Differences in socioeconomic status, whether measured by income, educational achievement, or occupation, are associated with large disparities in health status.1 This association persists across the life cycle2,3 and across measures of health, including health status,4 morbidity,5 and mortality.6 Although effects are largest for those living in poverty, gradients of disparity are seen across the socioeconomic spectrum.7
This article discusses health disparities based on socioeconomic status in the context of urban health care. We begin by discussing the relationships among race, socioeconomic status, and health. We trace disparities in health based on socioeconomic status throughout the course of an individual's life and review potential explanations for this relationship. We conclude by discussing the implications of these disparities for the provision of health care to urban, low-income, and minority patients. Studies for this review were identified through selected Medline searches, bibliographic searches of key articles, and the authors’ knowledge of the literature. The size of the literature on health disparities precluded a complete, systematic literature search.
The Interrelation of Race, Socioeconomic Status, and Health
Race, socioeconomic status, and health have historically been inextricably intertwined in the United States. Unlike most countries, however, the United States collects national health data primarily by race and not by socioeconomic status.8 African Americans have experienced varying levels of social, economic, and political exclusion that have resulted in poorer health since their arrival on this continent as slaves several hundred years ago.9 Historically, slavery in the United States was rationalized on the basis of racism—an ideology of oppression based on a belief in the inherent racial biological inferiority of one race and the superiority of another.10 The construct of race, however, is socially derived with limited biological basis.11
To this day, as a legacy of this oppression, African Americans experience dramatically worse health across the age spectrum, including higher adult and infant mortality.12,13 They have significantly higher mortality rates from cardiovascular and cerebrovascular disease, most cancers, diabetes, HIV, unintentional injuries, pregnancy, sudden infant death syndrome, and homicide than do whites.14 These health disparities have been rationalized on the basis of genetic “differences” despite evidence that genetics does not contribute significantly to these disparities.15,16 Racial differences in socioeconomic status, not genetics, are the most important cause of these health disparities.6
Racism perpetuates these health disparities by operating at three distinct levels: institutionalized policies and practices that maintain racial disadvantage, individual racial discrimination and biased treatment, and internalized cognitive processes.17 Each reinforces the others. Institutionalized racism, manifested through long-standing racial inequities in employment, housing, education, health care, income, wealth, and criminal justice, is reinforced through racist beliefs.18 Individual racism, including unconscious bias, is manifested through discrimination in housing, banking and employment, racial profiling by police, harsher sentencing for minority defendants, lower educational expectations for minority students, and unequal medical treatment.19 Racial stereotypes contribute to voting patterns and public policies that, in turn, reinforce institutionalized racism. Internalized racism refers to introjection of racial stereotypes by the minority group members. Internalized racism may contribute to self doubts, lower school performance, depressive symptoms, substance abuse, dropouts, and other risk behaviors.20–22
Residential segregation, a product of long-standing institutional and individual racism,23 represents a fundamental cause of racial disparities in health because it perpetuates racial disparities in poverty, education, and economic opportunity that, in turn, drive disparities in health.24 The social and spatial marginalization associated with segregation reinforces substandard housing, underfunded public schools, employment disadvantages, exposure to crime, environmental hazards, and loss of hope, thus powerfully concentrating disadvantage.25
Health Disparities Across the Life Cycle
Fetal and Neonatal Health
Health disparities resulting from socioeconomic status begin early in life, but have potential for lasting effects.26 Disparities in health potentially begin in utero because the health of the fetus is so closely linked to the health of the mother. A mother's low socioeconomic status is associated with multiple risk factors for adverse birth outcomes, including unplanned and unwanted pregnancy,27 single and/or adolescent motherhood,27 smoking,28 urogenital tract infections,29 chronic illness in the mother, and inadequate prenatal care.30 Not surprisingly, a mother's low socioeconomic status, and to some extent the low socioeconomic status of the father, are associated with low birth weight31 and infant mortality.32
Socioeconomic disparities continue into childhood.33 Children of low socioeconomic status have greater risks of death from infectious disease,34 sudden infant death,35 accidents,36 and child abuse.37 They have higher rates of exposure to lead poisoning38 and household smoke.39 They have higher rates of asthma,40 developmental delay and learning disabilities,41 conduct disturbances,42 and avoidable hospitalizations.43 They more often reside in families with marital conflict44 and are more often exposed to intimate-partner45 and community violence.45 Low socioeconomic status and overcrowding are associated with infectious disease including tuberculosis34 and Helicobacter pylori infection.46 By their preteen years, children of low socioeconomic status report lower health status and more risk behaviors.2
Low socioeconomic status affects adolescents as well. Low socioeconomic adolescents report worse health; they have higher rates of pregnancy,47 sexually transmitted disease,48 depression, obesity,49 and suicide.50 They are more likely to be sexually abused,51 drop out of high school,52 or be killed.53 Satisfaction with health, better family involvement, better problem solving, more physical activity, better home safety, having higher school achievement, and being in the best health profiles are all positively related to parental socioeconomic status during adolescence.54
