Autoimmunity Reviews 13 (2014) 641–654

Contents lists available at ScienceDirect

Autoimmunity Reviews
journal homepage: www.elsevier.com/locate/autrev

Review

Socioeconomic status. The relationship with health and

autoimmune diseases
Omar-Javier Calixto, Juan-Manuel Anaya ⁎
Center for Autoimmune Diseases Research (CREA), Mederi Hospital Universitario Mayor, Universidad del Rosario, Bogota, Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Socioeconomic status (SES) is a hierarchical social classification associated with different outcomes in health and
Received 1 December 2013 disease. The most important factors influencing SES are income, educational level, occupational class, social class,
Accepted 24 December 2013 and ancestry. These factors are closely related to each other as they present certain dependent interactions. Since
Available online 10 January 2014
there is a need to improve the understanding of the concept of SES and the ways it affects health and disease, we
review herein the tools currently available to evaluate SES and its relationship with health and autoimmune
Keywords:
Socioeconomic status
diseases.
Rheumatoid arthritis © 2014 Elsevier B.V. All rights reserved.
Systemic lupus erythematosus
Sjögren's syndrome
Systemic sclerosis
Type 1 diabetes

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
2. What is SES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
3. Measurement tools for SES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
4. SES and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
5. SES and ADs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646
5.1. SES and rheumatoid arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646
5.2. SES and systemic lupus erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
5.3. SES and multiple sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
5.4. SES and type 1 diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
6. Conclusions and perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Take-home messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650

Abbreviations: ACR, American College of Rheumatology; ADs, Autoimmune Diseases;
AIMs, Ancestry Informative Markers; DMARDs, Disease Modifying Anti-Rheumatic
Drugs; HAQ, Health Attitude Questionnaire; HbA1C, Glycated hemoglobin; HRQOL,
Health related Quality of Life; LN, Lupus Nephritis; MS, Multiple Sclerosis; NS-SEC,
National Statistics Socio-Economic Classification; QOL, Quality of Life; RA, Rheumatoid
Arthritis; RAI, Rheumatoid Arthritis Index; RF, Rheumatoid Factor; SES, Socioeconomic
Status; SF-36, Short From-36; SLE, Systemic Lupus Erythematosus; SS, Sjögren's syn-
drome; SSc, Systemic Sclerosis; T1D, Type 1 Diabetes; UK, United Kingdom.
⁎ Corresponding author at: Center for Autoimmune Diseases Research (CREA), School of
Medicine and Health Sciences, Universidad del Rosario, Carrera 24 # 63-C-69, Postal code:
111221 Bogotá, Colombia. Tel.: +57 1 349 9650; fax: +57 1 349 9340.
E-mail address: juan.anaya@urosario.edu.co (J.-M. Anaya).
1. Introduction
There has been a global interest in determining the impact of socio-
economic status (SES) on health and disease. The importance of analyzing
the influence of environmental factors on complex diseases results in
positive or deleterious effects on overall disease activity indexes, self-
reported health, access to specialized health care and treatment, health
behavior, and mortality. Since there is a need to improve the understand-
ing of the concept of SES and the ways in which it affects health and
disease, we review herein the tools currently available to evaluate SES
as well as the relationship between SES and autoimmune diseases (ADs).

1568-9972/$ – see front matter © 2014 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.autrev.2013.12.002
642 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
2. What is SES?
SES was defined by Mueller and Parcel in 1981 as “the relative posi-
tion of a family or individual in a hierarchical social structure based on
their access to or control over wealth, prestige and power” [1]. More
recently, SES has been also defined as “a broad concept that refers to
the placement of persons, families, households, and census tracts or
other aggregates with respect to the capacity to create or consume
goods that are valued in our society” [2]. Others defined SES as an
individual or group's position within a hierarchical social structure,
which is measured by variables such as education, occupation, income,
wealth and place of residence [3,4], and these resources may enable
people to achieve certain goals (e.g., health) [5].
For centuries there has been a belief that poor living and working
conditions are associated with shorter lives [6]. In the 19th century,
the most important improvements in health were caused by changes
in nutritional and environmental conditions [7], but the problem of
those with fewer resources having worse health outcomes for a number
of different causes persisted [3].
Geographical differences are associated with the characteristics of a
place, the influence of local cultures, scarcity of resources, and lack of
mobility as major determinants [8,9]. In certain areas, life expectancies
increase and, in other areas, they fail to improve due to unacceptable
disparities in health that are caused by global inequities in wealth
[10–14].
The impact of SES on health is increasing as it has important reper-
cussions on local and international public policies [15]. The relationship
between a lower SES and higher incidence and prevalence of health
problems, disease, and death is present all around the world [16].
The reason for governments to be interested in health inequity
policies is to take action with respect to them and close the gap
[17–20]. This is a topic that has been discussed at several World Health
Organization meetings since Brock Chisholm, as first Director General,
postulated the death rate in tuberculosis as a sensitive index of the
state of public health and economic and social well-being in a commu-
nity [21]. Growing socioeconomic disparity is a global concern as it
could affect population health. Health disparities have grown geometri-
cally over the past 20 years [22]. Policy initiatives have included rural
employment, food security, universal health care, social security for
informal workers, education, housing, and rights of tribal and forest
dwellers [17]. Nevertheless, research on how social changes in a
population are reflected in health and disease is scarce [23,24].
Health disparities frequently refer to disparities in health care in-
cluding different access to screening and treatment options, or unequal
availability of culturally or linguistically knowledgeable and sensitive
health personnel [22,25]. The most common study design involved a
comparison of health status or mortality for individuals whose individ-
ual or household income fell below the US federal poverty line com-
pared to those who were above this line [22,26]. Developments in
health measurement instruments including everything from gathering
data by census to national health surveys have improved the way this
research is handled [27,28].
The effects of severe poverty on health could be directly associated
with the effects of poor nutrition or unsanitary living conditions, but
there is little information on the effects of SES at other levels of the social
hierarchy [29]. A great variety of factors may account for the health
effects of a low SES including exposure to environmental toxins, air
and water pollution, ambient noise, employment in jobs that have a
high risk of injury or disability, lack of health insurance or access to
high quality and preventative health care, poor nutrition as well as
adverse health behaviors such as smoking, excessive alcohol intake,
sleeping patterns, and physical inactivity [16,30–33]. This highlights
the inverse relationship between income and overall mortality [34],
and between income and population health [35].
It has been widely reported that in countries where there is a lack of
universal coverage, the population with lower incomes does not have
any insurance [22], and those who do not have health insurance are
not receiving the care they may require [31].
A report from two different cohorts, one from France and one from
the United Kingdom (UK) [36,37], found that psychosocial work charac-
teristics were a determinant of health when they were compared to
the type of employment and self-reported health. However, this was
greater in the UK cohort than in the French one, a finding that may
reflect cultural differences in the subjective perception of health
[36,37]. Data from a cohort in the US showed similar results [5].
Marmot has established 10 major social determinants of health with
respect to cardiovascular disease, a common chronic condition: social
gradient, unemployment, stress, social support, early life, addiction,
social exclusion, food, work, and transportation [18]. An analysis of
disparities in health is difficult to assess even in developed countries.
In the US, there are millions of individuals who do not have health insur-
ance, and in places such as the UK or Sweden, it is difficult to evaluate
the impact of lack of medical care [38].
A report from Singapore showed that a prevalence of health-
damaging behaviors (i.e., no physical activity, daily smoking, and regu-
lar alcohol consumption) was consistently highest among men and
women who had elementary or no education [39]. High SES could be as-
sociated with better health, but it could only influence men because
women practice healthier behaviors [40]. Other studies have shown
that each year of education is associated with a lower probability of
smoking [41,42]. Results from a UK cohort found that educational
achievement had a major impact in early adulthood. This effect was
not marked among women after they finished formal schooling, got
older, [43] and started smoking [44]. Thus, education acts as a predictor
for attitudes and values shaping health-related behavior [45,46]. In the
US, smoking rates among the better educated were one-third the rate
for the less educated, and obesity rates were reduced among the better
educated for each additional schooling year [41]. In the Netherlands, the
lower educated [47,48] and manual workers [47] were associated with a
higher presentation of myocardial infarction.
The most important factors reported to influence SES are income,
educational level, occupational class, social class, and ancestry. These
factors are closely related to each other as they present certain interde-
pendent interactions (Fig. 1).
3. Measurement tools for SES
Although there have been extensive research revealing socioeco-
nomic health inequalities across different societies, analysis and
measurement of SES are not an easy endeavor. Most health studies
that consider SES usually include only a single socioeconomic variable
measured during a single period and level [49]. There is less evidence
about multiple risk exposure across different levels of SES. Measure-
ment tools for SES vary greatly and their use also varies from country
to country. They include everything from single measurement tools to
complex questionnaires, which are used to extract variables in an
attempt to classify a population. A deeper understanding of the SES
health gradient can be achieved by studying individual-level variables
such as education, income, and occupational status. Others are influ-
enced by social level. These are depression, hostility, sense of control
and health behaviors, and these depend on one's residential neighbor-
hood, community, and work environment [28,29,33,50]. Although
socioeconomic data are not usually used in vital national statistics,
they can provide outstanding information on attributable morbidity or
death rate among people sharing certain characteristics [6]. Table 1
discloses tools that are the most widely used to measure SES and its
relationship with health.
4. SES and health
The aspects related to SES that are curtailed over the course of life
can be divided into two groups. The first is the physical environment,
 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
Fig. 1. Most relevant associations of socioeconomic status with health outcome. The analysis of socioeconomic status (SES) can integrate a general view of the individual, household, and
community. All of these are influenced by ancestry, ethnicity, poverty, allostatic load, environment, access to health care, social networks, and lifestyles. This results in positive or negative
effects in the development and prognosis of acute or chronic diseases.
which includes exposure to pathogens, carcinogens and other environ-
mental hazards. The second is the social environment, including
interpersonal vulnerability, violence, difficulty in getting access to social
support, psychological development, affection, and finally, health
behavior [26,29]. The main health exposures related to SES are cigarette
smoking, alcohol consumption, physical inactivity, depression, hostility,
and psychological stress [23,29].
The notion that societal conditions and social environment influence
states of health and disease has been reported broadly [51]. People
higher up on the social economic scale may have significant opportuni-
ties more frequently to influence the events affecting their lives by
modifying multiple variables involved in health determinants
[18,22,29,33,38]. One example would be receiving treatment in larger,
better, or more specialized hospitals as well as receiving medication
for secondary prevention more often [18].
SES influences mortality and morbidity rates in almost every disease
[14,29,38,52,53]. The relationship between prevalence of chronic
diseases and SES shows a linear gradient [26]. There is a strong and
consistent SES influence on cardiovascular disease, coronary heart
disease, obesity, diabetes, metabolic syndrome, arthritis, tuberculosis,
chronic respiratory disease, gastrointestinal disease, and adverse birth
outcomes as well as on accidental and violent deaths [16,22,26,54,55].
Social relationships affect the association between SES and health
across age [33,56]. Even though there is a gradient established for
different ages, the greatest impact of SES on health is during adulthood
(age 40–65) [3,22]. Older, lower SES adults are more vulnerable to
health problems [56]. However, disparities tend to narrow after the
age of 65 [3,22].
Encouraging policies that improve the economic status of low SES
populations (i.e., poverty reduction), leads to a tighter distribution of in-
come in society [57,58]. In Sweden, a two-fold rise in poor self-rated
health based on economic hardships was reported [52] while, in
Japan, the same results were observed from low income level individ-
uals [59]. Noteworthy, perceptions of SES may differ across populations
regardless of income level [53,60].
643
Educational attainment affects occupational class, which in turn
contributes to income, and these differences in earnings could affect
health [41,45]. Both income and education can influence the etiology
of many health outcomes partly due to material resources [49,61].
In a European cohort, there was an association between high
educational level and lower prevalence of chronic conditions such as
dyslipidemia, hypertension, insulin-dependent diabetes, hyperurice-
mia, myocardial infarction, stroke, cancer [62] and low back pain [63].
Even when life expectancies in the European region are analyzed,
people with a university degree have longer life spans compared to
those with lower secondary education [64]. Education is a factor that
has an impact on high income and better lifestyles [54].
In a study of social status inconsistency, an association between low
educational level and high occupational level resulted in higher
incidence of cardiovascular disease [65]. A causal relationship between
education and mortality has been also pointed out [66].
An association between higher educational attainment and
better health status has been repeatedly reported in the literature,
and the potential causal mechanisms linking schooling and income
to health were recently reviewed by Kawachi et al. [67], who highlight-
ed that schooling is causally related to improvements in health
outcomes and that raising the incomes of the poor leads to improve-
ment in their health outcomes. Nevertheless, according to authors,
“some issues still remain unanswered, for example, what type of educa-
tion matters for health, or whether there is a difference between
the health impacts of temporary income shocks versus changes in
long-term income” [67].
Income constantly changes over one's lifetime and there is also an
important transition phase between childhood and adulthood. Howev-
er, the time period of life in which socioeconomic gradients influence
health remains unclear [19,43,54,68,69]. The influence of parental SES
may be correlated to children's access to educational opportunities
and to higher status, but it is unclear if it really influences health in
adulthood [70,71]. Parental low educational level has been associated
with a higher risk of diarrhea [72], and earlier asthma presentation
 644
Table 1
Most widely tools used to measure SES and its relationship with health.

