Health Disparities Beginning in Childhood: A Life-Course ...

DOI: 10.1542/peds.2009-1100D 2009;124;S163Pediatrics

Paula Braveman and Colleen BarclayHealth Disparities Beginning in Childhood: A Life-Course Perspective

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Health Disparities Beginning in Childhood:A Life-Course Perspective

abstractIn this article we argue for the utility of the life-course perspective as atool for understanding and addressing health disparities across socio-economic and racial or ethnic groups, particularly disparities thatoriginate in childhood. Key concepts and terms used in life-courseresearch are briefly defined; as resources, examples of existing liter-ature and the outcomes covered are provided along with examples oflongitudinal databases that have often been used for life-course re-search. The life-course perspective focuses on understanding howearly-life experiences can shape health across an entire lifetime andpotentially across generations; it systematically directs attention tothe role of context, including social and physical context along withbiological factors, over time. This approach is particularly relevant tounderstanding and addressing health disparities, because social andphysical contextual factors underlie socioeconomic and racial/ethnicdisparities in health. A major focus of life-course epidemiology hasbeen to understand how early-life experiences (particularly experi-ences related to economic adversity and the social disadvantages thatoften accompany it) shape adult health, particularly adult chronic dis-ease and its risk factors and consequences. The strong life-courseinfluences on adult health could provide a powerful rationale for poli-cies at all levels—federal, state, and local—to give more priority toinvestment in improving the living conditions of children as a strategyfor improving health and reducing health disparities across the entirelife course. Pediatrics 2009;124:S163–S175

AUTHORS: Paula Braveman, MD, MPH and ColleenBarclay, MPH

Center on Social Disparities in Health and Department of Familyand Community Medicine, University of California, SanFrancisco, California

KEY WORDSadult, child, chronic disease, educational level,Europe/epidemiology, health status, health status disparities,longitudinal studies, morbidity, mortality, social class,socioeconomic factors, United States/epidemiology

The views presented in this article are those of the authors, notthe organizations with which they are affiliated.

www.pediatrics.org/cgi/doi/10.1542/peds.2009-1100

doi:10.1542/peds.2009-1100D

Accepted for publication Jul 20, 2009

Address correspondence to Paula Braveman, MD, MPH, Centeron Social Disparities in Health, University of California, SanFrancisco, 3333 California St, Suite 365, San Francisco, CA 94118-0943. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2009 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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A life-course perspective will not strikepediatricians, family physicians, orother providers of health care to chil-dren as an alien concept. The develop-mental perspective is a standard com-ponent of their training, throughwhichthey learn to consider the dynamic na-ture of growth during childhood andchildren’s evolving needs at differentphysical, cognitive, and socioemo-tional developmental stages. What,then, is newwhenwe focus on the “life-course?”

LOOKING ACROSS MULTIPLE LIFESTAGES

A life-course perspective encom-passes a developmental approach andadds important new elements. Themost prominent difference between alife-course and a developmental ap-proach is that, whereas a developmen-tal perspective generally focuses ondevelopment during childhood or ado-lescence (occasionally extending intoearly adulthood), a life-course studygenerally extends across multiple lifestages, typically examining links be-tween early childhood and later adulthealth. A life-course study focuses onunderstanding how early-life experi-ences can shape health across an en-tire lifetime and potentially acrossgenerations. A life-course study mightexamine child or adolescent health asintermediate outcomes while investi-gating links between childhood experi-ences and adult health. A life-courseperspective can be thought of as ex-tending the developmental perspec-tive across the life span.

