Demography of Aging (1994) / Chapter Skim
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8 Socioeconomic Differences in Adult Mortality and Health Status
8 Socioeconomic Differences in Adult Mortality and Health Status
Pages 279-318
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From page 279... ...
Although views may differ about the desirable or appropriate extent of inequality, few would argue that inequality is irrelevant or outside the suitable domain of government action. Second, the widely available data on socioeconomic differentials in mortality and health sometimes provide important clues regarding the etiology of particular diseases, as in the case of polio, breast and cervical cancer, and coronary heart disease.
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From page 280... ...
Indeed, some of the early efforts to do so yielded interpretations that proved to be seriously misleading (e.g., the supposed link between highly demanding intellectual activities and coronary heart disease in Ryle and Russell, 19491. And socioeconomic groups are also a rather amorphous basis for designing health interventions, for which geographic or organizational detail is often more salient.
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From page 281... ...
It is worth noting that neither relative nor absolute differences in survival can be recovered from estimates of relative risk; it is the difference between mortality rates, not their ratio, that determines the ratio of survival rates. SOCIOECONOMIC MEASURES The principal indicators of one's position in contemporary society are income, occupation, and educational attainment.
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From page 282... ...
So the use of education does not resolve all problems of reverse causation. Educational attainment has also become the measure of choice among demographers and statisticians who study socioeconomic differences in mortality (e.g., Kitagawa and Hauser, 1973~.
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From page 283... ...
This observation is consistent with much observed human experience; in comparing the typical age pattern of mortality of a high-mortality population to that of a low-mortality population, proportionate differences narrow above age 40 or so as age advances (Coale and Demeny, 1982~. Table 8-1 shows that much of the widening of educational differentials for white males aged 65-84 is attributable to a massive change in the educational distribution of heart disease mortality.
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From page 284... ...
9 1 2 yrs. l l l l 1 1 1960 1971~84 1960 1971~84 1960 1971 84 Age 55-64 years Age 65-74 years Age 75-84 years FIGURE 8-1 Estimated annual death rates by age at death, sex, and educational attainment among white persons aged 55-84 years, United States, 1960 and 19711984.
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From page 285... ...
This study thus provides a firm basis for inferring the magnitude of socioeconomic differences in mortality. Table 8-2 presents educational differences in mortality from this study in the form of ratios of actual to expected deaths, where expected deaths are developed by applying the average probability of dying in a particular sex, race, and 5-year age group to each individual's years of exposure.
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From page 286... ...
286 DEMOGRAPHY OF AGING TABLE 8-2 Ratio, Actual to Expected Deaths by Age and Education in the National Longitudinal Mortality Study Education White White Black Black (years) Males Females Males Females Age 25-64 0-4 119 143 115 113 5-7 134 127 113 119 8 121 120 105 105 9-11 124 109 113 116 12 98 94 89 90 13-15 92 94 86 72 16 70 78 60 47 17+ 58 83 51 63 Total 100 100 100 100 Age 65+ 0-4 106 110 98 97 5-7 106 103 101 110 8 108 104 123 108 9- 11 105 99 97 104 12 94 100 102 83 13-15 94 91 ~ 16 85 88 ~ 68 ~ 75 17+ 75 76 J J Total 100 100 100 100 Age 85+ 0-4 107 110 102 93 5-7 93 101 ~115 8 103 101 9-11 107 95 1 1 12 100 96 ~ 98 ~97 13-15 105 95 ~ 16 93 ~J 1 17+ 82 J 105 ~ Total 100 100 100 100 NOTE: Categories with 40 or fewer expected deaths have been combined with adjacent categories.
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From page 287... ...
has provided a masterful review of socioeconomic differences in mortality in Europe. He assembles data from different countries on educational differentials in mortality for men and women age 35-54 during 1976-1980.
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From page 288... ...
As in Europe, the educational differentials in the prime working ages are much sharper for males than for females (see Valkonen, 1989, for a more rigorous confirmation)
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From page 289... ...
A widening of socioeconomic differences in England and Wales (measured principally by occupation rather than by income) has evoked a storm of controversy, in part because the National Health Service instituted after World War II was expected by some to mute class differences in
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From page 290... ...
For a particular cause of death category, it sets observed equal to expected deaths for all education groups and shows the impact of such equalization on differentials from all causes combined. Lung cancer deaths clearly contribute a minor amount to overall differentials; that is, setting observed equal to expected deaths from lung cancer for each group would lead to relatively little contraction in educational differentials from all causes combined.
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From page 291... ...
If educational differentials in heart disease mortality were eliminated, the excess mortality of those with 0-8 years of schooling, relative to those with some college, would be reduced by 41 percent for males aged 25-64, 57 percent for males aged 65+, 66 percent for females aged 25-64, and 67 percent for females aged 65+. For three of the four groups, the majority of educational differences in mortality are attributable to differentials in heart disease.
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From page 292... ...
Table 8-5 identifies some of the major chronic conditions for which differences in prevalence among education groups are largest. As with mortality differentials, morbidity differentials contract as age advances be yond 55 or Ob.
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From page 293... ...
SOURCES OF SOCIOECONOMIC DIFFERENTIALS IN MORTALITY AND HEALTH STATUS In order to infer whether and how a policy to reduce socioeconomic differences should be pursued, it is obviously important to understand their sources. The factors contributing to the differences just described have
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From page 294... ...
