The British Journal of Psychiatry (2015)

206, 461465. doi: 10.1192/bjp.bp.114.147280

Socioeconomic gradients and mental health:

implications for public health
Sarah Stewart-Brown, Preshila Chandimali Samaraweera, Frances Taggart,
Ngianga-Bakwin Kandala and Saverio Stranges
Background
Research on mental well-being is relatively new and studies
of its determinants are rare.
Aims
To investigate whether the socioeconomic correlates of
mental well-being mirror those for mental illness.
Method
Using logistic regression analyses, the independent odds
ratios of high and low mental well-being, compared with
middle-range mental well-being, were estimated for a
number of sociodemographic variables known to be
associated with mental illness from 13 983 participants in the
2010 and 2011 Health Surveys for England.
Results
Independent odds ratios for low mental well-being were as
expected from studies of mental illness with increased odds
for the unemployed (OR = 1.46, 95% CI 1.012.10) and those
aged 3554 years (OR = 1.58, 95% CI 1.351.84) and reduced
odds for the married (OR = 0.78, 95% CI 0.620.97). A linear

The case for the promotion of positive mental health or mental

well-being has been made convincingly on both health1 and
economic grounds2 and, as a consequence, mental well-being
now assumes an important place in mental health and public
health policy.35 Key features of mental well-being are that it
creates resilience to both mental and physical illness, increases
longevity in general populations,6 increases educational achievement
and enhances performance in the workplace.1 The World Health
Organization (WHO) describes mental well-being as a state in
which the individual realises his or her own abilities, copes with
the normal stresses of life, works productively and makes a
contribution to his or her community.7 Mental well-being is
widely recognised as extending beyond the absence of mental
illness and comprising both affective components (emotions/
feelings) and psychological functioning.1 Arguments have been
advanced that mental well-being and mental illness may represent
two different but correlated continua. In this case mental wellbeing can be positive or negative and low mental well-being is
not synonymous with mental illness. For clarity we have referred
in this paper to low and high mental well-being and to mental
illness and positive mental health, which we regard as synonymous
with high mental well-being. Effective public health practice
demands a sound understanding of the determinants not only
of illness but also of positive states of health. Whereas mental
illness is distributed according to familiar social gradients8,9 with
a high prevalence among deprived groups and those living in
poverty, less is known about the social determinants of positive
mental health. There is some indication that the distribution is
1
different from that for mental illness. The Health Survey for
10
England (HSE) collected data on mental well-being in 2010
and 2011, making it possible to assess socioeconomic gradients
of high and low mental well-being in a large representative sample

trend was observed with education and equivalised income.

Odds ratios for high mental well-being differed from those
for low mental well-being with regard to age (55+ years:
OR = 1.48, 95% CI 1.231.79); employment status where there
was an association only with retirement (OR = 1.35, 95% CI
1.091.69); education where there was no association; and
equivalised income for which the association was non-linear.
Conclusions
Odds ratios for low mental well-being mirrored those for
mental illness, but not those for high mental well-being,
suggesting that the socioeconomic factors associated with
positive mental health are different from those associated
with mental illness.
Declaration of interest
S.S.-B. developed the WarwickEdinburgh Mental Well-being
Scale, but has no financial interests in the scale.
Copyright and usage
B The Royal College of Psychiatrists 2015.

of the English population and to test the hypothesis that these

gradients are different from those observed for mental illness.
Method
Study population
The HSE is an annual survey of a nationally representative
population that samples adults and children in households at
private residential addresses.10 In both 2010 and 2011, 66% of
households agreed to participate providing samples of 14 112
(8420 age 16+ years) and 10 617 (8610 age16+ years), respectively.
Detailed information was collected on mental and physical health
in relation to demographic and socioeconomic characteristics of
adults and children. Regarding, ethical approval as the study
design was of secondary data analysis using data collected in the
HSE; permission to use the data was granted by the UK Data
Service.
Mental well-being
The WarwickEdinburgh Mental Well-being Scale (WEMWBS)11
was administered in English only to respondents over 16 years of
age, a total of 17 030 people across both years. The WEMWBS is
a well validated, popular measure currently used to monitor mental
well-being in the English public health outcomes framework12 and
the Scottish Governments Mental Health Indicators data-set.13 It
has been validated in a number of different cultural and linguistic
settings including English-speaking minority ethnic groups in the
UK.14,15 Valid responses were available for 13 983 (82.1%) of adult
(16+ years) respondents for the combined 2010 and 2011 datasets. (See online Table DS1 for comparison of respondents and
non-respondents). These were used to define three population

461

Stewart-Brown et al

groups: more than one standard deviation from the mean in

either direction (top 15th centile: WEMWBS score 6070; and
bottom 15th centile: WEMWBS score 1442) and the remainder
(1684th percentile: WEMWBS score 4359). Valid responses
were those in which all items in the scale had been completed.
In the first series of models, odds ratios (ORs) were generated
for the low well-being group compared with the middle-range
group and in the second series for the high well-being group
compared with the middle-range group.
Sociodemographic correlates
Sociodemographic variables known to be relevant to inequalities
in mental illness and available in the HSE data-sets were included.
These were: age (1634, 3554, 55+); gender; ethnicity (White,
Indian and Pakistani (including mixed race), AfricanCaribbean
and African (including mix race), Chinese and other Asian, and
other); religion (none, Christian, Muslim, other); economic status
(employed, unemployed seeking work, retired, economically
inactive); marital status (single, married/civil partnership/
cohabitee, divorced/separated/widowed); educational attainment
(NVQ4/NVQ5/degree or equivalent, secondary education to,
NVQ3/GCE A-level equivalent, NVQ2/GCE O-level equivalent,
NVQ1/CSE other grade equivalent, no qualification) and
equivalised household income in quintiles.16 In order to maximise
sample size and avoid bias, missing values were included for all
covariates.
Statistical analysis
2