By adulthood, health disparities related to socioeconomic status are striking. Compared with persons who have a college education, those with less than a high school education have life expectancies that are six years shorter.6 People with low socioeconomic status experience higher rates of death across the spectrum of causes.55 They experience premature chronic morbidity and disability including the onset of hypertension at an earlier age,56 diabetes,57 cardiovascular disease,58 obesity,59 osteoarthritis,60 depression,61 oral pathology,62 many cancers,63 and cardiovascular disease.64
Health disparities among the elderly that are related to socioeconomic status begin to narrow slightly, perhaps due to healthy survivor effects.65 Nonetheless, elderly people of low socioeconomic status experience greater disability,66 more limitations in activities in daily living,67 and more frequent and rapid cognitive decline.68 Having achieved higher educational levels tends to be associated with the prevention of functional limitations, while a higher income level is associated with both prevention and delayed progression of functional decline.69
The relationship between socioeconomic status and health is complex. Socioeconomic status has been defined as potential or realized access to resources in three major domains: material, human, and social capital.70 Thus, it is not surprising that a relationship between socioeconomic status and health has persisted across time, place, and changes in epidemiology. Socioeconomic status represents a fundamental cause of health.71
Undoubtedly, poor health can result in low socioeconomic status. Persons with disabilities, whether physical or psychiatric, often achieve lower educational, occupational, and income outcomes than do persons without such disabilities. Similarly, persons who experience serious illness or disability often face unemployment or downward mobility. While health status can affect socioeconomic status, there is compelling evidence that socioeconomic status strongly affects health. Longitudinal studies have documented that low education usually predicts a decline in health.72 Education is typically achieved during early adulthood when morbidity is relatively uncommon.73 Furthermore, disparities have been demonstrated among the fully employed.7 Thus, although poor health contributes to low socioeconomic status, there is convincing evidence that low socioeconomic status also causes poor health.
Genetic factors may partly confound the relationship between health and socioeconomic status, but socioeconomic status clearly affects health independently of genetic factors. Cognitive ability74 and personality75 are partly genetically determined; childhood IQ76 predicts adult survival; and personality is associated with educational attainment.77 However, socioeconomic status in childhood has been shown to predict adult health independent of childhood IQ,78 and quantitative genetic studies show that the effects of the level of educational attainment are independent of genetic confounding.79 Twin studies80 and natural experiments42 show that neighborhood environment and the socioeconomic status of parents affect children's health outcomes. Disparities in cognitive performance related to socioeconomic status tend to diverge as children progress through school, suggesting that the detrimental effects of low socioeconomic status on cognitive ability are cumulative.81 The available evidence shows that postneonatal-, preschool-, and school-age interventions can reduce disparities in cognitive and socioemotional development based on socioeconomic status.82
The available evidence suggests that socioeconomic status affects health through myriad pathways. As illustrated earlier, disparities in health begin early in life. There is growing evidence to support the Barker hypothesis that fetal growth restriction is associated with higher rates of obesity, hypertension, diabetes, and cardiovascular disease.83 If this hypothesis is correct, then disparities in fetal health based on socioeconomic status likely predispose a person to disparities in adult health. Similarly, fetal exposure to the effects of maternal smoking have been linked to behavioral disorders in childhood.84 Multiple risk factors likely combine in complex ways to affect subsequent health. One recent study found that, at 24 months, low-income children exposed to both prenatal tobacco smoke and material hardship had the highest cognitive deficits.85
The level of socioeconomic status during childhood independently predicts educational attainment and adult mortality.86 The pathways through which socioeconomic status of children affects adult health include cognitive stimulation,82 family conflict,44 childhood abuse,87 exposure to environmental toxins,88 family structure,89 divorce,90 and autonomy support.86 These risks appear to be additive, if not multiplicative.91
Inadequate cognitive stimulation, child abuse, and neglect can have lasting effects on emotional development, psychiatric health, and risk-taking behavior.92,93 Thus, early childhood effects may affect mental functioning of adults, which in turn can affect their physical health.94 People with lower socioeconomic status are also at higher risk for exposure to environmental toxins including lead,38 passive smoke,39 air pollution,95 cockroach excrement,96 violent crime, alcohol stores,97 and cigarette and smoking advertising.98 The built environment in inner cities also adversely affects mental health.99 Presumably, as a consequence of repeated exposure to stress and psychological trauma, children of low socioeconomic status show heightened cardiovascular response to psychological stress.100
Rates of unhealthy behavior, including inadequate physical activity, smoking, and poor diet, are more prevalent among persons of low socioeconomic status, but differences in these behaviors explain a relatively small portion of disparities in mortality.101 Furthermore, disparities in these behaviors are largely socially determined.102 They likely represent a combination of differences in the built and social environments, self-efficacy, and maladaptive responses to stress.
