Trends in education gradients of 'preventable' mortality: a test of fundamental cause theory

Disparities in High School Graduation by Identity and Disability Using Intermediate and Long-Term Educational Outcomes

Multiple factors influence a student's success in high school graduation. Individual factors such as disability, racial or ethnic identity, and gender may result in inequity in the school environment, interfering with learning and possibly leading to poorer educational outcomes. This secondary analysis of student educational records (N = 3,782) from 2008-2018 tested the associations among the disability, racial or ethnic identity, gender, and 5th grade attendance on high school attendance and graduation. Linear and logistic regression analysis identified students without a disability had a 40% greater chance of graduation (AOR = 1.4 [95% CI = 1.15, 1.71]) than those with a disability. Students identifying as Black, Hispanic, or Native American had half the odds of graduating compared to White students. When controlling for 9th grade attendance, these disparities decreased. Attendance in 5th grade, disability, and racial and ethnic identity influenced attendance, being on track to graduate, and high school graduation.

Socioeconomic and Racial/Ethnic Inequalities in Infertility Prevalence, Help-Seeking, and Help Received Since 1995

BACKGROUND

In the United States, infertility and treatment for infertility are marked by racial/ethnic and socioeconomic inequalities. Simultaneously, biomedical advances and increased public health attention toward preventing and addressing infertility have grown. It is not known, however, whether the racial/ethnic and socioeconomic inequalities observed in infertility prevalence, help-seeking, or help received have changed over time.

METHODS

Using National Survey of Family Growth data (1995 through 2017-2019 cycles), this study applied multivariable logistic regression with interaction terms to investigate whether and how racial/ethnic and socioeconomic inequalities in 1) the prevalence of infertility, 2) ever seeking help to become pregnant, and 3) use of common types of medical help (advice, testing, medication for ovulation, surgery for blocked tubes, and artificial insemination) have changed over time.

RESULTS

The results showed persisting, rather than narrowing or increasing, inequalities in the prevalence of infertility and help-seeking overall. The results showed persisting racial/ethnic inequalities in testing, ovulation medication use, and surgery for blocked tubes. By contrast, the results showed widening socioeconomic inequalities in testing and narrowing inequalities in the use of ovulation medications.

CONCLUSIONS

There is little evidence to suggest policy interventions, biomedical advances, or increased public health awareness has narrowed inequalities in infertility prevalence, treatment seeking, or use of specific treatments.

Immigration, Educational Attainment, and Subjective Health in the United States

Objectives

Although educational attainment is a major social determinant of health, according to Marginalization-related Diminished Returns (MDRs), the effect of education tends to be weaker for marginalized groups compared to the privileged groups. While we know more about marginalization due to race and ethnicity, limited information is available on MDRs of educational attainment among US immigrant individuals.

Aims

This study compared immigrant and non-immigrant US adults aged 18 and over for the effects of educational attainment on subjective health (self-rated health; SRH).

Methods

Data came from General Social Survey (GSS) that recruited a nationally representative sample of US adults from 1972 to 2022. Overall, GSS has enrolled 45,043 individuals who were either immigrant (4,247; 9.4%) and non-immigrant (40,796; 90.6%). The independent variable was educational attainment, the dependent variable was SRH (measured with a single item), confounders were age, gender, race, employment and marital status, and moderator was immigration (nativity) status.

Results

Higher educational attainment was associated with higher odds of good SRH (odds ratio OR = 2.08 for 12 years of education, OR = 2.81 for 13-15 years of education, OR = 4.38 for college graduation, and OR = 4.83 for graduate studies). However, we found significant statistical interaction between immigration status and college graduation on SRH, which was indicative of smaller association between college graduation and SRH for immigrant than non-immigrant US adults.

Conclusions

In line with MDRs, the association between educational attainment and SRH was weaker for immigrant than non-immigrant. It is essential to implement two sets of policies to achieve health inequalities among immigrant populations: policies that increase educational attainment of immigrants and those that increase the health returns of educational attainment for immigrants.

Using repeated measures to study the contribution of alcohol consumption and smoking to the social gradient in all-cause mortality: Results from the Stockholm Public Health Cohort

INTRODUCTION

The social gradient in consumption behaviours has been suggested to partly explain health inequalities. The majority of previous studies have only included baseline measurements and not considered potential changes in behaviours over time. The study aimed to investigate the contribution of alcohol consumption and smoking to the social gradient in mortality and to assess whether the use of repeated measurements results in larger attenuations of the main association compared to using single baseline assessments.

METHODS

Longitudinal survey data from the population-based Stockholm Public Health Cohort from 2006 to 2014 was linked to register data on mortality until 2018 for 13,688 individuals and analysed through Cox regression.

RESULTS

Low socioeconomic position (SEP) was associated with increased mortality compared with high SEP; hazard ratios 1.56 (95% CI 1.30-1.88) for occupational status and 1.77 (95% CI 1.49-2.11) for education, after adjustment for demographic characteristics. Using repeated measurements, alcohol consumption and smoking explained 44% of the association between occupational status and all-cause mortality. Comparing repeated and baseline measures, the percentage attenuation due to alcohol consumption increased from 11% to 18%, whereas it remained similar for smoking (25-23%).

DISCUSSION AND CONCLUSIONS

Smoking and alcohol consumption explained a large part of the association between SEP and mortality. Comparing results from time-fixed and time-varying models, there was an increase in overall percentage attenuation that was mainly due to the increased proportion explained by alcohol consumption. Repeated measurements provide a better estimation of the contribution of alcohol consumption, but not smoking, for the association between SEP and mortality.

One versus two biological parents with mental disorders: Relationship to educational attainment in the next generation

BACKGROUND

Both maternal and, separately, paternal mental illness are associated with diminished academic attainment among children. However, the differential impacts of diagnostic type and degree of parental burden (e.g. one v. both parents affected) on these functional outcomes are unknown.

METHODS

Using the Swedish national patient (NPR) and multi-generation (MGR) registers, 2 226 451 children (1 290 157 parental pairs), born 1 January 1973-31 December 1997, were followed through 31 December 2013. Diagnostic status of all cohort members was defined for eleven psychiatric disorders, and families classed by exposure: (1) parents affected with any disorder, (2) parents affected with a disorder group (e.g. neuropsychiatric disorders), and (3) parents affected with a specific disorder (e.g. ADHD). Pairs were further defined as 'unaffected,' 'single-affected,', or 'dual-affected.' Among offspring, the study evaluated fulfillment of four academic milestones, from compulsory (primary) school through University (college). Sensitivity analyses considered the impact of child's own mental health, as well as parental education, on main effects.

RESULTS

Marked reductions in the odds of achievement were observed, emerging at the earliest levels of schooling for both single-affected [adjusted odds ratio (aOR), 0.50; 95% CI 0.49-0.51] and dual-affected (aOR 0.29, 95% CI 0.28-0.30) pairs and persisting thereafter [aOR range (single), 0.52-0.65; aOR range (dual), 0.30-0.40]. This pattern was repeated for analyses within diagnosis/diagnostic group. Main results were robust to adjustment for offspring mental health and parent education level.

CONCLUSIONS

Parental mental illness is associated with profound reductions in educational attainment in the subsequent generation, with children from dual-affected families at uniquely high risk.

Differential Employment Quality and Educational Inequities in Mental Health: A Causal Mediation Analysis

BACKGROUND

In the United States, inequities in mental distress between those more and less educated have widened over recent years. Employment quality, a multidimensional construct reflecting the relational and contractual features of employer-employee relationships, may mediate this inequity throughout adulthood, yet no study has examined the extent of this mediation in the United States, or how it varies across racialized and gendered populations.

