End-of-Life & Socioeconomic Status Fact Sheet
Socioeconomic status (SES) is often measured as a combination of education, income, and occupation. It is commonly conceptualized as the social standing or class of an individual or group. When viewed through a social class lens, privilege, power, and control are emphasized. Furthermore, an examination of SES as a gradient or continuous variable reveals inequities in access to and distribution of resources. SES is relevant to all realms of behavioral and social science, including research, practice, education, and advocacy.
SES Affects our Society
Low SES and its correlates, such as lower education, poverty, and poor health, ultimately affect our society as a whole. Inequities in wealth distribution, resource distribution, and quality of life are increasing in the United States and globally. Society benefits from an increased focus on the foundations of socioeconomic inequities and efforts to reduce the deep gaps in socioeconomic status in the United States and abroad. Behavioral and other social science professionals possess the tools necessary to study and identify strategies that could alleviate these disparities at both individual and societal levels.
SES and End-of-Life Issues
Research has elucidated several areas where SES appears to significantly affect end-of-life issues. Two such areas include the early detection of life-threatening illnesses and the quality of life for people so diagnosed. This fact sheet aims to expand on these two areas, noting the ways that SES acts as a moderator.
Disparities in Chronic and Terminal Illness
Recent research has found disparities in early detection of life-threatening illnesses among persons of varying SES. Lower SES has been associated with less utilization of preventative and early detection services — methods that may prevent or mitigate the effects of potentially life-limiting illnesses. Research shows persons of low SES are likely to have:
Fewer breast cancer screenings (Breen, Wagner, Brown, Davids, & Ballard-Barbash, 2001; Katz, Zemencuk, & Hofer, 2000; O’Malley et al., 2001; Sambamoorthi & McAlpine, 2003)
Fewer colorectal screenings (Breen, Wagner, Brown, Davids, & Ballard-Barbash, 2001; Ward et al., 2004)
Fewer blood pressure and cholesterol screenings (Sambamoorthi & McAlpine,., 2003)
The difference in utilization of early detection screenings may be influenced by the likelihood that persons of lower SES more often hold jobs that offer partial or no health insurance coverage. However, some research indicates that disparities in utilization exist even when these services are covered by a health plan, suggesting the need to educate persons of low SES of the benefits of early screenings and preventative care. These screenings increase the chances of diagnosing a disease early. A later (and often lesstreatable) diagnosis is likely when individuals do not adhere to these screenings. Later-stage diagnosis appears to affect persons of lower SES more than would be expected by chance:
Females under age 65 years of lower SES who had cervical cancer were 2.65 times more likely to be diagnosed with a later stage of the disease than their higher SES peers (Bradley et al., 2001).
Adults of lower SES with colon or lung carcinoma were about 1.5 times more likely to be diagnosed with a later stage of the disease than their higher SES peers (Bradley, Given, & Roberts et al., 2001).
Adults of lower SES were significantly more likely to be diagnosed with a later stage of colorectal, lung, or breast cancer than their higher SES peers (Ward et al., 2004).
Quality of Life
End-of-life choices can directly affect an individual’s quality of life. Participation in palliative care programs has been shown to significantly increase self-reported quality of life in persons diagnosed with a terminal illness (Cohen, Boston, Mount, & Porterfield, 2001). Use of these programs, however, is not universal, and lower SES appears to be associated with less utilization of these quality-of-life sustaining programs: Persons making more than $25,000 annually were 2.3 times more likely to elect hospice use than those who made less (Greiner, Perera, & Ahluwalia., 2003).
Persons who attended some college were 1.45 times more likely to elect hospice use than those who never attended college (Greiner, Perera, & Ahluwalia et al., 2003).
Individuals living in neighborhoods with higher median income were more likely to elect hospice use than their peers living in lower SES neighborhoods (McCarthy, Burns, Davis, & Phillips et al., 2003).
Little information is available to explain why such disparities exist. However, it appears that education may play a key role in understanding this disproportion: A recent study by Silveira and colleagues (2000) found that persons with a college degree or higher showed 3-times-better knowledge of end-of-life options than those without a degree.
The above research areas — incidence of terminal illnesses and the quality of life for people so diagnosed — indicate that disparities in end-of-life issues are moderated by factors of SES. Increased research is needed to support and extend the noted findings and to close the gap that socioeconomic differences appear to cause.
What You Can Do
Include SES in your research, practice, and educational endeavors
Measure, report, and control for SES in all research and published work with persons with terminal illness and at risk for terminal illnesses and those who may be facing end-of-life choices.
Contribute to the body of research on the societal barriers experienced by persons with terminal illness, particularly low-SES groups and/or persons of minority status, and the impact of these barriers on health and positive well-being.
Practice proactive screening of psychological and physical distress in terminally diagnosed or at-risk clients, educate patients of their options to maintain their quality of life, and practice coordinated care with other health professionals.
Ensure that trainees are sensitive to health disparities. Provide trainees with exposure to terminally ill populations and specialized training on the screening, education, and treatment of persons at risk for terminal illness.
Support legislation and policies that explore and work to eliminate socioeconomic disparities. Visit the Office on Government Relations for more details.
Become an SES Key Contact! As an expert, advocate for SES related issues.
Join APA’s SES Network to contribute to and stay abreast of current developments in SES-related activities.
Visit APA’s Office on Socioeconomic Status (OSES) website.
Visit APA’s End of Life Issues and Care website.
References can be found online.