Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis.

BACKGROUND: Higher educational attainment predicts lower hypertension. Yet, associations between nontraditional educational trajectories (eg, interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories. METHODS: In National Longitudinal Survey of Youth 1979 cohort data (N = 6 317), we used sequence and cluster analyses to identify groups of similar educational sequences-characterized by timing and type of terminal credential-that participants followed from age 14-48 years. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status [cSES]). RESULTS: Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR: 1.32; 95%CI: 1.04, 1.66) or Associate degree after

Understanding the benefits of different types and timing of education for mental health: A sequence analysis approach.

OBJECTIVES: Individuals increasingly experience delays or interruptions in schooling; we evaluate the association between these non-traditional education trajectories and mental health. METHODS: Using year-by-year education data for 7,501 National Longitudinal Survey of Youth 1979 participants, ages 14-48 (262,535 person-years of education data), we applied sequence analysis and a clustering algorithm to identify educational trajectory groups, incorporating both type and timing to credential. Linear regression models, adjusted for early-life confounders, evaluated relationships between educational trajectories and mental health component scores (MCS) from the 12-item short form instrument at age 50. We evaluated effect modification by race, gender, and race by gender. RESULTS: We identified 24 distinct educational trajectories based on highest credential and educational timing. Compared to high school (HS) diplomas, < HS (beta=-3.41, 95%CI:-4.74,-2.07) and general educational development credentials (GEDs) predicted poorer MCS (beta=-2.07,95%CI:-3.16,-0.98). The following educational trajectories predicted better MCS: some college immediately after High School (beta=1.52, 95%CI:0.68,2.37), Associate degrees after long interruptions (beta=1.73, 95%CI:0.27,3.19), and graduate school soon after Bachelor's completion (beta=1.13, 95%CI:0.21,2.06). Compared to White men, Black women especially benefited from educational credentials higher than HS in predicting MCS. CONCLUSIONS: Both type and timing of educational credential predicted mental health. Black women's mental higher especially benefited from higher educational credentials.

Short-term effects of the earned income tax credit on mental health and health behaviors.

Poverty has consistently been linked to poor mental health and risky health behaviors, yet few studies evaluate the effectiveness of programs and policies to address these outcomes by targeting poverty itself. We test the hypothesis that the earned income tax credit (EITC)-the largest U.S. poverty alleviation program-improves short-term mental health and health behaviors in the months immediately after income receipt. We conducted parallel analyses in two large longitudinal national data sets: the National Health Interview Survey (NHIS, 1997-2016, N = 379,603) and the Panel Study of Income Dynamics (PSID, 1985-2015, N = 29,808). Outcomes included self-rated health, psychological distress, tobacco use, and alcohol consumption. We employed difference-in-differences analysis, a quasi-experimental technique. We exploited seasonal variation in disbursement of the EITC, which is distributed as a tax refund every spring: we compared outcomes among EITC-eligible individuals interviewed immediately after refund receipt (Feb-Apr) with those interviewed in other months more distant from refund receipt (May-Jan), "differencing out" seasonal trends among non-eligible individuals. For most outcomes, we were unable to rule out the null hypothesis that there was no short-term effect of the EITC. Findings were cross-validated in both data sets. The exception was an increase in smoking in PSID, although this finding was not robust to sensitivity analyses. While we found no short-term "check effect" of the EITC on mental health and health behaviors, others have found long-term effects on these outcomes. This may be because recipients anticipate EITC receipt and smooth their income accordingly.

Does the Type and Timing of Educational Attainment Influence Physical Health? A Novel Application of Sequence Analysis.

Nontraditional education trajectories are common, but their influence on physical health is understudied. We constructed year-by-year education trajectories for 7,501 National Longitudinal Survey of Youth 1979 participants aged 14 to 48 years (262,535 person-years of education data from 1979 to 2014). We characterized trajectory similarity using sequence analysis and used hierarchical clustering to group similar educational trajectories. Using linear regression, we predicted physical health summary scores of the participants at age 50 years from the 12-item Short-Form Survey, adjusting for available confounders, and evaluated effect modification by sex, race/ethnicity, and childhood socioeconomic status. We identified 24 unique educational sequence clusters on the basis of highest level of schooling and attendance timing. General education development credentials predicted poorer health than did high school diplomas (ß = -3.07, 95% confidence interval: -4.07, -2.07), and bachelor's degrees attained at earlier ages predicted better health than the same degree attained at later ages (ß = 1.66, 95% confidence interval: 0.05, 3.28). Structurally marginalized groups benefited more from some educational trajectories than did advantaged groups (e.g., Black vs. White Americans with some college; those of low vs. high childhood socioeconomic status who received an associate's or bachelor's degree). Both type and timing of educational credentials may influence physical health. Literature to date has likely underestimated the impact of educational trajectories on health.

