Post on 17-Dec-2015
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
The Gift That Keeps on Giving:Racial Inequalities, Socioeconomic Status
& Health Across the Lifecourse
Cynthia G. Colen, PhD, MPHSeptember 22, 2008
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Life Expectancy At Birth, By Race & Gender
50
55
60
65
70
75
80
85
White MenWhite WomenBlack MenBlack Women
U.S. Census Bureau. 2007. Statistical Abstract of the United States: 2007.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Infant Deaths Per 1,000 Live Births in U.S.
0
2
4
6
8
10
12
14
16
18
1990 1995 2000 2002 2004
WhiteBlackNative AmAsianLatino
National Center for Health Statistics. 2007. Health, United States, 2007.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Age Adjusted All-Cause Mortality Rates Per 1,000 (18+) in U.S., 2005
0
2
4
6
8
10
12
WhiteBlackNative AmAsianLatino
Source: National Vital Statistics System (NVSS), 2005.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Source: National Vital Statistics System (NVSS), 2005.
Age Specific All-Cause Mortality Rates Per 1,000 (18-64 y.o.) in U.S., 2005
0
2
4
6
8
10
12
14
16
18-24 25-44 45-54 55-64
WhiteBlackNative AmAsianLatino
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Percent of U.S. Adults (18+) Who Rate Health As Fair/Poor, Adjusted for Age, 2004-2006
02
468
1012
141618
20
WhiteBlackNative AmAsianLatino
Source: National Health Interview Survey (NHIS), 2004-2006.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Source: National Health Interview Survey (NHIS), 2004-2006.
Percent of U.S. Adults (18+) Who Rate Health As Fair/Poor, 2004-2006
0
5
10
15
20
25
30
35
40
45
18-24 25-44 45-54 55-64 65+
WhiteBlackNative AmAsianLatino
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Source: National Vital Statistics System (NVSS), 2003-2005.
All-Cause Mortality per 100,000 Among Children in U.S.
0
10
20
30
40
50
60
70
80
90
1-4 5-9 10-14 15-17
WhiteBlackNative AmAsianLatino
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Source: National Health & Nutrition Examination Survey (NHANES IV), 2003-2006.
Percent of Women in U.S. with Hypertension
0102030405060708090
100
20-44 45-64 65-74
NH Whites
NH Blacks
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Probability of Hypertension Among U.S. Women, 1999-2002
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63
WhitesBlacks
Geronimus et al. In Press. Black-White Differences in Age Trajectories of HypertensionPrevalence Among Adult Women & Men, 1999-2002. Ethnicity and Disease.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Complicated Relationship Between Race & SES Racial disparities in health often more pronounced at
higher levels of SES
True for variety of outcomes across lifecourse (esp. in infancy & mid-life)
Why do we see this pattern? Can lifecourse perspective help us understand unexpected relationship?
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Source: National Health Interview Survey (NHIS), 2004-2006.
Percent U.S. Adults (18+) Who Rate Health As Fair/Poor
Income to Needs Ratio
NH White NH Black
Black-White Difference
(%)
< 100% Poverty
26.1 30.6 10
100-200% Poverty
18.4 21.9 10
> 200% Poverty
7.5 12.3 60
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Maternal Education
NH White NH Black
Black-White Difference
(%)
0-8 8.82 13.40 52
9-11 9.38 14.96 60
12 7.31 13.57 86
13-15 6.37 12.43 95
16+ 6.05 11.37 88
US DHHS, CDC, NCHS, Division of Vital Statistics, Natality Public Use Data 1995-2002, on CDC WONDER On-line Database.
Percent U.S. Infants Weighing < 2500g at Birth, 2002
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Two Possible Explanations
1. Middle-class African Americans more likely to be poor in childhood
OR
2. Middle-class African Americans gain fewer health benefits from lifetime gains in SES (ie. upward mobility)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Two Possible Explanations
1. Exposure to poverty in childhood negatively impacts adult health (cumulative lifecourse model)
2. Diminishing health returns to upward mobility for African Americans (interactive lifecourse model)*
*Problem: current lifecourse models tend to ignore interactions!
