Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004) / Chapter Skim
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9 Race/Ethnicity, Socioeconomic Status, and Health
9 Race/Ethnicity, Socioeconomic Status, and Health
Pages 310-352
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From page 310... ...
The potential power of the socioeconomic status (SES) paradigm in understanding health disparities -- including racial/ethnic disparities -- is evident in the fact that socioeconomic differences in health outcomes have been widely documented for most health conditions in most countries.
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From page 311... ...
Many studies have documented the importance of blacks' low SES as a partial explanation for poor health outcomes relative to whites. Studies have also clarified that socioeconomic differences often do not "explain" all health differences between African Americans and non-Hispanic whites, with black-white differences in health remaining after controlling for socioeconomic conditions (Hayward et al., 2000)
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From page 312... ...
Based on these surveys, we then investigate the socioeconomic and health differences among racial/ethnic groups. Our purpose for the empirical analysis is to assess the consistency of key empirical associations among race/ethnicity, the various measures of SES, and multiple dimensions of health (major chronic diseases, physical and cognitive impairment, and mortality)
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From page 313... ...
. Wealth accumulation may represent total material capital available at the moment, but this may be highly affected by life circumstances, including health.
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From page 314... ...
If people stop working at a young age because of disability, they are more likely to have reduced pension funds for the rest of their lives. Because education is not affected by health events after young adulthood, many researchers prefer the use of education as an index of lifetime SES for the adult population.
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From page 315... ...
The development of chronic diseases and conditions -- while generally not clinically recognized until at least middle age -- is affected by lifelong circumstances that are related to both socioeconomic status and race/ethnicity. Many of these mechanisms have been mentioned already, but additional factors affect the likelihood that people of different ethnic groups and social status groups will not only get diseases, but also whether diseases will result in functioning loss, disability, or death.
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From page 316... ...
For example, black men have higher death rates from heart disease than white men, but they do not differ in the prevalence of reported heart disease (Hayward et al., 2000)
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From page 317... ...
SOCIOECONOMIC STATUS, AGE, AND HEALTH As we noted earlier, the importance of socioeconomic status in explaining health differences and even the direction of causation may differ by age if one includes indicators of material well-being. While socioeconomic resources affect health throughout the lifecycle, many scholars report that SES differentials in health are reduced at older ages (House et al., 1994; Marmot and Shipley, 1996)
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From page 318... ...
Some of the effect of earlier aging of lower status persons is not captured in this examination of diseases among people in their 50s because a TABLE 9-1 Age at Which Persons of Different Educational Levels Experience Equivalent Prevalence and Incidence of Specified Diseases: Based on Logistic Models of Prevalence and Hazard Models of Incidence from the Health and Retirement Survey* Years of Education 8 12 16 Prevalence Heart problems 51 54 ~57 Heart attack 51 58 ~64 Hypertension 51 55 ~58 Stroke 51 56 ~61 Diabetes 51 57 ~64 Chronic lung disease 51 60 ~70 Incidence Heart problems 52 56 ~60 Heart attack 52 59 ~65 Stroke 52 58 ~64 Death 52 57 ~61 *
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From page 319... ...
Understanding health disparities at the older ages thus requires an understanding of the role of the disease process in selective survival, the prevalence of the disease in a baseline population, and the subsequent morbidity and mortality experiences into advanced ages. Healthy life expectancy approaches capture the effect of both mortality and morbidity differentials among population groups in a summary indicator.
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From page 320... ...
HOW DOES SOCIOECONOMIC STATUS VARY BY RACE/ETHNIC GROUPS IN MAJOR HEALTH SURVEYS? In this section we address an empirical question: How does socioeconomic status as indicated by educational attainment, family income, and wealth vary across race and ethnicity?
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From page 321... ...
This number includes 933 African Americans, approximately 450 U.S.-born Hispanics, and 300 foreign-born Hispanics. The NHIS is a nationally representative survey of the population of all ages, which allows examination of not only the major racial/ethnic groups already listed, but also provides limited information for residents of Asian and Pacific Island origin and Native Americans.
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From page 322... ...
For comparison we also show education of the foreign born of Mexican origin in the NHIS; this group has an educational level similar to foreign-born Hispanics in AHEAD and NHANES. This comparison makes it clear that the Hispanic population captured in these surveys varies across surveys; it also indicates the importance of considering both nativity and country of origin when analyzing the Hispanic population.
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From page 323... ...
323 Years of Education 10 12 14 16 0 2 4 6 8 White 1993 70+ Black AHEAD U.S.-born Hispanic surveys. Foreign-born Hispanic health White Black selected 1988-1994 65+ U.S.-born Hispanic from Foreign-born NHANES range Hispanic White Black interquartile with U.S.-born Hispanic 1994 Foreign-born Hispanic 65+ U.S.-born Asian NHIS race/ethnicity by Foreign-born Asian Native American education Foreign-born of Mexican years White 1992 Black Median 51-61 9-2 U.S.-born Hispanic HRS Foreign-born Hispanic FIGURE
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From page 324... ...
Census, 2000 Racial/Ethnic Group Median Education Level Non-Hispanic whites 12.0 Blacks 10.3 Hispanics 9.3 Native born 10.2 Foreign born 7.3 Asians 12.0 Native born 12.0 Foreign born 12.0 SOURCE: Calculated from U.S. Bureau of the Census (2000)
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From page 325... ...
