Social Science & Medicine 69 (2009) 1460–1467
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Can subjective and objective socioeconomic status explain minority health
disparities in Israel?q
Orna Baron-Epel a, *, Giora Kaplan a, b
a
b
School of Public Health, Faculty of Social Welfare and Health Studies, University of Haifa, Israel
The Gertner Institute for Epidemiology and Health Policy Research, The Sheba Medical Center, Tel Hashomer, Israel
a r t i c l e i n f o
a b s t r a c t
Article history:
Available online 16 September 2009
Disparities in health exist between the three main population groups in Israel, non-immigrant Jews,
immigrants from the former Soviet Union (arriving in Israel since 1990) and Arabs. This study examines
the relationship between health and socioeconomic status in this multicultural population and assesses
to what extent subjective and objective socioeconomic measures may explain the disparities in health.
A random cross sectional telephone survey of 1004 Israelis aged 35–65 was performed. The questionnaire measured physical and mental health-related quality of life using the Short Form 12. Information
regarding subjective socioeconomic status (SSS) and objective socioeconomic status (SES) was collected.
Arabs and immigrant women from the former Soviet Union had worse physical health compared to
non-immigrant Jews. Immigrant and Arab men and women had worse mental health compared to nonimmigrant Jews. Multivariable log-linear regression analysis adjusting for age, SSS or SES explained the
disparities in physical health between Arab and non-immigrant Jewish men. However, SSS and SES did
not explain the disparities in physical health between the three groups of women. The disparities in
mental health between immigrants and non-immigrant Jews can be explained by SSS for both men and
women, whereas the disparities between Arabs and Jews can be explained by objective SES only among
women. Employed men reported better physical and mental health. Part of the disparities in mental
health in Israel can be attributed to differences in SSS and SES in the different groups. However, there is
a need to identify additional factors that may add to the disparities in both physical and mental health.
The disparities due to socioeconomic status vary by health measure and population group.
Ó 2009 Elsevier Ltd. All rights reserved.
Keywords:
Israel
Disparities
Subjective socioeconomic status
Objective socioeconomic status
Quality of life
Gender
Multicultural
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 &
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
q Funding: The study was founded by a grant from The Israel National Institute
for Health Policy and Health Services Research.
* Corresponding author.
E-mail address: [email protected] (O. Baron-Epel).
0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2009.08.028
has been studied (Adler & Ostrove, 1999; Banks, Marmot, Oldfield, &
Smith, 2006; Lokshin & 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 & 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-
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
reported health (Adler et al., 2008; Franzini & Fernandez-Esquer,
2006; Singh-Manoux, Marmot, & Adler, 2005), mental health and
physical health (Franzini & 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, Adler, Goldman, Weinstein,
& Seeman, 2005; Ostrove, Adler, Kuppermann, & Washington,
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 & Fernandez-Esquer,
2006; Ostrove et al., 2000). Other studies have looked at European
and Asian populations (Hu et al., 2005; Kopp, Skrabski, Rethelyi,
Kawachi, & Adler, 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 multicultural 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 selfappraisal 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
1461
the two minority groups, Arabs and fSU immigrants, and the
majority of non-immigrant Jews in Israel.
Methods
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 households (94%), Jews and Arabs,
have telephone lines (Central Bureau of Statistics, 2003). Exclusion
of fax numbers, disconnected numbers, commercial numbers,
numbers of households where nobody answered after six intents or
no residents in the target age was available, left 1541 eligible
households in the sample. Immigrants were over sampled until
reaching a quota of 200 interviews. The over sampling was needed
as the sample of Jewish households did not include enough
immigrant interviewees from the fSU for statistical analysis.
Immigrants not from the fSU were not included in the study. A total
of 1004 respondents, men and women, completed the questionnaire, yielding a response rate of 65%. Non-responses included
outright refusals (331), partially completed interviews due to
difficulty answering the questions (109) and stopping the interview
in the middle without answering to the socioeconomic status
questions (97). The final database included 404 non-immigrant
Jews, 200 immigrants and 400 Arabs. The survey was conducted by
the Haifa University Survey Center.
Of the valid questionnaires, 17 questionnaires lacked data on
subjective socioeconomic status, another 78 lacked information on
income, 7 lacked information on education and employment, 7
lacked information on health, and 6 lacked information on age;
therefore, the sample analyzed in the final regression models
consisted of 916–917 completed questionnaires (some respondents
lacked data on more than one variable). The respondents with
missing data did not differ in their self-reported health from those
with no missing data.
