Educational Attainment and Smoking Status in a National Sample of American Adults; Evidence for the Blacks' Diminished Return

COVID-19 Pandemic as an Equalizer of the Health Returns of Educational Attainment for Black and White Americans

BACKGROUND

COVID-19 pandemic has immensely impacted the social and personal lives of individuals around the globe. Marginalized-related diminished returns (MDRs) theory suggests that educational attainment shows a weaker protective effect for health and behavioral outcomes for Black individuals compared to White individuals. Previous studies conducted before the COVID-19 pandemic demonstrated diminished returns of educational attainment for Black individuals compared to White individuals.

OBJECTIVES

The study has three objectives: First, to test the association between educational attainment and cigarette smoking, e-cigarette vaping, presence of chronic medical conditions (CMC), self-rated health (SRH), depressive symptoms, and obesity; second, to explore racial differences in these associations in the USA during the COVID-19 pandemic; and third, to compare the interaction of race and return of educational attainment pre- and post-COVID-19 pandemic.

METHODS

This study utilized data from the Health Information National Trends Survey (HINTS) 2020. Total sample included 1313 adult American; among them, 77.4% (n = 1017) were non-Hispanic White, and 22.6% (n = 296) were non-Hispanic Black. Educational attainment was the independent variable operationalized as years of education. The main outcomes were cigarette smoking, e-cigarette vaping, CMC, SRH, depressive symptoms, and obesity. Age, gender, and baseline physical health were covariates. Race/ethnicity was an effect modifier.

RESULTS

Educational attainment was significantly associated with lower CMC, SRH, depressive symptoms, obesity, cigarette smoking, and e-cigarette vaping. Educational attainment did not show a significant interaction with race on any of our outcomes, suggesting that the health returns of education is similar between non-Hispanic White and non-Hispanic Black individuals.

CONCLUSION

COVID-19 may have operated as an equalizer of the returns of educational attainment. This observation may be because White may have more to lose; Black communities may be more resilient or have economic and social policies that buffered unemployment and poverty regardless of historical anti-Black oppression.

Early Life Disadvantage and the Risk of Depressive Symptoms among Young Black Women

OVERVIEW

We examined the association between early-life socioeconomic disadvantage and depressive symptoms in adulthood and assessed whether social factors in adulthood modify the association.

METHODS

The 11-item Center for Epidemiologic Studies-Depression Scale (CES-D) assessed adult depressive symptoms among 1612 Black women and other participants with a uterus (hereafter participants) in the Study of Environment, Lifestyle and Fibroids. Baseline self-reported childhood factors (i.e., parents in the household, mother's educational attainment, food insecurity, neighborhood safety, childhood income, and quiet bedroom for sleep) were included in a latent class analysis to derive an early life disadvantage construct. Multivariable log-binomial models estimated the association between early life disadvantage and adult depressive symptoms. Potential effect modifiers included adult educational attainment, social support, and financial difficulty.

RESULTS

Participants classified as having high early life disadvantage had 1.34 times (95% CI: 1.20, 1.49) the risk of high depressive symptoms than those in the low early life disadvantage class after adjusting for age, first born status, and childhood health. Adult educational attainment and social support modified the association.

CONCLUSION

Early life disadvantage increased the risk of depressive symptoms in adulthood. Participants with at least some college education and with high social support had greater risk than those with less than college education and low social support, respectively. Thus, the mental health of Black women and other participants with a uterus exposed to early life disadvantage do not necessarily benefit from higher education or from social support.

Household Income and Subsequent Youth Tobacco Initiation: Minorities' Diminished Returns

Introduction

Household income, a prominent socioeconomic status (SES) indicator, is known to mitigate youth engagement in various health risk behaviors, including tobacco use. Nevertheless, the Minorities' Diminished Returns theory suggests that this protective effect may be less pronounced for racial and ethnic minorities compared to majority groups. This study aimed to investigate the protective role of high household income against tobacco use among youth and explore potential variations across different racial and ethnic groups.

Methods

Conducted as a longitudinal analysis, this study utilized data from the initial three years of the Adolescent Brain Cognitive Development (ABCD) Study spanning 2016-2022. The cohort consisted of 11,875 American youth aged 9-10 years, tracked over a three-year period. The dependent variable was tobacco initiation, irrespective of the product, while household income served as the independent variable. Covariates included youth age, gender, family education, structure, and employment, with race/ethnicity acting as the moderating variable.

Results

Out of the 8,754 American youth who were non-smokers at baseline, 3.1% (n = 269) initiated tobacco use during the 30-month follow-up, while 96.9% (n = 8,485) remained non-smokers. A family income exceeding $100,000 per year was associated with a lower hazard ratio for tobacco initiation (transitioning to ever-use) over the follow-up period (HR = 0.620, p = 0.022). However, household income of $50-100k exhibited significant interactions with race/ethnicity on tobacco initiation, indicating weaker protective effects for Black (HR for interaction = 7.860, p < 0.001) and Latino (HR for interaction = 3.461, p = 0.001) youth compared to non-Latino White youth.

Conclusions

Within the United States, the racialization and minoritization of youth diminish the protective effects of economic resources, such as high household income, against the transition to tobacco use. Non-Latino White youth, the most socially privileged group, experience greater protection from their elevated household income regarding tobacco initiation compared to Black and Latino youth, who face minoritization and racialization. Policymakers should address not only the SES gap but also the mechanisms contributing to the heightened risk of tobacco use among racialized and minoritized youth from affluent backgrounds.

Intersectional Effects of Race and Educational Attainment on Memory Function of Middle-Aged and Older Adults With Alzheimer's Disease

BACKGROUND

High educational attainment may protect individuals, particularly middle-aged and older adults, against a wide range of health risks, including memory decline with age; however, this protection is less clear in patients with Alzheimer's disease (AD). In addition, this effect may differ across racial groups. According to the Marginalized-Related Diminished Return (MDR) theory, for example, the protective effect of high educational attainment on mental and physical health shows a weaker protective effect for racial minority groups, particularly Black people compared to White individuals.

OBJECTIVES

This longitudinal study used data of middle-aged and older adults with AD with two aims: first, to test the association between educational attainment and memory, and second, to explore racial differences in this association in the USA.

METHODS

Data came from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study. The total sample was 1673 American middle-aged and older adults. The independent variable was educational attainment measured as years of education. The main outcome was memory operationalized as Rey Auditory Verbal Learning Test (RAVLT) Verbal Forgetting percentage (VF%). Age, gender, and follow-up duration were covariates. Race was the effect modifier. Linear regression model was utilized to analyze the data.

RESULTS

Of all participants, 68 (4.1%) were Black, and the remaining were White, with a mean age of 75 years old. In the pooled sample, educational attainment did not show a significant association with memory, independent of confounders. Educational attainment showed a significant interaction with race on memory, with higher educational attainment having a different effect on memory in White patients compared to Black patients.

CONCLUSION

The effect of higher educational attainment on memory differs for Black patients with AD compared to White patients. To prevent cognitive disparities by race, we need to go beyond racial inequality in access to resources (e.g., education) and minimize diminished returns of educational attainment for racial minorities. To tackle health inequalities, social policies should not be limited to equalizing socioeconomic status but also help minority groups leverage their available resources, such as educational attainment, and secure tangible outcomes.

Racial/Ethnic Heterogeneity in Parental Wealth and Substance Use from Adolescence to Young Adulthood

BACKGROUND

Substance use has a negative impact on health outcomes, at the individual and population levels. Little consensus exists regarding the relationship between socioeconomic position and substance use across race/ethnicity. This study examines how race/ethnicity and socioeconomic factors, especially parental wealth, are associated with substance use across an 18-year span from adolescence to young adulthood.

METHOD

Data were drawn from the National Longitudinal Survey of Youth 1997. Substance use behaviors were measured by self-reported heavy episodic drinking, daily cigarette smoking, and use of cannabis. Parental wealth and parental education were measured at baseline. Other socioeconomic factors included education, employment status, and household income. Two-level logistic regression was performed.

RESULTS

White respondents were more likely to drink, smoke cigarettes, and use cannabis compared to other racial/ethnic groups. More parental wealth was associated with greater odds of heavy episodic drinking, but lower odds of cigarette and cannabis usage. Race/ethnicity modifies the relationships between parental wealth and substance use. Whereas Black respondents from wealthier families had lower odds of heavy episodic drinking, the direction was opposite among white respondents. Wealth functioned as a protective factor against smoking for all groups, although to a lesser extent among respondents of color than for white respondents. Finally, wealthier Hispanics were more likely to smoke daily and use cannabis compared to other racial/ethnic groups.

CONCLUSION

These findings highlight a nuanced patterning of racial/ethnic heterogeneity in the relationship between parental wealth and substance use behaviors. Implications for policy and programming are discussed.

Black Americans' Diminished Return of Educational Attainment on Tobacco Use in Baltimore City

BACKGROUND

Socioeconomic status (SES) indicators such as educational attainment are fundamental factors affecting health. One mechanism through which education affects health is by reducing the likelihood of engaging in high-risk behaviors such as smoking. However, according to the marginalization-related diminished returns (MDRs) theory, the association between education and health may be weaker for marginalized populations such as Black than White, primarily due to racism and discrimination. However, little is known about the racial variations in the differential associations between educational attainment and tobacco use in a local setting.

AIM

This study aimed to investigate the differential association between educational attainment and tobacco use among racial groups in a community sample in Baltimore City.

METHODS

This cross-sectional study used data from a community survey conducted in 2012-2013 in Baltimore City among adults aged 18 years or older. The participants were 3501 adults. Univariate, bivariate, and logistic regression analyses were performed using Stata to investigate the racial difference in the association between education and two outcomes: current smoking status and menthol tobacco product use.