Method Characteristics Strengths Limitations References

Income Quantitative variable grouped by categories. The Gini Allows access to material goods and services. Age dependent, casual relation is limited by [1,37,67,172]

O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654

Wealth
Education
Occupation
Health insurance status
Marital status
Wright Singelmann class structure
Registrar General's measure of
social class
National Statistics Socio-Economic
Classification (NS-SEC)
Occupational prestige scale
Townsend index
Nam Socio-Economic Status score
Erikson–Goldthorpe class schema
Cambridge scale
McClements equivalence scale
Carstairs score
coefficient is sometimes used.
Household or individual. Results are based on inherited
wealth or savings.
Years of educational attainment, credentials earned.
Classification of work based on manual vs. non-manual
labor or occupational classes.
Classifies people in private or public health care
Classifies people into married, unmarried, widow, and
divorced.
Classifies classes according to decision-making power,
supervisory power, or work autonomy.
Assesses explanatory variables by assigning scores from 1 Useful in the initial assessment of coronary heart disease. Does not include self-employment. Less accurate for the
to 6 (i.e., professionals to unskilled manual workers).
Based on employment relations and conditions.
Design for National Opinion Research Center. Range from 0 Assesses social hierarchy based on social level of
to 100 points.
Consists of data on percentages of crowding,
unemployment, lack of car ownership, and renters.
Employs occupation, education and income as indicators in Widely used in the US.
a composite index of social position.
Eleven classes are defined according to labor market
condition characteristics (i.e., employment, degree of
occupational security and promotion prospects).
Hierarchical measurement of social distance between
occupations. Six categories are established.
Household total income is classified into sextiles.
Measures the level of social deprivation based on four
variables: male unemployment, social class of the head of
household, overcrowding, and access to a car.
methodological flaws.
Reflects the ability to meet emergencies or to absorb Difficult to calculate because of the multiple factors that [1,12,58,173]
economic shock. Could be presented as the remains of contribute to its assessment. It changes over time.
deficits from previous income.
Easy to measure. Excludes few members of the population. Economic returns may differ significantly across racial/ [1,2,56,174]
Less likely to be influenced by disease in adulthood than ethnic and gender groups. SES does not rise consistently
income and occupation. Higher levels of education are with increases in years of education.
usually predictive of better jobs, housing, neighborhoods,
working conditions and higher incomes.
Major structural link between education and income. Measurement may be influenced by variation in [1,83]
Provides a measure of environmental and working education, income and prestige. Lacks of accuracy.
conditions. Assesses benefits and hazards related to job. Homemakers and retirees are difficult to classify.
Informs about health care access. Influenced by the quality of service. [141,175–177]
Informs primary close social status, and informs about Does not directly correlate with other SES variables. Low [175,177]
possible additional incomes accuracy.
One of the first population analysis used. Does not include information on other members of the [178–180]
household.
[3,44,81,181–183]
assessment of SES than income and other measurements,
and varies depending on ethnicity.
Assesses the relationship between social working class and Does not properly assess non-working population, [76,81,82,184–187]
health outcomes including ethnicity. Highly associated with unemployment, handicaps, or housewives.
self-assessed health.
Does not change according to other variables. [188]
employment.
Simple census-based index of material deprivation Does not account for differences in rural and urban [172,189,190]
calculated by the combination of four census variables. measurement of SES
Modified on repeated occasions. [183,189]
Combines trust, confidence and autonomy indicators. Few significant associations with health outcomes. [2,76,181,182,189,
191]
Strong association with smoking, behavior and social Based more on social interactions than individual [76,181,182,184,189,
support. Represents a better measurement of social perceptions. 192]
inequities.
Most direct measurement of material and economic Based only in income. [185,193]
circumstances. Other equivalence scales may produce lower
estimates of inequality and poverty.
Based on income and occupational status. Does not involve other members of household in the [194–196]
score evaluation.
Swedish socio-economic classifica-
tion (SEI)
New Zealand Index of Deprivation
Graffar scale
Index of relative socioeconomic
disadvantage
Critério de Classificação Econômica Based on educational level of head of household, and
Brasil
Winkler index
Duncan Socioeconomic status
index
Census Zip code-based
Socioeconomic stratification
SES Index of Agency for Healthcare Based on unemployment, number of people below line of
Research and Quality
Index of Multiple Deprivation
Subjective SES (MacArthur ladder
measure)
Wealth Questionnaire
Index of Social Position (ISP)
Poverty income ratio (PIR)
Childhood SES
Neighborhood SES
Classifies occupation as manual workers, non-manual
employees, and employers.
Uses household census data and includes nine aspects of
material and social deprivation to divide New Zealand into
tenths (scored from 1 to 10)
Measures educational level of head of household,
occupational status, and housing characteristics.
Based on Australian census data. Provides a summary of
SES measurement at a geographical area
number of possessed items.
Ranged from 3 to 21 points. Categorized as low (3–8),
moderate (9–14), and high (15–21)
Three household characteristics are evaluated: number of
assets, number of people sleeping in the same room and a
subjective assessment of the family's material situation.
Data from US national census are used to define areas with
similar SES characteristics.
Measurement by housing characteristics. Results given in
block units from an average taken of buildings within a
single block.
poverty, median income, property values, low education,
high education and crowded households in block analysis.
Data relating to 10 domains and subdomains: income,
employment, health, child education, adult education,
crime, barriers to housing, barriers to services, indoor
environment, and outdoor environment.
Analog scale. Asks individuals to place themselves on one
of the rungs of a 10-rung ladder where the top represents
the most education, money or prestige and the bottom
those with the least of these.
Four variables are measured: duration of living standards
after hypothetical income is lost, description of food eaten
over the last year, family patrimony, and familial debts.
Based on place of residence and head of household
characteristics. Categorized into 5 different classes.
Index of household income relative to the federally defined
poverty level.
Based on parental occupation status.
Based on the proportion of total household gross income
earned by the poorer 50% of the households in the area.
Aggregate measurements of individual data.
Reports classification based in Nordic occupational Do not assess retired status, unemployed, housewives, [197,198]
classification. and students.
Establishes a regional analysis for SES in a scale according to Do not provide individual information. Lack of replication [167]
residential address. in other countries.
Addresses interest in housing characteristics such as Information based only on the head of household. [199,200]
property, house type, water supply, disposal management
and house assets.
Indigenous descent, unemployed, and relatively unskilled Do not provide individual information. Lack of replication [201]
occupations are variables included. in other countries.
It implements a score addressing 8 classes according an Does not include information on other members of the [202]
approximation to household's income. household. Lack of replication in other countries.
Graduation, school and professional education, academic Information based only on the head of household. [169]
training, profession, and income are the main variables.
Includes subjective information related to household Assumes that all SES variables are represented by the [74,183]
situation. household ability to maintain the same living standards.
Used in big studies gathering population. Information is not based on individuals. Only used in US. [203]
Provides easily documented data. Reported in public services Information is not based on individuals. Data do not vary [111,131,204,205]
O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
classification. over time. Does not provide ownership status.
Provides an analysis integrating multiple SES variables. Does not provide individual characteristics. [206]
Assesses an integrated questionnaire with multiple SES Does not provide individual data. [207]
variables.
Perception shows significant associations with health Accuracy is low. [37,67]
outcomes.
Allows multiple ranges in every variable. Adapted from Variables are not aggregated into a score but examined [6,208,209]
Women's Health Initiative study. individually.
Variables are used as a whole allowing a better SES Does not include other household member in the [16,93,183,210–212]
measurement. measurement.
A governmental measure providing general information. Varies depending on level of poverty reported by each [89]
country.
Family income during childhood is a significant predictor of Changes according to external variables and across ages. [37,67,71]
adult health.
Assesses the impact of community risk factors. Based on census data. Does not establish individual [34,103,104,213,214]
information.
645
646 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
[73]. However, variables of parental SES such as educational level can be
questionable due to its inconsistency [74].
Scharown-Lee et al. [54] found that education among different
ethnic groups had an inverse association with obesity, where SES can
motivate and encourage positive health related behaviors [16]. In a
study done on the US population [68], there was a significant association
between acute diseases and poverty conditions in the younger popula-
tion. Mackenbach et al. [75] showed that mortality inequalities, based
on low educational levels and occupational classes, tended to increase
in Europe. However, this does not always imply a relationship between
health and the occupational hierarchy [76].
The Whitehall study showed significant increases in relative risks of
mortality over 10 years in the population at the lowest employment
level [22,29,77]. The Whitehall II study presented consistent evidence
of an inverse relationship between the level of employment and self-
rated health [78–80]. Similar results were reported using National
Statistics Socio-Economic Classification (NS-SEC) in the UK [81,82].
Some measurements of occupational status may lack of accuracy
since they are recorded as a dichotomous variable (i.e., manual and
non-manual workers) [49]. The assessment of working conditions is
becoming difficult as nonstandard work arrangements and unskilled
labor become increasingly common. This is related to the health impact
of job insecurity, high work strain, limited control at the place of work,
repetitive work, exposure to uncomfortable conditions, contract work,
self-employment, and increasing underemployment as important new
factors to be measured [16,83]. Nevertheless, occupational status is a
better long term indicator than income [84]. Hypertension rates in
blue-collar (production) and white-collar (supervisors and administra-
tive) workers found elevated hypertension risks in the former [83].
Blue-collar workers also showed elevated psychophysiological stress
levels [85].
Under the influence of economic stress, low job satisfaction, unem-
ployment or the threat of unemployment, and lack of influence and con-
trol over his life, the individual is more likely to adopt a passive lifestyle
[85]. The aforementioned characteristics influence the appearance of
unhealthy behaviors and depression symptoms [85,86].
Social class, referred as social groups arising from interdependent
economic relationships among people, was considered to be the result
of resource-based and prestige-based measurements of access to and
consumption of goods, occupational prestige, and educational level
[6]. People born into a lower social class grow up in an environment
which is in many respects less stimulating intellectually and emotional-
ly than people born into a higher social class [87]. A low social class is
linked to the activity of the two main biological stress pathways: the
sympatho-adreno-medullary axis and the hypothalamic-pituitary-
adrenal axis [31,38,85]. When this stress persists, it becomes chronic
and induces an allostatic load, a cumulative physiological consequence
of chronic exposure to fluctuating or heightened neural or neuroendo-
crine responses that results from repeated stress. This involves past
stressful experiences and changes in lifestyle associated with chronic
stress [88–90]. The allostatic load modifies risks for a range of health
problems including metabolic syndrome, obesity, hypertension, diabe-
tes mellitus type 2, lipid imbalance, atherosclerosis, accelerated brain
aging, hippocampal atrophy, cognitive impairment, loss of bone mineral
density, sarcopenia, and immune dysfunction [89,91,92]. The allostatic
load is elevated in those of low SES as compared to those of high SES
[88–90]. Another interesting fact is the influence of social classes on
quality of mental illness treatment [93,94].
Other factors such as race and ethnicity can also influence health
[95]. Ethnicity is closely related to those socio-demographic variables
that constitute common measures of SES, and it can be argued that
social inequalities such as discrimination and prejudice typically
linked to minority status can be associated with lower SES groups
[31,54,84,96]. The confusion between SES and racial disparities is a
function of the wider distribution of risky health behavior among
lower class people [97].
Education may be a poor indicator of SES in studies of the elderly and
varies depending on ethnicity [98], which is an important determinant
of health perception [99]. Although it is difficult to disentangle the
relationship between genetics and social factors in their contributions
to health and disease risk [100], higher SES in Latin America is character-
ized by lower levels of Native American ancestry [101].
SES is both complex and dynamic. That is, not only can individuals
move up or down the social ladder, but also the definitions of, and rela-
tionships between social classes can also change over time. Thus, the
analysis of SES data should be done at different levels. The study of
health at certain times in a person's life needs to be done not only on
the individual level but also on the household and, ideally, the neighbor-
hood levels [6,18,102,103]. Moreover, analyses of individual risks may
not provide the right kind of information as a result of the atomistic
fallacy (i.e., inferring individual behavior from aggregate data) [7].
Therefore, caution should be exercised in making inferences for a
population based on observed relationships at the individual level.
The place of residence is strongly related to social position and
ethnicity. Neighborhoods or residential areas have emerged as poten-
tially relevant contexts because they possess both physical and social at-
tributes which could plausibly affect individual health [104]. This is due
to the fact that the neighborhood characteristics reflect SES, culture,
physical environment, and access to facilities. This will affect whether
or not people are exposed to risk situations [6,31,103,104].
Residence in a deprived or fragmented neighborhood is associated
with poorer mental health apart from personal economic status [105].
It also influences mortality rates even when controlling for individual
SES [29,106]. Environments dominated by easy access to tobacco prod-
ucts and alcohol, fast food outlets, scarcity of affordable and appealing
fresh fruit and vegetables, and unsafe, uninviting community conditions
that restrict physical activity increase the odds against good health
[22,107]. Segregation of poor communities increases as a result of the
concentration of the low income population in deprived neighborhoods
[106,108–111]. Nevertheless, there are cities where the impact of socio
economic features does not influence health [106]. Results from a study
done on a Scottish population did not support the theory that lower SES
influences regular physical activity or a sedentary behavior [112]. Fur-
thermore, a neighborhood analysis from Syria disclosed no significant
SES association in spite of the fact that it is considered a developing
country. [113].
The presence of social capital can boost self-esteem, provide social
support, help people to get access to better resources, and act as a buffer
for stressful events [22,114]. Other social factors include trust, civic par-
ticipation, reciprocity and optimism, and norms facilitating cooperation
for mutual benefit [51,61,114]. These factors are evident in studies that
analyze social trust on the national level and correlate it with positive
association with self-rated health [51]. In addition, results from a gener-
al social survey in the US showed residents who believed that people
could be trusted had a lower age-adjusted rate of death from all causes
[114]. Generally, stronger social ties have been linked to lower mortali-
ty, and higher participation in social activities is related to better mental
and physical health [114].
In Fig. 2, a summary of contrasting characteristics associated with
higher or lower SES in the general population is presented.
5. SES and ADs
Table 2 summarizes the relationship between SES and some
common ADs according to different countries results.
5.1. SES and rheumatoid arthritis
A large number of economic evaluations have been done in recent
years to assess the burden of rheumatoid arthritis (RA) for patients,
healthcare providers, and society in general [115]. Different studies of
diverse populations, reported an RA risk reduction as the educational
 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
Fig. 2. Contrasting characteristics associated with socioeconomic status (SES). There are multiple variables affected by SES. Here we listed some of the most recognized. They are repre-
sented by arrows pointing up or down depending on whether the characteristics referred to higher or lower SES. *non-Caucasian includes ancestry populations that are Amerindian,
African, Asian, and Islander.
and income level rose [116–119]. An inverse relationship between the
mortality rate and years of education has been reported. Eleven years
of education or less correlate with a two-fold increase in poor prognoses
[120]. Thus, in RA, the lower the patient's educational level, the greater
the chance of mortality and the lower the functional capacity is [29,121].
Residential location in deprived areas could also bring about the same
outcomes [122]. However, a study of a Chilean population showed
that a low educational level was not associated with severity of
RA [123]. Furthermore, a low educational level was associated with
rheumatoid factor positivity [121].
According to self-assessment, health quality is typically low in
patients with RA who are older, female, less educated, obese, unem-
ployed, and less affluent than other groups [124-128]. Patients with
a low SES may present with worse disease activity, physical health,
mental health, and quality of life (QOL) than patients with a high
SES [129–131].
Many patients with RA are unable to work due to low functional
capacity and thus become dependent on the state for their health
services and social welfare support [123,132–134]. Individuals with a
low income and those living in low SES neighborhoods received
fewer disease-modifying anti-rheumatic drugs (DMARDs) [36,135].
There is evidence that African Americans with RA who went to non-
rheumatologists did not receive DMARD therapy in 30% of the
cases [136] or got sub-optimal treatment [137].
Increased Health Assessment Questionnaire scores and low SES
are associated with depression in patients with RA. As stated by
Margaretten et al. [138], “at every level of functioning, persons from
a lower SES may not have the support and coping skills to perform
as well as those from a higher SES, leading to even higher rates of
depression”.
647
5.2. SES and systemic lupus erythematosus
Systemic lupus erythematosus (SLE) tends to present earlier and
is often associated with worse outcomes in people of Hispanic, Asian
or African ancestry than in Caucasians. This may be related in part to
overall poor SES including less structured families, fewer years of formal
education, occupational status, household income, higher poverty, and
inadequate health insurance [139–148]. Results showing evidence of
genetic influence alone are also reported [149].
The relationship between ancestry and SES in SLE patients was
evaluated recently. An association between Amerindian ancestry and a
low SES, which also influenced important clinical differences that
depended on genetic ancestry, was observed [146]. Note that ethnic
self-identification is culturally and biologically complex and is not
correlated with ancestry, which should be no longer evaluated by ques-
tionnaire but rather by the use of ancestry information markers (AIMs)
at the molecular level [150,151].
The costs of SLE can be different depending on the health care
system. The impact of indirect costs is influenced by poor physical or
mental health, low social support, low educational level, unemploy-
ment, and high disease activity [152].
Clusters of SLE patients with elevated mortality reported greater
levels of poverty [140,153,154]. The incidence of end stage renal disease
in poverty-stricken areas also suggested a relationship with poor access
to health care [155–158].
5.3. SES and multiple sclerosis
Multiple sclerosis (MS) in the African American population has been
reported to start at a younger age than Caucasians or Hispanics.
 648
Table 2
Results from diverse measure of SES in ADs.

