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Social Science & Medicine 69 (2009) 1460–1467

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Social Science & Medicine

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Can subjective and objective socioeconomic status explain minority healthdisparities in Israel?q

Orna Baron-Epel a,*, Giora Kaplan a,b

a School of Public Health, Faculty of Social Welfare and Health Studies, University of Haifa, Israelb 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

Article history:Available online 16 September 2009

Keywords:IsraelDisparitiesSubjective socioeconomic statusObjective socioeconomic statusQuality of lifeGenderMulticultural

q Funding: The study was founded by a grant fromfor Health Policy and Health Services Research.

* Corresponding author.E-mail address: ornaepel@research.haifa.ac.il (O. B

0277-9536/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.socscimed.2009.08.028

a b s t r a c t

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 examinesthe relationship between health and socioeconomic status in this multicultural population and assessesto 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 question-naire measured physical and mental health-related quality of life using the Short Form 12. Informationregarding 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 tonon-immigrant Jews. Immigrant and Arab men and women had worse mental health compared to non-immigrant Jews. Multivariable log-linear regression analysis adjusting for age, SSS or SES explained thedisparities in physical health between Arab and non-immigrant Jewish men. However, SSS and SES didnot explain the disparities in physical health between the three groups of women. The disparities inmental health between immigrants and non-immigrant Jews can be explained by SSS for both men andwomen, whereas the disparities between Arabs and Jews can be explained by objective SES only amongwomen. Employed men reported better physical and mental health. Part of the disparities in mentalhealth in Israel can be attributed to differences in SSS and SES in the different groups. However, there isa 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.

� 2009 Elsevier Ltd. All rights reserved.

Introduction

Gaps in health between various sub-populations have beenreported consistently over the years in many societies and muchresearch has gone into understanding what stands behind theseinequalities or disparities. These gaps may be due to biology,environment, behavior, healthcare and social factors (Adler &Rehkopf, 2008; Braveman, 2006). Understanding the causes ofthese disparities may help to improve the health of deprivedpopulations.

One major and consistent cause of health disparities is socio-economic status (SES) and the association between health and SESis well documented and has been found in almost every nation that

The Israel National Institute

aron-Epel).

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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 isfar from understood.

Most of the studies on SES and health use measures of socialstatus such as income, education and employment, which repre-sent 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 influ-ences health but the psychosocial impact of low social class, thelarger the inequalities in the society the larger the psychosocialimpact of low social class. Lately studies have shown thatthe effect of social status on health may depend also on theindividual’s perception of his/her relative placement in the socialhierarchy, the later being a more general and subjective measureof social status (SSS).

Since the development of a scale to measure SSS (Adler, Epel,Castellazzo, & Ickovics, 2000) much research has looked at theassociation between SSS and various health measures such as self-

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467 1461

reported health (Adler et al., 2008; Franzini & Fernandez-Esquer,2006; Singh-Manoux, Marmot, & Adler, 2005), mental health andphysical health (Franzini & Fernandez-Esquer, 2006; Singh-Manouxet al., 2005), self-reported diseases (Singh-Manoux, Adler, &Marmot, 2003), and depression (Adler et al., 2008; Singh-Manouxet al., 2003). SSS seems to be strongly associated with health evenafter controlling for the objective socioeconomic measures such asincome, education and employment. This suggests that thepsychological perception the individual has of his/her position insociety may be more important in influencing health than theactual employment, income and education he or she has (Adleret 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 compareddifferent ethnic groups within the USA (Franzini & Fernandez-Esquer,2006; Ostrove et al., 2000). Other studies have looked at Europeanand Asian populations (Hu et al., 2005; Kopp, Skrabski, Rethelyi,Kawachi, & Adler, 2004). Although in most studies a similar pictureemerges, the relationship between SSS, SES and health may differ invarious ethnic groups (Adler et al., 2008). For example, SSS wasassociated with self-reported health in White and Chinese Americansafter adjusting for the objective indicators of SES, but not in Latinasand African Americans, where only education and income weresignificant predictors of self-reported health (Ostrove et al., 2000).