EXAMINING THE ROLE OF SOCIALCONTEXT OVER TIME

Although developmental researchersoften examine social influences onphysical, cognitive, or socioemotionaldevelopment, the social context is notnecessarily an inherent component ofdevelopmental studies. In contrast, alife-course perspective explicitly con-

siders the psychosocial as well as thephysical environment, along with bio-logical factors, as potential influenceson child development and adult health.This perspective focuses attention onthe role of context, including socialcontext, over time. A major focus oflife-course epidemiology has been tounderstand how early-life experiences(particularly experiences related toeconomic adversity and the social dis-advantages that often accompany it)shape adult health (particularly adultchronic disease and its risk factorsand consequences).1 Again, the life-course perspective is entirely compat-ible with a developmental perspective,but it explicitly broadens the focusto include contextual elements thatmight not always be applied by investi-gators using the developmentalmodel.

Important concepts in life-course re-search include the notions of critical orsensitive periods, cumulative effectsover time, trajectories or pathways, andintergenerational models. A “critical pe-riod” generally refers to a window oftime during the life course when a givenexposure has a critical or even perma-nent influence on later health. Accordingto the “Barker hypothesis” or “fetal orbiological programming,” the fetal pe-riod is a particularly critical period dur-ing which certain exposures can perma-nently alter particular organ structuresand metabolic functions. According toBarker’s hypothesis, adult cardiovascu-lar disease, type 2 diabetes, stroke, hy-pertension, and other adverse adulthealth outcomes have their origins in aresponse to inadequate nutrition duringfetal and infant growth, leading to al-tered metabolic and endocrine functionand/or increased vulnerability to the ef-fects of later adverse living conditions.2

Some reserve the term “critical period”for a period during which exposures re-sult in unalterable changes; they mayuse the term “sensitive period” to referto periods during which exposures have

large effects that might be modified bylater experiences. Others use “criticalperiod” more generally to encompassthe latter. Cumulative effects result fromthe accumulation of risk (or protection)over time in additive or synergisticways.Kuh et al3 have discussed different waysin which risks can accumulate over timeand how the relationships can be con-ceptualized in a life-course study. The no-tion of cumulative risk is that long-termdamage occurs through the compound-ing of environmental, socioeconomic,and behavioral exposures over the life-course; risks may accumulate throughindependent exposures, or exposureclusters related to, for example, an indi-vidual’s or family’s socioeconomic posi-tion. Another model posits a chain of se-quential exposures, with each exposureincreasing the probability of the nextexposure aswell as influencing later dis-ease risk in an additive effect, indepen-dently of subsequent exposures. Alter-nately, in amodelwith a so-called triggereffect, exposures follow one another se-quentially (andprobabilistically), butdis-ease risk is not increased until the effectof the final event in the chain.1 “Trajec-tory” or “pathway” generally refers tothe sequence of exposures and out-comes over an individual’s lifetime,whereas intergenerational studies focuson the transmission of health or illhealth, and the predictors of both,across more than 1 generation.

Several excellent reviews of the life-course literature have been pub-lished.4–12 In this article we provide abrief introduction to the life-courseperspective to discuss its relevance tounderstanding and addressing healthdisparities.

WHAT EVIDENCE SUPPORTS THELIFE-COURSE PERSPECTIVE?

Considerable epidemiologic evidencehas accumulated, particularly over thepast 2 decades, linking exposures in

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early life to health at later life stages. Arange of predictors and outcomes hasbeen examined, but a recurring themehas been consideration of early-life so-cial factors and their links to adultchronic disease. Behavioral and men-tal health outcomes in adulthood alsohave been linked to early experience oftrauma or adversity. In the retrospec-tive Adverse Events in Childhood (ACE)study, adult respondents were as-signed scores on the basis of their re-ports of abuse (emotional, physical, orsexual) or 5 types of household dys-function in their first 18 years of life; agraded relationship was observed be-tween this ACE score and adverse out-comes inmeasures of depression, anx-iety, substance abuse, and sexual riskbehaviors in adulthood.13 Data fromthe same population also revealed astrong dose response between thelevel of exposure to abuse or family

dysfunction during childhood and riskfactors for several leading causes ofdeath.14

The life-course literature is particu-larly rich in studies that have investi-gated the early-life antecedents of car-diovascular disease; outcomes havespanned ischemic heart disease andstroke, associated mortality, and riskfactors, including hypertension, otherbiological markers, and behavioralrisk factors. As shown in Table 1, child-hood socioeconomic conditions alsohave been linked to adult-onset diabe-tes mellitus and mortality from diabe-tes, respiratory disease, smoking-related cancer, stomach cancer, andother adult outcomes.