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From page 295... ...
It is useful to take a step back and consider several theoretical approaches or frameworks that can shed light on the causal processes involved. In this section we review the two major frameworks that have been used to investigate the processes that create differences in mortality and health status by social class and describe some of the evidence that has been developed with the aid of those frameworks.
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From page 296... ...
They are also more able to afford to live in less polluted areas with better public services. There have been scores of studies relating personal or family income to health status (see Sickles and Taubman, 1992, for a brief review)
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From page 297... ...
We have already reviewed evidence that socioeconomic differences widened rather than narrowed during this period. Such a widening occurs above age 65 for males even if NLMS data are used because the earlier study by Kitagawa and Hauser showed negligible educational differentials in mortality for this group in 1960 (Kitagawa and Hauser, 19731.
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From page 298... ...
According to this approach, medical technique interacts not only with aggregate features that affect access, but also with many household characteristics, to influence the pattern of social class differences in health status.
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From page 299... ...
The role of genetic variation in social class mortality differentials has been emphasized by Illsley (e.g., 1955) , but there has been no convincing demonstration of the role of genetic factors in fashioning class differentials in mortality.
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From page 300... ...
Identical twins have a smaller variance in age of death than other twins, and differential smoking behavior between twins strongly affects the risk of death over a given time interval (Behrman et al., 1980; Kaprio and Koskenvero, 1990~. These research traditions have developed independently of one another, and their implications for understanding social class differences in mortality are unclear.
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From page 301... ...
Are systematic variations in tastes a likely source of socioeconomic differences in mortality? The concept is psychologically so vacuous that it is hard to see how it could prove helpful.
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From page 302... ...
Social relations are also typically treated as exogenous to the individual, although once again it is clear that people are not passive participants in the formation and maintenance of social ties. There is abundant evidence from hundreds and even thousands of studies that personality traits, exposure to stressors, and social relations are powerful influences on the risk of contracting and dying from chronic diseases, especially heart disease.
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From page 303... ...
For example, a massive volume on Social Support and Health contains not a single reference to education, income, social class, or occupation in its 10-page subject index (Cohen and Syme, 19851. Williams (1990)
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From page 304... ...
(1992) about the dominant impact of TABLE 8-7 Socioeconomic Differences in the Prevalence of Cigarette Smoking: United States, 1987 Males (%)
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From page 305... ...
With these controls, the only significant negative relationship between education and blood pressure occurs for white male's systolic pressure. A new biomedical factor that has begun to receive attention as a potentially important mediating variable in the relation between class and coronary heart disease is plasma fibrinogen, a blood protein related to clotting.
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From page 306... ...
In a logistic regression predicting the risk of death from coronary heart disease, introducing information on smoking status, systolic blood pressure, serum cholesterol levels, blood glucose, and height reduced the risk associIntroducing physical activity levels ated with grade by less than 25 percent. and disability at baseline also had little effect on occupational coefficients.
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From page 307... ...
reports on ischemic heart disease (IHD) mortality in an 18-year follow-up study of 6,928 adults in Alameda County, California.
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From page 308... ...
Access to, and quality of, medical care may be another such factor; surprisingly little research attempts to understand the contribution to class differences of variation in medical care. But the experimental studies described above, the widening of class differences in Britain after the National Health Service was introduced, and the widening of education differences above age 65 in the United States after Medicare was introduced all suggest that medical care does not hold the key to socioeconomic differences.
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From page 309... ...
If white age and cause-specific death rates were substituted for the equivalent black rates, the largest reduction in black mortality would be produced by changes in heart disease for females and homicide for males (Manton et al., 19871.
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From page 310... ...
An initial black-white mortality ratio of 2.3 with no controls is reduced to 1.4 after controls are instituted for six risk factors (e.g., blood pressure, smoking) and family income.
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From page 311... ...
Initially large black-white differences in all-cause and coronary heart disease mortality were reduced to insignificance when socioeconomic status was controlled. In a subsequent analysis of these data, Keil et al.
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From page 312... ...
In most countries where evidence is available, social disparities in mortality have widened during the past two decades, although inconsistencies among data sources in the United States make this conclusion uncertain. Heart disease is the principal cause of death responsible for social class differences in mortality from all causes combined.
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From page 313... ...
Efforts to ascribe class differences in mortality or health status to various intervening biomedical variables such as smoking or elevated blood pressure have not been entirely successful. Although some reduction in class differences typically results from controlling these variables, the bulk of the differences remains.
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From page 314... ...
Diamond 1983 Socioeconomic and racial differences in lung cancer incidence. American Journal of Epidemiology 118(6)
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From page 315... ...
Koskenvero 1990 Cigarette smoking as a cause of lung cancer and coronary heart disease: A study of smoking discordant twin pairs. Acta Geneticae Medicae et Gemellologiae 39:25-70.
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From page 316... ...
Theorell 1988 Social class and cardiovascular disease: The contribution of work. International Journal of Health Services 18(4)
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From page 317... ...
Novick 1991 Independent associations of educational attainment and ethnicity with behavioral risk factors for cardiovascular disease. American Journal of Epidemiology 134(6)
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From page 318... ...
Fortmann 1992 Socioeconomic status and health: How education, income and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health 82(6)
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