The Role of Perceived Stress in Associations Between Subjective Social Status and Health-Related Quality of Life Among Homeless Smokers

Introduction: Cigarette smoking is common among individuals who are homeless, and homeless smokers are at increased risk for poorer health and health-related quality of life (HRQoL). HRQoL is a multidimensional construct related to social functioning and physical, mental, and emotional health. Limited work has focused on the mechanisms related to poorer HRQoL among individuals who are homeless. Subjective social status (SSS)—a person’s perception of their position in society relative to a defined referent group—is related to HRQoL among disadvantaged adults; however, this relation has not been examined among homeless smokers. Further, perceived stress (PS) may serve as a linking mechanism. Examining the indirect effects of PS on the SSS-HRQoL relation among homeless smokers may provide crucial information to inform future interventions and further elucidate determinants of health disparities experienced by this at-risk and understudied group. The current study investigated the relation between SSS and four HRQoL dimensions, and examined PS as an underlying explanatory mechanism within a sample of homeless smokers.

Methods: Homeless smokers (N=227; 70.9% male; M_age=43.2) provided informed consent and completed self-report measures. Indirect effects were examined using the PROCESS macro for SPSS. Eight models were conducted with the following dependent variables: (A) self-rated health, (B) poor physical health days, (C) poor mental health days, and (D) activity limited days due to poor physical or mental health as criterion variables. Models were conducted with SSS-US and SSS-Community as the predictor, respectively. The Perceived Stress Scale served as the linking mechanism for all models. Covariates included sex, age, education, income, health insurance status, race, and cigarettes per day.

Results: The indirect effects of SSS-US on each HRQoL dimension through PS were significant (A: ab=-.03, CI_95%=-.06, -.01; B: ab=-.20, CI_95%=-.43, -.05; C: ab=-.43, CI_95%=-.81, -.10; D: ab=-.23, CI_95%=-.47, -.07). The indirect effects of SSS-Community on each HRQoL dimension through PS were significant (A: ab=-.04, CI_95%=-.06, -.02; B: ab=-.26, CI_95%=-.49, -.11; C: ab=-.60, CI_95%=-.96, -.31; D: ab=-.31, CI_95%=-.55, -.14). Across all models, lower SSS was significantly associated with greater PS, which was subsequently associated with poorer HRQoL.

Conclusions: Findings indicated that SSS influences HRQoL domains among homeless smokers through indirect pathways involving PS. These findings extend current conceptualizations of perceived social standing and affective vulnerability on domains of self-reported health and elucidate pathways that may contribute to poorer HRQoL among homeless smokers.