Relative Deprivation, Poor Health Habits, and Mortality
Christine Eibner William N. Evans
A B S T R A C T
Using individual-level data on males from the 1988–91 National Health Interview Survey Multiple Cause of Death Files, we examine the impact of
relative deprivation within a reference group on health. We define reference groups using combinations of state, race, education, and age. High relative
deprivation in the sense of Yitzhaki is associated with a higher probability of death, worse self-reported health, higher self-reported limitations, higher
body mass index, and an increased probability of taking health risks.
I. Introduction
In 2001 the United States’ per capita health care expenditures totaled about 4,887, first overall and 47 percent more than the second highest spending
country in the OECD. In spite of this spending, the United States performs poorly in aggregate measures of population health. Among OECD countries, the United States
ranks 20th in both women’s and men’s life expectancy, and the United States has the sixth highest infant mortality rate in the developed world Organization for Economic
Cooperation and Development 2003.
1
These numbers, as well as other evidence, sug- gest that—at least in developed countries—money and health are not as closely linked
Christine Eibner is an Associate Economist at RAND. William N. Evans is a professor of economics at the University of Maryland, College Park, and a research associate at both the Maryland Population Research
Center and the National Bureau of Economic Research. The authors thank Angus Deaton, Jonah Gelbach, Judith Hellerstein, Sandy Jencks, Larry Katz, Edward Montgomery, Seth Sanders, and Robert Schwab
for a number of helpful comments. The authors also thank Negasi Beyene, Bob Krasowski, and the staff of the National Center for Health Statistics NCHS Research Data for assistance with the geocoded files
from National Health Interview Survey. The geocoded data from the National Health Interview Survey can be obtained from the NCHS Research Data Center. The rest of the data for this article are available from
October 2005 through September 2008 from Christine Eibner, RAND Corporation, 1200 South Hayes Street, Arlington, VA, 22202.
[Submitted July 2002; accepted June 2005] ISSN 022-166X E-ISSN 1548-8004 © 2005 by the Board of Regents of the University of Wisconsin System
1. Life expectancy and mortality figures come from OECD Health Data 2003. T H E J O U R NA L O F H U M A N R E S O U R C E S
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The Journal of Human Resources 592
as one might guess.
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One contentious explanation for the weak relationship between income and health at the aggregate level is the “relative deprivation” hypothesis,
which argues that individuals are adversely affected when they perceive themselves to be economically deprived relative to their peers. The relative deprivation hypothesis
is distinct from more traditional models that argue an individual’s health is a function solely of his or her underlying characteristics, such as own income, education, and
race. According to the relative deprivation hypothesis, an individual’s health is also a function of the incomes of others in his or her reference group. It is typically assumed
that a person’s health is negatively related to the income of others, so that as person j becomes richer, person i’s health deteriorates. Low relative income may cause stress
and depression, conditions that may raise the probability of contracting a disease or increase the tendency to engage in risky behavior.
While the concept of relative deprivation has existed in the economics literature for years Duesenberry 1949; Yitzhaki 1979; Frank 1985, interest in the link between
relative deprivation and health is heightened by a group of studies that link income inequality to population health. Income inequality can be seen as a proxy for dep-
rivation, in that as inequality increases, the gap between the “haves” and the “have- nots” grows, and the overall deprivation in society increases. However, income
inequality could influence health independently of relative deprivation, and most of the current literature does not attempt to disentangle the two effects. At the aggregate-
level, income inequality seems highly correlated with public health measures such as mortality rates Kaplan, et al. 1996; Kennedy, Kawachi, and Prothrow-Stith 1996;
Wilkinson 1996. Studies that use individual-level data find less support for the income inequality hypothesis Daly, et al. 1998; Mellor and Milyo 2002; Sturm and Gresenz
2002; Fiscella and Franks 1997. To date, few studies use individual-level data to focus specifically on the relative deprivation hypothesis.
In the first part of this paper, we use restricted-use micro-level data from the National Health Interview Survey Multiple Cause of Death Files NHISMCOD to
investigate the relative deprivationmortality link. We define reference groups using a combination of characteristics including state of residence, age, race, and education.
Our results indicate that, even after controlling for reference group effects and indi- vidual income, relative deprivation is positively associated with an individual’s prob-
ability of death. Relative deprivation is also positively linked to cause-specific mortality, notably for deaths due to tobacco-related cancers and coronary heart dis-
ease CHD. In many cases, relative deprivation has a stronger impact on health than own income. While relative deprivation is consistently linked to poor health, mea-
sures of relative performance such as centile rank and z-score have an inconsistent impact on health.
The finding that relative deprivation has a large impact on deaths linked to smok- ing and CHD is suggestive, mainly because these two causes of death that are highly
related to behavior. One theory relating relative deprivation to health outcomes argues that individuals respond to the stress, hostility, and low self-esteem caused by relative
2. Some argue that the weak link between income and health is due to the fact that there are diminishing returns to investment in health, and that the United States is operating on the flat of the curve. However, this
does not explain why health outcomes in the United States are worse than those in other developed countries.
Eibner and Evans 593
deprivation by engaging in health compromising behavior. Wilkinson explains “among the many ways people respond to stress, unhappiness and unmet needs, one
is to increase their consumption of various comforting foods . . . including alcohol and of course tobacco” pp. 185–86. The notion that relative deprivation increases the
probability of taking health risks is consistent with evidence that individuals of low socioeconomic status tend to smoke more and exercise less than their peers Lynch,
Kaplan, and Salonen 1997; Lantz, et al. 1998. In the second part of this paper, we use data from the National Health Interview Survey NHIS and the Behavioral Risk
Factor Surveillance System BRFSS to explore whether relative deprivation is asso- ciated with health-compromising behavior. Using a number of outcomes including
smoking, seatbelt use, body mass index, and propensity to exercise, we find that rel- ative deprivation in the sense of Yitzhaki is consistently linked to the probability that
an individual engages in risky behaviors. Although we control for individual charac- teristics and reference group fixed effects, we cannot rule out the possibility that part
of the relative deprivation effect is driven by unobserved factors correlated both with low income and poor health.
II. Background