Table 2 lists selected studies (also notan exhaustive list) that have linked lowbirth weight to adult ill health or itspredictors. Other studies have linkedlow birth weight of offspring to ad-verse socioeconomic conditions dur-ing their parents’ childhood.53–56 Someintergenerational studies have exam-ined low birth weight as an intermedi-ate outcome between childhood adver-sity in 1 generation and adult ill health(or its predictors) in the subsequentgeneration.57

QUESTIONS UNANSWERED BYEXAMINING ONLY PROXIMATEEXPOSURES (ie, EXPOSURESOCCURRING SHORTLY BEFORE ANOUTCOME)

Some of us have been drawn to con-sider a life-course approach as weconfront persistent gaps in knowl-edge from research focused on expo-sures occurring not long before out-comes. For example, the two- tothreefold disparity in low birthweight and preterm birth betweenblack and white newborns is not ex-plained by the known risk factors foradverse birth outcomes; these riskfactors include current or recentsmoking, drug use, underweight orinadequate pregnancy weight gain,and chronic disease.79

As we attempt to understand the so-cial patterning of birth-outcome dis-parities according to class and nativ-ity as well as to race, many of us havecome to suspect that stressful expe-riences over women’s lives beforepregnancy represent a biologicallyplausible missing piece of the puzzle.At every level of current income andeducation, black women are morelikely than their white counterpartsto have experienced chronic stressas children caused by economic dif-ficulties, racial discrimination, orboth.80 Accumulating evidence aboutthe physiology of stress demon-strates that stressful experiences,particularly when they are chronic,could result in hypothalamic-pituitary-adrenal axis and/or im-mune function dysregulation, mak-ing a woman more likely to have anexcessive physiologic response toeven minor stress.81,82 High cortisollevels or immune dysfunction duringpregnancy could lead to adversebirth outcomes through immune, in-flammatory, or vascular pathways ora combination of these pathways.83–88

TABLE 1 Adult Health Outcomes AssociatedWith Childhood SocioeconomicConditions

All-cause mortality15–19

Cause-specific mortalityAlcoholic cirrhosis20

Cancer, smoking-related18,20,21

Cancer, stomach18,20,21

Cardiovascular disease15,16,18,21–24

Diabetes20

Respiratory disease18,21

Cardiovascular diseaseCarotid atherosclerosis25

Coronary heart disease26–28

Ischemic heart disease29

Myocardial infarction26,29

Stroke30

Metabolic outcomesInsulin resistance31

Obesity32–38

Type 2 diabetes39,40

Behavioral outcomesAlcohol or drug abuse41–43

Smoking44–47

Other health outcomesDepression48

Functional limitations19,49

Inflammatory markers50

Periodontal disease42,51

Self-rated health52

This list is not exhaustive; it is provided to indicate thescope of adult health outcomes that have been examinedwith life-course research.

TABLE 2 Adult Health Outcomes AssociatedWith Low Birth Weight

All-cause mortality58

Cause-specific mortalityCardiovascular disease58,59

Respiratory disease60

Cardiovascular diseaseCoronary heart disease61–64

Hypertension65–69

Ischemic heart disease70,71

Metabolic outcomesImpaired glucose tolerance72

Metabolic syndrome73

Type 2 diabetes61,72,74,75

Other health outcomesChronic kidney disease76

Depression77

Spontaneous hypothyroidism78

This list is not exhaustive; it is provided to indicate thescope of adult health outcomes that have been examinedwith life-course research.

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HOW IS THE LIFE-COURSEPERSPECTIVE RELEVANT TO HEALTHDISPARITIES?

