The purpose of this study was twofold-(1) investigate the role of subjective social status as a predictor of ill-health, with a further exploration of the extent to which this relationship could be accounted for by conventional measures of socioeconomic position; (2) examine the determinants of a relatively new measure of subjective social status used in this study. A 10 rung self-anchoring scale was used to measure subjective social status in the Whitehall II study, a prospective cohort study of London-based civil service employees. Results indicate that subjective status is a strong predictor of ill-health, and that education, occupation and income do not explain this relationship fully for all the health measures examined. The results provide further support for the multidimensional nature of both social inequality and health. Multiple regression shows subjective status to be determined by occupational position, education, household income, satisfaction with standard of living, and feeling of financial security regarding the future. The results suggest that subjective social status reflects the cognitive averaging of standard markers of socioeconomic situation and is free of psychological biases.

Subjective SES is a better predictor of health status and decline in health status over time in middle-aged adults. These results are discussed in terms of three possible explanations: subjective SES is a more precise measure of social position, the results provide support for the hierarchy-health hypothesis, and the results could be an artifact of common method variance.

Context Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study. Objective To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only one point in time to that assessed longitudinally through the follow-up. Main outcome measures All-cause and cause-specific mortality. Design, Setting, and Participants Participants are drawn from the British Whitehall II longitudinal cohort study, established in 1985 on 10,308 London based civil servants, aged 35–55 years. Analyses are based on 9,590 men and women followed for mortality until 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate and low) at baseline. Smoking, alcohol consumption, diet and physical activity were assessed four times over the follow-up. Results 654 participants died during the follow-up. In analysis adjusted for sex and year of birth, those in the low socioeconomic position had 1.60 times higher risk of death from all causes than those in the high position (a rate difference of 1.94 per 1000 person-years). This association was attenuated by 42% (95% CI, 21%–94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%–154%) when they were entered as time dependent covariates. The corresponding attenuations were 29% (95% CI, 11%–54%) and 45% (95% CI, 24%–79%) for cardiovascular mortality and 61% (95% CI, 16%–425%) and 94% (95% CI, 35%–595%) for non-cancer non-cardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality), physical activity (from 5% to 21% for all-cause mortality) and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality). Conclusions In a civil service population in London, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.

SummaryBackgroundPublished work assessing psychosocial stress (job strain) as a risk factor for coronary heart disease is inconsistent and subject to publication bias and reverse causation bias. We analysed the relation between job strain and coronary heart disease with a meta-analysis of published and unpublished studies.MethodsWe used individual records from 13 European cohort studies (1985–2006) of men and women without coronary heart disease who were employed at time of baseline assessment. We measured job strain with questions from validated job-content and demand-control questionnaires. We extracted data in two stages such that acquisition and harmonisation of job strain measure and covariables occurred before linkage to records for coronary heart disease. We defined incident coronary heart disease as the first non-fatal myocardial infarction or coronary death.Findings30 214 (15%) of 197 473 participants reported job strain. In 1·49 million person-years at risk (mean follow-up 7·5 years [SD 1·7]), we recorded 2358 events of incident coronary heart disease. After adjustment for sex and age, the hazard ratio for job strain versus no job strain was 1·23 (95% CI 1·10–1·37). This effect estimate was higher in published (1·43, 1·15–1·77) than unpublished (1·16, 1·02–1·32) studies. Hazard ratios were likewise raised in analyses addressing reverse causality by exclusion of events of coronary heart disease that occurred in the first 3 years (1·31, 1·15–1·48) and 5 years (1·30, 1·13–1·50) of follow-up. We noted an association between job strain and coronary heart disease for sex, age groups, socioeconomic strata, and region, and after adjustments for socioeconomic status, and lifestyle and conventional risk factors. The population attributable risk for job strain was 3·4%.InterpretationOur findings suggest that prevention of workplace stress might decrease disease incidence; however, this strategy would have a much smaller effect than would tackling of standard risk factors, such as smoking.FundingFinnish Work Environment Fund, the Academy of Finland, the Swedish Research Council for Working Life and Social Research, the German Social Accident Insurance, the Danish National Research Centre for the Working Environment, the BUPA Foundation, the Ministry of Social Affairs and Employment, the Medical Research Council, the Wellcome Trust, and the US National Institutes of Health.