We used w -tests to determine the statistical significance of any

difference in the distributions of the selected sociodemographic
variables across categories of WEMWBS scores (low, middle, high)
(online Table DS2). Data were analysed in logistic regression
models in order to identify differences in the pattern of
association of sociodemographic variables with high and low
mental well-being. Unadjusted (Model 1), partially adjusted (age
and gender) (Model 2) and fully adjusted (all variables) (Model
3) models were generated to calculate odds ratios of low mental
well-being compared with middle-range (see Table 1 for the fully
adjusted model and online Table DS3 for details of all three
models), and high mental well-being compared with middle-range
(see Table 2 for the fully adjusted model and online Table DS4 for
details of all three models), using SPSS 21 for Windows for
different levels of socioeconomic variables. The significance of
linear trends and gender differences in the associations of low
and high mental well-being were assessed for each of the
correlates, the latter using tests for interaction (see online Tables
DS5 and DS6, respectively).
Results
Significant differences were found for all characteristics of study
participants with and without complete data except for gender
(online Table DS1). Respondents were more likely to be young,
married/cohabiting, employed, White, with higher levels of
education, higher incomes and either no religion or Christian.
In descriptive analyses, significant associations were evident by
age, marital status, education, household income, religion,
employment and ethnicity across the three categories of mental
well-being (online Table DS2).
In the fully adjusted models for low mental well-being
compared with middle-range (Table 1), middle age (3554 years)
was associated with an increased odds ratio (OR = 1.58, 95% CI
1.351.84), whereas marriage/cohabitee status was associated with
a reduced odds (OR = 0.78, 95% CI 0.620.97). Education showed

462

Table 1 Fully adjusted (Model 3) odds ratios for low mental

well-being referenced to middle-range mental well-being a
Fully adjusted OR
(95% CI)
Age, years
1634
3554
55+

Ref
1.58 (1.351.84)
0.96 (0.771.18)

Gender
Male
Female

Ref
1.04 (0.681.58)

Marital status
Single
Married/civil partnership/cohabitees
Separated/divorced/widowed

Ref
0.78 (0.620.97)
1.24 (0.921.68)

Educationb
NVQ4/NVQ5/degree or equivalent
Higher education below degree
NVQ3/GCE A-Level equivalent
NVQ2/GCE O-Level
NVQ1/CSE other grade equivalent
No qualification

Ref
1.03 (0.761.41)
1.28 (0.961.72)
1.35 (1.031.77)
1.47 (0.992.19)
2.00 (1.502.68)

Equivalised incomeb
Highest (447 794.12)
Second highest (427 704.92 to 447 794.12)
Middle (419 117.65 to 427 704.92)
Second lowest (411 676.65 to 419 117.65)
Lowest (411 676.65)

Ref
0.92 (0.701.22)
1.24 (0.941.63)
1.40 (1.051.87)
1.19 (0.791.78)

Employment
In employment
Unemployed seeking work
Retired
Other economically inactive

Ref
1.46 (1.012.10)
1.11 (0.851.47)
2.89 (2.213.78)

Religion
No religion
Christian and other denominators
Muslims
Any other

Ref
1.02 (0.851.24)
0.67 (0.301.53)
0.71 (0.391.30)

Ethnicity
White
Indian and Pakistani
AfricanCaribbean
Chinese and other Asian
Other

Ref
0.73 (0.351.53)
0.36 (0.190.66)
0.77 (0.331.82)
0.71 (0.271.87)

a. The univariate (Model 1) and partially adjusted (age and gender) (Model 2) odds
ratios can be found in online Table DS3. Low mental well-being defined as a
WarwickEdinburgh Mental Well-being Scale (WEMWBS) score of 1442 and middlerange mental well-being as a WEMWBS score of 4359. The fully adjusted model
included: age, gender, marital status, education, equivalised income, employment,
religion and ethnic origin.
b. P-value for linear trend: 0.001.

the expected doseresponse relationships (P-value for linear

trend 50.001) with significantly increased odds of low mental
well-being among those with GCE O levels (OR = 1.35, 95% CI
1.031.77) and those with no qualifications (OR = 2.00, 95% CI
1.502.68) compared with those with a degree. Low mental
well-being was linearly associated with equivalised income
(P50.001) with increased odds for those in the second lowest
income bracket (OR = 1.40, 95% CI 1.051.87) compared with
the highest. Unemployment, both in those seeking work
(OR = 1.46, 95% CI 1.012.10) and those inactive for other
reasons (OR = 2.89, 95% CI 2.213.78), increased the odds of
low mental well-being. The African and AfricanCaribbean group
was protected from low mental well-being (OR = 0.36, 95% CI
0.190.66). There were no associations with religion or gender.
In the fully adjusted models for high mental well-being
compared with middle-range (Table 2) both older age (55+ years)
(OR = 1.48, 95% CI 1.231.79) and being retired (OR = 1.35, 95%

Socioeconomic gradients and mental health

Table 2 Fully adjusted (Model 3) odds ratios for high mental

well-being referenced to middle-range mental well-being a
Fully adjusted OR
(95% CI)
Age, yearsb
1634
3554
55+

Ref
0.96 (0.821.12)
1.48 (1.231.79)

Gender
Male
Female

Ref
0.95 (0.641.41)

Marital status
Single
Married/civil partnership/cohabitees
Separated/divorced/widowed

Ref
1.01 (0.801.28)
0.98 (0.711.36)

Education
NVQ4/NVQ5/degree or equivalent
Higher education below degree
NVQ3/GCE A-level equivalent
NVQ2/GCE O-level
NVQ1/CSE other grade equivalent
No qualification

1.01
1.04
1.00
1.26
0.97

Equivalised income
Highest (447 794.12)
Second highest (427 704.92 to 447 794.12)
Middle (419 117.65 to 427 704.92)
Second lowest (411 676.65 to 419 117.65)
Lowest (411 676.65)

Ref
0.80 (0.640.99)
0.78 (0.620.99)
0.71 (0.550.93)
0.79 (0.581.07)

Employment
In employment
Unemployed seeking work
Retired
Other economically inactive

Ref
1.34 (0.921.95)
1.35 (1.091.69)
1.05 (0.741.74)

Religion
No religion
Christian and other denominators
Muslims
Any other

Ref
1.12 (0.941.35)
1.15 (0.642.05)
1.00 (0.611.64)

