Our results demonstrated that among low SES children, those who engaged in a specific psychological strategy for dealing with daily life stress, labeled shift-and-persist, showed better asthma profiles prospectively. That is, lower SES children with asthma who worked to reinterpret stressors in a more positive light (shifting) while remaining optimistic about their futures (persisting) had less asthma inflammation at baseline, as well as less asthma impairment (less rescue inhaler use and school absences) at a 6 month follow-up assessment. In fact, low SES children with asthma with high levels of shift-and-persist resembled high SES children with asthma on a number of these dimensions. This study is the first that we are aware of to demonstrate the health-protective effects – both biologically and clinically – of a psychological characteristic for coping with stress that uniquely protects low SES children confronting a chronic disease.
There were no main effects of shift-and-persist, only an interaction with SES, indicating that shift-and-persist strategies are not uniformly beneficial, but rather specifically helpful to those who come from low SES backgrounds. Because low SES individuals on average live under circumstances consisting of more frequent stressors that are more uncontrollable 41
, an approach that emphasizes shifting oneself (reframing stressors more positively) may be beneficial for slowing down the pathophysiologic processes that contribute to diseases such as asthma. In addition, maintaining optimism about the future may provide meaning in life, and foster striving towards long-term goals, processes which in turn mitigate asthma-relevant physiologic processes over time. Thus there may be psychological qualities that are uniquely beneficial to low SES children’s asthma, and that are different from those that are beneficial to high SES children.
Our findings are consistent with several adult studies that have examined individual psychological characteristics that moderate the effects of SES on health outcomes. For example, perceived control buffered a community sample of adults who were low in SES from poor self-reported health, acute health symptoms, and functional limitations 18
. Similarly, high purpose in life buffered a community sample of adults who were low in SES from high levels of the inflammatory cytokine IL-6 19
. Our study is novel in documenting specific protective factors that emerge in childhood, and in documenting their relevance to clinically relevant outcomes in a chronic disease such as asthma.
In addition, our findings are also consistent with other studies that have examined the benefits of positive childhood social relationships for those low in SES. These studies have documented that factors such as maternal warmth can buffer low SES individuals from adverse physiological and inflammatory risk profiles in both childhood and adulthood 21, 42, 43
. In the present study, rather than focusing on broader family contexts, we focused on children themselves, and the characteristics that they can acquire to protect themselves from adverse health outcomes.
This type of work has important implications for efforts to reduce the increased burden of asthma among those lower in SES 44, 45
. Our findings are important in documenting that it is possible for some children, despite being dealt a life of adversity, to show good asthma control. Furthermore, this study identifies a set of psychological factors that contributes to this resilience. Because we pinpointed qualities that naturally occur in some low SES children, this will hopefully allow researchers and clinicians to identify realistic targets for future interventions. That is, if we can identify characteristics that some low SES children already possess that promote good asthma profiles, these may be ones that may be most possible to alter through intervention in other low SES individuals. In order to meaningfully reduce health disparities, we may need to tailor interventions to the realities of low SES life, and to acknowledge that approaches that work in higher SES communities may not be similarly effective in a low SES context.
Strengths of the present study include the longitudinal design, the multiple measures of inflammatory, pulmonary, and impairment outcomes, and the novel approach of focusing on strengths (rather than detrimental factors) within low SES communities. Limitations include not having objective records of physician visits and hospitalizations, and not having longer monitoring periods for asthma outcomes and for examining variations by seasonality in asthma. In addition, as this study was observational we cannot draw firm conclusions about causality. Future studies could undertake experimental manipulations of shift-and-persist strategies and test the effects on asthma impairment in low SES children. Finally, future studies should explore other factors associated with shift-and-persist, such as temperament or family relationships, that may help explain the use of shift-and-persist strategies and their association with asthma outcomes.
In sum, children who came from low SES backgrounds and who engaged in shift-and-persist strategies (dealing with stressors by reframing them more positively, while at the same time, persisting in optimistic thoughts about the future) showed better asthma profiles, both in terms of reduced inflammation at baseline, as well as less asthma impairment at a 6-month follow-up. In contrast, shift-and-persist strategies were not beneficial to high SES children with asthma. Future studies should test whether these effects extend to other chronic illnesses as well. Given that broader social policies (e.g., anti-poverty programs) and environments (e.g., neighborhoods) can be difficult to change, an approach that focuses on low SES children themselves and the psychological qualities they could develop to adapt to the stressors they are forced to confront on a daily basis may be both a practical and effective starting point in efforts toward the long-term goal of eventually eliminating health disparities by social class.