RESULTS

The study found that adults with a graduate degree were less likely to be current smokers (adjusted odds ratio [AOR]: 0.10, 95% confidence interval [CI]: 0.08-0.13) and menthol tobacco users (AOR: 0.10, 95% CI: 0.07-0.14) compared to those with less than high school diploma. The inverse associations between educational attainment and current smoking (AOR: 1.83, 95% CI: 1.05-3.21) and menthol tobacco product use (AOR: 4.73, 95% CI: 2.07-10.80) were weaker for Back individuals than those who were White.

CONCLUSION

Due to MDRs of educational attainment, while highly educated White adults show a low risk of tobacco use, educated Black adults remain at a disproportionately increased risk. The study emphasizes the need for better policies and programs that address minorities' diminished return of education for tobacco use.

Patient-Level Characteristics Associated with Tobacco Users and Nonusers at a Student-Run Free Clinic

OBJECTIVES

Many tobacco users are motivated to quit but lack the resources to do so. To date, studies characterizing tobacco users at student-run free clinics have used small sample sizes, which may not be large enough to detect differences across key variables. As such, we assessed sociodemographic differences between tobacco users and nonusers at a student-run free clinic using a pooled cross-sectional design.

METHODS

We used patient-level data from the electronic health records for all of the patients who were seen during January 2012 to February 2020 inclusive. Our dependent variable was whether patients self-reported tobacco use. We assessed for differences across age, sex, race/ethnicity, and education level using a multivariable logistic regression model.

RESULTS

Across 4264 patients, 28.7% reported tobacco use. When controlling for other factors, greater odds of tobacco use were observed in this cohort for patients who were male (odds ratio [OR] 1.690, 95% confidence interval [CI] 1.468-1.944), those with educational attainment of 9th to 11th grade (OR 2.291, 95% CI 1.558-3.369), and those who were high school graduates/completed the General Education Development test (OR 1.849, 95% CI 1.295-2.638) compared with those with less than a high school education. Similarly, patients of older age had greater odds of tobacco use.

CONCLUSIONS

Our study found patient-level differences that may need to be integrated into improving the reach of intervention methods. Future research should look at a broader set of metrics (eg, geographic location, socioeconomic status) and ascertain reasons for sociodemographic differences observed.

Association between School Achievement and Tobacco Susceptibility among US Adolescents: Ethnic Differences

BACKGROUND

Although risky behaviors such as educational problems and tobacco use tend to co-occur, these associations may vary across diverse ethnic groups, in part because ethnic minorities tend to reside in worse neighborhoods and tend to attend worse schools than Non-Latino White adolescents.

AIM

To compare the association between baseline school achievement (student grades) and subsequent tobacco use susceptibility (openness to smoke in future) by ethnicity, we compared African American, Latino, and Non-Latino White adolescents in the US over a four-year period.

METHODS

This longitudinal study followed 3636 adolescents who were never smokers at baseline for a period of four years. Baseline and four-year data of the Population Assessment of Tobacco and Health (PATH) study were used for this analysis. All participants were 12 to 17 years old at baseline and were either Non-Latino White (Majority), African American (Minority), or Latino (Minority). The outcome was a tobacco use susceptibility score at wave 4 which was defined as openness to use tobacco in the future, measured at year four. The predictor was school achievement at wave 1, measured as grades from F to A+. The moderator was ethnicity (African American, Latino, Non-Latino White), and covariates were age, gender, parental education, and family structure.

RESULTS

Our linear regressions in the pooled sample showed an inverse association between baseline school achievement and subsequent tobacco use susceptibility four years later. However, this inverse association was weaker for ethnic minorities than for Non-Latino White adolescents, as documented by interaction effects between ethnic minority status and baseline school grades.

CONCLUSION

Higher educational success better correlates with lower tobacco use susceptibility of non-Latino White than African American and Latino adolescents, which may reflect some tobacco use susceptibility of Latino and African American adolescents with highly educated parents. Future research should investigate how social context such as high-risk school environment, neighborhood risk, peer risk, and other mechanisms increase behavioral risk of educationally successful African American and Latino adolescents.

Temporal Trends (from 2008 to 2017) in Functional Limitations and Limitations in Activities of Daily Living: Findings from a Nationally Representative Sample of 5.4 Million Older Americans

This study's objectives are as follows: (1) to identify the temporal trends in the prevalence and the odds of activities of daily living (ADL) limitations and functional limitations (FLs) among Americans aged 65 and older; (2) to explore if these trends vary by gender and age cohort; (3) to determine if generational differences in educational attainment play a role in the observed temporal trends. A secondary analysis of the American Community Survey (ACS) was conducted for ten consecutive waves of the annual cross-sectional survey (2008-2017). The respondents were community-dwelling and institutionalized adults aged 65 and older (n = 5.4 million). The question on ADLs was "Does this person have difficulty dressing or bathing?". The question on FLs was "Does this person have serious difficulty walking or climbing stairs?". There was a substantial decline over the decade in the prevalence of ADL limitations, from 12.1% to 9.6%, and FLs, from 27.3% to 23.5%. If the 2017 prevalence rates had remained at the same level as the 2008 prevalence rates, there would have been an additional 1.27 million older Americans with ADL limitations and 1.89 million with FLs. Adjusting for educational attainment substantially attenuated the odds of the decline for both ADL limitations and FLs.

Parental Education and Adolescents' Asthma: The Role of Ethnicity

While high parental education is associated with better health, this association may be weaker for ethnic minority than for ethnic majority families. It is unknown whether the association between parental education and adolescents' asthma also varies by ethnicity.

AIM

To study the association between parental education and adolescents' asthma overall and by ethnicity.

METHODS

The current study used data from the Population Assessment of Tobacco and Health (PATH)-Adolescents study. All participants were 12 to 17-year-old non-smokers (n = 8652). The outcome of interest was adolescents' asthma. The predictor of interest was baseline parental education, the covariates were age, sex, and number of parents present at baseline, and the moderator was ethnicity.

RESULTS

According to logistic regression analyses, higher parental education was predictive of adolescents' asthma; however, this association was weaker for Latino than non-Latino adolescents (OR 1.771; CI 1.282-2.446). We did not find a significant difference in the effect of parental education on asthma of White and African American adolescents. Our stratified models also showed that higher parental education was associated with lower asthma for non-Latino but not for Latino adolescents.

CONCLUSION

The effect of high parental education on adolescents' asthma prevalence differs between Latino and non-Latino families, with Latino families showing weaker protective effects of parental education on adolescents' asthma. Future research should test the role of exposure to environmental pollutants, neighborhood quality, and prevalence of smoking in social network members as well as other contextual factors at home, in school, and in the neighborhood that may increase prevalence of asthma in Latino adolescents regardless of their parental education. Given that these potential causes are multi-level, potential causes of such disparities should be tested in future multi-level research.

Race and Ethnic Differences in the Protective Effect of Parental Educational Attainment on Subsequent Perceived Tobacco Norms among US Youth

BACKGROUND

Although parental educational attainment is known to be associated with a lower prevalence of behaviors such as tobacco use, these effects are shown to be weaker for Black than White youth. It is important to study whether this difference is due to higher perceived tobacco use norms for Black youth.

AIM

To study the association between parental educational attainment and perceived tobacco use norms overall and by race/ethnicity among youth in the US.

METHODS

The current study used four years of follow-up data from the Population Assessment of Tobacco and Health (PATH-Youth) study conducted between 2013 and 2017. All participants were 12- to 17-year-old non-smokers at baseline and were successfully followed for four years (n = 4329). The outcome of interest was perceived tobacco use norms risk at year four. The predictor of interest was baseline parental educational attainment, the moderator was race/ethnicity, and the covariates were age, sex, and parental marital status at baseline.

RESULTS

Our linear regressions in the pooled sample showed that higher parental educational attainment at baseline was predictive of perceived disapproval of tobacco use at year four; however, this association was weaker for Latino than non-Latino youth. Our stratified models also showed that higher parental educational attainment was associated with perceived tobacco use norms for non-Latino but not for Latino youth.

CONCLUSION

The effect of high parental educational attainment on anti-tobacco norms differs between Latino and non-Latino youth. Latino youth with highly educated parents remain at risk of tobacco use, while non-Latino youth with highly educated parents show low susceptibility to tobacco use.

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.

Immigration Status, Socioeconomic Status, and Self-Rated Health in Europe

The literature has established a protective effect of socioeconomic status (SES) indicators on health. However, at least in the US, these SES indicators tend to generate fewer health gains for marginalized groups including immigrants. As this literature mainly originated in the US, it is necessary to study whether these indicators similarly correlate with the health of foreign-born and native-born individuals in Europe. The current study was based on the Marginalization-related Diminished Returns (MDRs) theory and compared the effects of three SES indicators, namely parental education, own education and income, on self-rated health (SRH) of immigrant and native-born individuals. We used data from the European Social Survey 2020 (ESS 2020). Participants included 14,213 individuals who identified as either native-born (n = 9052) or foreign-born (n = 508). Education, income, and parental education were the independent variables. Self-rated health (SRH) was the outcome. Age and sex were covariates. Linear regression and logistic regression were used for data analysis. Overall, high education, income, and parental education were associated with lower odds of poor SRH. We documented a statistical interaction between immigration status and parental education, indicating a weaker inverse association between parental education and poor SRH for foreign-born than native-born individuals. The links between some but not all SES indicators vary across foreign-born and native-born individuals in Europe. Host countries seem to undervalue the parental educational attainment of foreign-born families. Future research should explore the role of time, period, cohort and country of origin as well as host country and associated policies in equalizing returns of SES indicators on the health of population subgroups. The results are important given that most studies on MDRs are developed in the US, and less is known about Europe. The results are also very important given the growing anti-immigrant sentiment and nationalist movements in Europe and the rest of the world.

