Well Off
Inside the War on Poverty: The Impact of Food Stamps on Birth Outcomes
Douglas Almond, Hilary Hoynes & Diane Whitmore Schanzenbach
Review of Economics and Statistics, forthcoming
Abstract:
This paper evaluates health impacts of a signature initiative of the War on Poverty: the introduction of the modern Food Stamp Program (FSP). Using variation in the month FSP began operating in each U.S. county, we find that pregnancies exposed to FSP three months prior to birth yielded deliveries with increased birth weight, with largest gains at the lowest birth weights. We also find small, but statistically insignificant, improvements in neonatal infant mortality. We conclude that the sizeable increase in income from FSP improved birth outcomes for both whites and African Americans, with larger impacts for African American mothers.
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The Pervasive Role of Rank in the Health of U.S. Veterans
Alair MacLean & Ryan Edwards
Armed Forces & Society, October 2010, Pages 765-785
Abstract:
The following article tests the hypothesis that veterans have better health if they were officers when they were in the U.S. military than if they served in the enlisted ranks. It examines this hypothesis by presenting results from logistic regressions that are based on four surveys: the National Survey of Veterans, the Survey of Retired Military, the Panel Study of Income Dynamics, and the Wisconsin Longitudinal Study. In all four of these surveys, the evidence is consistent with the hypothesis that military rank is associated with health, particularly among veterans who served longer. It also suggests that the health gradient by rank is independent of similar gradients by education and income as well as health differences by race. These findings indicate that health may be influenced not just by differences in civilian society but also by those in the military.
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Mortality Differentials and Religion in the United States: Religious Affiliation and Attendance
Allison Sullivan
Journal for the Scientific Study of Religion, December 2010, Pages 740-753
Abstract:
Using data from the Health and Retirement Study, I examine the relationship between adult mortality and religious affiliation. I test whether mortality differences associated with religious affiliation can be attributed to differences in socioeconomic status (years of education and household wealth), attendance at religious services, or health behaviors, particularly cigarette and alcohol consumption. A baseline report of attendance at religious services is used to avoid confounding effects of deteriorating health. Socioeconomic status explains some but not all of the mortality difference. While Catholics, evangelical Protestants, and black Protestants benefit from favorable attendance patterns, attendance (or lack of) at services explains much of the higher mortality of those with no religious preference. Health behaviors do not mediate the relationship between mortality and religion, except among evangelical Protestants. Not only does religion matter, but studies examining the effect of "religiosity" need to consider differences by religious affiliation.
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Childhood circumstances and height among older adults in the United States
Reginald Tucker-Seeley & S.V. Subramanian
Economics & Human Biology, forthcoming
Abstract:
We investigated the association between adult height and three indicators of childhood circumstances: mother's education, childhood financial hardship, and childhood health in the United States. Cross-sectional analysis of adults aged 50 and older in the 2004 Health and Retirement Study (N = 14,079) was conducted. Gender and gender-race stratified regression models were used to model the association between adult height and childhood circumstances. The gender-stratified results showed a positive gradient association between mother's education and adult height; those reporting up to grade 8, high school graduate, and greater than high school education for their mother were 4.17 cm (p < .001), 4.92 cm (p < .001), and 5.83 cm (p < .001) taller for men and 2.57 cm (p < .001), 3.16 cm (p < .001), and 3.85 cm (p < .001) taller for women, respectively than those reporting no education for their mother. Childhood health was not statistically significantly associated with adult height, controlling for birth cohort, mother's education, and childhood financial hardship. Those who did not experience childhood financial hardship were slightly taller than those who did experience such hardship. Gender-race stratified results also showed a positive gradient association between mother's education and adult height; however, this association was only significant for white men and white women. The study reiterates the importance of childhood circumstances for adult height and for building health stock.
