So what have we learned? We do not live in a perfect world where valuable materials and resources are unlimited and evenly distributed. In the United States and on a worldwide level, social stratification is an unfortunate reality. In a class-based economic system such as ours, status and power are inextricably linked, which can either facilitate or hinder access to social capital and its associated rewards. This is especially the case for certain disadvantaged groups based on categories of class, race, gender, and age. While not perfect, our class system does tend to allow for upward social mobility either in one’s lifetime or across generations. At the heart of America’s socioeconomic values is the principle of meritocracy, which means that through hard work, credentials, and dedication, one can move up in society. However, many people in the United States remain impoverished. Social inequality and social exclusion make it increasingly difficult for low-income groups to improve their socioeconomic condition. Some hold that social inequalities such as poverty remain because these inequalities are passed down from one generation to another. While there is some truth to the social reproduction of poverty, one’s situational context also plays a role through spatial inequality. Where one lives in this world has an impact on one’s position in life, especially in terms of accessing key resources and prosperous opportunities. Spatial inequality remains at the residential, environmental, and global level.
But how do such social inequalities influence health and healthcare disparities? Well, as is the case with many facets of life, wealth matters. Those with greater income typically have access to better quality healthcare. This is especially the case in the U.S. healthcare system because of uneven levels of coverage and high healthcare costs. Socioeconomic status or class greatly impacts one’s ability to navigate the system and procure healthcare in the United States. Low-income racial and ethnic minorities tend to be worse off, having both poorer health and poorer access to healthcare. Women, despite being more prone to chronic and degenerative diseases, tend to fare better than men when it comes to overall health and accessing and utilizing healthcare resources.
While the U.S. healthcare system is undergoing a significant reorientation and taking on a more preventative approach, it is more important now than ever to place a greater emphasis on sociological issues to understand the relationship between social stratification and health and healthcare disparities. Illness and disease are a product of social as well as psychological and physiological issues. This chapter is the last chapter in MCAT Behavioral Sciences Review; you have therefore covered all of the psychology and sociology content required for the MCAT. This is a fitting chapter to finish this discussion, and we leave you with a charge: as you prepare for the MCAT, medical school, and life as the physician you deserve to be, think about the changes that are needed in the U.S. healthcare system. Serve your local, national, and international community and improve the health status of those around you, while contributing to a future where everyone can access quality healthcare.
· Social stratification is based on socioeconomic status (SES). Socioeconomic status depends on ascribed status and achieved status.
o Ascribed status is involuntary and derives from clearly identifiable characteristics, such as age, gender, and skin color.
o Achieved status is acquired through direct, individual efforts.
· A social class is a category of people with shared socioeconomic characteristics. The three main social classes are upper, middle, and lower class. These groups also have similar lifestyles, job opportunities, attitudes, and behaviors.
· Prestige is the respect and importance tied to specific occupations or associations.
· Power is the capacity to influence people through real or perceived rewards and punishments. It often depends on the unequal distribution of valued resources. Power differentials create social inequality.
· Anomie is a state of normlessness. Anomic conditions erode social solidarity by means of excessive individualism, social inequality, and isolation.
· Social capital is the investment people make in their society in return for economic or collective rewards. Social networks, either situational or positional, are one of the most powerful forms of social capital and can be achieved through establishing strong and weak social ties.
· Meritocracy refers to a society in which advancement up the social ladder is based on intellectual talent and achievement.
· Social mobility allows one to acquire higher-level employment opportunities by achieving required credentials and experience. Social mobility can either occur in a positive upward direction or a negative downward direction depending on whether one is promoted or demoted in status.
· Poverty is a socioeconomic condition. In the United States, the poverty line is determined by the government’s calculation of the minimum income requirements for families to acquire the minimum necessities of life.
· Social reproduction refers to the passing on of social inequality, especially poverty, from one generation to the next.
· Poverty can either be absolute or relative.
o Absolute poverty is when people do not have enough resources to acquire basic life necessities, such as shelter, food, clothing, and water.
o Relative poverty is when one is poor in comparison to a larger population.
· Social exclusion is a sense of powerlessness when individuals feel alienated from society.
