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International Journal of Adolescent Medicine and Health. 2017; 20170079

Katharina Diehl1 / Jens Hoebel2 / Diana Sonntag3,4 / Jennifer Hilger3

Subjective social status and its relationship to health and health behavior: comparing two di昀ferent scales in university students 1

Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Straße 7-11, 68167 Mannheim, Germany, Phone: +49 621 383 9602, Fax: +49 621 383 9920, E-mail: [email protected] 2 Unit of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany 3 Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany 4 Department of Health Sciences, University of York, York, UK Abstract: Background: Little is known about the relationship between socioeconomic status (SES) and health in late adolescence. As it is difficult to measure SES in this age group directly, we used two subjective social status (SSS) scales with different reference groups for social comparison in the relatively homogeneous group of university students and analyzed the relationship with health and health behaviors. Methods: We used two 10-rung ladders, a societal and a university one, to measure SSS in students (n = 689, 16–29 years). We compared the scales’ ratings and analyzed relationships with sociodemographic factors, health outcomes and behaviors. Results: On average, students rated their individual SSS higher on the university scale (6.87) than on the societal one (6.41). Regarding health outcomes and behaviors, we found similar results for both scales, while sociodemographic variables were more likely to be associated with the societal scale. Conclusion: SSS seems to be a useful measure besides the objective SES. Our data suggest that both SSS scales are helpful in the framework of health inequality but differ slightly in what they measure. More detailed research may help to determine which scale is appropriate for individual study context.

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Keywords: adolescence, health, health behavior, socioeconomic status DOI: 10.1515/ijamh-2017-0079 Received: May 4, 2017; Accepted: July 10, 2017

Introduction The relationship between health outcomes and behaviors, on the one hand, and the individual’s socioeconomic status (SES), on the other hand, is well established for children and adults [1], [2]. However, among adolescents this relationship is less clear, with former studies showing inconsistent results [1]. Adolescents’ SES is mainly determined by their parents’ status or their own school performance [3]. However, these measures might not be able to fully reflect the social status within this age group [3], because adolescents start to develop their own SES during their transition to adulthood [1]. Besides being an objective measurement of SES, the subjective social status (SSS) has become more important in health research in the past few decades [4], [5], [6]. The rationale behind including the SSS in health research was the fact that not only objective socioeconomic factors (e.g. income, education and occupation) but also one’s individually perceived standing in a social hierarchy can affect one’s health [4], [7]. To assess the individual SSS, Adler et al. [5] developed the MacArthur Scale of SSS. This instrument presents a “social ladder” in a pictorial format and asks individuals to choose the rung that best reflects their social standing from their point of view [5], [8], [9]. Possibly, the SSS is able to better reflect the social position of adolescents and young adults than objective SES measures, such as income and occupational position of their parents [10]. Previous studies indicate that the individual rating on the SSS scale may be influenced by the reference group selected for social comparison [11]. While individuals are generally asked to rate their position in relation Katharina Diehl is the corresponding author. ©2017 Walter de Gruyter GmbH, Berlin/Boston.

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to the national population, there are other variations of the scale that refer to smaller reference groups, such as the school or community [1], [12], [13]. Although the SSS scale is increasingly used in public health, there is still a lack of studies that investigate differences in the association between the SSS and health outcomes depending on the reference group used for comparison [11]. We therefore aimed to address these gaps in the relatively homogeneous target group of university students, who are at the life stage of late adolescence, by using two SSS scales with different reference groups – a societal and a university-specific one [14]. Our aims were to identify (1) whether individual rating on the two scales differs, (2) which scale has a better fit to sociodemographic characteristics of university students, and (3) whether both scales are associated with health outcomes and health behaviors. The results will be helpful for future studies focusing on or including the subgroup of university students.

Materials and methods Study sample Our analyses are based on data from the cross-sectional Nutrition and Physical Activity (NuPhA) Study. The NuPhA Study is an online survey, which was conducted among university students from all over Germany between October 31, 2014 and January 15, 2015. Participants were recruited via flyers, social networks, mailing lists, and university lectures. They were informed about study aims, data security, and the option of terminating participation at any time. Each participant gave informed consent before filling out the online questionnaire. As an incentive, we raffled off 40 gift cards (20 × €25, 20 × €50) among all participants. Altogether, 689 students filled in the online questionnaire (duration approximately 30 min). The study obtained positive ethics approval by the Medical Ethics Committee of the Medical Faculty Mannheim, Heidelberg University (2013-634N-MA).

Measures

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Subjective social status (SSS) To assess the SSS we used two scales with different reference groups. First, we used the German version of the MacArthur Scale [4], which is a 10-rung ladder measuring respondents’ SSS with reference to the general population in Germany (societal SSS). Second, we created an additional ladder to assess respondents’ perceived social standing with reference to other university students (university SSS). Pictures of both the societal and university ladder (Figure 1) were shown to the students, and they were asked to choose the rung they felt they were on a) compared to the general German population and b) compared to other university students [rung 1 to 10; rung 1 (lowest rung) = lowest status; rung 10 (highest rung) = highest status].

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Diehl et al.

Figure 1: Subjective social status in German University students (NuPhA Study). n = 689 university students. Societal subjective social status = in comparison to the general population in Germany. University subjective social status = in comparison to other university students.

Sociodemographic variables We included the following sociodemographic characteristics in our analyses: gender (male/female); immigrant background, partner status, financial support by parents, public financial support by the Federal Training Assistance Act, and side job (all variables: yes/no); age, amount of money available per month and amount of money available per semester (all continuous variables).

Health-related variables (health outcomes/health behaviors)

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Our aim was to include a range of different variables presenting different health issues that were shown to be related with SES in previous studies. Besides measuring general, mental and physical subjective health [15], [16], we included health related risk behaviors such as alcohol use, e.g. related to parental education [17], [18], parental income [19], and parental unemployment [20] as well as smoking [21], [22]. Additionally, we included use of e-cigarettes as a new potential health-related risk factor as well as body mass index (BMI) and body image as important parameters in the phase of adolescence. Self-rated general health, self-rated mental health, and self-rated physical health were dichotomized into very good/good vs. moderate/bad/very bad. Self-reported weight and height were used to calculate the BMI. We used the BMI as a continuous variable within the analyses. Additionally, we used three categories to describe the individual subjective body image: too thin (much too thin/too thin), just right, too fat (much too fat/too fat). To measure health-related risk behaviors, we assessed students’ current smoking habits (current smoking vs. past/never smoked), alcohol consumption (weekly vs. nonweekly), and use of e-cigarettes (yes/no). Previous studies found associations between SES and depression [14]. Therefore, we included the Patient Health Questionnaire 4 (PHQ-4), which is a four-item measure of depression and anxiety ranging from 0 to 12 [23]. As loneliness as an indicator of subjective social integration was associated with SES in other studies [24], [25] measured emotional loneliness and social loneliness by implementing the German version of the revised UCLA Loneliness Scale, each ranging from 0 to 3 [26].

Statistical analyses To describe the groups of students who differed in their rating of societal and university SSS, we used χ2 statistics and the Kruskal-Wallis H test, respectively. We calculated linear regression models (best fit) to analyze potential associations between societal and university SSS on the one hand and sociodemographic characteristics on the other hand. Additionally, we performed individual linear regression models to analyze the potential associations between societal and university SSS with health outcomes and behaviors. As the residuals of societal and university SSS were not normally distributed, we transformed them for all regression models (square root). p-Values

Subjective social status and its relationship to health and health behavior: comparing two different scales in university students.

Background Little is known about the relationship between socioeconomic status (SES) and health in late adolescence. As it is difficult to measure SES...
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