Sot.

Sci.

Med.

Vol.

34. No.

7, pp. 157-762,

1992

0277-9536192

Printedin Great Britain. All rights reserved

STATUS INCONGRUENCE IN AN ENGLISH

$5.00

+ 0.00

Copyright 0 1992 Pergamon Press plc

AND SERUM CHOLESTEROL GENERAL PRACTICE

WILLIAM W. DRESSLER,’ PHILIP EVANS~

and DENIS J. PEREIRA GRAYS

‘Department of Behavioral and Community Medicine, The University of Alabama School of Medicine, Box 870326, Tuscaloosa, AL 35487-0326, U.S.A., *General Practice, Exeter, U.K. and Department of General Practice, University of Exeter, Exeter, U.K.

Abstract-The relationship between status incongruence and serum cholesterol was examined in a case-control study carried out in an English general practice population. Patients (n = 54) with elevated serum cholesterols (2 7.0 mmol/l) were compared to age and sex matched controls (n = 54). A specific type of status incongruence-lifestyle incongruity-was measured as the degree to which style of life (material consumption and status-enhancing behaviors) exceeded occupational status. Lifestyle incongruity was associated with higher serum cholesterol and an increased odds of being a case. This association was independent of age, sex, the body mass index, family history of cardiovascular disease, alcohol use, and, for women, menopausal status. Implications of these results for research on social inequality and the risk of cardiovascular disease are discussed. Key

words-status

incongruence, serum cholesterol, general practice

INTRODUCt-ION

The United Kingdom exhibits rates of ischemic heart disease (IHD) that are characteristic of all industrialized nations [l]. Not surprisingly, there are high rates of IHD risk factors in the U.K. as well, especially serum cholesterol. It is generally recognized now that mean levels of serum cholesterol and rates of hyperlipidemia are higher in Britain than in other parts of Western Europe or North America [2]. Understanding the factors leading to high serum cholesterol is thus of considerable significance in the control and prevention of IHD. The examination of factors related to serum cholesterol is also useful in expanding our understanding of social processes in IHD. From carefully controlled studies conducted on metabolic wards it is wellknown that the intake of dietary fat is related to serum cholesterol, and equations describing the relative contributions of dietary cholesterol, saturated fatty acids, and polyunsaturated fatty acids to total serum cholesterol have been derived [3]. At the same time, given that there are uniformly high levels of total fat intake in Western diets, probably in excess of 40% of total caloric intake, it seems likely that different individuals respond differently to similar diets, since some persons fail to exhibit elevated cholesterol despite a high fat intake. Also, some individuals exhibit chronically high cholesterol in spite of low fat intake. Therefore, diet is probably not the only influence on an individual’s cholesterol level. Some researchers have examined the effects of psychological and social factors on cholesterol. There is some evidence that the type A behavior pattern [4], stressful life events [5], and occupational stress [6] are related to elevated cholesterol. Like so many studies conducted within the so-called ‘stress’ model, how-

ever, these have failed to describe more comprehensively the range of social influences on metabolic and physiologic processes; neither are the models useful in understanding the larger social structural processes from which these social influences arise. Finally, the relative effects of social and dietary influences on lipids have not been examined, with few exceptions. Recently, Dressler et al. [7,8] have developed and tested a model of social and dietary influences on serum lipids, using data collected in Brazil. This model was formulated in research on another IHD risk factor, elevated arterial blood pressure. Both blood pressure and serum cholesterol population averages increase with social change and modemization [9]. A model was developed to account for the individual-level social and behavioral changes accompanying modernization, in an effort to account for within-population differences in the development of hypertension or hyperlipidemia. Our aim in this paper is to extend this model to the study of serum cholesterol in the U.K., to see if the same social processes related to elevated serum cholesterol in a developing society might be applicable in the study of a fully industrialized society. A sociocultural model of IHD risk

As described by Worsley [IO], sociocultural modernization or development leads to intra-community differentiation along dimensions of socioeconomic status. As the secondary and tertiary sectors of a developing economy expand, individuals are variably able to take advantage of opportunites for upward occupational mobility or new options in education. Accompanying these structural changes are cultural changes that emphasize new social and personal identities. Above all, individuals seek to adopt

757

758

WILLIAM

W.