Lack of resources—whether financial hardship, low literacy, limited access to health care, or social marginalization—is associated with chronic stress. Exposure to chronic stress is detrimental to health because it results in continued “wear and tear,” termed “allostastic load.”103 Available evidence suggests that the stress associated with low socioeconomic status has cumulative physiological effects,104 including adverse metabolic, autonomic, and brain effects such as hippocampal atrophy.105 Conversely, high socioeconomic status is associated with improved psychological coping, including self-efficacy and perceived control, which in turn is associated with improved health and reduced mortality.106
Notably, low socioeconomic status is consistently related to reduced access to quality health care.107 Low income is associated with higher rates of reduced access to health care, higher rates of uninsurance, and absence of a regular source of care.108 Low income and type of insurance are associated with less preventative care for children or adults109; lower-intensity hospital care,110 including fewer cardiac or vascular procedures; and worse outcomes following these procedures.111,112 Low-income persons receive lower quality ambulatory113 and hospital care,114 including fewer prescriptions for aspirin and/or provision of thrombolysis for myocardial infarction.115 Absence of insurance has been consistently related to a range of adverse outcomes, including higher mortality.116
The Concentration of Risk
The effects of socioeconomic status on health are amplified because risk factors associated with low socioeconomic status tend to cluster within individuals, families, and communities. Risk factors are further concentrated by racial and socioeconomic residential segregation.117 Moreover, each of the three domains of socioeconomic status (material, human, and social capital) are correlated with each other. Consequently, a person with little education is at risk for being low income and jobless. People of low socioeconomic status likely share a household with others of the same status and reside in a low-socioeconomic-status community. Although there are more poor white than black persons in the United States, one reason for the greater adverse impact of poverty on African Americans is that poor blacks are markedly more likely than are their white peers to reside in high-poverty residential areas.25 Even if the health of a person of low socioeconomic status has not yet been affected, there is greater risk for ill health among his or her family members. Furthermore, living in a community of low socioeconomic status is associated with higher cardiovascular mortality independent of the socioeconomic characteristics of the individual.118 Low-income children, particularly those living in racially segregated communities, typically attend schools where risk factors are further concentrated. Given these contextual effects, persons with low socioeconomic status are more likely to be exposed to crime, violence, and drug trafficking, and they are less likely to be exposed to successful role models119 or social networks that facilitate upward mobility.120 The cumulative toll from these concentrated risk factors can be devastating to individual, families, and communities.
Implications for Urban Medicine
Most health care provided to the urban poor is delivered by safety-net providers,121 including hospital outpatient clinics, community health centers, and other not-for-profit organizations. However, this safety net of providers is endangered.122 Half of all community health centers have endured financial crises,123 and many struggle to retain physicians.124
Providers serving urban, low-socioeconomic-status, minority patients will be confronted with clinical, logistical, paperwork, and administrative challenges. Their work is more clinically challenging not simply because patients suffer greater levels of biomedical morbidity, but also because this morbidity is embedded within a complex web of psychosocial morbidity. Physicians are likely to confront problems in communication and shared understanding that are related to differences in language, culture, and health literacy.125 Unlike suburban practices where patients often present with single problems, patients in low-income, urban practices often present with a complex array of problems.126 For example, it is not uncommon to see low-income minority women with diabetes, hypertension, hyperlipidemia, obesity, arthritis, depression, and low levels of health literacy who are overwhelmed by financial hardships and family problems. Working with the urban poor means working with patients who not only have greater biopsychosocial morbidity and risk factors,4 but also have far fewer resources at their disposal to cope with these problems.127
The number of patients presenting with complex biopsychosocial problems can be overwhelming to urban health care providers. Patients with low levels of health literacy require more time, not less, to explain treatment.128 Posttraumatic stress management among refugees requires working across differences in language and cultural beliefs.125,129 Specialty services are often not easily available for the uninsured.130 Caring for a handful of such patients is challenging. Caring for multiple patients with complex needs can be overwhelming in the absence of adequate systems of care. Preventive care services may be neglected in the face of multiple and competing providers’ demands.131 Access to specialist, diagnostic, and behavioral health services may be limited.132
Providing medical care to urban low-income populations also poses administrative challenges. Appointment-time scheduling can be problematic. Missed appointments are significantly higher at practices with patients from low socioeconomic status.133 A patient coming in for a routine diabetes checkup might suddenly disclose that she is homeless or that her son has been murdered. Practices frequently compensate for missed appointments by overbooking patients, which results in long wait times for patients.
