"Outside the Skin": The Persistence of Black-White Disparities in U.S. Early-Life Mortality.

Research on Black-White disparities in mortality emphasizes the cumulative pathways through which racism gets "under the skin" to affect health. Yet this framing is less applicable in early life, when death is primarily attributable to external causes rather than cumulative, biological processes. We use mortality data from the National Vital Statistics System Multiple Cause of Death files and population counts from the Surveillance, Epidemiology, and End Result Program to analyze 705,801 deaths among Black and White males and females, ages 15-24. We estimate age-standardized death rates and single-decrement life tables to show how all-cause and cause-specific mortality changed from 1990 to 2016 by race and sex. Despite overall declines in early-life mortality, Black-White disparities remain unchanged across several causes-especially homicide, for which mortality is nearly 20 times as high among Black as among White males. Suicide and drug-related deaths are higher among White youth during this period, yet their impact on life expectancy at birth is less than half that of homicide among Black youth. Critically, early-life disparities are driven by preventable causes of death whose impact occurs "outside the skin," reflecting racial differences in social exposures and experiences that prove harmful for both Black and White adolescents and young adults.

The Relationship Between Education and Pain Among Adults Aged 30-49 in the United States.

Pain is a major health problem among U.S. adults. Surprisingly little, however, is known about educational disparities in pain, especially among the nonelderly. In this study, we analyze disparities in pain across levels of educational attainment. Using data from the 2010 to 2017 National Health Interview Survey among adults aged 30 to 49 (N = 74,051), we estimate logistic regression models of pain prevalence using a dichotomous summary pain index and its 5 constituent pain sites (low back, joint, neck, headache/migraine, and facial/jaw). We find a significant and steep pain gradient: greater levels of educational attainment are associated with less pain, with 2 important exceptions. First, adults with a high-school equivalency diploma (GED) and those with "some college" have significantly higher pain levels than high school graduates despite having an equivalent or higher attainment, respectively. Second, the education-pain gradient is absent for Hispanic adults. After taking into account important covariates including employment, economic resources, health behaviors, physical health conditions, and psychological wellbeing, educational disparities in pain are no longer statistically significant except for the GED and "some college" categories, which still show significantly higher pain levels than high school graduates. We thus document the overall education-pain gradient in most younger U.S. adult populations, and identify groups where pain is higher than expected (certain educational categories) or lower than expected (eg, less-educated Hispanics). Understanding the causes of these anomalous findings could clarify factors shaping pain prevalence and disparities therein. PERSPECTIVE: Over 50% of U.S. adults age 30 to 49 report pain. Overall, more educated Americans report substantially less pain than the less educated. However, adults with a GED and "some college" report more pain than other groups. Understanding the causes could help illuminate the mechanisms through which social factors influence pain.

Maternal Educational Attainment and Child Health in the United States.

PURPOSE: To identify how child health status differs by mother's educational attainment for the overall US population and by race/ethnicity and to assess whether these disparities have changed from 2000 to 2017. DESIGN: Repeated cross-sectional data from the 2000-2017 National Health Interview Survey (NHIS). SETTING: United States. PARTICIPANTS: Children aged 1 to 17 years from a nationally representative sample of the noninstitutionalized US population (N = 199 427). MEASURES: Reported child health status, mother's educational attainment, child's race/ethnicity, and control variables were measured using the NHIS. ANALYSIS: Using logistic regression models, we assessed the relationship between maternal education and child health. Missing data were imputed. RESULTS: Children whose mothers had less than a high school education (odds ratio [OR] = 3.84, 95% confidence interval [CI]: 3.62-4.07), high school diploma or equivalent (OR = 2.57, 95% CI: 2.44-2.70), or some college (OR = 1.90, 95% CI: 1.80-2.00) had worse reported health status compared to children whose mothers graduated college. These associations were strongest among non-Hispanic white children, with significantly (P < .05) smaller associations observed for non-Hispanic black, Mexican origin, and other Hispanic children. The associations were smaller but persisted with inclusion of controls. From 2000 to 2017, child health disparities slightly narrowed or remained stagnant among white, non-Hispanic black, and other Hispanic children but widened for Mexican origin children (P < .05). CONCLUSION: Maternal education disparities in child health are wide and have persisted.

Race/ethnicity, maternal educational attainment, and infant mortality in the United States.

