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Contents Previous (Section 8.) Next (Section 10.)

9. Questions on socio-economic status

Prevalence of several cardiovascular disease risk factors (hypertension, obesity, ect.) is known todiffer by socio-economic status. People with lower socio-economic status are generally morelikely to be e.g. obese (1) and hypertensive (2).

Socio-economic status can be assessed by a set of questions about the educational achievement,income and occupation.

9.1 Questions

International standardization of questions about socio-economic status is difficult. There areproblems in developing internationally comparable measures of educational level, since theeducational systems vary so much between different countries. In international studies, one of the most commonly used indicators for educational achievement has been "total years of schooling". Obviously, there are also problems with this indicator. Simply counting years doesnot fully reflect educational level, even within an educational system. For example, highly giftedchildren may skip school grades and achieve graduation with fewer years of schooling, oralternatively, some students may have to repeat one or more grades and accumulate more years

before graduating. The problem becomes worse when using the number of years of schooling tocompare educational achievements between education systems. Also, in multinationalcomparisons it is always a problem to develop wording of the questions in the local languagessuch that they produce comparable results.

Assessing socio-economic status by income raises the question of how to measure income. It isonly straight forward to assign a monetary value to income, if a person's income is all derivedfrom employment, social assistance, pension etc.. Even if a numerical value can be assigned to

income, its relation to socio-economic status can only be appreciated if it is set in relation to thecost of living, which can be different from region to region within a country and it usually differsbetween countries.

An other frequently employed indicator for socio-economic status is occupation. Forinternational comparisons, this indicator may pose a problem with occupations that are peculiar


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to a particular society. Also, the social ranking of an occupation may differ from one society tothe next. Finally, even within a society an occupation can cover a large range of social standing,e.g. the occupation "lawyer" is equally applicable to a high-power corporate lawyer as well asone who is subsisting as a public defender for the indigents.

As a result of these difficulties, one indicator by itself is usually not enough to adequatelycharacterize socio-economic status.

9.1.1 The WHO MONICA Project

In the WHO MONICA Project (3) only information about the educational achievement wascollected using following two questions:

1. "What is the highest level of education you have completed?"

1 = university or college or equivalent

2 = intermediate between secondary level and university (e.g. technical training)

3 = secondary school

4 = primary school only (or less)

9 = insufficient data |__|

2. "How many years have you spent at school or in full time study?"

99 = insufficient data |__|__|

For the Question 1 the MONICA Manual (3) gives the additional instructions:

Codes 1, 2 and 3 are self-explanatory. The lowest code should take precedence.

Code 4 if primary school only or if less than primary school.

Code 9 for insufficient data.

9.1.2 Risk factor monitoring in the Netherlands


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In the MORGEN Project in the Netherlands, education was estimated from the question "What isthe highest level of education that you have completed"? with response categories primaryeducation (or less), lower occupational education, secondary level education, higher occupationalor equivalent education, university education. (4)

9.1.3 Risk factor monitoring in Germany

The German Federal Health Survey 1998 had a 107-question instrument that included sectionson elementary level schooling (eight choices), occupational or university education (eightchoices), employment status (6 choices), occupations status (19 choices), job stress (5 choices),and category of household income (13 levels). (5).

1. What level of schooling did you complete? If more apply, select the highest one.

Elementary school

Middle school

10-year poly-technical high school

Advanced professional college

High school with university entrance qualification

Other graduation

School with no graduation

Not yet graduated

|__|

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2. Do you have completed occupational or university education? If more apply, select thehighest one

Apprenticeship

Trade schoolProfessional college

Advanced professional college

University

Other professional training

No professional training completed

Not yet in professional training|__|

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3. Which of the following statements about occupational status apply to you?

Not working at the moment

Part-time or hourly work (< 15 hours per week)

Part-time work (15 to 34 hours per week)

Full-time work

On temporary leave (education leave, public service leave)

In training (apprentice)


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4. Does any of the following statements apply to your present situation?

In school

In university

In age-related retirement

In early retirement

Unemployed

Exclusively house wife/ house man

In military/community/voluntary social service

In retraining

None of the above apply

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5. If you are presently not working. Did you ever work before?

