The SEP Gradient, Race, or the SEP Gradient
and Race: Understanding Disparities in Child
Health and Functioning
Lisa Dubay, PhD, ScM
The Urban Institute
Academy Health Annual Research Meeting
June 25, 2006
1
Gaps in Knowledge
US policy and research focus is on children in
poverty and not on the gradient
No consistent measure of SEP
Child health is usually narrowly defined
Policy focus on eliminating race/ethnicity
disparities
2
New Research
Use a life-course developmental approach to
conceptualizing child health and functioning
Construct and validate a measure of SEP based
on Britain's new National Statistics – Social
Classification System (NS-SEC)
Examine the association between SEP and child
health and functioning in the context of race and
ethnic disparities
3
Lifecourse Developmental Approach to
Conceptualizing Child Health
Elements of the human condition necessary for
successful functioning and development in
childhood and over the lifecourse are
considered key components of child health
including:
Overall health status and disorders
Psychological and social functioning
Cognitive functioning
4
Primary Data Source
Child Development Supplement to the Panel
Survey of Income Dynamics
Family units with children under 13 drawn from the
1997 PSID
3563 children interviewed in 1997
3271 eligible to participate in CDS-II in 2002
2844 participating with valid data for age, race, and SEP
5
Measuring Socio-economic Position
Classification scheme adapts for use in the US
Britain's newly designed and implemented
National Statistics – Socio-economic
Classification System (NS-SEC)
Use information on employment status and
occupation of the head and spouse to group
households into five classes
6
Classification Scheme
Class 1 - Higher managerial and professional occupations
and incorporated business owners (22%)
Class 2 - Lower managerial and professional occupations
(23%)
Class 3 - Intermediate occupations and small business
owners (20%)
Class 4 - Lower technical, craft, semi-routine and routine
occupations (28%)
Class 5 - Long term unemployed and disabled (5%)
7
Validation of SEP Measure
Percent of Population
100%
88%
80%
70%
85%
71%***
55%***
60%
46%***
35%
40%
31%
27%***
24%***
18%***
20%
20%***
8%***
6%***
4%***
0%
Head in Excellent
Health
Class 1
Highest Education Family Owns Home
College Plus
Class 2
Class 3
Class 4
Class 5
9
Validation of SEP Measure
500
405
400
283
261
$1,000
300
185
200
100
122
96***
84***
57*** 44***
15***
60***
8***
-1***
0
-100
46***
23***
Income
Class 1
Assets No Home
Class 2
Class 3
Assets Including
Home
Class 4
Class 5
10
Percent of Population
Distribution of SEP by Race
70
60
61
50
40
30
20
10
0
41
29
29 29
24
21 19
16
3
White NonHispanic
Class 1
7
22 21 23
6
Black NonHispanic
Class 2
15
12
9
8
Hispanic
Class 3
Class 4
4
Other Race
Class 5
11
Estimation Strategy
Continuous variables:
Outcome j   0   1c Class c   2r Race r   3a Agea   4 Sex   j
Binary variables:
 P(Outcome j  1) 
     Class   Race   Age   Sex
log 
c
r
0
1c
2r
3a
a
4
 P(Outcome j  0) 


Where:
 Outcomej represents each child health and functioning measure;
 Classc is a vector of indicator variables measuring the SEP of the child;
 Racer is a vector of indicator variables measuring the race of the child;
 Agea is a vector of indicator variables measuring the age of the individual child; and
 Sex is an indicator that the child is female..
