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9. Questions on socio-economic status

Prevalence of several cardiovascular disease risk factors (hypertension, obesity, ect.) is known to differ by socio-economic status. People with lower socio-economic status are generally more likely to be e.g. obese (1) and hypertensive (2).

Socio-economic status can be assessed by a set of questions about the educational achievement, income and occupation. 

9.1 Questions

International standardization of questions about socio-economic status is difficult. There are problems in developing internationally comparable measures of educational level, since the educational systems vary so much between different countries. In international studies, one of the most commonly used indicators for educational achievement  has been "total years of schooling". Obviously, there are also problems with this indicator. Simply counting years does not fully reflect educational level, even within an educational system. For example, highly gifted children may skip school grades and achieve graduation with fewer years of schooling, or alternatively, some students may have to repeat one or more grades and accumulate more years before graduating. The problem becomes worse when using the number of years of schooling to compare educational achievements between education systems. Also, in multinational comparisons it is always a problem to develop wording of the questions in the local languages such that they produce comparable results.

Assessing socio-economic status by income raises the question of how to measure income. It is only straight forward to assign a monetary value to income, if a person's income is all derived from employment, social assistance, pension etc.. Even if a numerical value can be assigned to income, its relation to socio-economic status can only be appreciated if it is set in relation to the cost of living, which can be different from region to region within a country and it usually differs between countries.

An other frequently employed indicator for socio-economic status is occupation. For international comparisons, this indicator may pose a problem with occupations that are peculiar to a particular society. Also, the social ranking of an occupation may differ from one society to the next. Finally, even within a society an occupation can cover a large range of social standing, e.g. the occupation "lawyer" is equally applicable to a high-power corporate lawyer as well as one who is subsisting as a public defender for the indigents.

As a result of these difficulties, one indicator by itself is usually not enough to adequately characterize socio-economic status. 

9.1.1 The WHO MONICA Project

In the WHO MONICA Project (3) only information about the educational achievement was collected using following two questions:

1. "What is the highest level of education you have completed?"
1 = university or college or equivalent
2 = intermediate between secondary level and university (e.g. technical training)
3 = secondary school
4 = primary school only (or less)
9 = insufficient data
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2. "How many years have you spent at school or in full time study?"
99 = insufficient data
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For the Question 1 the MONICA Manual (3) gives the additional instructions:

Codes 1, 2 and 3 are self-explanatory. The lowest code should take precedence.
Code 4 if primary school only or if less than primary school.
Code 9 for insufficient data.

9.1.2 Risk factor monitoring in the Netherlands 

In the MORGEN Project in the Netherlands, education was estimated from the question "What is the highest level of education that you have completed"? with response categories primary education (or less), lower occupational education, secondary level education, higher occupational or equivalent education, university education. (4)

9.1.3 Risk factor monitoring in Germany

The German Federal Health Survey 1998 had a 107-question instrument that included sections on elementary level schooling (eight choices), occupational or university education (eight choices), employment status (6 choices), occupations status (19 choices), job stress (5 choices), and category of household income (13 levels). (5). 

1. What level of schooling did you complete? If more apply, select the highest one.
Elementary school
Middle school
10-year poly-technical high school
Advanced professional college
High school with university entrance qualification
Other graduation
School with no graduation
Not yet graduated

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2. Do you have completed occupational or university education?  If more apply, select the highest one
Apprenticeship
Trade school
Professional college
Advanced professional college
University
Other professional training
No professional training completed
Not yet in professional training

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3. Which of the following statements about occupational status apply to you?
Not working at the moment
Part-time or hourly work (< 15 hours per week)
Part-time work (15 to 34 hours per week)
Full-time work
On temporary leave (education leave, public service leave)
In training (apprentice)

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4. Does any of the following statements apply to your present situation?
In school
In university
In age-related retirement
In early retirement
Unemployed
Exclusively house wife/ house man
In military/community/voluntary social service
In retraining
None of the above apply

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5. If you are presently not working. Did you ever work before?
No Go to question 10.
Yes
Since when are you no longer working

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Since |__||__|(month)19|__||__|(year)
6. How many months during the past five years were you without work?
Altogether
Does not apply

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7. In what occupational capacity are you presently working or (of no longer working) in what occupation did you last work?
Specify exact job title ___________________________________________________
8. What is your present occupational position or (if no longer working) was your last position?

