key: cord-0803470-pzvtqrb1
authors: Andersson, Matthew A.; Hitlin, Steven
title: Subjective dignity and self-reported health: Results from the United States before and during the Covid-19 pandemic
date: 2022-05-07
journal: SSM Ment Health
DOI: 10.1016/j.ssmmh.2022.100113
sha: e50cc507934b301bb698d3d29834c6fbd632e40c
doc_id: 803470
cord_uid: pzvtqrb1

AIMS: To describe disparities in depressive symptoms and self-rated health with a novel, individual-level measure of subjective dignity administered before and during the COVID-19 pandemic. METHODS: National survey data were collected across the United States by the Gallup Organization in Spring (2017) (n = 1459) and again in Spring (2021) (n = 1244). Subjective dignity is measured by self-reported perceptions of dignity in one’s own life. Numerous demographic subgroups constructed across age, gender, race/ethnicity, education, income, urbanicity, labor force status, and political background are used to test for robustness of dignity-health associations within and across years. RESULTS: All demographic subgroups studied reported numeric decreases in dignity from 2017 to 2021, with many of these decreases being both large and significant. With few group-year exceptions, subjective dignity relates to lower levels of depression and higher self-rated health, with dignity-depression associations significantly increasing from 2017 to 2021. CONCLUSIONS: Dignity, as a pluralistic moral concept, is purported to anchor legal, human rights, and cultural discourses on justice, equity, and social inclusion. This study provides timely, original evidence that subjective appraisals of dignity should be considered as a public health indicator, especially across periods of societal unrest or adversity. Given groupwise robustness of dignity-health associations as documented here, subgroup determinants and lay definitions of dignity may merit closer attention.

Immanuel Kant distinguished "price" from "dignity": that which has dignitysuch as human lifeis priceless. 1 Tragically, however, the dignity of life does not guarantee its societal realization. In fact, the Universal Declaration of Human Rights (UDHR) in 1948 actively sought the "(social) recognition of the inherent dignity" of persons. 2 Since then, dignity conceptions have continued to flourish across legal, constitutional, human rights, global health, and cultural institutional discourses. [3] [4] [5] [6] [7] In these modern usages by prominent institutions, conceptions of dignity entail that each human should benefit from autonomy, a lack of abuse or humiliation, relief from poverty, protection of or a right to health, a realization of their capabilities, or some combination of these processes. Given how it typically foregrounds the sanctity of individual life, dignity could help constitute a unifying morality in pluralistic, democratic societies such as the United States. 4, 8 Despite its proposed role in orienting modern political and legal regimes, however, dignity is quite difficult to define concretely, 4, 6, 9 which in turn places a premium on subjective or implicit understandings of dignity across societies, groups, and individuals. [10] [11] [12] These lay understandings may have practical, meaningful consequences for how individuals evaluate their social standing or treatment. [9] [10] [11] [12] Recently, Sir Michael Marmot asked, "if we cannot measure it (dignity), how will we know we are achieving it?" 5 Marmot suggests that definitional stalemates about dignity across discourse communities have stalled the development of needed empirics on dignity.

Similarly elusive concepts like happiness, compassion, or meaning-in-life have gained empirical progress by yielding to subjective measurement in view of philosophic quagmires yet undeniable conceptual resonance, 13 suggesting that a similar scientific path forward may exist for furthering J o u r n a l P r e -p r o o f empirical knowledge about dignity. Therefore, beginning to heed Marmot's call involves a consideration of new measurement opportunities for dignity.

In this study, we draw on two recent waves of national survey data collected in 2017 and 2021 by the Gallup Organization, to document levels of what we term 'subjective dignity' across the COVID-19 pandemic. Across diverse sociodemographic groups in America, we track an innovative measure of whether individuals perceive or experience dignity in their own lives, thus relying on public understandings of dignity to capture important societal forces as instantiated within individuals' self-conceptions. We ask not only how subjective dignity levels have changed across groups defined by education, income, age, gender, race, marital status, urbanicity, labor force status, and political party, but also whether dignity associates with mental and physical well-being for these groups. Given how multifaceted structural inequalities interwoven with American capitalism shape dignity's meaning, we explore whether dignity serves as an efficient indicator capturing differing life situations, whether it matters for wellbeing across multiple social hierarchies, and how these levels and associations have changed from before to during the global pandemic.