The questionnaire
The questionnaire covered a range of socioeconomic and
demographic variables, as well as different health status
measurements. When the Hebrew questionnaire was ready it was
translated into Arabic and Russian, then back-translated to ensure
the correct meaning. Professionals speaking both Arabic and
Hebrew and familiar with Israeli-Arab culture validated the translation of the questionnaire into Arabic, and confirmed that the
questions had the same meaning as in Hebrew. The same process
was performed for the Russian questionnaire. A pretest was conducted to ensure cultural adaptation of the questionnaire, from
each population group 15 people were interviewed (45 all
together), and no problems were identified. The questionnaire was
administered over the telephone by trained interviewers from the
corresponding population group for each language, Hebrew, Arabic,
and Russian.
No official ethical approval was sought for this study. At the time
of the research official ethical approval was not needed in Israel for
this kind of study which was a random digit dial survey (no data
from lists of patients or clients were used) and no medical information was obtained from other sources. Even so, the highest
1462
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
ethical standards were adhered to and maintained in the study’s
procedures and methods. The following steps were followed by the
interviewers: they introduced themselves; they briefly described
the survey topic; they identified the person and organization
conducting the research; described the purpose of the research and
gave a ‘‘good faith’’ estimate of the time required to complete the
interview; they also promised anonymity and confidentiality; the
interviewers mentioned to the participant that participation is
voluntary and that item-nonresponse is acceptable. Finally,
permission to begin was asked. Informed consent was considered
to have been obtained when potential participants agreed to
answer the questionnaire.
The Short Form 12 served as the questionnaire for measuring
physical and mental health-related quality of life (Ware, Kosinski, &
Keller, 1996). The questionnaire was previously validated in
Hebrew (Amir, Lewin-Epstein, Becker, & Buskila, 2002). Six questions measured mental health and six measured physical health.
The scores were transformed to a scale of 100, where 100 was
optimal health and 0 was bad health, and a mean score was
calculated for mental health and for physical health. Physical and
mental health variables were not normally distributed therefore
the variables were dichotomized. Health status was categorized as
suboptimal (0) including scores from 0 to 79.99, and optimal health
(1) including score 80 and above. The cut of point was based on the
median scores of the three population groups.
Variables
Statistical analysis
All variables were self-reported. Arabs were defined as those
describing themselves as Arab Muslims, Druze, or Arab Christians.
Immigrants were those reporting arriving in Israel since 1990 from
the former Soviet Union (fSU). Non-immigrant Jews were those
born in Israel or living in Israel from before 1989. The subjective
socioeconomic status scale (SSS) was adopted from Adler et al.
(2000). The description of the ladder read to the respondents was
a translation of the English version. Participants were told to think
of a ladder with 10 rungs as representing where people stand in
Israeli society. The interviewee indicated his or her subjective
socioeconomic status (SSS) compared to the Israeli society, on
a scale from 1 to 10 (Adler et al., 2000; Ostrove et al., 2000). The
self-reported objective socioeconomic status (SES) measures
included income, education and employment. Employment status
was categorized as working (1) or not working (0) (unemployed,
retired, housewife). Education was assessed by the highest degree
the respondent attained, and two categories were formed: a high
school education or less (1), an academic degree or any other
studies beyond high school (2). Income was evaluated by asking the
respondent to choose from five possible ranges of household
income. The average monthly household income at the time of the
survey was about 8500 new Israeli shekel (NIS), this was about
2100$. Two levels of household income were formed: 8500 NIS and
less (1), and more than 8500 NIS (2). The Pearson’s correlation
coefficient for SSS and the objective SES was the highest for income
(0.48, 0.59 and 0.36 for non-immigrant Jews, immigrants and Arabs
respectively). Spearman’s correlations of SSS with income and
education were around 0.4.
Chi-square analysis was used to identify differences in demographic and socioeconomic variables between the three population
groups and to assess differences between the population groups in
the proportion of those reporting optimal mental and physical
health by demographic and socioeconomic status. In order to assess
the association between health, population group, SSS and objective measures of SES, after adjusting for age, six multivariable loglinear regression models were run for physical health, and another
six for mental health-related quality of life as the dependant variables. The rate ratios (RR), 95% confidence intervals (CI) and p
values are presented. As there was a significant interaction between
gender and population group regarding health, a separate analysis
for men and women was performed. The regression models
assessed if the socioeconomic variables could explain the differences in health between the population groups. Age and SSS were
entered into the models as continuous variables; while income,
education and employment were added as dichotomized variables.
To test if the addition of the SSS or SES variables to the log-linear
models made significant improvement to the models we used the
likelihood ratio test and compared the first model (only the variable
population group in the models) with the second and third models
including the SSS or SES.
Population group was added to the models as a categorical
variable comparing immigrants and Arabs to non-immigrant Jews
(the reference group). Marital status was not added to the final
models as it was not found to be significantly associated with
health. Statistical significance was set at a p value of less than 0.05.