12
Overall Health Status and Disorders – Excellent
Health
Adjusted Odds Ratio
1.2
1
1.1
1.0
0.9
0.8
0.6**
0.6**
Class 4
Class 5
0.6
0.4
0.2
0
Excellent Health
Class 1
Class 2
Class 3
13
Overall Health Status – Excellent Health
Adjusted Odds Ratio
2.0
1.0
0.8
1.0
0.6***
0.5***
0.0
Excellent Health - Parent Report
White Non-Hispanic
Black Non-Hispanic
Hispanic
Other Race
14
Psychological Functioning – Behavioral
Problems Index
Adjusted Difference
4.0
3.4***
3.0
2.1***
2.0
1.8**
1.3***
1.0*
1.0
0.5 0.6
0.3
0.7**
0.5
0.2
0.0
0.0
0.1
0.0
0.0
Behavioral
Problems Index
Externalizing
Problems
Class 1
Class 3
Class 2
Class 4
Internalizing
Problems
Class 5
15
Adjusted Difference
Cognitive Functioning – Woodcock-Johnson
Tests of Achievement
0
-2
-4
-6
-8
-10
-12
-14
-16
0.0
0.0
0.0
-1.2
-2.7
-4.0***
-4.7***
-6.4***
-7.8***
-6.2***
-7.5***
-9.8***
-12.5***
-13.9***
Letter Word
Class 1
Class 2
Passage
Comprehension
Class 3
Class 4
-14.3***
Applied
Problems
Class 5
16
Cognitive Functioning – Woodcock-Johnson
Tests of Achievement
Adjusted Difference
0
0.0
0.0
-2
0.0
-1.1
-4
-3.1*
-6
-4.1**
-5.6***
-8
-7.4**
-8.1***
-10
-8.9***
-9.5***
-10.7***
-12
Letter Word
White Non-Hispanic
Passage
Comprehension
Black Non-Hispanic
Applied
Problems
Hispanic
Other Race
17
Effect of Eliminating Disparities on Population
Health – General Health Status
68%
65%
Percent of Population
66%
63%
64%
62%
62%
60%
58%
58%
56%
54%
52%
Excellent Health
Parent Report
Overall Mean
Eliminate Race/ethnic Disparities
Child Report
Elliminate SEP Disparities
Eliminate SEP and Race/ethnic Disparities
18
Number of Problem Behaviors
Effect of Eliminating Disparities on Population
Health – Psychological and Social Functioning
10
9
9.4
9.3
8.5
8.3
8
7
5.6
6
5.6
5.1
5.1
5
4
3.3
3
3.0
3.3
2.9
2
1
0
Total Behavioral
Problems Index
Overall Mean
Eliminate Race/ethnic Disparities
Externalizing Behavior
Problems
Internalizing Behavior
Problems
Elliminate SEP Disparities
Eliminate SEP and Race/ethnic Disparities
19
Effect of Eliminating Disparities on Population
Health – Cognitive Functioning
116
114
114
113
112
112
111
110
111
109
108
108
108
108
106
105
106
105
104
102
100
Letter Word
Passage Comprehension
Applied Problems
Woodcock-Johnson Tests of Achievement
Overall Mean
Elliminate SEP Disparities
Eliminate Race/ethnic Disparities
Eliminate SEP and Race/ethnic Disparities
20
Conclusions
Clear evidence of an association between SEP
and overall child health and disorders
Particularly strong evidence of a gradient in
behavioral and cognitive functioning
Addressing both SEP gradients and racial/ethnic
disparities is necessary to achieve an equitable
distribution of population health
21
A Life-course Developmental Theory of Health
Disparities
 SEP is causally related to general health status and psychosocial
and cognitive abilities
 SEP directly and indirectly influences health behaviors, educational
attainment, social relationships and the formal transition into the
labor market
 The transition into the labor market is also influenced by cognitive
functioning and educational attainment
 This transition determines additional exposures to health promoting
and threatening environments that accumulate over the lifecourse
 SEP remains the fundamental cause of the gradient in health
22
Implications for Policy
Addressing SEP and race/ethnic disparities will
require a fundamental political and policy shift
towards major social, educational, and
economic policies as mechanisms for
eliminating disparities
Understanding the pathways through which SEP
and race/ethnic disparities are produced is
critical to their elimination
23