Contents lists available at ScienceDirect SSM - Population Health journal homepage: www.elsevier.com/locate/ssmph Article Relative deprivation and its association with health indicators: Lower inequality may not improve health Asena Caner a,∗ , Yenal Can Yiğit b a TOBB University of Economics and Technology, Department of Economics, Sogutozu Cad. No. 43, Sogutozu, Ankara, 06560, Turkey b TOBB University of Economics and Technology, The Directorate of Financial Afairs, Sogutozu Cad. No. 43, Sogutozu, Ankara, 06560, Turkey ARTICLE INFO JEL classifcation: I14 I12 Keywords: Yitzhaki index Inequality Self-rated health Chronic illness Smoking ABSTRACT This study tested the hypothesis of relative deprivation (RD) to investigate how inequality is associated with health and health related behaviors in a developing country context. Data from two nationally representative surveys in 2010, 2012, and 2014 were used to estimate logit and ordered logit models stratifed by sex. RD was calculated based on both income and education, unlike most studies in the earlier literature that relied only on income. All results of the study were found to be robust to alternative reference groups. First, consistent with the earlier literature, RD was found to be positively correlated with indicators of poor health. Secondly, and more interestingly, unlike the results in the earlier RD literature, women with more income or education (and lower RD) were found to be more likely to be current smokers and more likely to consume a higher number of ci- garettes. The main policy implication is that reducing inequality can help improve self-rated health indicators, but it will not be sufcient to achieve health policy goals. Unless smoking patterns change, reducing inequalities in income or education among women will not necessarily lead to better health; because smoking is more common among better educated and richer women. 1. Introduction Understanding the association between inequality and health out- comes is important in designing policies that aim to improve public health. The literature on the socioeconomic determinants of health provides us with a large number of studies which suggest that in- equality has adverse consequences for health (Subramanyam, Kawachi, Berkman, & Subramanian, 2009; R. Wilkinson & Pickett, 2011; Richard G Wilkinson & Pickett, 2006). One explanation ofered in the literature about why inequality damages health is the relative deprivation (RD) hypothesis (Adjaye-Gbewonyo & Kawachi, 2012; Kawachi & Kennedy, 1999; Smith, Pettigrew, Pippin, & Bialosiewicz, 2012; Wilkinson, 1997). The idea behind this hypothesis is that an individual's health or health related behavior is determined both by his own resources (such as own income or educational attainment) and by his relative position in terms of these resources (i.e., how much others have versus how much he has). The concept of RD is based on the feeling of being deprived of something while others have it (Runciman, 1966, p. 10). Higher inequality in socioeconomic status generates a higher sense of RD. People compare themselves to those in their reference group and if they feel disadvantaged they experience a sense of RD. In theory, there are two channels through which RD may afect one's health: Material pathway and psychosocial pathway. In the material pathway channel, RD limits one's access to goods, services, and social activities such as employment or social networks that represent the standards of living in a society and thereby adversely afects one's health. In the second channel, increased inequality produces shame, frustration and stress among those who are relatively deprived, leading to negative health impacts (Adjaye-Gbewonyo & Kawachi, 2012; Kuo & Chiang, 2013; Lhila & Simon, 2010; Sweet, 2011; Åberg Yngwe, Fritzell, Lundberg, Diderichsen, & Burström, 2003). According to psy- chosocial theory, psychological stress may impact mental or physical well-being either directly, or indirectly via health behaviors (e.g. sub- stance use) (Elstad, 1998; R. Wilkinson & Marmot, 2003; Wilkinson, 1997). Evidence suggests that social deprivation is associated with high rates of smoking and low rates of quitting (Wilkinson & Marmot, 2003). A large literature examined the link between RD and health, relying https://doi.org/10.1016/j.ssmph.2019.100381 Received 13 August 2018; Received in revised form 20 February 2019; Accepted 3 March 2019 The authors are thankful to the Turkish Institute of Statistics (TurkStat) for granting permission to use micro-data from the SILC and the Health Surveys. They are grateful to Cengiz Erdoğan and Mehmet Günal for answering numerous questions on the data. Comments and suggestions from Dilek Kılıç, Ozan Ekşi, and careful review of two anonymous referees are highly appreciated. ∗ Corresponding author. E-mail addresses: acaner@etu.edu.tr (A. Caner), ycyigit@etu.edu.tr (Y.C. Yiğit). SSM - Population Health 7 (2019) 100381 2352-8273/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). T