Public Health (1990), 104, 399~16

The Society of Public Health, 1990

Relationship of Social Class Characteristics and Risk Factors for Coronary Heart Disease in West Germany
U. Helmert ~, S. Shea 2, B. H e r m a n 1 a n d E. Greiser ~

1Department of Epidemio/ogy, Bremen Institute for Prevention Research and Social Medicine (BIPS). Bremen, Federal Republic of Germany 2Department of Medicine and School of Public Health. Columbia University. New York, USA

A cross-sectional analysis of the baseline survey of the German Cardiovascular Prevention Study was carried out to analyse the relationship between four different social class characteristics and major risk factors for coronary heart disease. 4,796 randomly selected German residents aged 25-69 years participated in the health survey between 1984 and 1986. The response rate was 66.2%. No significant association with social class variables was observed for prevalence of hypertension, hypercholesterolaemia or low high density lipoproteins. Multiple logistic regression analysis showed that obesity and lack of physical activity were significantly more prevalent in lower social classes for both sexes, while for cigarette smoking this relationship held for males only. The strongest social class gradient was found for lack of physical activity, adjusted odds ratio 4.75, P < 0.001, comparing lowest social class by composite index to highest. The number of coronary heart disease risk factors per study subject increased strongly with decreasing social class. Education, measured as years of schooling, showed a stronger association with coronary heart disease risk factors than household income, occupational status, or a threedimensional composite index of social class. These findings indicate the need to focus on lower social class population groups when carrying out community-based coronary heart disease primary prevention programmes, particularly with regard to smoking, obesity, and lack of physical activity.

Introduction
C o r o n a r y heart disease ( C H D ) in developed countries, which in the past m a y have occurred m o r e frequently in affluent segments o f the p o p u l a t i o n , n o w shows a higher incidence in people with lower s o c i o - e c o n o m i c s t a t u s J ,2 There exists evidence at least for G r e a t Britain 3 a n d the U n i t e d States 4'5 that c o r o n a r y heart disease has become a 'disease o f the p o o r within rich societies'. 6 In the last two decades, a wide variety o f public health activities have Correspondence: U. Helmert, Department of Epidemiology, Bremen Institute for Prevention Research and Social Medicine (BIPS), St Juergen Strasse 1, D 2800 Bremen 1, Federal Republic of Germany. The German Cardiovascular Prevention Study is funded by the Federal Ministry of Research and Technology and the Federal Ministry of Youth, Family, Womens Affairs and Health, The principal investigators are: E. Greiser, Bremen Institute for Prevention Research and Social Medicine (BIPS), Bremen; J. Hoeltz, lnfratest Research Inc., Munich; H. Hoffmeister, Institute for Social Medicine and Epidemiology, Federal Health Office, West Berlin; K.D. Huellemann, Clinical Institute for Physiology and Sports Medicine (KIPSI), Prien; H. Kreuter, Scientific Institute of the German Medical Association (WIAD), Bonn; U. Laaser, German Institute for High Blood Pressure Research, Heidelberg; E. Nuessel, Division of Clinical Social Medicine, Department of Internal Medicine, University of Heidelberg; L v. Troschke, Division of Medical Sociology, University of Freiburg.

400

U. Helmert et al.

been undertaken to change individual health behaviour regarding the most important modifiable CHD risk factors such as cigarette smoking, hypertension, hypercholesterolaemia, obesity, and physical inactivity. These CHD-related public health campaigns in the US have had positive effects in reducing smoking in adults, although primarily in males] and in improving control of hypertension. 8 Inherent in the current C H D prevention approach in the US is the hope that positive changes in health attitudes and behaviours, which have been achieved to date mainly in the segments of the population with a higher socio-economic status, will diffuse to the lower strata of the socio-economic scale. However, the question of whether this impact on C H D prevention reaches all segments of the population, especially minority groups and low income subpopulations, needs to be investigated in more depth. The multicentre community-based German Cardiovascular Prevention Study (GCP) was started in the Federal Republic of Germany in 1984. 9 The concepts and methods for this study were developed during a pilot phase from 1979 to 1983, using experiences obtained mainly from several US intervention studies in the field of cardiovascular disease, tc~3 The aim of this paper is to describe the relationship between social class characteristics and the most important risk factors for coronary heart disease. This question is important for improving the implementation of intervention programmes, for proper allocation of intervention resources in regard to different social groups, and for the outcome evaluation of the study. The pooled data of six regional and one national health survey o f the GCP were analysed previously regarding the association between a composite index of social class and major C H D risk factors. ~4 Because the use of only one social class index and the pooling of the regional and national data sets were criticised this report provides an analysis in more depth exclusively with the national survey, which consists of a random sample for the whole FRG, and applies several different indices for social class.

