcesentered in the model).First, psycho-social resources are measured and defined in a variety of waysacross these studies, reflecting the lack of consensus among social scientists(even among economists) on what social capital really is (Scheffler, this issue).Second, all studies show at least one significant positive relationship betweenaccess to psycho-social resources and current health. However, there is no gen-eral agreement about which type of psycho-social resource (social support,social capital, or sense of control and perceived position in the social hierarchy)is more strongly associated with health. Only one study (Rose, 2000) finds a 1 We do not mean here that we are interested in individual social capital only (e.g. the type of socialcapital stemming from one’s own participation in an association) and dismiss collective social capital.Rather, we attempt to measure the latter as it is (subjectively) perceived by the individual. 368  F L O R E N C E J U S O T E T A L  .  negative impact of access to social support on health: searching informationfrom friends increases the likelihood of being in poor health in Russia, whereastrust and sense of control have the expected positive impact on health. Interest-ingly, this is also the only study attempting to measure all three types of psycho-social resources. Lavis and Stoddart (2003) compare trust and civic engagementand find the former dimension of social capital to be strongly correlated with Table 1.  Previous studies – main characteristicsStudy Country Dependent variable Psycho-social resourcesBolin  et al  .(2003) Sweden Self-assessed Health Social supportChavez  et al  . (2004) Sydney (Australia) Self-assessed Health Social support, trust,civic engagementDunn  et al  . (2006) Canada Self-assessed Health Perceived position inreference groupsHyyppa ¨, Ma ¨ki (2001) Osthrobothnia(Finland)Self-assessed Health Trust, civicengagementLavis, Stoddart (2003) G7 (Canada, France,Germany, Italy, Japan,UK, US)Self-assessed Health Trust, civicengagementLindstro ¨m, (2004) Scania (Sweden) Self-assessed Health Trust, civicengagementLiukkonen  et al  . (2004) Finland Self-assessed Healthand PsychologicaldistressSocial support, sense of controlMcCulloch (2001) Great Britain Self-reportedconditions (self reported)(psychological, legs,arms and members,heart and bloodpressure)Social capital: level of perceiveddisorganization in theneighbourhoodMelchior  et al  . (2003) France, EDF Sick leave Social support, sense of controlPaterniti  et al  . (2002) France, EDF Depression Social support, sense of controlRose (2000) Russia Self-assessed Health Social support, sense of control, civicengagement, trustSundquist  et al  . (2004) Sweden Coronary healthdiseases (events)Social participationVeenstra (2000) Saskatchewan(Canada)Self-assessed Health Civic engagement Access to psycho-social resources and health 369
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