Socioeconomic inequalities and Black/White disparities in US cocaine-involved overdose mortality risk

PURPOSE

This study examined whether socioeconomic inequalities account for Black/White disparities in: (a) the prevalence of potential risk factors for overdose among adults using cocaine; and (b) national mortality rates for cocaine-involved overdose.

METHODS

Data from 2162 Non-Hispanic (NH) Black or White adults (26 +) who reported past-year cocaine use in the 2015-2019 National Survey of Drug Use and Health were analyzed to obtain predicted probabilities of potential overdose risk factors by race and sex, using marginal effects via regression analyses, adjusting for age and socioeconomic indicators. Next, National Center for Health Statistics data (for 47,184 NH Black or White adults [26 +] who died of cocaine-involved overdose between 2015 and 2019) were used to calculate cocaine-involved overdose mortality rates by race and sex across age and educational levels.

RESULTS

Several potential overdose vulnerabilities were disproportionately observed among NH Black adults who reported past-year cocaine use: poor/fair overall health; cocaine use disorder; more days of cocaine use yearly; hypertension (for women); and arrests (for men). Adjusting for age and socioeconomic indicators attenuated or eliminated many of these racial differences, although predicted days of cocaine use per year (for men) and cocaine use disorder (for women) remained higher in NH Black than White adults. Cocaine-involved overdose mortality rates were highest in the lowest educational strata of both races; nonetheless, Black/White disparities were observed even at the highest level of education, especially for adults ages 50 + .

CONCLUSION

Age and socioeconomic characteristics may account for some, yet not all, of Black/White disparities in vulnerability to cocaine-involved overdose.

The effect of race/ethnicity and adversities on smoking cessation among U.S. adult smokers

INTRODUCTION

Black and Hispanic individuals in the US experience more socioeconomic adversities that are associated with disparities in tobacco use and cessation than White individuals. This study examined if racial/ethnic differences in smoking abstinence were mediated by socioeconomic (SES) adversities.

METHODS

Data from 7,101 established smokers were identified in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) and followed to Wave 4 (2016-2018). The study outcome was cigarette abstinence at Wave 4. The main independent variable was race/ethnicity (Non-Hispanic White [White], Non-Hispanic Black [Black] and Hispanic). The mediators were five measures of SES adversities (unemployment, poverty, difficulty with money, lower education level, lack of health insurance). A weighted Generalized Structural Equation Model (GSEM) was used to estimate the total, direct, and indirect effect of race/ethnicity on the odds of quitting mediated by the five SES adversities. This model was adjusted by study covariates, including health and smoking characteristics.

RESULTS

The indirect effect of race/ethnicity on cessation showed that differences in quitting between Black and White individuals as well as Hispanic and White individuals were mediated by SES adversities. However, the differences in quitting between Hispanic and Black individuals were not mediated by SES adversities. Black and Hispanic individuals were less likely to quit than White individuals, but Hispanic individuals were more likely to quit than Black individuals. There were no direct effects between Black or Hispanic individuals compared to White individuals. Those with higher SES were more likely to quit compared to those with lower SES.

DISCUSSION

Smoking abstinence is higher in White individuals compared to Black and Hispanic individuals and is mediated by SES adversities. However, smoking abstinence is higher among Hispanic individuals compared to Black individuals and it is not mediated by SES adversities. Future studies should consider the role of other factors, such as psychosocial support, racism, discrimination, and stress over the life course in explaining differences in smoking abstinence between Black and Hispanic individuals.

Tobacco-related health inequalities among Black Americans: A narrative review of structural and historical influences

We conducted a narrative literature review to examine contributing factors of disparities in tobacco usage and outcomes affecting Black Americans. We propose potential solutions that can be used to effectively address these disparities. We identified historical factors; socioeconomic factors; targeted marketing/advertising; the influence of racism/discrimination; neighborhood socioeconomic disadvantage; and mass incarceration. We call for more thorough examinations of these factors as a key element of tobacco-focused research and interventions to eliminate the disproportionate burdens faced by Black Americans. We advocate for greater emphases on the impacts of personal and structural racism on tobacco usage and outcomes affecting Black Americans.

Secondhand smoke exposure for different education levels: findings from a large, nationally representative survey in Turkey

OBJECTIVES

The aim of this study is to determine the factors that influence individuals' exposure to tobacco smoke in Turkey according to their education level.

DESIGN

Secondary data analysis.

PARTICIPANTS

Altogether, 17 084 individuals aged 15 and over were included in this study.

SETTINGS

Data set of the Turkey Health Survey in 2019.

METHODS

Binary logistic regression analysis was used to determine the factors associated with individuals' exposure to tobacco smoke.

PRIMARY AND SECONDARY OUTCOME MEASURES

The variables age, gender, marital status, general health status, employment status, receipt of psychosocial support and tobacco use were found to be correlated with exposure to tobacco smoke.

RESULTS

The study determined that individuals who are illiterate/unschooled were exposed to tobacco smoke at a rate of 32.61%, primary school graduates at a rate of 34.32%, primary education graduates at a rate of 41.75%, high school graduates at a rate of 41.04% and university graduates at a rate of 40.34%.

CONCLUSION

As a result of the study, it is emphasised that men, young individuals, individuals with moderate and very good general health status, those who use tobacco, those who are unemployed and those who receive psychosocial support should be targeted. In addition, appropriate strategies for reducing secondhand smoke (SHS) exposure should be developed, taking into account public health strategies for increasing awareness of the adverse health effects of SHS exposure and the determinants of tobacco exposure according to the study.

Association Between Parental Educational Attainment and Children's Negative Urgency: Sex Differences

Background and aims

Negative urgency reflects a specific facet of impulsivity and correlates with a wide range of health-related risk behaviors, including, but not limited to, problematic substance use. Negative urgency is also shaped by family socioeconomic position (SEP), such as parental educational attainment (PEA). This study aimed to explore sex differences regarding protective effects of PEA on children's negative urgency in the US.

Methods

This cross-sectional study used the Adolescent Brain Cognitive Development (ABCD) study data. Baseline ABCD data included 10,535 American children in the age range of 9-10 years old. The independent variable was PEA, treated as a 5-level categorical variable. The primary outcome was negative urgency measured by the Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency, Impulsive Behavior Scale (UPPS-SS). Mixed-effects regression models were applied for data analysis.

Results

In sex-stratified regression models, high PEA was predictive of lower levels of negative urgency in female but not male children. In the overall sample, sex showed a statistically significant interaction with PEA on children's negative urgency, indicating a stronger protective effect of high PEA for female compared to male children.

Conclusion

PEA was a more salient determinant of negative urgency in female children than male ones. Our results also showed that American boys tend to have high levels of negative urgency, which is a risk factor of drug use, at all parental education levels.

Social Determinants of Cigarette Smoking among American Women during Pregnancy

Educational attainment is among the most substantial protective factors against cigarette smoking, including during pregnancy. Although Minorities’ Diminished Returns (MDRs) of educational attainment, defined as weaker protective effect of education for racial and ethnic minority groups compared to Non-Hispanic Whites, has been demonstrated in previous studies; such MDRs are not tested for cigarette smoking during pregnancy. To better understand the relevance of MDRs to tobacco use during pregnancy, this study had three aims: firstly, to investigate the association between educational attainment and cigarette smoking in pregnant women; secondly, to compare racial and ethnic groups for the association between educational attainment and cigarette smoking; and thirdly, to explore the mediating effect of poverty status on such MDRs, among American adults during pregnancy. This cross-sectional study explored a nationally representative sample of pregnant American women (n = 338), which was taken from the Population Assessment of Tobacco and Health (PATH; 2013). Current smoking was the outcome. Educational attainment was the independent variable. Region and age were the covariates. Poverty status was the mediator. Race and ethnicity were the effect modifiers. Overall, a higher level of educational attainment (OR = 0.54, p < 0.05) was associated with lower odds of current smoking among pregnant women. Race (OR = 2.04, p < 0.05) and ethnicity (OR = 2.12, p < 0.05) both showed significant interactions with educational attainment on smoking, suggesting that the protective effect of educational attainment against smoking during pregnancy is smaller for Blacks and Hispanics than Non-Hispanic Whites. Poverty status fully mediated the above interactions. In the United States, highly educated pregnant Black and Hispanic women remain at higher risk of smoking cigarettes, possibly because they are more likely to live in poverty, compared to their White counterparts. The results suggest the role that labor market discrimination has in explaining lower returns of educational attainment in terms of less cigarette smoking by racial and ethnic minority pregnant women.

Prospective estimation of the age of initiation of cigarettes among young adults (18-24 years old): Findings from the Population Assessment of Tobacco and Health (PATH) waves 1-4 (2013-2017)

OBJECTIVES

To prospectively estimate the age of cigarette initiation among young adults (18-24 years old) who were never cigarette users at their first wave of adult study participation overall, by sex, and by race/ethnicity given recent increases in cigarette initiation occurring in young adulthood.

METHODS

Secondary analyses were conducted using the PATH restricted-use adult datasets among young adult never users of cigarettes in waves 1-3 (2013-2016) with outcomes followed-up in waves 2-4 (2014-2017). Interval censoring survival methods were used to estimate the age of initiation of (i) ever, (ii) past 30-day, and (iii) fairly regular cigarette use. Among never cigarette users when they first entered the adult study, interval censoring Cox proportional hazard models were used to explore differences in the estimated age of initiation of the three cigarette use outcomes by sex and by race/ethnicity, controlling for the effect of previous e-cigarette use and the total number of other tobacco products ever used (0-5 products) before cigarette initiation outcomes.