Materials and Methods

The German Cardiovascular Prevention Study is a multicentre community-based intervention study with the goal of primary prevention of coronary heart disease (ICD-9: 410-414) and stroke (ICD-9: 430438). Its main aim is to reduce the age-specific mortality for these diseases among German residents 25 69 years of age in six regions exposed to 8 years of intervention by at least 8% beyond the rate expected from the mortality experience of the remaining non-intervention population of comparable ages of the Federal Republic of Germany. 9 The intervention population encompasses six study regions comprising a total of 1,228,400 inhabitants. Baseline health surveys were conducted in these regions in the period 1984-1986 with a sample size for each regional survey of 2,700. In addition, 8,000 reference subjects were randomly chosen from 200 sample points within the Federal Republic for the first National Health Survey. The addresses of eligible candidates were randomly selected from population registries. The examinations took place in special examination buses and were carried out by specially trained medical staff. The survey procedures have been described in more detail elsewhere. ~5 4,796 persons participated in the survey. Thus, a response rate of 66.2% was achieved for the National Health Survey. This proportion was arrived at by deducting persons who had moved prior to the start of the survey, who could not be located due to an incorrect address, or who were deceased.

Social Class and CHD Risk Factors Study variables

401

The examination part of the survey comprised measurement of height, weight, blood pressure (using a random-zero sphygmomanometer), and pulse rate. Determinations of total serum cholesterol (CHOD-PAP method) and high density lipoprotein (HDL) cholesterol (method by Boehringer Mannheim, Mg2+/Phosphotungsticacid) were performed. All laboratory assessments were done by the Laboratory Division of the Institute for Social Medicine and Epidemiology of the Federal Health Office (BGA) in West Berlin ~5 and were standardised against the W H O Lipid Reference Centre in Prague. An extensive self-administered questionnaire covering, among other items, socio-demographic factors, smoking status, and physical activity was completed by all participants. The following definitions for C H D risk factors were used for this analysis: Hypertension was defined as systolic blood pressure > 160 mm Hg and/or diastolic blood pressure > 9 5 mm Hg. The second blood pressure reading was used. Hypercholesterolaemia was defined as total serum cholesterol of 250 mg dl-i or greater. Low HDL-cholesterol was defined as less than 3 5 m g d l J for males and less than 45 mg dl- ~ for females. Obesity was defined as body mass index (weight in kg/(height in metres squared))_>_ 30. Cigarette smoking was defined as smoking regularly at least one cigarette per day. All participants who said that they did not exercise regularly were considered physically inactive. Two variables concerning the place of residence of the participants were considered in this analysis: first, the grade of urbanisation, measured as the number of inhabitants o f the community, divided into four categories; and second, the region of residence, operationalised by the eleven federal states and then summarised into five regional clusters as North, West, Middle, Southwest, and South. Measurement of social class characteristics Education." Compared to income and occupation as single indicators of social class, education has been used much more frequently in epidemiological studies, in part because it is rather easily obtained, without frequent refusal, and it has been a consistent correlate of mortality, morbidity, and risk factors for cardiovascular disease. ~6-~sThe operationalisation of education is generally done as 'years o f education completed'; in addition, degrees or certificates awarded are sometimes taken into consideration, l 'Years of education completed' was measured in the G C P Study using two questions regarding highest level of schooling completed (range: 'Hauptschule' to 'Abitur') and earned degree in vocational/professional education, and applying a scale developed by Pappi. ~9 This scale permits conversion of these two variables into 'number of years of education' (range: 7 to 17 years). The following four levels were used to categorise educational status: low (7-8 years of education), middle (9-11 years), high (12-13 years), and very high (15-17 years). Income: In the G C P questiolinaire there were eleven pre-coded categories for answers to questions regarding total monthly household net income after deductions. The refusal rate for this particular question was the highest o f all variables (approximately 9%). The lowest category was 'less than 1,000 German marks per month' and the highest '6,000 and more marks per month'. Each category had a range of 500 marks. Since the empirical

402

U. Helmert et al.

distribution of total household income was strongly associated with marital status, yielding a markedly higher household income for married persons or persons living together with a partner, compared to single, divorced, separated or widowed persons, an adjusted household income was calculated by subtracting 800 marks for all households o f married or unmarried couples from the midpoint o f the income category. Households with children also had a slightly higher total income. Therefore, based on the empirical distribution, an adjustment of total household income was carried out by subtracting 200 marks for one child, 350 for two children, and 450 for three or more children from the midpoint o f income category. These adjustment procedures were especially necessary for females, because a much higher percentage lived in one-person-households than males; many such women were widowed. The averaged unadjusted household income of females was markedly lower. Five categories for adjusted household income, each comprising about 20% o f all observations, were used: low (adjusted income less than 1,000 marks per month), low medium (1,000-1,500 marks), medium (1,500 2,000 marks), high medium (2,000-3,000 marks), and high (3,000+ marks).

