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Prevalence of several cardiovascular disease risk factors (hypertension, obesity, ect.) is known to differ by socio-economic status. People with lower socio-economic status are generally more likely 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.
International standardization of questions about socio-economic status is difficult. There are problems in developing internationally comparable measures of educational level, since the educational 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 does not fully reflect educational level, even within an educational system. For example, highly gifted children may skip school grades and achieve graduation with fewer years of schooling, or alternatively, 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 to compare educational achievements between education systems. Also, in multinational comparisons it is always a problem to develop wording of the questions in the local languages such that they produce comparable results.
Assessing socio-economic status by income raises the question of how to measure income. It is only straight forward to assign a monetary value to income, if a person's income is all derived from 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 the cost of living, which can be different from region to region within a country and it usually differs between countries.
An other frequently employed indicator for socio-economic status is occupation. For international comparisons, this indicator may pose a problem with occupations that are peculiar to a particular society. Also, the social ranking of an occupation may differ from one society to the 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 as one 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 adequately characterize socio-economic status.
In the WHO MONICA Project (3) only information about the educational achievement was collected 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 |
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| 2. | "How many years have you spent at school or in full time study?" 99 = insufficient data |
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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.
In the MORGEN Project in the Netherlands, education was estimated from the question "What is the highest level of education that you have completed"? with response categories primary education (or less), lower occupational education, secondary level education, higher occupational or equivalent education, university education. (4)
The German Federal Health Survey 1998 had a 107-question instrument that included sections on elementary level schooling (eight choices), occupational or university education (eight choices), 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 the highest one Apprenticeship Trade school Professional 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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| 6. | How many months during the past five years were you without work? Altogether Does not apply |
|__||__| months without work |__| |
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| 7. | In what occupational capacity are you presently working or (of no
longer working) in what occupation did you last work? Specify exact job title ___________________________________________________ |
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| 8. | What is your present occupational position or (if no longer
working) was your last position? Laborer: Self-employed: Employee: Civil servant (including judges and professional soldiers): Other: |
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| 9. | If you are not presently working go to question 10,
else, is your job characterized by:
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| 10. | In what job position is your partner at present Laborer: Self-employed: Employee: Civil servant (including judges and professional soldiers): Other: |
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| 11. | What is the monthly household income, net income after taxes and fringe
benefit deductions < 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 6,000 to < 8,000 DM 8,000 to < 10,000 DM 10,000 and more |
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Questions used in the 1998 Health Survey for England (6) about the educational level are as follows:
| 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 5. 16 6. 17 7. 18 8. 19 or over |
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| 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 |
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| 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 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? 1. Yes (Go to Question 4) 2. No |
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| 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? 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's grants, rent) 12. No source of income |
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| 2. | Which of the groups represents your and your husband/wife/partner's)
income from all these sources before any deductions for income tax, National Insurance,
etc.? (Show card with 31 alternatives for weekly, monthly or annual income) |
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| 3. | Does anyone else in the household have an income from any source? 1. Yes 2. No |
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| 4. | Which of the groups represents the total income of the whole household
before deductions for income tax, National Insurance, etc. ? (Show card with 31 alternatives for weekly, monthly or annual income) |
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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? 1. Full-time 2. Part-time |
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| 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 |
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| 7. | Are you a Director of a limited company? 1. Yes 2. No |
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| 8. | Are you? 1. Manager 2. Foreman or supervisor 3. Other employee |
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| 9. | Including yourself, about how many people are (were) employed at the
place where you usually work (usually worked/will work)? 1. 1 or 2 2. 3-24 3. 35-499 4. 500+ |
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| 10. | What does (did) your employer make or do at the place where you usually word (usually worked/will work)? | |
| 11. | What do (did/will) you make or do in your business? |
The NHANES III household family questionnaire included questions about the educational level of each of the family members surveyed (7):
| 1. | What is the highest grade or year of regular school you have ever
attended? 00 never attended or kindergarten only Elementary 1 2 3 4 5 6 7 8 High 9 10 11 12 College 1 2 3 4 5 + |
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| 2. | Did you finish grade/year? 1. Yes 2. No |
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The questions for income in the household family questionnaire were following (7):
| 1. | During the last month, did anyone in the family receive income from
