Original article 1
Updating indicators for scaling the socioeconomic level of
families for health research
Sawsan I. Fahmya, Laila M. Nofald, Shehata F. Shehatad, Heba M. El Kadyb
and Hala K. Ibrahimc
a
Family Health, bGeriatric Health, cPublic Health
Nursing, Family Health Department and dBiostatistics
Department, High Institute of Public Health, Alexandria
University, Alexandria, Egypt
Correspondence to Hala K. Ibrahim, Public Health
Nursing, Family Health Department, High Institute of
Public Health, Alexandria University, 165 El Horreya
Avenue, El Hadara, Alexandria, Egypt
Tel: + 20 342 85575; fax: + 20 342 88436;
e-mail: halakadry69@gmail.com
Received 12 December 2014
Accepted 1 February 2015
Journal of the Egyptian Public Health
Association 2015, 90:1–7
Introduction
Health problems are closely related to the social level of
families with these problems. As mentioned by Oakes and
Rossi [1] socioeconomic status (SES) and health are
highly correlated and clearly impact each other. Hence,
the need to determine the significance of this relation in
most public health research is of great importance.
In the early 1980s, Fahmy and El-Sherbini published the
paper ‘Determining simple parameters for social classifi-
cation for health research’ [2]. This paper aimed to help
public health researchers in scaling social levels of
families in their researches. The indicators used in this
early scaling were meant to be simple and easy to be
weighed and scored. They were deduced from several
previous researches in the Family Health Department in
the High Institute of Public Health (HIPH), Alexandria
University, and included education and work of the
mother (highly scored) and the father, per-capita income
0013-2446 & 2015 Egyptian Public Health Association
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Background
Socioeconomic position is a community-used concept in health research. The social
level is related to numerous exposures, resources, and susceptibilities that may affect
health.
Aim
To update and validate a tool for scaling the socioeconomic level of families for health
research.
Participants and methods
A multistage stratified cluster sampling technique was used to select 900 families (one
index person per family) from urban and rural areas in the Alexandria governorate using
the proportional allocation method. Ten variables reflecting parental education,
parental occupation, family characteristics, financial status as well as home sanitation
were reduced to a single socioeconomic status (SES) index using two methods: the
Sigma scoring method and factor analysis. Reliability and validity were assessed for
the developed scale. Factor scores were classified into three categories (low, medium,
high) using cluster analysis, and then different cut-off points for the Sigma scoring
method were used and compared with the cluster solution using the k statistic.
Results
Results showed that the developed scale was both reliable (Cronbach’s a coefficient
a = 0.79) and valid [8 out of the 10 items had high loading ( 40.5) for SES]. The best
cut-off points for SES classification using the proposed scoring system that yielded
the highest agreement with the cluster solution (k = 0.77) were less than 40%,
40 to o70%, and at 70% or more, with an overall correct classification of 84.7%.
Conclusion and recommendation
The new scale proved to be valid and reliable. This scale is recommended for use for
scaling the socioeconomic level of families for health research.
Keywords:
health research, social indicators, socioeconomic scaling, validity and reliability
J Egypt Public Health Assoc 90:1–7
& 2015 Egyptian Public Health Association
0013-2446
of the family members, family size, crowding index, and
house sanitation (water supply, sewage, and refuse
disposal) [3–5].
However, there was always, along with the social move-
ment of our community, whether forward or backward,
the need to update the indicators, especially in relation to
education and modern technical communication facilities
and economic changes.
Socioeconomic position (SEP) is a community-used
concept in health research [6]. A variety of other terms,
such as social class, social stratification, social status, or
SES, are often used interchangeably despite their
different theoretical bases and, therefore, interpreta-
tions [7]. These issues have been discussed by Krieger
et al. [6], who decided to use SEP rather than other terms.
However, one point of view is that the economic status is
an important indicator of the social status, which is why
we sought to determine the social level through different
DOI: 10.1097/01.EPX.0000461924.05829.93
 2 Journal of the Egyptian Public Health Association
indicators, among which the economy is very important.
The social level is related to numerous exposures,
resources, and susceptibilities that may affect health [7].
These are translated into the following domains.
Education domain
Education
This is a frequently used indicator in epidemiology and
hence in our scaling procedures for social leveling. It