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Jun Yim, Seung-sik Hwang, Keun-young Yoo & Chang-yup Kim
Journal of Epidemiology and Community Health, forthcoming
Objectives: To examine differences in the survival rates of cancer patients according to socioeconomic status, focusing on the role of the degree of healthcare utilisation by the patient.
Methods: An observational follow-up study was done for 261 lung cancer, 259 liver cancer, 268 stomach cancer and 270 colon cancer patients, diagnosed during 1999-2002. Income status and healthcare utilisation were assessed with National Health Insurance (NHI) data; survival during 1999-2002 was identified by death certificate. HRs and 95% CI were derived from Cox proportional hazards regression.
Results and Conclusions: The HRs for low income status are larger for colon cancer (2.37, 95% CI 1.17 to 4.80), followed by stomach (1.67, 95% CI 1.01 to 2.78), liver (1.57, 95% CI 1.03 to 2.39) and lung cancers (1.46, 95% CI 0.99 to 2.14). In the model including the variable of healthcare utilisation, colon and stomach cancers exhibited a lower HR in the moderate healthcare utilisation groups (0.40, 95% CI 0.21 to 0.76 in colon; 0.59, 95% CI 0.37 to 0.96 in stomach), whereas for liver cancer, the high utilisation group exhibited a higher hazard (1.72, 95% CI 1.07 to 2.75). A lower income status is independently related to a shorter survival time in cancer patients, especially in less fatal cancers. Healthcare utilisation independently affects the likelihood of survival from colon and stomach cancers, implying that a moderate degree of healthcare utilisation contributes to a longer survival time.
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Do the wealthy have a health advantage? Cardiovascular disease risk factors and wealth
A. Hajat, J.S. Kaufman, K.M. Rose, A. Siddiqi & J.C. Thomas
Social Science & Medicine, December 2010, Pages 1935-1942
Abstract:
The use of wealth as a measure of socioeconomic status (SES) remains uncommon in epidemiological studies. When used, wealth is often measured crudely and at a single point in time. Our study explores the relationship between wealth and three cardiovascular disease (CVD) risk factors (smoking, obesity and hypertension) in a US population. We improve upon existing literature by using a detailed and validated measure of wealth in a longitudinal setting. We used four waves of data from the Panel Study of Income Dynamics (PSID) collected between 1999 and 2005. Inverse probability weights were employed to control for time-varying confounding and to estimate both relative (risk ratio) and absolute (risk difference) measures of effect. Wealth was defined as inflation-adjusted net worth and specified as a six category variable: one category for those with less than or equal to zero wealth and quintiles of positive wealth. After adjusting for income and other time-varying confounders, as well as baseline covariates, the risk of becoming obese was inversely related to wealth. There was a 40%-89% higher risk of becoming obese among the less wealthy relative to the wealthiest quintile and 11 to 25 excess cases (per 1000 persons) among the less wealthy groups over six years of follow up. Smoking initiation had similar but more moderate effects; risk ratios and differences both revealed a smaller magnitude of effect compared to obesity. Of the three CVD risk factors examined here, hypertension incidence had the weakest association with wealth, showing a smaller increased risk and fewer excess cases among the less wealthy groups. In conclusion, this study found a strong inverse association between wealth and obesity incidence, a moderate inverse association between wealth and smoking initiation and a weak inverse association between wealth and hypertension incidence after controlling for income and other time-varying confounders.
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Intelligence in youth and all-cause-mortality: Systematic review with meta-analysis
Catherine Calvin et al.
International Journal of Epidemiology, forthcoming
Background: A number of prospective cohort studies have examined the association between intelligence in childhood or youth and life expectancy in adulthood; however, the effect size of this association is yet to be quantified and previous reviews require updating.
Methods: The systematic review included an electronic search of EMBASE, MEDLINE and PSYCHINFO databases. This yielded 16 unrelated studies that met inclusion criteria, comprising 22 453 deaths among 1 107 022 participants. Heterogeneity was assessed, and fixed effects models were applied to the aggregate data. Publication bias was evaluated, and sensitivity analyses were conducted.