SAS and SPSS version 14.0 was used for the analysis.
Table 1
Demographic and socioeconomic characteristics by population group [percent and (number), mean and (standard deviation)].
Characteristics
Non-immigrants Jews
Immigrants
Arabs
Total
Gender
404
40.3 (163)
59.7 (241)
200
40.0 (80)
60.0 (120)
400
42.5 (170)
57.5 (230)
Mean (SD)
49.1 (8.8)
50.2 (8.7)
45.0 (8.1)
Married
Non-married
78.0 (314)
21.9 (88)
71.2 (141)
28.8 (57)
91.0 (363)
9.0 (36)
Incomea (New Israeli Shekel)
Low–8500 NSH and less
High–More than 8500 NSH
42.1 (144)
59.9 (198)
60.9 (117)
39.1 (75)
85.2 (334)
14.8 (58)
Educationa
Low–12 years of schooling and less
High–More than 12 years of schooling
39.8 (159)
60.3 (241)
12.5 (25)
87.5 (175)
70.2 (280)
29.8 (119)
Employmenta
Employed
Non-employed
77.7 (313)
22.3 (90)
78.3 (155)
21.7 (43)
49.3 (197)
50.8 (203)
Subjective socioeconomic statusa
Low 1–5
High 6–10
31.0 (123)
69.0 (274)
81.4 (158)
18.6 (36)
51.8 (205)
48.1 (191)
Men
Women
Agea (years)
Marital status
a
a
differences between population groups p < 0.0001.
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
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 nonmarried 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 difference in subjective socioeconomic status (SSS) between the groups,
the lowest level was reported by immigrants, and Arabs rated
themselves higher than immigrants but lower than non-immigrant
Jews.
Among men, Arabs reported lower levels of physical healthrelated quality of life, however there was no significant difference
between the three population groups: 75.5%, 72.5%, 65.3% of nonimmigrant Jews, immigrants and Arabs respectively (Table 2).
Mental health-related quality of life was lower among immigrant
and Arab men compared to non-immigrant Jewish men: 47.5%,
46.2% and 71.8% reported optimal health respectively (Table 3).
Among women, immigrants had the lowest levels of both mental
and physical health (39.2% and 31.7% respectively) while Arab
women had higher levels (46.1% and 40.0% respectively) compared
to immigrant women, but lower levels compared to non-immigrant
Jewish women (68.5% and 55.6% respectively) (Tables 2 and 3). Age
was not associated with reporting optimal health in any of the
groups except for less of the older non-immigrant Jewish women
reporting optimal physical health (data not presented).
To assess if subjective and objective SES measures can explain
the differences in health between the minority groups (immigrants
and Arabs) and the non-immigrant Jewish majority, physical and
mental health of the three population groups were compared by
socioeconomic levels and gender (Tables 2 and 3). Among men
there were no statistical differences between the groups in any
1463
category of income, education and SSS; excluding employment
status where only 27–28% of immigrants and Arabs that were
unemployed reported optimal physical health compared to 69% of
unemployed non-immigrant Jews (Table 2). Among women, the
differences in physical health between non-immigrant Jews,
immigrants and Arabs were significant for both categories of
income, education and SSS and also among employed and
unemployed.
In relation to mental health, Arab and immigrant men with low
income, education and SSS did not significantly differ in levels of
optimal mental health from Jewish men at the same low income,
education and SSS, however, the difference between the minority
men and the non-immigrant Jewish men were significant at the
higher level of these SES variables. Only in the employment status
variable the differences between the three groups were significant
in both categories, employed and unemployed (Table 3). Among
women the differences in the percent of those reporting optimal
mental health between the three groups are significant only at the
lower level of income, at the higher level of education and at both
categories of the employment status variable.
Log-linear regression models were run for the entire population
of men and women separately to assess the differences between
the three population groups after adjusting for age and socioeconomic status (Tables 4 and 5). Both the subjective and the objective
SES measures separately can explain the difference in physical
health-related quality of life between Arabs and non-immigrant
Jewish men. When including SSS to the model, the RR for Arab
men’s physical health changes from RR ¼ 0.86, CI ¼ 0.75–0.99 to
RR ¼ 0.91, CI ¼ 0.80–1.04 and is not significant any more (model 1–
2, Table 4). When adding the objective SES measures without SSS,
the RR changes to 1.05, CI ¼ 0.93–1.20 and is not significantly
different from 1.00. Immigrant men did not differ in the level of
physical health from non-immigrant Jewish men (RR ¼ 0.96,
CI ¼ 0.82–1.13) and the addition of the socioeconomic variables to
the model did not change this relationship (models 2–3, Table 4).