Israel seems to be a good setting to further investigate therelationship between SSS, SES and health because of the multi-cultural and multi-ethnic character of its population, its social andeconomic western lifestyle, a highly developed national healthcaresystem and a universal national health insurance to which all thepopulation 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; immi-grants who during the last two decades are mainly from the formerSoviet Union (fSU) and Arab citizens. During 1990–2006 a largeimmigration wave from the fSU arrived in Israel, including 937,100immigrants (13.3% of the population in 2006) (Central Bureau ofStatistics, 2005). About 55% of the immigrants arrived during thefirst 5 years of the immigration wave and about 14% of them arrivedin Israel since 2000 (Central Bureau of Statistics, 2005). Theimmigrants are entitled to all national services on immigration,including healthcare services. Immigrants differ in their culture andlanguage from non-immigrant Jews. Studies have reported lowerlevels of self-reported health among these immigrants (Baron-Epel& Kaplan, 2001). In addition, self-reported disease prevalence rateswere reported to be high among the fSU immigrants compared towestern countries (Gad, Nurit, Ada, & Yitzhak, 2002).

Arabs living within the state of Israel comprised 19.8% of thepopulation in 2006 (about 1.4 million people) and are also entitledto all national services provided by the state. Arabs and Jews differin religion, culture, and language. The mortality and morbidity ofthe Arab population is higher than the Jewish population and lifeexpectancy is lower (Israel Center for Disease Control, 2005). Arabsalso have higher levels of emotional distress and lower self-appraisal of mental health (Levav et al., 2007). The Arabs are mostlysegregated in their living areas, only a small percentage live inmixed towns or cities, and more Arab communities are rural. Arabsin Israel are largely an underprivileged minority with a history ofdisadvantage in income, education and employment (Okun &Friedlander, 2005).

The objectives of this study were to examine the relationshipbetween self-reported health status and objective and subjectivesocioeconomic measures in a multicultural population and to assesto what extent do subjective and objective socioeconomicmeasures explain the disparities in self-reported health between

the two minority groups, Arabs and fSU immigrants, and themajority of non-immigrant Jews in Israel.

Methods

The sample

This is a cross sectional study, based on a random sample of theIsraeli population aged 35–65 years performed during the Januaryand February of 2006. This age group was chosen so as to representpeople that are part of the work force, not including students orretired individuals.

Two random samples of telephone numbers were drawn froma computerized list of subscribers to the national telephonecompany: one including only Arab subscribers and one includingthe Jewish majority. Most Israeli households (94%), Jews and Arabs,have telephone lines (Central Bureau of Statistics, 2003). Exclusionof fax numbers, disconnected numbers, commercial numbers,numbers of households where nobody answered after six intents orno residents in the target age was available, left 1541 eligiblehouseholds in the sample. Immigrants were over sampled untilreaching a quota of 200 interviews. The over sampling was neededas the sample of Jewish households did not include enoughimmigrant interviewees from the fSU for statistical analysis.Immigrants not from the fSU were not included in the study. A totalof 1004 respondents, men and women, completed the question-naire, yielding a response rate of 65%. Non-responses includedoutright refusals (331), partially completed interviews due todifficulty answering the questions (109) and stopping the interviewin the middle without answering to the socioeconomic statusquestions (97). The final database included 404 non-immigrantJews, 200 immigrants and 400 Arabs. The survey was conducted bythe Haifa University Survey Center.

Of the valid questionnaires, 17 questionnaires lacked data onsubjective socioeconomic status, another 78 lacked information onincome, 7 lacked information on education and employment, 7lacked information on health, and 6 lacked information on age;therefore, the sample analyzed in the final regression modelsconsisted of 916–917 completed questionnaires (some respondentslacked data on more than one variable). The respondents withmissing data did not differ in their self-reported health from thosewith no missing data.

The questionnaire

The questionnaire covered a range of socioeconomic anddemographic variables, as well as different health statusmeasurements. When the Hebrew questionnaire was ready it wastranslated into Arabic and Russian, then back-translated to ensurethe correct meaning. Professionals speaking both Arabic andHebrew and familiar with Israeli-Arab culture validated the trans-lation of the questionnaire into Arabic, and confirmed that thequestions had the same meaning as in Hebrew. The same processwas performed for the Russian questionnaire. A pretest was con-ducted to ensure cultural adaptation of the questionnaire, fromeach population group 15 people were interviewed (45 alltogether), and no problems were identified. The questionnaire wasadministered over the telephone by trained interviewers from thecorresponding population group for each language, Hebrew, Arabic,and Russian.

