The concept of socioeconomic status (SES) involves a range of categories such as, but not limited to, occupational position, income, and education. In terms of healthcare, the evidence shows that people with low SES are likely to encounter challenges in accessing the necessary services and improper treatment (Manstead, 2018). It is also suggested that the increased levels of depression and anxiety are characteristic of low SES. In particular, some studies indicate greater prevalence of poor care quality provided to racial and ethnical minorities, as well as people with a lack of education and employment (Villatoro, Mays, Ponce, & Aneshensel, 2018). Accordingly, poorer mental health can be, to some extent, the result of the correlation between low SES and related care access disparities. This literature intends to provide an in-depth literature review, examining such links between SES and mental therapy access as social identity, behavior, attitudes, and cultural aspects.
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SES Dimensions: Education, Income, and Occupation in Terms of Therapy Access
In recent decades, research on the role of SES in healthcare increased tremendously. All over the world, many people are doomed to live in poverty due to health conditions. They cannot pay for treatment, which prevents them from ending their struggles. Moreover, when these people get sick, they cannot work, provide themselves and their families with the means for living, and become a burden for their state (Delgadillo, 2015; Packness et al., 2017). The authorities of many countries are trying to reduce the inequality in the health of citizens since this reduces the state’s expenses for healthcare. Equal access to medical services also increases the stability of the state as, in conditions of inequality, people express discontent, feeling a lack of concern for themselves.
Considering inequality in the incomes of the population of different countries, it becomes evident that it is the greatest in the US. According to statistics, the higher this inequality, the lower the life expectancy of people (Villatoro et al., 2018). It is caused by the fact that the fewer people in the country with relatively high incomes, who are able to access high-quality medical care, the more poor that cannot afford it, which means they live less, which affects the overall picture. Recent studies show the existence of a health gradient in all countries that have been studied (Arpey, Gaglioti, & Rosenbaum, 2017; Tyagi & Ranga, 2018). The higher one’s social and economic position, the better his or her well-being is. For example, those working in poorly paid jobs are more likely to suffer from cardiovascular disease than their higher-paid fellow citizens, while no correlation is noted in terms of age group and gender.
It is important to note that income inequality is a characteristic of a social system, while income is a characteristic of an individual. Despite the fact that most of the effects of income inequality are indirect effects of the difference in individual incomes, it would be a mistake to reduce the problem to individual effects. Finegan, Firth, Wojnarowski, and Delgadillo (2018) argue that the causes of specific cases of the disease sometimes differ from the causes of the incidence, in other words, there may be various determinants. At the individual and population levels, and sometimes the factors that cause illness in people differ from the incidence factors among the population group. Individual income, for the most part, is determined by a person’s education, skills, and efforts, while income inequality is determined by history, politics, and economics. Different researchers agree that reducing income inequality by increasing the incomes of more vulnerable groups of the population will improve their health and, consequently, the average state of the population’s health.
Thus, SES dimensions can be regarded as powerful yet not fully understood determinants of health. They may not have a direct effect, but serve as closely intertwined factors for either improving or deteriorating access to therapy (Finegan et al., 2018). One can suggest that, instead of a direct influence, inequality in social and economic conditions differentially impacts other factors that can be integrated in more direct relationship with the level of health, including healthcare, environment, and lifestyle (Epping, Muschik, & Geyer, 2017). The articles included in this section are consistent in their arguments that the dimensions of SES are interrelated and important in determining access to therapy. Some of the suggest further research areas, such as potential ways to combat social and economic inequality, while others state that more studies are needed for better understanding the trajectories that impede and promote care access.
Social Identity in Terms of Behaviors and Attitudes
People’s resources with regard to others identify their social and economic position in a society. The evidence shows that socioeconomic deprivation correlates with poor treatment outcomes compared to a lack thereof. The article by Finegan et al. (2018) considers low SES as social deprivation to clarify its impact on the utilization of mental health services. Based on the method of the literature review, the authors covered 165,574 patients and used this data to conduct a quantitative analysis. It was found that the results are mixed, although some relations between low SES and poor psychological treatment were detected. The statistical analysis demonstrates that the overall effect is noted as small yet significant. In turn, Packness et al. (2017), who explores mental health in terms of the impact of socioeconomic position, claims that the patients with low SES are likely to refer to care less frequently, even if service is provided for free. Likewise Finegan et al. (2018), Packness et al. (2017) conducted a quantitative analysis based on a nationwide register-based cohort study. Both studies assume that there is a trend: people with low SES make fewer mental health care visits.
The critical review of the literature shows that many scholars attempt to understand these differences in mental care access in the contexts of SES. Destin, Rheinschmidt-Same, and Richeson, (2017) emphasize that greater attention is paid to the understanding of one’s status-based identity, which identify the changes that occur in his or her behaviors, thoughts, and attitudes. The study by Destin et al. (2017) explores the impacts of status transition, focusing on perceived uncertainty. Consistent with Manstead (2018), the above authors claim that financial stability plays one of the key roles in making decisions. In particular, if a person has fewer unknown factors, he or she is more likely to visit a therapist and try to resolve mental problems instead of avoiding them. People with lower SES are also more likely to interpret their problems in terms of situational terms since they have low personal control over socially-important events. Those with middle and high SES, on the contrary, tend to distinguish between their position and contexts.