Is it possible to overcome the 'long arm' of childhood socioeconomic disadvantage through upward socioeconomic mobility?

OBJECTIVES: Socioeconomically disadvantaged children have worse adult health; we test if this 'long arm' of childhood disadvantage can be overcome through upward socioeconomic mobility in adulthood. METHODS: Four SES trajectories (stable low, upwardly mobile, downwardly mobile and stable high) were created from median dichotomized childhood socioeconomic status (SES; childhood human and financial capital) and adult SES (wealth at age 67) from Health and Retirement Study respondents (N = 6669). Healthy ageing markers, in tertiles, were walking speed, peak expiratory flow (PEF), and grip strength measured in 2008 and 2010. Multinomial logistic regression models, weighted to be nationally representative, controlled for age, gender, race, birthplace, outcome year and childhood health and social capital. RESULTS: Upwardly mobile individuals were as likely as the stable high SES group to be in the best health tertile for walking speed (OR = 0.81; 95% CI: 0.63, 1.05; P = 0.114), PEF (OR = 0.97; 95% CI: 0.78, 1.21; P = 0.810) and grip strength (OR = 0.97; 95%CI: 0.74, 1.27; P = 0.980). DISCUSSION: Findings suggest the 'long arm' of childhood socioeconomic disadvantage can be overcome for these markers of healthy ageing through upward socioeconomic mobility.

Do the health benefits of education vary by sociodemographic subgroup? Differential returns to education and implications for health inequities.

PURPOSE: Evidence suggests education is an important life course determinant of health, but few studies examine differential returns to education by sociodemographic subgroup. METHODS: Using National Longitudinal Survey of Youth 1979 (n = 6158) cohort data, we evaluate education attained by age 25 years and physical health (PCS) and mental health component summary scores (MCS) at age 50 years. Race / ethnicity, sex, geography, immigration status, and childhood socioeconomic status (cSES) were evaluated as effect modifiers in birth year adjusted linear regression models. RESULTS: The association between education and PCS was large among high cSES respondents (ß = 0.81 per year of education, 95% CI: 0.67, 0.94), and larger among low cSES respondents (interaction ß = 0.39, 95% CI: 0.06, 0.72). The association between education and MCS was imprecisely estimated among White men (ß = 0.44; 95% CI: -0.03, 0.90), while, Black women benefited more from each year of education (interaction ß = 0.91; 95% CI: 0.19, 1.64). Similarly, compared to socially advantaged groups, low cSES Blacks, and low and high cSES women benefited more from each year of education, while immigrants benefited less from each year of education. CONCLUSIONS: If causal, increases in educational attainment may reduce some social inequities in health.

Military Service, Childhood Socio-Economic Status, and Late-Life Lung Function: Korean War Era Military Service Associated with Smaller Disparities.

BACKGROUND: Military service is associated with smoking initiation, but U.S. veterans are also eligible for special social, financial, and healthcare benefits, which are associated with smoking cessation. A key public health question is how these offsetting pathways affect health disparities; we assessed the net effects of military service on later life pulmonary function among Korean War era veterans by childhood socio-economic status (cSES). METHODS: Data came from U.S.-born male Korean War era veteran (service: 1950-1954) and non-veteran participants in the observational U.S. Health and Retirement Study who were alive in 2010 (average age = 78). Veterans (N = 203) and non-veterans (N = 195) were exactly matched using coarsened exact matching on birth year, race, coarsened height, birthplace, childhood health, and parental and childhood smoking. Results were evaluated by cSES (defined as maternal education <8 yr/unknown or ≥8 yr), in predicting lung function, as assessed by peak expiratory flow (PEF), measured in 2008 or 2010. FINDINGS: While there was little overall association between veterans and PEF [ß = 12.8 L/min; 95% confidence interval (CI): (-12.1, 37.7); p = 0.314; average non-veteran PEF = 379 L/min], low-cSES veterans had higher PEF than similar non-veterans [ß = 81.9 L/min; 95% CI: (25.2, 138.5); p = 0.005], resulting in smaller socio-economic disparities among veterans compared to non-veterans [difference in disparities: ß = -85.0 L/min; 95% CI: (-147.9, -22.2); p = 0.008]. DISCUSSION: Korean War era military service appears to disproportionately benefit low-cSES veteran lung functioning, resulting in smaller socio-economic disparities among veterans compared with non-veterans.

Trends for Reported Discrimination in Health Care in a National Sample of Older Adults with Chronic Conditions.