Table 2
Optimal physical healtha by population group, gender, objective SES and SSS [p value, percent and (number)].
Characteristics
Non-immigrants Jews
Immigrants
Arabs
Men
Total
p
75.5 (123)
72.5 (58)
65.3 (111)
0.12
Income
Low
High
68.8 (33)
80.5 (70)
58.8 (20)
83.3 (35)
60.7 (82)
82.8 (24)
0.56
0.91
Education
Low
High
65.0 (39)
81.0 (81)
75.0 (9)
72.1 (49)
52.4 (54)
84.8 (56)
0.14
0.17
SSS
Low (1–5)
High
60.0 (27)
80.2 (89)
68.3 (41)
83.3 (15)
54.3 (44)
75.6 (65)
0.24
0.65
Employment status
Employed
Non-employed
76.9 (103)
69.0 (20)
79.7 (55)
27.3 (3)
77.3 (99)
28.6 (12)
0.89
0.002
68.5 (165)
39.2 (47)
46.1 (106)
<0.0001
Women
Total
Income
Low
High
62.5 (60)
72.1 (80)
36.1 (30)
51.5 (17)
43.7 (87)
58.6 (17)
0.001
0.06
Education
Low
High
57.6 (57)
76.6 (108)
15.4 (2)
42.1 (45)
42.4 (75)
58.5 (31)
0.004
<0.0001
SSS
Low (1–5)
High (6–10)
56.4 (44)
74.2 (121)
34.7 (34)
66.7 (12)
38.7 (48)
55.2 (58)
0.009
0.006
Employment status
Employed
Non-employed
73.2 (131)
54.1 (33)
44.2 (38)
28.1 (9)
53.6 (37)
42.9 (69)
<0.0001
0.05
Income: low- 8500 NSH and less, High-More than 8500 NSH.
Education: Low-12 years of schooling and less, High-More than 12 years of schooling.
a
Based on the SF12 instrument.
1464
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
Table 3
Optimal mental healtha by population group, gender, objective SES and SSS [p value, percent and (number)].
Characteristics
Non-immigrants Jews
Men
Total
Immigrants
Arabs
p
71.8 (117)
47.5 (38)
46.2 (78)
<0.0001
Income
Low
High
54.2 (26)
83.9 (73)
38.2 (13)
57.1 (24)
42.5 (57)
55.2 (16)
0.28
0.001
Education
Low
High
56.7 (34)
81.0 (81)
33.3 (4)
50.0 (34)
42.2 (43)
51.5 (34)
0.13
<0.0001
SSS
Low (1–5)
High (6–10)
51.1 (23)
80.2 (89)
45.0 (27)
61.1 (11)
32.1 (26)
58.8 (50)
0.08
0.004
Employment status
Employed
Non-employed
73.1 (98)
65.5 (19)
50.7 (35)
27.3 (3)
55.9 (71)
16.7 (7)
0.002
<0.0001
55.6 (134)
31.7 (38)
40.0 (92)
<0.0001
Income
Low
High
47.9 (46)
55.9 (62)
27.7 (23)
39.4 (13)
37.2 (74)
58.6 (17)
0.002
0.20
Education
Low
High
47.5 (47)
61.7 (87)
23.1 (3)
32.7 (35)
36.7 (65)
50.9 (27)
0.098
<0.0001
SSS
Low (1–5)
High (6–10)
41.0 (32)
62.2 (102)
28.6 (28)
50.0 (9)
33.1 (41)
48.6 (51)
0.22
0.066
Employment status
Employed
Non-employed
55.3 (99)
55.7 (34)
37.2 (32)
18.8 (6)
46.4 (32)
37.3 (60)
0.02
0.002
Women
Total
Income: low- 8500 NSH and less, High-More than 8500 NSH.
Education: Low-12 year.
a
Based on the SF12 instrument.
The likelihood ratio test comparing models was highly significant
for the addition of both SSS and SES variables (p < 0.001).
Among women, both immigrant and Arab women had significantly lower levels of physical health compared to non-immigrant
Jewish women (RR ¼ 0.57 and 0.67 respectively). The addition of
SSS or the objective socioeconomic variables to the model did not
eliminate the differences between the minority groups and the
majority Jewish population (models 2–3, Table 4).
In addition, SSS and education were associated with physical
health in men and women, and employment status was associated
with physical health only among men (Table 4).