No official ethical approval was sought for this study. At the timeof the research official ethical approval was not needed in Israel forthis kind of study which was a random digit dial survey (no datafrom lists of patients or clients were used) and no medical infor-mation was obtained from other sources. Even so, the highest

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–14671462

ethical standards were adhered to and maintained in the study’sprocedures and methods. The following steps were followed by theinterviewers: they introduced themselves; they briefly describedthe survey topic; they identified the person and organizationconducting the research; described the purpose of the research andgave a ‘‘good faith’’ estimate of the time required to complete theinterview; they also promised anonymity and confidentiality; theinterviewers mentioned to the participant that participation isvoluntary and that item-nonresponse is acceptable. Finally,permission to begin was asked. Informed consent was consideredto have been obtained when potential participants agreed toanswer the questionnaire.

Variables

All variables were self-reported. Arabs were defined as thosedescribing themselves as Arab Muslims, Druze, or Arab Christians.Immigrants were those reporting arriving in Israel since 1990 fromthe former Soviet Union (fSU). Non-immigrant Jews were thoseborn in Israel or living in Israel from before 1989. The subjectivesocioeconomic status scale (SSS) was adopted from Adler et al.(2000). The description of the ladder read to the respondents wasa translation of the English version. Participants were told to thinkof a ladder with 10 rungs as representing where people stand inIsraeli society. The interviewee indicated his or her subjectivesocioeconomic status (SSS) compared to the Israeli society, ona scale from 1 to 10 (Adler et al., 2000; Ostrove et al., 2000). Theself-reported objective socioeconomic status (SES) measuresincluded income, education and employment. Employment statuswas categorized as working (1) or not working (0) (unemployed,retired, housewife). Education was assessed by the highest degreethe respondent attained, and two categories were formed: a highschool education or less (1), an academic degree or any otherstudies beyond high school (2). Income was evaluated by asking therespondent to choose from five possible ranges of householdincome. The average monthly household income at the time of thesurvey was about 8500 new Israeli shekel (NIS), this was about2100$. Two levels of household income were formed: 8500 NIS andless (1), and more than 8500 NIS (2). The Pearson’s correlationcoefficient for SSS and the objective SES was the highest for income(0.48, 0.59 and 0.36 for non-immigrant Jews, immigrants and Arabsrespectively). Spearman’s correlations of SSS with income andeducation were around 0.4.

Table 1Demographic and socioeconomic characteristics by population group [percent and (num

Characteristics

TotalGender Men

Women

Agea (years) Mean (SD)

Marital statusa MarriedNon-married

Incomea (New Israeli Shekel) Low–8500 NSH and lessHigh–More than 8500 NSH

Educationa Low–12 years of schooling and lessHigh–More than 12 years of schooling

Employmenta EmployedNon-employed

Subjective socioeconomic statusa Low 1–5High 6–10

a differences between population groups p< 0.0001.

The Short Form 12 served as the questionnaire for measuringphysical and mental health-related quality of life (Ware, Kosinski, &Keller, 1996). The questionnaire was previously validated inHebrew (Amir, Lewin-Epstein, Becker, & Buskila, 2002). Six ques-tions measured mental health and six measured physical health.The scores were transformed to a scale of 100, where 100 wasoptimal health and 0 was bad health, and a mean score wascalculated for mental health and for physical health. Physical andmental health variables were not normally distributed thereforethe variables were dichotomized. Health status was categorized assuboptimal (0) including scores from 0 to 79.99, and optimal health(1) including score 80 and above. The cut of point was based on themedian scores of the three population groups.

Statistical analysis

Chi-square analysis was used to identify differences in demo-graphic and socioeconomic variables between the three populationgroups and to assess differences between the population groups inthe proportion of those reporting optimal mental and physicalhealth by demographic and socioeconomic status. In order to assessthe association between health, population group, SSS and objec-tive measures of SES, after adjusting for age, six multivariable log-linear regression models were run for physical health, and anothersix for mental health-related quality of life as the dependant vari-ables. The rate ratios (RR), 95% confidence intervals (CI) and pvalues are presented. As there was a significant interaction betweengender and population group regarding health, a separate analysisfor men and women was performed. The regression modelsassessed if the socioeconomic variables could explain the differ-ences in health between the population groups. Age and SSS wereentered 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-linearmodels made significant improvement to the models we used thelikelihood ratio test and compared the first model (only the variablepopulation group in the models) with the second and third modelsincluding the SSS or SES.