No Go to question 10.

Yes

Since when are you no longer working

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Since |__||__|(month)19|__||__|(year)

6. How many months during the past five years were you without work?

Altogether

Does not apply

|__||__| months without work

|__|

7. In what occupational capacity are you presently working or (of no longer working) inwhat occupation did you last work?

Specify exact job title ___________________________________________________

8. What is your present occupational position or (if no longer working) was your lastposition?

Laborer:

unskilled

trained on the job

skilled

foreman

Self-employed:

independent or co-op farmer


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professional or independent academic

independent with up to 9 employees

independent with 10 or more employees

Employee:

industrial foreman with some management responsibility

in regular position (sales person, typist)

with special qualifications (e.g. draftsperson, book keeper, accounts specialist)

in highly specialized position (e.g. division head, scientist)

in leadership position (e.g. director, president of larger corporation)

Civil servant (including judges and professional soldiers):

lower level service

middle level service

higher lever service

upper level service

Other:

trainees, students, conscripts, ect.

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9. If you are not presently working go to question 10, else, is your job characterized by:

Do you perceive it as a health threat


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No Yes No Yes

Heavy physical labor |__| |__| |__| |__|

Noise, dust, gases, vapors, "polluted" air |__| |__| |__| |__|

Work stress (time pressure, concentration), worry about job security |__| |__| |__||__|

Overtime, long working hours |__| |__| |__| |__|

Shift work/night shift

shift work without night shift

shift work with night shiftalways night shift

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|__|

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How long have you been doing that work |__||__| years |__||__| months

10. In what job position is your partner at present

Laborer:

unskilled

trained on the job

skilled

foreman

Self-employed:

independent or co-op farmer

professional or independent academic

independent with up to 9 employees

independent with 10 or more employees

Employee:

industrial foreman with some management responsibility

in regular position (sales person, typist)

with special qualifications (e.g. draftsperson, book keeper, accounts specialist)

in highly specialized position (e.g. division head, scientist)

in leadership position (e.g. director, president of larger corporation)


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Civil servant (including judges and professional soldiers):

lower level service

middle level service

higher lever service

upper level service

Other:

trainees, students, conscripts, ect.

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11. What is the monthly household income, net income after taxes and fringe benefitdeductions

< 1.000 DM

1.000 to < 1,500 DM

1,500 to < 2,000 DM

2,000 to < 2,500 DM

2,500 to < 3,000 DM

3,000 to < 3,500 DM

3,500 to < 4,000 DM

4,000 to < 4,500 DM

4,500 to < 5,000 DM

5,000 to < 6,000 DM


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6,000 to < 8,000 DM

8,000 to < 10,000 DM

10,000 and more

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9.1.4 UK National Health Surveys

Questions used in the 1998 Health Survey for England (6) about the educational level are asfollows:

1. At what age did you finish your continuous full-time education at school or college?

1. Not yet finished

2. Never went to school

3. 14 or under

4. 15


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5. 16

6. 17

7. 18

8. 19 or over |__|

2. Do you have any of the qualifications listed on this card? (See Question 3 for the list)

1. Yes (Go to Question 3)

2. No |__|

3. Which of the qualifications on this card do you have?

1. Degree/degree level qualification (including higher degree)

2. Teaching qualification

3. Nursing qualifications SRN, SCM, SEN, RGN, RM, RHV, Midwife

4. HNC/HND, BEC/TEC Higher, BTEC Higher/SCOTECH Higher

5. ONC/OND/BEC/TEC/BTEC not higher

6. City and Guilds Full Technological Certificate

7. City and Guilds Advanced/Final Level

8. City and Guilds Craft/Ordinary Level

9. A-levels/Higher School Certificate

10. AS level

11. SLC/SCE/SUPE at Higher Grade or Certificate of Sixth Year Studies

12. O-level passes taken in 1975 or earlier

13. O-level passes taken after 1975 GRADES A-C

14. O-level passes taken after 1975 GRADES D-E

15. GCSE GRADES A-C

16. GCSE GRADES D-G

17. CSE GRADES 1/SCE BANDS A-C/Standard Grade LEVEL 1-3


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18. CSE GRADES 2-5/SCE Ordinary BANDS D-E