Laborer:
unskilled
trained on the job
skilled
foreman

Self-employed:
independent or co-op farmer
professional or independent academic
independent with up to 9 employees
independent with 10 or more employees

Employee:
industrial foreman with some management responsibility
in regular position (sales person, typist)
with special qualifications (e.g. draftsperson, book keeper, accounts specialist)
in highly specialized position (e.g. division head, scientist)
in leadership position (e.g. director, president of larger corporation)

Civil servant (including judges and professional soldiers):
lower level service
middle level service
higher lever service
upper level service

Other:
trainees, students, conscripts, ect.




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9. If you are not presently working go to question 10, else, is your job characterized by:
Do you perceive it as a health threat
No Yes No Yes
Heavy physical labor |__| |__| |__| |__|
Noise, dust, gases, vapors, "polluted" air |__| |__| |__| |__|
Work stress (time pressure, concentration), worry about job security |__| |__| |__| |__|
Overtime, long working hours |__| |__| |__| |__|
Shift work/night shift
  • shift work without night shift
  • shift work with night shift
  • always night shift


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How long have you been doing that work |__||__| years |__||__| months
10. In what job position is your partner at present

Laborer:
unskilled
trained on the job
skilled
foreman

Self-employed:
independent or co-op farmer
professional or independent academic
independent with up to 9 employees
independent with 10 or more employees

Employee:
industrial foreman with some management responsibility
in regular position (sales person, typist)
with special qualifications (e.g. draftsperson, book keeper, accounts specialist)
in highly specialized position (e.g. division head, scientist)
in leadership position (e.g. director, president of larger corporation)

Civil servant (including judges and professional soldiers):
lower level service
middle level service
higher lever service
upper level service

Other:
trainees, students, conscripts, ect.

 


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11. What is the monthly household income, net income after taxes and fringe benefit deductions
< 1.000 DM
1.000 to < 1,500 DM
1,500 to < 2,000 DM
2,000 to < 2,500 DM
2,500 to < 3,000 DM
3,000 to < 3,500 DM
3,500 to < 4,000 DM
4,000 to < 4,500 DM
4,500 to < 5,000 DM
5,000 to < 6,000 DM
6,000 to < 8,000 DM
8,000 to < 10,000 DM
10,000 and more

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9.1.4 UK National Health Surveys

Questions used in the 1998 Health Survey for England (6) about the educational level are as follows:

1. At what age did you finish your continuous full-time education at school or college?
1. Not yet finished
2. Never went to school
3. 14 or under
4. 15
5. 16
6. 17
7. 18
8. 19 or over
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2. Do you have any of the qualifications listed on this card? (See Question 3 for the list)
1. Yes (Go to Question 3)
2. No
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3. Which of the qualifications on this card do you have?
1. Degree/degree level qualification (including higher degree)
2. Teaching qualification
3. Nursing qualifications SRN, SCM, SEN, RGN, RM, RHV, Midwife
4. HNC/HND, BEC/TEC Higher, BTEC Higher/SCOTECH Higher
5. ONC/OND/BEC/TEC/BTEC not higher
6. City and Guilds Full Technological Certificate
7. City and Guilds Advanced/Final Level
8. City and Guilds Craft/Ordinary Level
9. A-levels/Higher School Certificate
10. AS level
11. SLC/SCE/SUPE at Higher Grade or Certificate of Sixth Year Studies
12. O-level passes taken in 1975 or earlier
13. O-level passes taken after 1975 GRADES A-C
14. O-level passes taken after 1975 GRADES D-E
15. GCSE GRADES A-C
16. GCSE GRADES D-G
17. CSE GRADES 1/SCE BANDS A-C/Standard Grade LEVEL 1-3
18. CSE GRADES 2-5/SCE Ordinary BANDS D-E
19. CSE Ungraded
20. SLC Lower
21. SUPE Lower or Ordinary
22. School Certificate or Matric
23. NVQ Level 5
24. NVQ Level 4
25. NVQ Level 3/Advanced level GNVQ
26. NVQ Level 2/Intermediate level GNVQ
27. NVQ Level 1/Foundation level GNVQ
28. Recognised Trade Apprenticeship completed
29. Clerical or Commercial Qualification (e.g. typing/book-keeping/commerce)

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3. Do you have any qualifications not listed on this card?
1. Yes (Go to Question 4)
2. No
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4. What qualifications are these?