METHODS

Using the information on working-age adults from the 2001 to 2019 Panel Study of Income Dynamics, we construct a composite measure of employment quality via principal component analysis. Using this measure and the parametric mediational g-formula, we then estimate randomized interventional analogs for natural direct and indirect effects of low baseline educational attainment (≤high school: no/yes) on the end-of-follow-up prevalence of moderate mental distress (Kessler-6 Score ≥5: no/yes) overall and within subgroups by race and gender.

RESULTS

We estimate that low educational attainment would result in a 5.3% greater absolute prevalence of moderate mental distress at the end of follow-up (randomized total effect: 5.3%, 95% CI = 2.2%, 8.4%), with approximately 32% of this effect mediated by differences in employment quality (indirect effect: 1.7%, 95% CI = 1.0%, 2.5%). The results of subgroup analyses across race and gender are consistent with the hypothesis of mediation by employment quality, though not when selecting on full employment (indirect effect: 0.6%, 95% CI = -1.0%, 2.6%).

CONCLUSIONS

We estimate that approximately one-third of US educational inequities in mental distress may be mediated by differences in employment quality.

Educational Disparities in Hypertension Prevalence and Blood Pressure Percentiles in the Health and Retirement Study

OBJECTIVES

Hypertension and uncontrolled high blood pressure (BP) are more prevalent among less-educated older adults than those with more schooling. However, these dichotomous indicators may fail to fully characterize educational disparities in BP, a continuous measure that predicts morbidity and mortality across much of its range. This study therefore focuses on the distribution of BP, assessing educational disparities across BP percentiles in addition to disparities in hypertension and uncontrolled BP.

METHODS

Data are from the 2014-2016 Health and Retirement Study, a nationally representative survey of older U.S. adults (n = 14,498, ages 51-89). To examine associations between education, hypertension, and uncontrolled BP, I estimate linear probability models. To assess relationships between education and BP, I fit linear and unconditional quantile regression models.

RESULTS

Less-educated older adults are not only more likely to have hypertension and uncontrolled BP than those with more schooling, they also have higher systolic BP across nearly the entire BP distribution. Educational disparities in systolic BP increase in magnitude across BP percentiles and are largest at the highest levels of BP. This pattern is observed for those with and without diagnosed hypertension, is robust to early-life confounders, and is only partially explained by socioeconomic and health-related circumstances in adulthood.

DISCUSSION

Among older U.S. adults, the distribution of BP is compressed at lower, healthier levels for those with more education, and skewed toward the highest, most harmful levels among those with less education. Educational inequities in hypertension awareness and treatment efficacy may underlie these patterns. Implications for fundamental cause theory are discussed.

Relationship between social cohesion and basic public health services utilisation among Chinese internal migrants: a perspective of socioeconomic status differentiation

Social cohesion and socioeconomic status (SES) have been widely considered important factors influencing health services utilisation, but little is known about the association between social cohesion and health services utilisation across different SES groups. Based on a nationally representative survey, this study explores the influence of social cohesion on basic public health services utilisation in Chinese internal migrants at different SES levels. It is observed that objective and subjective cohesion forms have different effects on health record establishment and health education receipt. The positive effect of objective cohesion on health services utilisation is significantly larger than that of subjective cohesion, but two cohesion forms show similar effect sizes on health services utilisation among poor-SES migrants. With the promotion of SES, the effect size of objective cohesion gradually increases while that of subjective cohesion declines, showing a distribution of 'scissors gap'. For basic public health services utilisation, migrants not only have the agency to receive but are constrained by their SES. For migrants with poor SES, strong structural constraints hinder the utilisation of basic public health services.

Intergenerational educational trajectories and inequalities in longevity: A population-based study of adults born before 1965 in 14 European countries

Background

While educational gradients in longevity have been observed consistently in adult Europeans, these inequalities have been understudied within the context of family- and country-level influences. We utilized population-based multi-generational multi-country data to assess the role (1) of parental and individual education in shaping intergenerational inequalities in longevity, and (2) of country-level social net expenditure in mitigating these inequalities.

Methods

We analyzed data from 52,271 adults born before 1965 who participated in the Survey of Health, Ageing and Retirement in Europe, comprising 14 countries. Mortality from all causes (outcome) was ascertained between 2013 and 2020. Educational trajectories (exposure) were High-High (reference), Low-High, High-Low, and Low-Low, corresponding to the sequence of parental-individual educational attainment. We quantified inequalities as years of life lost (YLL) between the ages of 50 and 90 estimated via differences in the area under standardized survival curves. We assessed the association between country-level social net expenditure and YLL via meta-regression.

Results

Inequalities in longevity due to educational trajectories were associated with low individual education regardless of parental education. Compared to High-High, having High-Low and Low-Low led to 2.2 (95% confidence intervals: 1.0 to 3.5) and 2.9 (2.2 to 3.6) YLL, while YLL for Low-High were 0.4 (-0.2 to 0.9). A 1% increase in social net expenditure led to an increase of 0.01 (-0.3 to 0.3) YLL for Low-High, 0.007 (-0.1 to 0.2) YLL for High-Low, and a decrease of 0.02 (-0.1 to 0.2) YLL for Low-Low.

Conclusion

In European countries, individual education could be the main driver of inequalities in longevity for adults older than 50 years of age and born before 1965. Further, higher social expenditure is not associated with smaller educational inequalities in longevity.

Mothers' Nonstandard Work Schedules and Children's Behavior Problems: Divergent Patterns by Maternal Education

Increasing evidence has demonstrated that nonstandard work schedules are more prevalent among the less-educated population, and mothers' nonstandard work schedules have adverse influences on children's development. Yet, we have known relatively little about how such impacts differ across the educational distribution. Using data from the Fragile Families and Child Wellbeing Study, random and fixed effects regression results revealed a general "pattern of disadvantage" in the sense that detrimental influences of mothers regularly working nonstandard schedules on children's behavior were concentrated among those born to mothers without high school education, a "truly disadvantaged" group in the contemporary United States. In addition, regular nonstandard schedules appeared to play a mixed role in the behavioral development of children who had college-educated mothers, depending on the specific type of nonstandard schedule. These findings suggest that children born to the least-educated mothers experience compounded disadvantages that may reinforce the intergenerational transmission of disadvantages and also illustrate that negative implications of nonstandard work schedules for child wellbeing may extend to the more advantaged group.

Dynamic Changes in the Association Between Education and Health in the United States

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

The Roles of Adolescent Occupational Expectations and Preparation in Adult Suicide and Drug Poisoning Deaths within a Shifting Labor Market

Research suggests that economic declines contribute to mortality risks from suicide and drug poisoning, but how the economy impacts individuals' risks of these deaths has been challenging to specify. Building on recent theoretical advances, we investigate how adolescent occupational expectations and preparation contribute to suicide and drug poisoning deaths in a shifting economy. We use High School and Beyond data linked to adult mortality records for men that were exposed to a decline in labor market share and wages in predominantly blue-collar occupations during early adulthood. We find that adolescent men who expected these occupations had increased risks of suicide and drug poisoning death as adults net of educational and occupational attainment in early adulthood. Family background and occupational preparation are risk factors for death by drug poisoning but not suicide. Our findings improve our understanding of how labor market uncertainty shapes individuals' vulnerability to suicide and drug poisoning death.