RESULTS

Among the young adults who were never cigarette users at their first wave of adult participation, the highest increase in cigarette initiation occurred between 18 and 19 years old. By age 21, 10.6% (95% CI: 9.5-11.7) initiated ever cigarette use, 7.7% (95% CI: 6.1-8.1) initiated past 30-day of cigarette use, and 1.9% (95% CI: 1.4-2.5) initiated fairly regular cigarette use. After controlling for other tobacco products: (a) males were 83% more likely to initiate past 30-day cigarette use at earlier ages than females; (b) Hispanic and Non-Hispanic Black young adults had increased risk to initiate past 30-day cigarette use at earlier ages than Non-Hispanic White young adults (62% and 34%, respectively).

CONCLUSIONS

The substantial amount of cigarette initiation among young adults reinforces the need for prevention strategies among this population. Although, interventions are needed for all young adult populations, strategies should target 18-21-year-olds, with potentially differential prevention targets by sex and by race/ethnicity.

Do the Benefits of Educational Attainment for Late-life Cognition Differ by Racial/Ethnic Group?: Evidence for Heterogenous Treatment Effects in the Kaiser Healthy Aging and Diverse Life Experience (KHANDLE) Study

INTRODUCTION

Educational attainment is associated with late-life cognitive performance and dementia; few studies have examined diverse racial/ethnic groups to assess whether the association differs by race/ethnicity.

METHODS

We investigated whether the association between educational attainment and cognition differed between White, Black, Asian, and Latino participants in the Kaiser Healthy Aging and Diverse Life Experiences study (n=1348). Covariate-adjusted multivariable linear regression models examined domains of verbal episodic memory, semantic memory, and executive functioning.

RESULTS

We observed significant effect heterogeneity by race/ethnicity only for verbal episodic memory (P=0.0198), for which any schooling between high school and college was beneficial for White, Asian, and Black participants, but not Latino participants. We found no evidence of heterogeneity for semantic memory or executive function.

DISCUSSION

With the exception of Latino performance on verbal episodic memory, more education consistently predicted better cognitive scores to a similar extent across racial/ethnic groups, despite likely heterogenous educational and social experiences.

Parental Education and Left Lateral Orbitofrontal Cortical Activity during N-Back Task: An fMRI Study of American Adolescents

Introduction. The Orbitofrontal Cortex (OFC) is a cortical structure that has implications in cognition, memory, reward anticipation, outcome evaluation, decision making, and learning. As such, OFC activity correlates with these cognitive brain abilities. Despite research suggesting race and socioeconomic status (SES) indicators such as parental education may be associated with OFC activity, limited knowledge exists on multiplicative effects of race and parental education on OFC activity and associated cognitive ability. Purpose. Using functional brain imaging data from the Adolescent Brain Cognitive Development (ABCD) study, we tested the multiplicative effects of race and parental education on left lateral OFC activity during an N-Back task. In our study, we used a sociological rather than biological theory that conceptualizes race and SES as proxies of access to the opportunity structure and exposure to social adversities rather than innate and non-modifiable brain differences. We explored racial variation in the effect of parental educational attainment, a primary indicator of SES, on left lateral OFC activity during an N-Back task between Black and White 9–10 years old adolescents. Methods. The ABCD study is a national, landmark, multi-center brain imaging investigation of American adolescents. The total sample was 4290 9–10 years old Black or White adolescents. The independent variables were SES indicators, namely family income, parental education, and neighborhood income. The primary outcome was the average beta weight for N-Back (2 back versus 0 back contrast) in ASEG ROI left OFC activity, measured by functional Magnetic Resonance Imaging (fMRI) during an N-Back task. Ethnicity, age, sex, subjective SES, and family structure were the study covariates. For data analysis, we used linear regression models. Results. In White but not Black adolescents, parental education was associated with higher left lateral OFC activity during the N-Back task. In the pooled sample, we found a significant interaction between race and parental education on the outcome, suggesting that high parental education is associated with a larger increase in left OFC activity of White than Black adolescents. Conclusions. For American adolescents, race and SES jointly influence left lateral OFC activity correlated with cognition, memory, decision making, and learning. Given the central role of left lateral OFC activity in learning and memory, our finding calls for additional research on contextual factors that reduce the gain of SES for Black adolescents. Cognitive inequalities are not merely due to the additive effects of race and SES but also its multiplicative effects.

Do Financial Literacy and Financial Education Influence Smoking Behavior in the United States?

Smoking is still a serious economic, health, and social problem despite various efforts to curb its prevalence. We examined the influence of financial literacy and financial education on the smoking behavior in the United States in terms of the use of rational decision-making abilities to reduce irrational behavior. We hypothesized that financial literacy and financial education, as proxies for rational decision making, would reduce the likelihood of smoking. We used data from the Preference Parameters Study (PPS) of Osaka University conducted in the United States in 2010 and applied probit regression models to test our hypothesis on a sample of 3831 individuals. We found that financially literate people are less likely to be smokers, though we found no clear role of financial education in reducing the likelihood of smoking. Further, respondents' gender, age, unemployment status, and risky health behaviors such as drinking and gambling, have a significantly positive association with smoking, while marital status, university degree, family size, household income, household assets, physical exercise, and level of happiness have a significantly negative association. Our findings suggest that financial literacy, as an instrument encouraging rational decision making, could be a tool to help reduce smoking in the United States.

Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project

BACKGROUND

Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior.

METHODS

A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. Adjusted prevalence ratios for current smoking versus not smoking were also computed.

RESULTS

MAP participants reported current smoking prevalence (33%) more than double the national adult smoking prevalence. Current smoking among participants with a reported diagnosis of chronic obstructive pulmonary disease and emphysema was 51.5 and 53.3%, respectively. Compared to participants age 65 years and older, those age 45 years or younger reported double the prevalence of smoking (PR: 2.04, 95% CI: 1.51-2.74). Adjusted analyses identified younger age, lower education, unmet financial need, and depression to be significantly associated with current smoking.

CONCLUSIONS

Despite declining rates of smoking across the United States, smoking remains a persistent challenge in Central Appalachia, which continues to face marked disparities in education funding and tobacco control policies that have benefitted much of the rest of the nation. Compared with national data, our cohort demonstrated higher rates of smoking among younger populations and reported a greater intensity of cigarette use.

Black-White Achievement Gap: Role of Race, School Urbanity, and Parental Education

Background

Recent research on Marginalization-related Diminished Returns (MDRs) has documented weaker boosting effects of parental educational attainment on educational outcomes of Black than White students. Such MDRs of parental education seem to contribute to the Black-White achievement gap. Given that Blacks are more likely than Whites to attend urban schools, there is a need to study if these MDRs can be replicated at both urban and suburban schools.

Aim

To test the contribution of diminished returns of parental educational attainment on the Black-White achievement gap in urban and suburban American high schools.

Methods

A cross-sectional study that used baseline Education Longitudinal Study (ELS-2002) data, a nationally representative study of 10th grade adolescents in the United States. This study analyzed 8315 youths who were either non-Hispanic White (n = 6539, 78.6%) or non-Hispanic Black (n = 1776, 21.4%) who were attending either suburban (n = 5188, 62.4%) or urban (n = 3127, 37.6%) schools. The outcome was standard math and reading grades. The independent variable was parental educational attainment. Gender, parental marital status, and school characteristics (% free lunch and relationship quality with the teacher) were the confounders. Race/ethnicity was the effect of modifier. School urbanity was the strata. Linear regression was used for data analysis.

Results

In urban and suburban schools, higher parental educational attainment was associated with higher math and reading test scores. In urban and suburban schools, Black students had considerably lower reading and math scores than White students. At urban but not suburban schools, significant interactions were found between race (Non-Hispanic Black) and parental education attainment (years of schooling) on reading and math scores, suggested that the protective effect of parental education on students’ reading and math scores (ie school achievement) is smaller for Non-Hispanic Black relative to Non-Hispanic White youth only in urban but not sub-urban schools.

Conclusion

Diminished returns of parental education (MDRs) contribute to the racial achievement gap in urban but not suburban American high schools. This result is important given Black students are more likely to attend urban schools than White students. As MDRs are not universal and depend on context, future research should study contextual characteristics of urban schools that contribute to MDRs.

Parental Education, Household Income, Race, and Children's Working Memory: Complexity of the Effects

Background. Considerable research has linked social determinants of health (SDoHs) such as race, parental education, and household income to school performance, and these effects may be in part due to working memory. However, a growing literature shows that these effects may be complex: while the effects of parental education may be diminished for Blacks than Whites, household income may explain such effects. Purpose. Considering race as sociological rather than a biological construct (race as a proxy of racism) and built on Minorities' Diminished Returns (MDRs), this study explored complexities of the effects of SDoHs on children's working memory. Methods. We borrowed data from the Adolescent Brain Cognitive Development (ABCD) study. The total sample was 10,418, 9- and 10-year-old children. The independent variables were race, parental education, and household income. The primary outcome was working memory measured by the NIH Toolbox Card Sorting Test. Age, sex, ethnicity, and parental marital status were the covariates. To analyze the data, we used mixed-effect regression models. Results. High parental education and household income were associated with higher and Black race was associated with lower working memory. The association between high parental education but not household income was less pronounced for Black than White children. This differential effect of parental education on working memory was explained by household income. Conclusions. For American children, parental education generates unequal working memory, depending on race. This means parental education loses some of its expected effects for Black families. It also suggests that while White children with highly educated parents have the highest working memory, Black children report lower working memory, regardless of their parental education. This inequality is mainly because of differential income in highly educated White and Black families. This finding has significant public policy and economic implications and suggests we need to do far more than equalizing education to eliminate racial inequalities in children's cognitive outcomes. While there is a need for multilevel policies that reduce the effect of racism and social stratification for middle-class Black families, equalizing income may have more returns than equalizing education.