BACKGROUND: Discrimination in health care settings is associated with poor health outcomes and may be especially harmful to individuals with chronic conditions, who need ongoing clinical care. Although efforts to reduce discrimination are growing, little is known about national trends in discrimination in health care settings. METHODS: For Black, White, and Hispanic respondents with chronic disease in the 2008-2014 Health and Retirement Study (N = 13,897 individuals and 21,078 reports), we evaluated trends in patient-reported discrimination, defined based on frequency of receiving poorer service or treatment than other people from doctors or hospitals ("never" vs. all other). Respondents also reported the perceived reason for the discrimination. In addition, we evaluated whether wealth predicted lower prevalence of discrimination for Blacks or Whites. We used generalized estimating equation models to account for dependency of repeated measures on individuals and wave-specific weights to represent the US non-institutionalized population aged 54+ . RESULTS: The estimated prevalence of experiencing discrimination in health care among Blacks with a major chronic condition was 27% (95% CI: 23, 30) in 2008 and declined to 20% (95% CI: 17, 22) in 2014. Reports of receiving poorer service or treatment were stable for Whites (17%, 95% CI: 16, 19 in 2014). The Black-White difference in reporting any health care discrimination declined from 8.2% (95% CI: 4.5, 12.0) in 2008 to 2.5% (95% CI: -1.1, 6.0) in 2014. There was no clear trend for Hispanics. Blacks reported race and Whites reported age as the most common reason for discrimination. CONCLUSIONS: Findings suggest national declines in patient-reported discrimination in health care among Blacks with chronic conditions from 2008 to 2014, although reports of discrimination remain common for all racial/ethnic groups. Our results highlight the critical importance of monitoring trends in reports of discrimination in health care to advance equity in health care.

Validation of a theoretically motivated approach to measuring childhood socioeconomic circumstances in the Health and Retirement Study.

Childhood socioeconomic status (cSES) is a powerful predictor of adult health, but its operationalization and measurement varies across studies. Using Health and Retirement Study data (HRS, which is nationally representative of community-residing United States adults aged 50+ years), we specified theoretically-motivated cSES measures, evaluated their reliability and validity, and compared their performance to other cSES indices. HRS respondent data (N = 31,169, interviewed 1992-2010) were used to construct a cSES index reflecting childhood social capital (cSC), childhood financial capital (cFC), and childhood human capital (cHC), using retrospective reports from when the respondent was <16 years (at least 34 years prior). We assessed internal consistency reliability (Cronbach's alpha) for the scales (cSC and cFC), and construct validity, and predictive validity for all measures. Validity was assessed with hypothesized correlates of cSES (educational attainment, measured adult height, self-reported childhood health, childhood learning problems, childhood drug and alcohol problems). We then compared the performance of our validated measures with other indices used in HRS in predicting self-rated health and number of depressive symptoms, measured in 2010. Internal consistency reliability was acceptable (cSC = 0.63, cFC = 0.61). Most measures were associated with hypothesized correlates (for example, the association between educational attainment and cSC was 0.01, p < 0.0001), with the exception that measured height was not associated with cFC (p = 0.19) and childhood drug and alcohol problems (p = 0.41), and childhood learning problems (p = 0.12) were not associated with cHC. Our measures explained slightly more variability in self-rated health (adjusted R2 = 0.07 vs. <0.06) and number of depressive symptoms (adjusted R2 > 0.05 vs. < 0.04) than alternative indices. Our cSES measures use latent variable models to handle item-missingness, thereby increasing the sample size available for analysis compared to complete case approaches (N = 15,345 vs. 8,248). Adopting this type of theoretically motivated operationalization of cSES may strengthen the quality of research on the effects of cSES on health outcomes.

Are There Spillover Effects from the GI Bill? The Mental Health of Wives of Korean War Veterans.

BACKGROUND: The Korean War GI Bill provided economic benefits for veterans, thereby potentially improving their health outcomes. However potential spillover effects on veteran wives have not been evaluated. METHODS: Data from wives of veterans eligible for the Korean War GI Bill (N = 128) and wives of non-veterans (N = 224) from the Health and Retirement Study were matched on race and coarsened birth year and childhood health using coarsened exact matching. Number of depressive symptoms in 2010 (average age = 78) were assessed using a modified, validated Center for Epidemiologic Studies-Depression Scale. Regression analyses were stratified into low (mother < 8 years schooling / missing data, N = 95) or high (mother ≥ 8 years schooling, N = 257) childhood socio-economic status (cSES) groups, and were adjusted for birth year and childhood health, as well as respondent's educational attainment in a subset of analyses. RESULTS: Husband's Korean War GI Bill eligibility did not predict depressive symptoms among veteran wives in pooled analysis or cSES stratified analyses; analyses in the low cSES subgroup were underpowered (N = 95, ß = -0.50, 95% Confidence Interval: (-1.35, 0.35), p = 0.248, power = 0.28). CONCLUSIONS: We found no evidence of a relationship between husband's Korean War GI Bill eligibility and wives' mental health in these data, however there may be a true effect that our analysis was underpowered to detect.