Paperwork demands are considerable. These include certification of employability for welfare, assessment of temporary or long-term disability, worker's compensation, disabled parking permits, case management, job training, childcare certification, school enrollment, Medicaid preauthorization for medications, transportation services, increase in Medicaid visit or medication thresholds, and medication refills. Although completing paperwork has become routine in primary care, the volume is magnified in practices with patients of low socioeconomic status who often lack adequate ancillary support.
Despite the greater amount of time and expense required to work with low-income patients, reimbursement is significantly lower. Medicaid reimburses physicians at significantly lower rates than does other insurance.134 Moreover, most persons living at or below federal poverty are not eligible for Medicaid135,136; many have no health insurance or have health care coverage that fails to cover needed prescriptions, and high prescription costs deter adherence.137 Even among patients with private insurance, reimbursement may be lower. Existing billing codes do not adequately capture the complexity, time, and expense involved in caring for patients in low-socioeconomic-status urban areas. For example, use of language interpreters can add from six to nine minutes to office visits.138 Given these challenges, it is hardly surprising that many physicians eschew working with poor139 or uninsured patients.140
Health Care Quality
Despite these challenges, providing quality health care in urban practices is feasible.141 Community health centers in particular have been shown to provide care comparable to that provided to more advantaged populations.142 Providing quality care requires not only sound clinical skills, but also the ability to effectively integrate biomedical, psychological, and social factors; cultural competency; and patient-centered care.143 It also requires the presence of systems designed to promote quality.144 Reminder systems for busy health care providers can mitigate the effects of competing demands, tracking systems help ensure follow-up on abnormal results, chronic disease registries can be used to promote adherence to treatment guidelines, and outreach can be extended to hard-to-reach patients.145 Electronic technology systems can facilitate these tasks.146 Same-day appointment scheduling can improve access and reduce no-show rates.147 On-site interpretation services are critical.148
Implementation of these measures should reduce disparities in health care quality based on patients’ racial, ethnic, or socioeconomic status and facilitate progress towards the Healthy People 2010 goal of eliminating disparities in health. However, achieving this goal will likely require more than the elimination of disparities in health care; it will require a sustained national commitment to addressing the fundamental causes of disparities in health.
1.Anderson RT, Sorlie P, Backlund E, Johnson N, Kaplan GA. Mortality effects of community socioeconomic status. Epidemiology. 1997;8:42–7.
2.Starfield B, Robertson J, Riley AW. Social class gradients and health in childhood. Ambul Pediatr. 2002;2:238–46.
3.Smith JP, Kington R. Demographic and economic correlates of health in old age. Demographics. 1997;34:159–70.
4.Fiscella K. Is lower income associated with greater biopsychosocial morbidity? Implications for physicians working with underserved patients. J Fam Pract. 1999;48:372–7.
5.Marmot M, Shipley M, Brunner E, Hemingway H. Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study. J Epidemiol Community Health. 2001;55:301–7.
6.Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347:1585–92.
7.Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337:1387–93.
8.Williams DR. Race/ethnicity and socioeconomic status: measurement and methodological issues. Int J Health Serv. 1996;26:483–505.
9.Byrd WM, Clayton LA. An American health dilemma: a history of blacks in the health system. J Nat Med Assoc. 1992;84:189–200.
10.Zuberi Z. Thicker than Blood: How Racial Statistics Lie. Minneapolis: University of Minnesota Press, 2001.
11.American Anthropological Association. Statement on race. Am Anthropol. 1998;100:712–3.
12.Otten MW Jr, Teutsch SM, Williamson DF, Marks JS. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA. 1990;263:845–50.
13.Sorlie P, Rogot E, Anderson R, Johnson NJ, Backlund E. Black-white mortality differences by family income. Lancet. 1992;340:346–50.
14.Eberhardt MS, Ingram DD, Makuc DM. Urban and Rural Health Chartbook, Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics, 2001.
15.Cooper RS. Race, genes, and health—new wine in old bottles? Int J Epidemiol. 2003;32:23–5.
16.Pearce N, Foliaki S, Sporle A, Cunningham C. Genetics, race, ethnicity, and health. BMJ. 2004;328:1070–2.
17.Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000;90:1212–5.
18.Hilfiker D. Urban Injustice: How Ghettos Happen. New York: Seven Stories Press, 2002.
19.Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press, 2002.
20.Patterson O. Rituals of Blood: Consequences of Slavery in Two American Centuries. New York: BasicBooks, 1999.
21.Taylor B, Henderson B, Jackson B. A holistic model for understanding and predicting depression in African American women. J Community Psychol. 1991;19:306–20.
