1. 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, MPH September 22, 2008

2. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Life Expectancy At Birth, By Race & Gender U.S. Census Bureau. 2007. Statistical Abstract of the United States: 2007.

3. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Infant Deaths Per 1,000 Live Births in U.S. National Center for Health Statistics. 2007. Health, United States, 2007.

4. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Age Adjusted All-Cause Mortality Rates Per 1,000 (18+) in U.S., 2005 Source: National Vital Statistics System (NVSS), 2005.

5. 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

6. 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 Source: National Health Interview Survey (NHIS), 2004-2006.

7. 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

8. 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.

9. 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

10. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Probability of Hypertension Among U.S. Women, 1999-2002 Geronimus et al. In Press. Black-White Differences in Age Trajectories of Hypertension Prevalence Among Adult Women & Men, 1999-2002. Ethnicity and Disease.

11. 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?

12. 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 WhiteNH Black Black-White Difference (%) < 100% Poverty 26.130.610 100-200% Poverty 18.421.910 > 200% Poverty 7.512.360

13. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Maternal Education NH WhiteNH Black Black-White Difference (%) 0-88.8213.4052 9-119.3814.9660 127.3113.5786 13-156.3712.4395 16+6.0511.3788 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

14. 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)

15. 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!

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Blacks Whites Lifetime SES Health Is This What I Am Proposing?

29. 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?

30. 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

31. 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)

32. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Shapiro. 2005. The Hidden Costs of Being African American. Net Worth by Income and Race, 1999

33. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Shapiro. 2005. The Hidden Costs of Being African American. Net Worth by Middle Class Status & Race, 1999

34. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Lifetime SES Psychosocial Stressors Interpersonal Discrimination Unique Coping Styles (ie. John Henryism) Dual/Competing Identities Maternal & Infant Health

35. 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)

36. 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

37. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Lifetime SES Weathering Hypothesis Physical deterioration Delayed fertility timing Kin network composition Maternal & Infant Health

38. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Weathering Hypothesis The health of African American women begins to…  decline in early adulthood  deteriorates at an accelerated rate  as a physical manifestation of social, economic, and political exclusion

39. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Probability of Hypertension Among U.S. Women, 1999-2002 Geronimus et al. In Press. Black-White Differences in Age Trajectories of Hypertension Prevalence Among Adult Women & Men, 1999-2002. Ethnicity and Disease.

40. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Timing of Reproduction Delayed Childbearing Accelerating Aging (Weathering) Exponential Increases In Maternal & Infant Morbidity & Mortality +=

41. 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!

42. 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

43. 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)

44. 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

45. 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

46. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Chronically Poor Upwardly Mobile Lifetime Income Time T1T2

47. 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!

48. 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)

49. 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

50. 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

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57. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Significant Predictors of LBW for Whites Who Were Poor in Childhood VariableOdds Ratio 95% Confidence Interval Family Income0.52(0.33, 0.82) Smoked Cigarettes2.71(1.25, 5.87)

58. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Significant Predictors of LBW for Blacks Who Were Poor in Childhood VariableOdds 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)

59. 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

60. 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!

61. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Maintaining Kin Networks Upward Mobility

62. 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

63. 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?

64. Racial Inequalities, Socioeconomic Status, & Health Across the Lifecourse Thank You!