Occupational status. In the US the most widely used occupational scale is the Edwards' Social-Economic Grouping of Occupations and its modifications by the US Bureau o f the Census, This scale gives a distribution o f all occupations according to thirteen categories (version 1980) only. These occupational categories are ordered on the basis of education and income. The Edwards' scale is somewhat similar to the British Registrar General's Scale, which comprises five social classes: I, professional; II, intermediate; III, skilled; IV, partly skilled; and V, unskilled. Because of many dissimilarities regarding occupational categories, none of the widely used US or British scales could be adopted directly to the data o f the GCP study. The operationalisation of occupational status was based on the question: 'What is your current occupational status? If no longer employed refer to your last job.' Twenty response categories were given. The following four main groups were established:
1 il IlI IV Professionals, managers, employers. Qualified white collar employees. Skilled blue collar workers, clerks with simple occupations. Unskilled and little trained blue collar workers.

The refusal rate for this question was less than 1%. Persons who have never been employed (i.e. housewives, students) were coded as missing values.

Composite index of social class

In addition to these three one-dimensional indicators o f social class, a composite index of social class combining education, income, and occupation was constructed. This index was built similarly to indices previously used in the F R G , which comprise the variables education, income, and occupational status. 2 The assignment o f scores for the three components of the index were achieved similarly to an approach by I N F R A T E S T . 2~ Instead of crude total monthly net household income, adjusted income (see above) was considered. In regard to occupational status, the score for the person in the household with the highest wage was always considered. For subjects with missing information for one of the three components of the index, the expected value - based on the two other given scores was considered, using the empirical distribution o f all other subjects, separately for males

Social Class and CHD Risk Factors

403

and females. This procedure reduced the number o f missing values for the composite score (less than 1%). Five social strata, as in most comparable studies, were used: I II III IV V Upper class Higher middle class Middle class Lower middle class Lower class (19-26 points). (15-18 points). (12-14 points). (10-11 points). (4-9 points).

Statistical analysis
Statistical analyses were performed using the Statistical Analysis System (SAS). 22 The odds ratio was used as the measure of effect of the relationship between social class characteristics and C H D risk factors. Multiple logistic regression was carried out to control for potential confounding factors, such as age and regional variables, 23,24utilising the SAS procedure P R O C - L O G I S T . 2s All statistical analyses were carried out separately for each sex group. The categories of social class characteristics were included as d u m m y variables in the model. The reference category was always the highest level of the social class characteristic.
Results

There were significant sex differences for smoking and hypertension, which were more frequent in males, and for lack of physical activity, which was more frequent in females (Table I). No sex differences were found for obesity, hypercholesterolaemia or low HDL-cholesterol. The proportion of subjects without any of these C H D risk factors was significantly higher for females, while the simultaneous prevalence of three or more risk factors was clearly higher for males.

Table I Age 25-29 30-39 4049 50-59 60-69 years years years years years

Age distribution and frequencies of CHD risk factors by sex Males n 283 548 718 522 347 2,418 % 11.7 22.7 29.7 21.7 14.3 100.0 n 273 545 657 494 409 2,376 Females % 11.5 22.9 27.6 20.8 17.2 100.0

Chi square= 8.42, df=4, n.s. Cigarette smoking 1 + cigarettes per day non-smoker Chi square = 116.8I, df= 1, P < 0.001 986 1,429 2,415 40.8 59.2 100.0 618 1,752 2,370 26.1 73.9 100.0

404 Table I

U. Helmert et al.
Age distribution and frequencies of C H D risk factors by sex Males Females % n %

Age Blood pressure (ram Hg) Systolic > 160 and/or diastolic > 95 Systolic < 160 and diastolic < 95

525 1,882 2,407

21.8 78.2 100.0

328 2,042 2,370

13.8 86.2 100.0

Chi square = 51.74, df= 1, P < 0.001 Total cholesterol (rag dl- ~) Cholesterol ~ 250 Cholesterol < 250 775 1,610 2,385 Chi square = 1.47, df= I, n.s. HDL-cholesterol (rag dl-~) < 35 (males); < 45 (females) > 35 (males); > 45 (females) 233 1,950 2,183 Chi square=0.06, df= 1, n.s. Obesity Body-mass-index > 3 0 Body-mass-index < 30 388 2,028 2,416 Chi square = 0.06, dr= l, n.s. Physical activity/exercise No regular exercise Regularly exercise 857 1,558 2,415 Chi square=24.79, df= 1, P<0.001 N u m b e r o f C H D risk factors 0 1-2 3~ 443 1,245 481 2,169 Chi square= 15.35, df=2, P<0.001 20.4 57.7 22.2 100.0 482 1,200 363 2,369 23.6 58.7 17.8 100.0 35.5 64.5 100.0 1,007 1,362 2,369 42.5 57.5 100.0 16.1 83.9 100.0 387 1,984 2,371 16.3 83.7 100.0 10.7 89.3 100.0 226 1,847 2,073 10.9 89.1 100.0 32.5 67.5 100.0 774 1,491 2,265 34.2 65.8 100.0