European and North American lifestyles, characterized by the accumulation of consumer goods and increased exposure to the mass media, as a means of enhancing their social status or prestige. Due to the fact that few developing economies expand rapidly enough to support the lifestyle aspirations of their population, it is virtually insured that some individuals will attempt to maintain a lifestyle that is indicative of a higher status than their occupations or educations would denote. This specific form of status incongruence is termed ‘lifestyle incongruity’. It is hypothesized that this incongruity leads to hypervigilance and uncertainty in social interaction as individuals attempt to manage a social identity represented by a high status lifestyle which is inconsistent with their occupational or educational status. The degree to which style of life exceeds occupational or educational status was related to higher blood pressure in St Lucia [I I], Mexico [12], Brazil [ 131, Alabama [ 141 and Samoa [IS]; more symptoms of depression in Alabama [ 161; and, an unfavorable profile of serum lipids in Brazil [7, 81. The association of lifestyle incongruity with these outcomes was independent of income; perceived total stress; perceived economic stress; Type A behavior; other forms of status inconsistency; the body mass index; dietary intake of fat or sodium; physical activity; and, age or sex. Clearly this model of cardiovascular disease risk replicates across samples of individuals in developing societies. How useful might this model be in understanding cardiovascular disease risk in industrialized nations? Research in industrialized nations like the United Kingdom has tended to focus solely on the main effects of occupational class or education, with little or no consideration given to other dimensions of social inequality such as style of life. Among sociological researchers, however, there has been a resurgence of interest in ‘consumption’ or the adoption of particular lifestyles, as that term is used here [ 17, 181. Even a cursory review of that literature would be beyond the scope of this paper. It should be noted only that observers are coming to re-emphasize the importance of lifestyle differences among individuals as a way of defining and reinforcing social distinctions in industrial societies. Or, in other words, the value placed on lifestyle as an indicator of social status in industrial society does not differ in kind from that value observed in developing societies. Similarly, careful social mobility studies, such as the classic work of Goldthorpe [20], do not demonstrate that all persons are being absorbed into upperlevel, or even middle-level, occupational classes. Given that individuals are variably distributed across occupational classes, and if style of life can be reliably assessed in an industrial society, then the kinds of status incongruence observed in developing societies should also be evident in industrial societies. Therefore, a pilot study was undertaken in Britain to determine if this sociocultural model of IHD risk

DRESLER er

al.

would be useful in distinguishing between persons with higher and lower levels of serum cholesterol. IMETHODS

Sampling A case-control study was conducted in a general practice patient population drawn from a practice in a city in southwestern England. All individuals age 64 years or younger with an elevated serum cholesterol (either random or fasting) within the past three years on the patient lists of two practice physicians were eligible for recruitment into the study. The clinical definition of ‘elevated serum cholesterol’ used was 7.0 mmol/l (270 mg/dl) or above. A total of 60 cases was selected randomly from the potential patient population. A further 60 patients were recruited as control subjects. These were patients with a normal blood cholesterol within the past 3 years. Cases and controls were matched on the basis of age, sex, and marital status. Data on serum cholesterol, body mass index, and other pertinent clinical data were abstracted from the medical record. Social data were collected by means of a semi-structured interview conducted in most instances in the respondent’s home. In the time allotted to the study interviews were completed with 1 I2 persons; an additional four interviews were discarded due to incomplete data, which resulted in a final sample size of 108 (54 cases and 54 controls). Measurement of social variables Style of life was operationalized through selfreports of the ownership of goods and the frequency with which higher status behaviors, especially those that increase exposure to media messages regarding lifestyles, were engaged in. Principal components analysis was used first to cluster items that had sufficient sample variability for purposes of measurement. Next, conventional psychometric scaling procedures were used to determine if the items could be combined together as a unidimensional scale of style of life. One item in the scale deserves special mention. It is argued here that style of life fundamentally involves the presentation of self, and in Britain one’s accent has long been considered to be an important social indicator [20]. Therefore, the interviewer was instructed to make a commonsense judgement of the respondent’s accent. The interviewer coded the respondent’s accent as either ‘standard English’ or as one of the regional accents (e.g. Devonshire, Yorkshire, etc.). This indicator was collapsed to a dichotomy of ‘standard English’ vs ‘other’. The results of the item analysis are shown in Table 1. Coding from item-to-item varies, and codes are summarized at the bottom of the table. As indicated by the summary coefficient of internal consistency (alpha = 0.83) we are justified in treating this as a unidimensional scale and hence summing the individual items to yield a single score. The total scale

and serum cholesterol Table I. Scale of style of life Variable I. 2. 3. 4. 5. 6. 7. 8. 9. 10. II. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Travel to beach Travel to country Travel to London Travel abroad Lived outside Devon Travel in Britain Total magazines read Books read in one year Holidays in last 5 yr Quality of furnishings Microwave Color TV Stereo system Car ownership Living room suite Food mixer Camera Home computer Shower Telephone Washing machine Central heat Accent House ownership House type