This study examines patterns of and explanations for racial/ethnic-education disparities in infant mortality in the United States. Using linked birth and death data (2007-2010), we find that while education-specific infant mortality rates are similar for Mexican Americans and Whites, infants of college-educated African American women experience 3.1 more deaths per 1,000 live births (Rate Ratio = 1.46) than infants of White women with a high school degree or less. The high mortality rates among infants born to African American women of all educational attainment levels are fully accounted for by shorter gestational lengths. Supplementary analyses of data from the National Longitudinal Study of Adolescent to Adult Health show that college-educated African American women exhibit similar socioeconomic, contextual, psychosocial, and health disadvantages as White women with a high school degree or less. Together, these results demonstrate African American-White infant mortality and socioeconomic, health, and contextual disparities within education levels, suggesting the role of life course socioeconomic disadvantage and stress processes in the poorer infant health outcomes of African Americans relative to Whites.

Family Socioeconomic Status and Early Life Mortality Risk in the United States.

OBJECTIVES: We examine the association between several dimensions of parental socioeconomic status (SES) and all-cause and cause-specific mortality among children and youth (ages 1-24) in the United States. METHODS: We use Cox proportional hazard models to estimate all-cause and cause-specific mortality risk based on data from the 1998 to 2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMFs), restricted to children and youth ages 1-17 at the time of survey followed through age 24, or the end of the follow-up period in 2015 (N = 377,252). RESULTS: Children and youth in families with lower levels of mother's education, father's education, and/or family income-to-needs ratio exhibit significantly higher all-cause mortality risk compared with children and youth living in higher SES families. For example, compared to children and youth living with mothers who earned college degrees, those living with mothers who have not graduated high school experience 40% higher risk of early life mortality over the follow-up period, due in part to higher mortality risks of unintentional injuries and homicides. Similarly, children/youth whose fathers did not graduate high school experience a 41% higher risk of dying before age 25 compared to those with fathers who completed college. CONCLUSIONS: Today's children and youth experience clear disparities in mortality risk across several dimensions of parental SES. As the U.S. continues to lag behind other high-income countries in health and mortality, more attention and resources should be devoted to improving children's health and well-being, including the family and household contexts in which American children live.

Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States.

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990-2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.

Racial/Ethnic Differences in Early-Life Mortality in the United States.

U.S. early-life (ages 1-24) deaths are tragic, far too common, and largely preventable. Yet demographers have focused scant attention on U.S. early-life mortality patterns, particularly as they vary across racial and ethnic groups. We employed the restricted-use 1999-2011 National Health Interview Survey-Linked Mortality Files and hazard models to examine racial/ethnic differences in early-life mortality. Our results reveal that these disparities are large, strongly related to differences in parental socioeconomic status, and expressed through different causes of death. Compared to non-Hispanic whites, non-Hispanic blacks experience 60 percent and Mexican Americans 32 percent higher risk of death over the follow-up period, with demographic controls. Our finding that Mexican Americans experience higher early-life mortality risk than non-Hispanic whites differs from much of the literature on adult mortality. We also show that these racial/ethnic differences attenuate with controls for family structure and especially with measures of socioeconomic status. For example, higher mortality risk among Mexican Americans than among non-Hispanic whites is no longer significant once we controlled for mother's education or family income. Our results strongly suggest that eliminating socioeconomic gaps across groups is the key to enhanced survival for children and adolescents in racial/ethnic minority groups.

Does the Hispanic health advantage extend to better management of hypertension? The role of socioeconomic status, sociobehavioral factors, and health care access.

Hispanics in the United States (and foreign-born Hispanics in particular) have relatively favorable health given their lower socioeconomic status compared to, for example, non-Hispanic whites. This phenomenon is often called the Hispanic health paradox (HHP). This study examines whether the previously documented HHP in hypertension prevalence extends to its management using clinical and self-reported measures from the 2007-2012 National Health and Nutrition Examination Surveys. Multivariate models adjusting for demographic, socioeconomic, and sociobehavioral characteristics show an advantage among foreign-born Mexicans in hypertension prevalence relative to non-Hispanic whites (adjusted OR = 0.85). However, compared to non-Hispanic whites, foreign-born Mexicans were 38% less likely to receive treatment recommendations and, when advised to undergo treatment, were 60% less likely to adhere to treatment. Adjusting for health care access and utilization dramatically reduces disparities in hypertension control between foreign-born Mexicans and non-Hispanic whites, suggesting that insufficient systematic access to and use of quality health care erodes the HHP and contributes to the deterioration of health throughout the immigrant experience. Without appropriate interventions, particularly in health care access and utilization, poorer hypertension management among foreign-born Mexicans may negatively affect the Hispanic health profile, increase risk of cardiovascular disease-related mortality, and erode the Hispanic health advantage in the future.

Racial disparities in health conditions among prisoners compared with the general population.

