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Estimating mechanisms linking relative income to self-rated health by multilevel modeling: the moderating role of healthcare access and quality index

樱花视频 volume听25, Article听number:听1735 (2025) Cite this article

Abstract

Income-health gradients vary in societies with diverse cultures and healthcare access levels, and generalized trust in unknown resources of health services may play a crucial role in these gradients. Multilevel models using a sample of 152,501 respondents from 89 societies are conducted to investigate the mediation effect of generalized trust in the correlation between relative income and self-rated health globally, and the moderating role of healthcare access in the association between relative income and self-rated health. Results show that individuals鈥� relative income significantly and positively predicts their generalized trust, which in turn significantly and positively predicts their self-rated health. In countries and regions with higher levels of healthcare access and quality, a higher level of relative income is positively correlated with increased self-rated health. This study theoretically contributes to the literature on income-health relationships by capturing medical resource access and individual characteristics. Specific policy recommendations include fostering generalized trust, improving healthcare education, and expanding telemedicine.

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Introduction

Self-rated health refers to individuals鈥� assessment of their health status including mental and physical health by themselves [1]. Self-rated health was influenced by factors with multiple dimensions including personal and environmental determinants. Specifically, individual predictors include socioeconomic status (i.e. income, education level, employment status), health lifestyle, access to resources and medical treatment [2,3,4]. Environmental factors, particularly physical conditions such as access to healthcare, play a crucial role in individuals鈥� health [5]. From this perspective, income-health gradients may vary in different countries and regions with varying levels of health systems [6].

Self-rated health and relative income

A large body of literature shows that relative income is viewed as a positive predictor of self-rated health [7,8,9]. Individuals with lower income may face greater difficulties in accessing medical resources compared to wealthier groups [10]. Especially when poor individuals live in areas with underdeveloped healthcare systems, they face higher relative medical costs, and often have limited medical knowledge [11]. In addition, people with lower relative incomes are more likely to suffer frustration and stress from their upward comparisons [6]. These stresses from social comparison can damage their mental health [12]. In this case, they may use unhealthy defensive behaviors such as smoking, marijuana use, excessive alcohol consumption, and problematic gaming for short-lived pleasure but these actions harm their physical health [13]. In contrast, individuals with higher incomes benefit from their status, prestige, and reputation in a society [14]. Rich individuals may have healthy lifestyles, and have access to effective medical treatments, which are positively associated with their health [15].

Existing literature extensively discusses income-based health inequality [6, 9, 12]. However, there appears to be a gap in the current understanding of the mechanisms underlying the correlation between relative income and self-rated health, particularly across diverse societies with varying cultural contexts and different levels of healthcare access. For instance, M Subramanyam et al. [16] found that relative deprivation partly explains the association between income and health status among Americans. Yet, Chinese evidence did not support the consistent relation between relative income and self-rated health, and this linkage differs in groups with different demographic information [17]. In this case, there may be a research gap regarding the mediating and moderating analyses of the association between relative income and self-rated health across societies.

Generalized trust as a mediator

Generalized trust refers to an expectation of the benign intentions of other people in general [18]. This type of trust may be a mediator of the association between relative income and self-rated health across societies. People with higher levels of relative income are more likely to experience success, greater social capital, and resources that afford them vulnerabilities of trust in strangers [19]. Conversely, individuals with lower relative income, who may frequently face hardships, may be less likely to trust strangers, perceiving them as potential threats to the already precarious situation [6]. Generalized trust is a type of bridging social capital and facilitates access to health-related information [20]. A meta-analysis confirms the positive link between social capital and self-rated health [21]. The utility of health information depends on the extent to which people trust the source of the information [22]. In this context, generalized trust plays a crucial role in health evaluations [23]. In this vein, wealthier individuals with higher levels of generalized trust are more likely to access health resources and report healthier outcomes. Therefore, we hypothesize that relative income positively predicts generalized trust, which in turn positively predict self-rated health across societies.

