An Examination of the Pathways Through Which Social Class Impacts Health Outcomes by Paul Henry (2001)

modes of thought: abstract general-level dispositions, which indirectly guide specific behavioral intentions. Includes distinctive conceptual resources, cognitive styles, personality traits, and aspects of selfconcept. The key commonalties are that these modes of thought are reasonably consistent across the life-span and their influence reaches across multiple behavioral domains. Cultural norms and habits: norms and habits are behavioral preferences that have primarily been instilled in childhood socialization. They consist of the set of behavioral preferences distinctive to class groups. Unlike abstract modes of thought, a particular cultural norm influences a more limited behavioral domain. Academy of Marketing Science Review Volume 2001 No. 03 Available: http://www.amsreview. org/articles/henry03-2001.pdf Copyright © 2001 – Academy of Marketing Science. Henry / The Pathways Through Which Social Class Impacts Health Outcomes 4 Health knowledge: potential to comprehend and apply health knowledge to foster general wellness and manage medical needs. Behavioral Constraints: this category includes any barrier that inhibits an individual from performing a desired healthpromoting behavior. There are two subcategories. Economic resources: these constitute financial limitations on ability to purchase health-promoting goods, services, and activities. Situation constraints: consists of access barriers in terms of lack of available health facilities in the community, transportation impediments, or time constraints on utilizing facilities. Physical Influences: this category includes distinctive conditions that have direct impact on physiological health. Note that the previous two categories indirectly impact physiological wellbeing via dispositions and behaviors. There are three subcategories. Environmental conditions: detrimental conditions in the living and working environments that have direct health effects. For example, toxicity effects resulting in elevated blood-lead levels. Physiological stress: the direct physiological impact of stress when accompanied by low sense of control. Genetics: distinctions in both heritable physical outcomes and cognitive tendencies. A Framework for Analyzing Resource Impacts Each of these resource categories will be further developed and illustrated below. However, this current section introduces a conceptual framework as to how each resource impacts health outcomes. It will be employed to inform public policy discussion in the concluding section. The framework laid out in figure 1 includes each of the resource categories detailed above. It specifies a set of hypothesized pathways of influence. Rationale for pathway specification will be developed in subsequent sections. Note at this point that each resource category is associated with multiple pathways to health outcomes. Many are indirect. For example, this framework hypothesizes that the health influences of the psychological domain are indirect via behavioral intentions, physical influences and behavioral constraints. Note also the distinction made between health-related behavioral intentions, actual health behaviors, and resultant health outcomes (following Ajzen 1988; Fishbein and Ajzen 1975). For example, a woman may hold a positive intention towards getting a mammogram, but may be constrained from actual behavior due to lack of access to facilities. Discussion as to how each resource influences health follows. THE CONTRIBUTING ROLE OF EACH RESOURCE CATEGORY Psychological Domain: Abstract Modes of Thought There is a considerable body of evidence that it is the abstract, general-level dispositions that indirectly guide the patterns of our more specific attitudes (e.g. Botschen and Hemetsberger 1998; Gutman 1982; Olson and Reynolds 1983; ValetteFlorence 1998). So a causal relation between our many object-specific attitudes can usually be traced back to a more limited set of general-level dispositions. For example, Halson and Baron (1994) described the tendency for one to hold either a ‘future’ or a ‘present’ orientation as being a type of general-level thought disposition. A presentorientation may manifest in more positive attitudes towards behaviors considered less healthy, but are attractive in that they provide short term sensual gratification -such as eating fatty foods. The more abstract, general-level thought dispositions could be described as being very centrally held attitudes (Homer and Kahle 1988). Many of these general-level dispositions have been found to be consistent across the life-course (Banaji and Prentice 1994). Given their enduring nature, the fact that there appear to be a limited number of these general-level thought dispositions, and their apparent guiding influence over a large range of specific behavioral attitudes, it is particularly interesting to examine patterns of difference between class groups. Academy of Marketing Science Review Volume 2001 No. 