Tracing the social gradient in the health of Canadians: primary and secondary determinants

Soc Sci Med. 2003 Jul;57(2):263-76. doi: 10.1016/s0277-9536(02)00345-3.


The social gradient in heath refers to the fact that inequalities in population health status are related to inequalities in social status. This study advances and tests a model of the relationships between what we term primary and secondary determinants of the social gradient in health. The primary determinants of health include socioeconomic and demographic indicators. Secondary determinants include stressors, control, self-esteem, social support, and social involvement. Health status is indicated by measures of physical health, self-reported health status, and mental distress. Data are taken from the Canadian National Population Health (NPH) Survey (1994-1995). The study sample consists of 7720 men and 9269 women 15 to over 80 years of age. Using path analysis, we found that higher household income, being retired and growing older are significantly associated with lower stressor levels. Higher stressor levels are associated with lower levels of control, self-esteem, and social support. Higher income Canadians experience greater levels of control and social support, while older Canadians experience lower rates of social support but higher rates of social involvement. Being employed and caring for one's family are positively associated with better physical and self-reported health status. Higher household income, being retired, and aging are associated with better physical health and lower mental distress when accounting for their role in lowering stressor levels and bolstering control, self-esteem, social support, and social involvement. Replicating this study with future samples of the NPH Survey should be of benefit in ascertaining whether the social gradient in Canadians' health status shows signs of declining.

Publication types

  • Comparative Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Canada / epidemiology
  • Demography
  • Female
  • Health Status*
  • Humans
  • Male
  • Middle Aged
  • National Health Programs
  • Self Concept
  • Social Class*
  • Social Environment*
  • Social Support
  • Stress, Psychological / epidemiology