This paper focused on three research questions, all related to the complex relationship between socioeconomic status and perceived total general health. Most respondents perceived their health quite positively: a little more than two-thirds evaluated their TGH as good and/or excellent. The lower standard deviation in TGH scores of respondents within a higher SES group shows a more common perception of their health; they are quite a homogeneous group in this respect. By contrast, there was a wide difference in perception of TGH between respondents within the lowest SES group, as shown by their higher standard deviation. In general, respondents in higher SES groups apparently not only perceived better TGH but also shared a more common evaluation of their health.
Answering the research questions
The first research question was about which health dimensions in life determine the perception of TGH. Using the concept of positive health, it appears that four out of the six dimensions impact evaluation of TGH. Evaluation of bodily functions, daily functioning, quality of life, and social and societal participation had a positive impact on the evaluation of TGH, and are also the most important health dimensions in determining TGH.
All SES groups had in common the positive impact of bodily functions and daily functioning on their TGH. However, the magnitude of the impact of these two more physical health dimensions as well as of the other two more social ones (as measured via the standardized betas) differed per SES group. The impact of the two more psychological health dimensions seemed to be rather small and only present in a few SES groups. This is in line with findings of Stronks et al. (2018) (33) showing in a concept map that, regardless of educational level, more physical aspects like ‘absence of disease and functioning’ and ‘health-related behaviours’ and more social aspects like ‘social life’ and ‘attitude towards life’ were perceived as important characteristics of health.
Evaluation of the other two dimensions (mental functions and meaningfulness) did not impact all respondents’ TGH. It could be argued that these two dimensions are perceived to overlap with the dimensions of daily functioning and quality of life and hence are not perceived as contributing to TGH as separate dimensions. Another interpretation could be that people only become aware of the importance of these dimensions when perceiving illness in TGH, as is the case only in the very low SES group. More research on this specific topic is needed, given the inconclusive results in this respect.
The second research question was about which socioeconomic and demographic variables determine the perception of TGH. It turned out that type of housing, age, and difficulties meeting financial obligations impacted on all respondents’ perceived TGH, which proportionately worsens with increasing home renting, age, and difficulties meeting financial obligations. Gender, household size and labour market status (= having a job or not) did not impact respondents’ TGH.
These determinants of perceived TGH are thus in line with earlier findings on determinants of objective health. First, it is established that objective health decreases and use of healthcare increases with age (34, 35). Second, it is widely known that housing conditions are a determinant of health. People living in substandard, often rented housing in deprived neighbourhoods have more impaired health than home owners in affluent neighbourhoods (1, 10, 36). Third, having trouble meeting financial obligations is at the core of socioeconomic inequality in objective and self-rated health (9, 37, 38).
Concerning gender differences in health, the present study shows no differences in perceived TGH between men and women. However, since men show more risky health behaviour and suffer significantly more from chronic diseases than women (4, 13), they might have been expected to perceive lower TGH than women. As we did not check for risky behaviour or chronic diseases, it is impossible to directly relate these findings to our results on perceived TGH. It might be speculated that good TGH can be perceived despite having a chronic disease, since other dimensions of health like daily functioning or quality of life might compensate for the impaired bodily function caused by the disease. Concerning risk behaviour, it might be speculated that men do not perceive their behaviour as risky but more as a social subjective norm which therefore does not influence their perception of TGH.
The determinant of household size not affecting perceived health confirms the results of a study suggesting a more social, hereditary component of SES negatively impacting health rather than family size (18).
Lastly, the determinant of labour market status might have been expected to affect perceived TGH, as unemployment or poor job satisfaction have detrimental effects on health (15–17). Our findings do not corroborate this expectation. However, being unemployed in general means less income and thus a higher likelihood of having difficulties meeting financial obligations. Hence, a possible explanation for perceived TGH being unaffected by the determinant of labour market status is that the determinant of having trouble meeting financial obligations is compensating for that. Besides, having a job is not a guarantee for health as such, but adequate payment for a job is (1, 39).
The third research question was about the extent to which the relationships between TGH, health determinants, and socioeconomic and demographic determinants differ between various groups of SES, distinguishing six instead of the traditional two groups of high and low SES. Our six-SES groups approach provided more detailed information than the traditional two-SES groups approach. It also produced more refined information on the similarities and differences between the SES groups. Similarities between all six groups could be found for impact of two additional physical health determinants of perceived TGH – bodily functions and daily functioning. The mean perceived TGH score did not differ between the four lowest SES groups, while these differed significantly from the mean perceived TGH score in the two highest SES groups. None of the socioeconomic and demographic determinants impacted perceived TGH in all the SES groups. The impact of all these health, socioeconomic and demographic determinants was contingent upon the specific SES group. There were different gestalts of the health dimensions and the socioeconomic and demographic variables, suggesting that health was perceived differently by each SES group. These findings on subjective SRH evaluation are in line with existing literature on the inequality of health defined in terms of the more objective health indicators by professionals: health is evaluated better as people’s SES is higher (38, 40). In terms of the methodology applied, the finding that our subjective approach leads to a similar conclusion as the professionals’ opinion used thus far is new to the existing literature. This corroborates the findings of Stronks et al. (2018) (33)showing differences between three levels of educational groups by conceptualising health using concept maps.
In general, it is important to emphasise that the six-SES group approach shows there is a gradient instead of a linear pattern in the magnitude of perceived TGH and its six health determinants across the six SES groups. The four lower SES groups (very low, low, mid-low and mid-high) did not differ from each other on perceived TGH score or the score on its six health determinants. However, all of these scores were significantly higher in the two highest SES groups (high and very high) than in the other four SES groups.