Ethnicity
White
Indian and Pakistani
AfricanCaribbean
Chinese and other Asian
Other

Ref
2.08 (1.233.54)
2.24 (1.613.12)
1.61 (0.853.05)
1.60 (0.783.29)

among women than men, and unemployment, which was not

associated with low mental well-being in women (online Table
DS5). For high mental well-being, results were consistent between
men and women with the exception of retired men and other
economically inactive women who had increased odds. Increased
odds of high mental well-being among African/AfricanCaribbean,
Indian and Pakistani populations were attributable to increased
odds among men (online Table DS6).
Discussion
Main findings

Ref
(0.781.30)
(0.811.34)
(0.781.27)
(0.881.81)
(0.741.26)

a. The univariate (Model 1) and partially adjusted (age and gender) (Model 2) odds
ratios can be found in online Table DS4. High mental well-being is defined as a
WarwickEdinburgh Mental Well-being Scale (WEMWBS) score of 6090 and
middle-range mental well-being as a WEMWBS score of 4359. The fully adjusted
model included: age, gender, marital status, education, equivalised income,
employment, religion and ethnic origin.
b. P-value for linear trend 50.001.

CI 1.091.69) were independently associated with an increased

odds. Odds of high mental well-being did not differ among other
categories of employed and unemployed. Education was not
associated with high mental well-being. With reference to the
highest income quintile, all other quintiles of equivalised income
showed similarly reduced odds of high mental well-being
(OR = 0.80, 95% CI 0.640.99 to OR = 0.71, 95% CI 0.550.93);
there was no significant trend across categories of income; the
lowest group had an odds ratio in the same range as the other
groups (OR = 0.79, 95% CI 0.581.07). Both Indian and Pakistani
(OR = 2.08, 95% CI 1.233.54), and African and African
Caribbean groups (OR = 2.24, 95% 1.613.12) showed an
increased odds of high mental well-being. High mental well-being
did not differ by marital status or gender.
Gender-stratified analysis were consistent between men and
women for low mental well-being with the exception of education,
which was more strongly associated with low mental well-being

These analyses have enabled the comparison of the social and

economic correlates of low and high mental well-being in a large,
representative sample of the adult English population and show
that they do not mirror one another. The results show that the
correlates of high mental well-being are different from those of
low mental well-being but that the latter closely mirror the
correlates of mental illness. Assumptions about socioeconomic
determinants made in planning public mental health programmes
focusing on the prevention of mental illness may therefore not be
applicable to programmes aiming to increase mental well-being.
Measuring mental well-being
The WEMWBS is used in clinical populations17 but is not
clinically validated as a measure of mental illness. We have referred
to low mental well-being throughout because of this and also in
recognition of the debate regarding the relationship between
mental well-being and mental illness. Studies based on diagnostic
categories of mental illness have shown only moderate correlation
(around 0.5) between mental illness and measures of mental wellbeing18 consistent with the philosophical position of the dual
continuum model.19 Studies based on continuous, clinically
validated measures of mental illness however, show a much
stronger correlation. For example there is a high inverse
correlation between WEMWBS scores and scores on the Center
for Epidemiologic Studies Depression Scale (CES-D), a clinically
valid measure of depression, widely used in population-based
studies.20 The latter study examined cut points on the WEMWBS
that corresponded to cut points on the CES-D. A WEMWBS score
of 42, which defined the cut point for the low mental well-being
group in this study, is below (clinically worse) than a CES-D score
of 16 and just above (clinically better) than that consistent with a
CES-D score of 26,21 both cut points which have been used to
define clinical populations of varying levels of severity. The
bottom 15% of the WEMWBS distribution the low mental
well-being population in the current study thus comprised
people who were very likely to have scored in the clinical range
on self-report measures of common mental disorders and is
consistent with estimates of clinically relevant levels of mental
illness in the UK population.8,22 The odds of low mental wellbeing associated with the socioeconomic factors described in this
study also correspond closely to those measured in studies using
clinically valid measures of mental illness,9 further supporting
the view that we have compared the odds for a population very
likely to have mental illness with the odds for a population with
high mental well-being or positive mental health.
Significance of our findings
and comparison with previous studies
Our findings suggest that socioeconomic factors relate to mental
well-being in a way that is not consistent with the way they relate
to mental illness. The differences are most striking with regard to

463

Stewart-Brown et al

education and employment where, although we found the

correlation with low mental well-being that we expected from
studies of mental illness, there was no discernible correlation with
high mental well-being, at least for those who were pre-retirement
in the employment analyses. If education and employment are key
drivers of mental health in general, we would expect to see them
correlating as a mirror image with both ends of the mental health
spectrum. In a recent analysis of the correlates of well-being,
undertaken by the Office of National Statistics and based on their
four proxy measures of mental well-being,23 people with the
highest levels of educational attainment were found to have higher
ratings of anxiety than people with lower educational attainment.
People in higher managerial and professional occupations also
showed higher scores for anxiety than those in lower supervisory
and technical occupations. Another recent analysis24 of crosssectional studies looking at predictors of mental well-being as
measured by the WEMWBS and the short version (SWEMWBS25)
found both employment and education to be significant
correlates, but the association with education was non-linear.
The latter study was based on linear regression analyses and the
findings will therefore have been weighted by the relationship
between low mental well-being and education and employment.
Our findings relating to income and high mental well-being
are also strikingly different from the linear trend expected from
analyses relating to mental illness. The highest quintile income
group had better odds of high mental well-being than the other
four income groups, but there was nothing to distinguish the
latter four groups from one another. It is important to note that
the starting point for the highest quintile income bracket was
47 794, which does not denote great wealth. Other investigators26
using linear regression analyses have in general found an
association between income and happiness and life satisfaction,
both used as proxy measure of mental well-being in economic
analyses, that was more evident in the least wealthy groups. In
the recent Office of National Statistics analysis based on their four
proxy measures23 increased earnings were associated with higher
levels of life satisfaction, but not with a sense that life was
worthwhile, or with happiness. Another analysis of predictors of
well-being found that being unsatisfied with personal income
was predictive of low mental well-being but less so than being
unsatisfied with leisure time.24 Mental well-being is more than life
satisfaction or happiness. It may be that the latter affective and
more transitory components of well-being are influenced by
income, whereas the more stable developmental components of
mental well-being relating to functioning are not.
Perhaps the most surprising finding, given the well-recognised
association between ethnicity and detention under the Mental
Health Act27 and the more general association between mental
illness and ethnicity,23 is the substantially increased odds of high
mental well-being among minority ethnic groups, particularly
African and AfricanCaribbean, Indian and Pakistani, and the
reduced odds of low mental well-being among African and
AfricanCaribbean groups. The findings relating to African and
AfricanCaribbean populations and mental well-being were also
evident in another recent analysis where it was shown, as it was
in this study, to be primarily because of high levels in Black
men.24 These findings are not incompatible with the existing
literature. It is possible that minority ethnic populations
experience both more severe mental illness of the sort that
warrants detention under the Mental Health Act and at the same
time more positive mental health than White populations. The
WEMWBS has been validated in English-speaking Chinese and
Pakistani groups14 and shown to be reliable and acceptable, but
has not yet been specifically validated in African/African
Caribbean populations. This study included only English-speaking

