Relationship between subjective social status and perceived health among Latin American immigrant women

Copyright © 2013 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms. Corresponding Author: Ma Visitación Sanchón-Macias Universidad de Cantabria. Escuela Universitaria de Enfermería Av. Valdecilla s/n CP 39010, Santander, España E-mail: sanchonm@unican.es Ma Visitación Sanchón-Macias1 Dolores Prieto-Salceda2 Andreu Bover-Bover3 Denise Gastaldo4


Introduction
Health inequalities are a major problem in the world.In all societies there is "a social gradient in health", observing that people suffer a progressive deterioration of health as their social position decreases (1) .Identifying the mechanisms determining the social gradient in health allows for the identification of reasons for health inequalities (2) .Socioeconomic status, usually measured by the level of income, education and type of occupation, is an important determinant of health and one of the indicators used for the study of health inequalities (1)(2) .
However, the measurement of socioeconomic status based on objective data may be irrelevant for the study of immigrant groups, as they do not reflect the real situation of these groups (3) .
For example, level of education acquired in their countries is not recognized, and they must share their wages with dependent family members in their home countries.
Subjective social status is defined as a person's belief regarding his position on the social ladder (4) .It is a measurement that includes both socioeconomic factors and the perception of the subjects about their social position.Recent studies show that subjective social status is significantly associated with health (5)(6) .
This can affect health, either directly, causing stress, or indirectly through health behaviors (7) .A low subjective social status has been associated with low self-perceived health, and higher mortality, depression, cardiovascular risk, diabetes and respiratory diseases (5) .
In Spain, starting in the 1990s, coinciding with economic growth, a sudden and rapid immigration originated (8)(9) .In Cantabria, the migratory flow occurred mainly in the decade of 2000, rising from 1.3% in 2000 to 6.6% in 2010.Latin nationalities predominate (46.5%), and within this group there is a greater presence of women (56.5%) than men (43.4%) (10) .
Although Latin American women are the largest group, information about their health is minimal, and no research on the influence of social status on perceived health has been conducted.
The objectives of this study were: a) to examine the association between traditional measurements of socioeconomic status and subjective social status, b) to assess the extent to which socioeconomic status and subjective social status explained differences in perceived health.

Methods
This was a cross-sectional study with an objective to quantify the association between socioeconomic status, subjective social status and perceived health.
The sample was calculated from the data of the National Health Survey of Spain and the frequency of women with perceived health as very bad (1.0%) or poor (50.0%).
We estimated a minimum size of 361, with maximum error of 10% and reliability of 95%, starting from a population of 7,056, according to the Census (8) .
The selection of participants was made using nonprobability sampling, due to the inability to access the records of the Census and the interest in including illegal immigrants.Inclusion criteria were: women born in Latin America, 16-65 years of age, living and working in Spain for at least six months.Data was collected through a self-administered questionnaire in small groups.
Although 16% had failed to finish primary education, they had no trouble answering the questions in the questionnaire.Participants were recruited consecutively through associations and social organizations, between June 2009 and July 2010.They were asked to complete the questionnaire on a voluntary basis, it is not possible to quantify the percentage that was lost, although a large majority followed up with the request.Finally, the "snowball" method was used, which has shown to be a suitable technique for recruiting immigrants, who are less accessible (12) .
The final sample was composed of 371 women, distributed geographically in a similar way to the records of the Census (8) .The study was part of a wider investigation, using a qualitative methodology which aimed to identify the determinants of subjective social status and the mechanisms through which they affected health.

Variables
Perceived health (dependent variable) was assessed through the question In the past 12 months, would you say your health has been: very good, good, regular, bad or very bad.This question has been used in other studies, showing that it is a good predictor of morbidity and mortality, and a good indicator of health in different ethnic groups (13)(14) .To carry out the statistical analysis, the categories "very good" or "good" were combined into a group called positive perceived health, and the categories "regular" "bad" or "very bad" composed the group, negative perceived health.
To assess the socioeconomic status, the sociodemographic questionnaire developed by the MacArthur network was used, which has been validated and used in numerous research projects (5) .
The questionnaire consisted of questions relating to: the level of education, with six possible answers: "no education or primary education", "general secondary education", "technical education or diploma", "university studies", "graduate studies" and "others, specify".
The final categories were grouped into four.Thus, undergraduate and graduate studies were merged into one, called university studies.The category "others" was deleted, due to the lack of answers.Income level included seven possible answers: less than 250 euros; from 250 to 499 euros; between 1,000 and 1,499 euros; 1,500 to 1,999 euros; between 2,000 and 2,999 euros; 2,999 euros per month; and, others, specify.
After the replies, the categories were grouped into four, the last three of which were removed, due to lack of answers.Finally, they were asked about their current job or most recent job activity.Occupations were recorded following the method of the National Classification of Occupations, whose classification criteria were based on the qualifications and type of work performed (15) .Of all the possibilities included, after the replies, these were reduced to four: Unemployed, Level III, Level IV and Level V.In the final analysis, they were pooled into qualified (III and IV) and unqualified (level V).
Other demographic data included: age, country of origin and residence time in Spain, family and friends in Spain (yes / no); economically dependent family members in Spain and in their country (yes / no) legal status (with / without documents / in the process of getting them) health card (with / without / in the process), and health status in relation to their country (better / same / worse).