22.Taylor J, Jackson B. Factors affecting alcohol consumption in black women. Part II. Int J Addict. 1990;25:1415–27.
23.Massey DS, Denton NA. Hypersegregation in U.S. metropolitan areas: black and Hispanic segregation along five dimensions. Demographics. 1989;26:373–91.
24.Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116:404–16.
25.Wilson WJ. The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy. Chicago: University of Chicago Press, 1987.
26.Lundberg O. The impact of childhood living conditions on illness and mortality in adulthood. Soc Sci Med. 1993;36:1047–52.
27.Cubbin C, Braveman PA, Marchi KS, Chavez GF, Santelli JS, Gilbert BJ. Socioeconomic and racial/ethnic disparities in unintended pregnancy among postpartum women in California. Maternal Child Health J. 2002;6:237–46.
28.Gazmararian JA, Adams MM, Pamuk ER. Associations between measures of socioeconomic status and maternal health behavior. Am J Prev Med. 1996;12:108–15.
29.Krieger N, Waterman PD, Chen JT, Soobader MJ, Subramanian SV. Monitoring socioeconomic inequalities in sexually transmitted infections, tuberculosis, and violence: geocoding and choice of area-based socioeconomic measures–the public health disparities geocoding project (US). Public Health Rep. 2003;118:240–60.
30.Abel MH. Maternal characteristics and inadequate prenatal care. Psychol Rep. 1996;79:903–12.
31.Hessol NA, Fuentes-Afflick E, Bacchetti P. Risk of low birth weight infants among black and white parents. Obstet Gynecol. 1998;92:814–22.
32.Wise PH, Kotelchuck M, Wilson ML, Mills M. Racial and socioeconomic disparities in childhood mortality in Boston. N Engl J Med. 1985;313:360–6.
33.Chen E, Matthews KA, Boyce WT. Socioeconomic differences in children's health: how and why do these relationships change with age? Psychol Bull. 2002;128:295–329.
34.Drucker E, Alcabes P, Bosworth W, Sckell B. Childhood tuberculosis in the Bronx, New York. Lancet. 1994;343:1482–5.
35.Nam CB, Eberstein IW, Deeb LC. Sudden infant death syndrome as a socially determined cause of death. Soc Biol. 1989;36:1–8.
36.Marcin JP, Schembri MS, He J, Romano PS. A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates. Am J Public Health. 2003;93:461–6.
37.Wolfner GD, Gelles RJ. A profile of violence toward children: a national study. Child Abuse Negl. 1993;17:197–212.
38.Bernard SM, McGeehin MA. Prevalence of blood lead levels >or= 5 micro g/dL among US children 1 to 5 years of age and socioeconomic and demographic factors associated with blood of lead levels 5 to 10 micro g/dL, Third National Health and Nutrition Examination Survey, 1988-1994. Pediatrics. 2003;112:1–13.
39.Mannino DM, Caraballo R, Benowitz N, Repace J. Predictors of cotinine levels in US children: data from the Third National Health and Nutrition Examination Survey. Chest. 2001;120:718–24.
40.Smith LA, Hatcher JL, Wertheimer R. The association of childhood asthma with parental employment and welfare receipt. J Am Med Womens Assoc. 2002;57:11–5.
41.To T, Cadarette SM, Liu Y. Biological, social, and environmental correlates of preschool development. Child. 2001;27:187–200.
42.Costello EJ, Compton SN, Keeler G, Angold A. Relationships between poverty and psychopathology: a natural experiment. JAMA. 2003;290:2023–9.
43.Hakim RB, Bye BV. Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics. 2001;108:90–7.
44.Conger RD, Ge X, Elder GH Jr, Lorenz FO, Simons RL. Economic stress, coercive family process, and developmental problems of adolescents. Child Develop. 1994;65:541–61.
45.Sheehan K, DiCara JA, LeBailly S, Christoffel KK. Children's exposure to violence in an urban setting. Arch Pediatr Adolesc Med. 1997;151:502–4.
46.Malaty HM, Graham DY. Importance of childhood socioeconomic status on the current prevalence of Helicobacter pylori
infection. Gut. 1994;35:742–5.
47.Gold R, Kennedy B, Connell F, Kawachi I. Teen births, income inequality, and social capital: developing an understanding of the causal pathway. Health Place. 2002;8:77–83.
48.Rice RJ, Roberts PL, Handsfield HH, Holmes KK. Sociodemographic distribution of gonorrhea incidence: implications for prevention and behavioral research. Am J Public Health. 1991;81:1252–8.
49.Goodman E, Slap GB, Huang B. The public health impact of socioeconomic status on adolescent depression and obesity. Am J Public Health. 2003;93:1844–50.
