SES Indicators

There are 126 racial and ethnic categories in the US (Winker, 2004). It is a well-recognized fact that many racial and ethnic minorities face unique health challenges and suffer from poorer health outcomes (Dorsey, 2011). The importance of adequately reporting and collecting relevant SES parameters, including race and ethnicity is evident. However, the question of how to properly categorize, measure, and report some of these parameters has been in the center of discussion for some time. In accordance with the Affordable Care Act, The department of Health and Human Services (HHS) came up with the new data standards for the collection of race, ethnicity, sex, primary language, and disability status. It is required by law that these standards be used in all the national population health surveys (Dorsey, 2011). The new standards have been in use since November 2011, and their stated purpose is to “understand the causes of health disparities, design effective responses, and evaluate progress in decreasing health disparities” (Dorsey, 2011). With the deepening social disparities and the effect they have on the nation’s health, it is essential to have a well-established system of documentation. It is also important for the researchers to select and appropriately measure all the indicators relevant for their study. HHS’s new data standards include fourteen racial and five ethnic categories, with the option to include more than one category within each group. When used as proxy for more accurate SES indicators such as education or income, race/ethnicity do not give the realistic picture of the population of interest. However, both race and ethnicity are important indicators of health disparities and need to be carefully measured and taken into consideration. Ideally, after transparently reporting it, the researcher would move beyond the race and look into many other social position components that can be addresses in order to improve the health status (Winker, 2004). Winker suggests that the best way to measure race is by self-designation, particularly if race is used as a proxy for other SES indicators. This way of measuring, he argues, corresponds best to what the person thinks is their cultural background. It is also important to note that different countries have different racial/ethnic make-up, so these two categories can’t be used to compare the health disparities between the countries. Race is a very important indicator of disparities in the US, but in England for example, income is much more relevant (Adler, 2007). Subjective social status (SSS) is a measure of people’s own assessment of their SES. It includes the objective components of education, income, and occupation, and relates to how an individual perceives their position in each of these categories compared to the rest of the society (Adler, 2007). High association was found between SSS and health disparities, and this measure proves useful when comparing across countries. Perception of low status can be associated with negative psychological effects (shame, stress) and deepen the feeling of social gap between the groups. Although the US has “an inherited ideology of classlessness”, it is the widening and deepening of this gap that is the root of class differentiation (Adler, 2007). Unlike European aristocracy that is born into it, class differentiation in America is based on wealth. Nevertheless, the social status stemming from it, and the social and health disparities that are the result of rich becoming richer, and poor becoming poorer are just the same. Class is ultimately associated with the clear social stratification, and not some blur historical construct. Whether we are comfortable accepting it or not, the US is a class society, with history of class discrimination that has severe effects on health outcomes of those lower on the social ladder. If we accept that the class itself is potentially important social determinant of health, which SES indicators provide the best measurement? Income relates directly to financial recourses that are related to health and is an obvious choice. However, it has been shown that income may not be enough, and that including wealth as an additional indicator of material recourses may be helpful. This is especially true when we compare health disparities among different racial groups. Whites tend to accumulate more wealth than Blacks, and although the two individuals may have the identical income status, they may not in reality belong in the same category. Education and occupation are the other two commonly used SES indicators. Education is very useful in general because it is available for both genders and doesn’t exclude many members of society. It is less subject to self-reporting bias (when compared to income) and it can predict success related to occupation and income. Strong association between education disparities and mortality of all causes has also been shown (Miech, 2011). However, the issue with the education as an indicator of SES in that years completed tell us nothing about the equality of the education received. Occupation is a complex indicator since it may not reflect the conditions of a specific job (Adler, 2007). It proved as a very insightful measure in Whitehall studies where the strong association was found between the employment grade and mortality. However, income rather than occupation is thought to be more strongly associated with health outcomes in the US (Adler 2007). Self-designation of race as well as the measurement of subjective social status may be an important addition to the common objective assessments of race/ethnicity and SES indicators. Individual perception of both our racial/ethnic identity as well as our place in the society we live in affects our health in ways that shouldn’t be ignored. Class and social stratification based on income/wealth seems to be the better indicator of social and health disparities, and race should probably not be used as a proxy for other SES indicators. Individuals with different racial but similar financial background face the same challenges that could potentially be solved with similar approaches. Researchers should take as many SES indicators into consideration as possible, and measure and report them appropriately. Race needs to be measured and reported transparently, however, other SES indicators may be better measurement across all groups and across different countries.