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Existing Lifecourse Models
Accumulation of Risk (Cumulative Class) Model
Chains of Risk (Pathways) Model
Critical Periods (Latency) Model
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Accumulation of Risk Model
SES typically captured using occupation (ie. civil servants in Great Britain)
Measured during childhood, at labor market entry, & in adulthood
Longer you are exposed to low SES, worse off your physical health is
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Chains of Risk Model
Focus is on transitions from one place in socioeconomic hierarchy to another
If individual born into poor family, most likely to adhere to certain trajectory
Least tested lifecourse model
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Critical Periods Model
Certain periods during lifecourse that impact long-term health outcomes
To date, focus has been on intrauterine environment
Restriction of resources (maternal nutrition) leads to growth retardation & ultimately poor adult health
Empirical evidence is mixed - methodological problems
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
What Existing Lifecourse Models Tell Us
2 of 3 models assume linear, cumulative association between SES & health
Upward mobility will result in better health & downward mobility will lead to worse health
Fetal origins hypothesis allows for more complexity but focus is on intrauterine environment & maternal nutrition
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Conceptual Shortcomings of Existing Lifecourse Models
Upward mobility may have restricted health returns for minorities
Largely due to structural & individual racism
Challenges linear, cumulative relationship between SES & health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Methodological Shortcomings of Existing Lifecourse Models Majority of studies rely solely on data from Western
Europe
Whether lifetime SES & health varies by race rarely assessed
Ignore how gender may influence impact of SES on health over time
Maternal and infant wellbeing not typically endpoints of interest
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
How Should Existing Lifecourse Models Be Strengthened?
Consider how…
Childhood exposures interact with socioeconomic conditions in adulthood
Dynamic processes shape health over time
Contextual factors influence probability that risk of disease or death decreases as SES increases
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
What Is (Desperately) Needed?
Create lifecourse models that reflect realities of minority women
Consider how inequalities interact across race, class, gender to influence health
Do not forget women are often key players in social networks
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SES
Structural Inequalities•Restricted Returns to Education•Labor Market Segmentation•Residential Segregation•Differential Wealth Accumulation
Psychosocial Stressors•Interpersonal Discrimination•Unique Coping Styles (ie. John Henryism)•Dual/Competing Identities
Weathering Hypothesis•Physical deterioration•Delayed fertility timing•Kin network composition
Physical Health Status
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SES
Structural Inequalities•Restricted Returns to Education•Labor Market Segmentation•Residential Segregation•Differential Wealth Accumulation
Psychosocial Stressors•Interpersonal Discrimination•Unique Coping Styles (ie. John Henryism)•Dual/Competing Identities
Weathering Hypothesis•Physical deterioration•Delayed fertility timing•Kin network composition
Maternal & Infant Health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SES
Structural Inequalities•Restricted Returns to Education•Labor Market Segmentation•Residential Segregation•Differential Wealth Accumulation
Psychosocial Stressors•Interpersonal Discrimination•Unique Coping Styles (ie. John Henryism)•Dual/Competing Identities
Weathering Hypothesis• Physical deterioration• Delayed fertility timing• Kin network composition
Maternal & Infant Health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Blacks
Whites
LifetimeSES
Health
Is This What I Am Proposing?
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Kind of…but not exactly
Relationship between SES & health over lifecourse likely to be different across racial/ethnic groups
Middle-class status provides less beneficial rewards for certain racial/ethnic groups
Upward mobility likely to be qualitatively different experience for African Americans compared to Whites. But why?
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SES
Structural Inequalities•Restricted Returns to Education•Labor Market Segmentation•Residential Segregation•Differential Wealth Accumulation
Maternal & Infant Health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Racial Residential Segregation
Blacks substantially less likely than Whites with similar sociodemographic characteristics to move from poor to nonpoor census tracts (Crowder & South 2005)
Live in communities that serve as “buffer” between poor Black areas & White areas (Pattillo-McCoy 1999)
African American women living in census tracts with highest concentration of Black residents are 2.7 times more likely to die (Jackson et al. 2000)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Me
dia
n N
et
Wo
rth
1st 2nd 3rd 4th 5th
Income Quintile
Black
White
Shapiro. 2005. The Hidden Costs of Being African American.
Net Worth by Income and Race, 1999
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Me
dia
n N
et
Wo
rth
Income Occupation Education
Definition of Middle Class
BlackWhite
Shapiro. 2005. The Hidden Costs of Being African American.