Healthcare access and quality index as a moderator

Healthcare Access and Quality (HAQ) refers to the availability, accessibility, and standard of healthcare services that individuals can receive within a given health system [5]. The country- or region-level Health Access and Quality Index may play a crucial role in residents鈥� perceived health outcomes in relation to their economic status. In countries and regions where healthcare is more accessible and of higher quality, the association between self-rated health and personal financial resources may become more pronounced [24]. In particular, Individuals with higher income are likely to experience better health outcomes for the possible reason that they can more effectively utilize healthcare services, whereas poorer individuals may not have the same access to these services [25]. In countries and regions with lower scores of Healthcare Access and Quality, healthcare services may be limited or of lower quality [26]. This weakens the income-health gradient, as even higher-income individuals may not benefit as much from healthcare improvements [27]. From this perspective, in societies with lower Healthcare Access and Quality, the association between relative income and self-rated health becomes weaker [28]. The possible reason is that residents in societies with lower levels of Healthcare Access and Quality, regardless of their income, face barriers to high-quality healthcare, narrowing the health disparity between income groups. Based on this, we hypothesize that the associations between inviduals鈥� relative income and self-rated health are more pronounced in societies with higher levels of Health Access and Quality.

Previous studies indicated that individuals鈥� self-rated health is predicted by several demographic information including gender, age, and education level [6, 29]. In this case, we set these above variables as individual-level controls in our empirical model. Given that political stability is a critical factor in population health [30], we include it as the country- or region-level control variable.

Current study

The relationship between relative income and self-rated health remains a critical issue in understanding health disparities, with significant implications for global health. However, existing studies provide unclear insights, particularly regarding the underlying mechanisms. Given that generalized trust serves as a proxy for bridging social capital, which facilitates health information searching, its mediating role in the income-health relationship warrants attention. Additionally, there are varying levels of healthcare systems across different countries and regions, so it is essential to explore the moderating role of healthcare access levels in the income-health gradients.

This study contributes to the existing literature by addressing three key areas. First, we use a cross-national sample to verify the positive associations between relative income and self-rated health across countries and regions. Second, it examines the mediating role of generalized trust in the relationship between relative income and self-rated health across different countries and regions. Lastly, this study explores how the levels of Healthcare Access and Quality across countries and regions moderate the relationship between relative income and self-rated health. The specific research framework is illustrated in Fig.听1.

Fig. 1
figure 1

Research frame

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Data and variables

Data

We used the joint EVS-WVS 2017鈥�2022 dataset (Version 4.0.0) to construct the individual-level data. The joint EVS-WVS dataset consists of European Values Study Wave 5 (EVS5) [31] and World Values Survey Wave 7 (WVS7), by the Integrated Values Surveys [32]. A total of 153,716 respondents from 90 countries or regions participated in this version of the joint EVS-WVS. There are 231 variables covering a wide range of disciplines including psychology, sociology, and public health, so it can offer empirical validation for the association between relative income, generalized trust, and self-rated health.

The data on health access were sourced from the Global Burden of Disease (GBD) Study 2019 [33]. Due to missing data on relative income of 1,215 individuals from Portugal, this country was excluded from the analysis. Missing values were imputed with the mean value of the corresponding variables within their respective countries and regions. This approach is preferable to simply deleting missing data, as missing data produce unbiased parameter estimates and standard errors [34]. Finally, a total of 152,501 respondents from 89 countries or regions participated in this study. Stata Version 15 and R Version 4.4.2 were utilized to obtain the multilevel model results of cross-level moderating analysis and mediation effects, respectively.

Variables

Self-rated health was measured using an item from the joint EVS-WVS dataset 鈥淎ll in all, how would you describe your state of health these days?鈥�. This variable is rated on a 5-point Likert scale. Responses of self-rated health were reverse scored. The higher scores represent that respondents reported healthier statuses.

Relative income was assessed by an item of the joint EVS-WVS dataset. Respondents selected a number from 1 to 10, with 1 indicating the lowest income group and 10 representing the highest income group. This value represents participants鈥� household income level, including wages, salaries, pensions, and other incomes.

Generalized Trust was measured by asking respondents鈥� levels of trust in people they met for the first time [19]. This measure is also an item of the joint EVS-WVS dataset. The responses were reverse scored and the final scores were rated on a 4-point Likert scale, ranging from 1 (Do not trust at all) to 4 (Trust completely). The higher values represent higher degrees of their generalized trust.

Healthcare Access and Quality (HAQ) index was derived from the GBD 2019 dataset. Country data from this index for the year 2019 was utilized. The HAQ index uses 32 causes of amenable mortality to measure Healthcare Access and Quality in a comparable manner across countries [5]. This index ranges from 0 to 100, with higher scores indicating greater ease of access to healthcare resources.

