Abstract
Despite growing evidence that social and economic factors are important determinants of health disparities, there is a lack of understanding of how these factors operate in relation to health. This article explores 3 conceptual and methodological issues impeding nursing research in this area: (1) ambiguity surrounding socioeconomic status (SES), both conceptually and as a scientific indicator; (2) the narrow focus on biological and behavioral risks for chronic disease development; and (3) the persistent centrality of individual behavior in studies examining SES-health contextual relationships. A brief overview of emerging approaches for enhancing nursing science in the area of SES and health disparities is presented.
"IDEAS about the inevitability of poverty, unequal access, unhealthy life styles, substandard living and working conditions, and poor health are reinforced when the relationships among these conditions are not fully examined or understood." 1(p11) So ended Nelson's contribution on economic impoverishment to a 1994 issue of this journal. Nearly a decade later the relationships she spoke to remain largely unexplained, although the evidence that socioeconomic status (SES) makes a difference in health continues to mount. How, precisely, SES is linked to health status is still not clear.
Progress, however, is being made with respect to decreasing health disparities and to creating innovative approaches that address the complexities of measuring socioeconomic determinants of health. These beginning advances are critical given that individuals at lower social and economic rungs often bear the brunt of economic, cultural, and political upheavals. In the United States, upheaval is evidenced in current state budget crises that are contributing to increasing health care costs, decreasing publicly funded health insurance plans, and eroding social welfare programs.
Much of the impetus for examining disparities in health has emerged from federal funding priorities. The National Institutes of Health (NIH) Work Group on Health Disparities defines health disparities as "differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the US" 2 As written, this definition is broad in scope and does not specify features that consistently account for some of the greatest disparities in population health, such as SES. The gradient in morbidity and mortality by SES in nearly every physical and mental dimension of health has been documented for hundreds of years, observed consistently across studies, within and across countries and cultures, and persists today. 3,4 Yet, even if the definition specifically referred to SES, it does not provide any indication of what may be the etiology-or etiologies-that underlie persistent gradients observed between SES and health.
Requests for applications from NIH within the past 2 years highlight the need for studies that explicitly examine how the broader social environment, represented by some measure of SES, affects health either indirectly (eg, via health behaviors or psychological processes) or directly (eg, by exposure to environmental toxins). 5,6 NIH requests for research that links social and economic determinants to health reflects the growing evidence that behavioral interventions at the individual level have done little to reduce large inequalities in health at the population level. 7 It also suggests that investigators-including nurse investigators-left to their own devices, may not independently think or look outside the proverbial "box" in order to better understand the multiple, likely interacting, mechanisms behind SES-related health disparities. The fact that, with few exceptions, the etiology of most disease states can only be found in a "web of causation" is clearly articulated in the literature. 8
Using Nelson's paper 1 as a foundation, this article advances the conversation about the conceptual and methodological issues implicated in exploring links between SES and health in nursing research. We concentrate on 3 conceptual and methodological issues that have impeded nursing research in the area of SES and health: (1) ambiguity surrounding SES, both conceptually and as a scientific indicator; (2) the narrow focus on biological and behavioral risks for chronic disease development; and (3) the persistent centrality of individual behavior in studies examining SES-health contextual relationships. Lastly, a brief overview of emerging approaches for enhancing nursing science in the area of SES and health disparities is presented.