Above questions are asked from the respondents aged 16 to 120 years.

Questions about the income in the household questionnaire (6) are:

1. Which kind of income you (and your husband/wife/partner) receives?
1. Earning from employment or self-employment
2. State retirement pension
3. Pension from former employer
4. Child benefit
5. Job-Seekers allowance
6. Income Support
7. Family Credit
8. Housing Benefit
9. Other state benefits
10. Interest from savings and investments (e.g. stocks & shares)
11. Other kinds of regular allowance from outside your household (e.g. maintenance, student's grants, rent)
12. No source of income
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2. Which of the groups represents your and your husband/wife/partner's) income from all these sources before any deductions for income tax, National Insurance, etc.?
(Show card with 31 alternatives for weekly, monthly or annual income)
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3. Does anyone else in the household have an income from any source?
1. Yes
2. No
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4. Which of the groups represents the total income of the whole household before deductions for income tax, National Insurance, etc. ?
(Show card with 31 alternatives for weekly, monthly or annual income)
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Questions about the occupation in the personal questionnaire (6) are:

1. What is (was/will be) the name or title of the job?
2. Are you (were you/will you be) working full-time or part-time?
1. Full-time
2. Part-time
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3. What kind of work do (did/will) you do most of the time?
4. What materials or machinery do (did/will) you use?
5. What skills or qualifications are (were) needed for the job?
6. Are you (were you/will you be)?
1. An employee (Go to Question 7)
2. Self-employed
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7. Are you a Director of a limited company?
1. Yes
2. No
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8. Are you?
1. Manager
2. Foreman or supervisor
3. Other employee
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9. Including yourself, about how many people are (were) employed at the place where you usually work (usually worked/will work)?
1. 1 or 2
2. 3-24
3. 35-499
4. 500+
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10. What does (did) your employer make or do at the place where you usually word (usually worked/will work)?
11. What do (did/will) you make or do in your business?

9.1.5 National Health and Nutrition Examination Survey (NHANES III), USA

The NHANES III household family questionnaire included questions about the educational level of each of the family members surveyed (7):

1. What is the highest grade or year of regular school you have ever attended? 
00 never attended or kindergarten only
Elementary 1 2 3 4 5 6 7 8
High           9 10 11 12
College      1 2 3 4 5 +

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2. Did you finish grade/year? 
1. Yes
2. No
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The questions for income in the household family questionnaire were following (7):

1. During the last month, did anyone in the family receive income from working for an employer or from self-employment?
1. Yes
2. No (Go to Question 4)
9. Don't know (Go to Question 4)
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2. Who was that?
3.  Anyone else?
1. Yes (Re-ask Questions 2 and 3)
2. No
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4. During the last month did anyone in the family receive Security or Railroad Retirement payments?
1. Yes
2. No (Go to Question 8)
9. Don't know (Go to Question 8)
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5. Who was that?
6. Anyone else?
1. Yes (Re-ask Questions 5 and 6)
2. No
7. Record a separate answer for each person less than 65 answering YES for Question 4.
What is the reason -- is getting Social Security or Railroad Retirement? 
1. Retired
2. Disabled
3. Widowed
4. Surviving child
5. Spouse
6. Dependent child
9. Don't know
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8. During the last month did anyone in the family receive any SSI (Supplemental Security Income) payments from the Federal Government?
1. Yes
2. No (Go to Question 11)
9. Don't know (Go to Question 11)
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9. Who was that?
10. Anyone else?
1. Yes (Re-ask Questions 9 and 10)
2. No
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11. During the last month did anyone in the family receive any pension or disability payment other than Social Security or Railroad Retirement?
1. Yes 
2. No (Go to Question 14)
9. Don't know (Go to Question 14)
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12. Who was that?
13. Anyone else?
1. Yes (Re-ask Questions 12 and 13)
2. No
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14. During the last month, did anyone in the family receive Public assistance or welfare payments from the State or Local welfare office? Do not include SSI.
1. Yes
2. No (Go to Question 17)
9. Don't know (Go to Question 17)
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15. What was that?
16. Anyone else?
1. Yes (Re-ask Questions 15 and 16)
2. No
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17. During the last month, did anyone in the family receive 'Aid to Families with Dependent Children', sometimes called AFDC or ADC.
1. Yes
2. No (Go to Question 20)
9. Don't know (Go to Question 20)
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18. Who was that?
19. Anyone else?
1. Yes (Re-ask Questions 18 and 19)
2. No
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20. During the last month, did anyone in the family receive income from any other source such as veteran's payments, workman's compensation, rental income, interest and dividend income, or child support and alimony?
1. Yes 
2. No (Go to Question 23)
9. Don't know (Go to Question 23)
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21. Who was that?
22.  Anyone else?
1. Yes (Re-ask Questions 21 and 22)
2. No
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23. Including wages, salaries, self-employment, and any other source of income we just talked about, was the total combined family income during the last 12 months 
1. Less than $20,000
2. $20,000 or more
0. No income (End this section)
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24. Show card with 30 income groups.