The term “health disparities” oftenmeans different things to differentpeople.89,90 Although the dictionarycould lead one to conclude that theterm refers generically to all differ-ences in health, it is used here to referto potentially avoidable differences inhealth among groups of people whohave different levels of social and eco-nomic advantage or disadvantage; itrefers to differences in health onwhich socially disadvantaged groups(eg, people of low incomes or educa-tional attainment or members of a ra-cial or ethnic group that historicallyhas experienced discrimination) sys-tematically do worse.89 For example,the large and persistent black-whitedisparities in low birth weight, infantmortality, and maternal mortality areexamples of health disparities; thehigher incidence of breast canceramong white women compared withblack women is a health differencethat deserves attention, but it is notwhat is meant by the term health dis-parity according to established usagein public health.91 In other words,health disparities are a subset of dif-ferences in health that deserve partic-ular attention not only because theymay be avoidable but also becausethey are unfair and unjust.

People might be socially advantagedor disadvantaged by virtue of theirrace or ethnic group or because ofsuch socioeconomic factors as in-come, accumulated wealth, education,or residence in a socioeconomicallyadvantaged or disadvantaged commu-nity. Other relevant dimensions in-clude gender, religion, sexual orienta-tion, disability, and other socialcharacteristics that are associatedwith different levels of social stigma orinfluence and, hence, with different re-sources and opportunities in life. In

this article, the term “health dispari-ties” refers to differences in health ac-cording to race or ethnic group, socio-economic factors, or both, on whichthe socially disadvantaged groups sys-tematically experience worse health.

Figure 1 illustrates disparities inhealth by showing national data onchild health levels (as assessed by par-ents) according to family income andrace or ethnic group. It shows a strik-ing stepwise gradient in health accord-ing to income within each of the larg-est racial or ethnic groups; as incomerises, health improves.

The patterns are noted here to make 2important points. First, substantial so-cioeconomic and racial disparities inhealth adversely affect the middle-class and low-income groups; thesepatterns have been observed for awide range of health indicators amongadults and children.93 Second, when in-vestigating health disparities, oneneeds to consider not only socioeco-nomic factors such as income and ed-ucation (the socioeconomic factorsmost frequently used in health re-search in the United States) but alsoracial or ethnic identity. Socioeco-nomic factors do not fully reflect someexperiences of race-based discrimina-tion that could have large health ef-fects. Neither socioeconomic dispari-ties nor disparities according to racial

or ethnic group can be reduced to theother; although many epidemiologicstudies fail to do so, both must beexamined.

Figure 2 demonstrates the importanceof examining a range of social factors,including socioeconomic characteris-tics and other measures (such as ra-cial residential segregation) associ-ated with racial or ethnic group thatmight not be captured by socioeco-nomic information. The figure illus-trates the need for a new way of exam-ining health and health disparities.This new perspective does not negatethe importance of medical care butrecognizes the need to look beyond itat the circumstances in which peoplelive, work, learn, and play. Thisbroader perspective is necessary toimprove the health of all Americansand reduce the large health disparitiesamong different groups according toclass and race or ethnic group.

The prevailing view has been that indi-viduals are solely responsible for theirhealth-related behaviors. In line withthat thinking, our health-promotion ef-forts have focused heavily on inform-ing and encouraging individuals tochange their behaviors. The contentionin this monograph, however, is that weneed to take a fresh look, because cur-rent approaches have not providedan acceptable return on investment.