Social Class and C H D Risk Factors

405

N e i t h e r the g r a d e o f u r b a n i s a t i o n n o r the region o f residence s h o w e d a n y differences with r e g a r d to sex d i s t r i b u t i o n . All social class v a r i a b l e s yielded, as expected, significantly higher ratings for males ( T a b l e II). O n a v e r a g e males h a d higher i n c o m e , higher o c c u p a t i o n a l status, better e d u c a t i o n , a n d were m o r e likely to b e l o n g to the higher social classes. Sex differences were s t r o n g e r for e d u c a t i o n a n d o c c u p a t i o n a l status, p r o b a b l y b e c a u s e those two i n d i c a t o r s t a k e into c o n s i d e r a t i o n o n l y c h a r a c t e r i s t i c s o f the s t u d y subject. T h e s m a l l e r sex differences o b s e r v e d for a d j u s t e d h o u s e h o l d i n c o m e a n d the c o m p o s i t e index o f social Table II Distribution of demographic variables and social class indicators by sex Males Grade of urbanisation 100,000 + inhabitants 50,001-100,000 inhabitants 5,001-50,000 inhabitants < 5,001 inhabitants Chi square=3.51, dr=3, n.s. Region North West Middle Southwest South Chi square= 1.73, df=4, n.s. Years of education 15-17 12-13 9-11 7-8 years years years years 289 96l 911 229 2,390 12.1 40.2 38.1 9,6 100.0 152 673 772 741 2,338 6.5 28,8 33,0 31.7 100.0 521 614 431 410 442 2,418 21.6 25.4 17.8 17.0 18.3 100.0 523 602 395 425 431 2,376 22.0 25.3 16.1 17.9 18.1 100.0 n 720 590 740 368 2,418 % 29.8 24.4 30.6 15.2 100.0 n 751 599 686 340 2,376 Females % 31.6 25.2 28.9 14.3 100.0

Chi square = 373,53, df= 3, P < 0.001 Income per month (adjusted) 3,000 + DM 2,001 3,000 DM 1,501-2,000 DM 1,001-1,500 DM 1,000 D M or less Chi square=24.88, df=4, P<0.001 461 569 418 392 454 2,294 20.1 24.8 18.2 17.1 19.8 100.0 361 462 408 464 456 2,151 16.8 21.5 19.0 19.0 21.2 100.0

406 Table II

U. Helmert et al.
Distribution of demographic variables and social class indicators by sex (continued) Males Females % n %

Grade of urbanisation Occupational status I II IH IV high high medium low medium low

549 473 886 369 2,227

24.1 20.8 38.9 16.2 100.0

189 697 619 553 2,058

9.2 33.9 30.1 26.9 100.0

Chi square = 292.27, df = 1, P < 0.001 Social class (composite index) I II III IV V high high medium medium lower medium low 428 525 565 485 400 2,403 17.8 21.9 23.5 20.2 16.6 100.0 351 530 583 436 458 2,358 14.9 22.5 24.7 18.5 19.4 100.0

Chi square= 14.19, df=4, P<O.OI

class are probably due to the fact that these indices consider characteristics of both household members when the study subject is married. The correlation matrix (Table III) indicated that there was an inverse relation between social class characteristics and age for both sexes. The highest inverse correlation with age was found for duration of education. The correlation between age and social class was in general stronger in females than for males. However, this trend of decreasing social class with age was in part an artefact due to size of household. When total household income was adjusted for marital status and number of children in the household a clear decrease of the correlation coefficient was observed, especially in women (from - 0 . 2 3 to - 0 . 1 6 for socio-economic status, and from - 0 . 1 7 to - 0 . 0 7 for income). When comparing the internal consistency of the four social class indices, as evaluated by their correlation coefficients, males generally showed a higher consistency among the four indicators. Only in regard to the correlation between education and occupational status did females yield a slightly higher correlation coefficient than males. For both sexes the highest correlation was observed for education and occupational status; this may be due to the fact that these indicators take into consideration only characteristics of the study subject and not additional information for the spouse. With the exception of low HDL-cholesterol, all risk factors were highly correlated with age. Cigarette smoking decreased with age. All other risk factors showed a much higher prevalence in older age groups. Because of these associations of risk factors with age and sex, all further analyses were done separately by sex and adjusting for age. Because none of the six C H D risk factors under study showed any significant differences in prevalence rates in the five regions of the F R G (North, West, Middle, Southwest, and South), no variable

Social Class and CHD Risk Factors

407

Table llI
i

Correlation between social class characteristics

2 3 4 5 6 7

Age I. Age 2. Socio-economic status* 3. Socio-economic statust 4. Education 5. Occupational status 6. Income unadjusted 7. Income adjusted -0.23 2,358 -0.16 2,358 -0.35 2,338 - 0.21 2,058 -0.17 2,151 -0.07 2,151

