Socioeconomic Disparities in Health Outcomes in Adolescence

A growing literature suggests that SES has a profound influence on a variety of health outcomes in adolescence, ranging from adolescents' perceptions of their own health to objective outcomes such as mortality.

Several large, cross-sectional studies have concluded that adolescents growing up in low SES environments generally experience greater mortality risks than their peers from higher SES families. For example, low SES youth are more likely to die from a number of causes, including pneumonia and influenza, fire, poisoning, and homicide (Nelson, 1992; Nersesian et al, 1985). In one of very few longitudinal studies, mothers were interviewed about SES at the time of their child's birth and families subsequently followed

A. Steptoe (ed.), Handbook of Behavioral Medicine, DOI 10.1007/978-0-387-09488-5_37, © Springer Science+Business Media, LLC 2010

until the children had reached age 20 (Oliveira et al, 2007). Low parental occupation at birth was predictive of greater adolescent mortality due to external causes, particularly among boys. Hence the existing data suggest that low SES environments increase adolescents' risk for premature mortality due to a wide range of causes across the adolescent years.

Most studies investigating health disparities in adolescence have focused on overall health status. Many of these studies draw from large, nationally representative samples. For example, two studies using large samples of US adolescents found that after accounting for other sociodemographic factors, low familial SES, measured through the family's income and parental education, was associated with below average self-rated physical health status and a greater likelihood of reporting fair to poor health (Caputo, 2003; Goodman, 1999). Similarly, in a British study (Emerson et al, 2005) lower household income was associated with lower health status as measured by a wide range of indicators, including overall health status, current physical illness, and disabilities, reported by parents and teachers. More recent research is beginning to indicate that adolescents' subjective perceptions of familial SES may be just as good, if not better, predictors of their health. Several studies have reported that adolescents' subjective perceptions and reports of family SES predicted self-reported health status and quality of life and did so even after objective and parent-reported indicators of family SES had been taken into account (Goodman et al, 2007; von Rueden et al, 2005; Piko and Keresztes, 2007). von Rueden and colleagues (2005) also demonstrated that the relationship between youth's perceptions of family wealth and health status as well as quality of life was much stronger among adolescents than children, suggesting that as youth become older their subjective perceptions of familial wealth may become increasingly important.

Symptom reports among adolescents also reveal SES disparities. Starfield et al (2002) found that lower SES, as measured by parents' income, was associated with a greater likelihood of adolescents reporting fair to poor health, physical activity limitations, bed-days, and restricted activity days. Huurre et al (2005) found that manual class origin was associated with higher rates of psychosomatic symptoms among adolescent females, but not males. Finally, one study found that low and high parental income is linked to different types of physical health symptoms (Rhee, 2005). Low SES youth's primary complaints included feeling hot, chest pain, urinary problems, and cold sweat, whereas high SES youth were more likely to complain about musculoskeletal pains.

Together, these studies suggest that SES influences not only symptom prevalence but also the types of symptoms that are reported. Overall, however, low SES adolescents tend to report greater symptoms, mirroring the findings for the relationship between SES and self-reported overall health.

We next provide examples using several specific types of health outcomes. For example, with respect to obesity, studies are fairly consistent in suggesting that low SES is associated with a greater likelihood of being obese among adolescents (e.g., Ahn et al, 2008; Goodman, 1999; Vieweg et al, 2007). For example, a longitudinal study (De Spiegelaere et al, 1998) followed adolescents from age 12 to 15 and tracked their obesity status. Consistent with other studies they found a relationship between low SES and increased risk of obesity. In addition, the gap between low and high SES youth also widened over time, indicating that existing SES differences may be further accentuated during adolescence. For a review on the negative impact of low SES on adolescent obesity, see Shrewsbury and Wardle (2008).

SES-based differences in adolescent sexual health have also been reported. For example, black adolescent females from low SES neighborhoods were more than twice as likely to report gonorrhea if their parents were unemployed, possibly indicating that youth from low SES neighborhoods are more likely to be part of high-risk sexual networks (Sionean et al, 2000). Similarly, Newbern et al (2004) reported data from a national sample in which lower and nonprofessional maternal education were related to higher rates of sexually transmitted infections (STIs) in adolescents, except for white females. Overall, higher rates of STIs were found among adolescents from one-parent homes. Note, however, that not all studies find relationships between SES and STIs (e.g., see Goodman, 1999; Santelli et al, 2000). Together these studies suggest some, although not definitive, evidence for a relationship between SES and adolescent sexual health.

Previous research furthermore points to SES differences in teenage pregnancy rates. US teenage women who become pregnant are more likely to come from low SES families (Boardman et al, 2006) and a British study examining teenage pregnancies in England across a 10-year period similarly reported higher mean conception rates in more deprived areas (Wilkinson et al, 2006). A study investigating teenage pregnancies among a sample of Scottish teenage women compared teenagers who gave birth with teenagers who also reported sexual intercourse but did not get pregnant and found that those who got pregnant were more likely to come from lower SES families (Buston et al, 2006). This suggests that the difference in teenage pregnancy rates between low and high SES teens may at least in part be explained by differences in contraceptive use and not simply differences in sexual activity. Finally, teenage women from low SES backgrounds also experience greater intended as well as unintended rapid repeat pregnancies, meaning they were more likely to become pregnant again within the 24 months following their first pregnancy (Boardman et al, 2006; Raneri and Wiemann,

SES has also been linked to chronic illness outcomes in adolescents. For example, adolescents from lower income families have overall poorer asthma control, even after taking into account controller medication use and primary care service utilization (Cope et al,

2008). Adolescents from low SES families are also more likely to live with undiag-nosed frequent wheezing (Yeatts et al, 2003), experience less preventive care (fewer general check-ups and prescription fills; Kim et al, 2009), and are more likely to have been previously hospitalized because of their asthma (Dales et al, 2002). Hence, low SES affects not only the prevalence of health problems but also how illnesses are experienced and managed.

Finally, research has examined SES differences in adolescent rates of injuries. These studies seem inconclusive at first as they often fail to find differences by SES in the number of total injuries (e.g., Simpson et al, 2005; Williams et al, 1997) or find different directions of associations for different SES measures (Potter et al, 2005). Closer examination of the available data, however, suggests that differences in types of injuries may help explain different patterns within different SES groups. Rauscher and Myers (2008) for example found a dose-response relationship between SES and work-related injuries among adolescents. After controlling for hours worked per week, work history, and race, there was a 30% increase in injuries among adolescents whose mother had a low education as opposed to high education background. In addition, while Simpson et al (2005), using cross-sectional Canadian data, also did not find a clear direction for overall injury rates, adolescents from low SES environments were at greater risk for being hospitalized due to injury as well as for reporting fighting injuries. These patterns suggest that injuries among low SES adolescents may result in part from interpersonal conflict and unsafe physical environments, such as unsafe neighborhoods or work environments. In contrast, higher SES adolescents appear to be at greater risk for recreational and sports injuries (Simpson et al, 2005; Williams et al, 1997). This may be in part because low SES youth are less likely to be able to afford such activities. In sum, adolescents from different SES groups appear to be vulnerable to different types of injuries. In particular, youth from low SES environments are at an increased risk from work-related injuries, injuries resulting from interpersonal conflict, and road injuries, whereas youth from high SES environments are at increased risk for sports injuries.

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