AD Country Year N SES measurement method Results Reference

SLE China 2013 170 Educational level, income, employment status. SES was significant correlated to disease activity, anxiety, and depression. [215]
Latin America 2012 1426 Graffar scale. Rural residency was associated with mestizo ethnicity, low SES, and renal disease occurrence. [216]
United Kingdom 2000 201 Occupational and household facilities. There was no association between SES and LN in Afro-Caribbean patients. [217]
United States 2013 34,349 Census Zip code-based. The association of county-level SES and LN prevalence was assessed. LN prevalence was higher in [218]
deprived areas.
2013 4214 Census Zip code-based, employment status, educational level. African Americans recipients with LN with lowest income had a significantly increased risk. [219]
2012 1752 Educational level and income. Low SES in Caucasians increases the risk of cardiovascular disease. [220]
2012 1129 Educational level, household income and neighborhood SES. European genetic ancestry was associated with a lower risk of LN, regardless of SES. [149]
2010 775 US Census, including educational level and neighborhood SES. The number of physician visits for SLE decreases according to low SES. [221]
2010 211 Educational level and census Zip code-based. SES was associated to HRQOL, independent of regional or individual SES measurement method. [143]
2010 702 Census Zip code-based. Inconclusive results were found about the effect of SES on ESRD. [203]
2008 957 Educational level, household income, poverty status and neighborhood Individual SES was associated with physical and mental health outcomes. Low neighborhood SES [222]

O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654

SES. contributed independently to high levels of depressive symptoms.
2007 867 Educational level and income health insurance status. Low income was associated to lower likelihood to report visits to rheumatologist, and health care [223]
access.
2007 459 Educational level, income, health insurance and marital status, and Association of SES; poverty is an important factor associated with ethnicity according disease [141]
housing. activity.
2006 459 SES according federal US guidelines adjusted for the number of Association of SES with presence of LN in a multi ethnic cohort. Admixture separately explained a [158]
inhabitants in the household. much larger proportion of the ethnicity explained variance that SES. Together, they explained the
majority of ethnicity related variability.
2004 202 Wealth Questionnaire and traditional values of SES. Wealth, per se, did not appear to have an additional predictive value over the traditional measures of [208]
SES in SLE disease activity.
2004 4779 Educational level. In Whites high educational level correlates with low mortality rates, but not in minorities [224]
(i.e., African-American, Asia or Pacific Islander.
2003 128 US Census, neighborhood SES Poverty is an important risk factor for progression of proliferative LN, independent of race/ethnicity. [225]
2001 200 Educational level, income, occupational prestige scale. Social support is particularly beneficial for those possessing social, economic and health advantages. [188]
2001 11,102 US Census Bureau. Geographical patterns of SES status were related to the variation of SLE mortality across US. [154]
Hispanics disclosed higher rates of mortality.
1999 67 Income, educational level, housing facilities, and US Census Bureau. Association between low SES and acculturation was found, but also with less disease activity at [226]
enrollment.
RA China 2011 353 Employment status. RA patients reported a lower rate of labor force participation than control group. [227]
2011 144 Educational level. Older age, lower education level and functional disability independently predicted high indirect [228]
costs.
Colombia 2003 79 Socioeconomic stratification. SES was not associated with disease activity. [131]
Denmark 2006 515 Educational level in year and grading, childhood SES, and subjective Low educational level was associated with the risk of developing RA (mainly rheumatoid factor [229]
SES. positive).
Korea 2012 17,311 Educational level, household income, individual income, and Women with RA had a significant lower employment rate compared population without RA. [230]
occupational status.
Latin America 2012 1093 Graffar scale. Patient disease activity indexes were significantly worse in those with low/low-middle SES, in very [200]
early disease.
Morocco 2012 100 Income. Low SES patients had lower scores on SF-36, and decreased educational level. [231]
2006 100 Marital status, educational level, occupational status, income, health Increased affection was associated with low SES and problems with health care services. [133]
insurance status.
Netherland 2003 878 Educational level. Low SES patients have worse outcomes as; disease activity, physical health, mental health. However [129]
these differences decreased over time.
Sweden 2012 1460 Occupation and immigrant status. RF positivity and occupational class referred as other were independently associated with poorer [232]
prognosis.
2011 290 Swedish socio-economic classification. Low SES and smoking were independent risk factors for RA. [198]
2008 28,339 Educational level. RA was associated with low childhood SES sustained into adulthood. [233]
2005 930 Educational level and occupation. There was an association between high SES and lower risk for RA. [121]
United Kingdom 2013 421 Carstairs score. SES had no significant effect in the analysis of height and disease activity. [234]
2012 25,455 Social class and educational level. Higher social class or degree education was associated with reduced risk of inflammatory [235]
polyarthritis.
 2012 6298 Townsend index. Area-level socio-economic deprivation was a significant risk factor for RF positivity. [236]
2012 553 Index of Multiple Deprivation. There was an association of low SES and poor outcomes; HAQ, but it was not significant including [237]
RAI into analysis, as a factor associated in SES influence.
2009 1393 Index of multiple deprivation and social class. Within the lowest social class, there was poorer outcome in patients from increasingly more [238]
deprived areas.
2005 466 Townsend index. Increasing social deprivation was associated to higher disease activity, higher pain, poorer physical [190]
function; poorer emotional aspects of mental health, and lower quality of life were found at baseline.
United States 2013 50,884 Childhood SES and educational level. Low childhood SES and adult education were associated to RA. [239]
2013 1100 Income, educational level, health insurance status. Patients presented cost-related medication non-adherence and spending less on basic needs to [240]
afford medication associated to educational level and low income.
2011 93,143 Census Zip code-based. Low personal income and those living in low SES neighborhoods had reduced DMARD receipt. [135]
2010 696 Educational level, household income, occupation status, home Individual's perception of neighborhood environment characteristics is predictive of health [241]
ownership, and neighborhood SES. outcomes among adults.
T1D Australia 2006 1143 Index of Relative Socioeconomic Disadvantage. A higher incidence of T1D was presented in high SES, especially in urban area. [201]
Bosnia and 2013 65 Parental educational level, employment status and Hollingshead index Low and middle SES in families with children with T1D was associated to low QOL. [242]
Herzegovina of social position.
Brazil 2012 3591 Critério de Classificação Econômica Brasil Low or very low SES was found in up to 87% of the studied patients. [243]
2011 71 Critério de Classificação Econômica Brasil The low educational level of the caregivers influenced the inadequate glycemic control. [244]
Germany 2011 296 Winkler index. Presence of low SES correlates with low metabolic control and increase of HbA1C levels. [169]
Greece 2008 127 Parental educational level, occupation and social class. Middle and upper social classes had a protective effect on T1D presentation. [245]