464

populations and findings among those who do not speak English

could have been different. The possibility of reporting biases in
this self-report measure of mental well-being also needs to be
addressed. However, if our findings relating to minority ethnic
groups prove robust they are of great interest. Strong arguments
are often made on the grounds of social deprivation that healthpromoting interventions should specifically target ethnic
minorities. When it comes to improving mental well-being, we
may end up needing to learn from these population groups, spreading their knowledge and attitudes to the majority population.
Cross-sectional surveys from which these results derive can
point towards possible causal inference but cannot demonstrate
it. Our study population was also biased in that respondents
differed from the eligible population in that they were more likely
to be middle-aged, White, well-educated and relatively wealthy.
We would therefore anticipate slightly lower levels of mental
illness in the study population and thus arguably lower levels of,
and a weaker correlation with, low mental well-being. The fact
that correlations with low mental well-being were strong suggests
that these biases have not greatly influenced our findings.
Although explanations for our findings must remain
speculative, they are compatible with a model in which low mental
well-being relates closely to mental illness and both are linearly
associated with socioeconomic position through a bidirectional
causal relationship that is poor social and economic
circumstances increase the risk of mental illness by increasing
personal stressors, but at the same time mental illness increases
the risk of poor social circumstances by interfering with social
relationships, educational attainment and productivity as it is
known to do.1 Positive mental health might not be associated so
closely with socioeconomic circumstances if causality operated
in only one direction, that is positive mental health improves socioeconomic circumstances by supporting educational attainment,
productivity and social relationships, but reverse causality does
not apply better social and economic circumstances do not
improve positive mental health.
In conclusion, the correlates of positive mental health may be
significantly different from the correlates of mental illness.
Programmes addressing the social determinants of health are
valuable from the point of view of preventing illness, but
programmes to improve mental well-being may need to adopt
new paradigms that do not rely on prevailing beliefs relating to
social inequalities.
Sarah Stewart-Brown, PhD, FFPHM, FRCP, FRCPH, Division of Health Sciences,
Warwick Medical School, University of Warwick, Coventry; Preshila Chandimali
Samaraweera, MBBS, MSc, MD, Division of Health Sciences, Warwick Medical
School, University of Warwick, Coventry and Ministry of Health in Sri Lanka;
Frances Taggart, MS, PhD, Ngianga-Bakwin Kandala, PhD, Saverio Stranges,
PhD, FFPH, Division of Health Sciences, Warwick Medical School, University
of Warwick, Coventry, UK
Correspondence: Sarah Stewart-Brown, Warwick Medical School,
University of Warwick, Gibbet Hill Campus Coventry CV4 7AL, UK.
Email: sarah.stewart-brown@warwick.ac.uk
First received 3 Mar 2014, final revision 9 Oct 2014, accepted 9 Oct 2014

Acknowledgements
The Health Survey for England was commissioned by the Department of Health and was
carried out by the Joint Health Survey Unit of National Centre for Social Research and
Department of Epidemiology and Public Health at University College London. The authors
would like to thank all the participants in the Health survey for England 2010 and 2011.

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22 Singleton N, Bumpstead R, OBrien M, Lee A, Meltzer. Psychiatric Morbidity
amongst Adults Living in Private Households in 2000. TSO (The Stationery
Office), 2001.
23 Oguz S, Merad S, Snape D. Measuring National Well-being What matters
Most to Personal Well-being? Office for National Statistics (May 2013)
Cross Sectional Analysis of Four Questions. ONS, 2013 (http://
www.ons.gov.uk/ons/rel/wellbeing/measuring-national-well-being/
what-matters-most-to-personal-well-being-in-the-uk-/index.html).
24 McManus S, Chanfreau J, Lloyd C. Predictors of Wellbeing. NatCen, 2013
(http://www.natcen.ac.uk/our-research/research/predictors-of-wellbeing).
25 Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S.
Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale
(WEMWBS): a Rasch analysis using data from the Scottish Health Education
Population Survey. Health Qual Life Outcomes 2009; 7: 15.
26 Dolan P, Peasgood T, White M. Do we really know what makes us happy?
A review of the economic literature on the factors associated with subjective
well-being. J Econ Psychol 2008; 29: 94122.
27 Singh SP, Burnsa T, Tyrera P, Islama Z, Parsons H, Crawford MJ. Ethnicity as a
predictor of detention under the Mental Health Act. Psychol Med 2013; 24:
18.

