NIH Program Announcement: SES and Health across the Life Course


Deadlines are published in the application kit, which is available on the web at


Release Date: August 14, 1998

PA NUMBER: PA-98-098


National Heart, Lung, and Blood Institute
National Institute on Aging
National Institute of Child Health and Human Development
National Institute of Environmental Health Sciences
National Institute of Mental Health


The National Heart, Lung, and Blood Institute (NHLBI), National Institute on Aging (NIA), National Institute of Child Health and Human Development (NICHD), National Institute of Environmental Health Sciences (NIEHS), and National Institute of Mental Health (NIMH) seek research grant applications on the cumulative and contemporaneous relationships between socioeconomic status (SES) and physical and mental health and functioning over the life course and across generations. Given that the relationships between SES and physical and mental health, morbidity, disability, and mortality have been long and extensively documented, additional studies aimed at merely describing or demonstrating these relationships are outside the scope of this program announcement. Encouraged are studies relating to:

o Appropriate conceptualization and measurement of SES over the life course, across generations, and in various population groups.

o Specification of the processes through which SES influences cumulatively and contemporaneously physical and mental health, disability, morbidity, and mortality outcomes over the life course, and how these outcomes, in turn, impact on SES. Attention should also be given to whether and how various indicators of socioeconomic disparities may have differential impacts on health and functioning outcomes at different ages and time periods (short-term vs. long-term).

o The relationship between SES and physical and mental health, disability, morbidity, and mortality over the life course in various population groups.


The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. This program announcement, Socioeconomic Status and Health Across the Life Course, is related to one or more of the priority areas. Potential applicants may obtain a copy of "Healthy People 2000" at


Applications may be submitted by foreign and domestic for-profit and non- profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of state and local governments, and eligible agencies of the Federal government. Racial/ethnic minority individuals, women, and persons with disabilities are encouraged to apply as principal investigators.


The mechanism of support will be the individual research project grant (R01). Responsibility for the planning, direction, and execution of the proposed project will be solely that of the applicant.


The relationship between socioeconomic status (SES) and physical and mental health, morbidity, disability, and mortality has been long and extensively documented. While the overall relationship of SES to mortality may attenuate in older ages, socioeconomic position continues to be linked to the prevalence of disability and chronic and degenerative diseases, including cardiovascular disease, many cancers, and Alzheimer's disease. Low SES may result in poor physical and/or mental health by operating through various psychosocial mechanisms such as poor or "risky" health-related behaviors, social exclusion, prolonged and/or heightened stress, loss of sense of control, and low self- esteem as well as through differential access to proper nutrition and to health and social services. In turn, these psychosocial mechanisms may lead to physiological changes such as raised cortisol, altered blood-pressure response, and decreased immunity that place individuals at risk for adverse health and functioning outcomes. Not only may SES affect health, but physical and mental health may have an impact upon the various components of SES (e.g., education, income/wealth, occupation) over the life course. For example, bouts of serious illness may result in a significant and sustained loss of wealth.

The purpose of this program announcement is to encourage research on the relationships between SES and physical and mental health over the life course and across generations. Acute or chronic occurrences of poor health (so- called "health shocks") for one member of the family may result in significant costs and sustained loss of wealth for all family members. Therefore, the immediate social context should be taken into account while examining the cumulative relationship of SES and health over the life course as well as their contemporaneous relationship at a given age. The increasing ethnic and racial diversity of the U.S. population heightens the need to understand better the relationship between SES and physical and mental health in minority groups. Among key issues are the degree to which SES accounts for health differences among population groups, how SES is related to the effects of discrimination and prejudice, and whether SES can be conceptualized and operationalized similarly among different population groups.

The following areas illustrate suitable topics for research. Throughout this program announcement, the terms "health" and "functioning" encompass both physical and mental aspects of well-being and morbidity. Applications need not be limited to these topics nor must they encompass all of these issues.

1. Conceptualizing and measuring SES

A life-course perspective leads to questions about the cumulative impact of SES and physical and mental health on each other as well as on their current or contemporaneous relationship. For example, do critical periods (ages or life stages) exist in which SES may have significant impact upon subsequent health or, vice versa, when health may impact upon the various components of SES? Recent research suggests that over the long-term SES affects health, but over the short-term the relationship may be reversed. How should such "time- lags" and reversals in causality be conceptualized and measured? Do the mediating variables and causal pathways between SES and health vary over the life course? Do the various components of SES (e.g., educational attainment, occupational status, wealth, and prestige) take on different weights in their relationships to health at different ages?