Population group was added to the models as a categoricalvariable comparing immigrants and Arabs to non-immigrant Jews(the reference group). Marital status was not added to the finalmodels as it was not found to be significantly associated withhealth. Statistical significance was set at a p value of less than 0.05.SAS and SPSS version 14.0 was used for the analysis.

ber), mean and (standard deviation)].

Non-immigrants Jews Immigrants Arabs

404 200 40040.3 (163) 40.0 (80) 42.5 (170)59.7 (241) 60.0 (120) 57.5 (230)

49.1 (8.8) 50.2 (8.7) 45.0 (8.1)

78.0 (314) 71.2 (141) 91.0 (363)21.9 (88) 28.8 (57) 9.0 (36)

42.1 (144) 60.9 (117) 85.2 (334)59.9 (198) 39.1 (75) 14.8 (58)

39.8 (159) 12.5 (25) 70.2 (280)60.3 (241) 87.5 (175) 29.8 (119)

77.7 (313) 78.3 (155) 49.3 (197)22.3 (90) 21.7 (43) 50.8 (203)

31.0 (123) 81.4 (158) 51.8 (205)69.0 (274) 18.6 (36) 48.1 (191)

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467 1463

Results

The characteristics of the three population groups are describedin Table 1. Arabs were the youngest population group, with thehighest percent of married individuals and the lowest socioeco-nomic status (highest percent of low income, low education andunemployment). Immigrants had the highest percent of non-married individuals, the highest levels of education and thepercentage of low income was higher than among non-immigrantsJews but lower than among Arabs. There was a significant differ-ence in subjective socioeconomic status (SSS) between the groups,the lowest level was reported by immigrants, and Arabs ratedthemselves higher than immigrants but lower than non-immigrantJews.

Among men, Arabs reported lower levels of physical health-related quality of life, however there was no significant differencebetween the three population groups: 75.5%, 72.5%, 65.3% of non-immigrant Jews, immigrants and Arabs respectively (Table 2).Mental health-related quality of life was lower among immigrantand 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 mentaland physical health (39.2% and 31.7% respectively) while Arabwomen had higher levels (46.1% and 40.0% respectively) comparedto immigrant women, but lower levels compared to non-immigrantJewish women (68.5% and 55.6% respectively) (Tables 2 and 3). Agewas not associated with reporting optimal health in any of thegroups except for less of the older non-immigrant Jewish womenreporting optimal physical health (data not presented).

To assess if subjective and objective SES measures can explainthe differences in health between the minority groups (immigrantsand Arabs) and the non-immigrant Jewish majority, physical andmental health of the three population groups were compared bysocioeconomic levels and gender (Tables 2 and 3). Among menthere were no statistical differences between the groups in any

Table 2Optimal physical healtha by population group, gender, objective SES and SSS [p value, pe

Characteristics Non-immigrants Jew

MenTotal 75.5 (123)

Income Low 68.8 (33)High 80.5 (70)

Education Low 65.0 (39)High 81.0 (81)

SSS Low (1–5) 60.0 (27)High 80.2 (89)

Employment status Employed 76.9 (103)Non-employed 69.0 (20)

WomenTotal 68.5 (165)

Income Low 62.5 (60)High 72.1 (80)

Education Low 57.6 (57)High 76.6 (108)

SSS Low (1–5) 56.4 (44)High (6–10) 74.2 (121)

Employment status Employed 73.2 (131)Non-employed 54.1 (33)

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.

category of income, education and SSS; excluding employmentstatus where only 27–28% of immigrants and Arabs that wereunemployed reported optimal physical health compared to 69% ofunemployed non-immigrant Jews (Table 2). Among women, thedifferences in physical health between non-immigrant Jews,immigrants and Arabs were significant for both categories ofincome, education and SSS and also among employed andunemployed.

