Is the mediating effect of psychosocial stress on the income-health relationship moderated by income inequality?

Background: There now exists a rich body of literature on the relationship between income, income inequality, and health. The discussion about the impact of income and income inequality on health includes psychosocial mechanisms, such as long-term perceptions of inferiority and social positioning, material advantage from income, and the structural conditions that define what people can do with their material resources. Aims: This study investigated the extent to which income's effects on health are mediated by psychosocial stress, and to what extent those effects are moderated by country-level income inequality and economic development. Methods: Data were collected from The European Social Survey, round 7. Multilevel moderated mediation analysis was applied to estimate the extent of psychosocial stress mediation of the effects of income on self-rated health. Moderated parameters were estimated over country-level income inequality and economic development. Results: Significant full or partial meditation by psychosocial stress was found in all 20 countries studied. Effects moderated by income inequality and GDP per capita showed expected relationships but failed to reach conventional levels of statistical significance. Conclusions: Individual-level income remains important for explaining the income-health gradient in self-rated health in Europe. The income-health relationship and the extent to which it is mediated by psychosocial stress varies among countries but is not significantly moderated by contextual income or income inequality. Policies should be aimed at allowing a greater proportion of people to live in material comfort and reduced sense of financial precarity, and protecting individuals from harmful consequences of low income.