O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654

Italy 2013 414 Parental educational level and crowding index. Crowding houses conferred and 3-fold greater risk of having T1D up to 3 years of age, and low [246]
parental educational level had a protective effect in the group of 4–14 years.
Malaysia 2000 926 Income and educational level. Household income was an important determinant of glycemic control in T1D. [247]
New Zealand 2008 555 New Zealand Index of Deprivation. Presence of low SES correlates with low metabolic control and increase of HbA1C levels. [167]
United States 2013 167 Health insurance status as indirect measure. Patients covered with Medicaid presented higher risk to present diabetic ketoacidosis. [248]
2012 1502 Income, educational level, poverty index ratio. Higher risks of T1D incidence were found in higher median income, higher housing value and no [249]
poverty designation.
2012 349 Hollingshead index of social position. Reported ethnic differences in HbA1C and disease care behaviors, better explained by SES. [250]
2011 505 Educational level, occupational status, and neighborhood SES. Neighborhood characteristics related to greater affluence, occupation, and education are associated [166]
with higher T1D risk.
2011 317 Household income, educational level and Hollingshead index of social Lower SES in T1D is a robust predictor for diabetes complications. [251]
position.
2011 317 Household income, educational level and Hollingshead index of social Baseline education level predicted all-cause mortality in T1D population. [212]
position.
2006 222 Index of social position. Poor glycemic control in pediatric T1D is associated with lower SES and depression. [252]
2003 184 Parental educational level, Income, health insurance status, marital Hispanic youths with T1D may be at greater risk for poor glycemic control because their low SES. [253]
status
MS Canada 2009 5458 Educational level, Income, health insurance status, marital status, and Low SES was associated with a minor report of smoking habit in MS patients. [175]
region of residence.
2009 8983 Educational level, Income, health insurance status, marital status, and Lower SES was associated with a higher frequency of adverse health behaviors accounting for other [254]
region of residence. demographic factors.
2008 8983 Educational level, Income, health insurance status, marital status, and Lower SES was associated with a higher presence of comorbidity. [177]
region of residence.
Denmark 2013 2205 Parental educational level and household income. Children whose mothers had a secondary or higher level of education reduced risks of MS. [255]
Iran 2010 174 Educational level, Income, occupation, marital status. SES groups showed no significant correlation with other factors related to education needs. [256]
Lebanon 2013 201 Educational level, employment status, region of residence, and QOL is determined by social support, living area, depression, educational level, employment, fatigue [257]
household integrant. and religiosity.
Sweden 2008 5231 Educational level. Increment of educational level was associated with slightly low risk for hospitalization. [258]
SS Morocco 2012 57 Income and educational level. Low SES and educational level altered fatigue level and QOL. [259]
Netherlands 2009 135 Education level and employment status. High level of education was associated to employment in SS. [260]
SSc Canada 2013 1145 Educational level. Educational level did not show significant differences in survival, as poor outcomes. [261]
France 2010 87 Employment status and income. Decreased income was associated with receiving a disability pension. [262]
Serbia 2010 35 Employment status. Symptoms of depression were associated with economic variables. [263]

ACR, American College of Rheumatology: ADs, Autoimmune Diseases: Disease Modifying Anti-Rheumatic Drugs, DMARDs: HAQ, Health Attitude Questionnaire: HbA1C, Glycated hemoglobin: HRQOL, Health related Quality of Life: LN, Lupus
Nephritis: MS, Multiple Sclerosis: QOL, Quality of Life: RA, Rheumatoid Arthritis: SES, Socioeconomic Status: SF-36, Short From-36: SLE, Systemic Lupus Erythematosus: SS, Sjögren's syndrome: SSc, Systemic Sclerosis: RAI, Rheumatoid Arthritis
Index: RF, Rheumatoid Factor: T1D, Type 1 Diabetes.

