Journal of Behavioral Medicine

, Volume 38, Issue 1, pp 9–16 | Cite as

Socioeconomic status and health: education and income are independent and joint predictors of ambulatory blood pressure

  • Jenny M. CundiffEmail author
  • Bert N. Uchino
  • Timothy W. Smith
  • Wendy Birmingham


Epidemiological research suggests that different indicators of socioeconomic status (SES) such as income and education may have independent and/or interactive effects on health outcomes. In this study, we examined both simple and more complex associations (i.e., interactions) between different indicators of SES and ambulatory blood pressure (ABP) during daily life. Our sample consisted of 94 married couples who completed a one-day ABP protocol. Both income and education were independently related to systolic blood pressure and only income was significantly related to diastolic blood pressure. There were also statistical interactions such that individuals with high levels of both income and education evidenced the lowest ABP. Gender moderated these findings. Three-way interactions revealed that, in general, women appear to benefit from either indicator of SES, whereas men appear to benefit more from income. The findings are consistent with epidemiological research and suggest one important physiological mechanism by which income and education may have independent and interactive effects on health.


Income Education Gender effects Socioeconomic status Ambulatory blood pressure Health 



This research was supported by NIH Grant # R01 HL68862 from the National Heart, Lung, and Blood Institute, awarded to Bert N. Uchino.


