Socioeconomic Inequalities in Adolescent Health

by

Bente Wold, Oddrun Samdal

• LAST REVIEWED: 26 August 2020
• LAST MODIFIED: 26 August 2020
• DOI: 10.1093/obo/9780199756797-0198

Introduction

Among adults, there is solid evidence of socioeconomic inequalities in health, with regard to both objective measures (such as mortality and morbidity) and subjective measures (such as self-rated health, health complaints, well-being, and health behaviors). Socioeconomic inequalities denote a range of differences in socioeconomic status (SES) linked with a person’s work experience and economic and social position in relation to others, based on income, education, wealth, and occupation. During adolescence, socioeconomic inequalities in health may be less profound, partly because adolescents (in the Western world) generally are in good health. Moreover, adolescents are in a transit position between the SES of their family of origin and the SES they obtain as adults, and upward or downward social mobility may mask inequalities in this specific period. Nevertheless, adolescence is regarded as a pivotal life phase in the development of health inequalities. Such inequalities probably reflect a way of life that is caused both by life choices and by life opportunities. Life opportunities refer to social position and access to resources in the environment, which may differ widely among adolescents and thus limit or enable their potential for healthy development. Adolescence is a crucial period for making important life choices in terms of education and occupation, as well as choices of lifestyle (including health habits such as food consumption, physical activity, or drug use). The combination of vulnerable life circumstances and unwise life choices is likely to yield negative consequences for adolescent health, and, during the life course, these accumulate to produce poorer adult health, compared to a combination of growing up in a prosperous environment and making choices that are conducive to good health. Globalization and economic and political development lead to changes in “modern” values, including an increasing emphasis on quality of life, self-expression, and freedom of choice. While such development may infer increased opportunities for adolescents to achieve good health and well-being, it can also marginalize those who do not have the capability to “make it” on their own, rendering significant segments of the populations at risk and creating a new type of health inequality.

General Overviews

Bartley 2017 gives an excellent presentation of the current state-of-the-art in theories and models explaining health inequalities, integrating the classic behavioral, psychosocial, and material approaches with a life-course perspective. Halfon, et al. 2018 offers an integrative conceptual framework about the individual and contextual processes involved in the development of health across the life course. Several chapters include reviews of the literature regarding the susceptibility of young children to social environmental conditions and examine the process by which early adversity becomes biologically embedded. Dmitrieva 2013 places socioeconomic status (SES) in the context of the psychology of adolescent development. Particularly useful is the overview of mechanisms mediating the association between SES and health in adolescence, such as access to resources, psychosocial mechanisms (stress, emotional processing, health behaviors, and exposure to risky social environments), and biological mechanisms. Due, et al. 2011 provides an interesting and comprehensive model of how health inequality may develop through various pathways from adolescence to adulthood. A thorough and detailed report from the WHO cross-national survey on health behaviors among school-aged children (the HBSC study), Inchley, et al. 2016 presents survey findings from 42 countries on SES (as indicated by a measure of family affluence) differences in subjective health, self-reported health behaviors, and psychosocial environment. The report shows that, in general, young people in countries and regions with large differences in wealth distribution are more vulnerable to poorer health outcomes, independent of their individual family wealth. The review Marmot, et al. 2012 was commissioned to support the development of the new health policy framework for Europe: Health 2020. The recommendations of the Review of Social Determinants of Health and the Health Divide are presented. Putnam 2016 argues that widening income gaps have brought profound but underappreciated changes to family life, neighborhoods, and schools in ways that favor adolescents at the top and make it ever harder for those below to achieve their potential. The meta-analysis Quon and McGrath 2014 reports findings on the association between subjective socioeconomic status (SES) and health outcomes during adolescence, demonstrating that subjective SES is associated with health during adolescence. Viner, et al. 2012 reviews what is known about social determinants of health in adolescence and assesses key determinants of adolescent health. Whitehead, et al. 2016 offers a synthesis to explore the principal pathways through which control in the living environment could influence health and health inequalities.

• Bartley, M. 2017. Health inequality: An introduction to concepts, theories and methods. 2d ed. Cambridge, UK: Polity Press.

