The Potential Explanatory Role of Perceived Stress in Associations Between Subjective Social Status and Health-Related Quality of Life Among Homeless Smokers

Examining Financial Strain and Subjective Social Status in Terms of Behavioral Health Among Latinx Adults in a Federally Qualified Health Center

There is a growing recognition that Social Determinants of Health (SDoH) can inform some sources of physical and mental health disparities among the Latinx population. The current study sought to expand previous research by exploring the singular and interactive influence of financial strain and subjective social status-two common and clinically important SDoH factors-on pain intensity, pain disability, general depression, social anxiety, and anxious arousal. The current sample consisted of 155 Latinx adults (81.3% female; Mage = 40.02 years, SD = 10.61) presenting for care at a Federally Qualified Health Center (FQHC). Multivariate results demonstrated that financial strain was statistically significantly associated with greater pain intensity, pain disability, general depression, and anxious arousal, but not social anxiety. Further, lower subjective social status was related to greater general depression, social anxiety, and anxious arousal but not with higher levels of pain indices. An interactive effect was found wherein the combination of higher levels of financial strain and low levels of subjective social status was related to general depression and anxious arousal. This is the first study to empirically evaluate the main and interactive effects of financial strain and subjective social status regarding numerous physical and mental health symptoms. These findings clarify how two prevalent SDoH factors influence health outcomes. Specifically, the results suggest that a multi-risk conceptualization can advance a fine-grained understanding of Latinx health disparities by showing differential associations between SDoH factors and clinical outcomes that are frequently the source of health inequities in the Latinx population.

Perceived Scarcity Across Sociodemographic Backgrounds Predicts Self-Reported Health

Abstract. Background: Perceived scarcity shows promise as an indicator of physical and mental health and a possible predictor of health disparities; however, a systematic investigation of how perceived scarcity is experienced across racial and ethnic, gender, and socioeconomic groups is imperative. Moreover, it is necessary to unpack the unique predictive power of each scarcity domain. Aims: First, differences in the experience of perceived scarcity by various sociodemographic groups in overall perceived scarcity and each of its three dimensions were explored using a cross-sectional sample. Next, using self-reported health outcome data collected from participants at a second time point, the direct and mediating role of perceived scarcity in the relationship between sociodemographic indicators and self-reported health was examined. Method: Participants included a racially and socioeconomically diverse online sample. One-way analyses of variance (ANOVAs) and t-tests were used to assess whether perceived scarcity, overall and by domain, varied by sociodemographic factors. PROCESS macro for SPSS v 3.5 was used to analyze the proposed direct effects and mediations. Results: Results indicate that sociodemographic differences do exist in perceived scarcity and in a variety of ways that may not be reflected when solely examining overall perceived scarcity. Dimensions of perceived scarcity were found to mediate the relationship between some sociodemographic factors and self-reported health. Limitations: Future research should address the limitations of the current study’s sample insofar as recruiting a wider sample of participants to include those experiencing the most extreme forms of scarcity. Conclusion: Findings support the importance of considering the unique experience of perceived scarcity by domain across sociodemographic groups when using it as a predictor or mediator of health.

The impact of patient-centred care on the relationship between access to care and subjective health outcomes amongst people experiencing homelessness: A mediation analysis

People experiencing homelessness (PEH) have stated that impersonal care and feelings of discrimination are barriers to accessing healthcare which is associated with poor health outcomes amongst PEH. This study examined whether patient-centred care (PCC) mediates the relationship between access to care and subjective health outcomes. Using the 2014-15 Healthcare Center Patient Survey, we identified 1873 homeless and vulnerably housed adults. Items related to the delay or inability to receive primary or mental healthcare, PCC provided by healthcare providers, general health status, and the Kessler-6 psychological distress scale were selected. Ordinary least squares analyses were used to perform mediation analysis. We found that both access to primary care and access to mental healthcare were positively associated with physical health status (β = 0.492, p < 0.001; β = 0.311, p < 0.001) and negatively associated with psychological distress (β = -2.53, p < 0.001; β = -1.85, p < 0.001). PCC partially mediated all associations, but the mediation was stronger in the relationships between access to primary care and health outcomes (ab = 0.25, 95% CI [0.002, 0.052]; ab = -0.21, 95% CI [-0.37, -0.07]) compared to mental healthcare (ab = 0.02, 95% CI [0.01, 0.04]; ab = -0.14, 95% CI [-0.25, -0.06]). The results of this study indicated access to primary and mental healthcare is important in the patient-centred health outcomes of PEH. Additionally, the partial mediation of PCC in these relationships indicated that participants' perception of collaborative, trustworthy, respectful care from healthcare providers impacted the relationship between access to healthcare and health outcomes.