Table 5 depicts the log-linear regression models for mental
health and the association with SSS, SES measures and population
groups. Both immigrants and Arabs, men and women, have
significantly lower levels of mental health compared to nonimmigrant Jews. Among immigrants the addition of SSS to the
models eliminates the differences in mental health compared to the
non-immigrant Jews (in men: RR ¼ 0.92, CI ¼ 0.76–1.12; in women:
OR ¼ 0.78, CI ¼ 0.58–1.05), whereas the addition of the objective
SES measures abolishes the differences in mental health between
Arabs and non-immigrant Jewish women (in men: RR ¼ 0.74,
CI ¼ 0.64–0.91 in women: RR ¼ 0.93; CI ¼ 0.72–1.20).
SSS is associated with mental health in both men and women,
whereas education and employment status are associated with
mental health among men while among women only education
remains significant. The addition of SSS or SES to the log-linear
model explaining mental health was significant (p < 0.001) using
the likelihood ration test.
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 & Ostrove, 1999; Banks
et al., 2006; Lokshin & Ravallion, 2008; Singh-Manoux et al., 2007).
Decreasing these health disparities is a major goal for the health
system; therefore, it is important to understand if differences in the
SES characteristics of the three groups can explain their disparities
in health status so that an improvement in SES levels can help
eliminating the health disparities. However, SES may not only
include the objective resources available to the individual to ensure
health, but may also comprise the subjective feeling the individual
has of his/her position within society. This subjective feeling individuals have may act as an additional source of stress, or may better
represent the objective socioeconomic resources the individual has
at his disposal.
Immigrant women in Israel report much worse mental and
physical health compared to the non-immigrant Jewish population,
and among immigrant men mental health was much worse but not
physical health. It may be assumed that this is due to lower levels of
health in the country of origin-the former Soviet Union (Tolts,
1996). In addition, the actual immigration process to Israel may
have provided new stressors and decreased mental health in both
genders, and physical health in women. Why there should be
a difference between immigrant men and women is not clear,
however it could be that the process of immigration and acculturation may be more challenging for women than for men, affecting
not only their mental health but also their physical health. More
objective health measures need to be assessed before better
understanding can be reached as the self-reported measures used
in this study may raise gender biases.
Among immigrants the objective SES measures did not explain
the disparities in mental health or physical health. However, the
SSS measure did explain the difference in mental health between
immigrants and non-immigrant Jews in both men and women. On
immigration the immigrant has to start from scratch finding work,
living accommodations, friends and a whole social network, in
addition they have to learn a new language and adapt to the new
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
1465
Table 4
Association between physical health-related quality of life and population groups while adjusting for socioeconomic status by gender, in log-linear regression models.a [rate
ratios, (RR), 95% confidence intervals (CI) and p values].
Model 1
RR
Model 2
95% CI
p
Men
Jews
Immigrants
Arabs
SSSb
Income
Education
Employment
N ¼ 413
1.00
0.96
0.86
–
–
–
–
–
0.82–1.13
0.75–0.99
–
–
–
–
–
Women
Jews
Immigrants
Arabs
SSSb
Income
Education
Employment
N ¼ 591
1.00
0.57
0.67
–
–
–
–
–
0.45–0.73
0.57–0.79
–
–
–
–
a
b
RR
Model 3
95% CI
p
–
0.91–1.27
0.80–1.04
1.03–1.09
–
–
–
–
–
–
–
–
N ¼ 401
1.00
1.07
0.91
1.06
–
–
–
–
<0.0001
<0.0001
–
–
–
–
N ¼ 586
1.00
0.74
0.72
1.09
–
–
–
–
0.57–0.96
0.61–0.84
1.05–1.12
–
–
–
–
0.63
0.04
0.40
0.17
<0.0001
–
–
–
0.02
<0.0001
<0.0001
–
–
–
RR
95% CI
p
N ¼ 373
1.00
0.95
1.05
–
1.05
1.27
1.82
–
0.81–1.10
0.93–1.20
–
0.92–1.20
1.08–1.48
1.36–2.43
–
N ¼ 548
1.00
0.58
0.82
–
1.09
1.29
1.18
–
0.45–0.74
0.67–0.99
–
0.92–1.29
1.08–1.53
0.98–1.41
–
<0.0001
0.046
–
0.33
0.004
0.08
0.47
0.43
–
0.46
0.004
<0.0001
Adjusted for age in all models.
Subjective Socioeconomic Status.
culture. Many immigrants loose their former position within
society on immigration, and have to regain it within the new social
surroundings. This change mostly has a social downwards direction
and may take at least a generation to overcome. The immigrant’s
expectations from life in Israel may have been high and their feeling
of disappointment great during the years of acculturation. This
situation may produce a low personal evaluation of the position
within the Israeli society causing stress related effects on mental
health.
These findings provide evidence to the importance of SSS in this
population, where SSS seems to be a major contributor to the
disparities in mental health. Therefore, it seems that in this
immigrant population the feeling people have of their position in
society has a major effect on their health and can explain the
disparities in mental health whereas the objective SES measures do
not explain these disparities.