Descriptive statistic

Item-remainder correlation

I.51 + 1.2) l.9( f 1.1) 0.4( k 1.6) 0.4 ( f 1.5) 56.6% 4.4( k 1.8) 3.1 (+ 1.4) I.1 (f 1.2) 3.5 ( f 1.9) 3.1 (k0.9) 62.0% I .7 ( f 0.9) 90.7% l.5( * 1.5) 93.5% 67.6% 89.8% 23. I % 69.4% 96.3% 94.4% 61.1% 22.2% 82.4% 22.2% . . Cronbach~s alpha =

0.23 0.44 0.28 0.39 0.29 0.45 0.25 0.21 0.40 0.59 0.36 0.20 0.37 0.50 0.43 0.38 0.3 I 0.39 0.36 0.40 0.37 0.43 0.31 0.41 0.33 _ __ II.83

Item codes Items l-4: 0 = never; I = l-5 times/year; 2 = 6-12 times/year; 3 2 I2 times/yr. Item 6: range of O-7, based on conventional regional classification of U.K. Item 7: range of O-5, based on kinds mentioned. Item 8: 0 Q 6/year; I = 5-6/year; 2 = I/month; 3 3 I/month. Item 9: Number stated, truncated at 5. IO: I = worn/dirty; 2 = shabby/clean; 3 = average; Item 4 = new/cheap; 5 = expensive. Item 14: O=no car; I =car> 5yr. old; 2=car< Syr. old (summed for 3 car items). Remaining items: All dichotomies, coded 0 = absent; 4 = present (to provide equivalent weights).

score has a mean of 60.18, with a standard deviation of 15.3, a kurtosis of 0.476, and a skewness of -0.498. Again, as noted above, the lifestyle incongruity hypothesis stems from a conception of the presentation of self in everyday life (to borrow a phrase) in which claims to status in lifestyle are discrepant with evidence of status in the occupational sphere. Therefore, unlike the Registrar General’s social class categories, an explicit scale of occupational status or prestige is needed. Occupational titles were coded using the Hope-Goldthorpe scale (henceforth HG scale) of occupational prestige [21]. The HG scale is designed to score occupations according to their general social standing, desirability, or prestige. All employed individuals living within the respondent’s household were scored. The next issue involved which HG value would be used to represent a household, or alternatively, how to combine HG values into household scores. This is not the place to enter into the continuing discussion of how best to score a family’s occupational class or prestige; suffice it to say that a growing consensus leans toward the use of household-level indicators [22]. In lieu of any guidance in weighting multiple HG scores from a single household and then combining them into a single score, we have opted for what has

759

been termed the “dominance” approach [23]. This involves taking the largest HG value for any employed person in the household and using that score to represent the status of the household relative to the occupational sphere. When this is done, the HG scores for the sample range from 18.36 to 82.05, with a mean of 39.49, a standard deviation of 14.6, a kurtosis of 0.71, and a skewness of 1.0. Following previous studies, lifestyle incongruity is calculated by standardizing lifestyle and the HG score each to a mean of 50 and a standard deviation of 10. Then, lifestyle incongruity is calculated as follows: lifestyle incongruity = (style of life - HG score). The resulting score ranges from -24.04 to + 20.85, with a mean of 0.0 and a standard deviation of 10.28. Negative values indicate a person whose HG score exceeds lifestyle; persons who are consistent on the two scales have scores around zero; and persons whose lifestyle exceeds the HG scores have positive values. (Kurtosis is 1.58 and skewness if -0.64). There has been considerable discussion surrounding the appropriate statistical models which include discrepancy terms like the lifestyle incongruity variable [24,25]. These discussions will not be reiterated; at a technical level, to control for the separate effects of lifestyle and HG score is impossible. These variables can only be controlled for by combining them into a summary score, which will be referred to as ‘socioeconomic rank’ and is calculated as follows: socioeconomic rank = (style of life + HG score). This is equivalent to assuming that overall rank in the system of social inequality is best estimated through the use of a multivariate measure, an assumption that is uncontroversial [26]. Once that assumption is made and an indicator (i.e. socioeconomic rank) is chosen, it then is appropriate both theoretically and technically to include the summary term and the discrepancy term in the same model. Finally, a number of covariates were assessed. As noted above, the body mass index was taken from the medical record. In the interview additional data on menopausal status, family history of cardiovascular disease, and alcohol use were obtained. Menopausal status was coded as a dichotomy. An index of family history was formed by counting the number of primary relatives (parents or sibs) whom the respondent reported as having had angina, acute myocardial infarction, stroke, early mortality, or hyperlipidemia. To measure alcohol use respondents were asked how many pints of beer, glasses of wine, or drinks including distilled spirits they had consumed in the week prior to the interview. The number of drinks (considering half-pints of beer, glasses of wine, and mixed drinks to be equivalent) was counted. RESULTS

