Socioeconomic Environment

Our "environment" includes both social and physical determinants of health. Social impacts on health are embedded in the broader environment and shaped by complex relationships between economic systems and social structures. These systems and structures impact the distribution of resources, money and power in a community and around the world. This distribution, known as the socioeconomic environment, shapes how communities and individuals can gain the resources needed to meet their basic human needs.¹

Measuring Status

Economic status is typically measured by income and education, social status measured by power and rank in a group, and work status measured by occupation.²

Access to resources is largely shaped by access to education, income and power. A person’s socioeconomic status (SES) is comprised of their economic, social and work status in comparison to their larger community.³

Occupational Status

Occupational status, a component of socioeconomic status, is determined by a person’s education, income and level of power (social position, working conditions, decision-making and psychological demands). Occupational status can determine access to resources that can affect exposure to hazards and risk for death and disability.⁴

Some characteristics of low socioeconomic status create a feedback loop that creates or maintains low status. Education is one: lower educational attainment limits access to higher-status jobs, which limits opportunities for further education. Similar feedback loops involve access to medical care, nutrition, injury, disease, disability, psychiatric disturbance, substance abuse and homelessness.

Educational Attainment

The current trend in the US is for fewer young people to complete both high school and college, especially those from schools that have fewer resources and higher rates of minority students. The cost of tuition is a barrier to education for low-income families, further perpetuating low socioeconomic status across generations:⁵

50 percent of children of college graduates earn a college degree, compared to 13 percent of children whose parents are not college graduates.
Over their lifetime, high school graduates earn half that of college graduates.
The US is the only industrialized nation where the current generation is less likely to graduate from high school than their parents’ generation.

Access to Health Care

A 2015 report from the World Health Organization states that 36% of the world's population, or nearly 2.5 billion people, lack access to improved sanitation facilities, putting them at risk of several diseases including dysentery, cholera and typhoid. In context, however, the report also states that disadvantaged subpopulations, such as rural residents, the poor and the less educated have seen greater increases in key coverage indicators over the past decade or so
than their urban, wealthier and better-educated counterparts.⁶ Access to vision care is a further example of a health issue that can impact educational attainment and earning potential. Worldwide, 80 percent of blindness is avoidable through prevention or treatment.⁷

In the US, access to medical care is limited more by costs than by availability of services. Costs of medical care are a significant contributor to financial stress, with more than half of personal bankruptcies explicitly tied to medical bills—even though three-quarters of those households had medical insurance at the onset of the medical condition. Analyses before the implementation of the 2010 Affordable Care Act concluded that 1.7 million Americans live in households that will declare bankruptcy due to their inability to pay their medical bills.⁸ Lack of access to medical care feeds back to health outcomes: uninsured adults are at least 25 percent more likely to die prematurely than adults who have private insurance, one indicator of poorer health.⁹ Households in which individuals, and especially wage earners, experience poor health or premature death are at added risk for low income, creating a self-reinforcing cycle.

Risk Factors for Poverty and Low Socioeconomic Status¹⁰

Single parenthood
High child:adult ratio
Teenage pregnancy
Unplanned pregnancy
Maternal social isolation
Low parental involvement
Marital conflict
Violence
Physical harm
Trauma
Low educational attainment
Illness
Peer rejection
Unstable peer group

The list of risk factors associated with low socioeconomic status includes higher teen pregnancy rates, high school dropouts, trauma, and illness—all potentially occurring simultaneously, and each increasing the risk of poor health outcomes.¹¹

Poverty

The lowest economic status is poverty, which is heavily influenced by education and thus influences social and work status. Poverty can be defined as insufficient resources to meet basic human needs. These needs include access to shelter, clean water, education, food, health care and clothing.¹²

Global Poverty

US Support Programs

Programs aimed at supporting education, health care, access to food and household utilities for families of low socioeconomic status are often indexed to the federal poverty guidelines. Programs using these guidelines include these:

Globally, poverty is considered living off less than two US dollars per day.¹³ In 2011, almost 13 percent of the world’s population lived in poverty.¹⁴ Globally 1.2 billion people are estimated to live on less than a dollar a day.¹⁵

Graphic from the World Bank;¹⁶ click to zoom.