Of those income groups, which letter better represents the total combined family income during the last 12 months? Include all sources of income we just talked about.

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25. Show card with 24 income groups.

Now, please think about your family income during (name of last month). Which letter best represents the total combined income during (name of last month). Again, include all sources of income we just talked about. 

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The questions for occupation in the household family questionnaire were  meant for the head of the family and were as follows (7):

1. Check item
1. Head of family is an SP (End this section)
2. Head of family not an SP (ask Questions 2-12 for head of family)
3. Head of family active military living at home (Question 10)
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2. During the past 2 months did -- work at a job or business, not counting work around the house?
1. Yes (Go to Question 7)
2. No
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3. Even though -- did not work during those 2 weeks, did -- have a job or business?
1. Yes
2. No
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4. Was -- looking for work or on layoff from a job?
1. Yes
2. No (Go to Question 6)
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5. Which, looking for work or on layoff from a job?
1. Looking (Go to Question 8)
2. Layoff (Go to Question 7)
3. Both (Go to Question7)
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6. Check item. Mark only if 'NO' in Question 4.
1. 'Yes' in Question 3 (Go to Question 7)
2. 'No' in Question 3 (Go to Question7)
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7. For whom did --- work?
Enter name of company, business, organization, or other employer.
Record response and skip to Question 9.
8. For whom did -- work at -- last full-time civilian job or business lasting 2 consecutive weeks or more?
Enter name of company, business, organization, or other employer.
9. What kind of business or industry is this? (For example, TV and radio, manufacturing, retail shoe store, State Labor Department, farm.)
10. What kind of work was -- doing? (From example, electrical engineer, stock clerk, typist, farmer.)
11. What were --'s most important activities or duties at that job? (For example, types, keeps account books, files, sells cars, operates printing press, finishes concrete.)
12. Complete from entries in Question 7 thru 11. If not clear ask:

Was -- 
01. an employee of a private company, business or individual for wages, salary or commission?
02. a federal government employee?
03. a state government employee?
04. a local government employee?
self-employed in own business, professional practice, or farm?

IF NOT FARM, ASK: Is the business incorporated?
05. Yes
06. No

07. working without pay in business or farm?
08. ARMED FORCES
00. never worked or never worked at a full-time civilian job lasting 2 weeks or more

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9.1.6 Norwegian Age-40 Programme

The questionnaire of the Norwegian Age-40 Programme inquiries about employment status and education.

Social security benefits

1. Do you now receive any of the following social benefits
Sick leave
Rehabilitation allowance
Disability pension (full time or partial)
Unemployment benefit
Yes
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No
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2. Is house-keeping your main occupation (answer No if you are working 18 hours or more per week for salary)
Yes
No

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Education

1. What level of education have you completed?
Primary school (less than 7 years)
Junior high school (7-10 years)
High school (occupational)
High school (university entrance qualification)
University (less than 4 year bachelor)
University (4 or more years)

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9.2 Quality assurance

9.2.1 Retrospective quality assessment report

WHO MONICA Project

The detailed description of the availability and quality of data on education achievement are documented in the Quality Assessment of Data on Marital Status and Educational Achievement in the WHO MONICA Project (8).