Afflicting spectacle of insanity

An afflicting spectacle of insanity, followed by a melancholy result, was witnessed a few days ago at the Lunatic Hospital at
Saumur. A lady and gentleman went to visit the establishment, accompanied by their child, a little girl of five or six years old.
As they passed one of the cells, the wretched inmate, an interesting young woman of about 25, who had irrecoverably lost
her reason, through the desertions of a seducer, and the death of their illegitimate offspring, suddenly made a spring at the little
girl, who had approached within her reach. In the height of her delirium, the poor creature fancied the strangers child her own
long-lost darling, and, devouring it with kisses, bore it in triumph to the further end of the cell. Entreaties and menaces having
proved equally ineffectual to induce her to restore the child to its terrified mother, the director of the establishment was sent for,
and, at his suggestion, the maniac was allowed for a few moments to retain peaceable possession of her prize, under the
impression that, exhausted with her own frantic violence, she would shortly fall asleep, when the child might be liberated from
her grasp without difficulty or the employment of harsh measures. This calculation was not erroneous: in a few minutes, the poor
sufferers eyes closed in slumber, and one of the keepers watching the opportunity, snatched the child from her arms, and
restored it to its mother. The shriek of delight uttered by the latter on recovering her treasure awakened the poor maniac,
who, on perceiving the child gone, actually howled with despair, and, in a paroxysm of ungovernable frenzy, fell to the ground
to rise no more. Death had released her from her sufferings.
From The Times, 27 October 1837, issue 16558, p. 1. Selected by Rafael Euba. News Syndication UK. Reprinted with permission.
The British Journal of Psychiatry (2015)
206, 465. doi: 10.1192/bjp.bp.114.147306

465

Stewart-Brown et al. Socioeconomic gradients and mental health: implications for public health. Br J Psychiatry doi: 10.1192/bjp.bp.114.147280

Supplementary Table DS1: Comparison of selected socio demographic characteristics between respondents and nonrespondents in Health survey data 2010/2011(17030)
Characteristics
Respondents(13983)
Non-respondents(3047)
P value
N
%
N
%
Sex
Male
6145
43.9
1379
45.3 0.187
Female
7838
56.1
1668
54.7
Age(10 year bands)
16-34
3539
25.3
633
20.8 <0.001
35-54
5048
36.1
920
30.2
55+
5396
38.6
1494
49.0
Marital Status
Single
2631
18.8
549
18.0 <0.001
Married/Civil partnership
7388
52.9
1585
52.1
Separated
355
2.5
73
2.4
Divorced
949
6.8
171
5.6
Widowed
960
6.9
386
12.7
Cohabitees
1696
12.1
278
9.1
Missing
4
0.1
5
0.1
Education
NVQ4/NVQ5/Degree or equivalent
3351
24.0
450
15.0 <0.001
Higher education below degree
1595
11.4
244
8.1
NVQ3/GCE A Level equivalent
2204
15.8
284
9.5
NVQ2/GCE O Level equivalent
3180
22.8
536
17.9
NVQ1/CSE other grade equivalent
635
4.5
178
5.9
Foreign/other
231
1.7
47
1.6
No qualification
2768
19.8
1255
41.9
Missing
53
1.7
19
0.1
Equivalised income*
Lowest (<=11676.65)
1787
12.8
547
18.0 P<0.001
Second lowest (>11676.65-<=19117.65)
2228
15.9
512
16.8

Middle (>19117.65-<=27704.92)
Second highest (>27704.92-<=47794.12)
Highest (>47794.12)
Missing
Employment
In employment
Unemployed seeking work
Retired
Other economically inactive
Missing
Religion
No religion
Christian and other denominators
Muslims
Any other
Missing
Ethnicity
White
Indian and Pakistani
African Caribbean
Chinese and Other Asian mix
Other
Missing

2346
2567
2586
2469

16.8
18.4
18.5
17.6

398
265
285
1037

13.1
8.7
2586
34.1

7779
696
3428
2057
23

55.6
5.0
24.5
14.7
0.2

1225
125
1047
604
46

40.2 <0.001
4.1
34.4
19.8
1.5

3689
9299
384
518
93

26.4
66.5
2.7
3.7
0.7

331
1472
146
89
1009

10.9 <0.001
48.3
4.8
2.9
33.1

12434
394
695
297
147
16

88.9
2.8
5.0
2.1
1.1
0.1

2422
144
257
117
58
49

79.5 <0.001
4.7
8.4
3.8
1.9
1.6

Table DS2 Baseline Characteristics of participants by category of WEMWBS groups in HSE 2010/2011 data
Variable

No. of subjects(13983)
Age
16-34
35-54
55+
Gender
Male
Female
Marital status
Single
Married/Civil partnership/cohabitees
Separated/Divorced/Widowed
Missing
Education
NVQ4/NVQ5/Degree or equivalent
Higher education below degree
NVQ3/GCE A Level equivalent
NVQ2/GCE O Level
NVQ1/CSE other grade equivalent
Foreign/other
No qualifications
Missing
Equivalised income*
Lowest (<=11676.65)
Second lowest (>11676.65-<=19117.65)
Middle (>19117.65-<=27704.92)
Second highest (>27704.92-<=47794.12)
Highest (>47794.12)

WEMWBS Score
Low(14-42)
Middle (43-59)
N (%)
N(%)
2252(16.1)
9446(67.6)

p Value
High(60+)
N(%)
2285(16.3)
P<0.001

553(24.6)
904(40.1)
795(35.3)

2467(26.1)
3467(36.7)
3512(37.2)

519(22.7)
677(29.6)
1089(47.7)
P=0.041

936(41.6)
1316(58.4)

4185(44.3)
5261(55.7)

1024(44.8)
1261(55.2)
P<0.001

560(24.9)
1205(53.5)
484(21.5)
3(0.1)

1711(18.1)
6320(66.9)
1415(15.0)
0(0.0)

360(15.8)
1559(68.2)
365(16.0)
1(0.0)

327(14.5)
203(9.0)
335(14.9)
591(26.2)
134(6.0)
27(1.2)
631(28.0)
4(0.2)

2442(25.9)
1095(11.6)
1526(16.2)
2143(22.7)
395(4.2)
151(1.6)
1681(17.8)
13(0.1)

582(25.5)
297(13.0)
343(15.0)
446(19.5)
106(4.6)
53(2.3)
456(20.0)
2(0.1)

519(23.0)
420(18.7)
354(15.7)
276(12.3)
256(11.4)

1015(10.7)
1476(15.6)
1619(17.1)
1863(19.7)
1857(19.7)