649
650 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
Caucasians as a group presented higher incomes and better health
care [159]. Access to neurologist consultation and rehabilitation services
was determined by absence of health insurance, poverty, and living in
rural areas as SES variables [159,160]. Important improvements in
QOL related to educational level and employment status in MS patients
has also been reported [161].
5.4. SES and type 1 diabetes
In Canada, Australia, and UK it has been observed that Type 1 diabe-
tes (T1D) is present in higher SES families as compared to families in de-
prived conditions [162,163]. Even at a national level, SES modifications
represent a change in disease incidence [164]. Non-Caucasian ancestry
and low SES were associated with low incidence [165,166], but long
term complications related to poor metabolic control were present in
these populations [167–169]. The presence of ketoacidosis at onset of
T1D in Latin Americans is notable and has been attributed, in part, to
difficulties in health care access and low SES [170].
6. Conclusions and perspectives
An explanation for the SES impact on health can be justified because
SES affects biological functions. However, the association may also
reflect the influence of illness on SES, rather than SES on illness. Based
on this, a spurious association should also be discarded when analyzing
SES and illness [29]. Whether SES is a surrogate of ancestry and environ-
ment should be further investigated.
Research on epigenetics is introducing further complexity into our
understanding of the interaction of genes and environment. Environ-
mental conditions may influence gene expression and thus, change be-
havioral and biological outcomes [22]. An analysis that could integrate
information from SES with the aspects involved in genetics could give
ancestry-related data that is important in today's society, especially
in diseases with a multifactorial etiology such as ADs, neurological
disorders, cancer, etc.
The majority of studies linking SES with health are cross-sectional
which decreases the level of evidence [22]. This may be improved
with more sensitive measurement methods and extended population
assays [20]. In the SES scenario, none of the models that have been
developed deals with the SES health risk factors as a whole. Rather,
the models are built around individual variables. Thus, models that
combine risks, in order to prepare a cumulative risk model are warrant-
ed [171]. Analyses about SES and health should include more than one
socioeconomic variable and, if possible, should be measured at two or
more points in time to establish the change over a period (years).
Take-home messages
• Related socioeconomic status (SES) factors can contribute to under-
standing disease distribution and severity.
• The most important factors reported to influence SES are income,
educational level, occupational class, social class, and ancestry.
• The main health exposures related to SES are cigarette smoking,
alcohol consumption, physical inactivity, depression, hostility, and
psychological stress.
• Studying SES in autoimmune diseases can influence clinicians and
public health decisions.
Acknowledgments
The authors are grateful to the members of the Center for Autoim-
mune Diseases Research (CREA) for their fruitful discussions and
contributions. This work was supported by the School of Medicine and
Health Sciences of Universidad del Rosario, Bogota, Colombia.
References
[1] Shavers VL. Measurement of socioeconomic status in health disparities research. J
Natl Med Assoc 2007;99:1013–23.
[2] Miech R a, Hauser RM. Socioeconomic status and health at midlife: a comparison of
educational attainment with occupation-based indicators. Ann Epidemiol
2001;11:75–84.
[3] Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and mecha-
nisms. Annu Rev Public Health 2008;29:235–52.
[4] Hauser RM, Warren JR. Socioeconomic indexes for occupations: a review, update,
and critique. Wisconsin: Center for Demography and Ecology, University of
Wisconsin; 1996.
[5] Gorman BK, Sivaganesan A. The role of social support and integration for under-
standing socioeconomic disparities in self-rated health and hypertension. Soc Sci
Med 2007;65:958–75.
[6] Krieger N, Williams D. Measuring social class in US public health research:
concepts, methodologies, and guidelines. Rev Public Health 1997;18:341–78.
[7] Marmot MG. Improvement of social environment to improve health. Lancet
1998;351:57–60.
[8] Jones K, Duncan C. Individuals and their ecologies: analysing the geography of chronic
illness within a multilevel modelling framework. Health Place 1995;1:27–40.
[9] Muntaner C, Rocha KB, Borrell C, Vallebuona C, Ibáñez C, Benach J, et al. Social class
and health in Latin America. Panam J Public Health 2012;31:166–75.
[10] Brown T, Moon G. Geography and global health. Geophys J Roy Astron Soc
2012;178:13–7.
[11] Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099–104.
[12] Kennickell AB. What is the difference? Evidence on the distribution of wealth,
health, life expectancy, and health insurance coverage. Stat Med 2008;27:3927–40.
[13] Murray CJ, Gakidou EE, Frenk J. Health inequalities and social group differences:
what should we measure? Bull World Health Organ 1999;77:537–43.
[14] Popham F, Dibben C, Bambra C. Are health inequalities really not the smallest in the
Nordic welfare states? A comparison of mortality inequality in 37 countries. J
Epidemiol Community Health 2013:412–8.
[15] Dow WH, Rehkopf DH. Socioeconomic gradients in health in international and
historical context. Ann N Y Acad Sci 2010;1186:24–36.
[16] Mulatu MS, Schooler C. Causal connections between socio-economic status
and health: reciprocal effects and mediating mechanisms. J Health Soc Behav
2002;43:22–41.
[17] Marmot M. Global action on social determinants of health. Bull World Health Organ
2011;89:702.
[18] Blas E, Kurup AS. Equity, social determinants and public health programmes.
Geneva, Switzerland: WHO Press, World Health Organization; 2010.
[19] West P. Health inequalities in the early years: is there equalisation in youth? Soc
Sci Med 1997;44:833–58.
[20] Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation
of disparities research to achieve health equity. Annu Rev Public Health
2011;32:399–416.
[21] Krech R. Social determinants of health: practical solutions to deal with a well-
recognized issue. Bull World Health Organ 2011;89:703.
[22] Adler NE, Stewart J. Health disparities across the lifespan: meaning, methods, and
mechanisms. Ann N Y Acad Sci 2010;1186:5–23.
[23] Prättälä RS, Puska P. Social determinants of health behaviours and social change.
Eur J Public Health 2012;22:166.
[24] Kumanyika S. Health disparities research in global perspective: new insights and
new directions. Annu Rev Public Health 2012;33:1–5.
[25] Braveman P. Health disparities and health equity: concepts and measurement.
Annu Rev Public Health 2006;27:167–94.
[26] Adler NE, Ostrove JM. Socioeconomic status and health: what we know and what
we don't. Ann N Y Acad Sci 1999;896:3–15.
[27] Etches V, Frank J, Di Ruggiero E, Manuel D. Measuring population health: a review
of indicators. Annu Rev Public Health 2006;27:29–55.
[28] Krieger N. Overcoming the absence of socioeconomic data in medical records:
validation and application of a census-based methodology. Am J Public Health
1992;82:703–10.
[29] Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, et al. Socioeconomic
status and health: the challenge of the gradient. Am Psychol 1994;49:15–24.
[30] Matthews K a, Gallo LC, Taylor SE. Are psychosocial factors mediators of socioeco-
nomic status and health connections? A progress report and blueprint for the
future. Ann N Y Acad Sci 2010;1186:146–73.
[31] Baum a, Garofalo JP, Yali a M. Socioeconomic status and chronic stress. Does stress
account for SES effects on health? Ann N Y Acad Sci 1999;896:131–44.
[32] Evans GW, Kantrowitz E. Socioeconomic status and health: the potential role of
environmental risk exposure. Annu Rev Public Health 2002;23:303–31.
[33] Pampel FC, Krueger PM, Denney JT. Socioeconomic disparities in health behaviors.
Annu Rev Sociol 2010;36:349–70.
[34] Osler M, Prescott E, Grønbaek M, Christensen U, Due P, Engholm G. Income
inequality, individual income, and mortality in Danish adults: analysis of pooled
data from two cohort studies. BMJ 2002;324:13–6.
[35] Kondo N. Socioeconomic disparities and health: impacts and pathways. J Epidemiol
2012;22:2–6.
[36] Fuhrer R, Shipley MJ, Chastang JF, Schmaus a, Niedhammer I, Stansfeld S a.
Socioeconomic position, health, and possible explanations: a tale of two cohorts.
Am J Public Health 2002;92:1290–4.
[37] Singh-Manoux A, Marmot MG, Adler NE. Does subjective social status predict
health and change in health status better than objective status? Psychosom Med
2001;67:855–61.
 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
[38] Marmot MG. Status syndrome: a challenge to medicine. JAMA 2006;295:1304–7.
[39] Fong CW, Bhalla V, Heng D, Chua a V, Chan ML, Chew SK. Educational inequalities
associated with health-related behaviours in the adult population of Singapore.
Singapore Med J 2007;48:1091–9.
[40] Borchers AT, Gershwin ME. Sociological differences between women and men:
implications for autoimmunity. Autoimmun Rev 2012;11:A413–21.
[41] Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by
education. J Health Econ 2010;29:1–28.
[42] McClure JB, Riggs K, St John J, Catz SL. [More] evidence to support oral health
promotion services targeted to smokers calling tobacco quitlines in the United
States. BMC Public Health 2013;13:336.
[43] Power C, Matthews S, Manor O. Inequalities in self-rated health: explanations from
different stages of life. Lancet 1998;351:1009–14.
[44] Davey Smith G, Hart C, Hole D, MacKinnon P, Gillis C, Watt G, et al. Education and
occupational social class: which is the more important indicator of mortality risk? J
Epidemiol Community Health 1998;52:153–60.
[45] Bagheri M. Impact of socio-economic and educational status on the family' s health.
Eur J Soc Sci 2009;9:243–56.
[46] Van Lenthe FJ, Mackenbach JP. Neighbourhood and individual socioeconomic in-
equalities in smoking: the role of physical neighbourhood stressors. J Epidemiol
Community Health 2006;60:699–705.
[47] Huisman M, Van Lenthe F, Avendano M, Mackenbach J. The contribution of job
characteristics to socioeconomic inequalities in incidence of myocardial infarction.
Soc Sci Med 2008;66:2240–52.
[48] Van Lenthe FJ, Gevers E, Joung IMA, Bosma H, Mackenbach JP. Material and behav-
ioral factors in the explanation of educational differences in incidence of acute
myocardial infarction: the Globe study. Ann Epidemiol 2002;12:535–42.
[49] Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al.
Socioeconomic status in health research: one size does not fit all. JAMA
2005;294:2879–88.
[50] Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic
inequalities in depression: a meta-analysis. Am J Epidemiol 2003;157:98–112.
[51] Kim D, Baum CF, Ganz ML, Subramanian SV, Kawachi I. The contextual effects of
social capital on health: a cross-national instrumental variable analysis. Soc Sci
Med 2011;73:1689–97.
[52] Ahnquist J, Wamala SP, Lindstrom M. Social determinants of health—a question of
social or economic capital? Interaction effects of socioeconomic factors on health
outcomes. Soc Sci Med 2012;74:930–9.
[53] Cohen S, Alper CM, Doyle WJ, Adler N, Treanor JJ, Turner RB. Objective and subjec-
tive socioeconomic status and susceptibility to the common cold. Health Psychol
2008;27:268–74.
[54] Scharoun-Lee M, Adair LS, Kaufman JS, Gordon-Larsen P. Obesity, race/ethnicity
and the multiple dimensions of socioeconomic status during the transition to
adulthood: a factor analysis approach. Soc Sci Med 2009;68:708–16.
[55] Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W. Diabetes prevalence and
socioeconomic status: a population based study showing increased prevalence of
type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health
2000;54:173–7.
[56] Antonucci TC, Ajrouch KJ, Janevic M. Socioeconomic status, social support, age, and
health. Ann N Y Acad Sci 1999;896:390–2.
[57] Dow WH, Schoeni RF, Adler NE, Stewart J. Evaluating the evidence base: policies
and interventions to address socioeconomic status gradients in health. Ann N Y
Acad Sci 2010;1186:240–51.
[58] Fiscella K, Franks P. Poverty or income inequality as predictor of mortality longitu-
dinal cohort study. BMJ 1997;314:1724–7.
[59] Shibuya K, Hashimoto H, Yano E. Individual income, income distribution, and self
rated health in Japan: cross sectional analysis of nationally representative sample.
BMJ 2002;324:16–9.
[60] Salinero-Fort MÁ, Jiménez-García R, del Otero-Sanz L, de Burgos-Lunar C,