In relation to mental health, Arab and immigrant men with lowincome, education and SSS did not significantly differ in levels ofoptimal mental health from Jewish men at the same low income,education and SSS, however, the difference between the minoritymen and the non-immigrant Jewish men were significant at thehigher level of these SES variables. Only in the employment statusvariable the differences between the three groups were significantin both categories, employed and unemployed (Table 3). Amongwomen the differences in the percent of those reporting optimalmental health between the three groups are significant only at thelower level of income, at the higher level of education and at bothcategories of the employment status variable.

Log-linear regression models were run for the entire populationof men and women separately to assess the differences betweenthe three population groups after adjusting for age and socioeco-nomic status (Tables 4 and 5). Both the subjective and the objectiveSES measures separately can explain the difference in physicalhealth-related quality of life between Arabs and non-immigrantJewish men. When including SSS to the model, the RR for Arabmen’s physical health changes from RR¼ 0.86, CI¼ 0.75–0.99 toRR¼ 0.91, CI¼ 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, CI¼ 0.93–1.20 and is not significantlydifferent from 1.00. Immigrant men did not differ in the level ofphysical health from non-immigrant Jewish men (RR¼ 0.96,CI¼ 0.82–1.13) and the addition of the socioeconomic variables tothe model did not change this relationship (models 2–3, Table 4).

rcent and (number)].

s Immigrants Arabs p

72.5 (58) 65.3 (111) 0.12

58.8 (20) 60.7 (82) 0.5683.3 (35) 82.8 (24) 0.91

75.0 (9) 52.4 (54) 0.1472.1 (49) 84.8 (56) 0.17

68.3 (41) 54.3 (44) 0.2483.3 (15) 75.6 (65) 0.65

79.7 (55) 77.3 (99) 0.8927.3 (3) 28.6 (12) 0.002

39.2 (47) 46.1 (106) <0.0001

36.1 (30) 43.7 (87) 0.00151.5 (17) 58.6 (17) 0.06

15.4 (2) 42.4 (75) 0.00442.1 (45) 58.5 (31) <0.0001

34.7 (34) 38.7 (48) 0.00966.7 (12) 55.2 (58) 0.006

44.2 (38) 53.6 (37) <0.000128.1 (9) 42.9 (69) 0.05

Table 3Optimal mental healtha by population group, gender, objective SES and SSS [p value, percent and (number)].

Characteristics Non-immigrants Jews Immigrants Arabs p

MenTotal 71.8 (117) 47.5 (38) 46.2 (78) <0.0001

Income Low 54.2 (26) 38.2 (13) 42.5 (57) 0.28High 83.9 (73) 57.1 (24) 55.2 (16) 0.001

Education Low 56.7 (34) 33.3 (4) 42.2 (43) 0.13High 81.0 (81) 50.0 (34) 51.5 (34) <0.0001

SSS Low (1–5) 51.1 (23) 45.0 (27) 32.1 (26) 0.08High (6–10) 80.2 (89) 61.1 (11) 58.8 (50) 0.004

Employment status Employed 73.1 (98) 50.7 (35) 55.9 (71) 0.002Non-employed 65.5 (19) 27.3 (3) 16.7 (7) <0.0001

WomenTotal 55.6 (134) 31.7 (38) 40.0 (92) <0.0001

Income Low 47.9 (46) 27.7 (23) 37.2 (74) 0.002High 55.9 (62) 39.4 (13) 58.6 (17) 0.20

Education Low 47.5 (47) 23.1 (3) 36.7 (65) 0.098High 61.7 (87) 32.7 (35) 50.9 (27) <0.0001

SSS Low (1–5) 41.0 (32) 28.6 (28) 33.1 (41) 0.22High (6–10) 62.2 (102) 50.0 (9) 48.6 (51) 0.066

Employment status Employed 55.3 (99) 37.2 (32) 46.4 (32) 0.02Non-employed 55.7 (34) 18.8 (6) 37.3 (60) 0.002

Income: low- 8500 NSH and less, High-More than 8500 NSH.Education: Low-12 year.

a Based on the SF12 instrument.

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–14671464

The likelihood ratio test comparing models was highly significantfor the addition of both SSS and SES variables (p< 0.001).

Among women, both immigrant and Arab women had signifi-cantly lower levels of physical health compared to non-immigrantJewish women (RR¼ 0.57 and 0.67 respectively). The addition ofSSS or the objective socioeconomic variables to the model did noteliminate the differences between the minority groups and themajority Jewish population (models 2–3, Table 4).

