1. New findings concerning social status inconsistency (SSI) and health Richard Peter 1, Holger Gässler 1, Siegfried Geyer 2 1 Department of Epidemiology, Ulm University, Germany 2 University Clinic Hannover, Germany Introduction Social status inconsistency (SSI) is defined as a mismatch between indicators of social status like education, income, occcupation (e.g. a doctor working as taxi driver). SSI was topic for scientific investigation into health about 30 years ago. Evidence at that time was mixed. Today more consistent findings might be expected since increasing pressure on the working force produced by globalization, high unemployment rates, employment contracts limited in time, and flexible job arrangements may contribute to SSI. Employees faced with such working conditions may be more likely to accept jobs which are characterized by SSI. Accordingly, we expected a high proportion of employees with SSI and more consistent associations of SSI with poor health today. Methods We tested our hypotheses with the help of two data sets: 1) a prospective cohort study in 68805 men and women using data from a statutory health insurance company in Germany. Data collected up to 2000 included information on in-patient diagnosis of ischemic heart disease (IHD) and on age, gender, education, occupation,and income. 2) a cross-sectional study in a representative sample of the German workforce (about 27000 men and women) including information on self- reported health, age, gender, education, and occupation. Indicators of social status (education, occupational position, income) were assigned values from 1 to 5. Differences > 2 between two indicators defined SSI. All analyses were restricted to employed men and women aged 25 to 65 years. Cox regression was used to analyse data of study 1 and logistic regression analysis to investigate data set 2. All multivariate analyses were performed separately for men and women. Results Findings (table 1) show a higher prevalence of SSI in the representative sample of study 2. Furthermore, different types of SSI are prevalent in both studies: in study 1 it is an occupational position lower than the average that could be expected regarding the educational years, in study 2 SSI relates to an educational level which is below the average in the respective occupational group. Tab. 1: Prevalence of SSI concerning education and vocational training (ET) and occupational position (OP) Study 1 Study 2 n % n % --------------------------------------------------------------------------------------- No SSI 54589 83.3 16625 62.4 SSI (ET < OP) 2205 3.4 8754 32.8 SSI (ET > OP) 8715 13.3 1267 4.7 --------------------------------------------------------------------------------------- Other types of SSI (not displayed here) were defined by a mismatch between education and income and between occupational position and income. Results from multivariate analyses showed an increased risk of IHD for men and women characterized by SSI in study 1 (table 2). Table 2: Cox regression analyses: SSI concerning education (ET) and occupational position (OP) and risk of IHD in study 1 (Peter et al 2006) Men women hazard ratio (95% CI) hazard ratio (95 % CI) ------------------------------------------------------------------------------------------------- No SSI 1.00 1.00 SSI (ET < OP) 1.31 (0.53 – 3.18) xxxx 1 SSI (ET > OP) 3.14 (2.49 – 3.98) 3.63 (2.27- 5.83) ------------------------------------------------------------------------------------------------- 1 not calculable due to small numbers Further results, not presented here in detail revealed a decreased risk of IHD among men with higher income than usual in their educational group (hazard ratio 0.29 (95% CI 0.23-0.37). Women earning less than usual in their educational group had an increased risk for IHD (hazard ratio: 3.53, 95 % CI 2.11-5.88). Findings for study 2 showed less pronounced effects of SSI (see table 3). Contrary to study 1men characterized by an educational level lower than usually present in their occupational group were at increased risk for poor self-rated health. Among women the same type of status inconsistency as in study 1 was associated with poor health. In addition, women with an occupational position higher than usual in their educational group had an decreased risk for poor health. Table 3: Logistic regression analyses: SSI concerning education (ET) and occupational position (OP) and poor self-rated health in study 2 Men Women odds ratio § (95% CI) odds ratio § (95% CI) --------------------------------------------------------------------------------------------- No SSI 1.00 1.00 SSI (ET < OP) 1.23 (1.07 – 1.41) 0.75 (0.65 – 0.85) SSI (ET > OP) 1.08 (0.82 – 1.43) 1.47 (1.12 – 1.94) --------------------------------------------------------------------------------------------- § adjusted for age Discussion The longitudinal sample is characterized by a higher proportion of blue- collar employees and of employees with basic education as compared to the German work force. However, findings from a representative sample of the German work force support the existence of associations between SSI and health. Conclusions Findings suggest that SSI is associated with poor health (risk of IHD, self- rated health) in employed men and women. Reference: Peter R, Gässler H, Geyer S. Social status, status inconsistency and risk of schemic heart disease among members of a statutory health insurance company. J Epidemiol Community Health 2006; accepted for publication Correspondence: richard.peter@uni-ulm.de