Descriptive statistics for the sample as a whole and for cases and controls are presented in Table 2. ‘Diagnostic serum cholesterol’ refers to the initial

760

WILLIAM W. DRE~~LER er al. Table 2. Descriptive Variable Diagnostic serum cholesterol*

6.54 ( & I .4) 51.6( f 7.4) 56.5 26.8 (k 4.2) 100.0 ( f 17.2)

Age Sex (% male) Body mass index Socioeconomic rank Lifestyle incongruity** Menopausal status Alcohol use Family history (% positive) *Case-control **Case-control

estimated estimated

using

ordinary

using logistic

( + 4.3) ( + 13.9)

71.3

74.1

Casexontrol statusb - 0.004 0.040 -0.062 -0.298 0.380. -

0.149 -0.046 -0.072 -0.187’ 0.235.’ 0.332’ 0.110

RI

( + 0.7) (I 7.3)

Control 5.4 51.8 55.6 26.9 102.4

( + 0.8) ( t 7.6) ( _+4.2) ( i: 19.7)

- 1.7 ( & 10.9) 33.3 4.3 ( * 6.6) 68.5

difference significant (P < 0.0001). difference significant (P < 0.05).

Diagnostic serum cholesterol’

lf c 0.05. l*p < 0.01. ‘Coefficients analysis. “Coefficients

7.6 51.5 57.4 26.9 97.6

1.8 (I 9.4) 31.5 4.4 ( * 7.5)

Table 3. Multiple regression analyses of diagnostic serum cholesterol and case-control status (standardized regression coefficients)

Age Sex Body mass index Socioeconomic rank Lifestyle incongruity R=

Cases

0.0 ( + 10.3) 32.4 4.40 ( * 7.0)

laboratory reading that was used to classify individuals as cases of hyperlipidemia or not. There is of course a large and significant difference between cases and controls on this variable. No attempt was made to match cases and controls other than roughly in terms of age, sex, and marital status. Cases and controls show no differences in mean age, and there is one case-control pair discordant on sex. The only difference is substantive interest between cases and controls is that cases are higher with respect to lifestyle incongruity than controls. As noted in the introduction, it is anticipated that higher lifestyle incongruity will be associated with a greater likelihood of being a case of hypercholesterolemia. This hypothesis can be tested using multiple logistic regression analysis. Because the data on the actual diagnostic serum cholesterol are available also, the hypothesis can also be tested using ordinary least squares regression analysis with diagnostic serum cholesterol as the dependent variable. With respect to covariates, because menopausal status, family history, and alcohol use show no association with case-control status, there is no reason to force them into the analysis as covariates. Similarly, age, sex, and body mass show no association; however, these are such well-known correlates of serum cholesterol [27], it seems prudent to force them into the analysis anyway. All reported tests of statistical significance are l-tailed tests. The ordinary least squares regression model for diagnostic serum cholesterol is shown in the first column of Table 3. Higher socioeconomic rank is

Variable

statistics

Total sample

_

least

regression

-

squares analysis.

regression

related to lower total serum cholesterol, and higher lifestyle incongruity is related to higher total serum cholesterol. The multiple logistic regression model for case-control status is shown in the second column of Table 3. Lifestyle incongruity is associated with greater likelihood of being a case at a significant level. The odds ratio (odds of being a case) associated with being one standard deviation above the mean on lifestyle incongruity versus being one standard deviation below the mean is 2.13. As a final step, the other covariates were added to these models. As observed in the bivariate analyses, none of these variables was significantly associated with either diagnostic serum cholesterol or case-control status. Addition of these variables to the analyses did not alter the effects of lifestyle incongruity.