How does subjective social status affect internalizing and externalizing problems among Syrian refugee adolescents?

Although previous studies found the importance of community subjective social status for adolescent health, its relationship with mental health problems among refugee adolescents is unclear. To close this gap, we examined the nature of the relationship between subjective social status and externalizing problems in refugee adolescents. We carried out a cross-sectional study among three hundred and six 11–18-year-old Syrian refugee adolescents in Turkey. The measurements of the study were the MacArthur Scale of Subjective Social Status, Strengths and Difficulties Questionnaire (SDQ), the Depression Self Rating Scale for Children (DSRS-C), and the Spence Children’s Anxiety Scale (SCAS). The results supported the idea that adolescent’s community subjective social status may affect internalizing problems directly and externalizing problems indirectly via internalizing problems. The mediation effect of the internalizing problems on the relationship between subjective social status and externalizing problems were confirmed by three separate mediation models. The results were discussed in terms of previous literature.

Are stress-related pathways of social status differentiation more important determinants of health inequities in countries with higher levels of income inequality?

We explored socioeconomic gradients in self-rated overall health (SROH) using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial perspectives (subjective social status (SSS)) among adults living in countries with varying levels of income inequality, and the importance of psychosocial stress in mediating these associations. If psychosocial processes at the individual and societal levels correspond, associations between SSS and SROH should be higher among adults in countries with higher income inequality, and psychosocial stress should be a more important mediator of these associations. We used multigroup structural equation models to analyse cross-sectional data from the International Food Policy Study of adults (n = 22,824) in Australia, Canada, Mexico, the UK and the United States. Associations between SSS and SROH were not higher in more unequal countries, nor was psychosocial stress a more important mediator of these associations. Inequities in SROH in more unequal countries may not predominantly reflect stress-related pathways of social status differentiation.

Factors That Influence Quality of Life in People Experiencing Homelessness: A Systematic Mixed Studies Review

BACKGROUND

An emerging category of morbidity in research among people experiencing homelessness (PEH) is quality of life (QoL). The Commission on Social Determinants of Health (CSDH) framework was used to explain the relationship between the resulting factors and their impact on QoL among PEH.

AIMS

The purpose of this systematic mixed studies review was to explore the factors that are associated with QoL among homeless individuals.

METHOD

A systematic mixed studies review was conducted using CINAHL, Medline, PubMed, and SocIndex databases. Quantitative, qualitative, and mixed methods studies were included and synthesized employing results-based convergent synthesis design.

RESULTS

The initial search resulted in 757 studies with 55 studies meeting the inclusion criteria. Thematic analysis revealed themes influencing QoL among PEH categorized by the CSDH determinants of structural, social cohesion and social capital, and intermediary determinants. Among these themes, higher social status, strong relationships, better reported physical and mental health, and a positive life outlook were associated with increased QoL. Social isolation, substance use, poorer life outlook, increased years spent homeless, and perceived quality of housing were associated with decreased QoL. Age, sex, and housing programs revealed inconsistent results on QoL.

CONCLUSIONS

While the factors presented in this review indicate some consistent relationships with QoL in PEH, this review has shown QoL among this population is complex and multifactorial. Future research should focus on relationships between the CSDH determinants, particularly the psychosocial factors and the QoL priorities defined by PEH, and how they may influence QoL among PEH.