Excess Deaths in the United States Compared to 18 Other High-Income Countries

The U.S. is exceptional among high-income countries for poor survival outcomes. Understanding the distribution of excess deaths by age, sex, and cause of death, is essential for bringing U.S. mortality in line with international peers. We use 2016 data from the World Health Organization Mortality Database and the Human Mortality Database to calculate excess deaths in the U.S. relative to each of 18 high-income comparison countries. The U.S. experiences excess mortality in every age and sex group, and for 16 leading causes of death. For example, the U.S. could potentially prevent 884,912 deaths by achieving the lower mortality rates of Japan, the comparison country yielding the largest number of excess deaths, which would be comparable to eliminating all deaths from heart disease, unintentional injuries, and diabetes mellitus. In contrast, the U.S. could potentially prevent just 176,825 deaths by achieving the lower mortality rates of Germany, the comparison country yielding the smallest number of excess deaths, which would be comparable to eliminating all deaths from chronic lower respiratory diseases and assault (homicide). Existing research suggests that policies that improve social conditions and health behaviors are more likely to bring U.S. mortality in line with peer countries than policies that support health care access or new biomedical technologies. Achieving the death rates of peer countries could result in mortality reductions comparable to eliminating leading causes of death.

Social Determinants of Mental, Physical, and Oral Health of Middle-Aged and Older African Americans in South Los Angeles

BACKGROUND

A growing body of research suggests that financial difficulties could weaken the protective effects of socioeconomic status (SES) indicators, including education and income, on the health status of marginalized communities, such as African Americans.

AIM

We investigated the separate and joint effects of education, income, and financial difficulties on mental, physical, and oral self-rated health (SRH) outcomes in African American middle-aged and older adults.

METHODS

This cross-sectional study enrolled 150 middle-aged and older African Americans residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics (education, income, and financial difficulties), and self-rated health (mental, physical, and oral health) were collected. Three linear regression models were used to analyze the data.

RESULTS

Higher education and income were associated with a lower level of financial strain in a bivariate analysis. However, according to multivariable models, only financial difficulties were associated with poor mental, physical, and oral health. As similar patterns emerged for all three health outcomes, the risk associated with financial difficulties seems robust.

CONCLUSIONS

According to our multivariable models, financial strain is a more salient social determinant of health within African American communities than education and income in economically constrained urban environments such as South Los Angeles. While education and income lose some protective effects, financial strain continues to deteriorate the health of African American communities across domains.

Expanded Contraceptive Access Linked To Increase In College Completion Among Women In Colorado

Public subsidies for contraception are often justified by assertions regarding their benefits for women's lives, yet there is limited contemporary evidence supporting these assertions. Beginning in 2009 the Colorado Family Planning Initiative abruptly expanded access to the full range of contraceptive methods through Colorado's Title X family planning clinics. Using eleven years of American Community Survey data linked to data from two decennial censuses, we assessed whether exposure to the program led to improvements in college completion among women. Exposure to the Colorado Family Planning Initiative at high school ages was associated with a population-level increase of 1.8-3.5 percentage points in women's on-time bachelor's degree attainment, which represents a 6-12 percent increase in women obtaining their degrees compared with earlier cohorts. Federal and state policies restricting or expanding access to the full range of contraceptive methods can affect women's attainment of higher education in addition to their reproductive health.

The effect of college degree attainment on neurodegenerative symptoms in genetically at-risk women

Using longitudinal data, the present study examined the association between college degree attainment and the manifestation of neurodegenerative symptoms among women (n = 93) at elevated genetic risk. The neurodegenerative symptoms investigated in this study are due to FXTAS (Fragile X-associated Tremor/Ataxia Syndrome), a condition with onset after age 50. Those at risk for FXTAS have a mutation of a single gene found on the X chromosome. FXTAS is characterized by intention tremor, gait ataxia, executive function deficits, memory issues, and neuropathy. College degree attainment has been shown to provide neuroprotective effects in the general population, delaying the development of neurodegenerative conditions such as Alzheimer's disease. For this reason, college degree attainment is a potentially salient resource for those at risk of FXTAS. The results of the present research indicated significantly more severe FXTAS symptoms in women who did not attain a college degree as compared with those who were college graduates, although the two groups were similar in age, genetic risk, household income, health behaviors, and general health problems. Furthermore, symptoms in those who did not attain a college degree worsened over the 9-year study period at a significantly faster rate than the college graduates. The association between college degree attainment and FXTAS symptoms was significantly mediated by depression, which was lower among the graduates than those who did not attain a college degree. Thus, the present research is an example of how a sociodemographic factor can mitigate neurodegenerative conditions in genetically at-risk adults.

Nursing Education and Social Determinants of Health: A Content Analysis

BACKGROUND

By integrating a social determinants of health (SDOH) perspective into nursing programs, there is potential to reduce health disparities shaped by these forces. However, little is known about the extent to which nursing program curricula include SDOH education.

METHOD

This study used course descriptions from 32 nursing programs in the United States to perform a frequency and content analysis on required course offerings. Healthy People 2020 was referenced to determine coding categories.

RESULTS

Although 18.5% of courses implicitly referenced SDOH, only 1% made explicit references to SDOH. Implicit references were likely to include themes such as cultural sensitivity and diversity, or social, cultural, economic, and political factors influencing health.

CONCLUSION

Although several required nursing course descriptions made implicit references to SDOH, explicit use of the term SDOH is still limited. Faculty, administrators, and program accrediting bodies must push to incorporate SDOH more thoroughly into nursing education. [J Nurs Educ. 2022;61(9):516-523.].

Predictors of Past-Year Health Care Utilization Among Young Men Who Have Sex with Men Using Andersen's Behavioral Model of Health Service Use

Purpose: This study examined factors associated with past-year health care utilization among young gay, bisexual, and other men who have sex with men (YMSM) using Andersen's behavioral model of health service use. Methods: From 2018 to 2020, 751 YMSM (aged 13-18) recruited online and offline for the MyPEEPS mHealth HIV prevention study completed an online survey. Hierarchical logistic regression models assessed associations between past-year health care utilization (i.e., routine checkup) and predisposing (parental education, race/ethnicity, age, and internalized homonegativity), enabling (health literacy, health care facility type, U.S. Census Divisions), and need factors (ever testing for HIV). Results: The sample included 31.8% Hispanic, 23.9% White, and 14.6% Black YMSM; median age was 16. Most (75%) reported past-year health care utilization, often from private doctor's offices (29.1%); 6% reported no regular source of care. In the final regression model, higher odds of past-year health care utilization were found for younger participants (age 13-14, adjusted odds ratio [AOR] = 1.91; 95% confidence interval [CI]: 1.07-3.43; age 15-16 AOR = 1.55; 95% CI: 1.04-2.30; reference: 17-18) and those with increasing health literacy (AOR = 1.71; 95% CI: 1.36-2.16). YMSM with lower parental education had lower odds of past-year health care utilization (AOR = 0.56; 95% CI: 0.38-0.84), as did those relying on urgent care facilities (AOR = 0.60; 95% CI: 0.41-0.87; reference: routine care facilities) and those who identified as Mixed/Other race (AOR = 0.50; 95% CI: 0.28-0.91; reference: White). Conclusions: Findings highlight opportunities to intervene in YMSM's health risk trajectory before age 17 to reduce drop-off in routine health care utilization. Interventions to improve routine health care utilization among YMSM may be strengthened by building resilience (e.g., health literacy) while removing barriers maintained through structural disadvantage, including equity in education. Clinical Trial Registration Number: NCT03167606.

Social isolation, homebound status, and race among older adults: Findings from the National Health and Aging Trends Study (2011-2019)

BACKGROUND

Multiple factors may influence the risk of being homebound, including social isolation and race. This study examines the relationship between social isolation and homebound status by race over 9 years in a sample of adults.