Chico-Moraleja RM, Martín-Madrazo C, et al. Self-reported health status in primary
health care: the influence of immigration and other associated factors. PLoS One
2012;7:1–10.
[61] Bobak M, Pikhart H, Hertzman C, Rose R, Marmot M. Socioeconomic factors,
perceived control and self-reported health in Russia: a cross-sectional survey. Soc
Sci Med 1998;47:269–79.
[62] Nagel G, Peter R, Braig S, Hermann S, Rohrmann S, Linseisen J. The impact of
education on risk factors and the occurrence of multimorbidity in the EPIC-
Heidelberg cohort. BMC Public Health 2008;8:384.
[63] Hestbaek L, Korsholm L, Leboeuf-Yde C, Kyvik KO. Does socioeconomic status in
adolescence predict low back pain in adulthood? A repeated cross-sectional
study of 4771 Danish adolescents. Eur Spine J 2008;17:1727–34.
[64] Jakab Z, Marmot M. Social determinants of health in Europe. Lancet
2012;379:103–5.
[65] Braig S, Peter R, Nagel G, Hermann S, Rohrmann S, Linseisen J. The impact of social
status inconsistency on cardiovascular risk factors, myocardial infarction and
stroke in the EPIC-Heidelberg cohort. BMC Public Health 2011;11:104.
[66] Lleras-muney A. The relationship between education and adult mortality in the
United States. Rev Econ Stud 2005;72:189–221.
[67] Kawachi I, Adler NE, Dow WH. Money, schooling, and health: mechanisms and
causal evidence. Ann N Y Acad Sci 2010;1186:56–68.
[68] Chen E, Martin AD, Matthews K a. Socioeconomic status and health: do gradients
differ within childhood and adolescence? Soc Sci Med 2006;62:2161–70.
[69] Power C, Matthews S. Origins of health inequalities in a national population
sample. Lancet 1997;350:1584–9.
[70] Cohen S, Janicki-Deverts D, Chen E, Matthews K a. Childhood socioeconomic status
and adult health. Ann N Y Acad Sci 2010;1186:37–55.
651
[71] Aitsi-Selmi a, Batty GD, Barbieri M a, Silva a a M, Cardoso VC, Goldani MZ, et al.
Childhood socioeconomic position, adult socioeconomic position and social mobil-
ity in relation to markers of adiposity in early adulthood: evidence of differential
effects by gender in the 1978/79 Ribeirao Preto cohort study. Int J Obes (Lond)
2013;37:439–47.
[72] Hatt LE, Waters HR. Determinants of child morbidity in Latin America: a pooled
analysis of interactions between parental education and economic status. Soc Sci
Med 2006;62:375–86.
[73] Dales RE, Choi B, Chen Y, Tang M. Influence of family income on hospital visits for
asthma among Canadian school children. Thorax 2002;57:513–7.
[74] Aarø LE, Flisher AJ, Kaaya S, Onya H, Namisi FS, Wubs A. Parental education as an
indicator of socioeconomic status: improving quality of data by requiring consis-
tency across measurement occasions. Scand J Public Health 2009;37(Suppl.
2):16–27.
[75] Mackenbach JP. Widening socioeconomic inequalities in mortality in six Western
European countries. Int J Epidemiol 2003;32:830–7.
[76] Muntaner C, Borrell C, Vanroelen C, Chung H, Benach J, Ho I, et al. Social science &
medicine employment relations, social class and health: a review and analysis of
conceptual and measurement alternatives. Soc Sci Med 2010;71:2130–40.
[77] Rose G, Marmot MG. Social class and coronary heart disease. Br Heart J
1981;45:13–9.
[78] Ferrie JE, Shipley MJ, Davey Smith G, Stansfeld SA, Marmot MG. Change in health
inequalities among British civil servants: the Whitehall II study. J Epidemiol
Community Health 2002;56:922–6.
[79] Chandola T, Bartley M, Sacker A, Jenkinson C, Marmot M. Health selection in the
Whitehall II study, UK. Soc Sci Med 2003;56:2059–72.
[80] Marmot M, Brunner E. Cohort profile: the Whitehall II study. Int J Epidemiol
2005;34:251–6.
[81] Chandola T. Ethnic and class differences in health in relation to British South
Asians: using the new National Statistics Socio-Economic Classification. Soc Sci
Med 2001;52:1285–96.
[82] Chandola T, Jenkinson C. Social class differences in morbidity using the new U.K.
National Statistics Socio-Economic Classification. Do class differences in
employment relations explain class differences in health? Ann N Y Acad Sci
1999;896:313–5.
[83] Clougherty JE, Souza K, Cullen MR. Work and its role in shaping the social gradient
in health. Ann N Y Acad Sci 2010;1186:102–24.
[84] Williams DR, Collins C. US socioeconomic and racial differences in health: patterns
and explanations. Annu Rev Sociol 1995;21:349–86.
[85] Lundberg U. Stress responses in low-status jobs and their relationship to health
risks: musculoskeletal disorders. Ann N Y Acad Sci 1999;896:162–72.
[86] Janicki-Deverts D, Cohen S, Matthews KA, Cullen MR. History of unemployment
predicts future elevations in C-reactive protein among male participants in the Cor-
onary Artery Risk Development in Young Adults (CARDIA) study. Ann Behav Med
2008;36:176–85.
[87] De Henauw S, Matthys C, De Backer G. Socio-economic status, nutrition and health.
Arch Public Health 2003;61:15–31.
[88] McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to
socioeconomic status, health, and disease. Ann N Y Acad Sci 2010;1186:190–222.
[89] Seeman T, Epel E, Gruenewald T, Karlamangla A, McEwen BS. Socio-economic
differentials in peripheral biology: cumulative allostatic load. Ann N Y Acad Sci
2010;1186:223–39.
[90] Szanton SL, Gill JM, Allen JK. Allostatic load: a mechanism of socioeconomic health
disparities? Biol Res Nurs 2005;7:7–15.
[91] Chandola T, Brunner E. Chronic stress at work and the metabolic syndrome:
prospective study. BMJ 2006;332:519–22.
[92] Marmot MG, Rose G, Shipley M, Hamilton PJ. Employment grade and coronary
heart disease in British civil servants. J Epidemiol Community Health
1978;32:244–9.
[93] Hollingshead AB, Redlich FC. Social class and mental illness: a community study.
1958. Am J Public Health 2007;97:1756–7.
[94] Williams JS, Cunich M, Byles J. The impact of socioeconomic status on changes in
the general and mental health of women over time: evidence from a longitudinal
study of Australian women. Int J Equity Health 2013;12:25.
[95] Lê Cook B, McGuire TG, Lock K, Zaslavsky AM. Comparing methods of racial and
ethnic disparities measurement across different settings of mental health care.
Health Serv Res 2010;45:825–47.
[96] Epstein AM, Ayanian JZ. Racial disparities in medical care. N Engl J Med
2001;344:1471–3.
[97] Dressler WW, Oths KS, Gravlee CC. Race and ethnicity in public health research:
models to explain health disparities. Annu Rev Anthropol 2005;34:231–52.
[98] Lauderdale DS, Cagney K a. Limitations to the use of education as an SES indicator
in studies of the elderly. Confounding by cognition. Ann N Y Acad Sci
1999;896:373–5.
[99] Salinero-Fort MÁ, Jiménez-García R, del Otero-Sanz L, de Burgos-Lunar C,
Chico-Moraleja RM, Martín-Madrazo C, et al. Self-reported health status in primary
health care: the influence of immigration and other associated factors. PLoS One
2012;7:e38462.
[100] Florez JC, Price a L, Campbell D, Riba L, Parra MV, Yu F. Strong association of
socioeconomic status with genetic ancestry in Latinos: implications for admixture
studies of type 2 diabetes. Diabetologia 2009;52:1528–36.
[101] Campbell DD, Parra MV, Duque C, Gallego N, Franco L, Tandon A, et al. Amerind an-
cestry, socioeconomic status and the genetics of type 2 diabetes in a Colombian
population. PLoS One 2012;7:e33570.
[102] Schneiders J, Drukker M, van der Ende J, Verhulst FC, van Os J, Nicolson NA.
Neighbourhood socioeconomic disadvantage and behavioural problems from
652 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
late childhood into early adolescence. J Epidemiol Community Health
2003;57:699–703.
[103] Lalloué B, Monnez J-M, Padilla C, Kihal W, Le Meur N, Zmirou-Navier D, et al. A
statistical procedure to create a neighborhood socioeconomic index for health
inequalities analysis. Int J Equity Health 2013;12:21.
[104] Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci
2010;1186:125–45.
[105] Stafford M, Gimeno D, Marmot MG. Neighbourhood characteristics and trajectories
of health functioning: a multilevel prospective analysis. Eur J Public Health
2008;18:604–10.
[106] Chandola T. Spatial and social determinants of urban health in low-, middle- and
high-income countries. Public Health 2012;126:259–61.
[107] Bader MDM, Purciel M, Yousefzadeh P, Neckerman KM. Disparities in neighbor-
hood food environments: implications of measurement strategies. Econ Geogr
2010;86:409–30.
[108] Williams DR. Race, socioeconomic status, and health: the added effects of racism
and discrimination. Ann N Y Acad Sci 1999;896:173–88.
[109] Kulkarni M. Social determinants of health: the role of neighbourhoods, psycholog-
ical factors and health behaviors in predicting health outcomes for the urban poor
in India. J Health Psychol 2013;18:96–109.
[110] Alcaldía Mayor de Bogotá. Segregación socioeconómica en el espacio urbano de
Bogotá D.C. Bogotá: Alcaldía Mayor de Bogotá; 2007.
[111] Uribe-Mallarino C. Estratificación social en Bogotá: de la política pública a la
dinámica de la segregación social. Univ Humanística 2008;65:139–71.
[112] Kelly LA, Reilly JJ, Fisher A, Montgomery C, Williamson A, McColl JH, et al. Effect of
socioeconomic status on objectively measured physical activity. Arch Dis Child
2006;91:35–8.
[113] Ahmad B, Ryan V, Maziak W, Pless-Mulloli T, White M. The influence of
neighbourhood formality status and socio-economic position on self-rated health
among adult men and women: a multilevel, cross sectional, population study
from Aleppo, Syria. BMC Public Health 2013;13:233.
[114] Ziersch AM, Baum FE, Macdougall C, Putland C. Neighbourhood life and social
capital: the implications for health. Soc Sci Med 2005;60:71–86.
[115] Furneri G, Mantovani LG, Belisari A, Mosca M, Cristiani M, Bellelli S, et al. Systematic
literature review on economic implications and pharmacoeconomic issues of
rheumatoid arthritis. Clin Exp Rheumatol 2012;30:S72–84.
[116] Reckner Olsson a, Skogh T, Wingren G. Comorbidity and lifestyle, reproductive
factors, and environmental exposures associated with rheumatoid arthritis. Ann
Rheum Dis 2001;60:934–9.
[117] Rajapaksa G, De Silva V, Goonathilake S, Athukorala I, Wijayarathna L,
Udagama-Randeniya P. A study of immunological profile, disease characteristics
and socioeconomic status of a population of rheumatoid arthritis patients in Sri
Lanka. Indian J Rheumatol 2009;4:3–10.
[118] Wolfe F, Michaud K. Out-of-pocket expenses and their burden in patients with
rheumatoid arthritis. Arthritis Rheum 2009;61:1563–70.
[119] Liao KP, Alfredsson L, Karlson EW. Environmental influences on risk for rheumatoid
arthritis. Curr Opin Rheumatol 2009;21:279–83.
[120] Callahan LF, Pincus T. Formal education level as a significant marker of clinical
status in rheumatoid arthritis. Arthritis Rheum 1988;31:1346–57.
[121] Bengtsson C, Nordmark B, Klareskog L, Lundberg I, Alfredsson L. Socioeconomic
status and the risk of developing rheumatoid arthritis: results from the Swedish
EIRA study. Ann Rheum Dis 2005;64:1588–94.
[122] Maiden N, Capell H a, Madhok R, Hampson R, Thomson E a. Does social disadvan-
tage contribute to the excess mortality in rheumatoid arthritis patients? Ann
Rheum Dis 1999;58:525–9.
[123] Massardo L, Aguirre V, García ME, Cervila V, Nicovani S, González a. Clinical expres-
sion of rheumatoid arthritis in Chilean patients. Semin Arthritis Rheum
1995;25:203–13.
[124] Gaujoux-Viala C, Fautrel B, Guillemin F, Flipo RM, Bourgeois P, Rat AC. Who are the
patients with early arthritis with worse than death scores on the EQ-5D? Results
from the ESPOIR cohort. Rheumatology (Oxford) 2013;52:832–8.
[125] Groessl EJ, Ganiats TG, Sarkin AJ. Sociodemographic differences in quality of life in
rheumatoid arthritis. Pharmacoeconomics 2006;24:109–21.
[126] Marra C a, Lynd LD, Esdaile JM, Kopec J, Anis a H. The impact of low family
income on self-reported health outcomes in patients with rheumatoid arthritis
within a publicly funded health-care environment. Rheumatology (Oxford)
2004;43:1390–7.
[127] Brekke M, Hjortdahl P, Thelle DS, Kvien TK. Disease activity and severity in patients
with rheumatoid arthritis: relations to socioeconomic inequality. Soc Sci Med
1999;48:1743–50.
[128] Bollegala D, Perruccio AV, Badley EM. Combined impact of concomitant arthritis
and back problems on health status: results from a nationally representative health
survey. Arthritis Care Res 2011;63:1584–91.
[129] Jacobi CE, Mol GD, Boshuizen HC, Rupp I, Dinant HJ, Van Den Bos G a M. Impact of
socioeconomic status on the course of rheumatoid arthritis and on related use of
health care services. Arthritis Rheum 2003;49:567–73.
[130] Margaretten M, Julian L, Katz P, Yelin E. Depression in patients with rheumatoid
arthritis: description, causes and mechanisms. Int J Clin Rheumatol
2011;6:617–23.
[131] Cadena J, Vinaccia S, Pérez A, Rico MI, Hinojosa R, Anaya J-M. The impact of disease