Group-based distinctions and legal rights are deeply, historically entwined with capitalism and its differential prioritization of individual lives. [16] [17] [18] As as a transnational superstructure, capitalism interweaves and calcifies different institutions of inequality (e.g., colonialism, racism, classism, ableism, ageism, and sexism) by legitimating intergenerationally transmitted advantages in cultural and economic capital, especially for those who are male, white, physically J o u r n a l P r e -p r o o f able, shielded from occupational risk, and have minimal family or care obligations. 14, 16, 19 Viewed this way, dignityanchored within intersubjective notions of morality, justice, and the reflected appraisals of othershas many profound, group-specific obstacles toward its societal realization.

In parallel, individuals in the U.S. are differentially prioritized in practice, if not in institutional principle, as observed through structured health inequities before and during the covid-19 pandemic. 20 Following #blacklivesmatter and #stopasianhate, for example, racial and ethnic minorities collectively protest cultural, legal, and social injustices. Meanwhile, Trump-era antiimmigrant legislation has devalued Latinx lives and placed them in search of sanctuary and respite from chronic stress. 21 Among non-Hispanic whites especially, a college divide in occupational and income inequality, and substance use and morbidity, fuels well-documented deaths of despair. 22 In general, the covid-19 pandemic has coexisted with many social inequities by race, gender, occupation, and socioeconomic status, such as through disproportionate disease, care, work, and financial burdens felt across America. 3 As a byproduct of these deepened inequities, society creates "recognition gaps," or variations in perceived dignity at the group and individual levels, based in perceived discrimination, exclusion, overwork, exposure to occupational hazard, or social disenfranchisement. 23 If a subjective measurement of dignity is to be pursued, group specificity is likely to matter fundamentally. 10, 14, 15 Systemic inequities inherent to pre-and during-pandemic American capitalism do not resolve a definitional pluralism of dignity, but rather provide a vivid context for appreciating it at a high level of abstraction, as particular social groups rally for rights, recognition, and fair treatment. 16 Societies are structured in ways that lead to certain groupspecific resources, discourses, or moral codes surrounding dignity and, beyond this, the concrete settings and resources within meaning-making transpires in ways that either confirm or challenge J o u r n a l P r e -p r o o f individuals' assessment of their own sense of dignity. 7, [9] [10] [11] [12] Existing qualitative research into dignity implies that it is defined, enabled, or achieved differently across social groups. These differing dignity conceptions reflect group-specific values, practices, or possibilities, among other structural factors, and different ways of anchoring self-worth across various social situations and communities. For instance, working-class dignification can be tied to manual or "honest" work, and middle-class dignification to traditional economic success or mobility. 10, 15, 19 Similarly, dignity is constructed differently for younger individuals facing uncertain futures and competition for good jobs than for older individuals who navigate or exist within medical or caregiving infrastructures; 24, 25 and across gender, race and political ideology due to differing experiences of obligation, discrimination, marginalization, or solidarity. [14] [15] [16] Higher-status positions in society come with their own strains and difficulties, such as overwork or workfamily conflict associated with professional occupations, as well. 26 However, on balance, these stresses at the top of social hierarchies have a far lesser impact on health, disease, and early death in the aggregate than do markers of strain, humiliation, disadvantage, or risky environmental exposures in lower socioeconomic strata. 5, 7, 14, 17, 18 Overall, a subgroup analysis should be placed at the forefront of any inquiry into associations between subjective dignity and individual health.

While social marginalization and discrimination stem from objective differences in life conditions across social groups, 5, 10, 19, 22, 23, 27, 28 dignity itself is fundamentally cultural and intersubjective, hardly defined in any strict sense by material conditions. 1, 9, 10 That is, it stems from collectively shared meanings, resources, or norms within social groups and individual lives.

While human rights and public health violations 1,2,3 and constitutional and criminal law 1,8,9 offer valuable points of departure for conceptualizing dignity, dignity must ultimately be understood J o u r n a l P r e -p r o o f and enacted by groups and individuals on an everyday or practical basis 10, 11 if it is to have broader value for society. In recognition of this fundamental fact, we contend in this study that dignity can and perhaps should be measured subjectively, by appealing to the word "dignity" itself as an element of public and personal culture used with different motivations. 12 Similar to how individuals deem themselves "happy" or as leading a "meaningful life" on the basis of how they personally understand happiness or life's meaning, 13 allowing individuals to interpret "dignity" for themselves circumvents philosophical, theoretical, and legal debates about the "true" meaning of dignity, towards a more pragmatic, 9 socially situated, 10 pluralistic, 8 and groupdifferentiated understanding of dignity, as advocated by sociological scholars of the concept.