METHODS

Utilizing a representative sample of 7788 Medicare beneficiaries aged 65+ from 2011-2019, we assessed the odds of becoming homebound by social isolation. We defined social isolation as the objective lack of contact with others. We defined severe social isolation as scoring a 0 or 1 on a social connection scale from 0 to 4. Homebound status was defined as never leaving home or only leaving home with difficulty. Utilizing a multivariate Cox proportional hazards model adjusting for age, gender, marital status, income, and education, we examined the association between social isolation at baseline and becoming homebound during the study in those who were not initially homebound.

RESULTS

Older adults in this study were on average 78 years old. Overall, most were white (69%), female (56.3%), and married (57.8%) and reported that they had a college education or higher (43.9%). Also, at baseline, approximately 25% of study participants were socially isolated, 21% were homebound, and 6.3% were homebound and socially isolated or severely socially isolated. Homebound status at baseline varied by race: Black, 23.9% and white, 16.6% (p < 0.0001). After 9 years, socially isolated black (hazard risk ratio, HRR 1.35, 95% confidence interval CI [1.05,1.73], p < 0.05) and white (HRR 1.25, 95% CI [1.09,1.42], p < 0.01) older adults were at higher risk of becoming homebound.

CONCLUSION

Socially isolated black and white adults are more likely to be homebound at baseline and become homebound over time. Further research is needed to determine whether community-based strategies and policies that identify and address social isolation reduce homebound status among community-dwelling older adults.

Comparative study of two birth cohorts: did the explanatory role of behavioural, social and psychological factors in educational inequalities in mortality change over time?

OBJECTIVES

To investigate the contribution of behavioural, social and psychological factors to inequalities in mortality by educational level between birth cohorts.

DESIGN

Cohort-sequential design.

SETTING

Two population-based studies in the Netherlands: the Longitudinal Aging Study Amsterdam (LASA) and the Doetinchem Cohort Study (DCS).

PARTICIPANTS

Data from the LASA included 1990 individuals with birth years 1928-1937 (cohort 1) and 1938-1947 (cohort 2) and, for replication, data from the DCS included 2732 individuals with birth years 1929-1941 (cohort 1) and 1939-1951 (cohort 2).

METHODS

Years of education, 15-year mortality, lifestyle factors, social factors and psychological factors were modelled using multiple-group accelerated failure time models based on structural equation modelling to compare indirect effects between cohorts.

RESULTS

Both studies showed similar educational inequalities, with higher mortality among those with lower education. The indirect effects of education via smoking (LASA: difference in survival time ratio (TR)=1.0018, 95% CI 1.0000 to 1.0155, DCS: TR=1.0051, 95% CI 1.0000 to 1.0183), physical activity (LASA: TR=1.0056, 95% CI 1.00009 to 1.0132) and alcohol use (LASA: TR=1.0275, 95% CI 1.0033 to 1.0194) on mortality were stronger in cohort 2 than in cohort 1. In contrast to the other effects, alcohol use was the only factor that was associated positively with education and survival time, which effect increased in the most recent cohort. Emotional support, network size and cognitive functioning showed no difference between cohorts.

CONCLUSIONS

Smoking, physical activity and alcohol use contributed more to educational inequalities in mortality in recent cohorts. Hence, in addition to tackling fundamental social causes of inequality, policies focusing on intermediary mechanisms such as lifestyle need to adapt their targets to those that prove to be most important within a given time frame.

Health Power Resources Theory: A Relational Approach to the Study of Health Inequalities

Link and Phelan's pioneering 1995 theory of fundamental causes urged health scholars to consider the macro-level contexts that "put people at risk of risks." Allied research on the political economy of health has since aptly demonstrated how institutions contextualize risk factors for health. Yet scant research has fully capitalized on either fundamental cause or political economy of health's allusion to power relations as a determinant of persistent inequalities in population health. I address this oversight by advancing a theory of health power resources that contends that power relations distribute and translate the meaning (i.e., necessity, value, and utility) of socioeconomic and health-relevant resources. This occurs through stratification, commodification, discrimination, and devitalization. Resurrecting historical sociological emphases on power relations provides an avenue through which scholars can more fully understand the patterning of population health and better connect the sociology of health and illness to the central tenets of the discipline.

The Association Between Cytomegalovirus and Disability by Race/Ethnicity and Sex: Results From the Health and Retirement Study

Recent studies have documented a decline in the overall prevalence of disability in the United States; however, racial/ethnic and sex disparities continue to persist. Cytomegalovirus (CMV) infection, a socially patterned exposure, may be a key mechanism in understanding these previously documented disparities. Using data from a nationally representative study, the 2016 Health and Retirement Study, we employed Poisson log-binomial models to estimate the prevalence of disability in a comparison of CMV-seropositive and -seronegative adults and investigated effect modification by race/ethnicity and sex. Among the 9,029 participants (55% women; mean age = 67.4 years), 63% were CMV-seropositive and 15% were disabled. CMV seropositivity was highest among non-Hispanic Black (88%) and Hispanic (92%) adults as compared with non-Hispanic White adults (57%). We found evidence for effect modification in the association between CMV and disability by sex but not race/ethnicity. While the 95% confidence intervals in the fully adjusted models included the null value, in comparison with seronegative women, our results suggest a greater prevalence of disability among CMV-seropositive women (prevalence ratio = 1.16, 95% confidence interval: 0.97, 1.38) but not among men (prevalence ratio = 0.85, 95% confidence interval: 0.69, 1.06). Results provide initial support for the hypothesis that CMV may be an important determinant of sex disparities in disability.

The Effects of Education on Mortality: Evidence From Linked U.S. Census and Administrative Mortality Data

Does education change people's lives in a way that delays mortality? Or is education primarily a proxy for unobserved endowments that promote longevity? Most scholars conclude that the former is true, but recent evidence based on Danish twin data calls this conclusion into question. Unfortunately, these potentially field-changing findings-that obtaining additional schooling has no independent effect on survival net of other hard-to-observe characteristics-have not yet been subject to replication outside Scandinavia. In this article, we produce the first U.S.-based estimates of the effects of education on mortality using a representative panel of male twin pairs drawn from linked complete-count census and death records. For comparison purposes, and to shed additional light on the roles that neighborhood, family, and genetic factors play in confounding associations between education and mortality, we also produce parallel estimates of the education-mortality relationship using data on (1) unrelated males who lived in different neighborhoods during childhood, (2) unrelated males who shared the same neighborhood growing up, and (3) non-twin siblings who shared the same family environment but whose genetic endowments vary to a greater degree. We find robust associations between education and mortality across all four samples, although estimates are modestly attenuated among twins and non-twin siblings. These findings-coupled with several robustness checks and sensitivity analyses-support a causal interpretation of the association between education and mortality for cohorts of boys born in the United States in the first part of the twentieth century.