Results: A 1-standard deviation (SD) advantage in cognitive test scores was associated with a 24% (95% confidence interval 23-25) lower risk of death, during a 17- to 69-year follow-up. There was little evidence of publication bias (Egger's intercept = 0.10, P = 0.81), and the intelligence-mortality association was similar for men and women. Adjustment for childhood socio-economic status (SES) in the nine studies containing these data had almost no impact on this relationship, suggesting that this is not a confounder of the intelligence-mortality association. Controlling for adult SES in five studies and for education in six studies attenuated the intelligence-mortality hazard ratios by 34 and 54%, respectively.
Conclusions: Future investigations should address the extent to which attenuation of the intelligence-mortality link by adult SES indicators is due to mediation, over-adjustment and/or confounding. The explanation(s) for association between higher early-life intelligence and lower risk of adult mortality require further elucidation.
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Bjørn Heine Strand, Emily Murray, Jack Guralnik, Rebecca Hardy & Diana Kuh
Journal of Epidemiology and Community Health, forthcoming
Background: In this study, the authors investigate gender-specific effects of childhood socio-economic position (SEP) on adiposity and blood pressure at three time points in adulthood.
Methods: Mixed models were used to assess the association of childhood SEP with body mass index (BMI), waist circumference, systolic blood pressure (SBP) and diastolic blood pressure (DBP) at ages 36, 43 and 53 years in a British birth cohort.
Results: The adverse effect of lower childhood SEP on adiposity increased between ages 36 and 53 years in women (BMI: trend test: p=0.03) and remained stable in men, but the opposite was seen for SBP, where inequalities increased in men (p=0.01). Childhood SEP inequalities in DBP were stable with age in both men and women. Educational attainment mediated some but not all of the effects of childhood SEP on adiposity and SBP, and their rate of change; adult social class was a less important mediator.
Conclusion: Childhood SEP is important for adult adiposity and blood pressure across midlife, especially for BMI in women and for blood pressure in men. Thus, pathways to adult health differ for men and women, and public health policies aimed at reducing social inequalities need to start early in life and take account of gender.
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Scott Beach, Richard Schulz, Nicholas Castle & Jules Rosen
Gerontologist, December 2010, Pages 744-757
Purpose: To examine racial differences in (a) the prevalence of financial exploitation and psychological mistreatment since turning 60 and in the past 6 months and (b) the experience - perpetrator, frequency, and degree of upset - of psychological mistreatment in the past 6 months.
Design and methods: Random digit dial telephone recruitment and population-based survey (telephone and in-person) of 903 adults aged 60 years and older in Allegheny County (Pittsburgh), Pennsylvania (693 non-African American and 210 African American). Covariates included sex, age, education, marital status, household composition, cognitive function, instrumental activities of daily living/activities of daily living difficulties, and depression symptoms.
Results: Prevalence rates were significantly higher for African Americans than for non-African Americans for financial exploitation since turning 60 (23.0% vs. 8.4%) and in the past 6 months (12.9% vs. 2.4%) and for psychological mistreatment since turning 60 (24.4% vs. 13.2%) and in the past 6 months (16.1% vs. 7.2%). These differences remained once all covariates were controlled in logistic regression models. There were also racial differences in the experience of psychological mistreatment in the past 6 months. Risk for clinical depression was also a consistent predictor of financial exploitation and psychological mistreatment.
Implications: Although the results will need to be replicated in national surveys, the study suggests that racial differences in elder mistreatment are a potentially serious issue deserving of continued attention from researchers, health providers, and social service professionals.