To arrive to the conclusions that oppose those that are noted above, Epping et al. (2017) employ the perspective of social inequality to clarify the impact of three socio-economic (SES) indicators on the trends of mental health care usage. In particular, on the basis of logistic regression analysis, the authors examine the population of Germany and argue that income is not the determinant that significantly affects access to care. At the same time, Epping et al. (2017) mention that the most noteworthy results are obtained for education, which can be explained by differential verbalization of psychological problems when it comes to the conversation between a therapist and patient. Compared to other articles that are discussed in this section, this one contradicts their findings. To make it clear, this controversy should be considered against the facts that Epping et al. (2017) included only people with health insurance and that Germany faces dropout in financial barriers to psychotherapy in outpatient settings. In other words, this study is limited by the inability to fully represent the social gradients of patients with mental issues.
Speaking of the articles that discuss social identity and its impact on a person’s attitudes, it is essential to consider theoretical frameworks that used by authors. Manstead (2018) clarifies the theoretical model that was elaborated by Kraus, Piff, Mendoza-Denton, Rheinschmidt, and Keltner, who identified the ways of how different classes perceive social context. While upper class representatives think in terms of solipsism, which implies an orientation on individual goals, emotions, and states, lower class focuses on contextualise, which means external orientation based on threats, constraints, and other people. In turn, Delgadillo (2018) refers to the social causation theory that posits on the link between environmental adversity and mental health problems. Material deprivation lies in the foundation of this theory, and as stressed by Delgadillo (2018), SES and treatment outcomes may be affected by negative life events. The comparison of the two mentioned theories reveals that the first of them illuminates a possible reason for perceived limitations to care access. In other words, it examines the very way persons with different SES observe their opportunities. In turn, the causation theory aims to explain the reasons behind poor mental health treatment outcomes.
The socioeconomic aspect is discussed by Delgadillo (2018) and Delgadillo (2015) in terms of politics, poverty, and psychology. There is a growing sense among the poor that inequalities in access to education and health care are unfair. At the same time, they do not perceive and do not use leisure as an opportunity to develop their own joint communicative competencies, which testifies to the absence or unconsciousness of their joint needs for attachment, recognition, and self-expression (Delgadillo, 2018). The closeness of the social space of people with low income determines the long-term social degradation of this group. The negative sides of inequality in the social sphere can be added to psychological problems created due to social competition (Delgadillo, 2015). Low-income people compare their standard of living with that of more successful individuals, and this puts pressure on their emotional state.
Regardless of the findings, all the studies that are taken into account in terms of behaviors and attitudes of patients report the marked under-coverage of people with low SES. Epping et al. (2017), Delgadillo (2015), and Packness et al. (2017) do not offer the considerations on future research, but Finegan et al. (2018) and Manstead (2018) are consistent in potential implications of their findings and further work. In particular, these authors prioritize the adoption of a standardized way of operationalizing SES in studies. In other words, the scholars insist on the establishment of a universal framework for further studies, which would allow minimizing limitations and increasing the accuracy of results.
Influence of Socioeconomic Status and Culture on Human Expression
The impact of social classification on a person’s cultural expressions is another topic of discussion, which determines the patterns of group beliefs. In the study that is conducted by Becker, Kraus, and Rheinschmidt-Same (2017), cultural expressions are observed via social media communication, namely, Facebook photographs. The authors conclude that social class implications are evident in the interests and preferences of users. According to the self-reported identification of participants’ SES, it is identified that low SES is associated with the perceived lack of control and worse group efficiency, which creates social boundaries (Becker et al., 2017). A similar trend is noted by Williams, Priest, and Anderson (2016), who focus on the intersection between SES, race, and health, suggesting that people with low SES are likely to remain passive in the face of social inequality, while those with higher SES would require meeting their needs.
Racial and ethnic minorities underuse mental health services due to their cultural background. The study by Ford, Lam, John, and Mauss, (2018) confirms that cultural background acts as one of the essential components of socio-economic status. For instance, among ethnic and racial minorities, there is a concentration of people with low income and a lack of insurance. They have fewer opportunities to receive higher education, and, consequently, a high income; their stress level is higher, while their ability to cope with it is lower. Another research by Neblett, Bernard, and Banks (2016) also reveals that the geography of the residence also plays a crucial role. Ethnic minorities accumulate in certain areas where services of the same quality are not always provided as for a majority group. In some cases, political reasons can be a factor as minorities do not have the political power to influence politicians.
African-Americans, Hispanics, Native Americans, and other minority groups are under the increased risk of mental health concerns die to racism-related stress they encounter. The participants were enrolled in the study from a university, where they were vulnerable to discrimination, clarified by Neblett et al. (2016). The interaction of gender and SES with mental health problems was a specific focus of the mentioned study that revealed that young females with higher SES and young males with lower SES as the main victims of racial discrimination. Accordingly, these groups had greater risks of developing mental health complications. Most importantly, not only individual problems but also group issues appeared, including the feeling of disconnectedness and uneasiness in social situations (Neblett et al. (2016). Thus, the key contribution of this article is that men are more prone to racial discrimination and related psychological health consequences.