DISCUSSION

The results of this pilot study support the utility of a sociocultural model of IHD risk for examining variation in serum cholesterol within a British general practice population. In terms of replicating and extending the sociocultural model of IHD risk, three major findings stand out. First, with respect to measurement, it has proven feasible to define and reliably measure a dimension of style of life using the same technique as has been used in developing and economically marginal communities. Given the wide range and assortment of consumer goods and services, and leisure-time behaviors, available to individuals in industrial society, it could plausibly be argued that such a dimension would be hard (if not impossible) to detect. This, however, proved not to be the case, and a single dimension measuring lifestyle variation could be reliably defined. Furthermore, one item appears in that inventory which is culture specific, namely accent. The argument that the use of an educated accent in Britain is an indicator of higher prestige or status is hardly novel. What is important is that coupling this wellknown observation with arguments concerning the status-value of material consumption leads to an important methodologic hypothesis; that accent, even coded as crudely as we have done, ought to contrib-

Status incongruence and serum cholesterol ute reliably to the operational definition of style of life. The moderate item-remainder correlation (attenuated by the skewness in the dichotomous indicator of accent) confirms this association. This lends further credence to the view that the importance of style of life is in the way it defines one’s presentation of self in mundane social interaction. Second, again with respect to measurement, the HG scale performed quite well in defining lifestyle incongruity. In prior studies, more limited rankings of occupational class, similar (in form if not in detail) to the Registrar General’s social class ranks, have been used. The use of the HG scale again lends further credence to the basic theory underlying the status incongruence hypothesis. That is, Goffman [26] described the process, in mundane social interaction individuals arrive at assessments of others’ social status by taking into account information of various kinds, and in turn combining that information to arrive at an overall evaluation of status by some unknown cognitive function. If the other person being evaluated presents himself or herself in a particular way through a medium of lifestyle, but does not have an occupational status commensurate with that proclaimed status, then he or she is unlikely to be received by another in the way intended. This in turn can lead to a hypervigilant state on the part of the person who is incongruent, a state characterized by a complex set of physiologic processes which, if repeated over time, can result in deleterious changes in health such as hyperhpidemia [28]. The use of the HG scale in defining incongruence lends further credence to this interpretation. Third, lifestyle incongruity was related both to diagnostic serum cholesterol and to the likelihood of being diagnosed as a case of hyperlipidemia. The relationship between social inequality and the risk of cardiovascular disease mortality is clear, as demonstrated by the Black report [29] and other studies [30]; recent analyses indicate that this health inequality in industrial societies is widening, not narrowing [31]. The model of status incongruence developed here may help to explain, in part, why these relationships occur. As Kemper and Collins [32] and Wright [33] argue, if theories of social inequality are to be truly illuminating, these must be sufficiently elaborated (or specified) to show how inequality operates in social interaction in the lived experience of individuals. Veblen [34] first articulated, and Bourdieu [35] elaborated, how styles of life are employed by individuals in social interaction to symbolically represent a claim to social status, and hence to manage a social identity. Where the management of the social identity is compromised by lower occupational status, however, the maintenance of that identity becomes increasingly untenable. Thus, fhe continued inequalities in cardiovascular health in industrial nations may be entailed by the stratification processes inherent in market-oriented societies.