253(11.1)
332(14.5)
373(16.3)
428(18.7)
473(20.7)

P<0.001

P<0.001

Missing
Employment
In employment
Unemployed seeking work
Retired
Other economically inactive
Missing
Religion
No religion
Christian and other denominators
Muslims
Any other
Missing
Ethnicity
White
Indian and Pakistani
African Caribbean
Chinese and Other Asian mix
Other
Missing

427(19.0)

1616(17.1)

426(18.6)

975(43.3)
1439(6.3)
525(23.3)
605(26.9)
4(0.2)

5621(59.5)
445(4.7)
2182(23.1)
1181(12.5)
17(0.2)

1183(51.6)
108(4.7)
721(31.6)
271(11.9)
2(0.1)

P<0.001

P<0.001
618(27.4)
1487(66.0)
60(2.7)
72(3.2)
15(0.7)

2562(27.1)
6235(66.0)
254(2.7)
333(3.5)
62(0.7

509(22.3)
1577(69.0)
70(3.1)
113(4.9)
16(0.7)
P<0.001

2064(91.7)
61(2.7)
57(2.5)
44(2.0)
23(1.0)
3(0.1)

8419(89.1)
242(2.5)
487(5.2)
195(2.1)
93(1.0)
10(0.1)

1951(85.4)
91(4.0)
151(6.6)
58(2.5)
31(1.4)
3(0.1)

Table DS3 Univariate (Model 1), partially adjusted (age and sex )(Model 2)and fully adjusted* (Model 3) Odds Ratios for Low Mental
Well-being (WEMWBS 14-42) referenced to Middle-Range Mental Well-being (WEMWBS 43-59)

Age
16-34
35-54
55+
Gender
Male
Female
Marital status
Single
Married/Civil partnership/cohabitees
Separated/Divorced/Widowed
Education
NVQ4/NVQ5/Degree or equivalent
Higher education below degree
NVQ3/GCE A Level equivalent
NVQ2/GCE O Level
NVQ1/CSE other grade equivalent
No qualification
Equivalised income
Highest (>47794.12)
Second highest (>27704.92-<=47794.12)
Middle (>19117.65-<=27704.92)
Second lowest (>11676.65-<=19117.65)
Lowest (<=11676.65)
Employment
In employment

Model 1
Unadjusted OR
(95% CI)

Model 2
Partially
adjusted OR
(95% CI)

Model 3
Fully adjusted OR
(95% CI)

Ref
1.16(1.03-1.31)
1.01(0.90-1.14)

Ref
1.16(1.03-1.31)
1.01(0.90-1.14)

Ref
1.58(1.35-1.84)
0.96(0.77-1.18)

Ref
1.12(1.02-1.23)

Ref
1.12(1.02-1.23)

Ref
1.04(0.68-1.58)

P value
for linear
trend

P for interaction
with sex

0.092
Ref
0.58(0.52-0.65)
1.05(0.91-1.20)

0.56(0.50-0.64)
0.97(0.83-1.15)

Ref
0.78(0.62-0.97)
1.24(0.92-1.68)
0.001

Ref
1.38(1.15-1.67)
1.64(1.39-1.93)
2.06(1.78-2.39)
2.53(2.02-3.18)
2.80(2.42-3.25)

Ref
1.45(1.20-1.76)
1.59(1.35-1.88)
2.08(1.79-2.41)
2.60(2.07-3.27)
3.08(2.64-3.60)

Ref
1.03(0.76-1.41)
1.28(0.96-1.72)
1.35(1.03-1.77)
1.47(0.99-2.19)
2.00(1.50-2.68)
0.001

Ref
1.08(0.90-1.30)
1.57(1.33-1.89)
2.06(1.74-2.45)
3.71(3.14-4.39)

Ref
1.07(0.90-1.29)
1.59(1.34-1.90)
2.07(1.74-2.45)
3.69(3.12-4.36)

Ref
0.92(0.70-1.22)
1.24(0.94-1.63)
1.40(1.05-1.87)
1.19(0.79-1.78)

Ref

Ref

Ref
5

Unemployed seeking work

1.85(1.52-2.26)
1.90(1.55-2.33)
1.46(1.01-2.10)
Retired
1.39(1.23-1.56)
1.30(1.12-1.49)
1.11(0.85-1.47)
Other economically inactive
2.95(2.62-3.33)
2.97(2.63-3.35)
2.89(2.21-3.78)
Religion
No religion
Ref
Ref
Ref
Christian and other denominators
0.99(0.89-1.10)
0.98(0.88-1.09)
1.02(0.85-1.24)
Muslims
0.98(0.73-1.31)
0.98(0.73-1.31)
0.67(0.30-1.53)
Any other
0.90(0.69-1.17)
0.89(0.68-1.17)
0.71(0.39-1.30)
Ethnicity
White
Ref
Ref
Ref
Indian and Pakistani
1.03(0.77-1.37)
1.02(0.77-1.36)
0.73(0.35-1.53)
African Caribbean
0.48(0.36-0.63)
0.47(0.36-0.62)
0.36(0.19-0.66)
Chinese and Other Asian mix
0.92(0.66-1.28)
0.91(0.65-1.26)
0.77(0.33-1.82)
Other
1.01(0.64-1.60)
1.00(0.63-1.59)
0.71(0.27-1.87)
*Fully adjusted model included: age, sex, marital status, education, equivalised income, employment, religion and ethnic origin

Table DS4 Univariate (Model 1), partially adjusted (age and sex )(Model 2)and fully adjusted* (Model 3) Odds Ratios for
High Mental Well-being (WEMWBS 60-70) referenced to Middle-Range Mental Well-being (WEMWBS 43-59)

Age
16-34
35-54
55+
Gender
Male
Female
Marital status
Single
Married/Civil partnership/cohabitees
Separated/Divorced/Widowed
Education
NVQ4/NVQ5/Degree or equivalent
Higher education below degree
NVQ3/GCE A Level equivalent
NVQ2/GCE O Level
NVQ1/CSE other grade equivalent
No qualification
Equivalised income
Highest (>47794.12)
Second highest (>27704.92<=47794.12)
Middle (>19117.65-<=27704.92)
Second lowest (>11676.65<=19117.65)