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The perceived need for mental health care can be evaluated as minor in people with low SES. In comparison to other articles that discuss this subtopic, Villatoro, Mays, Ponce, and Aneshensel (2018) claim that personal attitudes on social inequality shape lower expectations and self-care levels. The detailed analysis of various ethnicities shoes that African-American men and non-Latino whites are less likely to prioritize their care needs; the same can be noted regarding Asian-Americans and non-US born persons (Villatoro et al., 2018). These findings are consistent with the results that are provided by other scholars, stating that unprepared socio-cultural context is one of the reasons for dropping out of psychotherapy (Khazaie, Rezaie, Shahdipour, & Weaver, 2016). The latter emphasize that a lack of awareness of the need to visit a therapist often accompanied by unrealistic expectations of care provision.
In general, the results of the studies demonstrate that there is an objectively close relationship between the culture and the social class in relation to health, and this corresponds to both theoretical assumptions and available empirical evidence (Khazaie et al., 2016; Villatoro et al., 2018). However, this conclusion leads to the assumption that the propensity for health practices is formed on the basis of habitus and living conditions of a particular social group. One can, therefore, expect that with an increase in education and incomes and a corresponding decrease in the share of the lower class, the number of people referring to therapists would increase.
Trends in Literature and Future Research
In terms of further comprehensive research, the identified problem involves the construction of algorithms for the formation of an effective strategy for the interaction of the state and business in solving issues of social policy and social responsibility of business. Harmonization of interests of all subjects of society will ensure the stability of sustainable development and sustainable development at the difficult stage of global geopolitical changes.
Arpey, N. C., Gaglioti, A. H., & Rosenbaum, M. E. (2017). How socioeconomic status affects patient perceptions of health care: A qualitative study. Journal of Primary Care & Community Health, 8(3), 169-175.
Becker, J. C., Kraus, M. W., & Rheinschmidt-Same, M. (2017). Cultural expressions of social class and their implications for group-related beliefs and behaviors. Journal of Social Issues, 73(1), 158-174.
Delgadillo, J. (2018). Worlds apart: Social inequalities and psychological care. Counselling and Psychotherapy Research, 18(2), 111-113.
Delgadillo, J., Asaria, M., Ali, S., & Gilbody, S. (2016). On poverty, politics and psychology: The socioeconomic gradient of mental healthcare utilisation and outcomes. The British Journal of Psychiatry, 209(5), 429-430.
Destin, M., Rheinschmidt-Same, M., & Richeson, J. A. (2017). Status-based identity: A conceptual approach integrating the social psychological study of socioeconomic status and identity. Perspectives on Psychological Science, 12(2), 270-289.
Epping, J., Muschik, D. & Geyer, S. (2017). Social inequalities in the utilization of outpatient psychotherapy: Analyses of registry data from German statutory health insurance. International Journal for Equity in Health, 16(1), 1-8.
Finegan, M., Firth, N., Wojnarowski, C., & Delgadillo, J. (2018). Associations between socioeconomic status and psychological therapy outcomes: A systematic review and meta‐analysis. Depression and Anxiety, 35(6), 560-573.
Ford, B. Q., Lam, P., John, O. P., & Mauss, I. B. (2018). The psychological health benefits of accepting negative emotions and thoughts: Laboratory, diary, and longitudinal evidence. Journal of Personality and Social Psychology, 115(6), 1075-1092.
Khazaie, H., Rezaie, L., Shahdipour, N., & Weaver, P. (2016). Exploration of the reasons for dropping out of psychotherapy: A qualitative study. Evaluation and Program Planning, 56, 23-30.
Manstead, A. (2018). The psychology of social class: How socioeconomic status impacts thought, feelings, and behaviour. The British Journal of Social Psychology, 57(2), 267-291.
Neblett, E. W., Bernard, D. L., & Banks, K. H. (2016). The moderating roles of gender and socioeconomic status in the association between racial discrimination and psychological adjustment. Cognitive and Behavioral Practice, 23(3), 385-397.
Packness, A., Waldorff, F. B., Christensen, R. D., Hastrup, L. H., Simonsen, E., Vestergaard, M., & Halling, A. ( 2017). Impact of socioeconomic position and distance on mental health care utilization: A nationwide Danish follow-up study. Social Psychiatry and Psychiatric Epidemiology, 52(11), 1405-1413.
Tyagi, P., & Ranga, B. S. (2018). An examination of the correlation between socioeconomic status and mental health. International Journal of Management, IT and Engineering, 8(2), 252-262.
Villatoro, A. P., Mays, V. M., Ponce, N. A., & Aneshensel, C. S. (2018). Perceived need for mental health care: The intersection of race, ethnicity, gender, and socioeconomic status. Society and Mental Health, 8(1), 1-24.
Williams, D. R., Priest, N., & Anderson, N. B. (2016). Understanding associations among race, socioeconomic status, and health: Patterns and prospects. Health Psychology, 35(4), 407-411.