Introduction
The concept of socioeconomic status (SES) involves a range of categories such as, but not limited to, occupational position, income, and education. In terms of healthcare, the evidence shows that people with low SES are likely to encounter challenges in accessing the necessary services and improper treatment (Manstead, 2018). It is also suggested that the increased levels of depression and anxiety are characteristic of low SES. In particular, some studies indicate the greater prevalence of poor care quality provided to racial and ethnic minorities, as well as people with a lack of education and employment (Villatoro, Mays, Ponce, & Aneshensel, 2018). Accordingly, poorer mental health can be, to some extent, the result of the correlation between low SES and related care access disparities (Finegan, Firth, Wojnarowski, & Delgadillo, 2018). This literature intends to provide an in-depth literature review, examining such links between SES and mental therapy access as social identity, behavior, attitudes, and cultural aspects.
SES Dimensions: Education, Income, and Occupation in Terms of Therapy Access
In recent decades, research on the role of SES in healthcare increased tremendously. All over the world, many people are doomed to live in poverty due to health conditions. They cannot pay for treatment, which prevents them from ending their struggles. Moreover, when these people get sick, they cannot work, provide themselves and their families with the means for living, and become a burden for their state (Delgadillo et al., 2016; Packness et al., 2017). The authorities of the US and European countries are trying to reduce the inequality in the health of citizens since this reduces the state’s expenses for healthcare. Equal access to medical services also increases the stability of the state as, in conditions of inequality, people express discontent, feeling a lack of concern for themselves.
Considering inequality in the incomes of the population of different countries, it becomes evident that it is the greatest in the US. In particular, the Gini coefficient is 45 for the US, while Canada scores at 32.1, and this coefficient is less than 30 for the majority of European countries (“Gini coefficient by country 2020,” 2020). According to statistics, the higher this inequality, the lower the life expectancy of the population is (Villatoro et al., 2018). It is caused by the fact that people with relatively high incomes are able to access high-quality mental care, but poorer ones cannot afford it, which means that their health needs remain unaddressed. Recent studies show the existence of a health gradient in all countries that have been studied (Arpey, Gaglioti, & Rosenbaum, 2017; Tyagi & Ranga, 2018). The higher one’s social and economic position, the better his or her well-being is. For example, those working in poorly paid jobs are more likely to suffer from cardiovascular disease than their higher-paid fellow citizens, while no correlation is noted in terms of age group and gender.
It is important to note that income inequality is a characteristic of a social system, while income is a characteristic of an individual. Despite the fact that most of the effects of income inequality are indirect effects of the difference in individual incomes, it would be a mistake to reduce the problem to individual effects. Finegan et al. (2018) argue that the causes of specific cases of the disease sometimes differ from the causes of the incidence, in other words, there may be various determinants. At the individual and population levels, and sometimes the factors that cause illness in people differ from the incidence factors among the population group. Individual income, for the most part, is determined by a person’s education, skills, and efforts, while income inequality is determined by history, politics, and economics. Different researchers agree that reducing income inequality by increasing the incomes of more vulnerable groups of the population will improve their health and, consequently, the average state of the population’s health.
Thus, SES dimensions can be regarded as powerful yet not fully understood determinants of health. They may not have a direct effect but serve as closely intertwined factors for either improving or deteriorating access to therapy (Finegan et al., 2018). One can suggest that, instead of a direct influence, inequality in social and economic conditions differentially impacts other factors that can be integrated into a more direct relationship with the level of health, including healthcare, environment, and lifestyle (Epping, Muschik, & Geyer, 2017). The articles included in this section are consistent in their arguments that the dimensions of SES are interrelated and important in determining access to therapy. Some of them suggest further research areas, such as potential ways to combat social and economic inequality, while others state that more studies are needed for better understanding the trajectories that impede and promote care access.
