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Race and Urbanity Alter the Protective Effect of Education but not Income on Mortality

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      Abstract

      Background

      Although the effects of socioeconomic status (SES) on mortality are well established, these effects may vary based on contextual factors such as race and place. Using 25-year follow-up data of a nationally representative sample of adults in the U.S., this study had two aims: (1) to explore separate, additive, and multiplicative effects of race and place (urbanity) on mortality and (2) to test the effects of education and income on all-cause mortality based on race and place.

      Methods

      The Americans’ Changing Lives (ACL) Study followed Whites and Blacks 25 years and older from 1986 until 2011. The focal predictors were baseline SES (education and income) collected in 1986. The main outcome was time until death due to all causes from 1986 until 2011. Age, gender, behaviors (smoking and exercise), and health (chronic medical conditions, self-rated health, and depressive symptoms) at baseline were potential confounders. A series of survey Cox proportional hazard models were used to test protective effects of education and income on mortality based on race and urbanity.

      Results

      Race and place had separate but not additive or multiplicative effects on mortality. Higher education and income were protective against all-cause mortality in the pooled sample. Race and urbanity significantly interacted with baseline education but not income on all-cause mortality, suggesting that the protective effect of education but not income depend on race and place. While the protective effect of education were fully explained by baseline health status, the effect of income remained significant beyond health.

      Conclusion

      In the U.S., the health return associated with education depends on race and place. This finding suggests that populations differently benefit from SES resources, particularly education. Differential effect of education on employment and health care may explain the different protective effect of education based on race and place. Findings support the “diminishing returns” hypothesis for Blacks.

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      Most cited references 76

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        Socioeconomic inequalities in health in 22 European countries.

        Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care. Copyright 2008 Massachusetts Medical Society.
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          Neighborhoods and health.

          Features of neighborhoods or residential environments may affect health and contribute to social and race/ethnic inequalities in health. The study of neighborhood health effects has grown exponentially over the past 15 years. This chapter summarizes key work in this area with a particular focus on chronic disease outcomes (specifically obesity and related risk factors) and mental health (specifically depression and depressive symptoms). Empirical work is classified into two main eras: studies that use census proxies and studies that directly measure neighborhood attributes using a variety of approaches. Key conceptual and methodological challenges in studying neighborhood health effects are reviewed. Existing gaps in knowledge and promising new directions in the field are highlighted.
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            Author and article information

            Affiliations
            1Department of Psychiatry, University of Michigan , Ann Arbor, MI, USA
            2Center for Research on Ethnicity, Culture and Health, School of Public Health, University of Michigan , Ann Arbor, MI, USA
            3Medicine and Health Promotion Institute , Tehran, Iran
            Author notes

            Edited by: Martine Hackett, Hofstra University, USA

            Reviewed by: Peter John Somerford, Department of Health Western Australia, Australia; Kate E. Beatty, East Tennessee State University, USA

            *Correspondence: Shervin Assari, assari@ 123456umich.edu

            Specialty section: This article was submitted to Public Health Policy, a section of the journal Frontiers in Public Health

            Contributors
            URI : http://frontiersin.org/people/u/158295
            Journal
            Front Public Health
            Front Public Health
            Front. Public Health
            Frontiers in Public Health
            Frontiers Media S.A.
            2296-2565
            20 May 2016
            2016
            : 4
            27242992
            4873510
            10.3389/fpubh.2016.00100
            Copyright © 2016 Assari and Lankarani.

            This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

            Counts
            Figures: 0, Tables: 3, Equations: 0, References: 94, Pages: 9, Words: 7426
            Funding
            Funded by: United States Department of Health and Human Services 10.13039/100000016
            Award ID: AG05561, AG018418
            Funded by: National Institutes of Health 10.13039/100000002
            Funded by: National Institute on Aging 10.13039/100000049
            Categories
            Public Health
            Original Research

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