03 Available: http://www.amsreview. org/articles/henry03-2001.pdf Copyright © 2001 – Academy of Marketing Science. Henry / The Pathways Through Which Social Class Impacts Health Outcomes 5 FIGURE 1 Conceptual Model of Resource Influences One particular mode of thought that stands out as a central differentiator between class groups is self-efficacy -the sense of control over one’s environment and fate (Hess 1970; Kessler 1982; Tayler and Seeman 1999). Lachman and Weaver (1998) examined two aspects of control, including mastery and perceived constraint. Lower-class subjects were found to hold a more limited sense of mastery and higher perceived constraints. Mastery represents the empowering side of control in which the individual holds a sense that they are capable of achieving anything they want. Perceived constraints are disempowering in that the sense of control over one’s future is limited. Empowered individuals are more likely to take proactive steps in terms of personal health, whilst dis-empowered individuals are more likely to take a fatalistic approach. Evidence supporting this was found in an examination of smoker’s health beliefs whereby lower-class individuals exhibited poor self-efficacy perceptions, and more limited expectations for their health (Chamberland and O’Neill 1998). Stronger self-efficacy beliefs may be behind the finding that higher-class individuals are more likely to exhibit stronger persistence in pursuit of goal achievement (Halson and Baron 1994; Henry 1998). Persistence is a desirable personal characteristic in pursuit of good health, since diet and exercise requires long term adherence to an often-restrictive behavioral regime. Henry (2000) found that lower-class groups exhibit limited future focus and that they are less likely to plan for the future. This theme of lower-class being more focused on the present has also been noted by Martineau (1958), Bourdieu (1977), and Schaninger (1981). Zimbardo and Boyd (1999, p. 1284) proposed that time perspective influences many of our judgements, decisions, and actions -"our decades-long research . have convinced us that there are few other psychological variables capable of exerting such a powerful and pervasive impact on the behavior of individuals". These authors cite a range of research to support the relationship between time perspective and health behaviors. One reason for this lower-class present-orientation is that they hold a relatively pessimistic view regarding improvement of their material position in the future. Henry and Craig-Leas (1995) found that the salience of negative events, and of personal weaknesses Academy of Marketing Science Review Volume 2001 No. 03 Available: http://www.amsreview. org/articles/henry03-2001.pdf Copyright © 2001 – Academy of Marketing Science. Henry / The Pathways Through Which Social Class Impacts Health Outcomes 6 was much stronger amongst lower-class individuals. Stansfeld and Marmot (1998) found that lower grade workers exhibited greater depression, lower sense of wellbeing, together with greater salience of negative events. Pessimism, salience of weaknesses, lower sense of wellbeing will clearly impact self-efficacy and limit the sense that one can influence their situation. This reinforces an instant gratification orientation -living day to day. Self-efficacy seems to be at the core of a range of other class distinctive modes of thought. One is the value placed on accomplishment and achievement by higher-class individuals (Connell 1977; Henry 2000; McClelland 1987). Rokeach (1973) concluded that the priority values for higher-class individuals reflect greater self-direction and sense of possibilities. Henry (2000) found that higher-class individuals held a greater sense of possibilities and that this provided an empowering perception. This was associated with the individual being more likely to embrace change and to see change as an opportunity for growth. Lower-class individuals were found to be more likely to exhibit a preference for stability in their lives. This is probably related to limited self-efficacy perceptions in that a lower-class individual is more likely to worry about their ability to cope with change. Another manifestation of weaker self-confidence is the preference amongst lower-class groups to avoid stressful, challenging tasks in their lives (Henry and Craig-Leas 1995). These modes of thought also tend to impact share of economic resources. Ability to pay for goods and services determines the material affluence of one’s lifestyle. Modes of thought concentrated within the higher classes, including willingness to take on stressful challenges, achievement motivation, and focus on planning to attain future goals, can be construed as resources that better equip the individual for life’s challenges. For example, achievement motivation drives higher-class individuals to strive for stand-out success; acceptance of change allows them to adapt and take advantage of opportunities associated with change; an open-minded dispositi