Poverty in the United States

In the US, the Department of Health and Human Services sets annual poverty guidelines, often referred to as the federal poverty level (FPL), to determine eligibility for federal programs. If a family’s total income falls below that federal guideline, the family is classified as living in poverty. In 2016 in the lower 48 states, a family of four is considered living in poverty if their household income falls below $24,300 a year.¹⁷

Map from the Centers for Disease Control and Prevention;¹⁸ click to zoom

Health Impacts of Socioeconomic Status

impoverished neighborhood

image from Zoriah at Creative Commons

People in lower income or class status are often relegated to living and working environments that have a higher risk for pollution, stress, injury and other risk factors for disease outcomes.¹⁹ A pattern of disease and premature death corresponds to the social and economic environment in which a person lives, known as the social determinants of health.

Experiencing poverty directly undermines a person’s health as individuals are caught in a cycle that is self-reinforcing and difficult to break: less access to resources increases risk of illness and disability that further impacts household income and work status, and that ultimately diminishes a person’s quality of life.²⁰

Occupation and Health

Occupation is tied to physical and psychosocial hazards and stressors in the work place. A full discussion of links between occupation and health outcomes is beyond the scope of this website, but we offer some salient examples and refer readers to the Dig Deeper section in the right sidebar.

image from Jan Truter at Creative Commons

People with lower status employment—those in manual jobs, often called "blue-collar workers" in industrialized countries—have higher rates of disability and premature death than their white-collar counterparts. Blue-collar workers also report lower health-related quality of life.²¹
Research in Britain and Wisconsin found that the lower the occupational grade (status), the worse an individual’s health. The lowest ranked civil services workers had three times the risk of premature death than those at the highest rank. Lower status also increased the risk for depression, poor psychological well-being, poor self-perceived health and likelihood of smoking.²²
image from Bread for the World at Creative Commons

Occupational risk factors account for a substantial burden of disease worldwide. Exposures to chemicals, noise, particulate pollution, ergonomic stressors and risk factors for injuries are widespread. For example, selected occupational lung carcinogens, such as beryllium and silica, were estimated to cause 111,000 lung cancer deaths worldwide in 2004, while asbestos caused 59,000 deaths from mesothelioma.²³
Jobs with a high physical workload result in more musculoskeletal complaints, arthritis and leg pain than those with low physical workloads. Both job strain (high job demands and low control) and repetitive or hazardous work that are more common in blue-collar jobs can affect mental and physical health.²⁴
Some health outcomes are common in both high- and low-status jobs, such as low back pain, fatigue and upper respiratory problems. While low back pain is attributed to physical labor in blue color jobs, back pain may be associated with prolonged sitting in white-collar jobs, although research shows conflicting results.²⁵

Health Outcomes of Work-related Stress²⁶

In white-collar workers, high demands and low control predict heart disease.
In white-collar workers, job strain is associated with modest increases in blood pressure.
Men with job strain and low SES are at increased risk of elevated blood pressure.
In blue-collar workers, overtime (mandatory or voluntary) is associated with fatigue, sleep deprivation and risk for work-related accidents.
Blue-collar workers are twice as likely to smoke.
For those in industry and construction, job burnout is associated with male infertility.

Working conditions have shifted in recent decades, with psychological demands becoming more common than they once were.²⁷ The psychological demands in work-related stress include workload, a perceived sense of control, safety stress and workplace atmosphere.²⁸ Jobs with high levels of psychological demands, such as some white-collar jobs, have an increased risk of cardiovascular disease, distress and mental health disorders than those with low psychological demands. Lower-quality jobs with high psychological demands also increase risk of these health outcomes.
In a 2016 investigation, working adults in the US reported negative health impacts from their jobs: 28 percent said their job negatively affects their eating habits, 27 percent their sleeping habits, and 22 percent their weight.²⁹
Stress in the workplace can impact one’s lifestyle choices, such as smoking, alcohol use, use of health care and diet.³⁰ These choices, along with a lack of physical activity found in many jobs, can increase risks for obesity, cardiovascular disease, cancer and many other health outcomes. Obesity rates in white-collar workers increased significantly from 2004 to 2011, while obesity rates have not changed in blue-collar workers.³¹
Workplace stress on the whole is a risk factor for cardiovascular disease, diabetes, musculoskeletal problems and hypertension.³²

Education and Health

graph from Robert Wood Johnson Foundation³³ with data from the National Poverty Center;³⁴ click to zoom

More education generally leads to better income, fewer workplace exposures and more access to health care. Individuals with higher educational attainment are more likely to live longer and healthier lives, as are their children. Examples of associations between education and health:³⁵

Those who drop out of high school live five fewer years on average than those who complete college.
College graduates are less likely to be overweight or obese.
Less education is associated with higher risk of and death from chronic diseases.
Those with less education are more likely to smoke and expose children and other family members to secondhand smoke.
Mothers who drop out of high school have double the risk their infant will die compared to mothers with college degrees (8 percent versus 4 percent)

Nutrition and Poverty

Poverty increases the risk of poor nutrition, which can have far-reaching and lifelong impacts on health. Just one example is seen in the relationship between poverty, nutrition and chronic kidney disease.