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Socioeconomic variation in the impact of obesity on health-related quality of life
Jonas Minet Kinge & Stephen Morris
Social Science & Medicine, November 2010, Pages 1864-1871
Abstract:
There is evidence that obesity has a negative impact on health-related quality of life (HRQL). However, little attention has been paid to variations in this impact between population groups. This study investigates the relationship between HRQL and obesity, and whether or not this relationship varies by socioeconomic status (SES). Data were taken from four rounds of the Health Survey for England (2003-2006; n = 33,716) for persons aged 16 and above. Banded total annual household income is regressed against a comprehensive set of SES indicators using interval regression. We use the equivalised predicted values from this model, categorised into quartiles, as our measure of SES. We regress EQ-5D scores against interactions between body mass index and SES categories. Obesity is negatively correlated with HRQL. The negative impact of obesity is greater in people from lower SES groups. Overweight and obese people in lower SES groups have lower HRQL than those of normal weight in the same SES group, and have lower HRQL than those in higher SES groups of the same weight. This trend is also observed after controlling for individual and household characteristics, although the statistical significance and magnitude of effects is diminished.
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H.Y. Chen et al.
Journal of Epidemiology and Community Health, November 2010, Pages 998-1003
Background: Previous studies that found increased crash risks for young drivers of low socioeconomic status (SES) have failed to adjust for factors such as driving exposure and rural residence. This aim of this study is to examine the independent effect of SES on crash risk, adjusting for such factors, and to examine the relationship between injury severity following a crash and SES.
Methods: Information on risk factors for crash collected from 20 822 newly licenced drivers aged 17-24 years in New South Wales, Australia, as part of the DRIVE Study was prospectively linked to hospitalisation data. SES was classified as high, moderate or low based on the Australia 2001 Socio-Economic Index for Areas. Poisson regression was used to model risk of crash-related hospitalisation by SES, adjusting for confounders. Two measures of injury severity-urgency of treatment and length of hospital stay-were examined by SES.
Results: Results of multivariable analysis showed that drivers from low SES areas had increased relative risk (RR 1.8, 95% CI 1.1 to 3.1) of crash-related hospitalisation compared to drivers from high SES areas. This increased risk remained when adjusting for confounders including driving exposure and rurality (RR 1.9, 95% CI 1.1 to 3.2). No significant association was found between injury severity and SES.
Conclusion: The higher risk of crash-related hospitalisation for young drivers from low SES areas is independent of driving exposure and rural-urban differences. This finding may help improve and better target interventions for youth of low SES.
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Briana Mezuk et al.
American Journal of Epidemiology, forthcoming
Abstract:
Prevalence of depression is associated inversely with some indicators of socioeconomic position, and the stress of social disadvantage is hypothesized to mediate this relation. Relative to whites, blacks have a higher burden of most physical health conditions but, unexpectedly, a lower burden of depression. This study evaluated an etiologic model that integrates mental and physical health to account for this counterintuitive patterning. The Baltimore Epidemiologic Catchment Area Study (Maryland, 1993-2004) was used to evaluate the interaction between stress and poor health behaviors (smoking, alcohol use, poor diet, and obesity) and risk of depression 12 years later for 341 blacks and 601 whites. At baseline, blacks engaged in more poor health behaviors and had a lower prevalence of depression compared with whites (5.9% vs. 9.2%). The interaction between health behaviors and stress was nonsignificant for whites (odds ratio (OR = 1.04, 95% confidence interval: 0.98, 1.11); for blacks, the interaction term was significant and negative (β: -0.18, P < 0.014). For blacks, the association between median stress and depression was stronger for those who engaged in zero (OR = 1.34) relative to 1 (OR = 1.12) and ≥2 (OR = 0.94) poor health behaviors. Findings are consistent with the proposed model of mental and physical health disparities.
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Deeper and wider: Income and mortality in the USA over three decades
Jennifer Dowd et al.
International Journal of Epidemiology, forthcoming
Background: Literature on the socio-economic ‘gradient' in health often asserts that income is associated with better health not only for the very poor, but also across the entire income distribution. In addition, changes in the shape of the association between incomes during a period of increasing economic inequality have not been previously studied. The goal of the current study was to estimate and compare the shape of the relationship between income and mortality in the USA for the 1970s, the 1980s and the 1990s.