Dignity might serve as an efficient, subjective indicator of moral and social integration. 5 As Michèle Lamont contends, there are many potential paths to dignity. 10, 15, 23 In this study, we take a group-based approach to establishing subjective dignity as a public health concern and a useful social indicator of broader societal events. Societal hierarchies are structured according to categorical memberships such as gender, race, education, age, geography, marital status, and other life-defining characteristics, [14] [15] [16] [17] [18] [19] and ethnographic work on worker dignity and dignity across different hierarchical groups attests to the group-based structuring of dignity. 10, 15, 24, 27, 28 Some assumed definitional correlates of dignity, such as abuse, violence, perceived discrimination, efficacy, autonomy, or mattering to others, have well-established associations with mental and physical health, 7, 13, 15, 17, 18, 29, 30, 31 leading to the reasonable expectation that subjective dignity could be associated with group-level differences in mental and physical well-being across the covid-19 pandemic. 

Well-Being: Depressive Symptoms Scale and Self-Rated Health. Across both years, a two-item depressive symptom index based on items from the Center for Epidemiologic Studies -Depression Scale is available. It asks respondents how often each of the following was true during the past week: "I felt depressed" and "I felt sad" (0 = "Never"; 0.33= "Hardly Ever"; 0.67= "Some of the time"; 1.00= "Most or all of the time"; items averaged). Additionally, self- (2017 only) (for all items, 1=strongly disagree, 2=disagree, 3=undecided/neither agree nor disagree, 4=agree, 5=strongly agree; reverse-scored as necessary to denote higher levels of dignity). We used all five items in 2017 to assess the proposed subjective dignity construct, because using only three items does not allow degrees of freedom for global fit testing of a confirmatory factor model. These items vary in the degree to which they characterize dignity as coming from within rather than without (i.e. "dignity-of-self" and "dignity-in-relation") 7 , so we began with an exploratory factor analysis. 32 In 2017, principle-components exploratory factor analysis identified one factor with eigenvalue = 1.688 (factor 2 eigenvalue = 0.144). All factor loadings ranged from 0.42 to 0.71. Confirmatory factor analysis with asymptotically distribution free (ADF) estimation to address response nonnormality and free covariances among conceptually similar items retained a one-factor solution against the observed covariancevariance matrix, χ 2 (2) = 1.663, p = .44, RMSEA=0.000, CFI=1.000, TLI=1.008, SRMR=0.011.

Having established that a one-factor model was consistent with the observed data in 2017, we proceeded to treat all items as belonging to the same subjective dignity scale across both survey years. Specifically, we used the three items available across both survey years for all analyses in J o u r n a l P r e -p r o o f this paper. Latent factor scores were generated and normalized across both years using Stata 17.0. In 2017, the three-item latent score correlates highly with the five-item latent score (r = .900). Appendix Table 1 displays a polychoric correlation matrix for the five items (mean correlation = .478).

Sociodemographic Variables. We rely on sociodemographic variables to construct subgroups for the dignity analysis. Age is measured in years, current marital status is indicated, as is living with a partner (yes or no); level of education is specified as highest degree attained, and last year's household income is midpoint-imputed within broad survey question brackets. Race and ethnicity is treated as self-identification as white, Black, Hispanic, Asian, or American Indian / Alaska Native. Urbanicity is queried on a four-point self-reported scale ranging from "a large city" or "a suburb near a large city" (classified as urban) to "a small city or town" or "a rural area" (classified as rural). Political affiliation ranged from "strong republican" to "leaning republican" (classified as republican) to "strong democrat" to "leaning democrat" (classified as democrat). Labor force status is treated as working full-time, working part-time, or not currently working.

We seek to characterize subjective dignity levels across different segments of society as defined by multiple social hierarchies. Relatedly, we also document that the predictive value of dignity for well-being or health is not specific to certain groups but rather carries across groups and across years (2017 and 2021). A multivariate approach ultimately would mask this because it is structured around principles of average or net effects which are driven disproportionately by J o u r n a l P r e -p r o o f groups with larger sample representation. Moreover, there are substantial intercorrelations among memberships in the different sociodemographic groups we cover, and we cannot properly explore these intercorrelations without bringing in intersectional theoretical approaches beyond the scope of this paper. Therefore, we conduct most of our analyses using a within-group, bivariate approach to dignity and its association with well-being.

