Kopp, M.S., Szedmák, S. , Skrabski, Á.
Socioeconomic differences and psychosocial aspects of stress in a changing society

     It is an interesting phenomenon, that with the fundamental changes in the political-economic system in Central-Eastern-Europe, the life expectancy and the other epidemiological characteristics of our countries became worse and worse. It is especially true in Hungary. While in 1970 the mortality rate of Austria and Great-Britain was higher than in Hungary, up to the nineties Hungary has reached the worst situation with 14.0 mortality per 1000 persons. On the other hand between 1960 and 1988 there was a constant increase in the gross domestic product in Hungary, with a 208% increase compared to the 1960 level (1), thus the worsening health status of the Hungarian population cannot be explained by worsening material situation.
     According to the latest public health studies, in developed countries national mortality rates are strongly related to societal measures of inequality of socioeconomic situation within each country. (2) It is an unresolved paradox of public health studies today that in developed countries, despite social programmes which grant adequate food, housing and medical care, there is a considerable health inequality between the social strata (2-5). Relative socioeconomic deprivation seems to be an important stress factor, even when controled for traditional risk factors such as smoking, obesity, and lack of exercise (6,7). Among British civil servants, Marmot et al (8) found an inverse association between employment grade and prevalence of angina, EKG evidence of ischemia, and symptoms of chronic bronchitis, that is there exists a significant social class difference in morbidity, not only in mortality rates. Especially well estabilished is the relationship between social status and coronary heart diseases, with the more socially disadvantaged being at higher risk (9). According to a review of a number of studies (10) on health and social inequities in Finland, in comparison with other developed countries, mortality, overall morbidity, and perceived health (11) show similar relationships.

Socioeconomic stress factors in the Hungarian population

     The most important psychosocial and socioeconomic stress factors were analysed with the help of national representative studies in 1983, in 1988 and 1995 in the Hungarian population (12-15). In 1988 20.902 persons, in 1995 12.640 persons were examined in the form of home interviews. The studies represent the Hungarian population over the age of 16 according to sex, age, and place of residence.
     The group of questions concerning the socio-economic situation contained 107 questions, the group concerning the health status, health behaviour and psychosocial characteristics contained 209 questions.
     Depressive symptomatology was measured by Shortened Beck Depression Inventory (BDI).(16,14) Health status was quantified by sick days in the last year. The subjects answered two questions for 26 disease groups on whether they had been treated because of the given illness at some time in their life, and how many days they were actually sick because of the given illness in the past year. We calculated the total number of sick days for the whole past year for each subject.
     The interactive effects of socioeconomic factors, depressive symptomatology and sick days were analysed separately for men and women using hyerarchical loglinear regression analysis. Figure 1. shows these interrelationships for the Hungarian male population in 1995. According to hierarchical log linear analysis, depressive symptomatology mediates between the socioeconomic factors and higher morbidity rates, reflected in more sick days in more disadvantaged groups. When depressive symptomatology was included into the multivariate analysis, sick days and all of the measured socioeconomic factors were in more close direct connection with severity of depressive symptomatology, than the direct connection between socioeconomic factors and morbidity discussed above (2-5, 17).
     It is interesting, that between 1988 and 1995 among women the mediating effect of depression between socioeconomic situation and overall morbidity increased significantly. While in 1988 only the overall socioeconomic characteristics of the family, such as bad housing conditions and no access to a car were connected to depressive symptomatology (14), in 1995 the own employment status of women became more important in connection with depression and sick days (Figure 2).
     Between 1988 and 1994-95 a significant polarization of the psychosocial and health status of the population could be observed, with extremely high depression scores in persons relatively less successfull during the social and economic changes. Figure 3. shows the mean scores of Beck Depression Inventory by employment status in 1988, 1995 and among unemployed persons in 1995 (there was no unemployment in 1988 in Hungary). The active population (working and studying persons) were included into this analysis. There are significantly higher depression scores among unemployed persons. (Depression Score higher than 1o means mild depressive symptomatology) (14) Similarly high depression values are among unemployed managers to unskilled workers.That is unemployment is a most important stress factor, especially in the lowest and highest socioeconomic strata. It is striking the almost determining role of fathers emloyment in 1995, which means that in a changing society the low socioeconomic situation of the father is a fundamental risk factor in connection with emotional and physical vulnerability (Figure 4).
     During the last decades the socioeconomic situation of the Hungarian population became more and more polarized. Whereas in 1970 there was an almost equally low level of property ownership, by the end of the eighties a proportion of the society had reached a much better economic situation, posessing one or more cars, owning property and having a significantly higher income. That is, the relative differences within society increased considerably.
     A vicious circle might be hypothetised between depressive symptomatology and a socially deprived situation, which as a stress factor plays a significant casual role in ill health. Relatively deprived persons living among undesirable social conditions (such as without a car, living in bad housing conditions) might suffer from constant relative deprivation, might sense helplessness and constant loss of control over their own situation which in the long run might result in depressive symptoms. They might regard the future as hopeless, they might blame themselves for their low achievements, they are not as well supported when they become ill. This is a more important factor during a time period of rapid economical changes and the consequent polarisation of the social situation of the population, as has been happening in Hungary since 1970s. That is, not the objective socioeconomic situation, but the negative cognitive evaluation of the relative deprivation is the central stress factor.
     Depressive symptomatology as the mediator of socioeconomic stressors in socially disadvanted groups, might influence perceived health and health related behaviour and consequently might result in working disability without organic causes. In modern societies working disability caused by inability to cope with everyday situations, and emotional and behavioural disturbances have become more important factors than disabilities caused by physical handicaps or infectious diseases. There is a significant inverse relationship between depression and health behaviour, with a higher level of smoking, alcohol abuse and suicidal behaviour among more depressives (18-20).
     Persons with lasting mood disorders are both more susceptible to different kinds of disorder, and in parallel, they are less able to improve their social conditions. In the past years, depression or vital exhaustion has been found to be a risk indicator for coronary heart disease (21-23). Learned helplessness or hopelessness, which can be regarded the best model of depression result in decreased immunological activity that influences tumour growth (24) and an inverse relationship can be seen between severity of depression and susceptibility to different kinds of infections.
      These results indicate that the subjective evaluation of socioeconomic deprivation can be regarded as serious stress factor and the majority of health consequences of relativly lower socioeconomic situation are mediated by a depressive state. This phenomenon is probably an important component of deteriorating health status in Hungary after the 1970s, where socioeconomic polarisation increased suddenly and considerably and the masses left behind might apprais their situation as hopeless and helpless.