activity on the quality of life, mental health status, and family dysfunction in
Colombian patients with rheumatoid arthritis. J Clin Rheumatol 2003;9:142–50.
[132] Mody GM, Cardiel MH. Challenges in the management of rheumatoid arthritis in
developing countries. Best Pract Res Clin Rheumatol 2008;22:621–41.
[133] Rkain H, Allali F, Jroundi I, Hajjaj-Hassouni N. Socioeconomic impact of rheumatoid
arthritis in Morocco. Joint Bone Spine 2006;73:278–83.
[134] Uhlig T. Which patients with rheumatoid arthritis are still working? Arthritis Res
Ther 2010;12:114.
[135] Schmajuk G, Trivedi AN, Solomon DH, Yelin E, Trupin L, Chakravarty EF, et al. Re-
ceipt of disease-modifying antirheumatic drugs among patients with rheumatoid
arthritis in Medicare managed care plans. JAMA 2011;305:480–6.
[136] Solomon DH, Ayanian JZ, Yelin E, Shaykevich T, Brookhart MA, Katz JN. Use of
disease-modifying medications for rheumatoid arthritis by race and ethnicity in
the National Ambulatory Medical Care Survey. Arthritis Care Res 2012;64:184–9.
[137] Kalla AA, Tikly M. Rheumatoid arthritis in the developing world. Best Pract Res Clin
Rheumatol 2003;17:863–75.
[138] Margaretten M, Barton J, Julian L, Katz P, Trupin L, Tonner C, et al. Socioeconomic
determinants of disability and depression in patients with rheumatoid arthritis.
Arthritis Care Res 2011;63:240–6.
[139] Kumar K, Chambers S, Gordon C. Challenges of ethnicity in SLE. Best Pract Res Clin
Rheumatol 2009;23:549–61.
[140] Lau CS, Yin G, Mok MY. Ethnic and geographical differences in systemic lupus
erythematosus: an overview. Lupus 2006;15:715–9.
[141] Fernández M, Alarcón GS, Calvo-Alén J, Andrade R, McGwin G, Vilá LM, et al. A
multiethnic, multicenter cohort of patients with systemic lupus erythematosus
(SLE) as a model for the study of ethnic disparities in SLE. Arthritis Rheum
2007;57:576–84.
[142] Demas KL, Costenbader KH. Disparities in lupus care and outcomes. Curr Opin
Rheumatol 2009;21:102–9.
[143] Jolly M, Mikolaitis R a, Shakoor N, Fogg LF, Block J a. Education, zip code-based
annualized household income, and health outcomes in patients with systemic
lupus erythematosus. J Rheumatol 2010;37:1150–7.
[144] Wang M, Sun H, Zhang W, Zhang Y. Functional activation of proline-rich tyrosine
kinase2 (PYK2) in peripheral blood mononuclear cells from patients with systemic
lupus erythematosus. BMC Musculoskelet Disord 2009;10:141.
[145] Sule S, Petri M. Socioeconomic status in systemic lupus erythematosus. Lupus
2006;15:720–3.
[146] Sanchez E, Rassmusen A, Riba L, Acevedo E, Kelly JA, Langefeld CD, et al. Impact of
the Amerindian genetic ancestry on the clinical and socio-demographic expression
of systemic lupus erythematosus in a European- Amerindian admixed population.
Arthritis Rheum 2012;64:3687–94.
[147] Baker K, Pope J. Employment and work disability in systemic lupus erythematosus:
a systematic review. Rheumatology (Oxford) 2009;48:281–4.
[148] Pons-Estel GJ, Serrano R, Plasín M a, Espinosa G, Cervera R. Epidemiology and
management of refractory lupus nephritis. Autoimmun Rev 2011;10:655–63.
[149] Richman IB, Taylor KE, Chung S a, Trupin L, Petri M, Yelin E, et al. European genetic
ancestry is associated with a decreased risk of lupus nephritis. Arthritis Rheum
2012;64:3374–82.
[150] Rojas W, Parra MV, Campo O, Caro MA, Lopera JG, Arias W, et al. Genetic makeup
and structure of Colombian populations by means of uniparental and biparental
DNA markers. Am J Phys Anthropol 2010;143:13–20.
[151] Anaya J-M, Rojas-Villarraga A, Darío Mantilla R, Galarza-Maldonado C. Rheumatoid
arthritis in minorities. Arthritis 2013;2013:256493.
[152] Zhu TY, Tam LS, Li EK. Cost-of-illness studies in systemic lupus erythematosus: a
systematic review. Arthritis Care Res 2011;63:751–60.
[153] Walsh SJ, Gilchrist A. Geographical clustering of mortality from systemic lupus
erythematosus in the United States: contributions of poverty, Hispanic ethnicity
and solar radiation. Lupus 2006;15:662–70.
[154] Walsh SJ, DeChello LM. Geographical variation in mortality from systemic lupus
erythematosus in the United States. Lupus 2001;10:637–46.
[155] Hiraki LT, Lu B, Alexander SR, Shaykevich T, Alarcón GS, Solomon DH, et al. End-
stage renal disease due to lupus nephritis among children in the US, 1995–2006.
Arthritis Rheum 2011;63:1988–97.
[156] Ward MM. Laboratory abnormalities at the onset of treatment of end-stage renal
disease: are there racial or socioeconomic disparities in care? Arch Intern Med
2007;167:1083–91.
[157] Burling F, Ng J, Thein H, Ly J, Marshall MR, Gow P. Ethnic, clinical and immunolog-
ical factors in systemic lupus erythematosus and the development of lupus nephri-
tis: results from a multi-ethnic New Zealand cohort. Lupus 2007;16:830–7.
[158] Alarcón G, Bastian H, Beasley T, Roseman J, Tan F, Fessler B, et al. Systemic lupus
erythematosus in a multi-ethnic cohort (LUMINA): contributions of admixture
and socioeconomic status to renal involvement. Lupus 2006;15:26–31.
[159] Buchanan RJ, Zuniga MA, Carrillo-Zuniga G, Chakravorty BJ, Tyry T, Moreau RL, et al.
Comparisons of Latinos, African Americans, and Caucasians with multiple sclerosis.
Ethn Dis 2010;20:451–7.
[160] Minden SL, Hoaglin DC, Hadden L, Frankel D, Robbins T, Perloff J. Access to
and utilization of neurologists by people with multiple sclerosis. Neurology
2008;70:1141–9.
[161] Patti F, Pozzilli C, Montanari E, Pappalardo a, Piazza L, Levi a, et al. Effects of educa-
tion level and employment status on HRQoL in early relapsing-remitting multiple
sclerosis. Mult Scler 2007;13:783–91.
[162] Borchers AT, Uibo R, Gershwin ME. The geoepidemiology of type 1 diabetes.
Autoimmun Rev 2010;9:A355–65.
[163] Moroni L, Bianchi I, Lleo A. Geoepidemiology, gender and autoimmune disease.
Autoimmun Rev 2012;11:A386–92.
[164] Jarosz-Chobot P, Polanska J, Polanski A. Does social-economical transformation
influence the incidence of type 1 diabetes mellitus? A Polish example. Pediatr Dia-
betes 2008;9:202–7.
[165] D'Angeli MA, Merzon E, Valbuena LF, Tirschwell D, Paris CA, Mueller BA. Environ-
mental factors associated with childhood-onset type 1 diabetes mellitus: an explo-
ration of the hygiene and overload hypotheses. Arch Pediatr Adolesc Med
2010;164:732–8.
 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
[166] Liese AD, Puett RC, Lamichhane AP, Nichols MD, Dabelea D, Lawson AB, et al.
Neighborhood level risk factors for type 1 diabetes in youth: the SEARCH case–
control study. Int J Health Geogr 2012;11:1.
[167] Carter PJ, Cutfield WS, Hofman PL, Gunn a J, Wilson D a, Reed PW, et al. Ethnicity
and social deprivation independently influence metabolic control in children
with type 1 diabetes. Diabetologia 2008;51:1835–42.
[168] Walsh MG, Zgibor J, Songer T, Borch-Johnsen K, Orchard TJ. The socioeconomic cor-
relates of global complication prevalence in type 1 diabetes (T1D): a multinational
comparison. Diabetes Res Clin Pract 2005;70:143–50.
[169] Galler A, Lindau M, Ernert A, Thalemann R, Raile K. Associations between media
consumption habits, physical activity, socioeconomic status, and glycemic control
in children, adolescents, and young adults with type 1 diabetes. Diabetes Care
2011;34:2356–9.
[170] Tobon GJ, Arango a, Abad V, García J, Cuervo H, Velásquez a. Clinical and immuno-
logical characteristics of type 1 diabetes mellitus in a northwestern Colombian
population. Diabetes Res Clin Pract 2006;72:170–5.
[171] Evans GW, Kim P. Multiple risk exposure as a potential explanatory mechanism
for the socioeconomic status-health gradient. Ann N Y Acad Sci 2010;
1186:174–89.
[172] Krieger N. Geocoding and monitoring of US socioeconomic inequalities in mortality
and cancer incidence: does the choice of area-based measure and geographic
level matter?: the Public Health Disparities Geocoding Project. Am J Epidemiol
2002;156:471–82.
[173] Pollack CE, Chideya S, Cubbin C, Williams B, Dekker M, Braveman P. Should
health studies measure wealth? A systematic review. Am J Prev Med
2007;33:250–64.
[174] Hirst K, Baranowski T, DeBar L, Foster GD, Kaufman F, Kennel P, et al. HEALTHY
study rationale, design and methods: moderating risk of type 2 diabetes in
multi-ethnic middle school students. Int J Obes 2009;33(Suppl. 4):S4–S20.
[175] Marrie RA, Cutter G, Tyry T, Campagnolo D, Vollmer T. Smoking status over
two years in patients with multiple sclerosis. Neuroepidemiology
2009;32:72–9.
[176] Wang TF, Shi L, Nie X, Zhu J. Race/ethnicity, insurance, income and access to care:
the influence of health status. Int J Equity Health 2013;12:29.
[177] Marrie R, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Comorbidity,
socioeconomic status and multiple sclerosis. Mult Scler 2008;14:1091–8.
[178] Wright EO, Martin B. The transformation of the American class structure,
1960–19801. Am J Sociol 1987;93:1–29.
[179] Wright EO. Working-class power, capitalist-class interests, and class compromisel.
Am J Sociol 2000;105:957–1002.
[180] Wright EO. The comparative project on class structure and class consciousness: an
overview. Acta Sociol 1989;32:3–22.
[181] Chandola T. Social inequality in coronary heart disease: a comparison of occupa-
tional classifications. Soc Sci Med 1998;47:525–33.
[182] Prandy K. Class, stratification and inequalities in health: a comparison of the
Registrar–General's social classes and the Cambridge scale. Sociol Health Illn
1999;21:466–84.
[183] Haug MR. Measurement in social stratification. Annu Rev Sociol 1997;3:51–77.
[184] Chandola T, Bartley M, Wiggins R, Schofield P. Social inequalities in health by indi-
vidual and household measures of social position in a cohort of healthy people. J
Epidemiol Community Health 2003;57:56–62.
[185] Chandola T. Social class differences in mortality using the new UK National
Statistics Socio-Economic Classification. Soc Sci Med 2000;50:641–9.
[186] Ploubidis GB, Grundy E. Health measurement in population surveys: combining in-
formation from self-reported and observer-measured health indicators. Demogra-
phy 2011;48:699–724.
[187] Diez-Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, Shahar E, et al.
Neighborhood environments and coronary heart disease: a multilevel analysis.
Am J Epidemiol 1997;146:48–63.
[188] Bae SC, Hashimoto H, Karlson EW, Liang MH, Daltroy LH. Variable effects of social
support by race, economic status, and disease activity in systemic lupus erythema-
tosus. J Rheumatol 2001;28:1245–51.
[189] Cabieses B, Zitko P, Pinedo R, Espinoza M, Albor C. How has social status been mea-
sured in health research? A review of the international literature. Rev Panam Salud
Publica 2011;29:457–68.
[190] Harrison MJ, Tricker KJ, Davies L, Hassell A, Dawes P, Scott DL, et al. The relationship
between social deprivation, disease outcome measures, and response to treatment
in patients with stable, long-standing rheumatoid arthritis. J Rheumatol
2005;32:2330–6.
[191] Prandy K. Ideal types, stereotypes and classes. Br J Sociol 2002;53:583–601.
[192] Bottero W, Prandy K. Social interaction distance and stratification. Br J Sociol
2003;54:177–97.
[193] Banks J, Johnson P. Equivalence scale relativities revisited. Econ J 1994;104:883–90.
[194] Symmons DPM. Environmental factors and the outcome of rheumatoid arthritis.
Best Pract Res Clin Rheumatol 2003;17:717–27.
[195] ERAS Study Group. Socioeconomic deprivation and rheumatoid disease: what
lessons for the health service? Ann Rheum Dis 2000;59:794–9.
[196] McEntegart a, Morrison E, Capell H a, Duncan MR, Porter D, Madhok R. Effect of
social deprivation on disease severity and outcome in patients with rheumatoid
arthritis. Ann Rheum Dis 1997;56:410–3.
[197] Sweden Statistic. Swedish socio-economic classification SEI; 2007 1–2.
[198] Bergström U, Jacobsson LTH, Nilsson J-Å, Berglund G, Turesson C. Pulmonary
dysfunction, smoking, socioeconomic status and the risk of developing rheumatoid
arthritis. Rheumatology (Oxford) 2011;50:2005–13.
[199] Alvarez M, Musso S, Ivanovic D. Scale for measurement of socioeconomic level, in
the health area. Rev Med Chil 1985;113:243–9.
653
[200] Massardo L, Pons-Estel B a, Wojdyla D, Cardiel MH, Galarza Maldonado CM, Sacnun
MP, et al. Early rheumatoid arthritis in Latin America. Low socioeconomic status
relates to high disease activity at baseline. Arthritis Care Res 2012:1–24.
[201] Haynes A, Bulsara MK, Bower C, Codde JP, Jones TW, Davis E a. Independent effects
of socioeconomic status and place of residence on the incidence of childhood type
1 diabetes in Western Australia. Pediatr Diabetes 2006;7:94–100.
[202] Associação Brasileira de Empresas de Pesquisa. Critério de classificação econômica
Brasil; 2008 1–4.
[203] Ward MM. Access to care and the incidence of endstage renal disease due to
systemic lupus erythematosus. J Rheumatol 2010;37:1158–63.