50.McCall PL. Adolescent and elderly white male suicide trends: evidence of changing well-being? J Gerontol. 1991;46:S43–51.
51.Moore KA, Nord CW, Peterson JL. Nonvoluntary sexual activity among adolescents. Fam Plann Perspect. 1989;21:110–4.
52.Vartanian TP, Gleason PM. Do neighborhood conditions affect high school dropout and college graduation rates? J Socioecon. 1999;28:21–41.
53.Dahlberg LL. Youth violence in the United States: major trends, risk factors, and prevention approaches. Am J Prev Med. 1998;14:259–72.
54.Starfield B, Riley AW, Witt WP, Robertson J. Social class gradients in health during adolescence. J Epidemiol Community Health. 2002;56:354–61.
55.Howard G, Anderson RT, Russell G, Howard VJ, Burke GL. Race, socioeconomic status, and cause-specific mortality. Ann Epidemiol. 2000;10:214–23.
56.Vargas CM, Ingram DD, Gillum RF. Incidence of hypertension and educational attainment: the NHANES I epidemiologic followup study. First National Health and Nutrition Examination Survey. Am J Epidemiol. 2000;152:272–8.
57.Robbins JM, Vaccarino V, Zhang H, Kasl SV. Socioeconomic status and type 2 diabetes in African American and non-Hispanic white women and men: evidence from the Third National Health and Nutrition Examination Survey. Am J Public Health. 2001;91:76–83.
58.He J, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med. 2001;161:996–1002.
59.Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA. 1998;279:1703–8.
60.Hannan MT, Anderson JJ, Pincus T, Felson DT. Educational attainment and osteoarthritis: differential associations with radiographic changes and symptom reporting. J Clin Epidemiol. 1992;45:139–47.
61.Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003;157:98–112.
62.Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent. 2002;62:140–7.
63.Gorey KM, Vena JE. The association of near poverty status with cancer incidence among black and white adults. J Community Health. 1995;20:359–66.
64.Everson SA, Maty SC, Lynch JW, Kaplan GA. Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes. J Psychosom Res. 2002;53:891–5.
65.Von Dem KO, Luschen G, Cockerham WC, Siegrist J. Socioeconomic status and health among the aged in the United States and Germany: a comparative cross-sectional study. Soc Sci Med. 2003;57:1643–52.
66.Melzer D, Izmirlian G, Leveille SG, Guralnik JM. Educational differences in the prevalence of mobility disability in old age: the dynamics of incidence, mortality, and recovery. J Gerontol B Psychol Sci Soc Sci. 2001;56:S294–301.
67.Kington RS, Smith JP. Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. Am J Public Health. 1997;87:805–10.
68.Farmer ME, Kittner SJ, Rae DS, Bartko JJ, Regier DA. Education and change in cognitive function. The Epidemiologic Catchment Area Study. Ann Epidemiol. 1995;5:1–7.
69.Zimmer Z, House JS. Education, income, and functional limitation transitions among American adults: contrasting onset and progression. Int J Epidemiol. 2003;32:1089–97.
70.Oakes J, Rossi P. The measurement of SES in health research: current practice and steps toward a new approach. Soc Sci Med. 2003;56:769–84.
71.Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80-94.
72.Ross CE, Wu CI. The links between education and health. Am Soc Rev. 1995;60:719–45.
73.Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002;21:60–76.
74.Stoolmiller M. Implications of the restricted range of family environments for estimates of heritability and nonshared environment in behavior-genetic adoption studies. Psychol Bull. 1999;125:392–409.
75.McCrae RR, Jang KL, Livesley WJ, Riemann R, Angleitner A. Sources of structure: genetic, environmental, and artifactual influences on the covariation of personality traits. J Personality. 2001;69:511–35.
76.Whalley LJ, Deary IJ. Longitudinal cohort study of childhood IQ and survival up to age 76. BMJ. 2001;322:819.
77.Goodwin R, Engstrom G. Personality and the perception of health in the general population. Psychol Med. 2002;32:325–32.
78.Hart CL, Taylor MD, Davey SG, et al. Childhood IQ, social class, deprivation, and their relationships with mortality and morbidity risk in later life: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies. Psychosom Med. 2003;65:877–83.
79.Lichtenstein P, Harris JR, Pedersen NL, McClearn GE. Socioeconomic status and physical health, how are they related? An empirical study based on twins reared apart and twins reared together. Soc Sci Med. 1993;36:441–50.
80.Caspi A, Taylor A, Moffitt TE, Plomin R. Neighborhood deprivation affects children's mental health: environmental risks identified in a genetic design. Psychol Sci. 2000;11:338–42.
81.Jefferis BJ, Power C, Hertzman C. Birth weight, childhood socioeconomic environment, and cognitive development in the 1958 British birth cohort study. BMJ. 2002;325:305.