Educational Differences in Diabetes Mortality among Hispanics in the United States: An Epidemiological Analysis of Vital Statistics Data (1989-2018)

Background: Diabetes accounted for approximately 10% of all-cause mortality among those 20–79 years of age worldwide in 2019. In 1986–1989, Hispanics in the United States of America (USA) represented 6.9% of the national population with diabetes, and this proportion increased to 15.1% in 2010–2014. Recently published findings demonstrated the impact of attained education on amenable mortality attributable to diabetes among Non-Hispanic Whites (NHWs) and Non-Hispanic Blacks (HNBs). Previous cohort studies have shown that low education is also a detrimental factor for diabetes mortality among the Hispanic population in the USA. However, the long-term impact of low education on diabetes mortality among Hispanics in the USA is yet to be determined. Aims and methods: The aim of this study was to measure the impact of achieving a 12th-grade education on amenable mortality due to diabetes among Hispanics in the USA from 1989 to 2018. We used a time-series designed to analyze death certificate data of Hispanic-classified men and women, aged 25 to 74 years, whose underlying cause of death was diabetes, between 1989 and 2018. Death certificate data from the USA National Center for Health Statistics was downloaded, as well as USA population estimates by age, sex, and ethnicity from the USA Census Bureau. The analyses were undertaken using JointPoint software and the Age–Period–Cohort Web Tool, both developed by the USA National Cancer Institute. Results: The analyses showed that between 1989 to 2018, age- and sex-standardized diabetes mortality rates among the least educated individuals were higher than those among the most educated individuals (both sexes together, p = 0.036; males, p = 0.053; females, p = 0.036). The difference between the least and most educated individuals became more pronounced in recent years, as shown by independent confidence intervals across the study period. Sex-based analyses revealed that the age-adjUSAted diabetes mortality rate had increased to a greater extent among the least educated males and females, respectively, than among the most educated. Conclusions: The results of the analyses demonstrated a powerful effect of low education on amenable mortality attributable to diabetes among the Hispanic population in the USA. As an increasing prevalence of diabetes among the least educated Hispanics has been reported, there is a great need to identify and implement effective preventive services, self-management, and quality care practices, that may assist in reducing the growing disparity among those most vulnerable, such as minority populations.

Deindustrialisation, demographic decline, aging, economic crisis and social involution in a metropolitan area analysed by applying Socio-Economic and Health Deprivation Indices

AIMS

Genoa is a city hit by a strong economic, demographic and social involution. The changes in the demographic and socio-economic (SE) situation were analysed and the capacity of two Socio-Economic and Health Deprivation Indices (SEHDI) in describing the evolutions of the recent period were verified.

MATERIAL AND METHODS

The data about the evolution of demographic and SE situation in Genoa came from publications of Statistics Offices of Genoa Municipality and Liguria Region and from published analyses of Bank of Italy. The two SEHDIs, referring to 2001 and 2011 population, were computed at census tract level by linear regression, factor and clusters analyses and had been already validated and published.

RESULTS

Wide transformations in aging and population composition by age groups and gender occurred in Genoa between 1951 and 2016. Internal (from other Italian regions) and external (from other countries) migrations concurred to change the profile of Genoese population. These changes followed the industrial history of city and its deindustrialization occurred since 2001. A progressive SE involution, worsened by the Italian and international crises, carried out the recent impoverishment of the city. Between 2001 and 2011 the population at medium-high deprivation increased and the SEHDIs 2001 and 2011 contributed to describe the population distribution by deprivation groups, either geographically, and by groups of citizenships (Italians and Foreigners). The first identified in 2001 some aspects of a well-off society regarding education, labour market and characteristics of the family and housing structure. The second depicted in 2011 an impoverished society in aging, lack of family support and of property of the main house, diminishing of educational level.

DISCUSSION

Genoa city demonstrated an its own specific decline. Starting from the deindustrialization, a worsening of welfare, independently from the national and international economic troubles, was evident. The aging and the changed equilibria among age groups testified the growing difficulties of society in keeping up with the deep social and economic changes. The results demonstrated that specific deprivation indices aid to better define the populations under analysis, because they identify the subpopulations that could have the maximum benefit from investments of resources targeted to the correction of inequalities.

The role of education on Cancer amenable mortality among non-Hispanic blacks & non-Hispanic whites in the United States (1989-2018)

Background

Cancer mortality in the U.S. has fallen in recent decades; however, individuals with lower levels of education experienced a smaller decline than more highly educated individuals. This analysis aimed to measure the influence of education lower than a high school diploma, on cancer amenable mortality among Non-Hispanic Whites (NHW) and Non-Hispanic Blacks (NHB) in the U.S. from 1989 to 2018.

Methods

We analyzed data from 8.2 million death certificates of men and women who died from cancer between 1989 and 2018. We examined 5-year and calendar period intervals, as well as annual percent changes (APC). APC was adjusted for each combination of sex, educational level, and race categories (8 models) to separate the general trend from the effects of age.

Results

Our study demonstrated an increasing mortality gap between the least and the most educated NHW and NHB males and females who died from all cancers combined and for most other cancer types included in this study. The gap between the least and the most educated was broader among NHW males and females than among NHB males and females, respectively, for most malignancies.

Conclusions

In summary, we reported an increasing gap in the age-adjusted cancer mortality among the most and the least educated NHW and NHB between 25 and 74 years of age. We demonstrated that although NHB exhibited the greatest age-adjusted mortality rates for most cancer locations, the gap between the most and the least educated was shown for NHW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08633-7.

Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits

Recent trends in U.S. health have been mixed, with improvements among some groups and geographic areas alongside declines among others. Medical sociologists have contributed to the understanding of those disparate trends, although important questions remain. In this article, we review trends since the 1980s in key indicators of U.S. health and weigh evidence from the last decade on their causes. To better understand contemporary trends in health, we propose that commonly used conceptual frameworks, such as social determinants of health, should be strengthened by prominently incorporating commercial, political-economic, and legal determinants. We illustrate how these structural determinants can provide new insights into health trends, using disparate health trajectories across U.S. states as an example. We conclude with suggestions for future research: focusing on structural causes of health trends and inequalities, expanding interdisciplinary perspectives, and integrating methods better equipped to handle the complexity of causal processes driving health trends and inequalities.

Educational attainment of offspring and obesity among older adults in China

The study focuses on the role of adult offspring's educational attainment in obesity among older adults in China and investigates age and birth cohort heterogeneities in the educational effect. Using the longitudinal data from the 1993-2015 China Health and Nutrition Survey (CHNS), we employed three-level mixed-effects models and conducted sex-stratified analyses to examine the effects of co-resident offspring's education on body mass index (BMI), overweight, waist circumference (WC), and abdominal obesity among older people born before 1956. After controlling for confounding factors, the overall results showed inverted U-shaped educational gradients in BMI-based outcomes for males and positive gradients for females. The effect of education on WC exhibited an inverted U-shaped pattern for both sexes, but no significant effect on abdominal obesity was found among the overall population. However, further analyses of interaction effects indicated considerable age and cohort variations in the educational effects on obesity outcomes. Offspring's schooling was positively associated with obesity among earlier birth cohorts; Among more recent birth cohorts, especially among females, the educational effects were reversed, and disparities in obesity outcomes across education categories strengthened with age. These findings imply that offspring's education appears to gradually exert a protective role against obesity among Chinese older adults in successive cohorts.

Life-course risk factors are associated with activity of daily living disability in older adults

BACKGROUND

Multiple risk factors accumulate over the life-course and contribute to higher rates of disability at older ages. This study investigates whether three life-course risk factors (low educational attainment, poor health in childhood and multimorbidity) are associated with increased risk of disability [defined as any limitation in basic activities of daily living (BADL)] in older adults and whether this relationship is moderated by the national socioeconomic context, measured by the Human Development Index (HDI).

METHODS

Data include 100 062 adults (aged 50 and over) participating in longitudinal studies of aging conducted in 19 countries. Analyses include multivariable Poisson models with robust standard errors to assess the associations between HDI, life-course risk factors and other individual-level control variables (sex and age) with any BADL disability.

RESULTS

In country-specific analyses, both educational attainment and multimorbidity are independently associated with disability in nearly every country. The interaction between these risk factors further increases the magnitude of this association. In pooled regression analyses, the relationship between life-course risk factors and disability is moderated by a country's HDI. For individuals with all three life-course risk factors, the predicted probability of disability ranged from 36.7% in the lowest HDI country to 21.8% in the highest HDI country.