SES* -0.16 2,404 0.98 2,358 0.63 2,326 0.62 2,056 0.77 2,151 0.74 2,151

SESt -0.14 2,404 0.98 2,404 0.63 2,326 0.63 2,056 0.73 2,151 0.76 2,151

Education -0.19 2,390 0.66 2,379 0.66 2,379 0.61 2,026 0.31 2,119 0.33 2,119

Occ. status -0.08 2,277 0.84 2,277 0.83 2,277 0.56 2,256 0.30 1,882 0.33 1,882

Income unadj, -0.08 2,294 0.79 2,294 0.76 2,294 0.38 2,269 0.45 2,167 0.93 2,151

Income adj. -0.07 2,294 0.77 2,294 0.79 2,294 0.38 2,269 0.44 2,167 0.95 2,294

Spearman correlation coefficient. Number of observations. Above: males; below: females. * With unadjusted income. ~ With adjusted income. All P<0.01,

for region was included in the final regression models, while three d u m m y variables regarding grade o f urbanisation were included in all models. In males, the odds ratios for the association of cigarette smoking with decreasing levels of social class indicators were statistically significant and showed a consistent trend across social class levels (Table IV). In females, these relationships were not observed. In females, but not in males, cigarette smoking was strongly related to grade of urbanisation. Controlling for age and social class, the odds ratios for cigarette smoking in women increased from 1.58 (communities with 5,000~50,000 inhabitants), to 1.97 (50,000~100,000 inhabitants), and 2.41 (100,000+ inhabitants), with small villages ( < 5,000 inhabitants) considered as the reference category. In males, hypertension was not associated with any o f the four social class indicators (Table V). In females, hypertension was associated with lower education and occupational status, However, this relationship was largely due to confounding by obesity. When body mass index was included as a continuous variable in the regression model, much smaller and, with one exception, no longer statistically significant odds ratios were observed. For both sexes, no consistent significant associations were found between the four social class characteristics and hypercholesterolaemia (Table V1). Concerning low HDL-cholesterol, a significantly higher odds ratio was observed (1.97) in males for the lowest educational level. Adjusting for body mass index, this odds ratio decreased to 1.65 (n.s.) (Table VII). For females a stronger relation between low HDL-cholesterol and social class characteristics existed, especially for educational status. However, much of this association was due to relative body weight, which is strongly

408 Table IV

U. Helmert et al.
Cigarette smoking and social class indicators Social class level
1 2 3 4 5

Males Socio-economic status (2,403) Education (2,389) Occupational status (2,277) Income (2,294) Females Socio-economic status (2,356) Education (2,336) Occupational status (2,057) Income (2,149)
* P<0.05

1.00 1.00 1.00

1,00 1.00

1.54"* 1.45" 0.76

1.27 1.03 1.52

1.70"** 1.90"** 1.20

1.73"** 1.23 1.40

1.77"** 2.72*** 1.95"**

1.52"* 1.08

2.82***

1.86*** 1.51 *

1.00 1.00 1.00

1.16 0.93

1.14 1.01

1.54 1.53" 1.02

0.79

Logistic regression: odds ratios controlled for age and grade of urbanisation. ** P<0.01 *** P< 0.001

related to H D L , a n d the odds ratios were n o t highly statistically significant once b o d y mass index was i n c l u d e d as a c o n t r o l variable in the regression (Table VII). Obesity was m o s t strongly related to e d u c a t i o n in both sexes a n d showed a m u c h higher social class g r a d i e n t for females (Table VIII). I n a d d i t i o n , for females the odds ratios for obesity decreased with grade o f u r b a n i s a t i o n . In cities with 100,000 + i n h a b i t a n t s , the odds ratio was 0.58 ( P < . 0 0 1 ) as c o m p a r e d with subjects in villages with less t h a n 5,000 i n h a b i t a n t s , N o such relation existed for males.

Table V

Hypertension and social class indicators Social class level

1 2 3 4 5

Males Socio-economic status (2,393) Education (2,379) Occupational status (2,266) Income (2,283) Females Socio-economic status (2,350) controlled for body mass index Education (2,330) controlled for body mass index Occupational status (2,050) controlled for body mass index Income (2,143)
* P < 0.05

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.05
1.27

0.99
1.06

1.03
I. 17

1.05

1.14 1.05 1.02 0.78 1.93

1.43

1.17 1.10 0.89 0.68 2.29*

1.65

1.19 0.84 1.37 0.93 3.32**

2.10

0.90 1.55"

1.63
1.43

1.19
1.62

0.88

0.67

2.69 2.01 * 0.79

1.17

Logistic regression: odds ratios controlled for age and grade of urbanisation. ** P<0.01 *** P<0.001