Subjective Socioeconomic Status and Children's Amygdala Volume: Minorities' Diminish Returns

Considerable research has suggested that low socioeconomic status (SES) negatively influences brain structure, including but not limited to decreased amygdala volume. Considering race and ethnicity as sociological rather than biological constructs, this study was built on minorities' diminished returns (MDRs) to test if the effects of family SES on the total amygdala volume is weaker for black and Latino children than white and non-Latino children. We borrowed data from the Adolescent Brain Cognitive Development (ABCD) study, a national multi-center brain imaging investigation of childhood brain development in the US. The total sample was 9380 9-10-year-old children. The independent variables were subjective family SES and parental education. The primary outcome was total amygdala volume. High subjective SES and parental education were independently associated with larger total amygdala size. The association between high subjective SES and larger total amygdala volume was less pronounced for black and Latino children than white and non-Latino children. For American children, family SES has unequal effects on amygdala size and function, a pattern that is consistent with MDRs. This result suggests that SES loses some of its expected effects for racial and ethnic minority families.

Widening disparities in cigarette smoking by race/ethnicity across education level in the United States

Reducing tobacco use is an important public health objective. It is the largest preventable cause of death and disease, yet inequalities remain. This study examines combined educational and racial/ethnic disparities in the United States related to cigarette smoking for the three largest racial/ethnic groups (African Americans, Hispanics/Latinos, and non-Hispanic Whites). Data included nine Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) conducted in the United States from 1992/1993-2018 for four smoking metrics: ever smoking rates, current smoking rates, consumption (cigarettes per day), and quit ratios. Across all TUS-CPS samples, there were 9.5% African Americans, 8.8% Hispanics/Latinos, and 81.8% non-Hispanic Whites who completed surveys. Findings revealed that lower educational attainment was associated with increased ever and current smoking prevalence over time across all racial/ethnic groups, and education-level disparities within each race/ethnicity widened over time. Disparities in ever and current smoking rates between the lowest and highest categories of educational attainment (less than a high school education vs. completion of college) were larger for African Americans and non-Hispanic Whites than Hispanics/Latinos. Non-Hispanic Whites had the highest cigarette consumption across all education levels over time. College graduates had the highest quit ratios for all racial/ethnic groups from 1992 to 2018, with quit ratios significantly increasing for Hispanics/Latinos and non-Hispanic Whites, but not African Americans. In conclusion, educational disparities in smoking have worsened over time, especially among African Americans and Hispanics/Latinos. Targeted tobacco control efforts could help reduce these disparities to meet public health objectives, although racial/ethnic disparities may persist regardless of educational attainment.

Maternal Education at Birth and Youth Breakfast Consumption at Age 15: Blacks' Diminished Returns

Background

Based on the Marginalization-related Diminished Returns (MDRs) framework, high socioeconomic status (SES) such as parental education shows weaker effects for Blacks than Whites. For example, high SES Black individuals report a high level of depression, anxiety, suicide, chronic disease, smoking, and mortality. Limited knowledge exists on MDRs of parental education on dietary behavior.

Aims

Built on the MDRs framework, we tested the hypothesis of whether the effect of parental education on eating breakfast differs for Black compared to White families. We hypothesized that there is an association between mothers' educational attainment and eating breakfast and compared Blacks and Whites for the effect of mothers' educational attainment on the frequency of eating breakfast.

Methods

The Fragile Families and Child Wellbeing Study is a 15-year follow up study of a random sample of births in cities larger than 200,000 population. The predictor was parental education at birth. The outcome was the frequency of eating breakfast at age 15. Linear regression was used for data analysis.

Results

Maternal educational attainment at birth was positively associated with youth frequency of eating breakfast among Whites, not Blacks. We also found a significant interaction between maternal educational attainment at birth and race, suggesting that the association between maternal education and youth frequency of eating breakfast at age 15 was weaker for Black than White families.

Conclusions

Diminished returns of maternal educational attainment on healthy youth diet may contribute to the racial disparities in poor health of high SES Black families. That is, a smaller protective effect of maternal education on changing health behaviors for Black than White youth may be one of the mechanisms by which health is worse than expected in high SES Black families. The health disparities are not only due to racial differences in SES but also the diminishing returns of socioeconomic status indicators such as education for racial minorities. Research should study contextual and structural factors that reduce Black families' ability to mobilize their human capital and secure health outcomes in urban settings.

Protective Effects of Maternal Education against Low Birth Weight Deliveries: Blacks' Diminished Returns

Background

Racial and economic disparities in low birth weight (LBW) deliveries is among the most well-established differences between Blacks and Whites. As LBW is an established risk factor for chronic diseases such as asthma and diabetes, it is particularly important to understand drivers of racial and economic disparities in LBW deliveries in urban areas.

Aims

Built on the Minorities' Diminished Returns framework, which argues that educational attainment generates fewer positive health outcomes for Black than White Americans, we conducted this study with three aims: 1) to test the association between mothers' educational attainment and LBW of babies born in urban areas, 2) to compare Blacks and Whites for the effect of mothers' educational attainment on LBW, and 3) to test whether LBW is predictive of future chronic diseases 15 years later.

Methods

Data came from the Fragile Families and Child Well-being / included a random sample of births in cities larger than 200,000 population. For the aims 1 and 2, we analyzed data of 2,922 births to Black (n = 2,146) or White (n = 776) mothers. For aim 3, we analyzed data of a subsample of 1,604 Black or White newborns who were followed to age 15. The presence or absence of chronic diseases was determined at age 15. Logistic regression was used for data analysis.

Results

Maternal educational attainment was inversely associated with LBW overall. We, however, found a significant interaction between maternal educational attainment and race, suggesting that the inverse association between maternal education and LBW is weaker for Black than White babies. At the same time, LBW increased the odds of chronic disease 15 years later.

Conclusions

Diminished returns of maternal educational attainment contribute to racial disparities in LBW, which in turn contributes to future racial inequalities in chronic diseases in urban settings. That is, smaller protective effects of maternal education on reducing LBW for Black than White children contribute to the high prevalence of chronic diseases among adolescents in urban settings. Health disparities are not just due to racial differences in socioeconomic status but also diminishing returns of socioeconomic status indicators such as education for racial and ethnic minorities. Research should study contextual factors that reduce Blacks' ability to translate their human capital to health outcomes in urban settings.

Social determinants of alcohol and cigarette use by race/ethnicity: Can we ignore measurement issues?

Psychometric critiques of cross-cultural research emphasize testing whether instruments measure the same construct across cultural groups. We tested for measurement invariance (by race/ethnicity) of instruments used to evaluate the relationship between alcohol and tobacco use with perceived discrimination and socioeconomic status (SES). Tests of psychometric equivalence across race/ethnicity focused on: the latent organization of constructs (configural invariance); if observed indicators have equal factor loadings or "true score" variance (metric invariance); and whether manifest indicators change uniformly contingent on change in the latent variable (scalar invariance). A cross-sectional survey of 2,376 cigarette smokers (794 Black, 786 Latinx, 796 White; mean age = 43 [SD = 12]; 58% female) was recruited via an online research panel. Discrimination was indicated by self-report; SES was indicated by self-reported education, employment, income, and the "SES Ladder;" alcohol use was indicated by frequency and typical quantity of drinking, and frequency of heavy drinking; tobacco use was indicated by frequency of smoking, cigarettes per smoking day, and time to first cigarette. All instruments demonstrated configural invariance; either full metric invariance (alcohol and discrimination) or partial metric invariance (tobacco and SES); and all constructs demonstrated partial scalar invariance. Results support psychometric critiques; for example, all of the SES indicators violated assumptions of classical measurement theory for valid between group comparisons. All of our instruments displayed some degree of systematic bias in measurement across race/ethnicity. Studies testing ethnic/racial differences may need to move beyond classical measurement theory, and may benefit from using statistical approaches that can test for (and model) bias in measurement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Unequal Effect of Income on Risk of Overweight/Obesity of Whites and Blacks with Knee Osteoarthritis: the Osteoarthritis Initiative

BACKGROUND

Although the protective effect of socioeconomic status (SES) against risk of overweight/obesity is well established, such effects may not be equal across diverse racial and ethnic groups, as suggested by the marginalization-related diminished returns (MDR) theory.

AIMS

Built on the MDR theory, this study explored racial variation in the protective effect of income against overweight/obesity of Whites and Blacks with knee osteoarthritis (OA).

METHODS

This cross-sectional study used baseline data of the OA Initiative, a national study of knee OA in the USA. This analysis included 4664 adults with knee OA, which was composed of 3790 White and 874 Black individuals. Annual income was the independent variable. Overweight/obesity status (body mass index more than 25 kg/m2) was the dependent variable. Race was the moderator. Logistic regressions were used for data analysis.

RESULTS

Overall, higher income was associated with lower odds of being overweight/obese. Race and income showed a statistically significant interaction on overweight/obesity status, indicating smaller protective effect of income for Blacks compared with Whites with knee OA. Race-stratified regression models revealed an inverse association between income and overweight/obesity for White but not Black patients.

CONCLUSIONS

While higher income protects Whites with knee OA against overweight/obesity, this effect is absent for Blacks with knee OA. Clinicians should not assume that the needs of high-income Whites and Blacks with knee OA are similar, as high-income Blacks may have greater unmet needs than high-income Whites. Racially tailored programs may help reduce the health disparities between Whites and Blacks with knee OA. The results are important given that elimination of racial disparities in obesity is a step toward eliminating racial gap in the burden of knee OA. This is particularly important given that overweight/obesity is not only a prognostic factor for OA but also a risk factor for cardiometabolic diseases and premature mortality.