CONCLUSIONS

Social and health system policies directed toward reducing the development of life-course risk factors are essential to reduce disability in all countries, but are even more urgently needed in those with lower levels of socioeconomic development.

Social Inequality and the Future of U.S. Life Expectancy

Despite decades of progress, the future of life expectancy in the United States is uncertain due to widening socioeconomic disparities in mortality, continued disparities in mortality across racial/ethnic groups, and an increase in extrinsic causes of death. These trends prompt us to scrutinize life expectancy in a high-income but enormously unequal society like the United States, where social factors determine who is most able to maximize their biological lifespan. After reviewing evidence for biodemographic perspectives on life expectancy, the uneven diffusion of health-enhancing innovations throughout the population, and the changing nature of threats to population health, we argue that sociology is optimally positioned to lead discourse on the future of life expectancy. Given recent trends, sociologists should emphasize the importance of the social determinants of life expectancy, redirecting research focus away from extending extreme longevity and towards research on social inequality with the goal of improving population health for all.

Medical innovations can reduce social inequalities in health: an analysis of blood pressure and medication in the HUNT study

This paper examines whether the use of blood pressure medication has an influence on social inequalities in blood pressure levels. In Norway, cardiovascular disease has for decades been associated with high mortality and social inequalities. High blood pressure is an important risk factor in this aspect, and prescription drugs have been established as a standard treatment of hypertension. We have seen population blood pressure levels fall, blood pressure inequality levels remaining stabile, and medication use increase. The paper uses panel data from the Nord-Trøndelag Health Study linked with registry data on education and income. Results from fixed effects regression analyses indicate that blood pressure medication overall has a levelling effect. The traditional social gradient is mainly found among non-users of medication. With blood pressure medication being plausibly at a late stage of its diffusion, these findings give some support to the hierarchical diffusion model, while they also imply the need for equal access to sufficient blood pressure treatment.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

Maternal Education and Low Birth Weight in Low- and Middle-Income Countries: Systematic Review and Meta-Analysis

OBJECTIVE

Adverse birth outcomes, including low birth weight (LBW), remain the leading causes of child morbidity and mortality in many low- and middle-income countries (LMICs). We carried out a systematic review and meta-analysis to assess the strength and consistency of the association between maternal education and LBW in LMICs.

METHODS

We conducted an electronic search of studies published between 2000 and 2014 in four databases using three MeSH keywords - birth outcomes including LBW; individual-level socioeconomic measures including maternal education; and a list of LMICs. The methodological quality of each eligible study was evaluated following the GRADE approach. A total of 26 studies were entered into meta-analysis. Subgroup analyses were performed to account for heterogeneity in the measurement of exposure and country development level.

FINDINGS

The meta-analysis revealed a statistically significant pooled estimate (OR = 0.67; 95% CI = 0.61-0.74) indicating that maternal education is protective against LBW in LMICs. Heterogeneity was found high in subgroup analyses in studies from lower-middle income countries and in those measuring maternal education in academic classes, but drops considerably in studies from low-income countries and those measuring it in number of years of schooling. The quality of the overall body of evidence is moderate due to high observed heterogeneity in some subgroup analyses and the presence of studies with high risk of bias.

INTERPRETATION

Higher maternal education associates with a moderate but statistically significant decrease in the risk of delivering a LBW infant in LMICs. Enhancing girls' and women's access to education operates through a number of pathways to improve birth outcomes and reduce LBW in LMICs.

Incarceration as a Fundamental Social Cause of Health Inequalities: Jails, Prisons and Vulnerability to COVID-19

Although research has established the disproportionate health burdens among incarcerated persons, the literature has yet to identify a theoretical framework for outlining the harms of incarceration associated with pandemics. We advance the literature theoretically by arguing two points. First, we assert that incarceration is a potent structural driver of health inequalities that must be considered as a fundamental social cause of disease. To underscore this point, we review how incarceration meets each of the four fundamental social cause criteria originally proposed by Link and Phelan. Second, given that incarceration is a fundamental social cause of disease, both currently and formerly incarcerated populations are likely to face heightened vulnerabilities to pandemics, including COVID-19, further exacerbating health disparities among incarceration-exposed groups.

Evidence for a Causal Relationship Between Academic Achievement and Cigarette Smoking

INTRODUCTION

Academic achievement (AA) is associated with smoking rates. Can we determine the degree to which this relationship is likely a causal one?

METHODS

We predict smoking in male conscripts (mean age 18.2) assessed from 1984 to 1991 (N = 233 248) and pregnant females (mean age 27.7) receiving prenatal care 1972-1990 (N = 494 995) from AA assessed in all students at 16. Instrumental variable (IV) analyses used the instrument month-of-birth as in each school year, older children have high AA. Co-relative analyses used AA-smoking associations in the population, cousins and siblings to predict the AA-smoking relationship in MZ twins, thereby controlling for familial confounding.

RESULTS

In males, higher AA was associated with a substantial decrease in risk for smoking (odds ratio [OR] [95% confidence intervals [CIs]] per standard deviation [SD] = 0.41 [0.40-0.41]) while the parallel figures obtain from our IV and co-relative analyses were 0.47 (0.39-0.57) and 0.51 (0.43-0.60), respectively. In females, these figures for pre-pregnancy smoking were, respectively, 0.39 (0.39-0.39), 0.50 (0.46-0.54) and 0.54 (0.51-0.58). Results for heavy versus light smoking suggested a causal effect but were inconsistent across methods. However, among females smoking prior to pregnancy, AA predicted a reduced risk for continued smoking with ORs for uncontrolled, IV, and co-relative analyses equaling, respectively, were 0.54 (0.53-0.55) 0.68 (0.56-0.82) and 0.78 (0.66-0.91), respectively.

CONCLUSIONS

Two different methods produced consistent evidence that higher AA has a causal effect on reducing smoking rates and increasing cessation rates in smoking pregnant females. Improving AA may result in meaningful gains in population health through reduced smoking.

IMPLICATIONS

This study provides consistent evidence across two different methods that high AA is causally related to reduced rates of smoking and increasing rates of smoking cessation among pregnant women. Our results suggest that interventions that improve educational achievement in adolescence would reduce tobacco consumption, thereby improving public health.

Factors Associated With Positive Self-Rated Health: Comparing Older Adults in Brazil and in Portugal

Introduction: Self-rated health is a multidimensional health indicator and a predictor of adverse events in old age. Answers to this assessment are influenced by social, cultural and personality factors. Aim: Exploring common and distinctive characteristics of Brazilian and Portuguese older adults aged 70 and over regarding positive self-rated health according to sociodemographic variables, to functional capacity, to independent performance of basic activities of daily living and to neuroticism, as well as analyzing associations between positive self-rated health and these variables. Methods: The present paper is a comparative and cross-sectional study based on secondary data contained in the databases of the FIBRA (Frailty in Brazilian Older Adults) follow-up study, with 418 Brazilian older adults, and of the DIA (From Disability to Activity: The Challenge of Aging) study, with 380 Portuguese older adults. Both samples had higher percentages of women: 68.4% for Portugal and 69.9% for Brazil. The Brazilian sample had a higher average age (80.31 ± 4.67) than the Portuguese sample (76.80 ± 5.28). Results: The Portuguese older adults had better overall cognition scores, higher handgrip strength and higher neuroticism values than the Brazilian older adults. In the simple and multiple logistic regression analyses, it was found that among Brazilian older adults, subjects with higher scores in the MMSE (OR 1.16; 95% CI 1.08-1.24), regardless of ADL performance (OR 2.13; 95% CI 1.31-3.47) and with scores 24-29 (OR 1.92; 95% CI 1.07-3.43) or 11-23 (OR 2.09; 95% CI 1.15-3.79) in neuroticism were more likely to assess their health as very good/good. On the other hand, the Portuguese older adults with intermediate 24-9 (OR 2.38; 95% CI 1.31-4.33) or low 11-23 (OR 5.31; 95% CI 2.69-10.45) scores in neuroticism were more likely to evaluate their health as very good/good. Conclusion: Based on the findings of the present study and on the existing literature, it may be said that it is possible for people to age while keeping a positive perception of their own health, even in advanced old age; comparisons between the above-mentioned countries, however, point to the need for investments in healthcare systems so that older adults may enjoy greater physical independence and improved mental health.