Hispanic White health Black selected 65+1988-1994 U.S.-born Hispanic from NHANES Foreign-born Hispanic range White Black interquartile U.S.-born Hispanic with Foreign-born 1994 Hispanic 65+ U.S-born Asian NHIS race/ethnicity Foreign-born Asian by Native American income Foreign-born Mexican family White 1992 Black Median 51-61 9-3 U.S.-born Hispanic HRS Foreign-born Hispanic FIGURE
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From page 326... ...
The characteristics of Hispanic groups differ markedly across these surveys even though they are usually treated as nationally representative in most analyses of health differences. Asians included in these health surveys, while relatively small in number, indicate high levels of all measures of SES, with wealth being the indicator in which they are relatively highest.
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From page 327... ...
Hispanic health White selected Black from U.S.-born Hispanic range Foreign-born Hispanic 1994 65+ U.S.-born Asian interquartile NHIS with Native American Foreign-born Asian race/ethnicity by White assets 1993 Black 51-61 Median U.S.-born Hispanic HRS 9-4 Foreign-born Hispanic FIGURE
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From page 328... ...
The average educational level of parents in the HRS sample is just above 5 years for Hispanics' mothers and fathers and about 10 years for parents of non-Hispanic whites; again the parents of blacks were in the middle. Educational levels are related within and across the generations in each racial/ethnic group.
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From page 329... ...
Table 9-4 indicates the risk of having heart disease, heart attack, stroke, diabetes, cancer, hypertension, arthritis, and chronic lung disease by the time of the interview -- a prevalence measure -- for blacks and native- and
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From page 332... ...
332 $30,000 0.83 1.08 0.95 1.09 0.88 1.04 $10,000- $19,999 0.54* 1.03 1.10 1.09 1.04 1.07 $20,000-$29,999 to Relative <$10,000 0.69*
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From page 334... ...
Also, blacks over 70 have more arthritis. On the other hand, blacks are less likely than whites to report a number of other conditions (heart disease, cancer, and chronic lung disease)
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From page 335... ...
The odds ratios indicating the risk of physical functioning problems for blacks relative to whites are quite substantial -- from 1.6 to 2.4 for the older population and 2.5 for those near retirement age, and blacks are 6 times as likely as nonHispanic whites to have cognitive impairment, but this is reduced to 3.7 with controls for education and income. U.S.-born Hispanics report more functioning problems and disability than non-Hispanic whites in two of the surveys; foreign-born Hispanics report significantly more functioning problems in three surveys.
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From page 336... ...
equation Risk or in gender level Relative Blacks 1.58*
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From page 337... ...
There is less likely to be any relationship with income in this analysis when the income precedes the onset of the disease: Higher income is linked to less heart disease and chronic lung disease. Higher onset rates for blacks are found for the same conditions observed to be higher in prevalence: stroke, diabetes, and hypertension.
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From page 339... ...
339 0.70 0.93 0.98 1.16 0.67 0.75 1.04 (continued)
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From page 340... ...
equation or in gender Relative Blacks 0.56 0.51 0.47*
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From page 341... ...
Stroke and death are more likely among those with low education; chronic lung disease onset is more frequent with low income. Among those aged 70 and over, onset of functioning problems -- both physical and cognitive -- is more likely among those with lower education, but neither is related to income (Table 9-7)
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From page 342... ...
.98 .49 Non-Hispanic controlled; to below. equation Risk or in problem gender Relative Blacks 1.62*
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From page 343... ...
1.04 0.80 Hispanic N=772 1.39 1.31 1.03 2.41 1.77 1.18 1.16 Heart attack NHANES 65+ White N=2,242 1.23 1.10 1.25 1.12 1.12 0.81 Black N=657 0.83 0.76 1.14 1.56 1.84 0.70 Hispanic N=520 0.55 0.50 0.99 1.00 1.24 0.88 0.99 AHEAD 70+ White N=5,890 1.29 1.22 0.73 1.40* 1.10 1.08 Black N=1,021 2.94 2.45 1.30 0.55 0.81 0.55 Hispanic N=406 3.21 3.99 1.82 5.99 3.54 5.58 0.89 HRS 51-61 White N=5,936 1.70*
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From page 345... ...
0.90 0.93 Hispanic N=772 0.91 0.86 0.69 1.57 1.64 1.07 1.04 Lung disease AHEAD 70+ White N=5,898 1.41*
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From page 346... ...
Lower income is also linked to a significantly higher disease prevalence among blacks in the HRS sample for a number of diseases: hypertension, heart disease, and arthritis. In the models of functioning and disability, low SES is a strong predictor of all problems for whites.
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From page 347... ...
Cognitive impairment is significantly higher among both groups and appears highly affected by educational differences. Some of the observed differences in prevalence, such as higher levels of functioning loss and disability as well as lower levels of heart disease and cancer reported by blacks, may be related to differential likelihood of survival.
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From page 348... ...
Much thought needs to be given to how to better incorporate our theoretical ideas of the source of SES health differences into ongoing research. We need to be able to incorporate reasonable measurement of variables that represent the broad range of social, psychological, and financial mechanisms believed to mediate SES effects on health.
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From page 349... ...
4. Existing National Data Should Be Enhanced with Larger Samples of Some Ethnic Groups, More Information on Health Status That Is Not Influenced by Medical Contact or Cultural Differences, and More Information on Potential Mechanisms by Which Socioeconomic and Racial/Ethnic Differences Arise Understanding the Asian-American health advantage is as important as understanding the disadvantage of other groups.
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From page 350... ...
. The life course and adult chronic disease: An historical perspective with particular reference to coronary heart disease.
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From page 351... ...
. Socioeconomic differences in adult mortality and health status.
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From page 352... ...
. Ethnic and socioeco nomic differences in cardiovascular disease risk factors: Findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994.
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