A similar three-step gradient seems to be present in the scores on the significant socioeconomic and demographic determinants in the six SES groups, as these determinants impacted perceived TGH the most in the very low SES group, less in the following three SES groups (low, mid-low, mid-high), and little in the high and very high SES groups.
The gradient instead of linear trend in the relationship between SES and health inequality has been reported in several studies (9, 11, 37, 41). By simply dichotomising SES at a median cut-off point, possible socioeconomic effects on perceived health might have been obscured though. More SES groups should be distinguished, also in order to develop more effective interventions to improve people’s health.
The results of our study on the determinants of perceived TGH as a measure of SRH are not only in line with the existing literature, they also add to it on three accounts. First, perceived TGH and hence SRH were operationalised by elaborately scoring on 32 items corresponding not only to the physical and psychological dimensions but also to the social-societal, quality of life, meaningfulness and daily functioning dimensions. Instead of covering the 5-point scale used in the SHQOL and SF12 scores (9, 36, 42, 43) we covered the six health determinants, or dimensions as they are called in Huber’s concept of positive health (28) .
Second, we calculated a six-level SES score based on factor analysis of gross family income and education instead of using a dichotomised SES score. In this way we corrected for the possibility that during the life course income can rise or fall regardless of educational level. As has been shown, detrimental life events like divorce or unemployment due to crises like the recession of the early 2000s or the current Covid-19 pandemic (19, 20, 44) can cause serious loss of income for the higher educated. On the other hand, there are successful high-SES entrepreneurs with low educational levels.
Third, we evidenced a nonlinear gradient in SES impacting perceived TGH and its six health determinants. With regard to possible health-promoting interventions to improve health or TGH and reduce the socioeconomic gap in health, our findings support the suggestion made by Stronks et al. (2018, pp. 8)(33) that ‘the way health is conceptualized, challenges the legitimacy of policies that are based on a notion of health that resonates the conceptions that are valued in higher socioeconomic groups…’. Translated from policies to health-promoting interventions, this means that health-promoting interventions should be tailored to the way health is perceived and valued by the target population. More specifically, such customisation should be oriented towards the importance and magnitude of the six health dimensions perceived by the specific SES group being targeted. This topic will be elaborated upon below.
Implications of the significant relationships between TGH and the six health determinants in the six SES groups
From marketing literature, it is known that the combination of mean scores and importance is critical in making decisions and setting priorities about which changes should be made in marketing strategy, for instance to better meet customer needs (45). In this analogy, combining the significant impact of the evaluation of each of the six health dimensions on TGH in each SES group from Table 4 (importance scores based on standardized betas) with how high or low the evaluations are in each of the six SES groups from Table 3 (mean scores) yields the basis for setting priorities in potential interventions (Fig. 6).
Health inequality is shown by placing the very high SES group above and moving in roughly descending order to the lower left of the graph to very low SES. Some remarkable patterns do stand out. First, the importance score for evaluation of the significant health dimensions in the mid-high and high SES groups is rather low (i.e. placed more to the left of the graph) compared to the scores in the other lower SES groups. This indicates that health on these determinants is perceived the same but rated as more important by the lower SES groups and hence closer to their perception. Health-improving interventions aimed at daily functioning would therefore be more effective in the lowest three groups, whereas interventions aimed at bodily functions would yield a higher effect in the low and high SES groups.
Second, other significant dimensions are placed more to the upper left portion of the graph, indicating a smaller importance but still a rather high score on the evaluation itself. Determinants in this part are perceived as good-very good and of low(er) importance, meaning that interventions aimed at improving these determinants will have no to little effect in these SES groups.
Third, the middle portion of the graph shows a scattered pattern for the very low, low, mid-low and mid-high SES groups (it has been shown that these four – lower – SES groups are quite similar and differ significantly from the two higher SES groups). This indicates that perceived TGH was determined by different gestalts of the evaluation of the health dimensions and their importance to respondents from these four SES groups. These gestalts were different from those in the two higher SES groups. When aiming to reduce socioeconomic differences, mixed interventions targeting the determinants of bodily functions, daily functioning and quality of life would be indicated. The higher health-promoting effectiveness of applying an intervention mix has been shown in a study stimulating physical activity in prevocational secondary education (46).
Lastly, meaningfulness in the very low SES group was the only dimension with a negative impact on TGH, while the score was the lowest of all evaluations. As mentioned previously, this might suggest that people become aware of the psychological dimension of meaningfulness only when TGH is perceived as low, as was the case in the very low SES group. Further research is needed to gain more insight into this determinant affecting perceived TGH in the very low SES group.
In summary, in all six SES situations investigated the evaluation of daily functioning and bodily functions had a very large and positive impact on the evaluation of TGH. Given their high-importance score, these dimensions are the ones most determining equality or inequality in health. Also, quality of life often plays an important role. It appears that the evaluation of some health dimensions (i.e. mental functions and meaningfulness) did not have an impact on TGH in this sample. It may be that participants did not (yet) realise that these dimensions are also relevant in determining TGH. This study shows that different SES groups perceive different health determinants as important to their health, so there is no one-size-fits-all intervention. This could be the starting point for two approaches: to raise awareness in the SES groups for the importance of the other determinants participants do not (yet) perceive as important, and to apply health-promoting interventions matching the perceptions of the SES group. From a salutogenic and capability perspective, the latter might be preferred.