This paper asks if there are any statistically valid relationships between low control beliefs, low socioeconomic status (SES) and poor health outcomes and was published in 2019 by Orton et al. It is from week four of our semester reading list.

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The link between a sense of control and a good or improved sense of health has been established in other areas. Before reviewing this meta-analysis of the available research on health inequalities at the micro level of low SES individuals, a quick review of the existing links between concepts of control and health, and what is meant by control is useful.

The importance of autonomy, of the ability to exercise personal choice, is well understood as a positive factor in desirable work environments. It is a contributor to experiencing good “work health”. There is also an established relationship between high-demand/low-control work and occupation class that connects socioeconomic inequalities and coronary heart disease (CHD). This meta-analysis was looking for data or research against the hypothesis that “the amount of control a person perceives that they have, or they experience in the rest of their lives, may also be a contributing factor to observed health inequalities”.

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There are two definitions of control that are relevant to this meta-analysis, both were included in the design and understanding the difference between them is important. To explore the difference between “perceived control” and “actual control” we are going to undertake the following thought experiment.

• What is your first thought when you see a camera mounted in a public street?
  • What are such cameras usually protecting in the places that you see them?
  • When you are with friends, what do you call these cameras?
  • Do you think of them as “security cameras” or as “surveillance cameras”?

• When you look at the picture of the car accident, what is your first thought?
  • The inconvenience
  • How it happened
  • The insurance
  • The expense
  • If anyone was hurt
  • Job loss
  • Very little, cars do not play a role in your life/local community, or you can’t afford a car…
  • something else?

Your specific answer isn’t actually what is important here.
Think about WHY your response is your response.

• How does seeing a mounted camera when you are out make you feel
  • more secure?
  • or somewhat uneasy?
• In your life, is a mounted camera a symbol of
  • power?
  • Yours or someone else’s?
  • one of wealth?
  • or oppression?
• Does seeing a picture of the car accident not bother you too much. Its an end on collision and insurance will sort it out?
• Or, does any kind of car accident bother you? Car accidents are a sign of how little control we have over other drivers and even if no-one was hurt and there is insurance and it might cover it, dealing with the situation will still require time and resources that would need to come from somewhere!

Do your responses give you some insight into your personal levels of “perceived control”?

Do you think your personal sense of control over your life impacts on your ability to influence your own health outcomes?

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As has been mentioned, this paper is the write-up of a meta-analysis.

This slide is a summary of the key points of the Systematic Review, which resulted in only six studies making it through the review process for final inclusion.

• All six occurred in one of three high income countries.
• Each study was evaluated as being “high quality” by the meta-analysis quality assessment against the hypothesized pathways.
• Some studies used pre-existing tools, so had been validated, others relied on measures that had not been validated. This use of different tools means that, in addition to the measures being different across the studies, the concept of “Control” was not conceptualized consistently either.
• None of the studies included measures of actual control

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This meta-analysis found that

• While none of the studies measured “actual control”, all the included studies provide evidence of an explanatory relationship between lower control beliefs (the variable) and low SES and poorer health outcomes for those individuals.
• The research team assessed this evidence as being reliable, statistically significant, and based on data that was collected over a substantial time-frame as longitudinal design was a selection criteria of the Systematic Review.
• No studies were found that measured a person’s actual control and their health outcomes – even though the theoretical literature argues that personal agency is more important than perceived control.

The authors acknowledge that

• The studies cover only high-income countries
• Only a small number of studies were able to pass the strict selection criteria
• Gender may be a critical factor, and gender did surface in the analysis, but there was not enough data in the six studies to draw any conclusions
• The lack of research on actual/real control prevented any exploration of a connection between a person’s experience of “real” and “perceived” control on their health outcomes

Areas for future research include:

• how ‘actual control’ of a person’s living environment influences their health outcomes
• The role of gender on experiences of perceived and actual control
• The impact of parenting on experiences of perceived and actual control
• Clarification of the relationship between low perceived control, chronic stress reactions, and less successful behavioural change

Citation: Orton, L.C., Pennington, A., Nayak, S., Sowden, A., Petticrew, M., White, M. & Whitehead, M. 2019, “What is the evidence that differences in ‘control over destiny’ lead to socioeconomic inequalities in health? A theory-led systematic review of high-quality longitudinal studies on pathways in the living environment”, Journal of epidemiology and community health, vol. 73, no. 10, pp. 929.