Usually socioeconomic status is conceptualized as an attribute of an individual (or the person's family or household) that consists of different dimensions. These dimensions may be additive or interactive in defining SES. A life-course perspective poses questions about the adequacy of current conceptualizations, as noted in the preceding paragraph. Research is needed to develop and assess the construct and predictive validity of age-appropriate measures, especially for children, adolescents, and older people, in relevant population groups. Particular attention should be directed to the appropriateness of different measures by gender, race/ethnicity, nativity and immigrant status, household structure, relation to the labor force (e.g., in retirement), and rural-urban residence. For example, the socioeconomic position of women has been measured in terms of that of their husbands. However, with the significant changes in occupational and marital experiences of women, this practice has become questionable.

In addition to measures based upon the characteristics of individuals or households, measures are needed of larger social structural units. For example, what are the best measures of the socioeconomic characteristics of neighborhoods (e.g., resources, location, quality of housing, services) that may affect the risk of disability, morbidity, and mortality in early and/or later life?

Educational attainment is often noted as being positively correlated with health and functioning, absence of disability, lower incidence of some illnesses (e.g., Alzheimer's disease), even among the oldest-old. Higher levels of maternal education are typically associated with more timely receipt of prenatal care, contraceptive use, and less frequent and later childbearing. How is educational attainment best conceptualized and measured? What are the relevant aspects or components of education that should be measured beyond merely the number of years of schooling?

What are the relevant dimensions of occupation as a component of socioeconomic position (e.g., supervisory position, type of industry, part vs. full-time employment) for health and mortality risk over the life course? How can the lifetime experience of different occupations, careers, or activities be measured and summarized, especially for those who are retired?

Similarly, questions arise about the conceptualization and measurement of economic well-being over the life course. Should this aspect of SES be considered in terms of income, wealth, or both? How can trajectories in economic well-being be measured? Given the limitations of the construct of "poverty" as officially defined, how do alternative measures of poverty affect the relationship between SES and health? Can a measure of cumulative material deprivation for individuals and households over the life course be developed and refined?

2. Specifying relationships between SES and physical and mental health

Although the general relationship between SES and health, disease, and mortality has been long recognized, the pathways through which SES affects health have yet to be satisfactorily specified. A better understanding of the mediators of the relationships between SES and health, disease, and disability is essential for more efficacious clinical and policy interventions to reduce adverse health impacts. Specification should include consideration of various aspects and measurements of health such as all-cause mortality, cause-specific mortality and morbidity, perceived health status, life expectancy, active life expectancy, and functional/disability status. That is, SES and its components may evidence varying relationships depending upon specific diseases or health outcomes. For example, SES appears to be positively associated with breast cancer, but negatively associated with uterine cancer.

Research is needed to specify over the life course the nature, extent, and variability of such potential mediators as:

a) Life-styles (health-related behaviors and practices, including high-risk sexual behaviors).

b) Personality, self-concept, sense of control, social cognition, coping resources, cognitive abilities, problem-solving skills and styles.

c) Access to and use of health-care and social services, including such diverse factors as community characteristics and availability of health insurance.

d) Social networks and supports for receiving assistance or for managing health care needs, encouraging health-promoting behaviors, and mobilizing needed resources. Social networks include those created by marriage, other family ties, as well as nonfamilial relations. Family and kin networks can differ qualitatively from other social networks in their effects on SES, health, and functioning. To what extent does SES influence social networks and their supportive functions (e.g., instrumental, affective) and resources, which may affect health and functioning? Do the manner and mechanisms through which social networks are structured and operate differ by SES and as people age?

e) Interactions with significant gatekeepers such as health-care providers and family members. For example, some aspects of service utilization among children and the oldest old are probably highly influenced -- or even determined -- by family members. When these are adult children, the decisions are likely to reflect their educational level, income, and values.

f) Exposure to psychosocial, physical, chemical, and other environmental stressors, taking into account their magnitude, duration, and periodicity. People in lower socioeconomic strata are more likely to live and work in the most hazardous environments and occupations.

g) The occurrence, timing and sequencing of life events or demographic processes such as childbearing, marriage, divorce, widowhood, education, geographical mobility, employment, and retirement. Demographic processes are known to be fundamentally interrelated with both health and SES.

h) The nature of relationships between SES and disabilities associated with physical and/or mental conditions. For example, does SES increase risk for particular behavioral disabilities (e.g., for work, self care, social relations) and does this vary over the life course? How do specific disabilities affect subsequent SES?

i) Intergenerational effects, beginning with pregnancy planning, the prenatal environment, parental investments in their own health and human capital as well as in those of their offspring, and including intergenerational transfers (e.g., inheritance).