82.Hertzman C, Wiens M. Child development and long-term outcomes: a population health perspective and summary of successful interventions. Soc Sci Med. 1996;43:1083–95.
83.Barker DJ. The fetal and infant origins of adult disease. BMJ. 1990;301:1111.
84.Thapar A, Fowler T, Rice F, et al. Maternal smoking during pregnancy and attention deficit hyperactivity disorder symptoms in offspring. Am J Psychiatry. 2003;160:1985–9.
85.Rauh VA, Whyatt RM, Garfinkel R, et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol. 2004;26:373–85.
86.Bosma H, Mheen HD, Mackenbach JP. Social class in childhood and general health in adulthood: questionnaire study of contribution of psychological attributes. BMJ. 1999;318:18–22.
87.Rohner RP, Rohenr EC. Antecedents and consequences of parental rejection: a theory of emotional abuse. Child Abuse Negl. 1980;4:189–98.
88.Lanphear BP, Hornung R, Ho M, et al. Environmental lead exposure during early childhood. J Pediatr. 2002;140:40–7.
89.McLanahan SS. Parent Absence or Poverty: Which Matters More? In: Duncan GJ, Brooks-Gunn J (eds). Consequences of Growing up Poor. New York: Russell Sage Foundation, 1997.
90.Friedman HS. Long-term relations of personality and health: dynamisms, mechanisms, tropisms. J Personal. 2000;68:1089–107.
91.Evans GW. The environment of childhood poverty. Am Psychol. 2004;59:77–92.
92.Andersson HW, Sommerfelt K, Sonnander K, Ahlsten G. Maternal child-rearing attitudes, IQ, and socioeconomic status as related to cognitive abilities of five-year-old children. Psychol Rep. 1996;79:3–14.
93.Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med. 2003;37:268–77.
94.Rutter M. Childhood experiences and adult psychosocial functioning. Ciba Found Sympos. 1991;156:189–200.
95.Gunier RB, Hertz A, Von Behren J, Reynolds P. Traffic density in California: socioeconomic and ethnic differences among potentially exposed children. J Exposure Analysis and Environ Epidemiol. 2003;13:240–6.
96.Leaderer BP, Belanger K, Triche E, et al. Dust mite, cockroach, cat, and dog allergen concentrations in homes of asthmatic children in the northeastern United States: impact of socioeconomic factors and population density. Environ Health Perspect. 2002;110:419–25.
97.Morland K, Wing S, Diez RA, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med. 2002;22:23–9.
98.Laws MB, Whitman J, Bowser DM, Krech L. Tobacco availability and point of sale marketing in demographically contrasting districts of Massachusetts. Tob Control. 2002;11 suppl 2:ii71–3.
99.Evans GW. The built environment and mental health. J Urban Health. 2003;80:536–55.
100.Chen E, Matthews KA. Cognitive appraisal biases: an approach to understanding the relation between socioeconomic status and cardiovascular reactivity in children. Ann Behav Med. 2001;23:101–11.
101.Lantz PM, Lynch JW, House JS, et al. Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors. Soc Sci Med. 2001;53:29–40.
102.Chin NP, Monroe A, Fiscella K. Social determinants of (un)healthy behaviors. Educ Health. 2001;13:317–28.
103.McEwen BS. Stress, adaptation, and disease. Allostasis and allostatic load. Ann N Y Acad Sci. 1998;840:33–44.
104.Lynch JW, Kaplan GA, Shema SJ. Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. N Engl J Med. 1997;337:1889–95.
105.Seeman TE, Crimmins E, Huang MH, et al. Cumulative biological risk and socio-economic differences in mortality: MacArthur studies of successful aging. Soc Sci Med. 2004;58:1985–97.
106.Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet. 1997;350:235–9.
107.Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283:2579–84.
108.Shi L. The convergence of vulnerable characteristics and health insurance in the US. Soc Sci Med. 2001;53:519–29.
109.Hahn RA, Teutsch SM, Franks AL, Chang MH, Lloyd EE. The prevalence of risk factors among women in the United States by race and age, 1992-1994: opportunities for primary and secondary prevention. J Am Med Womens Assoc. 1998;53:96–104, 107.
110.Yergan J, Flood AB, Diehr P, LoGerfo JP. Relationship between patient source of payment and the intensity of hospital services. Med Care. 1988;26:1111–4.
111.Alter DA, Naylor CD, Austin P, Tu JV. Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med. 1999;341:1359–67.
112.Boxer LK, Dimick JB, Wainess RM, et al. Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States. Surgery. 2003;134:142–5.
113.Brook RH, Kamberg CJ, Lohr KN, Goldberg GA, Keeler EB, Newhouse JP. Quality of ambulatory care. Epidemiology and comparison by insurance status and income. Med Care. 1990;28:392–433.