Net Worth by Middle Class Status & Race, 1999
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SESPsychosocial Stressors•Interpersonal Discrimination•Unique Coping Styles (ie. John Henryism)•Dual/Competing Identities
Maternal & Infant Health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Ren et al. 1999. Racial/Ethnic Disparities in Health: The Interplay Between Discrimination and SES. Ethnicity & Disease 9:151-165.
Percent Reporting Racial Discrimination, By Race (NSFH)
0
10
20
30
40
50
60
70
80
Whites Blacks
LT High SchoolHS GradMT High School
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Competing Identities
Upwardly mobile African American women may need to adopt dual & often competing identities (Bell & Nkomo 2001; Jones & Shorter-Gooden 2003)
To navigate cultural & social distance between families/communities of origin and achieved SES
Maintaining dual identities could lead to conflict & stress when women forced to suppress key aspects of one of these identities
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Lifetime SES
Weathering Hypothesis•Physical deterioration•Delayed fertility timing•Kin network composition
Maternal & Infant Health
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Weathering Hypothesis
The health of African American women begins to…
decline in early adulthooddeteriorates at an accelerated rate as a physical manifestation of social, economic, and
political exclusion
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Probability of Hypertension Among U.S. Women, 1999-2002
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63
WhitesBlacks
Geronimus et al. In Press. Black-White Differences in Age Trajectories of HypertensionPrevalence Among Adult Women & Men, 1999-2002. Ethnicity and Disease.
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Timing of Reproduction
Delayed Childbearing
AcceleratingAging
(Weathering)
Exponential IncreasesIn Maternal & Infant
Morbidity & Mortality
+ =
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Putting My Money Where My Mouth Is…
Enough theorizing already…
Let’s test the idea that upward mobility will have restricted MCH health returns for African Americans
We want some empirical proof!
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Research Hypotheses
Among Whites, probability of LBW will be lower among upwardly mobile women compared to chronically poor counterparts
Among Blacks, probability of LBW will not be lower for upwardly mobile women compared to chronically poor counterparts
Black-White differences in association between upward mobility & LBW will not be explained by proximate maternal behavioral risk factors
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Three Data Sources
National Longitudinal Survey of Youth 1979 (NLSY79)
National Longitudinal Survey of Youth 1979 Children’s Supplement
1970 Public Use Microdata Samples from the U.S. Decennial Census (PUMS)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Description of NLSY79
NLSY79 includes data from 12,686 young men & women who were 14-22 in 1979
Only longitudinal U.S. dataset to include multigenerational measures of SES & maternal health behaviors
Retention rates range from 96% in 1983 to 77.5% in 2002
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Inclusion Criteria
NonHispanic Black and White women who were 14-22 in 1979
Had at least one child by 2002
Lived in a household at age 14 in which income-to-needs ratio did not exceed 200% of poverty
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Chronically Poor
Upwardly Mobile
LifetimeIncome
TimeT1 T2
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Data Includes Multiple Generations
1st Generation: Adult male/female in household of NLSY respondent when they were 14 years of age• Grandparents!
2nd Generation: NLSY respondent who gave birth to at least one child before 2002• Moms!
3rd Generation: Children for whom birthweight was reliably obtained• Kiddos!