Statistical analysis
The

Results
There were 371 participants in this study.It was not possible to determine exactly how many refused to answer the questionnaire, or to know the reasons for non-participation.However, the number of participants who rejected it was very small.These circumstances may introduce a selection bias.
The mean age of the female participants was 36.Bivariate analysis results showed that negative health perception increased significantly with age (p=0.041), and those that were at the lowest levels of subjective social status scale assessed their perceived health as negative more often (p=0.005).There was a higher prevalence of negative perceived health in women with no education (p=0.216),those with lower incomes (p=0.272), and the unemployed (p=0.699),although these differences were not statistically significant.above four times higher in women who were at levels 1 Sanchón-Macias MV, Prieto-Salceda D, Bover-Bover A, Gastaldo D.
Table 3 -Logistic regression analysis for negative perceived health (0 = good / very good 1 = fair, poor or very poor) *Confidence interval prevalence odds ratio or 2 (95% CI 1.6 to 11.2) or at levels 3 or 4 (95% CI: 1.9 to 9.9 ) and 2.3 times higher in those who were at levels 5 or 6.Regarding the other variables, the negative perception of health varied, although not significantly, depending on the level of education, income, legal status and social support.Finally, the perception of poor health did not vary according to the years that women had been residing in Spain.

Discussion
Our hypothesis was that subjective social status would explain differences in perceived health better than socioeconomic status in the group of immigrant women.
This hypothesis was confirmed after adjusting for age, education level, income, legal status, social support and time residing in Spain.
We found a weak association between the measurements of socioeconomic status and perceived health.These results, in part, differed from the literature in which a significant relationship between indicators of socioeconomic status and perceived health has been demonstrated in other groups (1)(2)(3)(4)(5)(6) .In addition to an insufficient sample, several reasons may explain the lack of association between objective measurements of the status and perceived health status in this study.
For immigrant women, indicators of socioeconomic status may have different meanings than for the general population.Equal levels of income or education may not provide them with the same benefits as the local population.For example, the educational level obtained in their home countries did not provide them with benefits as they are unable to have their degrees accepted within Spain.Their experience or professional qualifications were also not recognized, so they were forced to accept jobs that required low skills, and they had to share their wages with other dependent family members, both in Spain and in their countries of origin.
These reasons may explain why the pattern found in this group of Latin American women did not coincide with that of the general population, in terms of the relationship between education, occupation and income to perceived health.
Recent studies (17) have shown that the health of immigrants was influenced by the migration process, family status, social resources, working conditions, expectations or experiences of discrimination.Other authors found similar results to those in this study (18) , indicating that the indicators of socioeconomic status were irrelevant for studying immigrant groups because they did not capture the actual socio-economic situation of these groups, introducing limitations to the study of health inequalities.
Subjective social status was based on indicators of socioeconomic status.That is, individuals who developed better subjective social status were likely to have higher incomes, higher levels of education and a better occupation.However, in this study, only subjective social status maintained a significant relationship with income, reflecting the importance that these women gave to economic security.An explanation of these results may be that there are other determining factors of social position linked to gender, ethnicity or discrimination, which influenced the assessment of their social status and explained the relative importance of socioeconomic status indicators.Previous studies have found similar results between socioeconomic status and subjective social status (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) .The authors argued that subjective social status was based on indicators of socioeconomic status, but that this relationship was weaker in people from ethnic minorities.Although the measurements of socioeconomic status were major determinants of subjective social status, the groups that were socially disadvantaged tended to establish their status using other criteria derived from context.
The only predictor variable of negative perceived health in the population studied was subjective social status, highlighting the importance of this measurement in assessing the perceived health in this population.
As in previous research, it was shown that subjective social status assessment provided information about health that could not be captured by socioeconomic status (16)(17)19) . In tis study, as in the studies cited, it became clear that, regardless of their social or material circumstances, the way in which women considered their social position was a significant predictor of their perceived health status.
The explanation as to why the subjective social status significantly affected perceived health can be explained when one notes that it captured information about the social position of women, as well as impressions about their socio-economic and labor circumstances that were not achieved with the traditional indicators of socioeconomic status (4) .For example, poor working conditions, problems of discrimination, unfulfilled expectations, few social opportunities, irregular legal status or other social or cultural barriers when compared to the indigenous group.The perception of a low position on the social ladder could generate high levels of stress and the development of unhealthy behaviors that affected their health (7) .On the contrary, high levels of subjective social status may have provided psychological resources to people, such as higher self-esteem, security, hope and feelings of control, which were important resources for health (4) .
With the data obtained, it is not possible to explain what mechanisms mediated the association between subjective social status and perceived health.This article is part of a larger investigation in which we explored the determinants of subjective social status and mediating mechanisms between subjective social status and health, using a qualitative methodology.

Limitations
Since the sample was captured through social centers, where the women came with socioeconomic problems, our results may overestimate the number of women with these problems and the true prevalence of perceived health.There may also be a bias because of those refusing to participate, as well as for those who did not answer the questions.Furthermore, because the data was collected transversely, and due to temporary ambiguity bias, the results cannot assess causal relationships.Despite these limitations, the data from this study can be used to illustrate the relationships that occurred between socioeconomic status, subjective social status and perceived health in Latin American immigrant women.However, more studies are needed with larger random samples.

Conclusion
The results of the study suggested that subjective

Table 1 -
Description of the study population and

Table 3
age.Significantly higher prevalence odds of negative perceived health were observed in the lowest levels of the MacArthur scale, regarding levels 7 or 8 taken as reference (since very few cases were at levels 9 or 10);