114.Kahn KL, Pearson ML, Harrison ER, et al. Health care for black and poor hospitalized Medicare patients. JAMA. 1994;271:1169–74.
115.Rathore SS, Berger AK, Weinfurt KP, et al. Race, sex, poverty, and the medical treatment of acute myocardial infarction in the elderly. Circulation. 2000;102:642–8.
116.Institute of Medicine. Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press, 2002.
117.Massey DS, Denton NA. American Apartheid: The Making of the Underclass. Cambridge, MA: Harvard University Press, 1993.
118.Diez Roux AV, Merkin SS, Arnett D, et al. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001;345:99–106.
119.Elliot DS, Wilson WJ, Huizinga D, Sampson RJ. The effects of neighborhood disadvantage on adolescent development. J Res Crime Delinq. 1996;33:389–426.
120.Wegener B. Job mobility and social ties: social resources, prior job, and status attainment. Am Soc Rev. 1960;56:60–71.
121.Prinz TS, Soffel D. The primary care delivery system in New York's low-income communities: private physicians and institutional providers in nine neighborhoods. J Urban Health. 2003;80:635–49.
122.Institute of Medicine. America's Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press, 2000.
123.McAlearney JS. The financial performance of community health centers, 1996-1999. Clear evidence that many CHCs are on the brink of financial insolvency. Health Affairs. 2002;21:219–25.
124.Singer JD, Davidson SM, Graham S, Davidson HS. Physician retention in community and migrant health centers: who stays and for how long? Med Care. 1998;36:1198–213.
125.Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.
126.Blankfield RP, Goodwin M, Jaen CR, Stange KC. Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices. J Urban Health. 2002;79:173–85.
127.Weiner S. “I can't afford that!”: dilemmas in the care of the uninsured and underinsured. J Gen Intern Med. 2001;16:412–8.
128.Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Internal Med. 2003;163:83–90.
129.Eisenman DP, Gelberg L, Liu H, Shapiro MF. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA. 2003;290:627–34.
130.Weissman JS, Moy E, Campbell EG, et al. Limits to the safety net: teaching hospital faculty report on their patients’ access to care. Health Affairs. 2003;22:156–66.
131.Jaen CR, Stange KC, Tumiel LM, Nutting P. Missed opportunities for prevention: smoking cessation counseling and the competing demands of practice. J Fam Pract. 1997;45:348–54.
132.Gusmano MK, Fairbrother G, Park H. Exploring the limits of the safety net: community health centers and care for the uninsured. Health Affairs. 2002;21:188–94.
133.Weingarten N, Meyer DL, Schneid JA. Failed appointments in residency practices: who misses them and what providers are most affected? J Am Board Fam Pract. 1997;10:407–11.
134.Perloff JD, Kletke P, Fossett JW. Which physicians limit their Medicaid participation, and why. Health Serv Res. 1995;30:7–26.
135.Guyer J, Broaddus M, Dude A. Millions of mothers lack health insurance coverage in the United States. Most uninsured mothers lack access both to employer-based coverage and to publicly subsidized health insurance. Int J Health Serv. 2002;32:89–106.
136.Pezzin LE, Kasper JD. Medicaid enrollment among elderly Medicare beneficiaries: individual determinants, effects on state policy, and impact on service use. Health Serv Res. 2002;37:827–47.
137.Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Affairs. 2003;22:220–9.
138.Kravitz RL, Helms LJ, Azari R, Antonius D, Melnikow J. Comparing the use of physician time and health care resources among patients speaking English, Spanish, and Russian. Med Care. 2000;38:728–38.
139.Komaromy M, Lurie N, Bindman AB. California physicians’ willingness to care for the poor. West J Med. 1995;162:127–32.
140.Reed MC, Cunningham PJ, Stoddard JJ. Physicians pulling back from charity care. Issue Brief Cent Stud Health Syst Change. 2001;1-4.
141.Bayer WH, Fiscella K. Patients and community together: a family medicine COPC project in an urban private practice. Arch Fam Med. 1999;8:546–9.
142.Starfield B, Powe NR, Weiner JR, et al. Costs vs quality in different types of primary care settings. JAMA. 1994;272:1903–8.
143.Fiscella K. Reducing health care disparities through collaborative care. Fam Systems Health. 2002;20:365–74.
144.Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA. 2002;288:889–93.
145.Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775–9.
146.Bodenheimer T, Grumbach K. Electronic technology: a spark to revitalize primary care? JAMA. 2003;290:259–64.
147.Kennedy JG, Hsu JT. Implementation of an open access scheduling system in a residency training program. Family Med. 2003;35:666–70.
148.Jacobs EA, Lauderdale DS, Meltzer D, et al. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16:468–74.