In addition, SSS and education were associated with physicalhealth in men and women, and employment status was associatedwith physical health only among men (Table 4).

Table 5 depicts the log-linear regression models for mentalhealth and the association with SSS, SES measures and populationgroups. Both immigrants and Arabs, men and women, havesignificantly lower levels of mental health compared to non-immigrant Jews. Among immigrants the addition of SSS to themodels eliminates the differences in mental health compared to thenon-immigrant Jews (in men: RR¼ 0.92, CI¼ 0.76–1.12; in women:OR¼ 0.78, CI¼ 0.58–1.05), whereas the addition of the objectiveSES measures abolishes the differences in mental health betweenArabs and non-immigrant Jewish women (in men: RR¼ 0.74,CI¼ 0.64–0.91 in women: RR¼ 0.93; CI¼ 0.72–1.20).

SSS is associated with mental health in both men and women,whereas education and employment status are associated withmental health among men while among women only educationremains significant. The addition of SSS or SES to the log-linearmodel explaining mental health was significant (p< 0.001) usingthe likelihood ration test.

Discussion

Both minorities in Israel (Arabs and immigrants from the fSU)report worse physical and mental health compared to the Jewishmajority (except for physical health among immigrant men). Thiscan be corroborated with more objective reports (Israel Center forDisease 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; Bankset al., 2006; Lokshin & Ravallion, 2008; Singh-Manoux et al., 2007).Decreasing these health disparities is a major goal for the healthsystem; therefore, it is important to understand if differences in theSES characteristics of the three groups can explain their disparitiesin health status so that an improvement in SES levels can helpeliminating the health disparities. However, SES may not onlyinclude the objective resources available to the individual to ensurehealth, but may also comprise the subjective feeling the individualhas of his/her position within society. This subjective feeling indi-viduals have may act as an additional source of stress, or may betterrepresent the objective socioeconomic resources the individual hasat his disposal.

Immigrant women in Israel report much worse mental andphysical health compared to the non-immigrant Jewish population,and among immigrant men mental health was much worse but notphysical health. It may be assumed that this is due to lower levels ofhealth in the country of origin-the former Soviet Union (Tolts,1996). In addition, the actual immigration process to Israel mayhave provided new stressors and decreased mental health in bothgenders, and physical health in women. Why there should bea difference between immigrant men and women is not clear,however it could be that the process of immigration and accultur-ation may be more challenging for women than for men, affectingnot only their mental health but also their physical health. Moreobjective health measures need to be assessed before betterunderstanding can be reached as the self-reported measures usedin this study may raise gender biases.

Among immigrants the objective SES measures did not explainthe disparities in mental health or physical health. However, theSSS measure did explain the difference in mental health betweenimmigrants and non-immigrant Jews in both men and women. Onimmigration the immigrant has to start from scratch finding work,living accommodations, friends and a whole social network, inaddition they have to learn a new language and adapt to the new

Table 4Association between physical health-related quality of life and population groups while adjusting for socioeconomic status by gender, in log-linear regression models.a [rateratios, (RR), 95% confidence intervals (CI) and p values].

Model 1 Model 2 Model 3

RR 95% CI p RR 95% CI p RR 95% CI p

Men N¼ 413 N¼ 401 N¼ 373Jews 1.00 – – 1.00 – – 1.00 – –Immigrants 0.96 0.82–1.13 0.63 1.07 0.91–1.27 0.40 0.95 0.81–1.10 0.47Arabs 0.86 0.75–0.99 0.04 0.91 0.80–1.04 0.17 1.05 0.93–1.20 0.43SSSb – – – 1.06 1.03–1.09 <0.0001 – – –Income – – – – – – 1.05 0.92–1.20 0.46Education – – – – – – 1.27 1.08–1.48 0.004Employment – – – – – – 1.82 1.36–2.43 <0.0001

Women N¼ 591 N¼ 586 N¼ 548Jews 1.00 – – 1.00 – – 1.00 – –Immigrants 0.57 0.45–0.73 <0.0001 0.74 0.57–0.96 0.02 0.58 0.45–0.74 <0.0001Arabs 0.67 0.57–0.79 <0.0001 0.72 0.61–0.84 <0.0001 0.82 0.67–0.99 0.046SSSb – – – 1.09 1.05–1.12 <0.0001 – – –Income – – – – – – 1.09 0.92–1.29 0.33Education – – – – – – 1.29 1.08–1.53 0.004Employment – – – – – – 1.18 0.98–1.41 0.08

a Adjusted for age in all models.b Subjective Socioeconomic Status.