Education Level and Self-rated Health in the United States: Immigrants' Diminished Returns

Introduction

Although education is among the major socioeconomic status (SES) resources that influence populations' and individuals' health, social marginalization may reduce the health gain that follows access to SES indicators such as education, a pattern called marginalization-related diminished return (MDR). The literature on MDRs, however, has been mainly derived from studies that have defined marginalization based on race, ethnicity, and sexual orientation. Thus, more research is needed on MDRs that may follow as a result of immigration. To extend what is known on immigration status related MDRs, this study compared a national sample of immigrants and non-immigrants for the effect of education on the poor self-rated health (SRH) of adults in the United States.

Methods

With a cross-sectional design, this study employed data from the 2015 National Health Interview Survey (NHIS), a survey that had enrolled 33,654 adults who were either immigrants (n = 6225; 18.5%) or non-immigrants (n = 27 429; 81.5%). The independent variable was education level, treated as a categorical variable. The dependent variable was SRH treated as a dichotomous variable. Race, ethnicity, age, gender, marital status, and region were the confounders. Immigration (nativity) was the moderator. Logistic regression was used for data analysis.

Results

Higher education credentials were associated with better SRH in the pooled sample; however, immigration showed a significant statistical interaction with education level (college graduation) on the outcome. This interaction was indicative of a smaller protective effect of college graduation on poor SRH among immigrants than non-immigrant adults.

Conclusion

In line with the MDRs framework, the effect of education on SRH is weaker for immigrants than for non-immigrant adults. There is a need to help highly educated immigrants to mobilize their human capital to secure their best health outcomes, similar to non-immigrants. Such strategies may require bold and innovative policy solutions to reduce discrimination against immigrants, so they can more effectively translate their education and human capital into tangible outcomes such as health.

Diminished Returns of Parental Education in Terms of Youth School Performance: Ruling out Regression toward the Mean

Background: Minorities’ Diminished Returns (MDRs) refer to systemically weaker effects of socioeconomic status (SES) indicators on various developmental, behavioral, and health outcomes of ethnic minorities compared to non-Hispanic (non-Latino) Whites. Similar MDRs also exist for the effects of parental education on the school performance of ethnic minority youth. Aim: To assess whether regression toward the mean (RTM) has any role in explaining the diminished effects of parental education on the school performance of Black and Hispanic youth relative to non-Hispanic White youth. Materials and methods: Data for this cross-sectional study came from the Monitoring the Future survey (MTF, 2017), a nationally representative survey of American youth in 12th grade. The sample included 10,262 youth who were 12th graders (typically 17–18 years old). The independent variable was parental education with five categories: Some high school, High school graduate, Some college, College graduate, and Graduate school. The outcome was self-reported school performance measured as grade point average (GPA). Ethnicity was the effect modifier. Analysis of variance (ANOVA) and the Tukey Post Hoc test was used to analyze the data. Data visualization (line graphs) was used to visualize the shape of youth GPA as a function of parental education levels across ethnic groups. Results: While a perfect stepwise increase was seen in youth school performance as a result of parental education improvement, this pattern differed considerably across ethnic groups. Such a perfect stepwise increase in youth school performance as a result of the incremental increase in parental education was missing for Black and Hispanic youth. The shape of the association between parental education and youth school performance ruled out regression toward the mean (RTM) as an explanation for the observed diminished effects of parental education on the school performance of Black and Hispanic youth. Conclusion: Diminished returns of parental education on the school performance of Black and Hispanic youth cannot be explained by regression toward the mean. Other factors and contextual processes, such as segregation, discrimination, racism, and poor quality of schools in urban areas, should be investigated in future research.

Parental Education and Spanking of American Children: Blacks' Diminished Returns

Background

Based on the Minorities' Diminished Returns (MDRs) framework, high socioeconomic status (SES) indicators such as parental education shows weaker protective effects against adverse experiences for Blacks than Whites. For example, Black children with highly educated parents report high levels of depression, anxiety, suicide, smoking, obesity, and chronic disease. Limited knowledge exists on MDRs of parental education on the child's exposure to spanking by the mother.

Aims

Built on the MDRs framework, we tested the hypothesis of whether the effect of parental education on the child's exposure to spanking by the mother differs in Black and White families. We hypothesized that: 1) there is an inverse association between mothers' educational attainment and child spanking, and 2) the effect of mothers' educational attainment on mothers' spanking of the child is weaker for Black than White families.

Methods

We used data from the Fragile Families and Child Well-being Study (FFCWS), a 9-year follow up study of a random sample of births in cities larger than 200,000 population. In this analysis, 2722 Black or White families were followed. The main predictor was parental educational attainment at birth. The outcomes were exposure to spanking at ages 3, 5, and 9. Logistic regression was used for data analysis.

Results

Higher parental educational attainment at birth was inversely associated with the child's exposure to spanking by the mother among Whites, not Blacks. We also found a significant interaction between parental educational attainment at birth and race, suggesting that the associations between parental education and child exposure to spanking by the mother at ages 3, 5, and 9 were weaker for Black than White families.

Conclusions

Diminished returns of parental educational attainment in terms of reducing children's exposure to trauma and stress may be a mechanism that contributes to racial health disparities, particularly poor health of children in highly educated Black families. That is a smaller protective effect of parental education on reducing undesired exposures for Black than White children may be one of the mechanisms that may explain why children develop worse than expected physical, mental, and behavioral health in high SES Black families. Not all health disparities are due to racial differences in SES, but some of them are also secondary to the diminishing returns of socioeconomic status indicators such as parental education for racial minorities. Research should study contextual, structural, family, and behavioral factors that reduce Black families' ability to mobilize their human capital and secure health outcomes for themselves and their children.

College Graduation and Wealth Accumulation: Blacks' Diminished Returns

Background

Based on the Minorities' Diminished Returns (MDRs) framework, indicators of high socioeconomic status (SES), such as high maternal educational attainment, show weaker protective effects on various developmental, behavioral, and health outcomes for Black than White families. As a result of these MDRs, families and individuals with high educational attainment still report high levels of depression, smoking, obesity, and chronic disease. Limited knowledge exists on MDRs of maternal education on indicators of wealth such as home ownership and home value.

Aims

Built on the MDRs framework, we tested the hypothesis of whether the effects of maternal educational attainment at birth on home ownership and home value, as proxies of wealth, vary between Black and White families. We hypothesized that: 1) high maternal education would be associated with more wealth 15 years later, and 2) compared to Whites, Blacks would be less likely to accumulate wealth (own a house) across all educational levels, given a weaker boosting effect of maternal educational attainment on wealth for Black than White families.

Methods

The Fragile Families and Child Well-being Study, is a 15-year follow up study of a random sample of births in cities larger than 200,000 population in the US. A total number of 2004 White or Black youth were included and were followed from birth to the age of 15. The predictor of interest was maternal educational attainment at birth, treated as a categorical variable (college graduation). The outcomes were home ownership and home value (worth - owed) 15 years later, as proxies of wealth. Logistic and linear regression were used for data analysis.

Results

High maternal education at birth was associated with home ownership and higher value of owned home at age 15. We also found that maternal educational attainment at birth and race interact with each other, suggesting that the effects of high maternal educational attainment at birth on home ownership/value at age 15 were weaker for Black than White families.

Conclusions

Diminished returns of maternal educational attainment at birth on wealth accumulation in Black families may be a mechanism that contributes to racial health disparities in high socioeconomic status and also poor outcomes of high SES Black families. That is, a smaller effect of maternal educational attainment on changing the real lives of Black than White youth may be one of the mechanisms by which health remains worse than expected in high SES Black families. Not all of the health, behavioral, and developmental disparities are due to the racial gap in SES but also diminishing returns of socioeconomic status indicators such as maternal educational attainment for racial minorities. Research should study how social stratification, discriminatory mortgage and banking, residential segregation, family formation, employment, and occupational prestige reduce Black families' ability to mobilize their human capital and secure tangible economic and non-economic outcomes.

Prostate Cancer Screening in Middle-Aged and Older American Men: Combined Effects of Ethnicity and Years of Schooling

BACKGROUND

Prostate cancer screening is more commonly utilized by highly educated people. As shown by marginalization-related diminished returns (MDRs), the effects of socioeconomic status (SES) such as education on the health outcomes are considerably smaller for ethnic minorities than for Whites. The role of MDRs as a source of ethnic health disparities is, however, still unknown.

OBJECTIVES

The current study had two aims: first, to explore the association between years of schooling and having taken a prostate-specific antigen (PSA) test among men in the US, and second, to explore ethnic differences in this association.

METHODS

This study was a secondary analysis of data from the National Health Interview Survey (NHIS-2015). The data of 5,053 men aged 55 years or older who were either Latino, non-Latino, African-American, or White were analyzed. Years of schooling was the independent variable. The dependent variable was taking a PSA test sometime during one's lifetime. Age, region, and employment were the control variables. Ethnicity was the focal moderating variable. Binary logistic regression was used for data analysis.

RESULTS

A higher number of years of schooling was associated with higher odds of having taken a PSA test, net of all confounders. Ethnicity showed a significant statistical interaction with years of schooling on having taken a PSA test. This interaction was suggestive of a smaller slope for Latino men than non-Latino men. White and African American men did not show differential effects of years of schooling on having taken a PSA test.

CONCLUSION

Similar to the MDRs patterns in other domains, non-Latino White men show more health gain from their years of schooling than Latino men. Highly educated Latino men still need programs to encourage their use of prostate cancer screening.