Methods: Using income and mortality data from the Panel Study of Income Dynamics for respondents aged 35-64 years, we used a Bayesian Cox Model with regression splines to model the risk of mortality over three 10-year follow-up periods. To identify whether income was more strongly associated with mortality at different parts of the income distribution, we treated income as a linear spline with an unknown knot location.
Results: The shape of the association between income and mortality was quite non-linear, with a much stronger association at lower levels of income. The relationship between income and mortality in the USA was also not invariant across time, with the increased risk of death associated with lower income applying to an increasing proportion of the US population over time (9th percentile of income in 1970-79, 20th percentile in 1980-89 and 32nd percentile in 1990-99).
Conclusions: Our analyses do not support the claim that income is associated with mortality throughout the income distribution, nor is the association between income and mortality the same across periods. Based on our analyses, a focus on the bottom 30% of the income distribution would seem to return the greatest benefits in reducing socio-economic inequalities in health.
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Per Gustafsson, Urban Janlert, Töres Theorell, Hugo Westerlund & Anne Hammarström
Journal of Epidemiology and Community Health, forthcoming
Background: Although several studies have reported rather consistent associations between socioeconomic status (SES) and allostatic load (AL), so far no study has examined the influence of SES over the life course on AL. The aim of the present study was to investigate the association between SES over the life course and AL in mid-adulthood, guided by the conceptual models of cumulative risk, critical period and social chain of risk.
Methods: The sample comprises a 27-year prospective cohort (n=1071) from northern Sweden. Participants (n=855, 79.8%) completed questionnaires at the ages of 16, 21, 30 and 43 years. A health examination was performed at age 43 years after an overnight fast, including physical examination and blood sampling, and participants completed 1-day salivary cortisol sampling (four samples). SES was based on parental occupation at age 16 years and participants' own occupation at ages 21, 30 and 43 years. Information on daily smoking, snuff use, high alcohol consumption and physical inactivity was reported by the participants. An AL index was constructed from tertiles of 12 biological parameters.
Results: Cumulative socioeconomic disadvantage was related to AL in both women and men. The association was largely explained by health behaviours in men, but was independent of health behaviours in women. In women, an association was observed between AL and SES in adolescence, whereas in men only current SES was related to AL, independently of current health behaviours.
Conclusions: SES over the life course influences the level of multi-systemic dysregulation in mid-adulthood, with the strongest support for the cumulative risk model.
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Do biological measures mediate the relationship between education and health: A comparative study
Noreen Goldman, Cassio Turra, Luis Rosero-Bixby, David Weir & Eileen Crimmins
Social Science & Medicine, forthcoming
Abstract:
Despite a myriad of studies examining the relationship between socioeconomic status and health outcomes, few have assessed the extent to which biological markers of chronic disease account for social disparities in health. Studies that have examined this issue have generally been based on surveys in wealthy countries that include a small set of clinical markers of cardiovascular disease. The availability of recent data from nationally representative surveys of older adults in Costa Rica and Taiwan that collected a rich set of biomarkers comparable to those in a recent US survey permits us to explore these associations across diverse populations. Similar regression models were estimated on three data sets - the Social Environment and Biomarkers of Aging Study in Taiwan, the Costa Rican Study on Longevity and Healthy Aging, and the Health and Retirement Study in the USA - in order to assess (1) the strength of the associations between educational attainment and a broad range of biomarkers; and (2) the extent to which these biomarkers account for the relationships between education and two measures of health status (self-rated health, functional limitations) in older populations. The estimates suggest non-systematic and weak associations between education and high risk biomarker values in Taiwan and Costa Rica, in contrast to generally negative and significant associations in the US, especially among women. The results also reveal negligible or modest contributions of the biomarkers to educational disparities in the health outcomes. The findings are generally consistent with previous research suggesting stronger associations between socioeconomic status and health in wealthy countries than in middle income countries and may reflect higher levels of social stratification in the US. With access to an increasing number of longitudinal biosocial surveys, researchers may be better able to distinguish true variations in the relationship between socioeconomic status and health across different settings from methodological differences.