This paper compares black-white health disparities among state prisoners to disparities in the noninstitutionalized community to provide a more complete portrait of the nation's heath. We use data from the 2004 Survey of Inmates in State and Federal Correctional Facilities and the 2002 and 2004 National Health and Nutrition Examination Survey for incarcerated and noninstitutionalized adult (aged 18 to 65) men and women, respectively. Health disparities between black and white male prisoners based on self-reported prevalence are similar to disparities in the general population for hypertension and diabetes but significantly reduced for kidney problems and stroke. Health disparities between black and white female prisoners are similar to disparities in the general population for obesity but significantly reduced for hypertension, diabetes, heart problems, kidney problems, and stroke. Our study reveals that prisoners report far worse health profiles than non-prisoners but there is differential health selection into prison for whites and blacks, and population health estimates for adult black men in particular are underreporting the true health burden for U.S. adults. Our findings highlight the importance of incorporating prison populations in demographic and public health analyses.

Stagnating Life Expectancies and Future Prospects in an Age of Uncertainty*

OBJECTIVE: This article provides a timely assessment of U.S. life expectancy given recent stalls in the growth of length of life, the continuing drop in international rankings of life expectancy for the U.S., and during a period of growing social and economic insecurity. METHODS: Time series analysis is used on over 70 years of data from the Human Mortality Database to forecast future life expectancy to the year 2055. RESULTS: The results show limited improvements in U.S. life expectancy at birth, less than 3 years on average, for both men and women. CONCLUSIONS: Even in uncertain times, it is important to look forward in preparing for the needs of future populations. The results presented here underscore the relevance of policy and health initiatives aimed at improving the nation's health and reveal important insight into possible limits to mortality improvement over the next five decades.

Education and health among U.S. working-age adults: a detailed portrait across the full educational attainment spectrum.

This article presents detailed estimates of relative and absolute health inequalities among U.S. working-age adults by educational attainment, including six postsecondary schooling levels. We also estimate the impact of several sets of mediating variables on the education-health gradient. Data from the 1997-2009 National Health Interview Survey (N = 178,103) show remarkable health differentials. For example, high school graduates have 3.5 times the odds of reporting "worse" health than do adults with professional or doctoral degrees. The probability of fair or poor health in mid-adulthood is less than 5 percent for adults with the highest levels of education but over 20 percent for adults without a high school diploma. The probability of reporting excellent health in the mid-forties is below 25 percent among high school graduates but over 50 percent for those adults who have professional degrees. These health differences characterize all the demographic subgroups examined in this study. Our results show that economic indicators and health behaviors explain about 40 percent of the education-health relationship. In the United States, adults with the highest educational degrees enjoy a wide array of benefits, including much more favorable self-rated health, compared to their less-educated counterparts.

The Enduring Association between Education and Mortality: The Role of Widening and Narrowing Disparities.

This paper examines how educational disparities in mortality emerge, grow, decline, and disappear across causes of death in the United States and how these change contribute to the enduring association of education and mortality over time. Focusing on adults age 40-64, we first examine the extent to which disparities in all-cause mortality by education persisted from 1989-2007. We then test the "fundamental cause" prediction that mortality disparities persist, in part, by shifting to new health outcomes over time, most importantly for those causes of death that have increasing mortality rates. To test this hypothesis, we focus in depth on the period from 1999-2007, when all causes of death were coded to the same classification system. The results indicate (a) both substantial widening and narrowing of mortality disparities across causes of death, (b) almost all causes of death that had increasing mortality rates also had widening disparities by education, and (c) the total disparity by education in all-cause mortality would be about 25% smaller today were it not for newly widened or emergent disparities since 1999. These results point to the theoretical and policy importance of identifying the social forces that cause health disparities to widen over time.

Social, behavioral, and biological factors, and sex differences in mortality.

Few studies have examined whether sex differences in mortality are associated with different distributions of risk factors or result from the unique relationships between risk factors and mortality for men and women. We extend previous research by systematically testing a variety offactors, including health behaviors, social ties, socioeconomic status, and biological indicators of health. We employ the National Health and Nutritional Examination Survey III Linked Mortality File and use Cox proportional hazards models to examine sex diferences in adult mortality in the United States. Our findings document that social and behavioral characteristics are key factors related to the sex gap in mortality. Once we controlfor women's lower levels of marriage, poverty, and exercise, the sex gap in mortality widens; and once we control for women 's greater propensity to visit with friends and relatives, attend religious services, and abstain from smoking, the sex gap in mortality narrows. Biological factors-including indicators of inflammation and cardiovascular risk-also inform sex differences in mortality. Nevertheless, persistent sex differences in mortality remain: compared with women, men have 30% to 83% higher risks of death over the follow-up period, depending on the covariates included in the model. Although the prevalence of risk factors difers by sex, the impact of those risk factors on mortality is similar for men and women.