Stress-Related Poor Diet Quality Does Not Explain Socioeconomic Inequities in Health: A Structural Equation Mediation Analysis of Gender-Specific Pathways

BACKGROUND

Psychosocial stress and diet quality individually mediate associations between socioeconomic position (SEP) and health; however, it is not known whether they jointly mediate these associations. This is an important question because stress-related unhealthy eating is often invoked as an explanation for diet-related health inequities, particularly among women, seemingly with no empirical justification.

OBJECTIVE

This study examined whether psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women and men.

DESIGN

Multiple mediating pathways were modeled using data from the cross-sectional International Food Policy Study.

PARTICIPANTS AND SETTING

Data were collected from 5,645 adults (aged 18 years or older) in Canada during 2018 and 2019.

MAIN OUTCOME MEASURES

Participants reported SEP using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial pathways (subjective social status), along with psychosocial stress, dietary intake (to assess overall diet quality via Healthy Eating Index-2015 scores), and self-rated health.

STATISTICAL ANALYSES PERFORMED

Structural equation modeling modeled pathways linking SEP (ie, educational attainment, perceived income adequacy, and subjective social status) with self-rated health mediated by psychosocial stress and diet quality, stratified by gender.

RESULTS

There was no evidence that psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women or men. Diet quality mediated associations between educational attainment and self-rated health in women and men, with some evidence that it mediated associations between subjective social status and self-rated health in men (P = 0.051). Psychosocial stress mediated associations between perceived income adequacy and self-rated health in women and men, and between subjective social status and self-rated health in women.

CONCLUSIONS

Although often invoked as an explanation for diet-related health inequities, stress-related poor diet quality did not mediate associations between SEP and self-rated health in women or men. Psychosocial stress and diet quality individually mediated some of these associations, with some differences by gender.

Subjective social status, objective social status, and substance use among individuals with serious mental illnesses

Subjective social status (SSS) and objective socioeconomic status (OSS) may appear to be similar social determinants of mental health, but are actually independently associated with diverse health outcomes including substance use and substance use disorders (SUDs). Such associations have not been examined among individuals with serious mental illnesses (SMI) despite their high prevalence of comorbid substance use; frequent treatment and recovery complications associated with such use; and high levels of economic disadvantage, discrimination, and inequities in this marginalized population. These psychosocial adversities manifest as poor mental illness outcomes, poor physical health, and early mortality in populations with SMI. We hypothesized that both SSS and OSS would predict substance use severity and SUD diagnoses in 240 patients with SMI. SSS, measured by the MacArthur Scale of Subjective Social Status, was unassociated with a composite measure of income and education used to operationalize OSS. Additionally, SSS and OSS were differentially associated with various types of substance use disorders. Only OSS was associated with whether individuals smoked cigarettes, or the level of nicotine dependence. Conversely, only SSS was associated with drug use severity. Our results shed light on the potential for differential impacts of SSS and OSS among persons with SMI.

Predictors of Overnight and Emergency Treatment among Homeless Adults

High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.

Development and initial validation of the Perceived Scarcity Scale

Though socio-economic status (SES) partially explains the experience of stress and health outcomes, most research to date has relied on a small number of traditional indicators that fail to capture the full domain of socioeconomic factors. The recent reconceptualization of perceived scarcity is proposed as a subjective indicator of SES when attempting to predict both stress and health outcomes. Although a conceptualization of perceived scarcity has been advanced, a psychometrically sound scale is needed to assess the utility and scientific import of this concept. No such scale exists. Therefore, the current paper describes the development, psychometric properties, and initial validation of the Perceived Scarcity Scale (PScS). Four studies using traditional scale development processes were employed to develop (Studies 1 and 2) and provide an initial validation (Studies 3 and 4) for the PScS. Results support the existing model of perceived scarcity and indicate that the measure is valid. Moreover, the scale predicted concurrent perceived stress, as well as longitudinal ratings of perceived stress, global health, quality of life, and symptoms of depression and anxiety. The development of the new scale provides clinicians and researchers with a brief, validated measure that can assess the level of perceived scarcity individuals currently experience.