The joint EVS-WVS dataset also contains individuals鈥� demographic information including gender coded as 鈥�1: male, 0: female鈥�, age as a continuous variable, and education level coded as 鈥�0: less than primary, 1: primary, 2: lower secondary, 3: upper secondary, 4: post-secondary or non-tertiary, 5: short-cycle tertiary, 6: bachelor or equivalent, 7: master or equivalent, 8: doctoral or equivalent鈥�.

Empirical strategy

Multilevel modeling, also known as hierarchical linear modeling, was used to identify the association between relative income and self-rated health [35]. We also investigate the mediating role of generalized trust, and the cross-level moderating roles of Healthcare Access and Quality at the country or region-level in the individual-level correlation. Individual-level continuous independent variables were standardized within their respective countries and regions, while country- or region-level variables were standardized globally. Given that income-health gradients may vary across countries and regions, multilevel models with random slopes and intercepts were employed in both the main and full models. Stata software with the commend mixed was utilized to conduct the models.

Null models with self-rated health and generalized trust as dependent variables were run to investigate international differences in these two variables. The intraclass correlation coefficient (ICC) was calculated to determine the necessity of multilevel models. If the ICC is greater than 0.059, it is necessary to utilize multilevel models to consider the international differences in generalized trust and self-rated health [36]. ICC takes values in the range from 0 to 1.

Main models were conducted to investigate the association between self-rated health, generalized trust, and relative income at the individual level. By doing this, we can get the possible mediation effect of generalized trust on the correlation between self-rated health and relative income. Given potential country or region differences in generalized trust and self-rated health among residents, we conducted a 1-1-1 mediation model using multilevel models to analyze the mediating role that generalized trust plays in the associations between relative income and self-rated health [37]. Following KJ Preacher and JP Selig [38], we can calculate the mediation effect of the 1-1-1 mediation model. Finally, the Monte Carlo method was utilized to calculate the confident interval estimate of the mediation effect (See KJ Preacher and JP Selig [38] for more details).

Full models were developed to explore the moderation effect of country or region-level Healthcare Access and Quality on the individual-level association between self-rated health and relative income. Following KJ Preacher et al. [39], cross-level simple slope tests were used to investigate the significant moderating roles that country or region-level Healthcare Access and Quality plays in the individual-level association between self-rated health and relative income.

Results

Appendix Table听1 shows the descriptive statistics grouped by countries and regions. Columns 2 and 3 show the number and gender proportion of participants in a country or region, respectively. Columns 4鈥�13 indicate the mean and standard deviation of individual-level variables including age, education level, relative income, generalized trust, and self-rated health. Columns 14 exhibit the values of the country or region-level variables including the Healthcare Access and Quality index. The mean and standard deviation of the Healthcare Access and Quality index are 67.2 and 17.2, respectively. This means our sample countries and regions report a higher level of Healthcare Access and Quality, as the overall value around the world is 54.4 [5].

Table听1 indicates the estimations of null models with self-rated health and generalized trust. The ICC values of both null models are greater than 0.059, indicating it is necessary to conduct multilevel models to analyze the national differences in residents鈥� self-rated health and generalized trust [36].

Table 1 Estimations of null models
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Table听2 presents the results of the main models. Relative income significantly and positively predicted both self-rated health and generalized trust at the 0.1% significance level. Generalized trust demonstrated a significant positive relationship with self-rated health at the 0.1% significance level. After controlling for generalized trust, relative income remained a significant positive predictor of self-rated health, indicating a partial mediation effect of generalized trust on the relationship between relative income and self-rated health.

The point estimate for the indirect effect through generalized trust on the individual-level association between relative income and self-rated health was 0.004, accounting for 3.2% of the total effect across countries and regions. The Monte Carlo method was utilized to estimate 95% confidence intervals by resampling 20,000 times. The result showed that the confidence interval was [0.003, 0.005], excluding zero, indicating a significant mediation effect.

Table听2 also reports the prediction of demographic information on self-rated health. In particular, males relative to females significantly reported higher generalized trust and better health statuses. Age significantly negatively predicted self-rated health, while significantly positively predicted self-rated health. Education level significantly positively predicted both generalized trust and self-rated health.

Table听3 shows the results of the full models. Country- or region-level Healthcare access and Quality also had no significant prediction on self-rated health. Country- or region-level Healthcare access and Quality significantly positively moderated the correlation between generalized trust and self-rated health. The significance of individual-level variable coefficients remained consistent in the full models with the main models.