working for an employer or from self-employment? 1. Yes 2. No (Go to Question 4) 9. Don't know (Go to Question 4) |
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| 2. | Who was that? | |
| 3. | Anyone else? 1. Yes (Re-ask Questions 2 and 3) 2. No |
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| 4. | During the last month did anyone in the family receive Security or
Railroad Retirement payments? 1. Yes 2. No (Go to Question 8) 9. Don't know (Go to Question 8) |
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| 5. | Who was that? | |
| 6. | Anyone else? 1. Yes (Re-ask Questions 5 and 6) 2. No |
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| 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 |
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| 8. | During the last month did anyone in the family receive any SSI
(Supplemental Security Income) payments from the Federal Government? 1. Yes 2. No (Go to Question 11) 9. Don't know (Go to Question 11) |
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| 9. | Who was that? | |
| 10. | Anyone else? 1. Yes (Re-ask Questions 9 and 10) 2. No |
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| 11. | During the last month did anyone in the family receive any pension or
disability payment other than Social Security or Railroad Retirement? 1. Yes 2. No (Go to Question 14) 9. Don't know (Go to Question 14) |
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| 12. | Who was that? | |
| 13. | Anyone else? 1. Yes (Re-ask Questions 12 and 13) 2. No |
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| 14. | During the last month, did anyone in the family receive Public assistance
or welfare payments from the State or Local welfare office? Do not include SSI. 1. Yes 2. No (Go to Question 17) 9. Don't know (Go to Question 17) |
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| 15. | What was that? | |
| 16. | Anyone else? 1. Yes (Re-ask Questions 15 and 16) 2. No |
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| 17. | During the last month, did anyone in the family receive 'Aid to Families
with Dependent Children', sometimes called AFDC or ADC. 1. Yes 2. No (Go to Question 20) 9. Don't know (Go to Question 20) |
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| 18. | Who was that? | |
| 19. | Anyone else? 1. Yes (Re-ask Questions 18 and 19) 2. No |
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| 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 dividend income, or child support and alimony? 1. Yes 2. No (Go to Question 23) 9. Don't know (Go to Question 23) |
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| 21. | Who was that? | |
| 22. | Anyone else? 1. Yes (Re-ask Questions 21 and 22) 2. No |
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| 23. | Including wages, salaries, self-employment, and any other source of
income we just talked 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) |
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| 24. | Show card with 30 income groups. Of those income groups, which letter better represents the total combined family income during the last 12 months? Include all sources of income we just talked about. |
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| 25. | Show card with 24 income groups. Now, please think about your family income during (name of last month). Which letter best represents 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) |
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| 2. | During the past 2 months did -- work at a job or business, not counting
work around the house? 1. Yes (Go to Question 7) 2. No |
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| 3. | Even though -- did not work during those 2 weeks, did -- have a job or
business? 1. Yes 2. No |
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| 4. | Was -- looking for work or on layoff from a job? 1. Yes 2. No (Go to Question 6) |
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| 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) |
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| 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) |
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| 7. | For whom did --- work? Enter name of company, business, organization, or other employer. Record response and skip to Question 9. |
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| 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. |
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| 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, keeps account books, files, sells cars, operates printing press, finishes concrete.) | |
| 12. | Complete from entries in Question 7 thru 11. If not clear ask: Was
--
07. working without pay in business or farm? |
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The questionnaire of the Norwegian Age-40 Programme inquiries about employment status and education.
Social security benefits
| 1. | Do you now receive any of the following social benefits Sick leave Rehabilitation allowance Disability pension (full time or partial) Unemployment benefit |
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| 2. | Is house-keeping your main occupation (answer No if you are working 18
hours or more per 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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WHO MONICA Project
The detailed description of the availability and quality of data on education achievement are documented in the Quality Assessment of Data on Marital Status and Educational Achievement in the WHO MONICA Project (8).
Educational level
The categories for educational level did not have the same meaning in every population. Also in many 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 local questionnaires. In two populations the question did not explicitly define that the question is about the "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 different populations. The mean years of schooling at primary school level varied from 3.2 years up to14.6 years. At the secondary school level the variation was from 7.6 years to 14.6 years, at the intermediate level from 10.2 year to16.8 years and at the university level from 9.5 year to 21.8 years. (8)
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).
No details were found for health surveys in Germany, UK National Health Surveys, and NHANES III.
All surveys that included questions about the socio-economic status collected information on educational 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 full time education and categories of educational levels. In MONICA, the levels of educational were found difficult to interpret as they had different meaning in different countries . That is why the years spent in full time schooling are more frequently used when educational levels between different countries are compared.
Both the UK National Health Surveys and NHANES III asked about the family income using categorized income groups.
The European Commission Health Monitoring Program has a separate project which focuses on socio-economic issues. This "Socio-economic Inequalities in Health" project has submitted its final report to the EC in February 2001. The report recommends that educational level, income and occupation should be used for the monitoring purposes.
References
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