attempts to capture the knowledge-related assets of an
individual [8]. It is a strong determinant of future
employment and income. The higher an individual’s level
of education, the more likely he/she is to engage in a
range of health-enhancing self-maintenance activities [9].
As formal education is normally completed in young
adulthood and strongly determined by parental charac-
teristics, it can be conceptualized within a life-course
framework as an indicator that in part strongly measures
early life SEP. Every year of education contributes toward
a person-attained SEP [10]. Also, it captures the long-
term influence of both early life circumstances on adult
health as well as the influence of adult resource on
health [9].
The knowledge and skills gained through education may
affect the individual’s attitudes and motivation cognitive
functioning, make them more receptive to health
education messages, or more able to communicate with
and access appropriate health services [8]. Because of this
strong relation between education and attained health
status, it is used and scored high among other indicators
in the present scaling.
It is worth mentioning here that the association of the
level of education with a working status means a higher
social level. Especially with working educated mothers,
the expected family social level is projected on the health
of all family members. In other words, unemployment of
parents affects the health of the family negatively [9].
Computer use
This indicator was added to the education score to show
the family interest in new educational domains that
reflect certain social standards [11].
Economic domain
As with the previous education domain, income has a
close association with health and can influence a wide
range of material circumstances with direct implications
for health [12]. Money in itself directly affects health;
thus, it is the conversion of money into health-enhancing
commodities and services by expenditure that may be the
most relevant concept for interpreting how income
affects health [13]. Household income is a useful
indicator. However, family size or dependent members
enables calculation of the per-capita income, which is
more useful. These data were difficult to obtain most of
the time. Alternatively, the total household income could
be related to covering current household needs [14]. This
is classified and scored in the present updating of
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
indicators into the need for an outside loan, which can
or cannot be repaid later.
Family domain
Family size
This domain has been proven to be related closely to
health aspects of the family. Several researches [15,16] in
the family planning scope proved this close relation of the
family size with health aspects of the family members;
the larger the family size, the more the health problems
and hence its use as an indicator. Family size is an
important input in the health production function, where
an increase in family size would be associated with less
healthy children [17]. This may be explained by the fact
that a large family size means crowding within the
household, and poorer cleanliness and hygiene, which in
turn lead to poor nutritional status.
Crowding index
This is an indicator to be calculated of the share provided
to every family member from the sleeping place available
in the house of the family. It clarifies the relation
between the degree of crowding and the development of
health problems [18].
Housing sanitation domain
This indicator directly points to what is essentially
needed for a proper sanitary condition of a house in
relation to the social status [19]. The three main sanitary
indicators are potable water supply all the day, proper
sanitary sewage disposal with a flushing system, and
proper refuse deposal, which means a covered container
inside and proper collection outside [20]. Lack of running
water and a household toilet with a flushing system may
be associated with an increased risk of infection.
As reported by Duncan et al. [21], among the most
frequently used socioeconomic indicators are education
and type of occupation. However, in our early published
paper in 1983 [1], occupation was not used purposively as
an indicator. The reason was that at that time in Egypt,
education usually determined occupational strata or type
of occupation. By now, there is another strong reason for
not including occupation as an indicator. With the
tremendous social change in our community, skilled
laborers now have higher incomes than university
graduates; hence, it is not reasonable again to use the
type of occupation as an indicator of the SES [22].
Finally, socioeconomic status is important because it is
related to health and life outcomes for as long as social
groups exist. The higher the status or the rank of an
individual or a group, the better the chances they have for
a longer and healthier life [23].
Aim of the study
To update and validate a tool for scaling the socio-
economic level of families for health research.
 Updated indicators for SES of families Fahmy et al. 3