Table 2 Results of main models
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Table 3 Estimations of full models with self-rated health as the dependent variable
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The significant cross-level interaction term in the full model 2 suggests the need for further investigation into the moderating role of Healthcare Access and Quality. The simple slope test was conducted in order to investigate the cross-level moderation role of society-level Healthcare Access and Quality in the individual-level association between self-rated health and relative income [39]. Healthcare Access and Quality scores of the mean plus and minus their one standard deviation represent higher and lower levels of this index, respectively. Relative income is taken as the mean plus and minus three standard deviations, and the global sample can be covered. Figure听2 indicates that in countries and regions with higher levels of Healthcare Access and Quality, individuals with higher relative incomes tend to report a healthier status. For instance, the simple slope for the HAQ index scored at one standard deviation below the mean is 0.083 (95% CI = [-0.017, 0.183]). The simple slope for the HAQ index scored at one standard deviation above the mean is 0.123 (95% CI = [0.023, 0.233]).

Fig. 2
figure 2

Result of the simple slope test. Notes: 1. HAQ is the Healthcare Access and Quality Index. 2. 95% confidence intervals are reported

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Discussion

General discussion

There is evidence of a positive association between relative income and self-rated health across societies. Individuals with higher incomes tend to rate their health more favorably, while those with lower income levels report worse health outcomes. This relationship is likely influenced by several factors, and for instance, people with higher incomes show greater access to healthcare, healthier lifestyle options, and reduced financial stress [11, 40]. Conversely, individuals with lower income often face barriers such as limited access to healthcare, increased financial strain, and fewer resources for maintaining a healthy lifestyle, all of which contribute to poorer health outcomes [41, 42]. Moreover, higher income often correlates with increased social status, which can positively enhance one鈥檚 perception of their own health [43].

We found weak evidence that generalized trust plays a mediating role in the association between relative income and self-rated health across the globe. In particular, people with higher relative income exhibit higher levels of generalized trust, which is linked to their increased access to resources and reduced vulnerability to risks, in favor of their health [44]. Conversely, individuals with lower incomes tend to exhibit lower levels of generalized trust, which correlates with their reduced bridging social capital [45]. This limitation in bridging capital to unfamiliar sources of health information may restrict economically disadvantaged groups鈥� access to health services, ultimately adversely affecting their health [23]. This mediation effect was vilified by using the sample of many countries and regions and it sheds light on the crucial role of generalized trust in the income-health gradient across the globe [4]. Building a society with high generalized trust may reduce income-based inequalities in health outcomes [8].

Generalized trust is a mediator of income-related health across societies, and its cross-national measurement merits careful consideration. Traditionally, the survey item 鈥淕enerally speaking, would you say that most people can be trusted, or that you can鈥檛 be too careful in dealing with people?鈥� has served as a common indicator of generalized trust [46, 47]. However, 鈥渕ost people鈥� may conflate generalized forms of trust in different cultures [48]. For instance, in Confucian societies like Mainland China, respondents may read 鈥渕ost people鈥� as referring to in-group members [46, 49,50,51]. Since generalized trust is meant to capture trust in a broad circle of unfamiliar others, assessing individuals鈥� trust in strangers may yield higher validity for cross-national comparisons of generalized trust [51, 52]. Empirically, to reduce information loss, it is advisable to employ a multipoint item of measuring trust in people met for the first time, rather than a binary response option regarding trust in most people [53]. In light of these considerations, this study uses trust in strangers as the measure of generalized trust, consistent with the approach taken in previous studies [19, 54].

Our empirical evidence supports the moderating role that healthcare access plays in the individual-level correlation between relative income and self-rated health. Specifically, in countries and regions with higher levels of Healthcare Access and Quality, individuals with higher relative incomes tend to report healthier statuses. This is inconsistent with existing literature, which suggests that regional healthcare access can buffer the negative effects of economic disparities on health outcomes [55]. We found that in countries and regions with robust healthcare systems, individuals with higher relative incomes are more likely to experience better health outcomes, likely due to their enhanced ability to leverage healthcare resources that may not be as readily available to their lower-income counterparts [5]. This observation underscores the critical role of healthcare infrastructure in providing necessary services and promoting health equity [24]. Countries and regions aiming to enhance healthcare access should prioritize the equitable distribution of medical resources [27]. Ensuring that healthcare improvements benefit all socioeconomic groups can help mitigate health disparities and enhance overall community well-being [28].

