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Archived Comments for: Health inequality in adolescence. Does stratification occur by familial social background, family affluence, or personal social position?

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  1. Socioeconomic position of adolescents. Choosing the exposures.

    Rodrigo Lopez, Department of Community Oral Health & Pediatric Dentistry, Faculty of Health Sciences, University of Aarhus

    31 May 2006

    In a recent issue of the journal, Koivusilta et al. [1], presented a study on health inequalities among adolescents considering school performance as an individual level indicator of socioeconomic position. They further compared it with a set of social indicators at the family level including dimensions of wealth, parental education and occupation, which are broadly used as indicators of socioeconomic position [2]. The authors concluded that “adolescents’ personal social position is a new indicator that should be included in the studies of health inequalities at that age group” [1].

    Some problems may arise with the approach used by Koivusilta et al., calling for a cautious interpretation of the findings.

    When we use indicators of socioeconomic position, we attempt to estimate the position(s) the subjects have within the structure of society [2], and the choice of the indicator to be used should be related to the conceptual model underlying the connection between socioeconomic position, health damaging exposures, health protective resources, and health [2]. We should not believe that introducing a new student-level indicator, we are moving from estimating the position of the family (e.g., parental income, education, occupation, and wealth) towards the assessment of the socioeconomic position of the young, because both indicators are likely to be related, and are likely to determine the individuals’ socioeconomic position in this dependent age group. The potential advantage of personal-level-indicators is that a more direct explanation of the association can eventually be disentangled and that this may simplify the conceptual model.

    However, a common problem investigating the socioeconomic position of adolescents is the fact that the main domains of social position, hereby personal income, achieved education, occupation, and wealth are rather complicated to measure in a valid and reliable form among adolescents, if data are available at all. In fact many studies among adolescents include captive populations in schools does restricting the study population to a single occupation category, a standardized achieved education level by age, and virtually eliminating the personal income variable. On the other side, the use of parental indicators of socioeconomic position have been shown to be rather illustrative of the existence of social inequalities among adolescents and its impact on their health [3-6].

    The approach by Koivusilta et al., is interesting, but an additional problem may arise whit the use of school performance as an exposure variable, because childhood difficulties due to low socioeconomic position of the parents may seriously influence educational attainment [7] thus leaving school performance in the category of outcome instead of exposure. Similarly, poor health status in general is likely to influence school performance. The situation imposed by this relation between the health outcomes, and the variable school performance is risky. It remains unclear from the paper which is the conceptual model underlying the use of school performance, and the inclusion of variables that may be steps in the causal pathway in the regression model may introduce confounding thus leading to spurious results.

    An additional limitation of the use of school performance as an indicator of social position is that it includes only adolescents who attend school, thus excluding subjects at the bottom of the social hierarchy. In a general population based study, the use of achieved education level among adolescents may be more informative.

    Reference List

    1. Koivusilta LK, Rimpela A, Kautiainen SM: Health inequality in adolescence. Does stratification occur by familial social background, family affluence, or personal social position? BMC Public Health 2006, 6:110.

    2. Lynch J, Kaplan G: Socioeconomic position. In Social epidemiology. 1st edition. Edited by Edited by Berkman LF, Kawachi I. New York: Oxford University press, Inc; 2000:13-35.

    3. Macassa G, Ghilagaber G, Bernhardt E, Diderichsen F, Burström B: Inequalities in child mortality in Mozambique: differentials by parental socio-economic position. Soc Sci Med 2003, 57:2255-2264.

    4. Sleskova M, Salonna F, Geckova AM, Nagyova I, Stewart RE, van Dijk JP, Groothoff JW: Does parental unemployment affect adolescents' health? J Adolesc Health 2006, 38:527-535.

    5. Lopez R, Fernández O, Baelum V: Social gradients in periodontal disease among adolescents. Community Dent Oral Epidemiol 2006, 34:184-196.

    6. Wardle J, Robb K, Johnson F: Assessing socioeconomic status in adolescents: the validity of a home affluence scale. J Epidemiol Community Health 2002, 56:595-599.

    7. McLoyd VC: Socioeconomic disadvantage and child development. Am Psychol 1998, 53:185-204.

    Competing interests