Social Class and C H D Risk Factors

Table VI Hypercholesterolaemia and social class indicators Social class level
1 2 3 4 5

409

Males Socio-economic status (2,372) Education (2,358) Occupational status (2,248) Income (2,263) Females Socio-economic status (2,247) Education (2,228) Occupational status (1,973) Income (2,05 I)

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.12 1.41" 1.15 1.21 1.73"* 1.58 0.86 1.16

1.09 1.51"* 1.09 1.21 1.46" 1.58 1.00 1.17

1.20 1.31 1.14 1.05 1.65"* 1.38 1.05 1.14

1.19 1.27 1.40 1.20

Logistic regression: odds ratios controlled for age and grade of urbanisation. * P<0.05 ** P<0.01 *** P< 0,001

T h e s t r o n g e s t social g r a d i e n t was o b s e r v e d for lack o f p h y s i c a l activity. F o r all social class i n d i c a t o r s the o d d s r a t i o increased s t r o n g l y with d e c r e a s i n g level o f social class (TaMe IX). F o r the lowest social class ( c o m p o s i t e index), the o d d s r a t i o for lack o f physical activity was 4.75 for b o t h sexes as c o m p a r e d to the highest social class. Because o f the c u m u l a t i v e effect o f m u l t i p l e risk factors o n C H D m o r b i d i t y a n d m o r t a l i t y , the n u m b e r o f risk factors p e r s t u d y subject was a n a l y s e d . T h e o d d s ratios for h a v i n g n o n e o f the six C H D risk factors u n d e r c o n s i d e r a t i o n d e c r e a s e d s t r o n g l y from u p p e r

Table VII

Low HLD-cholesterol and social class indicators Social class level

1 2 3 4 5

Males Socio-economic status (2,172) Education (2,151) Occupational status (2,057) Income (2,070) Females Socio-economic status (2,058) controlled for body mass index Education (2,037) controlled for body mass index Occupational status (1,801) controlled for body mass index Income (1,886)

1.00

1.04

1.17

1.05

1.55
1.46

1.00 1.00 1.00 1.00

1.00

1.19 0.86 0.79 1.33

1.08

1.33 0.91 1.06 2.32**

1.95"

1.97" 1.17 0.86 2.41"*

1.75

2.08*
1.47

1.00 1.00 1.00

1.00

2.38 1.90 1.56

1.43

1.00

1.60

2.94 2.25 2.12* 1.95 1.60

3.32 2.20 2.07*

1.55

2.01 *

1.49

Logistic regression: odds ratios controlled for age and grade of urbanisation. * P<0.05 ** P<0.01 *** P<0.00I

410
Table VIII

U. Helmert et al.
Obesity and social class indicators Social class level
1 2 3 4 5

Males Socio-economic status (2,402) Education (2,388) Occupational status (2,275) Income (2,292) Females Soeio-economic status (2,352) Education (2,331) Occupational status (2,052) Income (2,146)

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.57* 1.60" 1.00 1.15 2.03** 3.38* 1.08 1.30

1.62" 1.84"* 1.25 1.05 1.97"* 4.95** 0.93 1.50

t.70"* 2.24** 1.42 1.31 3.78*** 8.17"** 2.12 1.92"*

1.84"*

1.28 4.01"** 1.82"*

Logistic regression: odds ratios controlled for age and grade of urbanisation. * P< 0.05 ** P<0.01 *** P<0.001 to lower social class, while the o d d s r a t i o s for h a v i n g three o r m o r e risk factors i n c r e a s e d f r o m u p p e r to lower social class ( F i g u r e 1). This finding is c o n s i s t e n t with the h y p o t h e s i s t h a t the n u m b e r o f risk f a c t o r s in general d e p e n d s s t r o n g l y on social class a n d is g r e a t e s t in the lower classes. T h e m a g n i t u d e o f effect on c u m u l a t i v e C H D risk o f social class i n d i c a t o r s was in g e n e r a l lowest for the v a r i a b l e ' a d j u s t e d t o t a l h o u s e h o l d i n c o m e ' a n d highest for the variable education.
Discussion

In e p i d e m i o l o g i c a l studies, a variety o f different terms a n d c o n c e p t s have been utilised for social c o n d i t i o n s , such as social class, social status, social inequality, social s t r a t a , Table IX Lack of physical activity and social class indicators Social class level
1 2 3 4 5

Males Socio-economic status (2,404) Education (2,389) Occupational status (2,277) Income (2,294) Females Socio-economic status (2,354) Education (2,335) Occupational status (2,055) Income (2,147)

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.40" 2.36*** 1.25 1.48"* 1.48" 1.75" 1.57" 1.36"

2.36*** 4.39*** 2.14"** 2.16"**

2.61"**

3.35*** 9.21"** 3.83*** 2.48***

2.91"**

4.75*** 2.83*** 4.76*** 2.39***

3.01"** 1.82"* 1.49"

7.39*** 4.13"** 2.13"**

Logistic regression: odds ratios controlled for age and grade of urbanisation. * P<0.05 ** P<O.OI *** P< 0.001

Social Class and C H D Risk Factors

no risk f a c t o r 3.5 3 - 6 risk f a c t o r s no risk f a c t o r 3 - 6 risk f a c t o r s

411

3.0

2.5

.o 2.o

~D1.5

1.0

0.5

0.0

1 2

3 4

5 1 2 Males

3 4

3 4

5 1 2 Females

Social class

Figure 1 Odds ratios for low and high risk factor load by sex and social class. Risk factors: cigarette
smoking, hypertension, hypercholesterolaemia, obesity, low HDL-cholesterol, physical inactivity. Social class: l = upper class, 2 =upper middle class, 3 = middle class, 4= lower middle class, 5 = lower class. Reference category: upper class.

socio-economic class, economic class, social position, and social prestige. But, according to Max Weber, status and class are two distinct concepts o f social stratification. Social status involves the ordering of people into strata based on prestige, honour, values, and lifestyles, whereas social class refers primarily to economic standing. ''26 However, in m a n y studies that utilise measurements o f social stratification, these distinct concepts o f class and status have been used interchangeably. Despite the variety of indicators of social class, most researchers agree that occupation, education, and income are the three most important dimensions o f social class. ''2~-28 In addition to these one-dimensional indicators, m a n y attempts have been made to construct indices of social class that combine two or three of these dimensions. In evaluating the appropriateness of the different measurements of social class in epidemiology, and especially in the field of cardiovascular disease, one finds that no c o m m o n standard has yet been defined, z6 Therefore, most researchers suggest that more than one separate indicator should be used to measure social ClaSS. 1'26'27'~9 Single dimension indicators are widely used because they allow greater flexibility, are easier to obtain, and yield a clearer interpretation of the results than composite indices. A review o f recently published epidemiological studies in the US showed that the most frequent measurement o f social class was education. 26 Years of education completed was recommended as well by a working group of the National Heart, Lung, and Blood Institute examining the effect ofsocio-economic factors on cardiovascular disease, because it was considered to be the most robust single indicator o f social class. The

412

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same group favoured separate assessments o f social class indicators rather than composite indices because the latter may obscure important differences in association of variables with the separate components, j C o m p a r e d to the situation in the US, in Great Britain by far the most widely used index of social class is occupation. The most important measure is the Registrar-General's classification, which allows a categorisation into five social classes? This social class indicator has been used for decades and has shown a variety of striking associations in regard to health experiences. 3~ Because no single standardised, valid, and reliable measurement of social class exists for use in epidemiological studies, the present analysis utilises different measures for social class characteristics and provides a comparative analysis. Following the recommendations and experiences with social class meausrements in other epidemiological studies, ~'26'2vthe three most c o m m o n single measurements - education, income, and occupation (employment status) and a composite index o f these three dimensions were considered. One important characteristic o f education is the stability o f this measurement. For most adults after the age of a b o u t 25 years no large changes occur in their educational status, although, in general, additional adult education has become more common. Furthermore, there is less difficulty in establishing the time order of association between this measurement of social class and disease occurrence, a problem that arises using income, since people with chronic disease tend to belong to lower income groups because they are restricted to less well-paid jobs. But the stability of educational attainment m a y also be a shortcoming in special circumstances, because m a n y social class characteristics, which come into play after the educational process is completed at the end o f young adulthood, are neglected by the measurement of education alone. These include long-term unemployment, poverty despite education qualifications, strong upward occupational mobility despite low formal education, and change in social standing due to marital status. Strong cohort effects on education, j6'26due to the increase in overall educational attainment over the past 50 years in most industrialised nations, require adjustment, usually by age, in any analysis of this variable. Finally, educational status is easy to determine for women, because it takes into consideration only the individual's education, and no additional information a b o u t years of schooling of the husband is necessary. Income, undoubtedly, is an important social class characteristic. It has a strong influence on access to medical care and individual health behaviours, such as following a healthy diet or engaging in regular exercise? 2 Typically, total household income is considered the appropriate information. The categorical approach is much more common, since for m a n y people it is difficult to provide an exact estimate of their income. In general, income is a very sensitive item, and refusal rates for this social class indicator are much higher than for education or occupation] 6 Current total household income is relatively unstable over time. Many circumstances, such as shortterm unemployment, returning to school, marriage, or divorce produce changes in household income, although these events may not give rise to a major change in social class position. Furthermore, there is an association between age and household income, since earnings tend to increase throughout the occupational career and drop off after retirement. The total household income depends as well on the number of working or pensioned adults in the household. Therefore, for a proper analysis of the relationship o f income to C H D risk factors, adjustments for household size and age effects should be carried out. Measurement of occupation is the most complex of all three social class indicators. Up to seven questions are required for sufficient information to code occupations a p p r o p r i a t e l y ] 6 More questions are needed to take into consideration such important items as length and