Family Income and Gang Presence in the Neighborhood: Diminished Returns of Black Families

BACKGROUND

Based on the Minorities' Diminished Returns (MDRs) framework, indicators of high socioeconomic status, such as higher family income, show weaker protective effects on various developmental, behavioral, and health outcomes for Black than White families. As a result of these MDRs, Black families who access education and income still report high levels of depression, smoking, obesity, and chronic disease. Limited knowledge exists on MDRs of income on neighborhood quality.

AIMS

Built on the MDRs framework, this study tested the hypothesis of whether the effect of family income and maternal education at birth on neighborhood gang presence varies between Black and White families. The hypotheses were that: (1) higher income families would report lower gang presence in their neighborhood, and (2) compared to Whites, Blacks would show weaker protective effects of family income on gang presence in their neighborhood.

METHODS

The Fragile Families and Child Wellbeing Study is a 15-year follow up study of a random sample of births in cities with larger than 200,000 population. Two thousand nine hundred and nineteen White or Black families were included and were followed from birth of their child for 15 years. The predictors were family income and maternal education at birth, treated as categorical variables. The outcome was gang presence in the neighborhood at age 15. Logistic regression was used for data analysis.

RESULTS

Higher maternal education at birth was inversely associated with gang presence in the neighborhoods, while family income at birth did not show an effect on reducing gang presence in the neighborhood at age 15. Family income at birth and race interact, suggesting that the association between family income at birth and gang presence in the neighborhood at age 15 was weaker for Black than White families. Our race-stratified models also showed an inverse effect of family income at birth on gang presence in the neighborhood at age 15 in White but not Black families.

CONCLUSIONS

Diminished returns of family income at birth on neighborhood safety and social disorder may be a mechanism that contributes to racial health disparities in higher socioeconomic status and also poor outcomes for Black families across socioeconomic status (SES) levels. That is, a smaller protective effect of family income on changing the real lives of Black compared to White families may be one of the mechanisms by which health is worse than expected in Black families, across the entire SES spectrum. The health, behavioral, and developmental disparities are not only due to the racial gap in SES but also diminishing returns of socioeconomic status indicators such as family income for racial minorities. Research should study contextual and structural factors that reduce Black families' ability to mobilize their human capital and secure health outcomes in urban settings.

Combined Effects of Race and Educational Attainment on Physician Visits Over 24 Years in a National Sample of Middle-Aged and Older Americans

Background

The literature on Minorities' Diminished Returns (MDRs) have shown worse than expected health of the members of racial and ethnic minority groups particularly Blacks. Theoretically, this effect can be in part due to weaker effects of educational attainment on preventive care and disease management in highly educated racial and ethnic minorities.

Objectives

The current study explored the racial and ethnic differences in the effect of baseline educational attainment on % adherance to the routine physician visits among middle-aged and older adults in the US.

Methods

This is a prospective study with 24 years of follow up. The Health and Retirement Study (HRS: 1992-2016) included 10 880 middle-aged and older adults who were Hispanic, non-Hispanic, Black or White. The independent variable was educational attainment. The dependent variable was adherance to the routine physician visits (%). Age, gender, marital status, income, health behaviors (smoking and drinking) and health (depression, self-rated health, and chronic diseases) were the covariates. Race and ethnicity were the focal moderators. Linear regression was used for data analysis.

Results

Overall, higher educational attainment was associated with higher % of adherance to the routine physician visits over the course of follow-up, net of all confounders. Race showed a significant statistical interaction with educational attainment suggesting of a smaller effect of high education attainment on % adherance to the routine physician visits for Black than White middle-aged and older adults. A similar interaction could not be found for the comparison of Hispanic and non-Hispanic middle-aged and older adults.

Conclusion

Educational attainment is associated with a larger increase in preventive and disease management doctor visits for White than Black middle-aged and older adults. This is a missed opportunity to improve the health of highly educated middle-aged and older adults. It is not race/ethnicity or class that shapes health behaviors but race/ethnicity and class that shape people's pro-health behaviors. At least some of the racial health disparities is not due to low SES but diminished returns of SES.

Protective Effects of Parental Education Against Youth Cigarette Smoking: Diminished Returns of Blacks and Hispanics

Background

High parental educational attainment is protective against youth health risk behaviors such as tobacco use. According to the Marginalization-related Diminished Returns (MDRs) theory, however, higher parental education is less protective for marginalized groups relative to non-Hispanic Whites.

Objective

To explore race/ethnic differences in the effects of parental educational attainment on cigarette smoking in a national sample of American adolescents.

Methods

In a cross-sectional study, we used baseline data of 10,878 American youth who had participated in the Population Assessment of Tobacco and Health (PATH 2013). The independent variable was parental educational attainment. The dependent variables were lifetime cigarette smoking, current (past 30-day) cigarette moking, and daily cigarette smoking. Youth age, youth gender, and parental marital status were the covariates. Race/ethnicity was the moderating variable. Logistic regression model was used for data analysis.

Results

Overall, a higher parental educational attainment was associated with a lower lifetime cigarette smoking, current (past 30-day) cigarette smoking, and daily cigarette smoking. Parental educational attainment showed significant interaction with race/ethnicity suggesting smaller protective effects of parental educational attainment on youth tobacco outcomes for Black and Hispanic than for non-Hispanic White youth.

Conclusion

For American youth, race/ethnicity limits the health gains that are expected to follow parental educational attainment. While high parental educational attainment is protective against smoking overall, non-Hispanic Whites (the most socially privileged group) gain most and Blacks and Hispanics (the least socially privileged groups) gain least from such resource. In addition to addressing low SES, researchers and policymakers should identify and address mechanisms by which high SES minority youth remain at risk of tobacco use.

Minorities' Diminished Returns of Parental Educational Attainment on Adolescents' Social, Emotional, and Behavioral Problems

Aim: To compare racial groups for the effect of parental educational attainment on adolescents' social, emotional, and behavioral problems. Methods: In this cross-sectional study, 10,762 youth from the Adolescent Brain Cognitive Development (ABCD) study were included. The independent variable was parental educational attainment. The main outcomes were 1) anxious and depressed mood, 2) withdrawn and depressed affect, 3) somatic complaints, 4) social and interpersonal problems, 5) thought problems, 6) rule-breaking behaviors, 7) attention problems, and 8) violent and aggressive behaviors. These scores were generated based on parent-reported behavioral problems measured using the Child Behavior Checklist (CBCL). Race and ethnicity were the moderators. Linear regression was used to analyze the ABCD data. Results: Overall, high parental educational attainment was associated with lower scores across all domains. Race and ethnicity showed statistically significant interactions with parental educational attainment on adolescents' fewer social, emotional, and behavioral problems (all domains), net of all confounders, indicating smaller tangible gains from their parental educational attainment for Black and Hispanic compared to non-Hispanic White adolescents. Conclusion: The protective effects of parental education against social, emotional, and behavioral problems are systematically diminished for Hispanic and Black than non-Hispanic White adolescents.

Parental Educational Attainment and Social Environmental of Urban Public Schools in the U.S.: Blacks' Diminished Returns

Background: Recent research has documented marginalization-related diminished returns (MDRs) of socioeconomic status (SES), defined as weaker effects of SES indicators, such as parental educational attainment, on securing tangible outcomes for the members of socially marginalized (e.g., racial and ethnic minority) groups, compared to privileged social groups (e.g., non-Hispanic Whites). Aims: To explore race/ethnic differences between non-Hispanic Blacks vs. non-Hispanic Whites who attend urban public schools on the effect of parental education on lower school environmental risk among American high schoolers. Methods: For this cross-sectional study, we borrowed the Education Longitudinal Study (ELS-2002) baseline data, a nationally representative study that enrolled 1706 10th grade youths who were attending urban public schools. From this number, 805 (47.2%) were non-Hispanic Black and 901 (52.8%) were non-Hispanic White youths. The dependent variable was the level of school social environmental risk measured using 18 items as self-reported, and was treated as a continuous variable. The independent variable was parental educational attainment, treated as a continuous measure. Gender, region, and parental marital status were the covariates. Race/ethnicity was the moderating variable. Linear regressions were applied to perform our data analysis. Results: Black students were found to attend schools with higher levels of social environmental risk. Youths with parents with a higher educational attainment were found to attend schools with a lower social environmental risk. We found a significant interaction between race (non-Hispanic Black vs. non-Hispanic White) and parental educational attainment on the level of school social environmental risk, suggesting that the protective effect of high parental education on reducing the school social environmental risk was smaller for non-Hispanic Black than for non-Hispanic White youths. Conclusions: Although high parental educational attainment is protective against social environmental risk for American youths, this protective effect is weaker for non-Hispanic Black than non-Hispanic White youths. The diminished returns of parental education in reducing school social environmental risk may explain why the effects of parental education on educational outcomes are smaller for non-Hispanic Black than non-Hispanic White youths (i.e., MDRs). The social environment indirectly generates racial youth educational disparities through deteriorating non-Hispanic Black youth educational outcomes across all SES levels. To prevent the confounding effects of private, suburban, rural, and Catholic schools, we limited this analysis to public urban schools. More research is needed on other settings.

A Qualitative Study to Explore Perception of Impacts of Preemption of Tobacco Regulation on Counties in Appalachian Tennessee

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee-a high-smoking, low-income region. During 2015-2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

Socioeconomic Status and Current Cigarette Smoking Status: Immigrants' Diminished Returns

Introduction

Although socioeconomic status (SES) resources influence population and individual health behaviors, socially marginalized groups gain significantly less health from their SES indicators, such as education and income, compared to the socially privileged groups. This pattern is called marginalization-related diminished returns (MDRs). However, most of the MDRs literature is derived from studies that have defined marginalization based on race and ethnicity. As a result, more research is needed on MDRs due to immigration. To extend what is known about MDRs due to immigration, the current study compared a national sample of immigrants and non-immigrants for the effects of education and income on current cigarette smoking of adults in the United States.