761

Of course, other interpretations are possible. Although the status incongruence hypothesis survived the imposition of a number of control variables, we have no illusions that these covariates were measured as reliably as they could be. Therefore, more reliable assessments of covariates could lead to the detection of confounding in future studies. Another interpretation might suggest that the failure to include direct measures of the dietary intake of fat and cholesterol precludes any assurance that the sociocultural factors have any independent effects. While plausible, in lieu of any well-formulated hypothesis concerning why people high in status incongruence should be eating more fat, this again is a difficult alternative to entertain seriously. It is also less plausible since in Brazil the sociocultural model was associated with lipids independently from dietary intake [7,8]. There is, however, one finding here that strongly suggests the operation of dietary factors. The analytic model used here has been explored in detail by Hope [24] and Whitt [25], and it allows for the decomposition of the effects of social inequality into two components: (a) an overall vertical effect represented by socioeconomic rank; and (b) a non-vertical effect represented by lifestyle incongruity. In the analysis of diagnostic serum cholesterol, socioeconomic rank has a significant effect such that persons who are of lower rank have higher cholesterols, independently of any effect of incongruity or social support. There is, in other words, some component of social inequality that is independent of the status or prestige system, and in turn influences cholesterol. Diet is an obvious choice. In future research, it would be useful to examine models of status incongruence in the U.K. Prior work in developing or economically marginal communities has shown that those persons who are, or perceive themselves to be, more well integrated into a system of social support are protected from the deleterious cardiovascular effects of lifestyle incongruity [36, 371. If lifestyle incongruity represents a dimension that leads individuals into social contexts in which they directly experience a fragmented and conflicted social identity, then the belief that one has support from others ought to soften the blow, so to speak. The belief in other kinds of social connections may help to extend and elaborate the social identity that is otherwise fragmented. This component of the process should be explored more fully. In the final analysis, caution must be exercised in interpreting what is a pilot study, using a case-control design, based on a modest sample, with some variables measured crudely. On the other hand, this general model has been replicated widely, and it is firmly grounded in social theory, rather than being ‘asocial’ as others have found typical stress models to be. Further research to explore in more detail the usefulness of this model in accounting for IHD risk in modern industrial societies is warranted.

762

WILLIAM W. DRESSLER et al.

Acknowledgemenrs-This research was supported by funds provided by The University of Alabama. The assistance of Dr John Vincent and MS Sara Blacksell of the Department of Sociology. University of Exeter. was invaluable. Dr Kathryn S. Oths and anonymous reviewers provided helpful comments on a previous draft.

I5

lb. 17

REFERENCES

mortality from heart disease: 1. Thorn T. J. International rates and trends. Inr. J. Epidemiol. 18, 520, 1989. J.. Winder A. F., 2. Mann J. I., Lewis B., Shepherd Fenster S., Rose L. and Morgan B. Blood lipid concentrations and other cardiovascular risk factors: distribution, prevalence and detection in Britain. Br. Med. J. 296, 1702, 1988. 3. Keys A., Anderson J. T. and Grande F. Serum cholesterol response to changes in the diet II: the effect of cholesterol in the diet. Merab. 14, 759,1965. R., Connor S. L. 4. Weidner G.. Sexton G.. McLellaren and Mutarazzo J. D. The role of Type A behavior and hostility in an elevation of plasma lipids in adult women and men. Psychosom. Med. 49, 136, 1987. 5. van Dooren L. J. P. and Orlebeke K. F. Stress. nersonality, and serum-cholesterol levels. J. Hum. Stress 8, 32, 1982. H. Restricted status control 6. Siegrist J. and Matschinger and cardiovascular risk. In Slress, Personal Control and Health (Edited by Steptoe A. and Appels A.), p. 65. John Wiley and Sons, Brussels, 1989. 7. Dressier W. W., DOS Santos J. E., Viteri F. E. and Gallagher P. N. Social and dietary predictors of serum lipids: a Brazilian example. Sot. Sci. Med. 32, 1229, 1991. 8. Dressier W. W., DOS Santos J. E. and Viteri F. E. Social and cultural influences in the risk of cardiovascular disease in urban Brazil. In Urban Henllh and Ecology in (he Third World (Edited by Bilsborough A. er al.) Cambridge University Press, Cambridge, 1991. 9. Dressier W. W. Social and cultural influences in cardiovascular disease: a review. Transculr. Psychiar. Res. Rev. 21, 5. 1984. In Social 10. Worlsey P. Social class and development. Inequality,: Comparative and Derelopniental Approaches (Edited bv Berreman G.). .D. 221. Academic Press, New York. I98 I. I I. Dressier W. W. H_yperrension and Culrure Change. Acculturarion and Disease in [he West Indies. Redgrave Publishing, South Salem, NY, 1982. 12. Dressier W. W., .Mata A., Chavez A. and Viteri F. E. Arterial blood pressure and individual modernization in a Mexican community. So

Status incongruence and serum cholesterol in an English general practice.

The relationship between status incongruence and serum cholesterol was examined in a case-control study carried out in an English general practice pop...
716KB Sizes 0 Downloads 0 Views