Social Identity in Terms of Behaviors and Attitudes
People’s resources with regard to others identify their social and economic position in society. The evidence shows that socioeconomic deprivation correlates with poor treatment outcomes compared to a lack thereof. The article by Finegan et al. (2018) considers low SES as social deprivation to clarify its impact on the utilization of mental health services. Based on the method of the literature review, the authors covered 165,574 patients and used this data to conduct a quantitative analysis. It was found that the results are mixed, although some relations between low SES and poor psychological treatment were detected. The statistical analysis demonstrates that the overall effect is noted as small yet significant. In turn, Packness et al. (2017), who explores mental health in terms of the impact of socioeconomic position, claims that the patients with low SES are likely to refer to careless frequently, even if service is provided for free. Likewise, Finegan et al. (2018), Packness et al. (2017) conducted a quantitative analysis based on a nationwide register-based cohort study. Both studies assume that there is a trend: people with low SES make fewer mental health care visits.
The critical review of the literature shows that many scholars attempt to understand these differences in mental care access in the contexts of SES. Destin, Rheinschmidt-Same, and Richeson, (2017) emphasize that greater attention is paid to the understanding of one’s status-based identity, which identifies the changes that occur in his or her behaviors, thoughts, and attitudes. The study by Destin et al. (2017) explores the impacts of status transition, focusing on perceived uncertainty. Consistent with Manstead (2018), the above authors claim that financial stability plays one of the key roles in making decisions. In particular, if a person has fewer unknown factors, he or she is more likely to visit a therapist and try to resolve mental problems instead of avoiding them. People with lower SES are also more likely to interpret their problems in terms of situational terms since they have low personal control over socially-important events. Those with middle and high SES, on the contrary, tend to distinguish between their position and contexts.
To arrive at the conclusions that oppose those that are noted above, Epping et al. (2017) employ the perspective of social inequality to clarify the impact of three socio-economic (SES) indicators on the trends of mental health care usage. In particular, on the basis of logistic regression analysis, the authors examine the population of Germany and argue that income is not the determinant that significantly affects access to care. At the same time, Epping et al. (2017) mention that the most noteworthy results are obtained for education, which can be explained by differential verbalization of psychological problems when it comes to the conversation between a therapist and patient. Compared to other articles that are discussed in this section, this one contradicts their findings. To make it clear, this controversy should be considered against the facts that Epping et al. (2017) included only people with health insurance and that Germany faces dropout in financial barriers to psychotherapy in outpatient settings. In other words, this study is limited by the inability to fully represent the social gradients of patients with mental issues.
Manstead (2018) clarifies the theoretical model of solipsism versus contextualism that was elaborated by Kraus, Piff, Mendoza-Denton, Rheinschmidt, and Keltner, who identified the ways of how different classes perceive social context. While upper-class representatives think in terms of solipsism, which implies an orientation on individual goals, emotions, and states, lower-class focus on contextualism, which means external orientation based on threats, constraints, and other people. In turn, Delgadillo (2018) refers to the social causation theory that posits the link between environmental adversity and mental health problems. Material deprivation lies in the foundation of this theory, and as stressed by Delgadillo (2018), SES and treatment outcomes may be affected by negative life events. The comparison of the two mentioned theories reveals that the first of them illuminates a possible reason for perceived limitations to care access. In other words, it examines the very way persons with different SES observe their opportunities. In turn, the causation theory aims to explain the reasons behind poor mental health treatment outcomes.
The socioeconomic aspect is discussed by Delgadillo (2018) and Delgadillo et al. (2016) in terms of politics, poverty, and psychology. There is a growing sense among the poor that inequalities in access to education and health care are unfair. At the same time, they do not perceive and do not use leisure as an opportunity to develop their own joint communicative competencies, which testifies to the absence or unconsciousness of their joint needs for attachment, recognition, and self-expression (Delgadillo, 2018). The closeness of the social space of people with low income determines the long-term social degradation of this group. The negative sides of inequality in the social sphere can be added to psychological problems created due to social competition (Delgadillo et al., 2016). Low-income people compare their standard of living with that of more successful individuals, and this puts pressure on their emotional state.
