Gaps in Knowledge
The SEP Gradient, Race, or the SEP Gradient
and Race: Understanding Disparities in Child
Health and Functioning
iUS policy and research focus is on children in
poverty and not on the gradient
iNo consistent measure of SEP
Lisa Dubay, PhD, ScM
The Urban Institute
iChild health is usually narrowly defined
iPolicy focus on eliminating race/ethnicity
disparities
Academy Health Annual Research Meeting
June 25, 2006
1
2
New Research
Lifecourse Developmental Approach to
Conceptualizing Child Health
iUse a life-course developmental approach to
conceptualizing child health and functioning
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:
iConstruct and validate a measure of SEP based
on Britain's new National Statistics – Social
Classification System (NS-SEC)
iOverall health status and disorders
iPsychological and social functioning
iCognitive functioning
iExamine the association between SEP and
child health and functioning in the context of
race and ethnic disparities
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4
Primary Data Source
Measuring Socio-economic Position
iChild Development Supplement to the Panel
Survey of Income Dynamics
iClassification scheme adapts for use in the US
Britain's newly designed and implemented
National Statistics – Socio-economic
Classification System (NS-SEC)
iFamily units with children under 13 drawn from the
1997 PSID
i3563 children interviewed in 1997
i3271 eligible to participate in CDS-II in 2002
iUse information on employment status and
occupation of the head and spouse to group
households into five classes
i2844 participating with valid data for age, race, and SEP
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6
1
Classification Scheme
Validation of SEP Measure
Class 1 - Higher managerial and professional occupations
and incorporated business owners (22%)
Percent of Population
100%
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%)
84%
83%
81%
70%
80%
63%**
51%***
60%
40%
27%***
17%***
14%***
20%
0%***
0%
Paid Based on Salary
Class 5 - Long term unemployed and disabled (5%)
Class 1
Class 2
ESI Coverage
Class 3
Class 4
Class 5
7
Validation of SEP Measure
Validation of SEP Measure
88%
70%
85%
500
71%***
405
400
283
55%***
46%***
35%
31%
40%
27%***
24%***
18%***
20%
20%***
8%***
Class 1
185
200
6%***
4%***
Class 3
96***
84***
57*** 44***
15***
60***
-100
Class 4
46***
23***
8***
-1***
0
Highest Education Family Owns Home
College Plus
Class 2
122
100
0%
Head in Excellent
Health
261
300
60%
$1,000
Percent of Population
100%
80%
8
Income
Class 1
Assets No Home
Class 2
Class 3
Assets Including
Home
Class 4
Class 5
Class 5
9
Distribution of SEP by Race
10
Estimation Strategy
Percent of Population
Continuous variables:
70
Outcome j = β 0 + β 1c Class c + β 2r Race r + β 3a Age a + β 4 Sex + ε j
61
60
Binary variables:
50
⎛ P (Outcome j = 1) ⎞
⎟ = β + β Class + β Race + β Age + β Sex
log⎜
c
r
0
1c
2r
3a
a
4
⎜ P (Outcome j = 0) ⎟
⎝
⎠
41
40
30
20
10
29
29 29
24
21 19
16
3
7
22 21 23
15
12
6
9
Where:
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4
i Outcomej represents each child health and functioning measure;
0
i Classc is a vector of indicator variables measuring the SEP of the child;
White NonHispanic
Class 1
Black NonHispanic
Class 2
Hispanic
Class 3
Other Race
i Racer is a vector of indicator variables measuring the race of the child;
i Agea is a vector of indicator variables measuring the age of the individual child; and
Class 4
i Sex is an indicator that the child is female..
Class 5
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12
2
Overall Health Status and Disorders – Excellent
Health
1.1
1.0
1
2.0
0.9
Adjusted Odds Ratio
A djusted Odds R atio
1.2
Overall Health Status – Excellent Health
0.8
0.6**
0.6**
0.6
0.4
0.2
1.0
0.8
1.0
0.6***
0.5***
0.0
0
Excellent Health - Parent Report
White Non-Hispanic
Excellent Health
Class 1
Class 2
Class 3
Class 4
Black Non-Hispanic
Hispanic
Other Race
Class 5
13
Psychological Functioning – Behavioral
Problems Index
Cognitive Functioning – Woodcock-Johnson
Tests of Achievement
3.4***
Adjusted Difference
Adjusted Difference
4.0
14
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
0.0
0.0
-4.0***
-4.7***
-6.2***
-6.4***
-7.8***
-7.5***
-9.8***
-12.5***
-13.9***
Class 1
Class 5
0.0
-1.2
-2.7
Letter Word
Internalizing
Problems
Class 4
0
-2
-4
-6
-8
-10
-12
-14
-16
Class 2
-14.3***
Passage
Comprehension
Class 3
Applied
Problems
Class 4
Class 5
15
Cognitive Functioning – Woodcock-Johnson
Tests of Achievement
68%
0.0
0.0
-2
0.0
-3.1*
-6
-4.1**
-5.6***
-8
-7.4**
-8.1***
-8.9***
-9.5***
-10.7***
-12
Letter Word
White Non-Hispanic
Passage
Comprehension
Black Non-Hispanic
65%
66%
-1.1
-4
-10
Effect of Eliminating Disparities on Population
Health – General Health Status
Percent of Population
Adjusted Difference
0
16
64%
62%
62%
60%
58%
58%
56%
54%
Applied
Problems
Hispanic
63%
52%
Excellent Health
Parent Report
Other Race
Overall Mean
Eliminate Race/ethnic Disparities
17
Child Report
Elliminate SEP Disparities
Eliminate SEP and Race/ethnic Disparities
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3
Number of Problem Behaviors
Effect of Eliminating Disparities on Population
Health – Psychological and Social Functioning
10
9
9.4
Effect of Eliminating Disparities on Population
Health – Cognitive Functioning
116
9.3
8.5
114
8.3
8
7
5.6
6
112
111
110
5.6
5.1
111
109
108
5.1
5
114
113
112
108
108
108
4
3.3
3.0
3.3
3
106
105
106
2.9
105
104
2
102
1
0
100
Total Behavioral
Problems Index
Externalizing Behavior
Problems
Overall Mean
Eliminate Race/ethnic Disparities
Internalizing Behavior
Problems
Letter Word
Passage Comprehension
Applied Problems
Woodcock-Johnson Tests of Achievement
Elliminate SEP Disparities
Eliminate SEP and Race/ethnic Disparities
Overall Mean
Eliminate Race/ethnic Disparities
Elliminate SEP Disparities
Eliminate SEP and Race/ethnic Disparities
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A Life-course Developmental Theory of Health
Disparities
Conclusions
i SEP is causally related to general health status and psychosocial
and cognitive abilities
iClear evidence of an association between SEP
and overall child health and disorders
i SEP directly and indirectly influences health behaviors, educational
attainment, social relationships and the formal transition into the
labor market
iParticularly strong evidence of a gradient in
behavioral and cognitive functioning
i The transition into the labor market is also influenced by cognitive
functioning and educational attainment
iAddressing both SEP gradients and
racial/ethnic disparities is necessary to achieve
an equitable distribution of population health
i This transition determines additional exposures to health promoting
and threatening environments that accumulate over the lifecourse
i SEP remains the fundamental cause of the gradient in health
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Implications for Policy
iAddressing 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
iUnderstanding the pathways through which
SEP and race/ethnic disparities are produced is
critical to their elimination
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