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–1467 1465

culture. Many immigrants loose their former position withinsociety on immigration, and have to regain it within the new socialsurroundings. This change mostly has a social downwards directionand may take at least a generation to overcome. The immigrant’sexpectations from life in Israel may have been high and their feelingof disappointment great during the years of acculturation. Thissituation may produce a low personal evaluation of the positionwithin the Israeli society causing stress related effects on mentalhealth.

These findings provide evidence to the importance of SSS in thispopulation, where SSS seems to be a major contributor to thedisparities in mental health. Therefore, it seems that in thisimmigrant population the feeling people have of their position insociety has a major effect on their health and can explain thedisparities in mental health whereas the objective SES measures donot explain these disparities.

A different pattern emerges for the Arab population. AmongArabs, SSS does not explain the differences in mental healthbetween Arabs and Jews. However, Arab men with higher levels ofeducation, income and SSS had similar rates of optimal physicalhealth compared to Jews and both objective SES and SSS seem toexplain the disparities in physical health between men in the twogroups. SES on its own explains the differences between Arab andnon-immigrant Jewish women in mental health-related quality oflife and explains the difference between Arab and Jewish menregarding physical health. SSS explains only the difference inphysical health among men, Arabs versus non-immigrant Jews, butnot the disparities among women neither the disparities in mentalhealth in both genders. The Arab community in Israel has a muchlower mean SES compared to Jews, high unemployment rates,lower education levels and lower income. In addition, healthindicators such as life expectancy and mortality rates are lower(Israel Center for Disease Control, 2005). It seems that a large part ofthese differences may be attributed mainly to overall lower levels ofSES and to some extent SSS. Objective SES in Arabs may be moreimportant in explaining the disparities in health compared to SSSfor two reasons: first the disparities in material resources forhealth, such as living conditions, may be much larger betweenArabs and Jews compared to the differences between the immi-grants and the non-immigrant Jewish population therefore, havinga larger effect on health. Second, the segregation of residentialareas between Arabs and Jews may protect the Arabs from the harm

low SSS can cause as they are not in daily contact with the higherSES communities in the Jewish populations in Israel, they livemostly within their communities where they may feel compara-tively better of.

Among Arab and immigrant women both SES and SSS did notexplain the disparities in physical health. SSS and education wereassociated with physical health but could not explain thedisparities. Other biological, behavioral, cultural and environ-mental factors should be studies to identify the causes of thesedisparities among women. These may be behavioral as men andwomen may have different health behaviors. Environmentalfactors may not play a part as we would not expect to find genderdifferences between men and women living in the sameenvironment.

In this study objective SES was measured by income, educationand employment and these were associated independently withhealth. Other studies have provided evidence of the associationbetween income and health. This association is stronger in thelower levels of income (Backlund, Sorlie, & Johnson, 1999; Mack-enbach et al., 2005). Education has been reported to be a variablethat predicts health in many populations and may increase accessto better work, favorable health behaviors and increase sense ofcontrol over life, this in turn may increase the ability to cope withstressors and provide a better physical, social and psychologicalenvironment for health (Ross & Van Willigen, 1997). Employmentstatus was associated with health only among men. Althoughamong the Jewish population about 60% of married women workand only 20% of Arab women work (Central Bureau of Statistics,2007) it is socially accepted in all population groups that a womancan stay home and not work and the man is expected to be thebread winner, therefore not having a job may have profound effectson mental health and also physical health among men but notamong women (Kasl & Jones, 2000, chap. 6).

The addition of SSS to the study of socioeconomic disparities inhealth is an important contribution to our understanding of therelationship between SES and health status of populations. It seemsthat not only objective socioeconomic factors can explain dispar-ities in health but the subjective feelings people have of theirrelative position in society can also explain these health disparities.However, some populations may be more sensitive to the subjec-tive feelings they have, such as the immigrant population, whereasother population are less affected by both types of socioeconomic

Table 5Association between Mental health-related quality of life and population groups while adjusting for socioeconomic status, by gender, in log-linear regression models.a [rateratios, (RR), 95% confidence intervals (CI) and p values].