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Long-Term Effects of Wealth on Mortality and Self-rated Health Status
Anjum Hajat, Jay Kaufman, Kathryn Rose, Arjumand Siddiqi & James Thomas
American Journal of Epidemiology, forthcoming
Abstract:
Epidemiologic studies seldom include wealth as a component of socioeconomic status. The authors investigated the relations between wealth and 2 broad outcome measures: mortality and self-rated general health status. Data from the longitudinal Panel Study of Income Dynamics, collected in a US population between 1984 and 2005, were used to fit marginal structural models and to estimate relative and absolute measures of effect. Wealth was specified as a 6-category variable: those with ≤0 wealth and quintiles of positive wealth. There were a 16%-44% higher risk and 6-18 excess cases of poor/fair health (per 1,000 persons) among the less wealthy relative to the wealthiest quintile. Less wealthy men, women, and whites had higher risk of poor/fair health relative to their wealthy counterparts. The overall wealth-mortality association revealed a 62% increased risk and 4 excess deaths (per 1,000 persons) among the least wealthy. Less wealthy women had between a 24% and a 90% higher risk of death, and the least wealthy men had 6 excess deaths compared with the wealthiest quintile. Overall, there was a strong inverse association between wealth and poor health status and between wealth and mortality.
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No time to lose: Time constraints and physical activity in the production of health
John Mullahy & Stephanie Robert
Review of Economics of the Household, December 2010, Pages 409-432
Abstract:
Although individuals are all endowed with the same time budgets-1,440 minutes per day-time use patterns differ owing to heterogeneity in preferences and in other constraints. In today's health policy arena there is considerable discussion, but little conclusive strategy, about how to improve health outcomes by increasing levels of physical activity. In this paper, we explore how individuals with different levels of human capital (educational attainment) allocate time to physically-demanding activities that we characterize as health-producing behaviors. Our hypothesis is that many individuals are confronted with significant constraints on their allocation of time to exercise, and that these constraints differ importantly by level of human capital (e.g., educational attainment). However, the prediction of how human capital influences time allocated to physical activity is ambiguous because there are both substitution and wealth effects at work: since the shadow price of non-labor time use is relatively greater for high-wage individuals, they may spend less time engaged in health-promoting activities (as has been documented for activities like sleep); yet individuals who have amassed high levels of human capital are both more able to afford health-producing behaviors and more likely to prefer greater levels of produced health. We explore a set of empirical questions suggested by this framework using data from the American Time Use Survey (ATUS), administered by the U.S. Bureau of Labor Statistics. We focus on respondents ages 25-64 using the combined 2005 and 2006 ATUS data. The ATUS data are based on daily time use diaries completed by individuals aged 15 and older, including information on a large number of detailed physical activity time uses. We compare time allocated to physical activity to time allocated to sleep, household and personal activities, care for others, work, and non-exercise leisure activities. Since the ATUS time use categories are mutually exclusive and exhaustive (i.e. "multitasking" is not accommodated) we employ econometric share equation techniques to enforce the adding-up requirement that time use is constrained to 1,440 minutes per day. Our findings largely bear out the hypothesis that different levels of human capital endowment (educational attainment) result in different manifestations of how time is used in ways that may produce different health outcomes. While more-educated individuals tend to sleep much less than less-educated individuals and to work more hours, they are more likely to allocate time to physical activity in their leisure time. Our application of economic share equation techniques allows us to extend the literature by demonstrating not only how educational status is associated with time allocated to physical activity, but also where the other minutes of the day are allocated to and from.