  Impressive and useful overview and discussion about reasons for socioeconomic inequalities in health, including materialist explanations and macro-social models. Contains thorough considerations on the concepts and definitions of social inequality and health inequality, challenges in measurement, implications, and recommendations.

• Dmitrieva, J. 2013. Socioeconomic influences on health and health behavior in adolescents. In Handbook of adolescent health psychology. Edited by William T. O'Donohue, Lorraine T. Benuto, and Lauren Woodward Tolle, 43–60. New York: Springer.

  This chapter provides a discussion about how profound neurological, hormonal, and psychosocial changes in adolescence also make it a time of higher vulnerabilities to risk factors such as poverty and low SES. Psychosocial, behavioral, and biological mechanisms that appear to mediate the SES-health association are presented.

• Due, P., R. Krølner, M. Rasmussen, et al. 2011. Pathways and mechanisms in adolescence contribute to adult health inequalities. Scandinavian Journal of Public Health 39.6 (Suppl.): 62–78.

  This paper introduces the Adolescent Pathway Model, a model that describes different pathways from adolescence that may contribute to health inequality in adulthood. The pathways presented in the model are: health, health behavior, school and education, and relational influences.

• Halfon, N., C. B. Forrest, R. M. Lerner, and E. M. Faustman. 2018. Handbook of life course health development. Cham, Switzerland: Springer International.

  Using a life-course health development approach, the authors demonstrate that although exposures at all points in the life course impact health inequalities, those early in life are particularly important. They indicate that heightened biological plasticity and behavioral sensitivity allows early experiences and events to influence health development pathways. The neurobiological mechanisms and processes by which SES-related adversity, including chronic stress, affect health trajectories from early life to old age are discussed.

• Inchley, J., D. Currie, T. Young, et al. 2016. Growing up unequal: Gender and socioeconomic differences in young people’s health and well-being. Health Policy for Children and Adolescents 7. Copenhagen: WHO Regional Office for Europe.

  A report from the Health Behaviour in School-aged Children (HBSC) study: a WHO collaborative cross-national study. The HBSC study collects country representative data every four years among 11-, 13- and 15-year-old boys and girls regarding their health, well-being, social environment, and health behaviors, and has been doing so for over thirty years. In this report, findings from the 2013/2014 survey on the demographic and socioeconomic influences on health are presented.

• Marmot, M., J. Allen, R. Bell, E. Bloomer, and P. Goldblatt. 2012. WHO European review of social determinants of health and the health divide. Lancet 380.9846: 1011–1029.

  This commissioned review gives an overview of inequities in health between and within countries across the 53 member states of the WHO European region. The authors call for action at all levels of governance in the region, on the social determinants of health across the life course, in wider social and economic spheres, and to protect future generations.

• Putnam, R. D. 2016. Our kids: The American dream in crisis. New York: Simon & Schuster.

  In a very insightful way, Putnam discusses lessening opportunities for adolescents in the United States from a social science perspective. He uses his high school class of 1959 in Port Clinton, Ohio, to illustrate his points.

• Quon, E. C., and J. J. McGrath. 2014. Subjective socioeconomic status and adolescent health: A meta-analysis. Health Psychology 33.5: 433.

  This meta-analysis comprehensively examines the association between subjective socioeconomic status (SES) and health outcomes during adolescence.

• Viner, R. M., E. M. Ozer, S. Denny, et al. 2012. Adolescence and the social determinants of health. Lancet 379.9826: 1641–1652.

  The authors argue for the need to expand the focus of health research from specific protective and risk factors to social patterns and structures that shape children’s chances to be healthy. They conclude that the most effective interventions are probably structural changes to improve access to education and employment for young people and to reduce the risk of transport-related injury.

• Whitehead, M., A. Pennington, L. Orton, et al. 2016. How could differences in “control over destiny” lead to socio-economic inequalities in health? A synthesis of theories and pathways in the living environment. Health & Place 39:51–61.

  This is the first synthesis of theories on causal associations and pathways connecting degree of control in the living environment to socioeconomic inequalities in health-related outcomes.