Materials and methods (3) Home sanitation included only proper sewage and
Study setting refuse disposal as water supply was found to be
This study was carried out in the Alexandria governorate available for all the families studied.
in a rural and an urban area (Smouha and Abbis).
Statistical analysis
Study design Analysis was carried out using SPSS version 20.0 (IBM
A cross-sectional design was used to carry out this study. SPSS Statistics for Mac, Released 2011; IBM Corp.,
Armonk, New York, USA; SPSS Inc., Chicago, Illinois,
Sampling design USA).
A multistage stratified cluster random sampling design
was used. The selection was performed in two stages. In Methods for construction of socioeconomic indices
the first stage, Alexandria was divided into urban and To formulate a single index indicating SES, two methods
rural areas and one area was selected from each group. In were used: Sigma score and factor analysis.
the second stage, random selection of 900 families (one
index person per family) was performed using the
Standardization of socioeconomic status variables
proportional allocation technique on the basis of the
The variables studied were converted into standard
Egyptian Demographic Health Survey 2008, urban : rural
scores using the Sigma scoring method [25]. The Sigma
ratio 1 : 1.3 [24].
scoring method assigns scores in reverse proportion to
ranks or position in a population. In other words, a ‘yes’
Formulation of the scale
response with a lower code (1) may yield a higher score
Indicators of the SES scale originally designed by Fahmy
than a ‘no’ response with a higher score (2).
and El-Sherbini [2] were revised and its items were
reformulated in light of current social and economic
Reliability was determined using Cronbach’s a [25].
changes in the Egyptian community. In addition, a list of
Discriminant validity was determined by comparing the
SES indicators was prepared on the basis of a literature
difference between the upper 25% and the lower 25% of
review. A jury of experts that included members of the
the SES scores using a t-test and concurrent validity was
Family Health Department and members of the Depart-
determined using factor analysis.
ment of Biostatistics in the HIPH, Alexandria University,
examined these indicators. There was a general agree- Different cut-off points were used for Sigma scores to
ment among the team for 10 variables that were differentiate respondents into broad socioeconomic
considered relevant for the measurement of SES of any
categories (low, medium, and high SES). Those with less
family: mother’s education, father’s education, working than a 40% score were classified as ‘low SES’, those with
status of mother, working status of father, use of more than a 70% score were classified as ‘high SES,’ and
computer, per-capita income, family size, crowding index, the rest were classified as the ‘medium’ group. Then,
sewage disposal, and refuse disposal (Table 3 shows the those with less than a 50% score were classified as ‘low
ranking of different components). SES’, those with more than a 75% score were classified as
‘High SES,’ and the rest were classified as the ‘medium’
Data collection SES. Finally, the households were divided into quartiles.
Data were collected by the junior staff of the HIPH,
Alexandria University, using an interview questionnaire Table 1. Sigma scoring method for mother’s education
that included the following updated social scale: Stand Z
Mother education F CF CFM CPM Z (score)
(1) Mother’s education.
Illiterate/read and write 204 204 102 0.1133 – 1.21 2
(2) Father’s education. Literate certificatea 40 244 224 0.2489 – 0.68 3
(3) Working status of the mother. Primary 118 362 303 0.3367 – 0.42 3
(4) Working status of the father. Preparatory 119 481 421.5 0.4683 – 0.08 4
Secondary 235 716 598.5 0.6650 0.43 5
(5) Use of computer. University 160 876 796 0.8844 1.2 6
(6) Per-capita income. Postgraduate 24 900 888 0.9867 2.23 8
(7) Family size. CF, cumulative frequency; CFM, cumulative frequency to midpoint;
(8) Crowding index. CPM, cumulative proportion to midpoint; F, frequency of response;
(9) Proper sewage disposal. Z, Sigma score (obtained by checking the corresponding CPM from
the table of Z – normal deviates).
(10) Proper refuse disposal. a
A certificate given to those who have attended education programs for
illiterates
The following changes were made to the modified scale
of 1983: (Appendix)
Table 2. Sigma scoring method for mother’s work
(1) Working status was separated from education of both
Mother’s work F P Area Z Stand Z
the father and the mother.
(2) A new educational domain, the use of computer, was No 537 59.7 0.2983 – 0.53 0
added. Yes 363 40.3 0.7983 0.84 3

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 4 Journal of the Egyptian Public Health Association

Table 3. Modified scale for social level of families to be used in nomic standard. The K mean clustering technique was
health research, modified after the original scale of Fahmy and then used to identify the cluster membership of ‘low’,
El-Sherbini [2].
‘medium’, and ‘high’ socioeconomic groups.
I-Education and work of mother and father Mother Father
Comparison of the two methods was then performed
Read and write or illiterate not working (1) (1) using kappa statistics and % of agreement calculated for
Read and write or illiterate working (2) (2) each of the different cut-off points used; the best cut-off
Literate certificate not workinga (3) (3)
Literate certificate workinga (4) (4) points that yielded the best results were then chosen.
Primary not working (5) (5)
Primary working (6) (6) Ethical approval
Preparatory not working (7) (7) This study was approved by the Ethics Committee at
Preparatory working (8) (8)
Secondary not working (9) (9) the HIPH, Alexandria University, on the basis of the
Secondary working (10) (10) Declaration of Helsinki. Researchers explained the
University not working (11) (11) purpose of the study and obtained written consent before
University working (12) (12)
Postgraduate not working (13) (13) carrying it out.
Postgraduate working (14) (14)
a
A certificate given to those who have attended education programs for
illiterates. Results
Standardization of socioeconomic status variables
II-Use of computer.
The 10 SES variables proposed were converted into standard
A lot of times (2)
Some times (1) scores using the Sigma scoring method. Examples of the
Not available (0) Sigma scoring methods for quantitative and dichotomous
responses are presented in Tables 1 and 2, respectively.
III-Per-capita income (10).
Z5000 (10) Enough and saving (10)
This scoring procedure was performed for the 10 variables
1000r5000 (8) Enough only (8) to generate the standard scores and the results are
500r1000 (6) Not enough + small loan (6) presented in the Appendix.
250r500 (4) Not enough + big loan (4)
o250 (2) Not enough + loan not repeat (2) A total score, on the basis of the 10 variables studied, was
then derived by summing up the discrete scores for each
IV-family size (parents + children) (8). case into a single index, and the total score was found to
3 or 4 (8) range from 0 to 48.
5 (6)
6 (4)
Z7 (0)
Reliability test of the scale
V-Crowding index. The internal consistency, calculated through Cronbach’s a
o2 (2) coefficient, confirmed that the scale was reliable (a = 0.79),
2– (1) which is considered good. Table 4 shows Cronbach’s a
Z4 (0) coefficients that would be generated if each item was to be
deleted from the scale. These results indicate that no item
VI-Home sanitation.
was worthwhile deletion. This expression is a well known
Pure water supply all day (1)
Proper sewage disposal (1) statistical expression used in reliability analysis.
Flushing system (1)
Proper refuse disposal (1) Discriminant validity of the scale
Total score = 54. The difference between the upper 25% and the lower
HighZ75%.
Medium 50 to < 75%.
25% of the SES scores was compared using a t-test. A
Lowo50%. t-value (t = 79.91, Po0.01) showed that there was a
statistically significant difference between the low and
the high SES scores. This means that the scale had
discriminant ability.

Calculation of the socioeconomic index from factor analysis
The appropriateness of factor analysis was examined
using the Kaiser–Meyer–Olkin [25] as a measure of
sampling adequacy and Bartlett’s Test of Sphericity for
model significance.
As a first step in the computation of socioeconomic
categories, factor score coefficients were estimated from
factor analysis. Using the factor scores as weights, a
dependent variable was then constructed, which can be
considered the ‘socioeconomic’ score, and the higher the
socioeconomic score, the higher the implied socioeco-
Concurrent validity (as obtained through factor analysis)
Factor analysis showed that the variables studied
explained 37.5% of the variability in the data. The factor
loadings associated with the variables are presented
in Table 5. The factor loadings indicate the relative
importance of each item in identifying SES categories. It
is clear that eight out of the 10 items had high loading
(40.5) for SES. The highest factor loading was for
mother’s education, refuse disposal, sewage disposal, and
father’s education, whereas the variables that were less
important in the index, but still contributed toward the
distinction, included crowding index and father’s work.

Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
 Updated indicators for SES of families Fahmy et al. 5

Calculation of the socioeconomic index from factor Discussion

analysis Population changes affect almost all components of social
Initially, the appropriateness of the factor analysis was and economic life from a macro perspective down to the
examined. Our sample size fulfilled both the cases-to- community level, and ultimately, the family and indivi-
variables ratio and the rule of 200. The Kaiser–Meyer–Olkin dual units [26]. Since the early scaling of SES by Fahmy
was 0.772, above the recommended value of 0.5. Bartlett’s and El-Sherbini [2], no updating effort was done till the
Test of Sphericity was significant (w2 = 40.32, Po0.00), thus work performed by El-Gilany et al. [27].
indicating that a factor analysis of the variables could be
carried out. A household socioeconomic score was then The overall aim of community development is to improve
constructed and classified into socioeconomic groups. individuals’ quality of life. A concept that has been
considered an important measure of quality of life is
The cut-off points to be used for SES classification using SES [26]. SES has in general been defined to include
the proposed scoring system that showed the highest several aspects: income, education, and working status.
agreement with the cluster solution (SES classification Educational attainment and income are also included.
using factor scores) were found to be 40 and 70%, with a k Education can be considered a prerequisite for an
statistic of 0.77, where the overall correct classification occupation and income as its reward [28].
was 84.7% (Table 6).
Measures of SES and statistics on the basis of these
These findings showed the very high validity of the variances are necessary to quantify the level of stratifica-
proposed scale and the selected cut-off points, indicating tion or inequality in or between societies. Without sound
its ability to discriminate between upper, middle, and measurement of SES, it is impossible to understand the
lower classes (Appendix). transgenerational change in social status over time and
specifically on health status.
Table 4. Cronbach’s a if item deleted
Communities are not static; there are always continuous
Item Cronbach’s a if item deleted social and economic changes. Cut-off points of social
Mother’s education 0.734 scales must always be updated. Since the early scaling of
Father’s education 0.749 Fahmy and El-Sherbini in Alexandria – Egypt [2],
Mother’s work 0.769 different health researchers and centers have repeatedly
Father’s work 0.804
Computer use 0.770 sought updation of the scale. El-Gilany et al. [27], in
Income 0.760 El-Mansoura University, conducted a study to update and
Family size 0.770 validate the Fahmy and El-Sherbini scale, with the new
Crowding index 0.804
Sewage disposal 0.755 scale including some modifications. These modifications
Refuse disposal 0.752 included separation of the working status of mothers and
fathers from their educational level. They also included
the addition of computer use in the education domain
and the presence of a flushing system in the home water
closets. However, the main differences from our final
updated scale are the inclusion of the occupational
Table 5. Factor loadings for items of socioeconomic status domain, the family possessions domain, and the health-
Item Factor loading care domain in the El-Mansoura University scale [27].
Mother’s education 0.815
Refuse disposal 0.795
On the basis of the present results of the new update, it
Sewage disposal 0.772 was found that the highest factor loadings were for
Father’s education 0.729 mother’s education, proper refuse and sewage disposal,
Mother’s work 0.639
Income 0.606
and father’s education. The lowest factor loadings were
Family size 0.521 crowding index and father’s work. Considering mother’s
Computer use 0.507 education, higher standard Z scores were found among
Crowding index 0.128
Father’s work 0.047
mothers with low educational levels than among fathers
with the same educational levels.

Table 6. Comparison of socioeconomic status classification using the factor score and the Z score
SES classification using the proposed scoring system

SES classification using factor scores Lowo40% Medium 40 to o70% High Z70% Total

Low 207 60 0 267

Medium 12 319 0 331
High 0 66 236 302
Total 219 445 236 900
SES, socioeconomic status.

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 6 Journal of the Egyptian Public Health Association
However, in the El-Mansoura scale, the most important
predictor of the social level was education in general and
the least important predictors were home sanitation and
the healthcare domain.
The current updation of the scale conducted by our team is
presented in this paper to test validity and reliability. Two
methods were used to formulate a single index indicating
the SES: the Sigma score and factor analysis. These results
were compared to yield the highest agreement.
Conclusion and recommendations
The newly proposed scale changed a few indicators in the
earlier scale and proved to be valid and reliable. They were
subjected to statistical analysis, which yielded the final scale
with the final score of each indicator. The total score of SES
was calculated and the cut-off points to be used for SES
classification are presented in the Appendix, where a high
level was indicated as at least 70%, a medium level as 40 to
less than 70%, and a low level as less than 40%.
The scale is recommended to be used for scaling the
socioeconomic level of families for health research.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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 Updated indicators for SES of families Fahmy et al. 7

Appendix
Socioeconomic status scale (final updated scale)

Variable number Variable name Response categories Standard score

1 Mother’s education Illiterate/read and write 2

Literate certificate 3
Primary 3
Preparatory 4
Secondary 5
University 6
Postgraduate 8
2 Father’s education Illiterate/read and write 1
Literate certificate 2
Primary 3
Preparatory 4
Secondary 5
University 6
Postgraduate 8
3 Mother’s work No 0
Yes 3
4 Father’s work No 0
Yes 4
5 Computer use Never 0
Sometimes 2
Lot of times 4
6 Per-capita income Not enough + loan not repaid 0
Not enough + big loan 1
Not enough + small loan 2
Enough only 3
Enough and saving 5
7 Family size Z7 0
6 1
5 3
o5 5
8 Crowding index Z4 0
2– 2
o2 5
9 Sewage disposal No 0
Yes 3
10 Refuse disposal No 0
Yes 3
Total 48
High Z70% 33.6–48
Medium 40 to < 70% 19.2 to < 33.6
Low o40% o19.2

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