· Spatial inequality is a form of social stratification across territories and their populations, and can occur along residential, environmental, and global lines.
o Urban areas tend to have more diverse economic opportunities and more ability for social mobility than rural areas. Urban areas also tend to have more low-income racial and ethnic minority neighborhoods than rural areas.
o Formation of higher-income suburbs is a common occurrence, and is due in part to the limited mobility of lower-income groups in urban centers.
o Environmental injustice refers to an uneven distribution of environmental hazards in communities. Lower-income neighborhoods may lack the social and political power to prevent the placement of environmental hazards in their neighborhoods.
· Globalization has led to further inequalities in space, food and water, energy, housing, and education as the production of goods shifts to cheaper and cheaper labor markets. This has led to significant economic hardship in industrializing nations.
Epidemiology and Disparities
· Incidence is calculated as the number of new cases of a disease per population at risk in a given period of time: for example, new cases per 1000 at-risk people per year.
· Prevalence is calculated as the number of cases of a disease per population in a given period of time: for example, cases per 1000 people per year.
· Morbidity is the burden or degree of illness associated with a given disease.
· Mortality refers to deaths caused by a given disease.
· Health is dependent on geographic, social, and economic factors.
o The second sickness refers to an exacerbation of health outcomes caused by social injustice.
o Poverty is associated with worse health outcomes, including decreased life expectancy, higher rates of life-shortening diseases, higher rates of suicide and homicide, and higher infant mortality rates.
o Certain racial and ethnic minorities have worse health profiles than others. African Americans are, on average, the worst off; white Americans, Native Americans, and Hispanic Americans are next; and Asian Americans and Pacific Islanders have the best health profiles.
o Females have better health profiles than males, including higher life expectancy, lower rates of life-threatening illnesses, and higher rates of accessing and utilizing health resources. However, females have higher rates of chronic diseases and higher morbidity rates.
· Efforts to improve healthcare for underserved populations include the Affordable Care Act (ACA) and the Medicare and Medicaid programs.
· Healthcare access and quality differ across the population.
o Low-income groups and racial and ethnic minorities (specifically, African Americans, Asian Americans, Native Americans, and Hispanic Americans) receive worse care than white Americans.
o Biases against overweight or obese patients are associated with lower-quality treatment, including less preventative care and fewer screenings.
o Women tend to have better access to healthcare and utilize more healthcare resources than men.
o LGBT men and women may have barriers to care due to prejudices, discrimination, and homophobia.
Answers to Concept Checks
1. SES is determined by two factors: it can be ascribed according to physical or external characteristics such as age, gender, or skin color, or acquired through direct efforts such as hard work or merit.
2. The less social capital a person has (reduced network equality and equality of opportunity), the more social inequality. This, in turn, decreases social cohesion.
3. Social inequality is highest among racial and ethnic minorities (especially African Americans and Hispanics), female-headed families, and the elderly. It is also most prevalent among those living in poverty.
4. Social mobility can be dependent on intellectual talent and achievement (meritocratic competition) but can also be obstructed by concentrated power as well as discrimination based on ethnicity, gender, age, or other identifiable characteristics.
5. Environmental hazards tend to be located in low-income areas with a higher population of racial and ethnic minorities. Poor living conditions can result in increased illness and disease among these groups of people.
1. The second sickness refers to the fact that health outcomes are exacerbated by social inequalities and social injustice. As a result, higher-income groups have longer life expectancies than lower-income groups.
2. Low-income racial and ethnic minorities have higher morbidity rates and overall worse health compared to the middle and upper classes. The lower class also has higher infant mortality rates, homicide rates, and suicide rates in comparison to wealthier classes.
3. Women typically have longer life expectancies and an overall better health profile in comparison to men. This can be attributed to both biological and sociological causes: women are less likely to have life-threatening conditions, although they do have higher morbidity rates. Women are also more likely to seek care and to utilize healthcare services than men.
4. Low-income groups have less access to healthcare services and often experience lower quality healthcare. Poor Americans are less likely to be insured and consequently are less likely to seek medical attention until conditions have become extremely serious, thereby limiting available interventions. As a result, morbidity and mortality rates are highest among low-income groups.