Social Class and C H D Risk Factors

413

recency o f employment, kind of business or industry, full-time or part-time status. In most epidemiological studies that utilise a measurement o f occupational status much simpler scales are adopted. This cross-sectional analysis of the baseline survey of the G e r m a n Cardiovascular Prevention Study revealed strong associations of lower social class characteristics to total number of C H D risk factors and to overweight and lack o f physical activity for both sexes and to cigarette smoking for males only. Hypertension, hypercholesterolaemia, and low HDL-cholesterol were slightly more frequent in lower social classes only for females, but these associations were not statistically significant once adjustment was made for relative body weight. A comparison of the relationship between C H D risk factors and the four indicators for social class used in this analysis shows that in general the associations have the same directions, but there are large differences in the magnitude of the odds ratios observed. For both sexes duration of education yielded the highest odds ratios regarding C H D risk factor prevalence, whereas household income had the lowest magnitude of association with C H D risk factors. In general, the findings of the present analysis can be seen as a confirmation of the results o f an earlier analysis carried out with the pooled data of the national and regional G C P health surveys, j4 With a response rate of 66.2% it m a y have been possible that a non-response bias affected the study outcome. But the analyses o f some important variables for non-participants, such as self-reported smoking status and relative body weight, carried out with a short questionnaire for non-participants (response rate 70%), showed only slightly and non-significant differences for these variables between participants and non-participants. J5 In recent years a large number of C H D risk factor studies have been conducted in western industrialised countries and were analysed in regard to the influence of social class characteristics on C H D risk factor prevalence. When comparing twelve such studies from the F R G , 33'34Switzerland, 35 Great Britain, 36'3vSweden, 38 Norway, j6 the United States, 7.18"39"4 and Canada, 4~ only one 39 used a composite index of education and occupation as social class index39; six of the remaining studies 7,~6,~s'33,4~,4~adopted educational level as social class index and the other five3~3a used occupational level. Seven studies v'~6,33-3s'4'4~have included both sexes and five studies included only males. As in the present study, all twelve studies demonstrated a strong social gradient for smoking behaviour in males with much higher prevalence of cigarette smoking in lower social classes. For females the results concerning smoking behaviour were inconclusive. In three studies, 7'16m in lower social classes a significant increase of cigarette smoking in females was documented, while in the other four studies 33-35'4 that included females no relation between social class characteristics and the prevalence o f cigarette smoking was observed. The same strong association between social class and obesity and lack o f physical activity, as found in the G C P Study, were documented in all of the studies that examined those risk factors. For obesity five studies for both sexes and four studies for males only, and for lack of physical activity three studies for both sexes and three studies for males only, consistently showed a significant increase of these two risk factors with decreasing level of social class. In regard to hypertension and hypercholesterolaemia, which had no or only a slight association to social class in the G C P Study, the other studies had inconsistent results. Regarding hypertension in males, six studies reported a significant association to social class, while three studies 33"35'41did not. For females, only the Canadian Health Survey 4j and one study from the US reported higher prevalence rates o f hypertension for lower levels o f

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education, while in one study in the F R G 34 and in the study in Switzerland 35 no such association was found. In females hypercholesterolaemia was found to be related to social class in only one study, ~6and no association was found in the other three studies which reported cholesterol measurements for females. 33'4'41 Even more inconclusive results were obtained for males. The studies in Sweden 3~ and Norway ~6 showed significantly higher mean values for serum cholesterol in lower social classes; most other studies did not observe any significant associations 18'34'39'4m and both studies in Great Britain yielded a significant increase of hypercholesterolaemia with increasing level of occupational status. 36'37 One explanation for the lack of association between hypercholesterolaemia and social class characteristics could be that during the time the National Health Survey was conducted there was only little public concern and individual awareness about this risk factor in the F R G . Although 33% of the participants in the survey had cholesterol levels greater than 2 5 0 m g d l -t, only 4% of all study subjects reported that they had hypercholesterolaemia. It may be possible that with increasing knowledge of the importance o f this risk factor and broadscale public health campaigns like the National Cholesterol Education P r o g r a m m e in the US 42 the social gradient for this risk factor may change. There are already some hints in the data (Table VI) that members of the highest social class can be seen as early adopters in reducing high cholesterol levels, since for this social group the odds ratio for hypercholesterolaemia is much lower compared to the other segments of the population. The present study confirms the results of m a n y other studies that strong social class-related differences exist for prevalence of some, but not all C H D risk factors. These associations m a y reflect the lack of health education activities and health promotion campaigns that target and are effective in reaching lower social class populations. The finding of a strong social gradient for the proportion of persons with three and more of the most important C H D risk factors points to the need for future risk factor intervention strategies to focus more on lower social classes.

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