racial inequalities, socioeconomic status, & health across the lifecourse the gift that keeps on...

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


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.


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.


Age Adjusted All-Cause Mortality Rates Per 1,000 (18+) in U.S., 2005

0

2

4

6

8

10

12


Source: National Vital Statistics System (NVSS), 2005.


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



Percent of U.S. Adults (18+) Who Rate Health As Fair/Poor, Adjusted for Age, 2004-2006

02

468

1012

141618

20


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+



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



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


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.


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?



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


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


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)


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!


Existing Lifecourse Models

Accumulation of Risk (Cumulative Class) Model

Chains of Risk (Pathways) Model

Critical Periods (Latency) Model


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


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


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


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


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


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


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


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


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


Lifetime SES




Maternal & Infant Health


Lifetime SES



Weathering Hypothesis• Physical deterioration• Delayed fertility timing• Kin network composition



Blacks

Whites

LifetimeSES

Health

Is This What I Am Proposing?


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?


Lifetime SES




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)


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


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


Lifetime SESPsychosocial Stressors•Interpersonal Discrimination•Unique Coping Styles (ie. John Henryism)•Dual/Competing Identities



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


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


Lifetime SES




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


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.


Timing of Reproduction

Delayed Childbearing

AcceleratingAging

(Weathering)

Exponential IncreasesIn Maternal & Infant

Morbidity & Mortality

+ =


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!


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


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)


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


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


Chronically Poor

Upwardly Mobile

LifetimeIncome

TimeT1 T2


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!


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)


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


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


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


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


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)


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)


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


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!


Maintaining Kin Networks

Upward Mobility


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


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?


Thank You!

racial inequalities, socioeconomic status, & health across the lifecourse the gift that keeps on...

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