References
1. STATISTICAL YEARBOOK OF HUNGARY, Budapest, 1993.
2. WILKINSON, R.G. 1992. National mortality rates: The impact of inequality? Am.J. Publ.Hlth. 82: 1082-1084.
3. SYME, S.L. & L.F. BERKMAN. 1976. Social class, susceptibility and sickness. Am. J. Epidemiology. 104: 1-8.
4. MARMOT, M.G. et al. 1987. Social/economic status and disease. Annual Rev Public Health. 8: 111-135.
5. KAPLAN, G.A. 1995. Where do shared pathways lead? Some reflections on a research agenda. Psychosom.Med. 57, 208
6. SLATER, C.H. et al. 1985. The independent contribution of socioeconomic status and health practices to health status. Prev Med. 14: 372-373.
7. WILEY, J.A.& T.C. COMACHO. 1986. Life-style and future health: Evidence from the Alameda county study. Prev Med. 9: 1-21.
8. MARMOT, M.G et al. 1986. Health inequalities among British servants: the Whitehall II study. Lancet. 337: 1387-1393.
9. SHEWRY, M.C. et al. 1992. Variation in coronary risk factors by social status: results from the Scottish Heart Health Study. British J. General Pract. 42: 406-410.
10. LAHELMA, E. & T. VALKONEN. 1990. Health and social inequities in Finland and elsewhere. Soc Sci Med. 31: 257-265.
11. WANNAMETHEE, G. & A.G. SHAPER. 1991. Self-assessment of health status and mortality in middle aged British men. Int. J. Epidemiol. 20: 239-245.
12. KOPP, M. & Á. SKRABSKI. 1989. What does the legacy of Hans Selye and Franz Alexander mean today? (The Psychophysiological approach in medical practice) Internat J Psychophisiology. 8: 99-105.
13. KOPP, M.S. et al. 1987. Neurotics at risk and suicidal behaviour in the Hungarian population. Acta Psychiatrica Scandinavica. 76: 406-413.
14. KOPP, M.S. et al. 1995. Socioeconomic factors, severity of depressive symptomatology, and sickness absence rate in the Hungarian population, Journal of Psychosomatic Research. 39, 8: 1019-1029.
15. KOPP, M. & Á. SKRABSKI. 1996. Behavioural Sciences Applied to a Changing Society, Bibliotheca Septem Artium Liberalium, Budapest.
16. BECK, A.T. & R.W. BECK. 1972. Shortened version of BDI. Post Grad Med. 52: 81-85.
17. WILKINSON, R.G. 1996. Health, civic society in Eastern Europe before 1989. In Environmental and non-environmental determinants of the East-West life expectancy gap. C. Hertzman, Ed. Cluwer, Amsterdam.
18. SKRABSKI, Á & M.S. KOPP. 1994. Health behaviour, psychiatric symptoms and psychosocial background factors. In Swiss Monographs in Psychology. Dauwalder, Ed. 2: 21-27.
19. LUNDBERG, O. 1992. The contribution of health related behaviour to class inequalities in health. Proc. Second Internat. Congr. of Behavioral Medicine, Hamburg.
20. NORTH, F. et al. 1993. Explaining socioeconomic differences in sickness absence:the Whitehall II Study, Br. Med. J. 306: 361-366.
21. APPELS A. 1983. The year before myocardial infarction. In Biobehavioural bases of coronary heart disease. T.M. Dembroski, H. Smidt, G. Blumchen, Eds. Karger, Basel.
22. FALGER, P & A. APPELS. 1982. Psychological risk factors over the life course of myocardial infarction patients. Advances in Cardiology. 29: 132-139.
23. FRASURE-SMITH, N. et al. 1995. Depression and 18 month prognosis after myocardial infarction, Circulation. 15, 91, 4: 999-1005.
24. SKLAR, L. & H. ANISMAN. 1979. Stress and coping factors influence tumour growth. Science. 205: 513-515.