Model 1
Unadjusted OR
(95% CI)

Model 2
Partially
adjusted OR
(95% CI)

Model 3 Fully
adjusted OR (95%
CI)

P
value
for
linear
trend

Ref
0.93(0.82-1.05)
1.47(1.31-1.66)

Ref
0.93(0.82-1.05)
1.47(1.31-1.66)

Ref
0.96(0.82-1.12)
1.48(1.23-1.79)

<0.001

Ref
0.98(0.89-1.07)

Ref
0.98(0.89-1.07)

Ref
0.95(0.64-1.41)

Ref
1.17(1.03-1.33)
1.23(1.04-1.44)

Ref
0.96(0.84-1.11)
0.91(0.76-1.10)

Ref
1.01(0.80-1.28)
0.98(0.71-1.36)

Ref
1.14(0.97-1.33)
0.94(0.81-1.09)
0.87(0.76-1.00)
1.13(0.89-1.42)
1.14(0.99-1.31)

Ref
1.07(0.91-1.25)
0.98(0.85-1.14)
0.85(0.74-0.97)
1.07(0.85-1.35)
0.98(0.85-1.13)

Ref
1.01(0.78-1.30)
1.04(0.81-1.34)
1.00(0.78-1.27)
1.26(0.88-1.81)
0.97(0.74-1.26)

Ref
0.90(0.78-1.04)

Ref
0.89(0.77-1.03)

Ref
0.80(0.64-0.99)

0.90(0.78-1.05)
0.88(0.76-1.03)

0.85(0.73-0.99)
0.83(0.71-0.97)

0.78(0.62-0.99)
0.71(0.55-0.93)

P for
interaction
with sex

Lowest (<=11676.65)
0.98(0.83-1.16)
0.97(0.81-1.15)
0.79(0.58-1.07)
Employment
In employment
Ref
Ref
Ref
Unemployed seeking work
1.15(0.93-1.44)
1.23(0.98-1.53)
1.34(0.92-1.95)
Retired
1.57(1.41-1.74)
1.37(1.20-1.56)
1.35(1.09-1.69)
Other economically inactive
1.09(0.94-1.26)
1.13(0.97-1.31)
1.05(0.74-1.74)
Religion
No religion
Ref
Ref
Ref
Christian and other denominators
1.27(1.14-1.42)
1.15(1.02-1.29)
1.12(0.94-1.35)
Muslims
1.39(1.05-1.84)
1.45(1.10-1.93)
1.15(0.64-2.05)
Any other
1.71(1.35-2.16)
1.69(1.33-2.13)
1.00(0.61-1.64)
0.077
Ethnicity
White
Ref
Ref
Ref
Indian and Pakistani
1.62(1.27-2.08)
1.86(1.45-2.39)
2.08(1.23-3.54)
African Caribbean
1.34(1.01-1.62)
1.53(2.63-1.86)
2.24(1.61-3.12)
Chinese and Other Asian mix
1.28(0.95-1.73)
1.47(1.09-1.98)
1.61(0.85-3.05)
Other
1.44(0.96-2.17)
1.73(1.14-2.61)
1.60(0.78-3.29)
*Fully adjusted model included: age, sex, marital status, education, equivalised income, employment, religion and ethnic origin

Supplementary Table DS5 Sex stratified multivariate logistic regression for low and average mental well-being
Variables
Univariate
Multivariate analysis(fully adjusted model)
Male
Female
Male
Female
Age(20 year bands)
16-34
Ref
Ref
Ref
Ref
35-54
1.37(1.14-1.66)
1.04(0.90-1.21)
2.01(1.56-2.58)
1.33(1.09-1.64)
55+
1.17(0.97-1.41)
0.92(0.79-1.08)
1.25(0.91-1.73)
0.78(0.58-1.04)
Marital status
Single
Ref
Ref
Ref
Ref
Married/Civil partnership/cohabitees
0.57(0.48-0.68)
0.59(0.51-0.69)
0.71(0.55-0.90)
0.68(0.55-0.84)
Separated/Divorced/Widowed
1.10(0.87-1.39)
1.01(0.84-1.20)
1.11(0.81-1.52)
0.89(0.69-1.14)
Education
NVQ4/NVQ5/Degree or equivalent
Ref
Ref
Ref
Ref
Higher education below degree
1.18(0.90-1.55)
1.64(1.26-2.13)
1.03(0.75-1.40)
1.51(1.12-2.04)
NVQ3/GCE A Level equivalent
1.67(1.30-2.12)
1.629(1.29-2.03)
1.31(0.98-1.76)
1.20(0.92-1.56)
NVQ2/GCE O Level
1.79(1.43-2.24)
2.25(1.85-2.74)
1.35(1.03-1.77)
1.70(1.35-2.15)
NVQ1/CSE other grade equivalent
2.2191.60-3.06)
2.92(2.12-4.01)
1.46(0.98-2.18)
1.82(1.25-2.64)
No qualification
2.72(2.18-3.40)
2.87(2.35-3.50)
1.97(1.47-2.63)
2.17(1.65-2.84)
Equivalised income
Highest (>47794.12)
Ref
Ref
Ref
Ref
Second highest (>27704.920.99(0.76-1.29)
1.16(0.90-1.49)
0.93(0.71-1.22)
1.09(0.84-1.42)
<=47794.12)
Middle (>19117.65-<=27704.92)
1.49(1.15-1.92)
1.68(1.32-2.13)
1.24(0.94-1.63)
1.39(1.07-1.80)
Second lowest (>11676.651.80(1.40-2.32)
2.29(1.82(2.88)
1.41(1.06-1.88)
1.65(1.28-2.13)
<=19117.65)
Lowest (<=11676.65)
3.42(2.66-4.01)
3.94(3.14-4.95)
1.92(1.41-2.62)
2.28(1.74-2.97)
Employment
In employment
Ref
Ref
Ref
Ref
Unemployed seeking work
2.25(1.68-3.00)
1.56(1.18-2.07)
1.52(1.05-2.20)
0.97(0.69-1.35)
Retired
1.38(1.15-1.64)
1.38(1.19-1.62)
1.06(0.79-1.43)
1.25(0.94-1.65)
9