[204] Alcaldía Mayor de Bogotá. La estratificación en Bogotá D.C. y estudios relacionados,
1983–2004; 2004 [Bogotá: Alcaldía Mayor de Bogotá].
[205] Congreso de la República de Colombia. Ley 142 de 1994 por la cual se establece el
régimen de los servicios públicos domiciliarios y se dictan otras disposiciones;
1994 [Colombia].
[206] Bonito J, Bann C, Eicheldinger C, Carpenter L. Creation of new race ethnicity codes
and socioeconomic status (SES) indicators for medicare beneficiaries. Final Report.
Agency Healthc Res Qual; 2008.
[207] Goodman A, Wilkinson P, Stafford M, Tonne C. Characterising socio-economic in-
equalities in exposure to air pollution: a comparison of socio-economic markers
and scales of measurement. Health Place 2011;17:767–74.
[208] Alarcón GS, McGwin G, Sanchez ML, Bastian HM, Fessler BJ, Friedman AW, et al.
Systemic lupus erythematosus in three ethnic groups. XIV. Poverty, wealth, and
their influence on disease activity. Arthritis Rheum 2004;51:73–7.
[209] Design of the Women's Health Initiative clinical trial and observational study. the
Women's Health Initiative Study Group. Control Clin Trials 1998;19:61–109.
[210] Nunes ED. Hollingshead and Redlich: research on social class and mental illness
fifty years after. Hist Cienc Saude Manguinhos 2010;17:125–40.
[211] Cirino PT, Chin CE, Sevcik RA, Wolf M, Lovett M, Morris RD. Measuring socioeco-
nomic status: reliability and preliminary validity for different approaches. Assess-
ment 2002;9:145–55.
[212] Secrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Association of
socioeconomic status with mortality in type 1 diabetes: the Pittsburgh epidemiology
of diabetes complications study. Ann Epidemiol 2011;21:367–73.
[213] Grimaud O, Lapostolle A, Berr C, Helmer C, Dufouil C, Kihal W, et al. Gender Differ-
ences in the association between socioeconomic status and subclinical atheroscle-
rosis. PLoS One 2013;8:e80195.
[214] Tektonidou MG, Ward MM. Validity of clinical associations of biomarkers in
translational research studies: the case of systemic autoimmune diseases. Arthritis
Res Ther 2010;12:R179.
[215] Shen B, Tan W, Feng G, He Y, Liu J, Chen W, et al. The correlations of disease activity,
socioeconomic status, quality of life, and depression/anxiety in Chinese patients
with systemic lupus erythematosus. Clin Dev Immunol 2013;2013:270878.
[216] Pons-Estel GJ, Saurit V, Alarcón GS, Hachuel L, Boggio G, Wojdyla D, et al. The
impact of rural residency on the expression and outcome of systemic lupus erythema-
tosus: data from a multiethnic Latin American cohort. Lupus 2012;21:1397–404.
[217] Hopkinson ND, Jenkinson C, Muir KR, Doherty M, Powell RJ. Racial group, socioeco-
nomic status, and the development of persistent proteinuria in systemic lupus
erythematosus. Ann Rheum Dis 2000;59:116–9.
[218] Feldman CH, Hiraki LT, Liu J, Fischer M a, Solomon DH, Alarcón GS, et al.
Epidemiology and sociodemographics of systemic lupus erythematosus and
lupus nephritis among US adults with Medicaid coverage, 2000–2004. Arthritis
Rheum 2013;65:753–63.
[219] Nee R, Jindal RM, Little D, Ramsey-Goldman R, Agodoa L, Hurst FP, et al. Racial
differences and income disparities are associated with poor outcomes in kidney
transplant recipients with lupus nephritis. Transplantation 2013;95:1471–8.
[220] Maynard JW, Fang H, Petri M. Low socioeconomic status is associated with cardio-
vascular risk factors and outcomes in systemic lupus erythematosus. J Rheumatol
2012;39:777–83.
[221] Tonner C, Trupin L, Yazdany J, Criswell L, Katz P, Yelin E. Role of community and in-
dividual characteristics in physician visits for persons with systemic lupus erythe-
matosus. Arthritis Care Res 2010;62:888–95.
[222] Trupin L, Tonner MC, Yazdany J, Julian LJ, Criswell LA, Katz PP, et al. The role of
neighborhood and individual socioeconomic status in outcomes of systemic
lupus erythematosus. J Rheumatol 2008;35:1782–8.
[223] Yazdany J, Gillis JZ, Trupin L, Katz P, Panopalis P, Criswell L a. Association of socio-
economic and demographic factors with utilization of rheumatology subspecialty
care in systemic lupus erythematosus. Arthritis Rheum 2007;57:593–600.
[224] Ward MM. Education level and mortality in systemic lupus erythematosus (SLE):
evidence of underascertainment of deaths due to SLE in ethnic minorities with
low education levels. Arthritis Rheum 2004;51:616–24.
[225] Barr RG, Seliger S, Appel GB, Zuniga R, D'Agati V, Salmon J, et al. Prognosis in pro-
liferative lupus nephritis: the role of socio-economic status and race/ethnicity.
Nephrol Dial Transplant 2003;18:2039–46.
[226] Alarcón GS, Rodríguez JL, Benavides G, Brooks K, Kurusz H, Reveille JD. Systemic
lupus erythematosus in three ethnic groups. V. Acculturation, health-related
attitudes and behaviors, and disease activity in Hispanic patients from the
LUMINA cohort. LUMINA Study Group. Lupus in Minority Populations, Nature
versus Nurture. Arthritis Care Res 1999;12:267–76.
[227] Langley PC, Mu R, Wu M, Dong P, Tang B. The impact of rheumatoid arthritis on the
burden of disease in urban China. J Med Econ 2011;14:709–19.
[228] Zhu TY, Tam L-S, Li EK. Societal costs of rheumatoid arthritis in Hong Kong: a
prevalence-based cost-of-illness study. Rheumatology (Oxford) 2011;50:1293–301.
[229] Pedersen M, Jacobsen S, Klarlund M, Frisch M. Socioeconomic status and
risk of rheumatoid arthritis: a Danish case–control study. J Rheumatol
2006;33:1069–74.
654 O.-J. Calixto, J.-M. Anaya / Autoimmunity Reviews 13 (2014) 641–654
[230] Kwon J-M, Rhee J, Ku H, Lee E-K. Socioeconomic and employment status of patients
with rheumatoid arthritis in Korea. Epidemiol Health 2012;34:e2012003.
[231] Ibn Yacoub Y, Amine B, Laatiris A, Hajjaj-Hassouni N. Health-related quality of
life in Moroccan patients with rheumatoid arthritis. Clin Rheumatol 2012;31:
1471–7.
[232] Andersson M Le, Bergman S, Söderlin MK. The effect of stopping smoking on
disease activity in rheumatoid arthritis (RA). Data from BARFOT, a multicenter
study of early RA. Open Rheumatol J 2012;6:303–9.
[233] Li X, Sundquist J, Sundquist K. Socioeconomic and occupational risk factors for
rheumatoid arthritis: a nationwide study based on hospitalizations in Sweden. J
Rheumatol 2008;35:986–91.
[234] Chen Y, Yu Z, Packham JC, Mattey DL. Influence of adult height on rheumatoid
arthritis: association with disease activity, impairment of joint function and overall
disability. PLoS One 2013;8:e64862.
[235] Lahiri M, Luben RN, Morgan C, Bunn DK, Marshall T, Lunt M. Using lifestyle factors
to identify individuals at higher risk of inflammatory polyarthritis (results from the
European Prospective Investigation of Cancer-Norfolk and the Norfolk Arthritis
Register—the EPIC-2-NOAR study). Ann Rheum Dis 2013:1–8.
[236] Mackie SL, Taylor JC, Twigg S, Martin SG, Steer S, Worthington J, et al. Relationship
between area-level socio-economic deprivation and autoantibody status in
patients with rheumatoid arthritis: multicentre cross-sectional study. Ann Rheum
Dis 2012;71:1640–5.
[237] Camacho EM, Verstappen SMM, Symmons DPM. Association between socioeco-
nomic status, learned helplessness, and disease outcome in patients with inflam-
matory polyarthritis. Arthritis Care Res 2012;64:1225–32.
[238] Harrison MJ, Farragher TM, Clarke AM, Manning SC, Bunn DK, Symmons DPM. As-
sociation of functional outcome with both personal- and area-level socioeconomic
inequalities in patients with inflammatory polyarthritis. Arthritis Care Res
2009;61:1297–304.
[239] Parks CG, D'Aloisio A a, DeRoo L a, Huiber K, Rider LG, Miller FW. Childhood socio-
economic factors and perinatal characteristics influence development of rheuma-
toid arthritis in adulthood. Ann Rheum Dis 2013;72:350–6.
[240] Harrold LR, Briesacher B a, Peterson D, Beard A, Madden J, Zhang F, et al. Cost-
related medication nonadherence in older patients with rheumatoid arthritis. J
Rheumatol 2013;40:137–43.
[241] Martin KR, Shreffler J, Schoster B, Callahan LF. Associations of perceived neighbor-
hood environment on health status outcomes in persons with arthritis. Arthritis
Care Res 2010;62:1602–11.
[242] Tahirović H, Toromanović A, Tahirović E, Begić H. Impact of socioeconomic status
on health-related quality of life in children with type 1 diabetes mellitus in
Bosnia and Herzegovina. Minerva Pediatr 2013;65:207–12.
[243] Gomes MB, Cobas R a, Matheus AS, Tannus LR, Negrato CA, Rodacki M, et al. Re-
gional differences in clinical care among patients with type 1 diabetes in Brazil:
Brazilian Type 1 Diabetes Study Group. Diabetol Metab Syndr 2012;4:44.
[244] Borges-Marques R de M, Schmid-Fornés N, Ferreira-Stringhini M-L. Fatores
socioeconômicos, demográficos, nutricionais e de atividade física no controle
glicêmico de adolescentes portadores de diabetes melito tipo 1. Arq Bras
Endocrinol Metabol 2011;55:194–202.
[245] Karavanaki K, Tsoka E, Karayianni C, Petrou V, Pippidou E, Brisimitzi M, et al.
Prevalence of allergic symptoms among children with diabetes mellitus type 1 of
different socioeconomic status. Pediatr Diabetes 2008;9:407–16.
[246] Bruno G, Spadea T, Picariello R, Gruden G, Barutta F, Cerutti F, et al. Early life
socioeconomic indicators and risk of type 1 diabetes in children and young adults.
J Pediatr 2013;162:600–605.e1.
[247] Ismail IS, Nazaimoon WM, Mohamad WB, Letchuman R, Singaraveloo M, Pendek R,
et al. Sociodemographic determinants of glycaemic control in young diabetic
patients in peninsular Malaysia. Diabetes Res Clin Pract 2000;47:57–69.
[248] Lewis KR, Clark C, Velarde MC. Socioeconomic factors associated with pediatric
diabetic ketoacidosis admissions in Southern West Virginia. Clin Endocrinol (Oxf)
2013:1–4.
[249] Puett RC, Lamichhane AP, D Nichols M, Lawson AB, A Standiford D, Liu L, et al.
Neighborhood context and incidence of type 1 diabetes: the SEARCH for Diabetes
in Youth study. Health Place 2012;18:911–6.
[250] Powell PW, Chen R, Kumar A, Streisand R, Holmes CS. Sociodemographic effects on
biological, disease care, and diabetes knowledge factors in youth with type 1 diabe-
tes. J Child Health Care 2012;17:174–85.
[251] Secrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations
between socioeconomic status and major complications in type 1 diabetes: the
Pittsburgh epidemiology of diabetes complication (EDC) Study. Ann Epidemiol
2011;21:374–81.
[252] Hassan K, Loar R, Anderson BJ, Heptulla RA. The role of socioeconomic status,
depression, quality of life, and glycemic control in type 1 diabetes mellitus. J
Pediatr 2006;149:526–31.
[253] Gallegos-Macias AR, Macias SR, Kaufman E, Skipper B, Kalishman N. Relationship
between glycemic control, ethnicity and socioeconomic status in Hispanic and
white non-Hispanic youths with type 1 diabetes mellitus. Pediatr Diabetes
2003;4:19–23.
[254] Marrie R, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. High frequency of
adverse health behaviors in multiple sclerosis. Mult Scler 2009;15:105–13.
[255] Nielsen NM, Jørgensen KT, Bager P, Stenager E, Pedersen BV, Hjalgrim H, et al. So-
cioeconomic factors in childhood and the risk of multiple sclerosis. Am J Epidemiol
2013;177:1289–95.
[256] Farnoush R, Sahebolzamani M, Aliloo L, Rahmani A. Educational, psycho mental
and socio economical needs of an Iranian Cohort with multiple sclerosis. Oman
Med J 2010;25:22–5.
[257] Yamout B, Issa Z, Herlopian a, El Bejjani M, Khalifa a, Ghadieh a S. Predictors of
quality of life among multiple sclerosis patients: a comprehensive analysis. Eur J
Neurol 2013;20:756–64.
[258] Li X, Hemminki K, Sundquist K. Regional, socioeconomic and occupational groups
and risk of hospital admission for multiple sclerosis: a cohort study in Sweden.
Mult Scler 2008;14:522–9.
[259] Ibn Yacoub Y, Rostom S, Laatiris A, Hajjaj-Hassouni N. Primary Sjögren's syndrome
in Moroccan patients: characteristics, fatigue and quality of life. Rheumatol Int
2012;32:2637–43.
[260] Meijer JM, Meiners PM, Huddleston Slater JJR, Spijkervet FKL, Kallenberg
CGM, Vissink A, et al. Health-related quality of life, employment and disabil-
ity in patients with Sjogren's syndrome. Rheumatology (Oxford)
2009;48:1077–82.
[261] Mansour S, Bonner A, Muangchan C, Hudson M, Baron M, Pope JE. Low socio-
economic status (measured by education) and outcomes in systemic sclerosis:
data from the Canadian scleroderma research group. J Rheumatol
2013;40:447–54.
[262] Nguyen C, Poiraudeau S, Mestre-Stanislas C, Rannou F, Bérezné A, Papelard A, et al.
Employment status and socio-economic burden in systemic sclerosis: a cross-
sectional survey. Rheumatology (Oxford) 2010;49:982–9.
[263] Ostojic P, Zivojinovic S, Reza T, Damjanov N. Symptoms of depression and anxiety
in Serbian patients with systemic sclerosis: impact of disease severity and socio-
economic factors. Mod Rheumatol 2010;20:353–7.