Methods

This is a cross-sectional study. The 2015 National Health Interview Survey (NHIS) enrolled 14,149 individuals who were either immigrants (n=1977; 14.0%) or non-immigrants (n=12,166; 86.0%). The independent variables (IV) were education and income that were treated as categorical variables. The dependent variable was current cigarette smoking. Age, gender, race, ethnicity, marital status, employment, and region were confounders. Immigration was the moderator. Logistic regression was used for data analysis.

Results

High education and income were associated with lower odds of current cigarette smoking. However, immigration showed significant statistical interactions with both education and income. These interactions were suggestive of smaller protective effects of high education and income on current cigarette smoking for immigrant than non-immigrant adults.

Conclusion

In line with the MDRs, the effects of education and income on tobacco use is weaker for immigrant than non-immigrant adults.

Diminished Returns of Educational Attainment on Heart Disease among Black Americans

Background

Socioeconomic Status (SES) indicators, such as educational attainment, are social determinants of heart disease. Marginalization related Diminished Returns (MDRs) refer to smaller health benefits of high SES for racial and ethnic minorities compared to the majority group. It is still unknown, however, if MDRs also apply to the effects of education on heart disease.

Purpose

Using a nationally representative sample, we explored racial/ethnic variation in the link between educational attainment and heart disease among American adults.

Methods

We analyzed data (n=25,659) from a nationally representative survey of American adults in 2013. The first wave of the Population Assessment of Tobacco and Health - Adult (PATH-Adult) study was used. The independent variable was education (college graduate, high school graduate, less than a high school diploma). The dependent variable was any heart disease. Age and gender were the covariates. Race, as well as ethnicity, were the moderators. Logistic regressions were used to analyze the data.

Results

Individuals with higher educational attainment had lower odds of heart disease. Race and ethnicity showed statistically significant interactions with education, suggesting that the protective effect of higher education on reducing odds of heart disease was smaller for Hispanic and Black people than for non-Hispanic and White individuals.

Conclusion

Education reduces the risk of heart disease better among non-Hispanic Whites than for Hispanics and Blacks. Therefore, we may expect a disproportionately higher than expected risk of heart disease in Hispanics and Blacks with high educational attainment. Future research should test if the presence of high levels of environmental and behavioral risk factors contribute to the high risk of heart disease in highly educated Black and Hispanic Americans. Policymakers should not reduce health inequalities to just gaps in SES because disparities are present across SES levels, with high SES Blacks and Hispanics remaining at risk of health problems.

Combined Effects of Ethnicity and Education on Burden of Depressive Symptoms over 24 Years in Middle-Aged and Older Adults in the United States

Ethnicity and educational attainment are among the major social determinants of depression in the general population. While high education credentials protect individuals against depressive symptoms, this protection may be weaker for ethnic minority groups such as Hispanic Whites compared to the majority group (non-Hispanic Whites). Built on marginalization-related diminished returns (MDRs), the current study used 24-year follow-up data from a nationally representative sample of middle-aged and older adults to explore ethnic variation in the protective effect of education levels against the burden of depressive symptoms over time. Data for this analysis were borrowed from the Health and Retirement Study (HRS 1992-ongoing), a nationally representative longitudinal study. HRS followed 8314 middle-aged and older adults (50+ years old) for up to 24 years. From this number, 763 (9.2%) were Hispanic White, and 7551 (90.8%) were non-Hispanic White Americans. Education level was the independent variable. We had two outcomes. Firstly, using cluster analysis, individuals were categorized to low- and high-risk groups (regarding the burden of depressive symptoms over 24 years); secondly, average depressive symptoms were observed over the 24 years of follow up. Age and gender were the covariates. Ethnicity was the moderator. Linear and logistic regression were used for analysis. Logistic regression showed that, overall, high educational credentials reduced the odds of chronic depressive symptoms over the 24 years of follow-up. Linear regression also showed that higher years of education were associated with lower average depressive symptoms over time. Both models showed statistically significant interactions between ethnicity and graduation, indicating a smaller protective effect of high education against depressive symptoms over the 24 years of follow-up time among Hispanic with respect to non-Hispanic White people. In line with the MDRs, highly educated Hispanic White Americans remain at high risk for depressive symptoms, a risk that is unexpected given their education. The burden of depressive symptoms, however, is lowest for highly educated non-Hispanic White Americans. Policies that exclusively focus on equalizing educational gaps across ethnic groups may fail to eliminate the ethnic gap in the burden of chronic depressive symptoms, given the diminished marginal health return of education for ethnic minorities. Public policies must equalize not only education but also educational quality across ethnic groups. This aim would require addressing structural and environmental barriers that are disproportionately more common in the lives of ethnic minorities across education levels. Future research should test how contextual factors, residential segregation, school segregation, labor market practices, childhood poverty, and education quality in urban schools reduce the health return of educational attainment for highly educated ethnic minorities such as Hispanics.

Alternative causal inference methods in population health research: Evaluating tradeoffs and triangulating evidence

Population health researchers from different fields often address similar substantive questions but rely on different study designs, reflecting their home disciplines. This is especially true in studies involving causal inference, for which semantic and substantive differences inhibit interdisciplinary dialogue and collaboration. In this paper, we group nonrandomized study designs into two categories: those that use confounder-control (such as regression adjustment or propensity score matching) and those that rely on an instrument (such as instrumental variables, regression discontinuity, or differences-in-differences approaches). Using the Shadish, Cook, and Campbell framework for evaluating threats to validity, we contrast the assumptions, strengths, and limitations of these two approaches and illustrate differences with examples from the literature on education and health. Across disciplines, all methods to test a hypothesized causal relationship involve unverifiable assumptions, and rarely is there clear justification for exclusive reliance on one method. Each method entails trade-offs between statistical power, internal validity, measurement quality, and generalizability. The choice between confounder-control and instrument-based methods should be guided by these tradeoffs and consideration of the most important limitations of previous work in the area. Our goals are to foster common understanding of the methods available for causal inference in population health research and the tradeoffs between them; to encourage researchers to objectively evaluate what can be learned from methods outside one's home discipline; and to facilitate the selection of methods that best answer the investigator's scientific questions.

Educational Attainment Better Increases the Chance of Breast Physical Exam for Non-Hispanic Than Hispanic American Women: National Health Interview Survey

Background

The Minorities' Diminished Returns (MDRs) theory suggests that the health effect of educational attainment is considerably smaller for members of racial and ethnic minority groups than for Whites.

Objective

The current study explored the racial and ethnic differences in the association between educational attainment and breast physical exam (BPE) among women in the U.S.

Methods

The National Health Interview Survey (NHIS 2015) included 12 510 women who were Hispanic or non-Hispanic Black or White people. The independent variable was the level of educational attainment. The dependent variable was lifetime BPE. Age, region, marital status, and employment were the covariates. Race and ethnicity were the focal moderators. Logistic regressions were used for data analysis.

Results

Overall, higher educational attainment was associated with higher odds of BPE, net of all confounders (odds ratio [OR] = 1.11, 95% CI = 1.09-1.13). Ethnicity showed a significant statistical interaction with educational attainment on BPE (OR = 0.96, 95% CI = 0.93-1.00), which was suggestive of a smaller effect of high education attainment on BPE for Hispanic than non-Hispanic women. The same interaction could not be found for the comparison of White and Black women (OR = 0.98, 95% CI =0.94-1.02).

Conclusion

In line with other domains, non-Hispanic White women show a larger amount of health gain from their educational attainment than Hispanic women. It is not ethnicity or class but ethnicity and class that shapes how people engage in pro-health behaviors. This result may help hospitals and healthcare systems to better reduce health disparities in their target populations.

Income and Mental Well-Being of Middle-Aged and Older Americans: Immigrants' Diminished Returns

Introduction

Although income is among the major social determinants of mental health of middle-aged and older individuals, socially marginalized groups gain less health from their income and other socioeconomic status (SES) resources compared to socially privileged groups. This pattern is called marginalization-related diminished returns (MDRs). Most of the existing knowledge on MDRs, however, has been derived from studies that have defined marginalization based on race, ethnicity, or sexual orientation. As a result, very limited information exists on whether similar MDRs can be observed for middle-aged and older immigrants or not. Building on the MDRs framework, this study compared a national sample of immigrants and non-immigrants for the effects of income on the mental well-being of middle-aged and older adults in the United States.

Methods

This is a cross-sectional study. The 2015 National Health Interview Survey (NHIS) enrolled 14 149 middle-aged and older individuals who were either immigrants (n=1977; 14.0%) or non-immigrants (n=12 166; 86.0%). The independent variable (IV) was income that was treated as a continuous variable. The dependent variable was mental well-being, also treated as a continuous variable. Age, gender, race, ethnicity, education, marital status, employment, self-rated health, obesity, and region were confounders. Immigration (nativity status) was the moderator. Logistic regression was applied for data analysis.

Results

High income was associated with higher odds of good mental well-being in middle-aged and older adults. However, immigration showed a significant statistical interaction with income, which was suggestive of a smaller protective effect of high income on mental well-being for immigrant than non-immigrant middle-aged and older adults.

Conclusion

In line with MDRs, the association between income and mental well-being is weaker for immigrant than non-immigrant middle-aged and older adults. There is a need to help high income immigrants secure health outcomes similar to those of non-immigrants. Such changes may require bold and innovative economic, public, and social policies that help immigrants more effectively translate their income and socioeconomic resources into tangible outcomes such as mental well-being.