Regardless of the findings, all the studies that are taken into account in terms of behaviors and attitudes of patients report the marked under-coverage of people with low SES. Epping et al. (2017), Delgadillo et al. (2016), and Packness et al. (2017) do not offer considerations on future research, but Finegan et al. (2018) and Manstead (2018) are consistent in potential implications of their findings and further work. In particular, these authors prioritize the adoption of a standardized way of operationalizing SES in studies. In other words, the scholars insist on the establishment of a universal framework for further studies, which would allow minimizing limitations and increasing the accuracy of results.
Influence of Socioeconomic Status and Culture on Human Expression
The impact of social classification on a person’s cultural expressions is another topic of discussion, which determines the patterns of group beliefs. In the study that is conducted by Becker, Kraus, and Rheinschmidt-Same (2017), cultural expressions are observed via social media communication, namely, Facebook photographs. The authors conclude that social class implications are evident in the interests and preferences of users. According to the self-reported identification of participants’ SES, it is identified that low SES is associated with the perceived lack of control and worse group efficiency, which creates social boundaries (Becker et al., 2017). A similar trend is noted by Williams, Priest, and Anderson (2016), who focuses on the intersection between SES, race, and health, suggesting that people with low SES are likely to remain passive in the face of social inequality, while those with higher SES would require meeting their needs.
Racial and ethnic minorities underuse mental health services due to their cultural background. The study by Ford, Lam, John, and Mauss, (2018) confirms that cultural background acts as one of the essential components of socio-economic status. For instance, among ethnic and racial minorities, there is a concentration of people with low income and a lack of insurance. They have fewer opportunities to receive higher education, and, consequently, a high income; their stress level is higher, while their ability to cope with it is lower (Villatoro et al., 2018). Another research by Neblett, Bernard, and Banks (2016) also reveals that the geography of the residence also plays a crucial role. Ethnic minorities accumulate in certain areas where services of the same quality are not always provided as for a majority group. In some cases, political reasons can be a factor as minorities do not have the political power to influence politicians.
African-Americans, Hispanics, Native Americans, and other minority groups are at an increased risk of mental health concerns due to the racism-related stress they encounter (Neblett et al., 2016). The participants were enrolled in the study from a university, where they were vulnerable to discrimination, clarified by Neblett et al. (2016). The interaction of gender and SES with mental health problems was a specific focus of the mentioned study that revealed that young females with higher SES and young males with lower SES as the main victims of racial discrimination. Accordingly, these groups had greater risks of developing mental health complications. Most importantly, not only individual problems but also group issues appeared, including the feeling of disconnectedness and uneasiness in social situations (Neblett et al. (2016). Thus, the key contribution of this article is that men are more prone to racial discrimination and related psychological health consequences.
The perceived need for mental health care can be evaluated as minor in people with low SES. In comparison to other articles that discuss this subtopic, Villatoro et al. (2018) claim that personal attitudes on social inequality shape lower expectations and self-care levels. The detailed analysis of various ethnicities shows that African-American men and non-Latino whites are less likely to prioritize their care needs; the same can be noted regarding Asian-Americans and non-US-born persons (Villatoro et al., 2018). These findings are consistent with the results that are provided by other scholars, stating that unprepared socio-cultural context is one of the reasons for dropping out of psychotherapy (Khazaie, Rezaie, Shahdipour, & Weaver, 2016). The latter emphasizes that a lack of awareness of the need to visit a therapist is often accompanied by unrealistic expectations of care provision.
In general, the results of the studies demonstrate that there is an objectively close relationship between the culture and the social class in relation to health, and this corresponds to both theoretical assumptions and available empirical evidence (Khazaie et al., 2016; Villatoro et al., 2018). However, this conclusion leads to the assumption that the propensity for health practices is formed on the basis of habitus and living conditions of a particular social group. One can, therefore, expect that with an increase in education and incomes and a corresponding decrease in the share of the lower class, the number of people referring to therapists would increase.