  1. Adler, N. E. (2009). Health disparities through a psychological lens. American Psychologist, 64, 663–673.PubMedCrossRefGoogle Scholar
  2. Adler, N. E., Chesney, M. A., Cohen, S., Folkman, S., Boyce, T., Kahn, R. L., et al. (1994). Socioeconomic status and health: The challenge of the gradient. American Psychologist, 49, 15–24.PubMedCrossRefGoogle Scholar
  3. Adler, N. E., & Ostrove, J. M. (1999). Socioeconomic status and health: What we know and what we don’t. Annals of the New York Academy of Sciences, 896(1), 3–15.PubMedCrossRefGoogle Scholar
  4. Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Sage Publications, Inc.Google Scholar
  5. Anderson, N. B., & Armstead, C. A. (1995). Toward understanding the association of socioeconomic status and health: A new challenge for the biopsychosocial approach. Psychosomatic Medicine, 57, 213–225.PubMedCrossRefGoogle Scholar
  6. Bowen, K. S., Birmingham, W., Uchino, B. N., Carlisle, M., Smith, T. W., & Light, K. C. (2012). Specific dimensions of perceived support and ambulatory blood pressure: Which support functions appear most beneficial and for whom? International Journal of Psychophysiology. doi: 10.1016/j.ijpsycho.2012.03.004.
  7. Braveman, P. A., Cubbin, C., Egerter, S., Chideya, S., Marchi, K. S., Metzler, M., et al. (2005). Socioeconomic status in health research: One size does not fit all. JAMA Journal of the American Medical Association, 294, 2879–2888.CrossRefGoogle Scholar
  8. Campbell, L., & Kashy, D. A. (2002). Estimating actor, partner, and interaction effects for dyadic data using PROC MIXED and HLM: A user-friendly guide. Personal Relationships, 9, 327–342.CrossRefGoogle Scholar
  9. Conen, D., & Bamberg, F. (2008). Noninvasive 24-h ambulatory blood pressure and cardiovascular disease: A systematic review and meta-analysis. Journal of Hypertension, 26, 1290–1299.PubMedCrossRefGoogle Scholar
  10. Davey Smith, G., Hart, C., Hole, D., MacKinnon, P., Gillis, C., Watt, G., et al. (1998). Education and occupational social class: Which is the more important indicator of mortality risk? Journal of Epidemiology and Community Health, 52, 153–160.PubMedCrossRefGoogle Scholar
  11. Elo, I. T., & Preston, S. H. (1996). Educational differentials in mortality: United States, 1979–1985. Social Science and Medicine, 42, 47–57.PubMedCrossRefGoogle Scholar
  12. Galecki, A. T. (1994). General class of covariance structures for two or more repeated factors in longitudinal data analysis. Communications in Statistics Theory and Methods, 23, 3105–3119.CrossRefGoogle Scholar
  13. Gallo, L. C., Bogart, L. M., Vranceanu, A. M., & Walt, L. C. (2004). Job characteristics, occupational status, and ambulatory cardiovascular activity in women. Annals of Behavioral Medicine, 28(1), 62–73.PubMedCrossRefGoogle Scholar
  14. Geyer, S., Hemstrom, N., Peter, R., & Vagero, D. (2006). Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice. Journal of Epidemiology and Community Health, 60, 804–810.PubMedCentralPubMedCrossRefGoogle Scholar
  15. Goodwin, J., Bilous, M., Winship, S., Finn, P., & Jones, S. C. (2007). Validation of the Oscar 2 oscillometric 24-h ambulatory blood pressure monitor according to the British Hypertension Society protocol. Blood Pressure Monitoring, 12, 113–117.PubMedCrossRefGoogle Scholar
  16. Grewen, K., Girdler, S. S., West, S. G., Bragdon, E., Costello, N., & Light, K. C. (2000). Stable pessimistic attributions interact with socioeconomic status to influence blood pressure and vulnerability to hypertension. Journal of Women’s Health & Gender-Based Medicine, 9, 905–915.CrossRefGoogle Scholar
  17. Hawkley, L., Lavelle, L. A., Berntson, G. G., & Cacioppo, J. T. (2011). Mediators of the relationship between socioeconomic status and allostatic load in the Chicago Health, Aging, and Social Relationships Study (CHASRS). Psychophysiology, 48, 1134–1145.PubMedCentralPubMedCrossRefGoogle Scholar
  18. Henrich, J., & Gil-White, F. J. (2001). The evolution of prestige: Freely conferred deference as a mechanism for enhancing the benefits of cultural transmission. Evolution and Human Behavior, 22, 165–196.PubMedCrossRefGoogle Scholar
  19. Herd, P., Goesling, B., & House, J. S. (2007). Socioeconomic position and health: The differential effects of education versus income on the onset versus progression of health problems. Journal of Health and Social Behavior, 48, 223–238.PubMedCrossRefGoogle Scholar
  20. Johnston, D. W., Propper, C., & Shields, M. A. (2009). Comparing subjective and objective measures of health: Evidence from hypertension for the income/health gradient. Journal of Health Economics, 28, 540–552.PubMedCrossRefGoogle Scholar
  21. Kamarck, T. W., Shiffman, S. M., Smithline, L., Goodie, J. L., Thompson, H. S., Ituarte, P. H. G., et al. (1998). The diary of ambulatory behavioral states: A new approach to the assessment of psychosocial influences on ambulatory cardiovascular activity. In D. S. Krantz & A. S. Baum (Eds.), Technology and methods in behavioral medicine. (pp. 163–193). Mahwah, NJ: Lawrence Erlbaum Associates Publishers.Google Scholar
  22. Kamarck, T. W., Shiffman, S., Sutton-Tyrrell, K., Muldoon, M. F., & Tepper, P. (2012). Daily psychological demands are associated with 6-year progression of carotid artery atherosclerosis: The Pittsburgh healthy heart project. Psychosomatic Medicine, 74, 432–439.PubMedCrossRefGoogle Scholar
  23. Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503.PubMedCrossRefGoogle Scholar
  24. Landsbergis, P. A., Schnall, P. L., Pickering, T. G., Warren, K., & Schwartz, J. E. (2003). Lower socioeconomic status among men in relation to the association between job strain and blood pressure. Scandinavian Journal of Work, Environment & Health, 29, 206–215.CrossRefGoogle Scholar
