in the IOM report and other sources (Williams, 1999; Collins, Hall, and Neuhaus, 1999; LaVeist, 2002; Krieger et al., 1993).

Evidence also supports a strong relationship between socioeconomic position (SEP) and both health status and health care access (Lynch and Kaplan, 2000; Krieger, Williams, and Moss, 1997). Explanations for the relationship between SEP and health tend to focus on how differences in material circumstances and in health-related knowledge and behavior are associated with differences in health outcomes (Townsend and Davidson, 1992; Lynch and Kaplan, 2000). Literature examines the relationships between pathways of SEP and health outcomes by suggesting that single indicators of SEP (i.e., education, occupation, or income and wealth) are interconnected (Krieger, Williams, and Moss, 1997). Specifically, education is an important determinant of future employment opportunities, and occupational status is related to earning potential, income, and future wealth. Income, in turn, can directly influence health by enabling the procurement of material circumstances associated with positive health outcomes. For example, individuals with higher incomes are more likely than their poorer counterparts to have the financial means to afford to live in a clean and safe environment and to afford health care insurance.

But the amount of money associated with an individual is only part of the picture. Knowledge of health-related issues and of where and how to seek health care, both typically associated with increased educational status, are also important factors contributing to health outcomes.

While much discussion has taken place regarding the endogeneity of health and socioeconomic position, evidence supporting a link between poor health and decreased SEP is limited and inconsistent across life stages. Instead, research has found stronger support for the pathway of lower socioeconomic position leading to worse health outcomes (Manor, Matthews, and Power, in press; McDonough and Amick, 2001).

It is also well recognized that race and socioeconomic position are highly interrelated and that both of these factors are strongly associated with health status (Adler et al., 1994; Krieger, Williams, and Moss, 1997; Williams, 1999). However, epidemiologists and other public health researchers in general fail to adequately account for the role of SEP factors in racial inequalities research. Socioeconomic position is often not taken into account at all. National Vital Statistics Reports produced by the Centers for Disease Control and Prevention are just one example of multiple official health reports that present data only on the racial distribution of health outcomes and fail to simultaneously address SEP issues (e.g., Anderson, 2002). While other epidemiologic studies find that racial disparities are attenuated once adjustments have been made to account for socioeconomic position, often such approaches are inadequate. Specifically, use of single indicators of socioeconomic position such as education or category of in-



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement