A Systematic Review of The Relationship Between Socio-Economic Position and Physical Activity

A systematic review of the relationship
between socio-economic position and

physical activity
Christopher Gidlow, Lynne Halley Johnston, Diane Crone,
Naomi Ellisa and David Jamesc
Abstract
Objective The aim of the present review was to examine epidemiological
evidence to determine if there is strong evidence of a positive gradient of
increasing physical activity across the socio-economic strata, and how
relationships are affected by socio-economic measurement.
Design Systematic review.
Method A search of major databases was conducted to identify pub-
lished studies that reported physical activity in relation to socio-eco-
nomic position (SEP) in adults.
Results Twenty-eight cross-sectional and five longitudinal studies met
the inclusion criteria. Approximately half of these were American.
Consequently education and income were most commonly used to rep-
resent SEP. The majority of studies were secondary analyses of existing
health survey data, which could explain the generally large sample sizes
and methodological weaknesses in physical activity and SEP measure-
ment. There was consistent evidence of a higher prevalence or higher
levels of leisure-time or moderate–vigorous intensity physical activity
in those at the top of the socio-economic strata compared with those at
the bottom. Evidence for positive gradients across the socio-economic
strata was less consistent. Education produced the most stable rela-

Centre for Sport and Exercise Research, Staffordshire University.

University of Newcastle Upon Tyne.

University of Gloucestershire.
Correspondence to: Christopher Gidlow, Centre for Sport and Exercise Research,
Staffordshire University, Mellor Building, College Road, Stoke-on-Trent, Staffordshire ST4
2DE, UK. c.gidlow@staffs.ac.uk
Health Education Journal copyright © SAGE 2006 www.sagepublications.com

[DOI: 10.1177/0017896906069378]
338 Health Education Journal 65(4) 2006 338–367

Downloaded from hej.sagepub.com at UNIV OF MICHIGAN on December 28, 2014
Socio-economic position and physical activity
tionships, less susceptible to confounding effects of ethnicity and the

environment.
Conclusion Those at the top of the socio-economic scale appear to per-
form more leisure-time activity than those at the bottom. Diverse and
often crude physical activity and socio-economic measurement made
it difficult to distinguish between artefact and true effect in a relation-
ship with so many potential confounding influences. Further studies
using up-to-date methods of socio-economic and physical activity
measurement are necessary to further explore this relationship and its
confounders.
Key words: physical activity, socio-economic, systematic review
Introduction
In Britain, higher rates of mortality1–4 and various morbidities2,4–6 in more socio-
economically disadvantaged individuals have been recognized for many years. More
recently the gap between health in the best and worst off in society has widened at an
increasing rate and this discrepancy is evident across the socio-economic spectrum7.
These health inequalities, combined with evidence of similar social patterning in
health behaviours such as smoking and dietary behaviour2,8–11, has led to assumptions
of socio-economic gradients in physical activity levels that mirror those for health12.
Indeed, interest in physical activity inequalities has grown13,14 and there is evidence
that those lower down the socio-economic scale face greater barriers to increasing
physical activity14,15.
Evidence for such socio-economic gradients in physical activity is reportedly
less consistent than for other health behaviours2,12, which could be a consequence of
the considerable problems associated with measuring this relationship. Measurement
of both physical activity16 and socio-economic position (SEP)17 are hindered by a com-
mon problem; the absence of a ‘gold-standard’ and the subsequent lack of consensus
on how best to measure these variables has created diversity in methods. Further, both
physical activity and SEP are multi-dimensional18,19, leaving researchers with a choice:
to focus on a single component and use this as a proxy for overall physical activity or
SEP; or alternatively, to use a composite SEP score (or deprivation index) or measure
total (habitual) physical activity.
Background
Socio-economic measurement issues
There are many ways of measuring SEP reviewed in detail elsewhere18,20. In epidemi-
ology, the most commonly used socio-economic indicators are social class based on
occupation, income and education, in addition to asset-based outcomes such as hous-
Health Education Journal 65(4) 2006 338–367 339

C Gidlow et al
ing tenure and car ownership. In Britain, priority areas for funding by government or
local authorities tend to be identified using area-level deprivation indices composed
from several socio-economic indicators21.
The original social classification schema of the British Registrar General (BRG)
(classes I–V) developed in Britain, was based on occupational skill, as have been many
subsequent derivations. However, accusations of statistical manipulation to engineer
smooth class-mortality gradients in the absence of a sound theoretical base led some
to question the validity of this approach and the relevance of skill-based classifications
in modern society17. Other shortcomings of social stratification on the basis of occu-
pation include an inability to account for changes in the nature of the employment
market and the common exclusion of non-working individuals22. Income is considered
a good measure of material well-being23; yet it fails to account for assets, accumulated
wealth and often the number of people supported by the income20. In Britain, due
to the sensitivity of income-related information, it is rarely collected. Education has
strength as a socio-economic indicator in its relative stability after a certain age and
ease of data collection18. However, when using education as a proxy for material wealth
there is an underlying assumption that a better education will lead to more highly paid
occupations. Further, the value of educational achievement changes over time and for
different generations18. Asset-based outcomes such as housing tenure and car owner-
ship are used less frequently, usually to compensate for the lack of income data, and
they have been criticized as markers for income in Britain due to rises in car and home
ownership in recent years24.
There has been tendency in health inequalities research to assume that the
best measure of SEP is that which produces the steepest socio-economic gradients in
health20. In reality none stands out as best for all or even most circumstances17,18, and
which socio-economic indicator(s) is most appropriate depends on the population in
question and the society and culture in which they live.
Physical activity measurement issues

Physical activity is characterized by frequency, intensity, duration and mode25 and
is therefore difficult to measure. Again this is discussed in more detail elsewhere19,25.
Traditionally, when measuring physical activity epidemiologists have emphasized fea-
sibility over validity, relying on large sample sizes for statistical power26.
It is most commonly self-reported through retrospective questionnaires or inter-
view methods, favoured for their relatively low cost and ease of administration; yet a
review of 10 physical activity questionnaires estimated that, at best, such instruments
explained just 45 per cent of variance in physical activity27. The disadvantages of using
these subjective self-reports include recall bias (recalling more structured high-inten-
sity activities more easily), overestimation of activity by less fit individuals and social
desirability bias19,26,28. Furthermore, there is inconsistency in whether researchers
measure habitual or total physical activity, leisure-time (LTPA), work-related (WRPA),

or household activity. Leisure-time and vigorous activities are often chosen as they are
easier to recall than lower intensity habitual activities such as walking or household
chores19.
In recent years, attention has turned towards objective physical activity meas-
urement using devices such as heart rate monitors, pedometers, and accelerometers
that can be worn over several days or weeks to record habitual physical activity. They
enable more accurate measurement of low intensity activities which account for most
daily activities, and circumvent some of the problems associated with self-reports19.
However, in addition to weaknesses associated with each device19, all require that
participants wear monitors for several days or weeks and are relatively expensive,
increasingly so with the increasing sophistication of the device. Therefore, in practice
such objective methods are rarely employed (in epidemilogical research) in favour of
retrospective self-report methods of physical activity that can be administered to a
large number of people, over a small period of time, at low-cost.
International and cultural factors

When exploring the relationship between SEP and physical activity in studies from
around the world, there are several considerations that relate to economic develop-
ment, culture, and socio-economic measurement.
First of all, the physical activity–SEP relationship is thought to be largely depen-
dent on a country’s level of development29. In developing countries, an active lifestyle
tends to be a necessity for those at the bottom of the social strata, whereas adopting
less healthy Western lifestyles is viewed as a privilege, affordable only by the wealthy.
In contrast, as a result of economic technological advances in developed countries, less
healthy behaviours have evolved such that healthy lifestyles require deliberate choices
that the affluent can most easily afford29,30. A country’s development might also influ-
ence the relative contributions of different types of activity to daily energy expenditure
(i.e. leisure-time, work-related and household activity). There is an increasing preva-
lence of sedentary occupations in developed societies where sedentary behaviours are
strongly reinforced31–34; yet in countries where labour-saving developments in trans-
port, communications, the workplace and so on are less advanced, the balance between
LTPA and other traditional sources of energy expenditure is likely to be different.
Second, there are some regional differences in socio-economic measure
ment20,29,35. For example, in America education is often the indicator of choice, whereas
in Britain it is not as the high proportion of people completing the minimum com-
pulsory education to the age of 16 reduces its effectiveness as a socio-economic
discriminator.
There are additional considerations of how the SEP–physical activity relation-
ship might be influenced by gender and age36,37 through the different roles of men and
women in different cultures, and possibly how different societies provide for older
people. As a result of these and numerous other possible contributory factors, the

C Gidlow et al
present review focuses on evidence from Western countries in an attempt to minimize

regional and cultural effects.
The aim of the present review was to examine epidemiological evidence for a
SEP-physical activity relationship: (1) to determine if there is strong evidence of a
p ositive gradient of increasing physical activity across the social strata; and (2) to
explore patterns for different socio-economic indicators.
Methods
Search of literature
A search of major databases (PubMed, PsychInfo, Sports Discuss, and Web of
Knowledge) was conducted in October 2004. Figures 1 and 2 illustrate the search
strategies used and study selection process, respectively. For inclusion, studies were
required to meet the following criteria:
1 English language.
2 Published in peer-reviewed journal.
3 Report a recognized socio-economic outcome: social class, income, education,
asset-based, or based on area of residence.
4 Report physical activity as a separate outcome.
5 Original study (reviews were excluded).
6 Adult populations (≥16yrs, at baseline if longitudinal).
7 Conducted in Western countries to limit cultural differences.
FIGURE 1 Search strategy

Pubmed search terms
1 Socio-economic OR socioeconomic
2 education
3 income
4 social class
5 exercise
6 physical activity
7 5 AND 6
8 1 OR 2 OR 3 OR 4
9 7 AND 8 [Title/Abstract]
10 9 Limits: Human
Web of Knowledge search terms

1 exercise OR physical activity
2 socio-economic OR socioeconomic OR education OR income OR social class
3 1 AND 2 [Title/Abstract]
Psychinfo and Sports Discuss search terms included: socio-economic OR socioeconomic,

education, income, social class, exercise OR physical activity.

FIGURE 2 Study selection
Total results from searches

N=5292
Abstracts excluded (N=31): Abstracts retrieved

– Participants <16 years N=64
old (N=11)
– Not single Western
country (N=9)
– Physical activity not
Full-text articles retrieved
reported separately
N=33
in relation to SEP (N=7)
– Not recognize socio-economic
outcome (N=1)
– Reviews (N=3)
Articles included
N=33
Quality assessment
In order to make an informed judgement about the strength of evidence from the
present review it was necessary to assess the quality of included studies. A quality
assessment instrument was developed, and Table 1 presents the criteria derived from
both criticisms of epidemiological studies made in a recent review38 and issues relating
specifically to the measurement of physical activity and SEP. Quality assessment was
undertaken independently by two experienced assessors and where disagreements
occurred, they were discussed until a consensus was reached.
Results
Country of origin
Twenty-eight cross-sectional and five longitudinal studies (total of 33) conducted
in 10 different countries met the inclusion criteria: America (n=16)39–54, Australia
(n=5)55–59, Canada (n=3)60–62, Spain (n=1)63, England (n=3)64–66, Finland (n=1)67,
Sweden (n=1)68, France (n=1)69, the Netherlands (n=1)70 and Greece (n=1)71. Two cross-
sectional studies by Crespo et al46,47 reported different analyses of data from the same
sample and are treated as a single study (total of 32). Table 2 presents the frequency
with which different indicators were reported and physical activity–SEP relationships
were observed.
Table 3 summarizes study design, quality and sample characteristics presented
by country of origin to illustrate international differences. Over half of the studies were
American, all of which reported income and education. Consequently, education was
most frequently reported overall and social class was least reported.

C Gidlow et al
Table 1 Quality assessment criteria

Level Criteria
1 Original data
Provide information on participant selection AND response rate
Representative sample (based on size, response rate, inclusion criteria, etc.)
Pre-validated physical activity measure
Justify selection of socio-economic measure AND all socio-economic data
continuous OR ≥ 3 categories
Performed multivariate statistical analysis
Level of significance clear (P values OR confidence intervals reported)
2 Original data OR data from previous survey

Representative sample (based on size, response rate, inclusion criteria, etc.)
Pre-validated physical activity measure
Justify selection of socio-economic measure OR all socio-economic data continuous
OR ≥ 3 categories

NOT representative sample (based on size, response rate, inclusion criteria, etc.)
NOT pre-validated physical activity measure
Justify selection of socio-economic measure OR all socio-economic data continuous
OR ≥ 3 categories

Provide information on participant selection OR response rate
NO justification for selection of socio-economic measure AND some socio-
economic data dichotomized

Provide information on participant selection OR response rate
NO justification for selection of socio-economic measure
Some socio-economic data dichotomized
Level of significance unclear

Inadequate information on participant selection AND response rate
NO justification for selection of socio-economic measure
Some socio-economic data dichotomized
Level of significance unclear

TABLE 2 Frequency of socio-economic indicators and presence of relationships

between physical activity and socio-economic indicators
Number of studies
Socio-economic indicator Total Positive No Negative

relationships relationship relationships
Social class 10 9 1 –
Income 18 11 6 1
Education 24 17 7 –
Asset-based 2 1 1 –
Area of residence 3 3 – –
Note: a. Positive or negative direction: with respect to physical activity–SEP relationship,

even if outcomes reported in terms of inactivity–SEP; b. Crespo et al46,47 included as single
study
Table 4 summarizes the main outcomes from studies in order of socio-economic

indicator to facilitate the identification of consistent themes. These findings are dis-
cussed in the following sections. As a result of the diversity in SEP and physical activity
the relationships are described and consistent themes identified, with consideration
for methodological issues.
Study quality
According to the criteria listed in Table 1 the number of studies with different qual-
ity ratings (QR) are presented in Table 3 (highest quality QR1 n=0; QR2 n=3; QR3
n=15; QR4 n=8; QR5 n=4; QR6 n=2). Two-thirds of studies (n=22) relied on data
from previous health surveys whose original focus and methodological quality thus
dictated their quality. This is a possible explanation for the common methodologi-
cal weaknesses, including the use of unvalidated self-reported measures of physical
activity (n=17), failure to justify the choice of socio-economic indicator(s) (n=16),
dichotomizing socio-economic variables (n=10) and failure to report response rate
(n=8). Further, although several authors gave some justification for their association
economic indicators (in terms of citing previous research), few provided a conceptual
rationale, which is a major criticism in socio-economic measurement17,18.
Study samples were generally large (range=84 to 61,239; mean=6960, calcu-
lated using numbers available for analysis in longitudinal studies). Where response
rate was reported it was relatively high, with some exceptions (range=31.3 to 97.5;
mean=68.0 per cent, calculated from mean response at baseline and follow-up in
longitudinal studies) thus reducing the potential for response bias in most studies. It
is likely that response bias would increase the proportion of respondents higher up
the socio-economic strata. Therefore, poor (or unspecified) response rates are

TABLE 3 Study design and sample characteristics
Study Study sample Data origin Methods Socio–economic measures Physical activity measure Quality
Description Validated rating
Britain
346
Boniface et al N=1166 Not original data Longitudinal Occupation: I–V (British Registrar Moderate–vigorous: number of 20- N 4
200166 Men (1984–5 and interviews Generals) and occ disadvantage minute episodes in past 2 wks
Age 18–49 yrs 1991–2) score:(Cambridge scale)
Education: no qual, up to GCSE,
A-level+
C Gidlow et al
Housing tenure: privately owned, the

local authority owned
Wardle and N=1691 Original data Cross-sectional Occupation: I–V (British Registrar Vigorous: in last wk (y/n) N 3
Steptoe 200364 758 men interviews Generals)
933 women
Aged >16 yrs
Bartley et al N=5458 Not original data Prospective study Occupation: high, middle, low Habitual: hrs mild, moderate and N 3
200465 4037 men (1991) (Cross-sectional vigorous activity per wk (none/light,
1421 women results reported) moderate, and vigorous categories)
Aged 35–55 yrs
Civil servants
America
Ford et al 199150 N=559 1980 census data Cross-sectional Area of residence: low vs high SES Walking Y 4
179 men interviews WRPA
380 women LTPA
Aged 18–89 yrs Household
Kaplan and N=4025 adults Not original data Longitudinal Occupation: blue-collar, white-collar, LTPA: frequency of given activities Y 4
Lazarus 199154 1787 men (1965 and 1974) interviews homemaker (often, sometimes, never)
2238 women Household income: quintiles (adjusted)
Aged ≥20 yrs Education: 0–8, 9–11, 12, 13+ yrs
Clark 199549 N=6780 Not original data Cross-sectional Income: 7 categories (from <$5,000 to Get as much as needed? N 5
Approx 63% (1984) interviews >$25,000) Have regular exercise routine?
women Education: completed <8 years vs 9+ Rate level of physical activity cf. peers
Aged 70+ years Rate level of physical activity cf. 1 yr ago

White and African Frequency with which walk 1 or more
Health Education Journal 65(4) 2006 338–367

Americans mile
Lantz et al N=3617 Not original data Cross-sectional Income: <$10,000, 10,000–29,999, Habitual activity: frequency of sports, N 3
199839 1358 men (1986) (baseline data from >30,000 exercise, gardening, yard work,
2259 women longitudinal study) Education: <12 yrs, 12–15 yrs, walking (placed in quintiles)
Aged ≥ 25 yrs interviews ≥30,000
McTiernan et al N=492 Original data Cross-sectional Income: <$15,000, $15,000–30,000, LTPA: frequency, duration in past 2 yrs N 4
199841 Women survey $30,000–45,000, >$45,000
Aged 50–64 yrs interviews Education: ≤12 yrs, >12 yrs
Yen and Kaplan N=1451 Not original data Longitudinal survey Area of residence: poverty vs non- LTPA: single question about frequency Y 3
199845 618 men (1965–74) questionnaire poverty area based on census of sports, swimming, long walks,
833 women gardening, physical exercises
Aged 20 in 1965
Crespo et al N=18,825 Not original data Cross-sectional Occupation: w-collar professional, w- LTPA: participation of named activities N 5

199946, 200047 Aged ≥20 yrs (1988–94) survey collar other, b-collar (plus 2 non-working in past month (+ 4 open ended Qs on
White , Mexican interviews categories) other activity)
and African- Income: 5 categories ($<10,000 to
Americans >$50,000)
Education: <12 yrs, 12 yrs, 13–15 yrs,
16+ yrs
Grzywacz and N=3032 Not original data Cross-sectional Education: yrs (12 categories) Vigorous: frequency of activities Y 2
Marks 200148 1471 men (1995) telephone Household income – continuous variable
1561 women interviews
Aged 25–74 yrs
Nies and N =198 Original data Cross-sectional Income: assumed continuous, not stated 7-day PAR: calculate EE Y 5
Kershaw 200240 Women survey Education: ≤high school, vs >high Time to walk 1 mile
Aged 30–60 yrs questionnaire school, graduate school vs <graduate
White/African- school
American
Parks et al N=1818 Original data Cross-sectional Education: <high school, high school Habitual activity: meeting and not Y 3
200351 Men and women telephone graduate, some college/tech school, meeting recommended guidelines
Aged 18–65+ yrs interviews college/post grad (from non-/occupational walking,
Household income: <$20,000, moderate LTPA, vigorous LTPA
>$20,000
Ainsworth et al N=917 Original data Cross-sectional Income: < $15, 000, $15,000–$35, Habitual Activity: meeting Y 3
200353 Women telephone 000, ≥ $35,000 recommendations, insufficiently active,
Aged 20–50 yrs interviews Education: college graduate, some and active
African-American college, high school/GED, < high school
Dowda et al N=4152 Not original data Cross-sectional Education: yrs of education as LTPA: frequency of named activities N 6
200352 1922 men (1988–94) interviews continuous variable and dichotomized as
2230 women <12 yrs, ≥12 yrs
Aged 18–30 yrs
White/Black,/
Mexican Americans
Eyler 200343 N=1000 Original data Cross-sectional Income: < $15, 000, $15,000–$35, Habitual Activity: meeting Y 3
Women survey 000, ≥ $35,000 recommendations, insufficiently active,

Aged 20–50 yrs interview Education: college graduate, some and active

White-American college, high school/GED, < high school
Rural area
Wilbur et al N=399 Original data Cross-sectional Income: < $15, 000, $15,000–$35, Habitual Activity: meeting Y 4
200342 Women survey 000, ≥ $35,000 recommendations, insufficiently active,
Aged 20–50 yrs interview Education: college graduate, some active
African-American college, high school/GED, < high school
Urban area
Tudor-Locke N = 209 Original data Experimental study Income: < $20, 000, $20,000–$44, Pedometer worn for 7 days Y 4
et al 200444 76 men, 133 interview 999, ≥ $45,000
347
Women Education: < high school, at least some

Aged ≥ 18 yrs college
(mean ~ 48 yrs)
continues
TABLE 3 Cont.
348
Study Study sample Data origin Methods Socio–economic measures Physical activity measure Quality
Description Validated rating
Australia
MacDougall N=1765 Not original data Cross-sectional Education: none/primary, secondary, SR physical activity – vig, mod, low N 4
C Gidlow et al
et al 199758 Men and women (1987) postal trade or business, tertiary (vig were excluded)
Age 17–75yrs questionnaire Income: <$15,000, ≥ $15,000
Kendig et al N=1000 Not original data Cross-sectional Occupation: managers, profs, clerks/ Mod–vig: dichotomized as have or N 3
199857 Men and women (1994) interviews and sales/services, tradesmen, labourers/ have not engaged in activity resulting
Aged 65+ yrs questionnaire operatives in breathing harder, puff/pant in past
Education achievement: 4 categories 2 weeks.
Income: above/below pension
Housing tenure: own vs rent
Burton and Turrell N=24252 Not original data Cross-sectional Occupation – professional, white- LTPA: dichotomized as sufficient or N 3
200056 Aged 18–64 yrs (1995) questionnaire collar, blue-collar (from Aus Standard insufficient for health
Classification)
Salmon et al N=7935 Not original data Cross-sectional Education: university, 12 yrs, <12 yrs LTPA: any Y 2
200059 3795 men (1989) questionnaire Occupation: 3 economically active Vigorous WRPA+household activity
4140 women categories
Aged 20–60+ yrs
Mean age ~42 yrs
Giles-Corti and N=1803 Original data Cross-sectional Area of residence: based on Social Physical activity recall (past 2 weeks) N 3
Donovan Aged 18–59 yrs interviews Advantage Index: and calculated EE
200255 Men and women – low SES (<20th percentile)
– high SES (>80th percentile)
Canada
Millar and N=11200 (1985) Not original data Longitudinal survey Education: <high school grad, high LTPA: duration and freq of activities N 5
Stephens 199361 N=11924 (1991) (1985–91) with 6–yr follow-up school grad, post secondary education Asked about 2 most frequent activities
Men and women interviews (not uni), University and assigned EE depending on light/

Aged ≥25 yrs mod/vig intensity

Pomerleau et al N=61239 Not original data Cross-sectional Occupational prestige: Low, LTPA: frequent , duration, and N 3
199762 ≥19 yrs (1990) survey intermediate, high number of activities in past month
interviews Education: post-secondary, some post- – dichotomized as active (≥1.5 kcal/
secondary, secondary, some secondary, kg/d) vs inactive (<1.5 kcal/kg/d)
primary or less
Household income: $<12,000,
$12,000–19,999, $20,000–29,999

Kaplan et al N=12611 Not original data Cross-sectional Education: < secondary, secondary, LTPA monthly moderate bouts of >15 N 3
200160 6306 men (1996–7) survey some postsecondary, postsecondary min – dichotomised as frequent/infreq
6305 women questionnaire
Aged 65+
Spain
Schroder et al N=1577 Not original data Cross-sectional Education: < primary school, primary LTPA: Minnesota physical activity Y 2
200463 838 men (1994–6) survey school, secondary school, > secondary questionnaire
910 women questionnaire school
Aged 25–74 yrs
Finland
Laaksonen et al N=19982 Not original data Cross-sectional Income: quintiles of household income LTPA: active more vs less than 4 N 3
200367 9324 men (2001) survey times/wk
10658 women questionnaires
Aged 25–64 yrs
Sweden
Lindstrom et al N=11837 Not original data Cross-sectional Occupation: high level non-manual, LTPA: 17–item questionnaire – mins/ Y 3
200168 5380 men (1992–4) questionnaire middle-level non-manual, low level non- wk for each season spent in 17
6457 women manual, skilled manual, unskilled manual activities – Low LTPA defined as lowest
aged 45–64 yrs quartile of the population (<33.4min/
wk walking)
Netherlands
Droomers et al N=3793 Not original data Longitudinal Income: quintiles LTPA: Time spent walking, cycling, N 3
200170 Men and women (1991 and 1997) questionnaires Education: higher vocational schooling gardening, it sports
Aged 15–74 yrs and university, intermediate schooling,
lower secondary or vocational
schooling, primary school
Greece
Papadopoulou N=84 Original data Cross-sectional Income: poverty level, above poverty Not described Y 6
et al 200371 65 men, 19 women survey level
Aged 65+yrs interview Education level: categorization not
At rehab centre specified

France
Betrais et al N=7404 Not original data Cross-sectional Education: primary, high school, LTPA: in past yr Y 4
200469 Men and women (1998) survey university
Aged 45–68 yrs
Quality rating from 1 (highest quality) to 6 (poorest quality); SE, socio-economic; SES, socio-economic status; PA, physical activity; LTPA, leisure-time physical activity; WRPA, work-related
physical activity
349
TABLE 4 Main outcomes for each socio-economic indicator
350
Study Country Sample size No. SE Type of Physical Significant SEP–PA associations Direction Sig level Other factors
categories* Activity (+/–)
Socio-economic indicator: Occupational social class
Kaplan and America 4025 3 Change in LTPA No association NS
C Gidlow et al
Lazarus 199154 (L)

Pomerleau et al Canada 61239 3 LTPA Lower inactivity in highest occupational prestige group + P<0.0500
199762
Kendig et al Australia 1000 5 Moderate– Lower activity in lowest class vs highest occupational class + P<0.0500
199857 Vigorous
Crespo et al America 18225 3 LTPA Higher inactivity in lowest occupational class + Not given
199946; 200047
Burton and Turrell Australia 24454 3 LTPA Positive gradient in women + P<0.0500 Gender differences
200056 Higher inactivity in lowest vs higher occupational + P<0.0500
classes
Salmon et al Australia 7935 4 LTPA Positive gradient in women + P<0.0010 Gender differences
200059 Vigorous WRPA Higher in highest vs lowest occupational class in men + P<0.0010
+ household Higher in highest vs intermediate occupational class in P<0.0100
activity women +
Boniface et al Britain 1166 3 Change in No association NS Age differences
200166 (L) Moderate–
Vigorous
Lindstrom et al Sweden 11837 5 LTPA Lower activity in lowest vs highest occupational class + P<0.0010
200168
Wardle and Britain 1691 3 Vigorous Positive gradient + P<0.0500
Steptoe 200364
Bartley et al Britain 5458 3 Habitual Positive gradient in men + P<0.0500 Gender differences
200465 Lower activity in lowest vs highest occupational class in + P<0.0500
women

Socio-economic indicator: Income (household)
Kaplan and America 4025 5 Change in LTPA Negative changes associated with being in the least vs + P<0.0500 Gender differences
Lazarus 199154 (L) most educated group
Clark et al 199549 America 6780 7 Habitual No association NS
MacDougall et al Australia 1765 2 LTPA No association NS

199758
Pomerleau et al Canada 61239 3 LTPA Lower inactivity in the highest vs lower income groups + P<0.0001
199762

Kendig et al Australia 1000 2 Moderate– Lower activity in low vs high income group + P<0.0500
199857 Vigorous
Lantz et al 199839 America 3617 3 Habitual Positive gradient + P<0.001
McTiernan et al America 492 4 LTPA Lower activity in lowest vs highest income group + P<0.0010 Female sample
199841
Crespo et al America 18225 3 LTPA Higher inactivity in lowest income groups + Not given Ethnic differences
199946; 200047
Droomers et al Netherlands 3793 5 Change in LTPA Greater increases in highest vs the lowest income group + P<0.01 Age differences
200170 (L) (<45 yrs) + P<0.001
Greater increases in highest vs the lowest income group
(>45 yrs)
Grzywacz and America 3032 Cont Vigorous Positive gradient in women only + P<0.0500 Gender differences
Marks 200148
Nies and Kershaw America 1998 – Habitual No association NS Female sample
200240
Parks et al 200351 America 1818 2 Meeting Lower % met guidelines in low vs high income group + Not given
guidelines for
habitual activity
Ainsworth et al America 917 3 Some vs no No association NS Female sample
200353 habitual activity No association NS
Meeting
guidelines for
habitual activity
Eyler et al 200343 America 1000 3 Some vs no No association P<0.0500 Female sample
habitual activity Higher % met guidelines in highest income group +
Meeting
guidelines for
habitual activity
Laaksonen et al Finland 19982 5 LTPA Lower activity in the highest vs lower income groups in – P<0.0500 Gender differences
200367 women only

Papadopoulou et al Greece 84 2 Not specified Lower activity in high vs low income level + P<0.0500

200371
Wilbur et al America 399 3 Some vs no No association NS Female sample
200342 habitual activity No association NS
Meeting
guidelines for
habitual activity
Tudor-Locke et al America 209 3 Habitual activity Positive gradient + P=0.0060
200444
351
continues
TABLE 4 cont.
Study Country Sample size No. SE Type of Physical Significant SEP–PA associations Direction Sig level Other factors
categories* Activity (+/–)
Socio-economic indicator: Education
352
Kaplan and America 4025 4 Change in LTPA No association NS
Lazarus 199154 (L)
Millar and Canada 11200 (b) 4 LTPA Lower prevalence of inactivity in most vs least educated at + Not given
Stephens 1993 (L)61 11924 (f–u) baseline and follow-up
C Gidlow et al
Clark 199549 America 6780 Cont Habitual activity Positive gradient + P<0.0010 Ethnic differences
MacDougall et al Australia 1765 4 LTPA Lower inactivity in most vs least educated group + P<0.0500
199758
Pomerleau et al Canada 61239 5 LTPA No association NS NS
199762
Kendig et al Australia 1000 4 Moderate– No association NS
199857 Vigorous
39
Lantz et al 1998 America 3617 3 Habitual Positive gradient + P<0.001
McTiernan et al America 492 2 LTPA Lower inactivity in low vs high education group + P≤0.0100 Female sample
199841
Crespo et al America 18225 3 LTPA Positive gradient + Not given Ethnic differences
199946; 200047
Salmon et al Australia 7935 3 LTPA Positive gradient + P<0.010 Gender differences
200059 Vigorous WRPA Positive gradient in women + P<0.0010
+ household Lower in least vs most educated men + P<0.0010
activity
Boniface et al Britain 1166 3 Change in Positive association with uptake (35–49 yrs) + P=0.0200 Age differences
200166 (L) Moderate– Positive association with continuation (18–34 yrs) + P=0.0300
Vigorous
Droomers et al Netherlands 3793 4 Change in LTPA Positive gradients and (<45 yrs) + P<0.0500 Age differences
200170 (L) Greater decreases in least vs most educated group (>45 P<0.0500
yrs)
Grzywacz and America 3032 12 Vigorous Higher in most vs least educated + P≤0.0010 Gender and age
Marks 200148 differences

Kaplan et al Canada 12611 4 LTPA Higher in most vs least educated group + P<0.0010

200160 Highest in intermediate group P<0.0010
Nies and Kershaw America 198 4 Habitual No association NS Female sample
200240
Parks et al 200351 America 1818 4 Meeting No association NS
guidelines for
habitual activity
Ainsworth et al America 917 3 Some vs no Lower % performed some vs no activity in less educated + P<0.05 Female sample
200353 habitual activity groups
Meeting No association (for meeting vs not meeting guidelines) NS
guidelines for
habitual activity
Dowda et al America 4152 Cont LTPA Positive gradient in White and Mexican Americans + P<0.0010 Ethnic differences

200352
Eyler et al 200343 America 1000 4 Some vs no No association NS Female sample
habitual activity
Meeting No association NS
guidelines for
habitual activity
Papadopoulou et al Greece 84 Not Not specified No association + NS
200371 specified
Wilbur et al America 399 4 Some vs no Lower % performed some vs no activity in lowest vs highest P<0.0500 Female sample
200342 habitual activity education groups + NS
Meeting No association (for meeting vs not meeting guidelines)
guidelines for
habitual activity
Betrais et al 200469 France 7404 3 Meeting Higher in most vs least educated group in women only + P<0.0500 Gender differences
guidelines for
LTPA
Schroder et al Spain 1748 4 LTPA No association NS
200463
Tudor-Locke et al America 209 2 Habitual Positive gradient + P<0.0001
200444
Socio-economic indicator: Area of residence

Ford et al 199150 America 559 2 LTPA Higher in high SEP women only + P<0.0001 Gender differences
WRPA Lower in high SEP women only – P<0.0001
Walking Lower in high SEP men only – P=0.0227
Household Lower in high SEP men and women – P≤0.0070
Yen and Kaplan America 1737 2 Change in LTPA Greater reduction in LTPA in poverty areas + P=0.0001 Ethnic differences
199845 (L)
Giles-Corti and Australia 1803 2 Meeting
Donovan 200255 guidelines: Lower in low vs high SEP group + P<0.0500
– total activity Lower in low vs high SEP group + P<0.0500

– vigorous

activity
Kendig et al Australia 1000 2 Moderate– No association NS
199857 Vigorous
Boniface et al Britain 1166 2 Change in Great uptake for those in private housing (18–34 yrs) + P=0.0500 Age differences
200266 (L) Moderate– Great uptake for those in private housing (35–49 yrs + P=0.0480
Vigorous
Note: a. All studies are cross-sectional unless (L) = longitudinal; b. If a significant effect was represented by Odds Ratios and 95% Confidence Intervals but a P-value not given, it is
353
reported as P<0.05. c. Positive or negative direction: with respect to physical activity–SEP relationship, even if outcomes reported in terms of inactivity–SEP. * No. SE categories refers to
number of categories for the socio-economic variable shown in the main analysis (multivariate if used); NS, non-significant; SE, socio-economic; SES, socio-economic status; PA, physical
activity; LTPA, leisure-time physical activity; WRPA, work-related physical activity; vig, vigorous; mod, moderate; cont, continuous; bl, baseline; f-u, follow-up.
C Gidlow et al
pertinent to this review. In addition to the likely influence of some response bias, the
representativeness of samples was further reduced by over half of the studies delimit-
ing to certain age groups.
The majority of studies performed multivariate analysis and reported signifi-
cance levels. Logistic regression was most common; consequently the frequent use of
dichotomous physical activity outcomes was not viewed as a weakness because use
of a binary dependent variable is required in basic logistic regression analysis72. The
following sections describe the main findings with consideration given to the method-
ological strengths and weaknesses.
Outcomes for occupational social class

Of the 10 studies reporting occupational class, only one collected original data64; the
remainder relied on existing survey data. Despite generally large samples (range=1000
to 61,239), all but one study68 used just three occupational classes. This reduces the
sensitivity of classification and increases intraclass heterogeneity. In most studies
that specified, non-working adults were excluded from analyses or treated separate-
ly56,59,64,65. This is a potential limitation given that several studies included samples with
both young and older adults who are more likely to be students and retired respec-
tively46,47,56,59,62,64. Therefore, the proportion of non-working adults is likely to have been
higher in these studies.
As Table 4 illustrates, all eight cross-sectional studies reported significantly
higher physical activity in the highest versus lowest social classes. Four of these found
positive gradients across classes56,59,64,65. Wardle and Steptoe64 classified occupations of
British adults according to the much criticized British Registrar Generals schema and
found an increased likelihood of performing no vigorous intensity activity in sequen-
tially lower classes (I/II OR=1.00; III OR=1.65 1.31–2.09; IV/V OR=2.17 1.60–2.94).
Similar trends were reported for LTPA in two analyses of Australian survey data56,59
that were significant in women only (P<0.01). Conversely, analysis of data on habitual
physical activity from the British Whitehall II study65 revealed a far stronger relation-
ship in men. The latter study was, however, restricted to those employed in the civil
service so results were not generalizable. Nevertheless, the advantage was that relative
position within a well-defined occupational hierarchy would have been more easily
determined, thus reducing misclassification.
Both of the aforementioned Australian studies56,59 reported significant LTPA dif-
ferences between men in the highest and lowest social classes; the study by Salmon
et al59 was one of the better quality studies reviewed (QR2). Similar patterns were
apparent in men and women in several large studies46,47,62,68. The only American study
used blue- and white-collar classifications in a multi-ethnic sample46,47. Researchers
reported a positive association. They also stated that this positive association failed
to fully explain the lower prevalence of leisure-time inactivity in Caucasians, although
the report lacked information on participant response rates and apparently conducted

no statistical analysis to support this (QR5). Significant LTPA differences between late
middle-aged Swedish adults in manual and non-manual occupations were revealed
(P<0.05) in analysis of data from a survey that used five social classes and an exten-
sive, pre-validated activity questionnaire (QR3)68. Similarly, a significant positive rela-
tionship with LTPA was evident (P<0.05) in 61,000 Canadians62. However, the sample
was stratified into just three classes of occupational prestige and the physical activity
measurement was inadequately described.
The only study to measure social class and physical activity in older adults57
reported high versus low social class differences for moderate–vigorous intensity
activity (P<0.05). The crude physical activity measurement (a single closed question)
was a limitation. Furthermore, occupational classification in older adults according
to last occupation would not have adequately accounted for those who chose semi-
retirement or less demanding occupations nearer to retirement that might have been
unrepresentative of lifetime social class.
Neither longitudinal study reporting occupational class54,66 was of high quality
(QR4). Boniface et al66 found that occupational class measured using two different
scales was not a significant predictor of uptake or maintenance of physical activity in
British men. Kaplan and Lazarus54 reported that a white- versus blue-collar occupation
was positively associated with physical activity change in basic regression analyses,
although income was used as the sole socio-economic variable in the full model.
Outcomes for income

Out of the 18 studies that reported income only six analysed original data40,41,51,53,71,
which was reflected in generally smaller sample sizes compared with the analyses of
existing data. Similar to social class measurement, the majority of studies used only
two or three income categories; only five used four or more categories41,49,54,67,70 one
study used a continuous variable48. The consequences in terms of misclassification
might be less serious than for occupation because income boundaries are clear (e.g.
US$20,000–25,000) although arbitrary, whereas the absence of such a linear scale for a
diverse range of occupations makes boundaries less defined. Eight studies focused on
middle-aged42,43,53, or middle-aged and older adults40,41,49,57,71. The remainder included
a full age range. Age is likely to be less pertinent when using income rather than social
class or education because non-working individuals can still be classified by income
but are often excluded from occupational classification. Furthermore, current income
is unaffected by temporal change, unlike education (changes in the education system
and employment market mean that obtaining the same qualification 30 years ago
would have had different consequences in terms of subsequent employment opportu-
nities and relative income than nowadays).
Nine cross-sectional studies found that income and physical activity were posi-
tively related, six reported no relationship, and a negative association was reported in
one of only two European studies67. Tudor-Locke et al44 conducted the only objective

C Gidlow et al
measurement of physical activity. Participants wore pedometers for seven days and a
gradient of increasing number of steps per day in sequentially higher income catego-
ries (P=0.006) was observed. Despite the advantages of the objective physical activ-
ity measure, greater participant burden is likely to have contributed towards the poor
response rate (31.3 per cent), which reduced sample size (n=209) and increased selec-
tion bias: the 209 participants were more likely to be white, more educated and have
higher incomes than the original sample (n=1200). The only other study that reported
a positive gradient between income and habitual physical activity (P<0.001) analysed
data obtained using a ‘physical activity index’ that was unvalidated and appeared to
focus primarily on the leisure-time activities39. One other study (QR2)48 reported a
positive gradient that was for vigorous intensity activity, but in women only (P<0.05).
This could be a reflection of the age of data that were collected prior to changes in
the physical activity guidelines from less frequent and vigorous, to regular moderate
activity73.
The analyses of survey data from older Australians by Kendig et al57 was simi-
larly limited to moderate–vigorous activity. Higher levels were reported by those with
incomes above pension level. This might be a more appropriate discriminator than
absolute income in older people (as used by Clark49), although comparability with other
studies is reduced. Another study of older adults conducted in Greece reported a posi-
tive association between income and physical activity level71; yet the brief report failed
to adequately describe study methods, participants or statistical analysis. Moreover, in
addition to the small sample (n=84) including only residents of a rehabilitation centre
meant that results were not even generalizable to other people of a similar age (QR6).
Several studies that did not find a gradient observed higher activity in the high-
est versus lowest income groups, in terms of LTPA41,46,47 and the likelihood of meet-
ing physical activity guidelines43,51. Crespo et al46,47 boasted a large study population
and adjusted income by household size but was limited as detailed previously (QR5).
McTiernan et al41 collected data in a population (n=492) of white, late middle-aged
women and found that those in the highest income group were twice as likely to per-
form LTPA than those in the lowest (OR=2.3, CI=1.2–4.5). Similarly, Eyler et al43 ana-
lysed data from white women in rural America and found that being in the highest
versus lowest income group significantly increased the likelihood of meeting guide-
lines for moderate or vigorous activity (OR=2.76, CI=1.08–4.01). Parks et al51 report-
ed the same findings in men and women but data were not presented. The income
effect was only apparent once the sample was divided according to the morphology
of participants’ area of residence (rural, urban, or suburban), which highlighted the
potential for environmental factors to mask socio-economic differences in physical
activity.
Out of the two longitudinal studies exploring changes in LTPA, Droomers et
al reported that being in the highest versus lowest income quintile at baseline had a
70
positive effect on subsequent LTPA changes (P<0.01). In basic regression Kaplan and

Lazarus54 observed a similar positive association that remained only for women when
all variables were entered into the model.
A total of six studies did not find a significant relationship40,42,49,53,58,62. This could
have been attributable to ethnic variation in four of these: two analysed survey data
on African-American women42,53; an original study that used a well-validated physical
activity measure (QR2) involved a multi-ethnic sample of women40; and Clark49 failed
to find an association in a multi-ethnic sample of older Americans. However, in the lat-
ter study, measuring absolute income (rather than relative to pension level) could have
contributed to this finding that conflicted with the study of older Australians57. In the
analysis of health survey data from Ontario62 an apparent income effect was attenuated
beyond significance (P=0.10) when occupation and education were entered into the
regression model; sample ethnicity was not reported. Ethnicity was not reported in
the Australian study by MacDougall et al58 that dichotomized income and determined
LTPA using only two questions (QR4).
One study reported a significant negative relationship. It was conducted in
Finland and found higher LTPA in women on lower incomes (P<0.05) but not men67.
It is, however, known that Finnish adults have particularly high physical activity
levels74 and therefore cultural differences in physical activity participation could be
responsible.
Outcomes for education

Education was the most commonly used socio-economic indicator. Out of 24 stud-
ies that reported education (in years or qualifications), six analysed original
data40,41,44,51,53,71. Most of these studies and their respective strengths and weaknesses
have been described previously and are therefore not discussed in detail.
Given the temporal changes in the value of education it is worth noting that
almost half of the studies limited the sample age ranges to young or middle-aged42,43,52,53,
or middle-aged and older adults41,49,57,60,69,71, which is likely to have reduced temporal
effects.
As illustrated in Table 4 the majority of cross-sectional studies found positive
relationships between education and physical activity; seven did not. Positive gradients
were reported in six studies (mostly those with a broad age range), in terms of habitual
activity39,44,49 or LTPA46,47,52,59. These relationships were stronger than those found for
income or social class in several cases39,44,46,47,49. Dowda et al52 reported this relationship
in a multi-ethnic sample of young adults, although an independent ethnic effect was
also apparent and the study had numerous methodological weaknesses (QR6).
The remaining positive associations generally manifested as differences
between the highest and lowest education groups in terms of LTPA41,58–60,62, vigorous
activity48, habitual activity42,49,53,58,62 and meeting physical activity guidelines51. Again,
these associations were often stronger or more consistent than those found for other
socio-economic indicators42,48,53,58,59,62. Five studies found that education, not income,

C Gidlow et al
was significantly related to physical activity in multivariate analysis42,49,53,58,62 despite

ethnic variation in three of these.
In contrast, out of the seven studies that failed to find significant association,
three found that income and not education predicted activity outcomes51,57,71, although
there are serious questions regarding the quality of data in the Greek study71. The
absence of associations in two analyses of all-female data samples40,43 conflicted
with three other all-female studies41,42,53. Area morphology and ethnicity might have
contributed, although study differences make it difficult to determine the dominant
influence.
Four longitudinal studies measured education. Three that have been described
previously reported a positive effect of education on changes in LTPA60,70 and habitual
physical activity66, although the size and consistency of the effect across educational
groups varied and was influenced by age in the latter study66. Further, Kaplan and
Lazarus54 excluded education from the full regression model. Another longitudinal
study analysed data from repeated Canadian Health Surveys61. The findings indicated
that less educated men were more likely to be inactive in 1985 and 1991 (OR=2.26 and
OR=1.55 respectively) and a similar but less marked pattern was evident in women
(OR=1.86 and OR=1.52 respectively). However, neither significance levels nor confi-
dence intervals were reported.
Outcomes for area of residence

Despite the wide availability of area-level socio-economic data from censuses, only
three studies45,50,55 socially stratified by area of residence. Study populations were sur-
prisingly small (n=559–1803), possibly a limitation of collecting additional individual
socio-economic data. Yen and Kaplan45 used data from the Alameda County Study,
which began in 1965 and compared individuals living in poverty and non-poverty
areas according to the 1965 census tract. Researchers found lower LTPA at baseline
(1965) and follow-up (1974) (p=0.0001) and a greater decrease in physical activity
(p=0.0001) in residents of poverty areas. Using 1980 census data Ford et al50 found
significant differences between women in low and high SEP areas in almost all physi-
cal activity categories, whereas in men, differences in total PA and LTPA were non-
significant. The most recent study by Giles-Corti and Donovan55 found that those in
low SEP areas were less likely than the high SEP group to meet recommendations for
total and vigorous physical activity (26 per cent and 46 per cent respectively).
Despite similarities, some study differences are worthy of note. First, there was
inconsistency in area classification: Yen and Kaplan45 compared poverty and non-
poverty areas; the Australian study compared those living in areas at the top and
bottom of the socio-economic scale (<20th vs ≥ 80th percentile); Ford et al50 did not
specify how SEP areas were defined. Second, all studies reported significant differ-
ences in education and income between high and low SEP groups (at the individual
level) to validate classification. However, Yen and Kaplan45 also found an independent

area socio-economic effect, which is consistent with health inequalities literature75–77.

Third, ethnicity was an important factor in both American studies45,50. Caucasians
and African Americans were overrepresented in high and low SEP areas respectively.
Indeed, in analysis of data from 1965 adjusting for ethnicity reduced the SEP–physical
activity effect by 55 per cent45. Finally, Giles-Corti and Donovan55 found that objec-
tively measured environmental variables offset SEP differences.
Outcomes for asset-based indicators

Housing tenure was used as a main socio-economic variable in the analysis of data
from older Australians (n=1000)57 and the longitudinal British survey66. Despite find-
ing significant associations for social class and income in the former, researchers failed
to find significant differences in moderate–vigorous activity between homeowners
and those renting properties. Boniface et al66 on the other hand, found that uptake of
LTPA was more likely in British men in privately owned compared with local authority
properties (P<0.05).
Discussion
A recent growth in interest surrounding inequalities in physical activity was evident
as out of 33 studies, 30 were conducted since 1995, and 23 since 2000. Despite the
wide availability of area-level socio-economic data from censuses, most researchers
favoured using individual level data. In many cases this involved analysis of existing
survey data collected up to 20 (and in one case, 40) years earlier. Possibly as a conse-
quence of this reliance on old data, the scope and quality of physical activity or SEP
measurement were often limited.
Is there strong evidence of a SEP–physical activity relationship?

Regardless of socio-economic indicator, higher levels of leisure-time or moderate–
vigorous activity (which are often equivalent) were consistently demonstrated in
those at the top versus the bottom of the socio-economic strata. Gradients of increas-
ing physical activity in sequentially higher socio-economic groups were reported less
frequently. This could be the result of crude SEP or physical activity measurement,
able only to detect extreme differences, or alternatively, because those closer to the
middle of the social strata might have similar physical activity levels. Where relation-
ships were not reported, ethnic and possibly urban–rural differences were likely con-
tributors. Most studies were delimited to measurement of LTPA (or similar outcomes),
often favoured as they are more easily recalled than less structured lower intensity
activities16,19. Indeed, work-related physical activity was reported as a separate out-
come in only one study. Self-reporting of any physical activity is fraught with prob-
lems that make accurate measurement of habitual activity virtually impossible. Some
studies that attempted to measure habitual physical activity reported relationships but
they were less consistent.

C Gidlow et al
Although longitudinal studies are intended to give a better impression of causal-

ity than simple prevalence or cross-sectional studies, failure to report socio-economic
data at follow-up in three out of five longitudinal studies54,66,70 and the absence of sta-
tistical analyses in another61, meant that this was not the case.
Within the evidence hierarchy, observational studies such as those reviewed
here are positioned near the bottom78. Guidelines on the strength of evidence from
reviews79 state that those including primarily nonrandomized trials or observational
studies rank third in the hierarchy (Category C from A to D). On this basis it would not
be possible to claim that evidence from the present review was strong. This said, evi-
dence for the presence of a socio-economic effect on physical activity was consistent,
despite the range of approaches and variable study quality, and therefore should not be
dismissed but used to improve future investigations of this relationship.
Differences between socio-economic indicators

Most studies defined SEP by occupational social class, income or education.
Occupational social class is categorical by its very nature but income and education
were also categorized with few exceptions, often with large samples stratified into
just two or three socio-economic categories. This reduced the sensitivity of measure-
ments and increased heterogeneity within groups. Presumably such restrictions were
imposed by the pre-collected survey data in most cases.
In general, associations between physical activity and education tended to be
stronger and more resistant to ethnic variation than those for income or occupational
social class, and the impact of reporting education in populations with a broad age
range was not apparent. Social classification by occupation was less commonly used
than income and education because, historically, the lack of a clearly defined class
structure in America has restricted its use in American epidemiology (which was
dominant in this review). Most classified occupation using skill-based distinctions,
similar to the much criticized British Registrar General’s schema, another possible
consequence of relying on old survey data. Despite this, all of the studies found a posi-
tive association, with some inconsistencies by gender, although only one study with
a multi-ethnic sample reported social class. Income produced the least consistent
trends, which could be the result of a number of factors: inaccurate reporting of sensi
tive income data; failure of many studies to adjust for household size; insensitivity
of broad income categories; and ethnic variation. Alternatively, income might be less
strongly related to physical activity.
Use of asset-based indicators and area-level socio-economic classification
was rare. The latter was always supported by individual level data, yet an independ-
ent area-level effect was also evident. This supports the concept that socio-physical
environment can influence health and health behaviours independent of individuals’
circumstances75 as did the apparent environmental influence reported in other fea-
tured studies51,55 and elsewhere32. Furthermore, a strong ethnic effect was evident at

the area-level, with disproportionately high concentrations of different ethnic groups

in different SEP areas.
Other factors
Several studies found that relationships between SEP and leisure-time or vigorous
intensity activity were stronger in women than men50,54,56,57,59,69, whereas one study
found the opposite65. Five all-female studies and just one all-male study66 might reflect
recent interest in gender health inequalities80–82. However, attempting to draw mean-
ingful conclusions from this pattern is complicated by diversity in study designs and
samples. Age was identified as an important factor in fewer studies and no consistent
themes emerged.
The present review was limited to studies from Western countries to minimize
the impact of cultural differences on the physical activity–SEP relationship. In addi-
tion, non-English language studies were excluded primarily for logistical reasons
and is a limitation of the present review. Dominance of studies from countries with
English as their first language was apparent, although a range of countries were
nevertheless represented. Furthermore, the literature search, although systematic,
was not exhaustive. Given the broad subject area, some studies might not have been
identified. However, a sufficient number were included to meet the objectives of this
review.
Conclusion
In summary, there was consistent evidence of a higher prevalence or higher levels of
leisure-time or moderate–vigorous intensity physical activity in those at the top of
the socio-economic strata compared with those at the bottom. However, the assump-
tion that socio-economic gradients for health are mirrored by those for physical
activity was not justified. In order to determine whether this is an accurate reflec-
tion or a result of insensitive measurement, objective physical activity measurement
and greater consistency in socio-economic measurement are required. In practice
the former is unlikely in large population-based studies, whereas collecting original
data would enable the use of more up-to-date socio-economic classification. Which
measurements are most appropriate will always vary by region or country, and ethnic-
ity and environmental variables should be considered. In Britain, differences in our
education systems and the lack of income data reduce comparability with American
studies, which dominated the present review.
There is potential for further use of area-level socio-economic measurement in
epidemiology: first, because the most up to date and sophisticated socio-economic
measurements are readily available from census data and an independent associa-
tion with physical activity should be explored; second, because they enable the study
of large samples. It is increasingly recognized that interventions to modify physical
activity behaviour of the individual are costly and difficult to implement and therefore

C Gidlow et al
community level interventions with the potential to modify the behaviour of a larger
number of people could be targeted using such area-level data.
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A Systematic Review of The Relationship Between Socio-Economic Position and Physical Activity

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A systematic review of the relationship

between socio-economic position and

Health Education Journal copyright © SAGE 2006 www.sagepublications.com

338 Health Education Journal 65(4) 2006 338–367

tionships, less susceptible to confounding effects of ethnicity and the

Key words: physical activity, socio-economic, systematic review

Health Education Journal 65(4) 2006 338–367 339

Physical activity measurement issues

340 Health Education Journal 65(4) 2006 338–367

International and cultural factors

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present review focuses on evidence from Western countries in an attempt to minimize

FIGURE 1 Search strategy

Web of Knowledge search terms

Psychinfo and Sports Discuss search terms included: socio-economic OR socioeconomic,

342 Health Education Journal 65(4) 2006 338–367

FIGURE 2 Study selection

Total results from searches

Abstracts excluded (N=31): Abstracts retrieved

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Table 1 Quality assessment criteria

2 Original data OR data from previous survey

3 Original data OR data from previous survey

4 Original data OR data from previous survey

5 Original data OR data from previous survey

6 Original data OR data from previous survey

344 Health Education Journal 65(4) 2006 338–367

TABLE 2 Frequency of socio-economic indicators and presence of relationships

Socio-economic indicator Total Positive No Negative

Note: a. Positive or negative direction: with respect to physical activity–SEP relationship,

Table 4 summarizes the main outcomes from studies in order of socio-economic

Health Education Journal 65(4) 2006 338–367 345

Housing tenure: privately owned, the

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Health Education Journal 65(4) 2006 338–367

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Health Education Journal 65(4) 2006 338–367

Women Education: < high school, at least some

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Health Education Journal 65(4) 2006 338–367

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Lazarus 199154 (L)

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MacDougall et al Australia 1765 2 LTPA No association NS

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Health Education Journal 65(4) 2006 338–367

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Socio-economic indicator: Area of residence

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Outcomes for occupational social class

354 Health Education Journal 65(4) 2006 338–367

Outcomes for income

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356 Health Education Journal 65(4) 2006 338–367

Outcomes for education

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was significantly related to physical activity in multivariate analysis42,49,53,58,62 despite

Outcomes for area of residence

358 Health Education Journal 65(4) 2006 338–367

area socio-economic effect, which is consistent with health inequalities literature75–77.

Outcomes for asset-based indicators