19. CSE Ungraded

20. SLC Lower

21. SUPE Lower or Ordinary

22. School Certificate or Matric

23. NVQ Level 5

24. NVQ Level 4

25. NVQ Level 3/Advanced level GNVQ

26. NVQ Level 2/Intermediate level GNVQ

27. NVQ Level 1/Foundation level GNVQ

28. Recognised Trade Apprenticeship completed

29. Clerical or Commercial Qualification (e.g. typing/book-keeping/commerce)

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3. Do you have any qualifications not listed on this card?


2. No |__|

4. What qualifications are these?

Above questions are asked from the respondents aged 16 to 120 years.

Questions about the income in the household questionnaire (6) are:

1. Which kind of income you (and your husband/wife/partner) receives?


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1. Earning from employment or self-employment

2. State retirement pension

3. Pension from former employer

4. Child benefit

5. Job-Seekers allowance

6. Income Support

7. Family Credit

8. Housing Benefit

9. Other state benefits

10. Interest from savings and investments (e.g. stocks & shares)

11. Other kinds of regular allowance from outside your household (e.g. maintenance, student'sgrants, rent)

12. No source of income |__|

2. Which of the groups represents your and your husband/wife/partner's) income from allthese sources before any deductions for income tax, National Insurance, etc.?

(Show card with 31 alternatives for weekly, monthly or annual income) |__||__|

3. Does anyone else in the household have an income from any source?

1. Yes

2. No |__|

4. Which of the groups represents the total income of the whole household beforedeductions for income tax, National Insurance, etc. ?

(Show card with 31 alternatives for weekly, monthly or annual income) |__||__|

Questions about the occupation in the personal questionnaire (6) are:

1. What is (was/will be) the name or title of the job?

2. Are you (were you/will you be) working full-time or part-time?


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1. Full-time

2. Part-time |__|

3. What kind of work do (did/will) you do most of the time?

4. What materials or machinery do (did/will) you use?

5. What skills or qualifications are (were) needed for the job?

6. Are you (were you/will you be)?

1. An employee (Go to Question 7)

2. Self-employed |__|

7. Are you a Director of a limited company?

1. Yes

2. No |__|

8. Are you?

1. Manager

2. Foreman or supervisor

3. Other employee |__|

9. Including yourself, about how many people are (were) employed at the place where youusually work (usually worked/will work)?

1. 1 or 2

2. 3-24

3. 35-499

4. 500+ |__|

10. What does (did) your employer make or do at the place where you usually word (usuallyworked/will work)?

11. What do (did/will) you make or do in your business?

9.1.5 National Health and Nutrition Examination Survey (NHANES III), USA


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4. During the last month did anyone in the family receive Security or Railroad Retirementpayments?

1. Yes

2. No (Go to Question 8)9. Don't know (Go to Question 8) |__|

5. Who was that?

6. Anyone else?

1. Yes (Re-ask Questions 5 and 6)

2. No

7. Record a separate answer for each person less than 65 answering YES for Question 4.What is the reason -- is getting Social Security or Railroad Retirement?

1. Retired

2. Disabled

3. Widowed

4. Surviving child

5. Spouse

6. Dependent child

9. Don't know |__|

8. During the last month did anyone in the family receive any SSI (Supplemental SecurityIncome) payments from the Federal Government?

1. Yes

2. No (Go to Question 11)

9. Don't know (Go to Question 11) |__|

9. Who was that?

10. Anyone else?



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2. No |__|

11. During the last month did anyone in the family receive any pension or disability paymentother than Social Security or Railroad Retirement?

1. Yes2. No (Go to Question 14)


12. Who was that?

13. Anyone else?


2. No |__|14. During the last month, did anyone in the family receive Public assistance or welfarepayments from the State or Local welfare office? Do not include SSI.