Model 1 Model 2 Model 3

RR 95% CI p RR 95% CI p RR 95% CI p

Men N¼ 412 N¼ 400 N¼ 372Jews 1.00 – – 1.00 – – 1.00 – –Immigrants 0.66 0.52–0.85 0.001 0.92 0.76–1.12 0.41 0.65 0.51–0.83 0.0005Arabs 0.64 0.53–0.78 <0.0001 0.80 0.70–0.92 0.001 0.74 0.64–0.91 0.003SSSb – – – 1.09 1.06–1.12 <0.0001 – – –Income – – – – – – 1.27 1.05–1.54 0.015Education – – – – – – 1.20 1.00–1.43 0.04Employment – – – – – – 1.54 1.07–2.20 0.02

Women N¼ 591 N¼ 586 N¼ 548Jews 1.00 – – 1.00 – – 1.00 – –Immigrants 0.57 0.43–0.76 0.0001 0.78 0.58–1.05 0.12 0.60 0.44–0.82 0.001Arabs 0.72 0.59–0.87 0.0009 0.76 0.63–0.90 0.002 0.93 0.72–1.20 0.56SSSb – – – 1.13 1.09–1.18 <0.0001 – – –Income – – – – – – 1.24 0.99–1.55 0.06Education – – – – – – 1.28 1.02–1.60 0.03Employment – – – – – – 0.99 0.79–1.24 0.94

a Adjusted for age in all models.b Subjective Socioeconomic Status.

O. Baron-Epel, G. Kaplan / Social Science & Medicine 69 (2009) 1460–14671466

status, subjective and objective, such as the Arab population inIsrael.

In other western societies SSS has been reported to be associ-ated 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 haveregarding their position in society as a factor that can explaindisparities in health in multiethnic populations around the world.Three competing hypotheses have been suggested to explain whySSS is a better predictor of health compared to objective SES (Singh-Manoux et al., 2005). The first assumes that SSS is a more precisemeasure of social position which may reflect more accurately andcomprehensively the individual’s position in society. The secondexplanation assumes that SSS reflects the person’s ‘‘relative’’ posi-tion in society as opposed to the more ‘‘absolute’’ social positionexpressed by the objective SES measures. It may be that the stressassociated with the feeling of being lower in the social hierarchymay increase levels of ill health or that high SSS may protect againstactivation of psychobiological pathways which may contribute tovariation in disease risk (Wright & Steptoe, 2005). The thirdhypothesis suggests the association is not a true relationship.

This study does not enable to differentiate between the threesuggested explanations for the effect of SSS on health (Singh-Manoux et al., 2005). However, it strengthens the evidence as to theimportance of the subjective feeling people have of their position insociety and its effect on health in majority and minoritypopulations.

This study suggests that decreasing disparities in health in Israelmay be achieved by changing two factors that may be related. First,increasing SES by providing jobs mainly for Arab and immigrantmen, and improving levels of education for both men and womenamong Arabs. Second, reducing the range of social disparities mayimprove the subjective status and then improve health. This wouldmainly be relevant for immigrants. Providing adequate jobs suit-able for their levels of education may improve their evaluation oftheir position in the Israeli society. However, SES cannot explain alldisparities and it seems that other factors not measured in thisstudy should be investigated.

This study has a few limitations. One concern is the lack ofobjective health data since all the health outcomes studied wereself-reported. Health-related quality of life is a more objectivemeasure than other frequently used measures, such as self-repor-ted 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 tosignificantly identify some associations, for example between SSS,SES and health among women. However, as we did observe asso-ciations in other groups, if the associations exist they would besmall. In addition this is a cross sectional analysis and causalitycannot be evaluated in this study. Worse health may cause lowerSES and not only, as expected, low SES causing worse health.

Conclusions

The disparities in health between the minorities and themajority population in Israel may be explained to a certain extentby subjective and objective measures of SES but it seems there arestill additional factors causing these disparities which need to beidentified, mainly among women. SSS explains the disparities inhealth mainly among immigrants and less so among Arabs.

Acknowledgment

The authors thank Nancy Adler for helpful discussions.

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