Education inequality in mortality: The age and gender specific mediating effects of cigarette smoking.

A debate within the mortality literature centers around the impact of health behaviors on the prospects of disadvantaged groups. Meanwhile, a growing body of work illustrates the social processes that shape changes in smoking levels by socioeconomic status (SES), especially educational attainment. These literatures are merged by examining the mediating effects of cigarette smoking on education gaps in U.S. adult mortality by age and gender. Findings reveal that cigarette smoking is an important mediator of the education-mortality gap for all males and for younger females. In particular, education-mortality gaps for young men narrow considerably when cigarette smoking is accounted for, while older women experienced no reduction in the education-mortality gap with controls for smoking. These results are consistent with diffusion arguments that describe SES differences in smoking adoption by age and gender and provide strong evidence that smoking is an important differentiator of mortality risks by education.

Race/ethnic and sex differentials in pulse pressure among us adults.

The prevalence of high blood pressure in the United States is a public health concern. This study uses the Third National Health and Nutrition Examination Survey (1988-1994) and linear regression to document variations in pulse pressure by race/ethnicity and sex in the United States. We find higher pulse pressures among racial and ethnic minorities than among non-Hispanic Whites and among males than females. The results indicate that the effect of race on pulse pressure decreases with the inclusion of various controls; nevertheless, African Americans maintain higher pulse pressures than non-Hispanic White Americans, even net of controls. Compared to females, males exhibit higher pulse pressures. Moreover, this sex gap progressively increases with controls for socioeconomic status and physical activity. Given the known health consequences associated with high pulse pressure, these results highlight the importance of better understanding and addressing the risk of high pulse pressure among demographic subpopulations in the United States.

Socioeconomic status, smoking, and health: a test of competing theories of cumulative advantage.

Although both low socioeconomic status and cigarette smoking increase health problems and mortality, their possible combined or interactive influence is less clear On one hand, the health of low status groups may be harmed least by unhealthy behavior such as smoking because, given the substantial health risks produced by limited resources, they have less to lose from damaging lifestyles. On the other hand, the health of low status groups may be harmed most by smoking because lifestyle choices exacerbate the health problems created by deprived material conditions. Alternatively, the harm of low status and smoking may accumulate additively rather than multiplicatively. We test these arguments with data from the 1990 U.S. National Health Interview Survey, and with measures of morbidity and mortality. For ascribed statuses such as gender, race, and ethnicity, and for the outcome measure of mortality, the results favor the additive argument, whereas for achieved status and morbidity, the results support the vulnerability hypothesis--that smoking inflicts greater harm among disadvantaged groups.

Race/ethnic and sex differentials in body mass among US adults.

Current research incompletely documents race/ethnic and sex disparities in body mass, especially at the national level. Data from the 2000 National Health Interview Survey, Sample Adult File, are used to examine overall and sex-specific disparities in body mass for non-Hispanic Whites, non-Hispanic Blacks, Native Americans, Asian Americans, Puerto Ricans, Mexican Americans, and Cuban Americans. Two complementary multivariate regression techniques, ordinary least squares and multinomial logistic, are employed to control for important confounding factors. We found significantly higher body masses for non-Hispanic Blacks, Native Americans, Puerto Ricans, and Mexican Americans, compared to non-Hispanic Whites. Among very obese individuals, these relationships were more pronounced for females. Given the known health consequences associated with overweight and obesity, and recent trends toward increasing body mass in the United States, these findings underscore the need for public health policies that target specific subpopulations, in order to close the wide disparities in body mass in the United States.

Individual and contextual risks of death among race and ethnic groups in the United States.

An emerging area of social science research focuses on individual-level and contextual-level determinants of black-white adult mortality differentials in the United States. However, no research on adult mortality differentials has distinguished multiple Hispanic subgroups and explored the role of nativity at both the individual and contextual levels for small geographic areas. Using the 1986-1997 National Health Interview Survey-National Death Index linked file, we examine the effects of individual and contextual factors on black-white and multiple Hispanic subgroups (Mexican Americans, Puerto Ricans, and "other" Hispanic) differentials in adult mortality. In addition, we use a new, innovative geographic area--the very small area--as our contextual unit of analysis. We find that excess mortality risks for all race-ethnic groups considered are associated with not only individual characteristics, but also neighborhood characteristics. In addition, percent foreign born in a neighborhood is protective of Hispanic subgroup mortality for Puerto Rican, Mexican American, and "other" Hispanic adults in the 45-64 age category. These findings indicate a need for future research to examine more throughly the pathways through which neighborhood factors affect multiple Hispanic subgroup mortality and the role of nativity as a protective factor for older adult Hispanic mortality.