Educational level

The categories for educational level did not have the same meaning in every population. Also in many populations the question changed between surveys. (8)

Years of schooling

The question about the years of schooling is similar to the MONICA question in almost all local questionnaires. In two populations the question did not explicitly define that the question is about the "full time study". The question stayed same from survey to survey in most populations. (8)

Educational level and years of schooling

There is big difference in mean years of schooling for different educational levels in different populations. The mean years of schooling at primary school level varied from 3.2 years up to14.6 years. At the secondary school level the variation was from 7.6 years to 14.6 years, at the intermediate level from 10.2 year to16.8 years and at the university level from 9.5 year to 21.8 years. (8)

9.3 Indicators used for reporting the results

WHO MONICA Project

In the WHO MONICA Project the results from educational levels are reported using means, median and tertiles of the years of schooling (9, 10).

Risk factor monitoring in the Netherlands

In the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands, educational level was divided  into three categories: low, intermediate and high (11).

No details were found for health surveys in Germany, UK National Health Surveys, and NHANES III.

9.4 Discussion and conclusions

All surveys that included questions about the socio-economic status collected information on educational level. Most surveys also included questions about family income and occupation of the survey respondent or head of the family.

When assessing the educational achievement, two types of questions are used; years spent in full time education and categories of educational levels. In MONICA, the levels of educational were found difficult to interpret as they had different meaning in different countries . That is why the years spent in full time schooling are more frequently used when educational levels between different countries are compared.   

Both the UK National Health Surveys and NHANES III asked about the family income using categorized income groups.

The European Commission Health Monitoring Program has a separate project which focuses on socio-economic issues. This "Socio-economic Inequalities in Health" project has submitted its final report to the EC in February 2001. The report recommends that educational level, income and occupation should be used for the monitoring purposes. 


References

  1. Seidell JC. Obesity in Europe. Obes Res 1995;3 Suppl 2:89s-93s.
  2. Brezinka V, Padmos I. Coronary heart disease risk factors in women. Eur Heart J 1994;15(11):1571-84.
  3. WHO MONICA Project. MONICA Manual. Part III: Population Survey. Section 1: Population survey data component. (1997). Available from: URL:http://www.thl.fi/publications/monica/manual/part3/iii-1.htm, URN:NBN:fi-fe19981151
  4. Blokstra A, Burns CM, Seidell JC. Perception of weight status and dieting behaviour in Dutch men and women. Int J Obes Relat Metab Disord 1999;23(1):7-17.
  5. Robert Koch Institut. Bundes-Gesundheitssurvey 1998. Questionnaire. Berlin; 1998.
  6. The Stationary Office. Health Survey of England, Cardiovascular disease. Volume 1: Findings; Volume 2: Methodology & Documentation. 1999. Available from: URL:http://www.official-documents.co.uk/document/doh/survey98/hse98.htm 
  7. U.S. Department of Health and Human Services. Plan and operation of the third National Health and Nutrition Examination Survey, 1988-1994. Vital and Health Statistics, 1994; Series 1, No. 32. 1994. Available from: URL:http://www.cdc.gov/nchs/data/srl_32.pdf 
  8. Molarius A, Kuulasmaa K, Moltchanov V, Ferrario M, for the WHO MONICA Project. Quality assessment of data on marital status and educational achievement in the WHO MONICA Project. (1998). Available from: URL:http://www.thl.fi/publications/monica/educ/educqa.htm, URN:NBN:fi-fe19991078
  9. Molarius A, Seidell JC, Sans S, Tuomilehto J, Kuulasmaa K. Educational level, relative body weight, and changes in their association over 10 years: an international perspective from the WHO MONICA Project. Am J Public Health 2000;90(8):1260-8.
  10. Tolonen H, Kuulasmaa K, Ruokokoski E, for the WHO MONICA Project. MONICA Population Survey Data Book. (2000). Available from: URL:http://www.thl.fi/publications/monica/surveydb/title.htm, URN:NBN:fi-fe20001206
  11. Verschuren W, van Leer E, Blokstra A, Seidell J, Smit H, Bueno de Mesquita H, de Oberman-Boer G, Kromhout D. Cardiovascular disease risk factors in the Netherlands. Neth J Cardiol 1993;6:205–10.

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