1. Yes



15. What was that?

16. Anyone else?


2. No |__|

17. During the last month, did anyone in the family receive 'Aid to Families with DependentChildren', sometimes called AFDC or ADC.

1. Yes



18. Who was that?

19. Anyone else?


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2. No |__|

20. During the last month, did anyone in the family receive income from any other source

such as veteran's payments, workman's compensation, rental income, interest and dividendincome, or child support and alimony?

1. Yes



21. Who was that?

22. Anyone else?


2. No |__|

23. Including wages, salaries, self-employment, and any other source of income we justtalked about, was the total combined family income during the last 12 months

1. Less than $20,000

2. $20,000 or more

0. No income (End this section) |__|

24. Show card with 30 income groups.

Of those income groups, which letter better represents the total combined family income duringthe last 12 months? Include all sources of income we just talked about.

|__|

25. Show card with 24 income groups.

Now, please think about your family income during (name of last month). Which letter bestrepresents the total combined income during (name of last month). Again, include all sources of income we just talked about.


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|__|

The questions for occupation in the household family questionnaire were meant for the head of

the family and were as follows (7):1. Check item

1. Head of family is an SP (End this section)

2. Head of family not an SP (ask Questions 2-12 for head of family)

3. Head of family active military living at home (Question 10) |__|

2. During the past 2 months did -- work at a job or business, not counting work around thehouse?


2. No |__|

3. Even though -- did not work during those 2 weeks, did -- have a job or business?

1. Yes

2. No |__|

4. Was -- looking for work or on layoff from a job?

1. Yes

2. No (Go to Question 6) |__|

5. Which, looking for work or on layoff from a job?

1. Looking (Go to Question 8)

2. Layoff (Go to Question 7)

3. Both (Go to Question7) |__|

6. Check item. Mark only if 'NO' in Question 4.

1. 'Yes' in Question 3 (Go to Question 7)

2. 'No' in Question 3 (Go to Question7) |__|

7. For whom did --- work?


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Enter name of company, business, organization, or other employer.

Record response and skip to Question 9.

8. For whom did -- work at -- last full-time civilian job or business lasting 2 consecutive

weeks or more?Enter name of company, business, organization, or other employer.

9. What kind of business or industry is this? (For example, TV and radio, manufacturing,retail shoe store, State Labor Department, farm.)

10. What kind of work was -- doing? (From example, electrical engineer, stock clerk, typist,farmer.)

11. What were --'s most important activities or duties at that job? (For example, types, keepsaccount books, files, sells cars, operates printing press, finishes concrete.)

12. Complete from entries in Question 7 thru 11. If not clear ask:

Was --

01. an employee of a private company, business or individual for wages, salary or commission?

02. a federal government employee?

03. a state government employee?04. a local government employee?

self-employed in own business, professional practice, or farm?

IF NOT FARM, ASK: Is the business incorporated?

05. Yes

06. No

07. working without pay in business or farm?

08. ARMED FORCES

00. never worked or never worked at a full-time civilian job lasting 2 weeks or more


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|__||__|

9.1.6 Norwegian Age-40 Programme

The questionnaire of the Norwegian Age-40 Programme inquiries about employment status andeducation.

Social security benefits

1. Do you now receive any of the following social benefits

Sick leave

Rehabilitation allowanceDisability pension (full time or partial)

Unemployment benefit

Yes

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|__| No

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2. Is house-keeping your main occupation (answer No if you are working 18 hours or moreper week for salary)

Yes

No

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|__|

Education

1. What level of education have you completed?

Primary school (less than 7 years)

Junior high school (7-10 years)

High school (occupational)

High school (university entrance qualification)

University (less than 4 year bachelor)

University (4 or more years)

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9.2 Quality assurance

9.2.1 Retrospective quality assessment report

WHO MONICA Project

The detailed description of the availability and quality of data on education achievement aredocumented in the Quality Assessment of Data on Marital Status and Educational Achievementin the WHO MONICA Project (8).