Trends in Literature and Future Research
Based on the trends of the scholarly literature that are examined in this paper, it is possible to summarize that there is a strong link between SES, gender, culture, and access to mental health treatment. While some authors clearly state the prospects for future academic works, others do not include this issue in their articles (Neblett et al. (2016). Namely, more than half of the reviewed articles contain little or no considerations about what should be done in this field. In their turn, Villatoro et al. (2018) and Becker et al. (2017) stress that SES-related factors should be taken into account in combination to better understand the existing social inequality in mental care utilization among the lower-class representatives. Such tendencies as staying inactive in the face of social and racial discrimination, as well as the idea of social disintegration and improper perception of care needs, are to be explored in the future.
It is evident that the mechanisms that deteriorate mental care access and create associated barriers are not yet fully understood in the literature. Consequently, further studies should pay attention to the concepts of social deprivation, under-evaluation of care needs, and the understanding of self as a part of SES groups, et cetera (Arpey et al., 2017). The paramount goal of future research is to ensure that the challenges of people with low SES are properly comprehended to design relevant strategies for improving their access to mental care. Many authors argue that risk-adjusted metrics, along with a population-matched approach, should be applied across the studies, which would allow decreasing biases and limitations to findings (Delgadillo et al., 2016; Manstead, 2018). Therefore, increased funding is required to conduct more research and eliminate the disadvantages of minorities and those with low income.
In terms of further comprehensive research, the identified problem may involve the construction of algorithms for the formation of an effective strategy for the interaction of the state and business in solving issues of social policy and social responsibility of business. The harmonization of interests of all the subjects of society will ensure the stability of sustainable development and at the difficult stage of global geopolitical changes.
Summary of Future Research Recommendations
The critical literature review shows that the current understanding of the links between access to mental therapy and socioeconomic status (SES) is insufficient. More studies are required in the field of determining how various dimensions of SES are related to each other, which would enrich the literature that largely focuses on analyzing social inequality factors separately (Becker, Kraus, & Rheinschmidt-Same, 2017). Namely, it would be beneficial to consider the impact of income, race, cultural background, and age in terms of their cooperative impact on reaching the necessary therapy (Destin et al., 2017). In addition, people’s attitudes on the existing inequality and perceived need to access mental services should be explored in detail (Manstead, 2018; Neblett et al., 2016). The importance of paying attention to the mentioned points is caused by the challenges that are faced by people with low incomes and minorities, living in disadvantaged areas.
Another area of potential research is associated with clarifying the ways to improve access to mental therapy for people with low SES. Among the dimensions to consider, social deprivation and the under-evaluation of care needs can be identified. It is critical to understand the resources that are necessary for making practical changes (Delgadillo et al., 2016). Delgadillo (2015) also adds that the questions related to funding are also important; namely, the main concern is whether the more deprived regions should receive more financial support or not. The ways to adjust the behaviors of people based on their social identity and narrative patterns can also be taken into account in future research (Destin et al., 2017). It is also essential to note that further studies should adopt a population-matched approach and risk-adjusted metrics to reduce biases.
Problem Statement
The available literature is characteristic of the fact that social inequality limits people in terms of accessing mental health services. It is known that low income, disadvantaged areas, and ethnic/racial minorities are among the factors that create barriers (Epping et al., 2017). Nevertheless, this topic remains poorly understood as there are many gaps and controversies. Among the most underrepresented issues, there is an association between mental health literacy and SES. The authors report that people with low SES are likely to underestimate the perceived need for referring to a psychiatrist, but it is unclear how their health literacy may affect their decisions regarding access to the therapy (Delgadillo, 2015; Stormacq, Van den Broucke, & Wosinski, 2019). In this connection, it seems to be relevant to introduce one more component of mental health literacy in the paradigm of SES and mental health access.
To guide further research, it is possible to use the common trends and recent findings of the literature. In particular, it is evident that people with higher SES tend to be more aware of mental disorders and their symptoms, which helps them to visit a doctor more often (Packness et al., 2017). As for those with lower SES, they encounter economic and social barriers that impede their treatment. Accordingly, little is known about awareness of people with low SES regarding specific diseases, including schizophrenia, eating disorders, and depression. It is especially exciting to explore their perceptions of the need to pay attention to these disorders and subsequent behaviors. The potential implication of examining the identified problem is that it would increase the contemporary understanding of the role of increasing mental health literacy among people with low SES.
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