Other economically inactive

Religion
No religion
Christian and other denominators
Muslims
Any other
Ethnicity
White
Indian and Pakistani
African Caribbean
Chinese and Other Asian mix
Other

4.00(3.28-4.88)

2.49(2.14-2.90)

2.95(2.25-3.87)

2.07(1.71-2.50)

Ref
1.03(0.88-1.20)
0.74(0.46-1.20)
0.76(0.50-1.16)

Ref
0.94(0.82-1.09)
1.18(0.81-1.72)
1.00(0.70-1.41)

Ref
0.99(0.83-1.20)
0.66(0.29-1.50)
0.69(0.38-1.27)

Ref
0.93(0.78-1.11)
1.40(0.75-2.60)
1.03(0.63-1.67)

Ref
0.76(0.48-1.20)
0.54(0.35-0.83)
0.85(0.49-1.48)
0.63(0.28-1.40)

Ref
1.30(0.90-1.88)
0.44(0.30-0.63)
0.95(0.63-1.44)
1.39(0.78-2.47)

Ref
0.75(0.36-1.58)
0.37(0.20-0.70)
0.80(0.34-1.90)
0.73(0.28-1.93)

Ref
1.07(0.60-1.90)
0.46(0.30-0.72)
0.54(0.28-1.02)
0.88(0.41-1.90)

10

Supplementary Table DS6 Gender stratified multivariate logistic regression for high and average mental well-being
Variables
Univariate
Multivariate analysis(fully adjusted model)
Male
Female
Male
Female
Age(20 year bands)
16-34
Ref
Ref
Ref
Ref
35-54
0.96(0.80-1.16)
0.90(0.76-1.07)
0.97(0.77-1.23)
0.95(0.77-1.17)
55+
1.52(1.28-1.81)
1.44(1.23-1.68)
1.52(1.15-2.00)
1.45(1.12-1.88)
Marital status
Single
Ref
Ref
Ref
Ref
Married/Civil partnership/cohabitees
1.21(1.00-1.45)
1.14(0.96-1.36)
1.00(0.79-1.28)
1.03(0.82-1.30)
Separated/Divorced/Widowed
1.32(1.01-1.71)
1.18(0.96-1.45)
0.98(0.70-1.36)
0.94(0.71-1.25)
Education
NVQ4/NVQ5/Degree or equivalent
Ref
Ref
Ref
Ref
Higher education below degree
1.02(0.82-1.27)
1.28(1.02-1.59)
1.00(0.78-1.30)
1.22(0.94-1.57)
NVQ3/GCE A Level equivalent
0.96(0.77-1.19)
0.94(0.76-1.14)
1.04(0.81-1.34)
1.03(0.81-1.29)
NVQ2/GCE O Level
0.84(0.68-1.03)
0.91(0.75-1.09)
0.99(0.78-1.27)
0.85(0.68-1.05)
NVQ1/CSE other grade equivalent
1.28(0.94-1.73)
0.92(0.63-1.33)
1.26(0.88-1.81)
1.02(0.66-1.56)
No qualification
1.10(0.89-1.35)
1.18(0.98-1.41)
0.97(0.74-1.26)
0.99(0.77-1.28)
Equivalised income
Highest (>47794.12)
Ref
Ref
Ref
Ref
Second highest (>27704.92-<=47794.12) 0.83(0.67-1.03)
0.97(0.79-1.18)
0.80(0.64-1.00)
0.95(0.77-1.17)
Middle (>19117.65-<=27704.92)
0.93(0.74-1.15)
0.89(0.72-1.10)
0.78(0.61-0.99)
0.80(0.63-1.00)
Second lowest (>11676.650.90(0.71-1.13)
0.88(0.71-1.08)
0.71(0.55-0.93)
0.79(0.62-1.00)
<=19117.65)
Lowest (<=11676.65)
0.98(0.75-1.27)
0.99(0.79-1.24)
0.79(0.58-1.07)
0.88(0.68-1.15)
Employment
In employment
Ref
Ref
Ref
Ref
Unemployed seeking work
1.18(0.85-1.63)
1.13(0.84-1.53)
1.34(0.92-1.96)
1.25(0.88-1.78)
Retired
1.61(1.38-1.87)
1.54(1.34-1.78)
1.34(1.05-1.71)
1.24(0.98-1.58)
Other economically inactive
1.01(0.77-1.33)
1.13(0.95-1.35)
1.05(0.74-1.48)
1.31(1.06-1.63)
11

Religion
No religion
Christian and other denominators
Muslims
Any other
Ethnicity
White
Indian and Pakistani
African Caribbean
Chinese and Other Asian mix
Other

Ref
1.29(1.10-1.50)
1.67(1.17-2.46)
1.53(1.08-2.17)

Ref
1.27(1.09-1.48)
1.07(0.69-1.66)
1.87(1.36-2.57)

Ref
1.12(0.93-1.34)
1.15(0.64-2.04)
1.00(0.61-1.64)

Ref
1.17(0.97-1.39)
0.69(0.35-1.35)
1.41(0.90-2.20)

Ref
1.71(1.22-2.40)
1.72(1.31-2.27)
1.61(1.04-2.49)
1.00(0.52-1.93)

Ref
1.54(1.07-2.20)
1.09(0.84-1.41)
1.08(0.72-1.62)
1.90(1.12-3.24)

Ref
2.09(1.23-3.55)
2.25(1.61-3.13)
1.61(0.85-3.06)
1.61(0.78-3.30)

Ref
1.57(0.93-2.64)
1.04(0.74-1.46)
1.15(0.65-2.04)
2.58(1.36-4.86)

12

Socioeconomic gradients and mental health: implications for

public health

Sarah Stewart-Brown, Preshila Chandimali Samaraweera, Frances Taggart, Ngianga-Bakwin Kandala

and Saverio Stranges
BJP 2015, 206:461-465.
Access the most recent version at DOI: 10.1192/bjp.bp.114.147280

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