There are effects of demographical information on self-rated health. Males relative to females reported higher health, possibly because women experiencing risk through pregnancy may harm their bodies [56]. Age positively and significantly predicts self-rated health, and a possible explanation is that a person鈥檚 physical condition deteriorates with increasing age [57]. Education level significantly and positively affects self-rated health for the possible reason that groups with higher levels of educational attainment have more access to fresh projects to maintain their health and sense of meaning in life [29].

Theoretical contributions

This study theoretically contributes to the literature on the effect of sociocultural differences in self-health related to relative income and its underlying mechanism. Our empirical models enrich the application of the social capital framework in the field of public health, providing knowledge to better understand the mediating role that bridging social capital like generalized trust plays in the association between relative income and self-rated health across the world. The correlation between higher income and better health in countries and regions with strong healthcare systems highlights the need to view health disparities through an economic lens, especially in countries and regions with higher levels of healthcare availability. This study connects micro-level healthcare access with income-related health outcomes, providing exploratory insights for the scientific community, particularly in the field of public health.

Policy implications

Based on our empirical evidence, the policy implications are as follows. It is essential to foster a climate of generalized trust and harmony to reduce health inequalities [4]. In countries and regions with higher levels of Healthcare Access and Quality, the more pronounced and positive correlation between income and health status underscores the need for policies that reduce income-based health disparities [58]. Policymakers should consider expanding access to preventive care and health education for lower-income groups to ensure that everyone can benefit from the available healthcare infrastructure [5]. Subsidizing healthcare services for vulnerable populations could also help mitigate the effects of income inequality on health outcomes [59, 60]. Improving the distribution of healthcare professionals in underserved regions through incentive programs or loan forgiveness for medical graduates who work in rural or low-income urban areas can further enhance healthcare access [61, 62]. Moreover, expanding telemedicine can enhance healthcare access in remote areas by offering consultations and follow-up care, reducing financial and logistical barriers [63].

Limitations

There are some shortcomings. Single-item and self-reported measures of core variables, including relative income, generalized trust, and self-rated health, may reduce the reliability of this study and may lead to some bias due to subjective interpretation or cultural response tendencies. Future research can utilize culturally universal scales to measure people鈥檚 multidimensional health such as Instrumental Activities of Daily Living and depressive symptoms. Cross-sectional data fails to infer causality, and the upcoming investigation can utilize longitudinal data to explore the potential causal association between income and health [64]. Income-health gradients are correlated with national dynamics, including medical [26], economic [64], political [65], and cultural factors [66], while this study investigates healthcare access in line with income-health gradients. Future research can explore a broader range of national factors shaping these gradients.

Conclusion

This study conducted multilevel models by using the joint EVS-WVS dataset (2017鈥�2022) and found a positive and significant association between relative income and self-rated health and its underlying mechanism. Relative income significantly positively predicted self-rated health across societies. Individuals鈥� relative income significantly positively predicted their generalized trust, which in turn significantly positively predicted their self-rated health. Income-health gradients are higher in societies with higher levels of healthcare access.

Data availability

The data used in this study is available in public, open access repositories. All data used in this study are publicly available from the joint EVS-WVS dataset: , Global Burden of Disease Study 2019 Data Resources .

Abbreviations

HAQ:

Healthcare access and quality

EVS:

European values study

WVS:

World values survey

EVS5:

European values study wave 5

WVS7:

World values survey wave 7

GBD:

Global burden of disease

ICC:

Intraclass correlation coefficient

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This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Faculty of Humanities and Social Sciences, Macao Polytechnic University, Rua de Lu铆s Gonzaga Gomes, Macau, China

    Jiansong Zheng,听Tao Zhang听&听Xi Wang

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  1. Jiansong Zheng

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  2. Tao Zhang

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  3. Xi Wang

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Contributions

J.Z. and T.Z. conceived and designed the study. J.Z. collected the data. J.Z. and T.Z. performed the statistical analysis. J.Z. drafted the initial manuscript. J.Z., T.Z., and X.W. revised the manuscript. X.W. supervised the research activity planning and execution. All authors approved the final version of the paper.

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Correspondence to Tao Zhang.

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Zheng, J., Zhang, T. & Wang, X. Estimating mechanisms linking relative income to self-rated health by multilevel modeling: the moderating role of healthcare access and quality index. 樱花视频 25, 1735 (2025). https://doi.org/10.1186/s12889-025-22783-4

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  • DOI: https://doi.org/10.1186/s12889-025-22783-4

Keywords

樱花视频

ISSN: 1471-2458

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