j) Biological mediators. Which biological or neurochemical processes and their measures (e.g., salivary cortisol, catecholamines, testosterone) are most powerful, efficient, and acceptable in various research settings (e.g., laboratory, clinic, field) in capturing possible biological mediators of SES and health relationships?

k) Status in multiple stratification systems. Does holding a higher rank or graded position in domains (e.g. social status based on age, race/ethnicity, or gender; rank in recreation, church, civic organizations) other than (current or prior) occupation modify or interact with the effects of economic/occupational gradients? In addition to possible SES differences in exposure to stressors (e.g., unemployment; occupational hazards), is the experience of rank or hierarchy per se (e.g., having to show or failing to receive respect or deference) a stressor and thereby a risk factor for adverse health outcomes?

In addition to specifying mediating variables and their relationships to each other and with SES and physical and mental health, consideration should be given to such additional issues as:

a) Does the nature of processes linking SES and health vary over the life course? If so, is the variation quantitative and/or qualitative (e.g., Are different mediators involved at different ages?) Do the various ways of conceptualizing SES imply different relationships with health as people develop and age?

b) Do the various components operate through different mediating variables? For example, research is needed to distinguish the effects of education from those of income, occupation, and other aspects of socioeconomic status. Does educational attainment operate directly, for example, on health-related life styles, or through occupational careers, or via knowledge and skills? Does education perhaps result in physiological changes (e.g., enhanced neural networks) that protect against declines in cognitive functioning? How do the content, meaning, and credentialing associated with different levels of education affect health and mortality and how do these vary by cohort?

c) How should possible feedback between health and SES be incorporated? For example, to what extent does the contemporaneous feedback from health to income dominate as the direction of causation in a current period? What is the long-term feedback from health status to socioeconomic status? Past health may affect an individual's educational attainment, labor force participation and/or wages. The timing and sequencing of events throughout the life course, including occupational and residential mobility, family formation and disruption, disrupted employment, part-time employment, and unemployment, are also likely to impact SES and health outcomes of individuals and their children. Understanding the extent to which these bi-directional effects operate is crucial to specifying the relationship between SES and health.

d) How might changes in social policies, such as welfare reform, Medicare, and Social Security Insurance modify the relationships among SES, health, and mediating variables? The advent of welfare reform has heightened interest in the relationship between SES and the health and well-being of poor families, children, and older people. Little is currently known about how transformations in social policy, which have started in the human service areas and now involve health entitlement programs, influence the allocation of resources within families and across generations. Families in different SES situations are likely to be affected by, and to respond to, changed policies differently, with potentially profound effects on the health and well-being of family members. How do diverse contextual environments condition the effects of welfare reform? How are families in rural areas responding in comparison to other communities? How do policies at the state and federal level interact with community level factors to condition the response of various SES groups? Better access to care and more knowledgeable strategies of actual utilization are often postulated to characterize the advantages conferred by higher SES. With expansion of managed care systems, will SES differentials in services utilization and health status at various ages shrink or swell?

3. SES and physical and mental health in different population groups

Research is needed to understand how the bi-directional relationship between SES and physical and mental health as well as the pathways and mediating variables may differ by race/ethnicity, gender, nativity, and rural-urban residence. Of particular concern is the potential interaction between SES and race/ethnicity-based discrimination and prejudice as they are related to health and functioning. Are the effects of SES and racism additive or multiplicative? To what degree can SES explain racial and ethnic differences in morbidity, disability, and mortality? What is the explanation for minority status magnifying the effects of SES on some health outcomes?

American minority groups show considerable variation in their average educational attainment. On the one hand, the difference in years of school completed between the Hispanic and white populations has markedly widened in recent years. Are these educational differences a significant factor in the health and functional status of Hispanics over their lives in comparison to other ethnic groups? Can an understanding of SES contribute to forecasting Hispanic health and disability at advanced ages in the future? On the other hand, Asian-American adults (ages 25-44) have attained educational levels far exceeding those of other groups. What health benefits, if any, is this educational advantage likely to confer as they age?

The past decade has seen a sharp increase in both the volume and diversity of U.S. immigration, with the majority drawn from Asia and Latin America. Although 18% of all U.S. births are to foreign-born women, 62% of Latino births and 85% of Asian/Pacific Islander births are to foreign-born women. Therefore, it is important to consider the possible impact of immigrant status and the assimilation process among immigrants on their health over the life course. How does SES and changes in SES influence health and functioning among immigrant groups? For almost all ethnic groups, infants of immigrant mothers experience lower rates of infant mortality and of low birth-weight than infants of native-born mothers, despite the fact that foreign-born women generally have lower education and income. These differentials are particularly striking among Mexicans, Puerto Ricans, and certain Asian subgroups. Is SES involved in the fact that Puerto Ricans living in New York City have higher rates of psychological distress and major depression than those living on the Island, who show rates comparable to the US population as a whole? For some groups (e.g., Hmong), positive birth outcomes are coupled with evidence of deteriorating health among older adults. Do SES factors have a role in explaining these apparent paradoxes?

