Over the years there has been a significant body of literature on the relationship between socioeconomic status and health outcomes. Generally speaking, individuals with a lower economic status also suffer the consequences of a lower educational level, which in turn impacts the degree to which they are able to comprehend the nature of their illness.

In a study published recently in "Arthritis Care and Research", it was demonstrated that other indicators of socioeconomic status, such as education, home ownership, income, and occupation can impact health outcomes. Individuals with an annual household income of less than $45,000 had worse health status compared to those with an income above $45,000. Nevertheless, location, location, location is relevant to both real estate and health outcomes: an above average income and a solid education is not a guarantee of good health if one lives in an area where poverty is endemic.

Psychosocial variables may mediate education's effects, and the relationship between psychosocial functioning and health-related outcomes may be moderated by educational level, with individuals lower in formal education being more susceptible to the deleterious effects of negative cognitive and affective states. A study published a few years ago in "Clinical Journal of Pain" found that education-related differences in pain report were accounted for by catastrophizing and depression. In addition, after controlling for demographic factors, disease severity, and depressive symptoms, education moderated the relationship between catastrophizing, pain affect, and social function. Catastrophizing was more highly associated with more reporting of affective pain among those with less formal education. Thus, there are multiple models of interaction between education and pain-related cognitive and affective functioning; lower levels of formal education act as a risk factor for adverse pain-related outcomes.

Other studies have shown that clinical markers of rheumatoid arthritis indicate substantially poorer clinical status in patients who did not complete high school, compared with those who had completed high school. In fact, the poorest results were seen in patients with only a grade school education, with a progressive improvement seen in patients with some high school education, high school graduates, and patients with some college education. These differences in clinical status according to formal education are not explained by age, sex, duration of disease, clinical setting, or multiple comparisons.

The role of the individual certainly looms large in how he or she responds to treatment. Socioeconomic status dictates the degree of improvement attained when fighting a chronic and potentially debilitating disease. If this country continues to see increases in the numbers of those living in poverty, it will be interesting to see if health care reform will truly produce significant improvement in health outcomes.

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