1

The SEP Gradient, Race, or the SEP Gradient and Race: Understanding Disparities in Child

Health and Functioning

Lisa Dubay, PhD, ScMThe Urban Institute

Academy Health Annual Research MeetingJune 25, 2006

2

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

3

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

4

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

5

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

6

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

7

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%)

9

Validation of SEP Measure

88%

70%

35%

85%

46%***

31%

71%***

20%***24%***

55%***

6%***

18%***

27%***

4%***8%***

0%

20%

40%

60%

80%

100%

Head in ExcellentHealth

Highest EducationCollege Plus

Family Owns Home

Pe

rce

nt

of

Po

pu

lati

on

Class 1 Class 2 Class 3 Class 4 Class 5

10

Validation of SEP Measure

405

283

122

261

185

84*** 96***

60***57*** 46***23***44***

8***

-1***

15***

-100

0

100

200

300

400

500

Income Assets No Home Assets IncludingHome

$1,0

00

Class 1 Class 2 Class 3 Class 4 Class 5

11

Distribution of SEP by Race

29

7 6

2929

169

222124

152119

41

61

23

3

128

4

0

10

20

30

40

50

60

70

White Non-Hispanic

Black Non-Hispanic

Hispanic Other Race

Per

cen

t o

f P

op

ula

tio

n

Class 1 Class 2 Class 3 Class 4 Class 5

12

Estimation Strategy

Continuous variables:

Binary variables:

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..

jSexAgeaaRacerrClassccOutcome j 43210

SexAgeaaRacerrClassccOutcome jP

Outcome jP

43210)0(

)1(log

13

Overall Health Status and Disorders – Excellent Health

1.01.1

0.9

0.6** 0.6**

0

0.2

0.4

0.6

0.8

1

1.2

Excellent Health

Adj

uste

d O

dds

Rat

io

Class 1 Class 2 Class 3 Class 4 Class 5

14

Overall Health Status – Excellent Health

1.0

0.5***0.6***

0.8

0.0

1.0

2.0

Excellent Health - Parent Report

Ad

just

ed O

dd

s R

atio

White Non-Hispanic Black Non-Hispanic Hispanic Other Race

15

Psychological Functioning – Behavioral Problems Index

0.0

0.5 0.6

1.8**

3.4***

0.00.3

0.5

1.0*

2.1***

0.0

0.20.1

0.7**

1.3***

0.0

1.0

2.0

3.0

4.0

Ad

just

ed D

iffe

ren

ce

BehavioralProblems Index

ExternalizingProblems

InternalizingProblems

Class 1 Class 2 Class 3 Class 4 Class 5

16

Cognitive Functioning – Woodcock-Johnson Tests of Achievement

0.0

-2.7

-6.4***

-7.8***

-13.9***

0.0-1.2

-4.7***

-6.2***

-12.5***

0.0

-4.0***

-7.5***

-9.8***

-14.3***-16-14-12-10-8-6-4-20

Ad

just

ed D

iffe

ren

ce

Letter Word PassageComprehension

AppliedProblems

Class 1 Class 2 Class 3 Class 4 Class 5

17

Cognitive Functioning – Woodcock-Johnson Tests of Achievement

0.0

-9.5***

-5.6***

-1.1

0.0

-8.1***

-8.9***

-3.1*

0.0

-10.7***

-7.4**

-4.1**

-12

-10

-8

-6

-4

-2

0

Ad

just

ed D

iffe

ren

ce

Letter Word PassageComprehension

AppliedProblems

White Non-Hispanic Black Non-Hispanic Hispanic Other Race

18

Effect of Eliminating Disparities on Population Health – General Health Status

58%

63%

62%

65%

52%

54%

56%

58%

60%

62%

64%

66%

68%

Excellent Health

Pe

rce

nt

of

Po

pu

lati

on

Overall Mean Elliminate SEP DisparitiesEliminate Race/ethnic Disparities Eliminate SEP and Race/ethnic Disparities

Parent Report Child Report

19

Effect of Eliminating Disparities on Population Health – Psychological and Social Functioning

9.4

5.6

3.3

8.5

5.1

3.0

9.3

5.6

3.3

5.1

2.9

8.3

0

1

2

3

4

5

6

7

8

9

10

Total BehavioralProblems Index

Externalizing BehaviorProblems

Internalizing BehaviorProblems

Nu

mb

er

of

Pro

ble

m B

eh

av

iors

Overall Mean Elliminate SEP DisparitiesEliminate Race/ethnic Disparities Eliminate SEP and Race/ethnic Disparities

20

Effect of Eliminating Disparities on Population Health – Cognitive Functioning

106105

105

111

109

111

108108 108

112

114113

100

102

104

106

108

110

112

114

116

Letter Word Passage Comprehension Applied Problems

Overall Mean Elliminate SEP DisparitiesEliminate Race/ethnic Disparities Eliminate SEP and Race/ethnic Disparities

Woodcock-Johnson Tests of Achievement

21

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

22

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

23

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