We begin by summarizing mean levels of subjective dignity for 25 distinct sociodemographic groups, as well as for the entire national Gallup sample, across 2017 and 2021. These surveyweighted group means are tabulated by year, along with their group-specific, year-specific weighted sample sizes. Across years, we test for significant differences at the group level by pooling group-specific samples and then implementing a survey-weighted, within-group regression coefficient test for Year.

Next, we evaluate year-specific associations between subjective dignity and well-being for these same groups. We analyze the depressive symptoms scale and self-rated health separately. For each group-year combination, a bivariate, survey-weighted regression of well-being on dignity is estimated within a given group's subsample, and coefficients are reported. Between-year differences are tested by use of a Dignity × Year two-way statistical interaction term, which is added to the specification, along with a Year main effect, in a second, additional model that pools group-specific samples across survey years. Probability values from these Dignity × Year coefficient tests are reported in tables. To enable valid statistical comparison of association sizes between sample-wide and group-specific estimates, we employ linear modeling of depressive symptoms and self-rated health. 33 J o u r n a l P r e -p r o o f Finally, we estimate multiple regressions of depressive symptoms, and self-rated health, in which survey data is pooled from both years and sociodemographic covariates are held constant. Thus, these multiple regressions report adjusted or net associations for subjective dignity across the entire Gallup sample. Two regression equations are fitted for each well-being measure. The first equation treats the subjective dignity association as year-invariant, while a second equation specifies a Dignity × Year two-way interaction.

All regression models are weighted by the Gallup post-stratification weight variable to enhance national representativeness. In the multiple regression analysis, parameters are estimated by fullinformation maximum likelihood (FIML), which is an optimal procedure for dealing with missing data that is asymptomatically equivalent to multiple imputation. 34 FIML uses all available data from each case to estimate model parameters. Table 1 Table 1 , levels of dignity generally are higher in 2017 compared to 2021, as evidenced by the fact that all groups showed percentage decreases in their dignity levels across these years (ranging from -3.1 to -27.8%). For most groups, these decreases are statistically significant at p < .05. The subjective dignity decrease across all Gallup respondents is 12.0% or non-college-educated respondents (.487) compared to married respondents (.570). Comparing groups across years, numerous significant between-group differences are evident. Table 2 reports group-specific coefficients between depressive symptoms and subjective dignity. Table 3 reports group-specific coefficients between self-rated health and subjective dignity. Self- As also shown in Table 4 , the association of dignity with self-rated health net of demographic population across many demographic groups defined by education, income, gender, age, race, marital status, political party, and labor force status. Many of these same groups also showed consistent associations between subjective dignity and self-rated health. Our adjusted, multivariate estimates suggest that dignity associates with well-being at levels comparable to or exceeding income gaps, working full-time, college degree differences, race, or political affiliation, adding quantitative levels to a range of important qualitative treatments of dignity most often tied to work and social class, while suggesting arenas for further research.

Individuals from diverse social groups rely on situated and cultural meanings, norms, and resources to determine whether their lives are dignified, helping to explain both the overall decline and the increased heterogeneity in dignity levels that we documented from 2017 to 2021. Rather than impose an academic limit on the nature of dignity, our measure allows respondents to draw on their own situated understandings of self, expectations, and moral desert to efficiently capture a range of social phenomena within three simple items.

In addition to these national associations with well-being across the pandemic, dignity as a term carries resonance and overlap with high-profile public health issues in multiple respects.

However, these more conceptual interpretations are made with the understanding that groupspecific understandings of dignity will need to be properly explicated by future research. First, following epidemiological characterizations of deaths of despair, 22 we find that low-income, rural, and non-college educated respondents report some of the lower or lowest levels of dignity, and sometimes increased associations between dignity and depressive symptoms from before the covid-19 pandemic. Second, while a Black-white paradox in mental health is well-documented, 35 so too is the elevation of racial inequality in America across the pandemic due to staggering community and work-based differences in pandemic vulnerability. Perhaps accordingly, Blacks show a relatively high level of dignity before the pandemic and a marked decrease across the pandemic and its related, prominent social movement events. Third, the burden of childcare, household tasks, and informal elder care has fallen disproportionately on women before and especially during the pandemic, as have psychological costs of opting out of full-time work, 36 which is consistent with a near-doubled association between dignity and depressive symptoms for women from before to during the pandemic, as well as women's significant decline in dignity from 2017 to 2021 compared to men's. While a more compelling investigation of gender disparities in dignity would need to jointly account for marital status, spousal employment, coresidential children, and elderly parents, for example, gender inequality still is so pervasive across the domestic, parental, and work realms that these results may hardly be surprising.