· Behavioral Sciences Chapter 5
o Motivation, Emotion, and Stress
· Behavioral Sciences Chapter 6
o Identity and Personality
· Behavioral Sciences Chapter 7
o Psychological Disorders
· Behavioral Sciences Chapter 8
o Social Processes, Attitudes, and Behavior
· Behavioral Sciences Chapter 10
o Social Thinking
· Behavioral Sciences Chapter 11
o Social Structure and Demographics
Discrete Practice Questions
1. Which of the following best describes the component of socioeconomic status attributable to direct individual efforts?
1. Ascribed status
2. Meritocratic competition
3. Anomic condition
4. Achieved status
2. Which of the following displays a correct association?
1. High social networking and low social capital
2. High social mobility and low social capital
3. Low social class and low social capital
4. Low social networking and high social capital
3. Which of the following concepts are LEAST likely to coincide?
1. Hazardous waste facilities and low-income neighborhoods
2. Tuberculosis and poor living conditions
3. Environmental pollution and high minority population
4. Globalization and global equality
4. Which of the following trends is most likely FALSE?
1. Mortality rates are increased in low-income racial and ethnic minorities.
2. Life expectancy is decreased in high-income groups.
3. Birth weights are decreased in children of low-income women.
4. Rates of lung cancer are increased in low-income groups.
5. Questions 5—6 refer to the scenario described below.
6. A small town has 1000 residents, including 500 men and 500 women. In this town, 20 of the men have prostate cancer. During a calendar year, 10 more men are diagnosed with prostate cancer. Assume none of the men are cured or die during the year.
5. What is the prevalence of prostate cancer in the population that can develop the condition at the end of the year?
1. 10 ÷ 480
2. 10 ÷ 1000
3. 20 ÷ 500
4. 30 ÷ 500
6. What is the incidence of prostate cancer in this population during the year?
1. 10 ÷ 480
2. 10 ÷ 1000
3. 20 ÷ 500
4. 30 ÷ 1000
7. A low-income single mother works a part-time job and lives in a small apartment in the city. When her children grow up, they take similar jobs and live in similar housing. This is an example of:
1. upward social mobility.
2. downward social mobility.
3. social exclusion.
4. social reproduction.
8. Which of the following is true with regard to relative poverty?
1. Individuals in relative poverty have incomes below the poverty line.
2. Individuals in relative poverty exhibit downward social mobility.
3. Individuals in relative poverty may be in the upper class.
4. Individuals in relative poverty exhibit upward social mobility.
9. In comparison to urban centers, suburbs tend to have:
1. larger racial and ethnic minority populations.
2. higher rates of poverty.
3. larger upper- and middle-class populations.
4. higher rates of crime and homicide.
10. Which of the following terms refers to the burden or degree of disease associated with a given illness?
3. Second sickness
11. Compared to white Americans, which of the following racial or ethnic groups tends to have a better overall health profile?
1. African Americans
2. Asian Americans
3. Hispanic Americans
4. Native Americans
12. Which of the following best describes the populations targeted by Medicare and Medicaid, respectively?
1. Medicare: mostly patients without employer-guaranteed healthcare; Medicaid: mostly patients who have recently immigrated
2. Medicare: mostly patients who have recently immigrated; Medicaid: mostly patients without employer-guaranteed healthcare
3. Medicare: mostly patients in older age groups; Medicaid: mostly patients with low socioeconomic status
4. Medicare: mostly patients with low socioeconomic status; Medicaid: mostly patients in older age groups
13. Morbidity is increased in low-income groups because of all of the following EXCEPT:
1. higher rates of obesity.
2. less access to healthcare.
3. higher rates of homicide.
4. lower rates of physical activity.
14. Hypertension (high blood pressure) can be diagnosed by having two or more blood pressure readings higher than 140/90 on two different occasions, separated by a week. Suppose that the criteria were changed to include anyone with a reading higher than 130/80 on at least one occasion. How would this change the prevalence of diagnosed hypertension in the population?