4. Methodological and data considerations

Until recently, many analyses of the relationship between SES and physical and mental health have used cross-sectional data. Social scientists who have long been interested in the lifetime or intergenerational attainment of social position have developed longitudinal data sets in order to follow individuals and cohorts over time. Longitudinal data are needed that include measures of both health and SES processes and outcomes. Such data sets, along with statistical techniques for creating synthetic cohorts, could be used to examine the critical chronological and developmental points in the life course when the relationship between SES and health might be particularly salient.

Many of the questions outlined above may be addressed through such extant data sets as the National Longitudinal Survey of Youth (NLSY), the Panel Study of Income Dynamics (PSID), Health and Retirement Study (HRS), the study of Assets and Heath Dynamics among the Oldest-Old (AHEAD), the National Longitudinal Study of Adolescent Health (Add Health), the Longitudinal Study of Aging (LSOA), the Wisconsin Longitudinal Survey (WLS), the Survey of Income and Program Participation (SIPP), National Maternal and Infant Health Survey (NMIHS), National Health and Nutrition Examination Survey (NHANES), National Medical Expenditure Survey (NMES), Current Population Survey (CPS), Epidemiologic Catchment Area (ECA) Program, and the Established Populations for Epidemiologic Studies of the Elderly (EPESE). Researchers are encouraged to identify other appropriate extant data sets. Moreover, a combination of data sets and/or the use of geocode data to address contextual or multilevel issues may be appropriate. Similarly, researchers may want to use survey data sets matched to death and/or birth records. Micro-level rather than aggregate analyses will be most appropriate for this initiative.

To address some questions, new data collection may be required. In addition to survey research approaches, the full range of quantitative and qualitative approaches to hypothesis testing are appropriate, including field or laboratory experiments, ethnographic and anthropological observational studies that may provide insights into the relationship of SES and health throughout the life course and across generations.

Multidisciplinary work is especially encouraged. Advancing the understanding of these issues is most likely to come from collaborations among disciplines such as epidemiology, economics, demography, sociology, psychology, neuroimmunology, endocrinology, and anthropology. Biological approaches might enrich demographic and behavioral research in several ways. Potential benefits may follow from including genetic information for use in both behavior genetic and molecular models. For example, understanding of race differences in birth weight must consider biological models as well as social factors. The addition of genetic indicators and twin and sibling samples to socio-behavioral surveys can help to measure the environmental component of the gene-environment interaction. Insights can also be gained from precedents in nature and evolution for aging and intergenerational exchanges, and the mathematics of intergenerational exchanges.

Cross-national data or data from other countries are appropriate if there is demonstrated relevance to understanding of SES and health in U.S. populations. Examples of potentially useful survey data include, but are not limited to, the British Child Development Survey, Russian Longitudinal Monitoring Survey, China Health and Nutrition Survey, Cebu Longitudinal Health and Nutrition Survey, Indonesian Family Life Survey, German Socio-Economic Panel, Second Malaysian Family Life Survey, Luxembourg Income Study, Australian Longitudinal Study of Aging, and Matlab (Bangladesh) Health and Socioeconomic Survey.


It is the policy of the NIH that women and members of minority groups and their sub-populations must be included in all NIH supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification is provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43).

All investigators proposing research involving human subjects should read the "NIH Guidelines For Inclusion of Women and Minorities as Subjects in Clinical Research," which have been published in the Federal Register of March 28, 1994 (FR 59 14508-14513) and in the NIH Guide for Grants and Contracts, Volume 23, Number 11, March 18, 1994.

Investigators also may obtain copies of the policy from the program staff listed under INQUIRIES. Program staff may provide additional information concerning the policy.


It is the policy of NIH that children (i.e., individuals under the age of 21) must be included in all human subjects research, conducted or supported by the NIH, unless there are scientific and ethical reasons not to include them. This policy applies to all initial (Type 1) applications submitted for receipt dates after October 1, 1998.