FIGURE 1In every racial or ethnic group, children’s health varies according to family income. (Adapted withpermission from Egerter et al.92)



Some public health campaigns haveactually led to awidening of disparitiesas individuals in more socially advan-taged groups experience greaterhealth improvements because theyhave fewer obstacles to adoptinghealthier behaviors; this was the casewith antitobacco efforts and, at leastinitially, with efforts to reduce theprevalence of sudden infant death syn-drome.94,95 Moreover, we spend farmore per capita on medical care thanany other country, yet our rank islower than that of most other affluentnations (and lower than that of evensome resource-poor nations) on keyindicators such as infant mortality andlife expectancy.96

Perhaps our lack of success stemsfrom a failure to examine the factorsthat can constrain or enable people tobehave in health-promoting ways, tolook at the factors that society mustinfluence because they are beyond thecontrol of individuals by themselves.This perspective does not question in-dividual responsibility; it does, how-ever, emphasize the importance ofdeveloping policies to remove the ob-stacles that—by exposing individualsto more hazards, providing them withfewer options for healthy behaviors, or

both—systematically make some peo-ple less healthy than others.

As shown in Fig 1, although those withthe least income suffer from the worsthealth, even those who are in the mid-dle class are less healthy than moreaffluent people. We need to overcomeobstacles to good health for everyone,with particularly concerted efforts to

improve the health of those who are atgreatest social and economic disad-vantage (ie, those with more obstaclesand fewer resources to address thoseobstacles). We need initiatives that willimprove the health of the society as awhole while reducing disparities.

Figures 2 and 3 are relevant to the life-course perspective because they illus-trate a way of drawing attention to so-cial context at 2 levels. The first level isthe underlying resources and opportu-nities that people have, reflectedpartly by income and education as wellas by race or ethnic group, because itis so strongly associated with differen-tial access to resources and opportu-nities. The second level is the living andworking conditions into which peopleare sorted according to their income,education, and race or ethnic group(and other underlying resources andopportunities). Figure 2 illustrates abuilding block for a life-course per-spective, without the dimension oftime; it is a static view of how socialfactors can influence health directly

FIGURE 2Influences on health: what shapes the conditions that shape health? (Reprinted with permission fromBraveman, Egerter.93)

FIGURE 3Health is shaped by social advantages and disadvantages across lifetimes and generations. (Re-printed with permission from Braveman, Egerter.93)

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and indirectly by shaping health-related behaviors.

Figure 3 adds the dimension of time,depicting how underlying resourcesand opportunities shape living andworking conditions, which, in turn, in-fluence health at each stage of life. Fig-ure 3 also depicts the ways in whichsocial context early in life can have astrong influence on resources and op-portunities (and, thus, on living andworking conditions) at later stages.The figure shows not only an individu-al’s trajectory across a lifetime fromchildhood to adulthood but also the in-tergenerational transmission of socialadvantage or disadvantage and, hence,of health.

Figure 4 offers a deeper look at howhealth disparities are created and sus-tained or compounded over a lifetimeand across generations. Starting atthe top, it shows how social stratifica-tion or social inequality (the formationof social hierarchies that systemati-cally give some groups, such as socialclasses or racial and ethnic groups,more resources and opportunitiesthan others) results in differentgroups that have differential exposureto health hazards or to health-promoting factors.

Also as a result of social stratification,some groups are systematically morelikely to develop health damage if theyare exposed to a given hazard. Thesegroups are then more likely to sufferthe adverse social consequences ofdeveloping a given disease. For exam-ple, someone with limited schoolingwho becomes disabled is more likelyto become unemployable than some-one with good computer technicalskills, because these skills are com-patible with telecommuting. This re-sults in more social stratification—widening inequality—over the lifetimeof an individual and across genera-tions as the children of adults who aredisadvantaged socially and by ill

health grow up in adversity. Figure 4depicts what can be a vicious or virtu-ous cycle of social disadvantage or ad-vantage, producing health damages orbenefits across a lifetime or acrossgenerations.