Unemployment and mental health in the German population: the role of subjective social status

Purpose

Subjective social status (SSS) reflects individuals’ perceived position in a social hierarchy. Low SSS is associated with several mental health impairments. The aim of this cross-sectional study was to examine if unemployed individuals report lower SSS in Germany (national SSS) and lower SSS in their social community (local SSS) than employed individuals. Moreover, the relationship between unemployment, SSS, and mental health was examined.

Patients and methods

113 unemployed and 1117 employed individuals from a representative German panel provided information on their national and local SSS, their monthly income and their mental health. SSS was assessed with the German version of the MacArthur Scales. Mental health was measured using the mental component scale (MCS) of the SF-12.

Results

Unemployed individuals reported significantly lower national SSS, local SSS and mental health compared to employed participants. Mediational analyses suggest that the negative effect of employment status on mental health was explained via a reduction of national SSS. Local SSS did not mediate the association of employment status and mental health.

Conclusion

Unemployment is associated with lower SSS and reduced mental health. The perceived position relative to others in the country (ie, national SSS) mediates the association between employment status and mental health.

Characterizing Discrimination Experiences by Race among Homeless Adults

Objectives: Among domiciled samples, racial discrimination is a known stressor linked with poorer quality of life. However, homeless adults may be particularly vulnerable to discrimination due to multiple factors beyond race. In this study, we characterized perceived discrimination and its reported impact on quality of life in a sample of adults who were homeless. Methods: Homeless adults recruited from Oklahoma City self-reported their socio-demographics, past discrimination experiences, and their impact on quality of life via the MacArthur Major Experiences of Discrimination Questionnaire. Descriptive statistics and frequencies were used to characterize perceived discrimination experiences and impact. Racial differences were examined using ANO- VAs/Kruskal-Wallis tests and chi-square tests. Results: Discrimination experiences attributed to homelessness were common and consistent between the races. Black adults perceived significantly more lifetime discrimination experiences than white adults, and attributed the majority to race. Relative to Whites and American Indians, black adults were more likely to endorse links between discrimination and having a harder life. Conclusions: Results suggest that black homeless adults may represent the most vulnerable racial subgroup for hardships in life as a conse- quence of perceived discrimination among homeless adults.

Health-Related Quality of Life Among Homeless Smokers: Risk and Protective Factors of Latent Class Membership

Health-related quality of life (HRQoL) is a multidimensional assessment of well-being and health status. Most work in this area assumes that HRQoL is a homogenous construct; however, it is possible HRQoL subgroups may exist. The purpose of the study was to characterize common classes of HRQoL among adult, homeless smokers, a particularly vulnerable group of the larger population, and to evaluate risk and protective factors of HRQoL class membership. Homeless smokers (N = 456; 65.1% male; M_age = 43.19 years [SD = 11.77]) completed self-report measures of sociodemographics, smoking characteristics, anxiety sensitivity, stress, social support, and the Center for Disease Control (CDC) four-item HRQoL measure. A latent class analysis was conducted for HRQoL. Multinomial regression models were used to simultaneously test correlates of class membership. A three-class solution, consisting of poor HRQoL, moderate HRQoL, and excellent HRQoL, demonstrated superior fit. Correlates of class membership included sex, age, lifetime months of being homeless, smoking characteristics, anxiety sensitivity, stress, and social support. The current findings provide novel evidence for three distinct classes of HRQoL among homeless smokers. Results suggest that older smokers with greater emotional distress, as evidenced by greater anxiety sensitivity, greater stress, and less social support, may be particularly vulnerable to poorer HRQoL.