A different pattern emerges for the Arab population. Among
Arabs, SSS does not explain the differences in mental health
between Arabs and Jews. However, Arab men with higher levels of
education, income and SSS had similar rates of optimal physical
health compared to Jews and both objective SES and SSS seem to
explain the disparities in physical health between men in the two
groups. SES on its own explains the differences between Arab and
non-immigrant Jewish women in mental health-related quality of
life and explains the difference between Arab and Jewish men
regarding physical health. SSS explains only the difference in
physical health among men, Arabs versus non-immigrant Jews, but
not the disparities among women neither the disparities in mental
health in both genders. The Arab community in Israel has a much
lower mean SES compared to Jews, high unemployment rates,
lower education levels and lower income. In addition, health
indicators such as life expectancy and mortality rates are lower
(Israel Center for Disease Control, 2005). It seems that a large part of
these differences may be attributed mainly to overall lower levels of
SES and to some extent SSS. Objective SES in Arabs may be more
important in explaining the disparities in health compared to SSS
for two reasons: first the disparities in material resources for
health, such as living conditions, may be much larger between
Arabs and Jews compared to the differences between the immigrants and the non-immigrant Jewish population therefore, having
a larger effect on health. Second, the segregation of residential
areas between Arabs and Jews may protect the Arabs from the harm
low SSS can cause as they are not in daily contact with the higher
SES communities in the Jewish populations in Israel, they live
mostly within their communities where they may feel comparatively better of.
Among Arab and immigrant women both SES and SSS did not
explain the disparities in physical health. SSS and education were
associated with physical health but could not explain the
disparities. Other biological, behavioral, cultural and environmental factors should be studies to identify the causes of these
disparities among women. These may be behavioral as men and
women may have different health behaviors. Environmental
factors may not play a part as we would not expect to find gender
differences between men and women living in the same
environment.
In this study objective SES was measured by income, education
and employment and these were associated independently with
health. Other studies have provided evidence of the association
between income and health. This association is stronger in the
lower levels of income (Backlund, Sorlie, & Johnson, 1999; Mackenbach et al., 2005). Education has been reported to be a variable
that predicts health in many populations and may increase access
to better work, favorable health behaviors and increase sense of
control over life, this in turn may increase the ability to cope with
stressors and provide a better physical, social and psychological
environment for health (Ross & Van Willigen, 1997). Employment
status was associated with health only among men. Although
among the Jewish population about 60% of married women work
and only 20% of Arab women work (Central Bureau of Statistics,
2007) it is socially accepted in all population groups that a woman
can stay home and not work and the man is expected to be the
bread winner, therefore not having a job may have profound effects
on mental health and also physical health among men but not
among women (Kasl & Jones, 2000, chap. 6).
The addition of SSS to the study of socioeconomic disparities in
health is an important contribution to our understanding of the
relationship between SES and health status of populations. It seems
that not only objective socioeconomic factors can explain disparities in health but the subjective feelings people have of their
relative position in society can also explain these health disparities.
However, some populations may be more sensitive to the subjective feelings they have, such as the immigrant population, whereas
other population are less affected by both types of socioeconomic
1466
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
Table 5
Association between Mental health-related quality of life and population groups while adjusting for socioeconomic status, by gender, in log-linear regression models.a [rate
ratios, (RR), 95% confidence intervals (CI) and p values].
Model 1
RR
Model 2
95% CI
Men
Jews
Immigrants
Arabs
SSSb
Income
Education
Employment
N ¼ 412
1.00
0.66
0.64
–
–
–
–
–
0.52–0.85
0.53–0.78
–
–
–
–
Women
Jews
Immigrants
Arabs
SSSb
Income
Education
Employment
N ¼ 591
1.00
0.57
0.72
–
–
–
–
–
0.43–0.76
0.59–0.87
–
–
–
–
a
b
p
RR
–
0.001
<0.0001
–
–
–
–
–
0.0001
0.0009
–
–
–
–
Model 3
95% CI
N ¼ 400
1.00
0.92
0.80
1.09
–
–
–
–
0.76–1.12
0.70–0.92
1.06–1.12
–
–
–
N ¼ 586
1.00
0.78
0.76
1.13
–
–
–
–
0.58–1.05
0.63–0.90
1.09–1.18
–
–
–
p
–
0.41
0.001
<0.0001
–
–
–
–
0.12
0.002
<0.0001
–
–
–
RR
95% CI
p
N ¼ 372
1.00
0.65
0.74
–
1.27
1.20
1.54
–
0.51–0.83
0.64–0.91
–
1.05–1.54
1.00–1.43
1.07–2.20
–
0.0005
0.003
–
0.015
0.04
0.02
N ¼ 548
1.00
0.60
0.93
–
1.24
1.28
0.99
–
0.44–0.82
0.72–1.20
–
0.99–1.55
1.02–1.60
0.79–1.24
–
0.001
0.56
–
0.06
0.03
0.94
Adjusted for age in all models.