Fourth, adults aged 70 or older showed relatively high declines in dignity across the pandemic, consistent with the great tolls the pandemic has taken on those who live with health or mobility limitations, and perhaps the group least used to digital maintenance of social ties. This group also J o u r n a l P r e -p r o o f showed the highest increase in associations with depressive symptoms from 2017 to 2021 of all groups investigated, but this difference was not statistically significant due in part to a nonsignificant association observed in 2017. Fifth, associations between dignity and well-being were consistent across partisan lines, which falls in line to a universal valuation of individual rights even at a time of political polarization. Democrats showed a somewhat larger decrease in dignity across the pandemic than did Republicans, which could indicate their larger representation among or identification with socially vulnerable groups, although their dignity decrease (-17%) was not statistically different from the decrease observed among Republicans (-10%).

Generally, associations between dignity and health were more reliableand reliably increasing across the pandemicfor depressive symptoms than for self-rated health. This suggests that subjective dignity may bear a more direct association with mental health than with physical health, like what has been documented for psychosocial resources such as mastery, social support, and self-esteem. 7, 13 In other research, we are examining the statistical and factor independence of subjective dignity against mastery, mattering, resilience, and other psychosocial constructs. Indeed, mastery and self-efficacy also carry strong associations with mental health.

While we cannot unpack all our tabulated findings piece-by-piece, our examples are meant as illustrative rather than exhaustive or conclusive. We recognize that some group trends might defy common expectations. For instance, the decline of only 3% in subjective dignity for Asian-Americans from 2017 to 2021 could be interpreted in terms of changing solidarity within this community or as a form of group-affirming boundary work at a time of historically high rates of anti-Asian violence in America. 10 The fact that subjective dignity correlates with well-being across a variety of demographic groups, even if declines in dignity seem unusual in view of J o u r n a l P r e -p r o o f objective atrocities confronting these groups, might signify a universalistic value of dignity for human flourishing that can be confirmed by future, longitudinal research into the topic.

Namely, our organizing framework for subjective dignity, for which we have offered a preliminary exploration using national Gallup data, specifies that, because a variety of social science, legal, and public health scholars have advanced group-specific understandings of social inequities, dignity must: (1) remain flexible to group-specific or pluralistic senses of the term; and (2) remain flexible to the possibility that observed, group-specific levels of dignity reflect (i) objective social conditions, (ii) subjective interpretations of these same conditions; and/or (iii) socially constructed, possibly dynamic understandings of what dignity means. All of these points fit into our innovative approach to conceptualizing and measuring dignity as a subjective construct, which we argue is long-overdue given the major definitional issues inherent to the concept and in view of the ethnographic and social-theoretic research programs revealing the fundamentally group-oriented and socially constructed nature of dignity.

According to the wide distribution of dignity levels and associations between health and wellbeing that we observe across the 2017 and 2021 Gallup data, we believe that a fundamental tension exists between inherent dignitythe philosophically derived basis for democratic equality and citizenshipand its societal realization. These pre-and during-pandemic epidemiological findings add to ethnographic research into dignity as an intellectual, theoretical concept, which is separate from lay understandings of dignity within individual lives. While current conditions certainly can uphold a sense that one is in fact a whole or deserving person in society, it also is possible that dignity carries origins in a deeper, firsthand knowledge about systemic oppressions, gained by women, Blacks, and other marginalized individuals through continued dealings with discrimination or injustice. 28, 37 Shifts in dignity could indicate dynamic J o u r n a l P r e -p r o o f shifts in political, economic, or social circumstances, which can be difficult to measure.