All investigators proposing research involving human subjects should read the "NIH Policy and Guidelines on the Inclusion of Children as Participants in Research Involving Human Subjects" that was published in the NIH Guide for Grants and Contracts, March 6, 1998, and is available at the following URL address:


Applications are to be submitted on the grant application form PHS 398 (rev. 5/95) and will be accepted at the standard application deadlines as indicated in the application kit. Application kits are available at most institutional offices of sponsored research and may be obtained from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301-435-0714, email: Applications are also available on the World Wide Web at

The program announcement title and number must be typed on line 2 of the face page of the application form and the YES box must be marked.

Submit the signed, original, single-sided application, along with five exact, single-sided copies and five collated sets of appendix materials to:

6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD 20817 (for express/courier service)

Applicants should include sufficient funds in the budget for an annual two-day meeting of investigators to be held at the National Institutes of Health, Bethesda, Maryland.

Whenever original data are collected, the National Institutes of Health (NIH) expects grantees to make available research data to the scientific community for subsequent analyses. Funds for data archiving and sharing may be requested in the grant application.


Applications will be assigned on the basis of established PHS referral guidelines. Applications that are complete will be evaluated for scientific and technical merit by an appropriate peer review group convened in accordance with NIH peer review procedures. As part of the initial merit review, all applications will receive a written critique and undergo a process in which only those applications deemed to have the highest scientific merit, generally the top half of applications under review, will be discussed, assigned a priority score, and receive a second level review by the appropriate national advisory council or board.

Review Criteria

The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. The reviewers will comment on the following aspects of the application in their written critiques in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered by the reviewers in assigning the overall score weighting them as appropriate for each application. Note that the application does not need to be strong in all categories to be judged likely to have a major scientific impact and thus deserve a high priority score. For example, an investigator may propose to carry out important work that by its nature is not innovative but is essential to move a field forward.

o Significance: Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field?

o Approach: Are the conceptual framework, design, methods, and analyses adequately developed, well-integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics?

o Innovation: Does the project employ novel concepts, approaches or method? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies?

o Investigator: Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the principal investigator and other researchers (if any)?

o Environment: Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support?

The initial review group will also examine: the appropriateness of proposed project budget and duration; the adequacy of plans to include children, both genders, and minorities and their subgroups as appropriate for the scientific goals of the research, and plans for the recruitment and retention of subjects; the provisions for the protection of human and animal subjects; and the safety of the research environment.


Applications will compete for available funds with all other approved applications. The following will be considered in making funding decisions:

o Quality of the proposed project as determined by peer review
o Availability of funds
o Program priority


Inquiries are encouraged. The opportunity to clarify any issues or questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to:

Sidney M. Stahl, Ph.D.
Behavioral and Social Research
National Institute on Aging
7201 Wisconsin Avenue, Suite 533, MSC 9205
Bethesda, MD 20892-9205
Telephone: (301) 402-4156
FAX: (301) 402-0051

Rose Maria Li, M.B.A., Ph.D.
Center for Population Research
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 8B13
Bethesda, MD 20892
Telephone: (301) 496-1174
FAX: (301) 496-0962

Emeline Otey, Ph.D.
Division of Mental Disorders, Behavioral Research, and AIDS
National Institute of Mental Health
5600 Fishers Lane, Room 18C-26
Telephone: (301) 443-9400
FAX: (301) 443-9876

Sarah S. Knox, Ph.D.
Division of Epidemiology and Clinical Applications
National Health, Lung, and Blood Institute
6701 Rockledge Drive, Room 8120, MSC 7936
Bethesda, MD 20892-7936
Telephone: (301) 435-0409
FAX: (301) 480-1773

Allen Dearry, Ph.D.
Division of Extramural Research and Training
National Institute of Environmental Health Sciences
P.O. Box 12233
Research Triangle Park, NC 27709
Telephone: (919) 541-4943
FAX: (919) 541-2843

Direct inquiries regarding fiscal matters to:

David Reiter
Grants and Contracts Management Office
National Institute on Aging
7201 Wisconsin Avenue, Suite 2N212, MSC 9205
Bethesda, MD 20892-9205
Telephone: (301) 496-1472
FAX: (301) 402-3672

Melinda B. Nelson
Grants Management Branch
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 8A17
Bethesda, MD 20892
Telephone: (301) 496-5481
FAX: (301) 402-0915

Diana Trunnell
Grants Management Branch
National Institute of Mental Health
5600 Fishers Lane, Room 7C-08
Rockville, MD 20857
Telephone: (301) 443-2805


This program is described in the Catalog of Federal Domestic Assistance No. 93.864, 93.866, 93.242, and 93.837. Awards are made under authorization of the Public Health Service Act, Title IV, Part A (Public Law 78-410), as amended by Public Law 99-158, 42 USC 241 and 285) and administered under PHS grants policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.