Educational level


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The categories for educational level did not have the same meaning in every population. Also inmany populations the question changed between surveys. (8)

Years of schooling

The question about the years of schooling is similar to the MONICA question in almost all localquestionnaires. In two populations the question did not explicitly define that the question is aboutthe "full time study". The question stayed same from survey to survey in most populations. (8)

Educational level and years of schooling

There is big difference in mean years of schooling for different educational levels in differentpopulations. The mean years of schooling at primary school level varied from 3.2 years up to14.6years. At the secondary school level the variation was from 7.6 years to 14.6 years, at theintermediate level from 10.2 year to16.8 years and at the university level from 9.5 year to 21.8years. (8)

9.3 Indicators used for reporting the results

WHO MONICA Project

In the WHO MONICA Project the results from educational levels are reported using means,median and tertiles of the years of schooling (9, 10).

Risk factor monitoring in the Netherlands

In the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands,educational level was divided into three categories: low, intermediate and high (11).


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No details were found for health surveys in Germany, UK National Health Surveys, andNHANES III.

9.4 Discussion and conclusions

All surveys that included questions about the socio-economic status collected information oneducational level. Most surveys also included questions about family income and occupation of the survey respondent or head of the family.

When assessing the educational achievement, two types of questions are used; years spent in fulltime education and categories of educational levels. In MONICA, the levels of educational werefound difficult to interpret as they had different meaning in different countries . That is why theyears spent in full time schooling are more frequently used when educational levels betweendifferent countries are compared.

Both the UK National Health Surveys and NHANES III asked about the family income usingcategorized income groups.

The European Commission Health Monitoring Program has a separate project which focuses onsocio-economic issues. This "Socio-economic Inequalities in Health" project has submitted itsfinal report to the EC in February 2001. The report recommends that educational level, incomeand occupation should be used for the monitoring purposes.

References

Seidell JC. Obesity in Europe. Obes Res 1995;3 Suppl 2:89s-93s.

Brezinka V, Padmos I. Coronary heart disease risk factors in women. Eur Heart J1994;15(11):1571-84.


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WHO MONICA Project. MONICA Manual. Part III: Population Survey. Section 1:Population survey data component. (1997). Available from:URL:http://www.ktl.fi/publications/monica/manual/part3/iii-1.htm, URN:NBN:fi-fe19981151

Blokstra A, Burns CM, Seidell JC. Perception of weight status and dieting behaviour in Dutch

men and women. Int J Obes Relat Metab Disord 1999;23(1):7-17.

Robert Koch Institut. Bundes-Gesundheitssurvey 1998. Questionnaire. Berlin; 1998.

The Stationary Office. Health Survey of England, Cardiovascular disease. Volume 1:Findings; Volume 2: Methodology & Documentation. 1999. Available from:URL:http://www.official-documents.co.uk/document/doh/survey98/hse98.htm

U.S. Department of Health and Human Services. Plan and operation of the third NationalHealth and Nutrition Examination Survey, 1988-1994. Vital and Health Statistics, 1994; Series 1,No. 32. 1994. Available from: URL:http://www.cdc.gov/nchs/data/srl_32.pdf

Molarius A, Kuulasmaa K, Moltchanov V, Ferrario M, for the WHO MONICA Project.Quality assessment of data on marital status and educational achievement in the WHO MONICAProject. (1998). Available from: URL:http://www.ktl.fi/publications/monica/educ/educqa.htm,URN:NBN:fi-fe19991078

Molarius A, Seidell JC, Sans S, Tuomilehto J, Kuulasmaa K. Educational level, relative bodyweight, and changes in their association over 10 years: an international perspective from theWHO MONICA Project. Am J Public Health 2000;90(8):1260-8.

Tolonen H, Kuulasmaa K, Ruokokoski E, for the WHO MONICA Project. MONICAPopulation Survey Data Book. (2000). Available from:URL:http://www.ktl.fi/publications/monica/surveydb/title.htm, URN:NBN:fi-fe20001206

Verschuren W, van Leer E, Blokstra A, Seidell J, Smit H, Bueno de Mesquita H, de Oberman-Boer G, Kromhout D. Cardiovascular disease risk factors in the Netherlands. Neth J Cardiol1993;6:205 10.

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