Understanding Health Disparities: The Promise of the Stress Process Model

Abstract

Evidence revealing racial and socioeconomic disparities in health has long been available and continues to accumulate. Among those that are now well documented are Black-white inequities in overall health, all-cause mortality and life expectancy, low birth weight, infant mortality, reproductive health, hypertension and heart disease, as well as various psychiatric and substance use problems. Similar disparities are found across socioeconomic status (SES). Although race and SES are associated, prior research has documented substantial health disparities across SES within race and across race within SES (Geronimus et al. 1996; Williams 1999). This paper argues that progress in understanding the origins of such consequential health disparities can be materially enhanced by adopting the theoretical guidance embodied in the work of Leonard I. Pearlin. It is hypothesized that health disparities arise to a substantial degree from differences in lifetime exposure to social stress. For more than a quarter century, Pearlin’s stress process model has represented the dominant perspective of researchers attempting to identify potentially modifiable social contingencies in mental health. The high degree of the success of the model in accounting for variations in depressive symptoms and psychological distress suggests its potential power for advancing our understanding of racial and SES health disparities.These disparities have a massive impact in terms of unequal suffering and dramatic social and economic costs. It is thus no surprise that substantial research has accumulated aimed at identifying the origins of such disparities. It is clear that racial and SES differences in the availability, use, and effectiveness of medical care (e.g. Escarce et al. 1993; Ferguson et al. 1997; Fincher et al. 2004; Johnson et al. 1993; Klabunde et al. 1998; Peterson et al. 1997), and in the level of trust in health care institutions and physicians, are implicated (Doescher et al. 2000; Kao et al. 1998a, b; Saha et al. 2003; Thom and Campbell 1997), as are differences in a variety of health behaviors (Fraser et al. 1997; Healthy People 1990; McGinnis and Foege 1993). However, it is also clear that adjustments for these collective differences leave the majority of racial and SES health disparities unexplained (e.g. Lynch et al. 1996; Marmot et al. 1997; Lantz et al. 1998; Lantz et al. 2001). Available evidence points to the conclusion that potentially modifiable social factors play a fundamental role in racial and SES health disparities – a role that includes but goes substantially beyond their significance for such well established risk factors as poor nutrition, smoking, sedentary life style, and obesity. However, no consensus has yet emerged about the identity or nature of these social factors or how they might be effectively addressed. It will be argued that this state of affairs arises from several significant deficiencies that have characterized most prior studies, including the failure within studies of physical health and general health outcomes to take advantage of the conceptual insights of Leonard I. Pearlin.