  25. Marler, M. R., Jacob, R. G., Lehoczky, J. P., & Shapiro, A. P. (1988). The statistical analysis of treatment effects in 24-hour ambulatory blood pressure recordings. Statistics in Medicine, 7, 697–716.PubMedCrossRefGoogle Scholar
  26. Marmot, M. G., Ryff, C. D., Bumpass, L. L., Shipley, M., & Marks, N. (1997). Social inequalities in health: Next questions and converging evidence. Social Science and Medicine, 44, 901–910.PubMedCrossRefGoogle Scholar
  27. Matthews, K., & Gallo, L. C. (2011). Psychological perspectives on pathways linking socioeconomic status and physical health. Annual Review of Psychology, 62, 501–530.PubMedCentralPubMedCrossRefGoogle Scholar
  28. Matthews, K. A., Kelsey, S. F., Meilahn, E. N., Muller, L. H., & Wing, R. R. (1989). Educational attainment and behavioral and biologic risk factors for coronary heart disease in middle-aged women. American Journal of Epidemiology, 129, 1132–1144.PubMedGoogle Scholar
  29. McGrath, J. J., Matthews, K. A., & Brady, S. S. (2006). Individual versus neighborhood socioeconomic status and race as predictors of adolescent ambulatory blood pressure and heart rate. Social Science and Medicine, 63, 1442–1453.PubMedCrossRefGoogle Scholar
  30. Newton, T. L. (2009). Cardiovascular functioning, personality, and the social world: The domain of hierarchical power. Neuroscience and Biobehavioral Reviews, 33, 145–159.PubMedCentralPubMedCrossRefGoogle Scholar
  31. Pickering, T. G., Shimbo, D., & Haas, D. (2006). Ambulatory blood pressure monitoring. New England Journal of Medicine, 354, 2368–2374.PubMedCrossRefGoogle Scholar
  32. Ross, C. E., & Wu, C. (1995). The links between education and health. American Sociological Review, 60, 719–745.CrossRefGoogle Scholar
  33. Schnittker, J. (2004). Education and the changing shape of the income gradient in health. Journal of Health and Social Behavior, 45, 286–305.PubMedCrossRefGoogle Scholar
  34. Services USDoHaH (2010). Healthy people 2010. In: Services USDoHaH (ed).Google Scholar
  35. Smith, T. W., & Brown, P. W. (1991). Cynical hostility, attempts to exert control, and cardiovascular reactivity in married couples. Journal of Behavioral Medicine, 14, 581–592.PubMedCrossRefGoogle Scholar
  36. Smith, T. W., Cundiff, J. M., & Uchino, B. N. (2012). Interpersonal motives and cardiovascular response: Mechanisms linking dominance and social status with cardiovascular disease. In R. A. Wright & G. H. E. Gendolla (Eds.), How motivation affects cardiovascular response: Mechanisms and applications (pp. 287–305). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  37. Smith, T. W., Gallo, L. C., Goble, L., Ngu, L. Q., & Stark, K. A. (1998). Agency, communion, and cardiovascular reactivity during marital interaction. Health Psychology, 17, 537–545.PubMedCrossRefGoogle Scholar
  38. Smith, T. W., Limon, J. P., Gallo, L. C., & Ngu, L. Q. (1996). Interpersonal control and cardiovascular reactivity: Goals, behavioral expression, and the moderating effects of sex. Journal of Personality and Social Psychology, 70, 1012–1024.PubMedCrossRefGoogle Scholar
  39. Smith, T. W., Uchino, B. N., Florsheim, P., Berg, C. A., Butner, J., Hawkins, M., et al. (2011). Affiliation and control during marital disagreement, history of divorce, and asymptomatic coronary artery calcification in older couples. Psychosomatic Medicine, 73, 350–357.PubMedCrossRefGoogle Scholar
  40. Sorlie, P. D., Backlund, E., & Keller, J. B. (1995). US mortality by economic, demographic, and social characteristics: The National Longitudinal Mortality study. American Journal of Public Health, 85, 949–956.PubMedCentralPubMedCrossRefGoogle Scholar
  41. Starr, J. M., & Deary, I. J. (2011). Blood pressure, socioeconomic status and health in the Lothian 1921 birth cohort: A longitudinal study. Public Health, 125, 196–200. doi: 10.1016/j.puhe.2010.11.017 PubMedCrossRefGoogle Scholar
  42. Steffen, P. R. (2006). The cultural gradient: Culture moderates the relationship between socioeconomic status (SES) and ambulatory blood pressure. Journal of Behavioral Medicine, 29, 501–510.PubMedCrossRefGoogle Scholar
  43. Steptoe, A., Fedlman, P. J., Kunz, S., Owen, N., Willemsen, G., & Marmot, M. (2002). Stress responsivity and socioeconomic status: A mechanism for increased cardiovascular disease risk? Eurpoean Heart Journal, 23, 1757–1763.CrossRefGoogle Scholar
  44. Torssander, J., & Erikson, R. (2009). Stratification and mortality: A comparison of education, class, status, and income. European Sociological Review, 26, 465–474.CrossRefGoogle Scholar
  45. Umberson, D., & Montez, J. K. (2010). Social relationships and health: A flashpoint for health policy. Journal of Health and Social Behavior, 51, S54–S66.Google Scholar
  46. Verdecchia, P. (2000). Prognostic value of ambulatory blood pressure. Hypertension, 35, 844–851.PubMedCrossRefGoogle Scholar
  47. Winkelby, M. A., Jatulis, D. E., Frank, E., & Fortmann, S. P. (1992). Socioeconomic status and health: How education, income and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health, 82, 816–820.CrossRefGoogle Scholar
  48. Zanstra, Y. J., & Johnston, D. W. (2011). Cardiovascular reactivity in real life settings: Measurement, mechanisms and meaning. Biological Psychology, 86, 98–105.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Jenny M. Cundiff
    • 1
    Email author
  • Bert N. Uchino
    • 1
  • Timothy W. Smith
    • 1
  • Wendy Birmingham
    • 1
  1. 1.Department of PsychologyUniversity of UtahSalt Lake CityUSA

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