Globally, poverty is associated with chronic kidney disease (CKD), in which the kidneys become less effective at filtering toxins out of the bloodstream. As kidney function decreases, CKD progresses in stages from one to five. At stage five, a person requires ongoing dialysis treatment or a kidney transplant.

Diet can influence a person’s risk for hypertension, and hypertension is a significant risk factor for CKD. The risk for CKD can be reduced by altering diet along nine nutrients:

Poverty and Diet

Poverty is associated with these factors that can impact diet:³⁶

Limited access to health -promoting foods, such as fresh fruits and vegetables ("food deserts")
Food insecurity
Eating more unhealthful, energy-dense but nutrition-poor foods.

Total fat
Saturated fat
Protein
Fiber
Cholesterol
Calcium
Magnesium
Sodium
Potassium

child in poverty

image from Children's Bureau Centennial at Creative Commons

Those living in poverty are more likely to have a diet that increases the risk for CKD: lower in magnesium, calcium, fiber and potassium and higher in cholesterol. In the US, the urban poor are the most at risk for CKD based on their dietary intake.³⁷

Insufficient nutrition in childhood, and especially early childhood, can lead to stunted growth and intellectual impairment, with cascading impacts on educational attainment, earning potential and health throughout life. A 2016 report estimates that 250 million children (43 percent) younger than five years in low-income and middle-income countries are at risk of not reaching their developmental potential because of extreme poverty and stunting.³⁸

Low-income families are more likely to experience maternal nutritional deficiencies and, especially in developing countries, preterm birth, low birth weight and other poor birth outcomes.³⁹

Multiple Risks

Conditions of Poverty

Poverty can include these conditions, often simultaneously:⁴⁰

Higher crime rates
More noise
Overcrowding
More toxic waste sites
Higher levels of lead and mercury
More freeway traffic and air pollution
Poorer indoor air quality
Poor-quality housing
Fewer parks and open spaces
Fewer sources of stable daycare
Fewer afterschool programs
Limited transportation options
Reduced access to medical care
Fewer sources of healthy, affordable foods

Low socioeconomic status communities, and thus the individuals within those communities, often experience more than one risk factor for disease at once. For instance, low income can lead to housing instability, poorer nutrition and living in polluted and noisy areas—all of which increase risk for disease.

Stressful life events—such as a loss of income, death in the family, residential relocation or divorce—are associated with low socioeconomic status: the lower the SES the greater the number and severity of stressful events on average. ‘Stressful life events’ is a measure that captures some of these overlapping risks for disease.

US children in low-income homes were three times more likely to have experienced two or more stressful life events compared to children in higher-income homes. Parental education and occupation—components of SES—are associated with the quality of a child’s home and neighborhood and are associated with the incidence of adverse childhood experiences (ACEs). ACES further increase risk for disease.⁴¹ See the Psychosocial Environment page for more information on adverse childhood experiences.

Parents' educational attainment also appears to influence the likelihood a child will abuse substances, mediated by the level of parental support, negative life events and peer groups. Substance abuse carries many health risks and can contribute to the cycle of joblessness and poverty.

Cumulative risk studies have found that many of these risk factors are linked to high blood pressure, increased stress response and general stress on the body’s systems, fostering chronic disease. Further, childhood exposure to more SES-related risks increased the risk for obesity, depression, smoking status, heart disease, poor executive control and diabetes that carried into adulthood. In adults, the more SES-related risk factors, the greater the risk for coronary heart disease.⁴²

The socioeconomic environment also interacts with the built environment, so that lower-income neighborhoods and homes are more likely to experience high rates of lead paint exposures, noise, air pollution, mold growth and extremes of heat and cold, while also less likely to have access to nature, safe areas for walking, affordable fresh food, and parks and playgrounds for physical exercise. All of these can lead to poorer health outcomes, as described on the Built Environment page.

This page's content was created by Lorelei Walker, PhD, and Nancy Hepp, and last revised in October 2016.

CHE invites our partners to submit corrections and clarifications to this page. Please include links to research to support your submissions through the comment form on our Contact page.

* header image from Alexandra Stevenson at Creative Commons