There are several limitations to this analysis of Gallup national data. First, while the 2017 Gallup survey confirmed that a one-factor subjective dignity scale is supported in a national sample, this does not rule out the possibility that specific dignity items may carry conceptual or empirical overlaps with perceived discrimination, self-efficacy, mattering, or other constructs discussed earlier. Second, the data are cross-sectional, leaving unclear the time ordering between dignity levels and levels of mental or physical health. For instance, feelings of worthlessness that are common with depression could lead to lower dignity scores, or serious health problems that are especially common among those with fair or poor physical health could lead to foregone autonomy or stigmatization due to disability or incapacitation. 7 If lowered subjective dignity depletes self-rated health, it then is a risk factor for morbidity and death. If, reciprocally, new mental or physical health issues lead to lowered levels of dignity, through the compromising of bodily or physical functioning, then these associations may be self-reinforcing and especially important as an intervention target. Advocates of "dying with dignity" already have noted interconnections among bodily and psychological dignity. 25 Third, the group-specific or precise underpinnings of dignity remain unclear; a more comprehensive analysisfor example among the non-college educated, racial or ethnic minorities, women, or the elderly, as outlined abovecould begin to disentangle dignity effects If implemented as a public health measure, subjective dignity could allow for idiosyncrasies in the situated, social standards individuals may use to determine their own sense of how they are treated socially despite, or tragically because of, profound structural oppressions that linger in modern democratic society. Asking individuals how they perceive particular issues, resources, norms, or relations within their lives does not automatically add up to a holistic assessment of whether their lives are dignified, a point made by leading scholars on dignity. Given how subjective appraisals operate across time, biography, history, culture, and imagined futures, these brief dignity items hold promise of measurement flexibility across these immense inputs to subjectivity, while also offering a new, robust avenue for relating modern, diverse individualities to health inequities.

Even as situated understandings of dignity vary across individuals or social groups, we contend that dignity itself still can serve as an efficient social indicator. 5 As one way to begin rectifying Note. Bivariate, within-group associations between depressive symptoms and subjective dignity shown by demographic group and by year. Estimated using Gallup survey weighting with linearized standard errors. 95% confidence intervals shown. Reference line drawn at 0 (to denote cutoff for non-significant association with alpha = 0.05). Dignity and depressive symptoms are normalized to range from 0 to 1. Note. Bivariate, within-group associations between depressive symptoms and subjective dignity shown by demographic group and by year. Estimated using Gallup survey weighting with linearized standard errors. 95% confidence intervals shown. Reference line drawn at 0 (to denote cutoff for non-significant association with alpha = 0.05). Dignity and self-rated health are normalized to range from 0 to 1.

J o u r n a l P r e -p r o o f

Dignity: Its History and Meaning

Universal declaration of human rights

Syndemic vulnerability and the right to health

Respect for human dignity as 'substantive basic norm'

The idea of dignity: its modern significance

Dignity and health: a review

Is democracy possible here?

Human dignity in concept and practice

Getting respect: Responding to stigma and discrimination in the United States, Brazil & Israel

The presentation of self in everyday life

Improving cultural analysis: considering personal culture and its declarative and nondeclarative modes

Reimagining health-flourishing

Social justice, epidemiology and health inequalities

The dignity of working men

Global capitalism as a societal determinant of health: a conceptual framework

Cultural trauma as a fundamental cause of health disparities

Health power resources theory: A relational approach to the study of health inequalities

Inequality in the 21 st century

COVID-19-the historical lessons of the pandemic reinforce systemic flaws and exacerbate inequality

An ecological expansion of the adverse childhood experiences (ACEs) framework to include threat and deprivation associated with U.S. immigration policies and enforcement practices: an examination of the Latinx immigrant experience

Deaths of Despair and the Future of Capitalism

From 'having' to 'being': self-worth and the current crisis of American society

Coming up short: working-class adulthood in an age of uncertainty

An integrative review of dignity in end-of-life care

Discovering pockets of complexity: socioeconomic status, stress exposure, and the nuances of the health gradient

Class, control, and relational integrity: labor process foundations for workplace humiliation, conflict, and shame

Recognizing dignity: young black men growing up in an era of surveillance

Parents' adverse childhood experiences and their children's behavioral health problems

Construct validation of the self-efficacy scale

Racial differences in physical and mental health: Socio-economic status, stress, and discrimination

Principles and practice of structural equation modeling

What do we rate when we rate our self-rated health? Decomposing age-related contributions to self-rated health

Handling missing data by maximum likelihood

Is the black-white mental health paradox consistent across gender and psychiatric disorders?

Women and health: the key for sustainable development

Note. Items reverse-scored such that higher levels indicate or suggest greater dignity.

☐ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Matthew A Andersson reports was provided by Baylor University.J o u r n a l P r e -p r o o f