Educational Disparities in COVID-19 Prevention in China: The Role of Contextual Danger, Perceived Risk, and Interventional Context

Despite the social disparities in COVID-19 infection, little is known about factors influencing social disparities in preventive behaviors during the pandemic. This study examined how educational disparities in mask-wearing, handwashing, and limiting public outings might be contingent upon three factors: contextual cue of danger, perceived risk of local outbreak, and interventional context with different levels of intensity (i.e, Wuhan vs. other areas). Data were obtained from a telephone survey of 3327 adults, who were recruited through a random-digit-dial method to be representative of all cell phone users in China. Interviews were conducted from 28 April to 26 May 2020. Stratified multiple regression models showed that educational disparities in all three behaviors were only consistently observed among people exposed to context cues of danger, with an enhanced sense of risk of a local outbreak, or in areas other than Wuhan. College education seems to make a difference in handwashing regardless of contextual cues of danger or perception of risk. The findings suggested that, in the process of an epidemic, emerging threats in one's immediate environment or raised awareness of risks are important conditions triggering educational disparities in prevention. However, effective public health interventions could potentially reduce such disparities.

Is educational attainment associated with young adult cardiometabolic health?

Educational disparities in health and mortality are well-documented and evidence suggests that they may be widening. Yet, there is much unknown about when educational disparities begin to emerge and for whom. This paper investigates the association between educational attainment and cardiometabolic health in young adults with critical attention paid to differences across racial/ethnic and sex subgroups. We focus on cardiometabolic health in young adulthood as it is particularly relevant for understanding current population health trends. We used data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) when participants were aged 12-19 years (Wave I) and aged 24-32 years (Wave IV). Using a series of logistic regression models, we first estimated the association between education and five markers of cardiometabolic health (high-risk blood pressure, high-risk waist circumference, diabetes/pre-diabetes, hyperlipidemia, and high-risk inflammation). We then examined the extent to which this association was explained by adolescent health and both adolescent and young adult socioeconomic status (SES) (including parental education, participant educational attainment, household income, and employment status). Finally, we investigated whether the association between educational attainment and cardiometabolic health differed by race/ethnicity and sex. We found evidence of an association between educational attainment and cardiometabolic health that persisted net of adolescent health, adolescent SES, and young adult SES. We also found some evidence of modest differences in this association by race/ethnicity and sex. Our findings suggest that even as early as young adulthood there are disparities in cardiometabolic health by educational attainment, which may lead to even larger disparities in late life health.

Socioeconomic pathways to inequalities in mental and functional health: a comparative study of three birth cohorts

Background

Although the educational expansion is often seen as a mechanism that might reduce health inequalities, socioeconomic inequalities in health (SEIH) have persisted or increased over the past decades. Theories suggest that this persistence could be due to a changing role of education as a ‘gatekeeper’ to access other socioeconomic resources such as occupation and income that are also associated with health outcomes. To test this, we examine whether the mediating role of occupation and income in the education–health relationship differs between three cohorts of 55–64 year old adults.

Methods

We used cross-sectional data from three cohorts of 988, 1002, and 1023 adults born in 1928/37, 1938/47 and 1948/57 and observed in 1992/93, 2002/03, 2012/13 respectively, who participated in the Longitudinal Aging Study Amsterdam, the Netherlands. We used multigroup structural equation modelling to compare the strength of indirect effects of education via occupational skill level and income to functional limitations and depressive symptoms between cohorts.

Results

Absolute educational inequalities in functional limitations increased for men and women in later cohorts, and in depressive symptoms only for men. Relative inequalities in functional limitations increased only for women and in depressive symptoms only for men. The indirect effect of education via income on both health outcomes was weaker in the most recent birth cohort compared to the earlier cohorts. In contrast, the indirect effect of education via occupation on functional limitations was stronger in the most recent cohort compared to the earlier cohorts. These differences were mainly due to a decreasing direct effect of education on income and an increasing direct effect of education on occupational skill level, rather than to changes in the direct effects of occupation and income on health.

Conclusions

The role of education in determining inequalities in health appears to have changed across cohorts. While education became a less important determinant of income, it became a more important determinant of occupational level. This changing role of education in producing health inequalities should be considered in research and policy.

Intercohort Variations in the Education-Health Gradient: Sociohistorical Changes in Early-Life Selection Mechanisms in the United States

OBJECTIVES

Most prior studies on cohort-specific changes in the education gradient relative to health treat the distribution of education within a particular cohort as a "starting place" for understanding later-life health disparities. This premise has obfuscated the role that sociohistorical changes in early-life selection mechanisms play in the widening of education-based inequalities in functional limitations across birth cohorts.

METHODS

Drawing from the Health and Retirement Survey (1992-2016; n = 20,920), this study employs inverse probability weight (IPW) to account for early-life selection mechanisms that are likely to affect both educational attainment and functional limitations. IPW-adjusted generalized linear mixed-effects models were used to estimate the total effect of education on functional limitations across birth cohorts (born 1924-1959).

RESULTS

A significant linear decline in the negative effects of childhood socioeconomic disadvantage on education (β = 0.005, p < .01) over the birth year was documented. By contrast, the same variable's negative effect on functional health increased significantly (β = 0.006, p < .001) across cohorts. Adjustment for childhood socioeconomic status did yield narrower education-based inequalities in functional limitations, but the difference between IPW-adjusted and unadjusted results was not statistically significant. The pattern of significant widening of education-based inequalities (β = -0.05, p < .001) in functional limitations across birth cohorts was maintained.

DISCUSSION

This study underscores the role that sociohistorical changes in early-life selection mechanisms play in modifying patterns of education-based inequalities in health across cohorts.

Health inequalities, fundamental causes and power: towards the practice of good theory

Reducing health inequalities remains a challenge for policy makers across the world. Beginning from Lewin's famous dictum that "there is nothing as practical as a good theory", this paper begins from an appreciative discussion of 'fundamental cause theory', emphasizing the elegance of its theoretical encapsulation of the challenge, the relevance of its critical focus for action, and its potential to support the practical mobilisation of knowledge in generating change. Moreover, it is argued that recent developments in the theory, provide an opportunity for further theoretical development focused more clearly on the concept of power (Dickie et al. 2015). A critical focus on power as the essential element in maintaining, increasing or reducing social and economic inequalities - including health inequalities - can both enhance the coherence of the theory, and also enhance the capacity to challenge the roots of health inequalities at different levels and scales. This paper provides an initial contribution by proposing a framework to help to identify the most important sources, forms and positions of power, as well as the social spaces in which they operate. Subsequent work could usefully test, elaborate and adapt this framework, or indeed ultimately replace it with something better, to help focus actions to reduce inequalities.

Association of Job Expectations Among High School Students With Early Death During Adulthood

Importance

Deaths from self-injury are increasing. Understanding the sources of risk is important for prevention and treatment.