Cigarette Smoking among Women Who Are Homeless or Unstably Housed: Examining the Role of Food Insecurity

Smoking prevalence remains high among individuals who are homeless, partly due to stressors related to homelessness. Beyond housing insecurity, homelessness involves financial stresses and unmet subsistence needs. In particular, food insecurity contributes to negative health outcomes and other health risks. This study examined associations between food insecurity severity and smoking among homeless and marginally housed women in San Francisco, California. We used data from 247 women from a longitudinal cohort study. Generalized estimating equations were used to estimate longitudinal associations between study factors and smoking based on data from five biannual assessment points between 2009 and 2012. The longitudinal adjusted odds of smoking were higher among severely food insecure individuals compared to those who were not food insecure (AOR = 1.68, 95% CI [1.02, 2.78]), while associations with other study factors, including demographics, time, HIV status, mental health, and substance use (except marijuana use), did not reach levels of significance. Similar adjusted longitudinal results were observed when food insecurity was the dependent variable and smoking an independent variable, suggesting the possibility of a bidirectional association. Considering unmet needs, such as food and hunger, may improve comprehensive smoking cessation strategies targeting individuals for whom mainstream tobacco control efforts have not been effective. Similarly, offering improved access to smoking cessation resources should be considered in efforts to address food insecurity among individuals experiencing homelessness.

Support Buffers Financial Strain's Effect on Health-related Quality of Life

OBJECTIVES

Financial strain represents a perceived inability to meet financial needs and obligations and is associated with poorer health outcomes. Distinct facets of perceived social support may mitigate the deleterious effects of financial strain on health. In the present study, we examined the extent to which appraisal, belonging, and tangible social support ameliorate the effects of financial strain on health-related quality of life (HRQoL).

METHODS

A community sample (N = 238; 67.2% female; MAge = 43.4 years, SD = 13.1) completed inperson surveys as part of a larger study of health behaviors.

RESULTS

Greater financial strain and less social support were associated with poorer HRQoL. Additionally, both appraisal and belonging support moderated the effects of financial strain on some HRQoL components, such that higher appraisal and belonging support were associated with diminished effects of financial strain on HRQoL.

CONCLUSIONS

These findings suggest nuanced associations between financial strain and HRQoL. We discuss the implications for prevention and intervention programs.

The Feasibility of an Exergaming Program in Underserved Older African Americans

The study tested the feasibility and efficacy of an exergaming program in underserved older African American communities. The study is a single-group with pre- and posttest design. Twelve female participants ( M age = 64.17 ± 6.74 years) completed an exergaming program once or twice a week for 24 sessions over 14 weeks. Community health workers implemented the program through coaching and supporting mechanisms to motivate participants to exercise. A mixed-methods analysis was used to assess the intervention. After the program, participants showed significant improvements in lower body flexibility ( p = .012), and physical health-related quality of life ( p = .005). Four themes were identified related to the self-reported benefits of the exergaming program: (a) improving health, (b) feeling enjoyment, (c) getting connected, and (d) knowing you. The exergaming program provides an easy-to-implement and potentially effective intervention that can be used in community-directed centers to improve health and well-being in the underserved population.

Psychosocial Mechanisms Linking the Social Environment to Mental Health in African Americans

Resource-poor social environments predict poor health, but the mechanisms and processes linking the social environment to psychological health and well-being remain unclear. This study explored psychosocial mediators of the association between the social environment and mental health in African American adults. African American men and women (n = 1467) completed questionnaires on the social environment, psychosocial factors (stress, depressive symptoms, and racial discrimination), and mental health. Multiple-mediator models were used to assess direct and indirect effects of the social environment on mental health. Low social status in the community (p < .001) and U.S. (p < .001) and low social support (p < .001) were associated with poor mental health. Psychosocial factors significantly jointly mediated the relationship between the social environment and mental health in multiple-mediator models. Low social status and social support were associated with greater perceived stress, depressive symptoms, and perceived racial discrimination, which were associated with poor mental health. Results suggest the relationship between the social environment and mental health is mediated by psychosocial factors and revealed potential mechanisms through which social status and social support influence the mental health of African American men and women. Findings from this study provide insight into the differential effects of stress, depression and discrimination on mental health. Ecological approaches that aim to improve the social environment and psychosocial mediators may enhance health-related quality of life and reduce health disparities in African Americans.