Subjective Socioeconomic Status.
status, subjective and objective, such as the Arab population in
Israel.
In other western societies SSS has been reported to be associated with health over and above objective SES (Adler et al., 2000;
Hu et al., 2005; Ostrove et al., 2000; Singh-Manoux et al., 2005),
emphasizing the importance of subjective feelings individuals have
regarding their position in society as a factor that can explain
disparities in health in multiethnic populations around the world.
Three competing hypotheses have been suggested to explain why
SSS is a better predictor of health compared to objective SES (SinghManoux et al., 2005). The first assumes that SSS is a more precise
measure of social position which may reflect more accurately and
comprehensively the individual’s position in society. The second
explanation assumes that SSS reflects the person’s ‘‘relative’’ position in society as opposed to the more ‘‘absolute’’ social position
expressed by the objective SES measures. It may be that the stress
associated with the feeling of being lower in the social hierarchy
may increase levels of ill health or that high SSS may protect against
activation of psychobiological pathways which may contribute to
variation in disease risk (Wright & Steptoe, 2005). The third
hypothesis suggests the association is not a true relationship.
This study does not enable to differentiate between the three
suggested explanations for the effect of SSS on health (SinghManoux et al., 2005). However, it strengthens the evidence as to the
importance of the subjective feeling people have of their position in
society and its effect on health in majority and minority
populations.
This study suggests that decreasing disparities in health in Israel
may be achieved by changing two factors that may be related. First,
increasing SES by providing jobs mainly for Arab and immigrant
men, and improving levels of education for both men and women
among Arabs. Second, reducing the range of social disparities may
improve the subjective status and then improve health. This would
mainly be relevant for immigrants. Providing adequate jobs suitable for their levels of education may improve their evaluation of
their position in the Israeli society. However, SES cannot explain all
disparities and it seems that other factors not measured in this
study should be investigated.
This study has a few limitations. One concern is the lack of
objective health data since all the health outcomes studied were
self-reported. Health-related quality of life is a more objective
measure than other frequently used measures, such as self-reported health, but it is still not an objective measure of health. Another
concern is the size of the sample. It may not be large enough to
significantly identify some associations, for example between SSS,
SES and health among women. However, as we did observe associations in other groups, if the associations exist they would be
small. In addition this is a cross sectional analysis and causality
cannot be evaluated in this study. Worse health may cause lower
SES and not only, as expected, low SES causing worse health.
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.
References
Adler, N. E., Epel, E. S., Castellazzo, G., & Ickovics, J. R. (2000). Relationship of
subjective and objective social status with psychological and physiological
functioning: preliminary data in healthy white women. Health Psychology, 19(6),
586–592.
Adler, N. E., & Ostrove, J. M. (1999). Socioeconomic status and health: what we
know and what we don’t. Socioeconomic Status and Health in Industrial Nations,
896, 3–15.
Adler, N. E., & Rehkopf, D. H. (2008). U.S. disparities in health: descriptions, causes,
and mechanisms. Annual Review Public Health, 29, 235–252.
Adler, N., Singh-Manoux, A., Schwartz, J., Stewart, J., Matthews, K., & Marmot, M. G.
(2008). Social status and health: a comparison of British civil servants in
Whitehall-II with European- and African-Americans in CARDIA. Social Science &
Medicine, 66(5), 1034–1045.
Amir, M., Lewin-Epstein, N., Becker, G., & Buskila, D. (2002). Psychometric properties of the SF-12 (Hebrew version) in a primary care population in Israel.
Medical Care, 40(10), 918–928.
Backlund, E., Sorlie, P. D., & Johnson, N. J. (1999). A comparison of the relationships
of education and income with mortality: the national longitudinal mortality
study. Social Science & Medicine, 49(10), 1373–1384.
Banks, J., Marmot, M., Oldfield, Z., & Smith, J. P. (2006). Disease and disadvantage in
the United States and in England. Journal American Medical Association, 295(17),
2037–2045.
Baron-Epel, O., & Kaplan, G. (2001). Self-reported health status of immigrants from
the former Soviet Union in Israel. Israel Medical Association Journal, 3(12),
940–946.
O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467
Braveman, P. (2006). Health disparities and health equity: concepts and measurement. Annual Review Public Health, 27, 167–194.
Central Bureau of Statistics. (2003). Statistical abstract of Israel 2003. Publication 54,
Jerusalem, Israel.