Can social policy influence socioeconomic disparities? Korean War GI Bill eligibility and markers of depression.

PURPOSE: The Korean War GI Bill provided socioeconomic benefits to veterans; however, its association with health is unclear; we hypothesize GI Bill eligibility is associated with fewer depressive symptoms and smaller disparities. METHODS: Data from 246 Korean War GI Bill eligible veterans and 240 nonveterans from the Health and Retirement Study were matched on birth year, southern birth, race, height, and childhood health using coarsened exact matching. Number of depressive symptoms in 2010 (average age = 78 years) was assessed using a modified, validated Center for Epidemiologic Studies-Depression Scale, dichotomized to reflect elevated depressive symptoms. Regression analyses were stratified into low (at least one parent < 8 years schooling/missing data, n = 167) or high (both parents ≥ 8 years schooling, n = 319) childhood socioeconomic status (cSES) groups. RESULTS: Korean War GI Bill eligibility predicted fewer depressive symptoms among individuals from low cSES backgrounds [ß = -0.64, 95% confidence interval (CI) = (-1.18, -0.09), P = .022]. Socioeconomic disparities were smaller among veterans than nonveterans for number of depressive symptoms [ß = -0.76, 95% CI = (-1.33, -0.18), P = .010] and elevated depressive symptoms [ß = -11.7, 95% CI = (-8.2, -22.6), P = .035]. CONCLUSIONS: Korean War GI Bill eligibility predicted smaller socioeconomic disparities in depression markers.

Short- and long-term associations between widowhood and mortality in the United States: longitudinal analyses.

BACKGROUND: Past research shows that spousal death results in elevated mortality risk for the surviving spouse. However, most prior studies have inadequately controlled for socioeconomic status (SES), and it is unclear whether this 'widowhood effect' persists over time. METHODS: Health and Retirement Study participants aged 50+ years and married in 1998 (n = 12 316) were followed through 2008 for widowhood status and mortality (2912 deaths). Discrete-time survival analysis was used to compare mortality for the widowed versus the married. RESULTS: Odds of mortality during the first 3 months post-widowhood were significantly higher than in the continuously married (odds ratio (OR) for men = 1.87, 95% CI: 1.27, 2.75; OR for women = 1.47, 95% CI: 0.96, 2.24) in models adjusted for age, gender, race and baseline SES (education, household wealth and household income), behavioral risk factors and co-morbidities. Twelve months following bereavement, men experienced borderline elevated mortality (OR = 1.16, 95% CI: 1.00, 1.35), whereas women did not (OR = 1.07, 95% CI: 0.90, 1.28), though the gender difference was non-significant. CONCLUSION: The 'widowhood effect' was not fully explained by adjusting for pre-widowhood SES and particularly elevated within the first few months after widowhood. These associations did not differ by sex.

Undergoing transformation to the patient centered medical home in safety net health centers: perspectives from the front lines.

OBJECTIVES: Safety net health centers (SNHCs), which include federally qualified health centers (FQHCs) provide primary care for underserved, minority and low income patients. SNHCs across the country are in the process of adopting the patient centered medical home (PCMH) model, based on promising early implementation data from demonstration projects. However, previous demonstration projects have not focused on the safety net and we know little about PCMH transformation in SNHCs. DESIGN: This qualitative study characterizes early PCMH adoption experiences at SNHCs. SETTING AND PARTICIPANTS: We interviewed 98 staff (administrators, providers, and clinical staff) at 20 of 65 SNHCs, from five states, who were participating in the first of a five-year PCMH collaborative, the Safety Net Medical Home Initiative. MAIN MEASURES: We conducted 30-45 minute, semi-structured telephone interviews. Interview questions addressed benefits anticipated, obstacles encountered, and lessons learned in transition to PCMH. RESULTS: Anticipated benefits for participating in the PCMH included improved staff satisfaction and patient care and outcomes. Obstacles included staff resistance and lack of financial support for PCMH functions. Lessons learned included involving a range of staff, anticipating resistance, and using data as frequent feedback. CONCLUSIONS: SNHCs encounter unique challenges to PCMH implementation, including staff turnover and providing care for patients with complex needs. Staff resistance and turnover may be ameliorated through improved health care delivery strategies associated with the PCMH. Creating predictable and continuous funding streams may be more fundamental challenges to PCMH transformation.