Objective

To estimate the risks of suicide and drug poisoning deaths among adult men whose adolescent occupational expectations were not met in adulthood.

Design, Setting, and Participants

This cohort study included a sample of men interviewed as part of the High School and Beyond study, a nationally representative study of US high school sophomores and seniors in 1980, who were interviewed every 2 years through 1986; those who were sophomores in 1980 were reinterviewed in 1992. Men who survived to 1992 and reported occupational expectations were included in the present study. Death records prior to 2018 were linked to mortality databases and released in 2019. Data analysis was conducted from May to October 2020.

Exposure

Occupational expectations.

Main Outcomes and Measures

Survival or death by suicide, drug poisoning, chronic liver disease, heart disease, cancer, or some other cause, categorized from International Classification of Diseases, Ninth Revision and Tenth Revision codes. Competing risk Fine-Gray survival models regressed cause of death on adolescent occupational expectations and covariates.

Results

The 11 680 men in the High School and Beyond cohort study had a median (interquartile range) age of 29 (28-30) years in 1992, when the analysis of their future mortality began. Most men survived until 2015 (11 060 [weighted percentage, 95.0%]). Reported causes of death were suicide (60 [weighted percentage, 0.5%]), drug poisoning (40 [weighted percentage, 0.4%]), chronic liver disease (20 [weighted percentage, 0.2%]), heart disease (130 [weighted percentage, 1.0%]), cancer (100 [weighted percentage, 1.0%]), and other (280 [weighted percentage, 2.0%]). Subhazard ratios for death by suicide and drug poisoning were 2.91 (95% CI, 1.07-7.88; P = .04) and 2.62 (95% CI, 1.15-5.94; P = .02) times higher, respectively, among those who in 1980 expected to hold a subbaccalaureate occupation that later declined in labor market share compared with those with professional occupational expectations. The actual job held by men did not attenuate the hazards of deaths from suicide and drug poisoning.

Conclusions and Relevance

In this cohort study, men whose occupational expectations were not met because of labor market declines were at a higher risk of death from suicide or drug poisoning than men with different occupational expectations. Interventions to mitigate labor market changes should account for individuals' expectational ideals.

Informal Caregiver Burden, Benefits, and Older Adult Mortality: A Survival Analysis

OBJECTIVE

Informal caregivers are crucial to maintaining older adults' health, but few studies examine how caregiving receipt is associated with older person longevity. In a nationally representative sample, we prospectively explore whether and how having an informal caregiver is associated with older adult overall mortality, and how caregivers' burden and benefits perceptions relate to care recipient mortality.

METHODS

We match six National Health and Aging Trends Study waves (2011-2016) with 2011 National Study of Caregiving data, conducting survival analysis on 7,369 older adults and 1,327 older adult-informal caregiver dyads.

RESULTS

Having an informal caregiver is associated with 36% (p < .001) higher mortality risk over 6-year follow-up, adjusting for demographic, economic, and health factors. Older adults whose caregivers perceive only burden have 38% higher (p < .05) mortality risk than those with caregivers reporting neither burden nor benefits. This risk is reduced from 38% higher to 5% higher (p < .001) for older adults with caregivers reporting benefits alongside burden, compared to those with caregivers reporting neither perception.

DISCUSSION

Having a caregiver may signal impending decline beyond known mortality factors. However, interventions to increase caregivers' benefit perceptions and reduce their burden may decrease mortality risk for older adults with declining health and functional ability.

SES inequalities in cause-specific adult mortality: a study of the long-term trends using longitudinal individual data for Sweden (1813-2014)

Higher socioeconomic status (SES) is associated with lower mortality, and this correlation has been confirmed using different indicators across several geographical settings. Nevertheless, the timing of the emergence of the SES gradient remains unclear. We used individual-level longitudinal data for a regional population in southern Sweden covering the period between 1813 and 2014, and we applied a cause-specific proportional hazard model. We estimated SES differences in all-cause, nonpreventable, preventable, and cause-specific adult mortality in four subperiods (1813–1921, 1922–1967, 1968–1989, 1990–2014) by gender adjusting for birth year, place of residence, marital status, and migration status. The SES gradient in mortality present today for both genders emerged only around 1970, and with few exceptions, it emerged at approximately the same time for all causes of death. It emerged earlier for women than for men, particularly in infectious diseases. In the nineteenth and early twentieth centuries, we found a positive association between SES and mortality from circulatory diseases for men. SES has not always been a fundamental cause of mortality; it only emerged as such in the second half of the twentieth century. We argue that habits and behaviors embedded in the different social strata played a major role in the emergence of the SES gradient.

Educational Attainment and Staphylococcus aureus Colonization in a Hispanic Border Community: Testing Fundamental Cause Theory

Unlike some types of S. aureus infections, S. aureus colonization is not associated with ethnicity or educational attainment and thus may be outside the influence of socioeconomic status-based resources typically mobilized to avoid or mitigate preventable health risks. This assessment of a clinically silent risk that usually precedes infections may illustrate a boundary of fundamental cause theory.

This study was carried out to evaluate hypotheses generated by fundamental cause theory regarding the socioeconomic status (SES) gradient in colonization with Staphylococcus aureus among Hispanic and non-Hispanic adults living in a border community. Participants (n = 613) recruited in naturally occurring small groups at public and private sites throughout Yuma County, AZ, completed a sociodemographic survey and swabbed their palms, noses, and throats to sample microbial flora. Positive S. aureus colonization among non-Hispanic white participants was nominally higher (39.0%; 95% confidence interval [CI] = 32.4 to 46.1%) than that in Hispanics (31.3%; 95% CI = 26.4 to 36.8%), but there was no education gradient for the sample overall (incidence rate ratio = 1.00; 95% CI = 0.90 to 1.12) or within each ethnic group separately. The education gradient between Hispanic and non-Hispanic whites was statistically equivalent. Results were consistent when home ownership was used as the SES indicator. These data show that S. aureus colonization is not linked to two different SES indicators or Hispanic ethnicity. S. aureus colonization may be considered a less preventable health risk that is outside the influence of SES-based resources.

IMPORTANCE Unlike some types of S. aureus infections, S. aureus colonization is not associated with ethnicity or educational attainment and thus may be outside the influence of socioeconomic status-based resources typically mobilized to avoid or mitigate preventable health risks. This assessment of a clinically silent risk that usually precedes infections may illustrate a boundary of fundamental cause theory.

The diffusion of innovative diabetes technologies as a fundamental cause of social inequalities in health. The Nord-Trøndelag Health Study, Norway

This study investigates patterns of adoption and diffusion of innovative health technologies by socioeconomic status (SES) in order to assess the extent to which these technologies may be a fundamental cause of health-related inequalities. Quantitative analyses examined SES-based inequalities in the adoption and diffusion of diabetes technologies. Diabetes data from three panels of the Nord-Trøndelag Health Study (HUNT), Norway, were combined with income and education data. Cross-sectional and longitudinal regression analyses were used to examine relevant inequalities. Cross-sectional analyses suggest often present SES-based gradients in the adoption of diabetes technologies, favouring high-SES groups. Statistically significant differences (p ≤ 0.05) were most often present when technologies were new. In a cohort followed from 1984 to 1997, high SES individuals were more likely to adopt insulin injection technologies but, due to modest sample sizes, these inequalities were not statistically significant after adjusting for age, gender, and duration of illness. Moreover, compared to low SES individuals, high SES individuals are more active users of diabetes technologies. Results suggest that SES-based variations in access and use of innovative health technologies could act as a mechanism through which inequalities are reproduced. This study provides a discussion of mechanisms and a methodological foundation for further investigation.