1. The prevalence would increase.
2. The prevalence would decrease.
3. The prevalence would remain the same.
4. There is not enough information to determine the change in prevalence.
15. Which of the following trends regarding healthcare disparities has NOT been documented?
1. Females are more likely to be insured than males.
2. Primary care use is more likely among males than females.
3. Low-income individuals have more difficulty accessing care than high-income individuals.
4. LGBT individuals have more barriers to healthcare than heterosexuals.
Discrete Practice Answers
1. DSocial stratification based on direct efforts, such as merit, is a form of achieved socioeconomic status. Ascribed socioeconomic status, (A), is based on identifiable external characteristics. Achieved status may be due to meritocratic competition, (B), but other individual efforts can also be associated with achieved status. Anomic conditions, (C), are those that cause a breakdown between the individual and society and erode social solidarity.
2. CLow social class may lead to low social capital. Members of the lower class often have smaller numbers of weak ties in social networks, and therefore have less opportunity to invest in society and reap its benefits.
3. DGlobalization does not typically lead to global equality; rather, globalization tends to create further global inequalities. In regard to environmental justice, higher numbers of hazardous waste facilities tend to be found in low-income neighborhoods, (A). Poor living conditions tend to be associated with greater health problems, including tuberculosis, (B). Finally, environmental pollution is more prevalent in areas with minority populations, especially low-income minority populations, (C).
4. BHigh-income groups tend to have increased life expectancy rates, not decreased. Low-income racial and ethnic minorities have higher mortality rates than high-income groups, (A). Low-income women tend to have children with lower birth weights, (C). Finally, rates of various diseases, including lung cancer, are increased among low-income groups, (D).
5. DPrevalence is defined as the total number of cases divided by the possibly affected population during a period of time. Here, the period of time is defined as one point: the end of the year. At the end of the year, there are 30 total cases in a population of 1000 individuals, but only 500 of those individuals can develop prostate cancer, meaning the prevalence is 30 ÷ 500.
6. AIncidence is defined as the total number of new cases divided by the at-risk population during a period of time. Here, the period of time is one year. There were 10 new cases in this year, and the at-risk population will be only the males who do not already have prostate cancer; the 20 men already diagnosed and the 500 women should not be included in the at-risk population. Therefore, the incidence in this population is 10 ÷ 480.
7. DIn this scenario, the children remain in the same socioeconomic class as their mother, indicating a lack of social mobility, (A) and (B). Rather, this is an example of social reproduction, in which social inequality, especially poverty, is passed from one generation to the next.
8. CRelative poverty is a comparative term: it describes being poorer than those in the surrounding population. Members of the upper class can live in relative poverty compared to others in their neighborhood if they are not as well-off as their neighbors. Relative poverty is not directly associated with upward or downward social mobility, eliminating (B) and (D); individuals living in relative poverty could exhibit mobility in either direction or no social mobility at all.
9. CSuburbs tend to have larger upper- and middle-class populations than urban centers; urban centers tend to have larger low-socioeconomic status populations than suburbs. This is due, in part, to the increased mobility seen in upper- and middle-class populations, which permits their migration into the suburbs.
10. AMorbidity refers to the burden of illness, or the severity or degree of illness. Mortality, (B), refers to deaths caused by a given illness. Second sickness, (C), is a term used to describe the exacerbation of health outcomes due to social injustice. Chronicity, (D), refers to the duration of a disease, not its severity or significance for the patient.
11. BIn comparison to white Americans, Asian Americans tend to have better overall health profiles. African Americans, (A), tend to have worse overall health profiles. Hispanic Americans and Native Americans, (C) and (D), both have mixed health profiles in comparison to white Americans: they are better off in some categories and worse off in others. However, Hispanic and Native Americans do not have better overall health profiles than white Americans.
12. CMedicare covers patients over the age of 65 (older age groups), those with end-stage renal disease, and those with amyotrophic lateral sclerosis (ALS). Medicaid covers patients below a certain socioeconomic level.
13. CMorbidity refers to the burden or severity of disease. All of the factors listed are true with regard to low-socioeconomic status populations; however, high homicide rates cause increases in mortality, not morbidity.
14. AIf the threshold for hypertension (high blood pressure) were lowered, more individuals would be fit the criteria for the disease. If the number of individuals with the disease increases and the population stays the same overall, there will be an increased prevalence of the disease.
15. BIn comparison to females, males visit primary care doctors less frequently. All of the other trends listed here have been documented.
Consult your online resources for additional practice.