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Dependent Variable
Low birthweight
1 = < 2500 grams
0 = 2500+ grams
Obtained through maternal recall rather than self-report
No difference in proportion of missing birthweight data across racial categories (8.5% for Whites & 8.7% for Blacks)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Independent Variables
Grandparents’ SES: combined education & occupation data from NLSY79 with income data from 1970 Public Use Microdata Samples (PUMS) to predict income-to-needs ratio
Maternal SES: continuous measure of household income during the year mothers became pregnant
All household income adjusted for inflation and reported in 2002 dollars
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Analytic Strategy
Series of logistic regression models estimated separately for Blacks and Whites
Ln[Pr(y = 1|x) / 1-Pr(y = 1|x)] = β0 + β1x1 + β2x2 + ……βnxn + ε
Robust SEs adjusted for clustering at level of original NLSY79 respondent
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Median Family Income 19,247 19,712 50,399 43,952
Age of MotherTeen (² 19) 30.85 35.37 10.31 9.09
Marital StatusNever Married 36.48 73.93 3.82 29.77Presently Married 46.88 14.57 93.27 65.29Other 16.65 11.50 2.90 4.94
Spouse/Partner in HHYes 62.19 22.45 95.12 70.25
Grandmother in HHYes 23.30 46.66 6.33 18.14
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Median Family Income 19,247 19,712 50,399 43,952
Age of MotherTeen (² 19) 30.85 35.37 10.31 9.09
Marital StatusNever Married 36.48 73.93 3.82 29.77Presently Married 46.88 14.57 93.27 65.29Other 16.65 11.50 2.90 4.94
Spouse/Partner in HHYes 62.19 22.45 95.12 70.25
Grandmother in HHYes 23.30 46.66 6.33 18.14
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Median Family Income 19,247 19,712 50,399 43,952
Age of MotherTeen (² 19) 30.85 35.37 10.31 9.09
Marital StatusNever Married 36.48 73.93 3.82 29.77Presently Married 46.88 14.57 93.27 65.29Other 16.65 11.50 2.90 4.94
Spouse/Partner in HHYes 62.19 22.45 95.12 70.25
Grandmother in HHYes 23.30 46.66 6.33 18.14
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Smoke CigarettesYes 47.05 30.09 29.44 16.65
Drink AlcoholYes 34.85 25.47 41.24 22.59
Prenatal CareDuring 1st Trimester 73.83 74.44 89.05 85.43
Inadequate Weight GainYes 26.76 40.22 25.68 23.76
Low Birthweight < 2500 grams 11.82 14.62 4.62 9.99
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Smoke CigarettesYes 47.05 30.09 29.44 16.65
Drink AlcoholYes 34.85 25.47 41.24 22.59
Prenatal CareDuring 1st Trimester 73.83 74.44 89.05 85.43
Inadequate Weight GainYes 26.76 40.22 25.68 23.76
Low Birthweight < 2500 grams 11.82 14.62 4.62 9.99
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Whites Blacks Whites Blacks(N=335) (N=991) (N=239) (N=279)
Smoke CigarettesYes 47.05 30.09 29.44 16.65
Drink AlcoholYes 34.85 25.47 41.24 22.59
Prenatal CareDuring 1st Trimester 73.83 74.44 89.05 85.43
Inadequate Weight GainYes 26.76 40.22 25.68 23.76
Low Birthweight < 2500 grams 11.82 14.62 4.62 9.99
Chronically Poor Upwardly Mobile
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Significant Predictors of LBW for Whites Who Were Poor in Childhood
Variable Odds Ratio
95% Confidence
Interval
Family Income 0.52 (0.33, 0.82)
Smoked Cigarettes 2.71 (1.25, 5.87)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Significant Predictors of LBW for Blacks Who Were Poor in Childhood
Variable Odds Ratio
95% Confidence
Interval
Married vs.
Never Married
0.35 (0.18, 0.69)
Grandmother in Household
0.47 (0.26, 0.85)
Inadequate Weight Gain
3.70 (2.42, 5.67)
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Conclusions
Among Whites, intergenerational gains in SES associated with almost 50% reduction in odds of LBW
Among Blacks, upward mobility does not appear to curtail the likelihood of LBW
Muted effect of adult SES for Blacks could not be explained by maternal health behaviors
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Conclusions
For African Americans, social networks – especially those maintained through familial ties – are important health promoting mechanisms
Among Blacks, having a coresidential grandmother was associated with a 53% reduction in the odds of LBW
This is net of effects of family income!
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
Maintaining Kin Networks
Upward Mobility
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
What Does This Mean for MCH Practice?
It is obvious that “rising tide will not lift all boats” equally
Expanding focus of certain programs to include nonpoor women
Cannot just focus on proximate determinants (maternal health behaviors) - have to consider structural factors as well
Racial Inequalities, Socioeconomic Status,& Health Across the Lifecourse
What Does This Mean for MCH Practice?
Need to consider unintended consequences of programs & policies
If we ask minority women - chronically poor or upwardly mobile - to delay childbearing, will MIH outcomes be worse?
If we ask them to delay childbearing, will key members of social networks be able (healthy enough) to help with childrearing?