Central Bureau of Statistics. (2005). Statistical abstract of Israel 2005. Publication 56,
Jerusalem, Israel.
Central Bureau of Statistics. (2007). Statistical abstract of Israel 2007. Publication 57,
Jerusalem, Israel.
Dowd, J. B., & Zajacova, A. (2007). Does the predictive power of self-rated health for
subsequent mortality risk vary by socioeconomic status in the US? International
Journal of Epidemiology, 36(6), 1214–1221.
Franzini, L., & Fernandez-Esquer, M. E. (2006). The association of subjective social
status and health in low-income Mexican-origin individuals in Texas. Social
Science & Medicine, 63(3), 788–804.
Gad, R., Nurit, L., Ada, T., & Yitzhak, P. (2002). Chronic disease prevalence in immigrants to Israel from the former USSR. Journal Immigrant Health, 4(1), 29–33.
Goodman, E., Adler, N. E., Daniels, S. R., Morrison, J. A., Slap, G. B., & Dolan, L. M.
(2003). Impact of objective and subjective social status on obesity in a biracial
cohort of adolescents. Obesity Research, 11(8), 1018–1026.
Hu, P. F., Adler, N. E., Goldman, N., Weinstein, M., & Seeman, T. E. (2005). Relationship between subjective social status and measures of health in older
Taiwanese persons. Journal of the American Geriatrics Society, 53(3), 483–488.
Israel Center for Disease Control. (2005). The health status of the Arab population in
Israel-2004. Publication 226. Tel-Hashomer, Israel: Israel Center for Disease
Control.
Kasl, S. V., & Jones, B. A. (2000). The impact of job loss and retirement on health. In
L. F. Berkman, & I. Kawachi (Eds.), Social epidemiology. NewYork: Oxford,
University Press.
Kopp, M., Skrabski, A., Rethelyi, J., Kawachi, I., & Adler, N. E. (2004). Self-rated
health, subjective social status, and middle-aged mortality in a changing
society. Behavioral Medicine, 30(2), 65–70.
Levav, I., Al-Krenawi, A., Ifrah, A., Geraisy, N., Grinshpoon, A., Khwaled, R., et al.
(2007). Common mental disorders among Arab-Israelis: findings from the
Israel National Health Survey. Israel Journal Psychiatry Related Sciences, 44(2),
104–113.
1467
Lokshin, M., & Ravallion, M. (2008). Testing for an economic gradient in health
status using subjective data. Health Economics.
Mackenbach, J. P., Martikainen, P., Looman, C. W., Dalstra, J. A., Kunst, A. E., &
Lahelma, E. (2005). The shape of the relationship between income and selfassessed health: an international study. International Journal Epidemiology,
34(2), 286–293.
Okun, B. S., & Friedlander, D. (2005). Educational stratification among Arabs and
Jews in Israel: historical disadvantage, discrimination, and opportunity. Population Studies–a Journal of Demography, 59(2), 163–180.
Ostrove, J. M., Adler, N. E., Kuppermann, M., & Washington, A. E. (2000). Objective
and subjective assessments of socioeconomic status and their relationship to
self-rated health in an ethnically diverse sample of pregnant women. Health
Psychology, 19(6), 613–618.
Ross, C. E., & Van Willigen, M. (1997). Education and the subjective quality of life.
Journal Health Sociology Behavior, 38(3), 275–297.
Singh-Manoux, A., Adler, N. E., & Marmot, M. G. (2003). Subjective social status: its
determinants and its association with measures of ill-health in the Whitehall II
study. Social Science & Medicine, 56(6), 1321–1333.
Singh-Manoux, A., Dugravot, A., Shipley, M. J., Ferrie, J. E., Martikainen, P.,
Goldberg, M., et al. (2007). The association between self-rated health and
mortality in different socioeconomic groups in the GAZEL cohort study. International Journal Epidemiology, 36(6), 1222–1228.
Singh-Manoux, A., Marmot, M. G., & Adler, N. E. (2005). Does subjective social status
predict health and change in health status better than objective status?
Psychosomatic Medicine, 67(6), 855–861.
Tolts, M. (1996). The Jewish population of Russia, 1989–1995. Jews in Eastern Europe.
Jerusalem: Hebrew University of Jerusalem. 3, pp. 5–19.
Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-Item short-form health survey:
construction of scales and preliminary tests of reliability and validity. Medical
Care, 34(3), 220–233.
Wilkinson, R. G. (1999). Health, hierarchy, and social anxiety. Annals New York
Academy Science, 896, 48–63.
Wright, C. E., & Steptoe, A. (2005). Subjective socioeconomic position, gender and
cortisol responses to waking in an elderly population. Psychoneuroendocrinology, 30(6), 582–590.