CHALLENGES IN APPLYING THELIFE-COURSE PERSPECTIVE TORESEARCH, POLICY, AND PRACTICE

The gold standard in life-course re-search is a longitudinal study that pro-spectively follows a birth cohort intoadulthood and, ideally, across genera-tions. In the ideal study design, the in-vestigators collect extensive informa-tion on the physical and socialenvironments and on psychosocial orbehavioral and biological measures;the researchers then repeat thesemeasures for the same individualsover time. Much of the life-course liter-ature comes from Europe, where in-vestigators have had access to high-quality longitudinal databases rich incontextual information. In Table 1, 28(73.7%) of the 38 listed studies, docu-menting a wide array of adult health

outcomes associated with childhoodsocioeconomic conditions, were con-ducted in Europe or Australia/New Zea-land, and of these, 13 used longitudinaldata sources that measured variablesfrom birth onward. The scope anddepth of these data sources are exem-plified by the Centre for LongitudinalStudies’ 1970 British Birth Cohort, thecurrent participants of which are thesurvivors from an original sample ofover 17 000 births in England, Wales,and Scotland during 1 week in 1970. Asof 2006, analysis of these data hadyieldedmore than 300 publications, re-porting key findings in areas such asprenatal and perinatal antecedents ofconditions, social circumstances andhealth outcomes, adult outcomes ofchildhood disease and health status,and predictors of adult health status.Research based on this birth cohorthas provided crucial evidence in anumber of government inquiries thatled to policy and practice changes.97

In the United States, however, manylife-course studies have had to rely on

FIGURE 4Why are some social groups more likely to experience ill health? Considering living conditions acrosslifetimes and generations. (Adapted with permission from Finn Diderichsen, Karolinska Institutet,Stockholm, Sweden.)



retrospective approaches, includingcase-control and retrospective cohortstudies that often have long recall pe-riods for early exposures. In contrastwith prospective longitudinal mea-surement of information from individ-uals followed over time, life-course re-search, particularly in the UnitedStates, often depends on record link-age, natural experiments, or historicalcohorts with limited follow-up acrosslife stages. Given the United States’high per-capita gross domestic prod-uct (in 2007 only those of 2 Organisa-tion for Economic Co-operation and De-velopment countries were higher98),lower levels of investment in admit-tedly costly longitudinal databases

and studies may be assumed to reflectprimarily differences in prioritiesrather than resources.

Table 3 lists longitudinal health-focused databases that US investiga-tors often have used for life-coursestudies. Table 4 lists longitudinal data-bases for which the primary focus isnot health but which contain health in-formation and have been used byhealth researchers. None of the exist-ing primarily health-focused data-bases begin at birth, and the EarlyChildhood Longitudinal Study-BirthCohort follows children from birthonly through preschool. Table 5 is alist of selected European longitudi-

nal databases that include somedata on participants from birththrough adulthood.

An exciting opportunity for many UShealth researchers is provided by theNational Children’s Study,115 which isscheduled to begin collecting datasoon on a representative sample of100 000 newborns and to follow the co-hort through the age of 21 years. TheNational Institutes of Health is leadingthe study but has been collaboratingextensively with other sectors to en-sure the collection of a rich array ofcontextual information.

As anyonewhohas analyzed longitudinaldata knows, it is exceedingly challenging

TABLE 3 Examples of Major Health-Focused Longitudinal Databases: United States

Name of Study, Lead Agency Initial Sample Follow-up

Alameda County Study,99 NIA 6928 noninstitutionalized Alameda County residents, aged�21 y atentry in 1965 (�16 y if married)

1965, 1974, 1994, and 1995

Coronary Artery RiskDevelopment in Young Adults(CARDIA),100 NHLBI

5115 black and white men and women aged 18–30 y at entry in1986, in 4 major US cities

7 waves over 20 y

Framingham Heart Study,101 NHLBI Original cohort: 5209 men and women aged 30–62 y in 1948 inFramingham, MA; offspring (1971): 5124 adult children andspouses in 1971; third generation (2005): 4095 adultgrandchildren of original participants

Every 2 y until present

Health and Retirement Study(HRS),102 NIA

�22 000 men and women aged�50 y in 1988 Biennially to present

Midlife Development in the UnitedStates (MIDUS),103 NIA

7000 men and women aged 25–74 y in 1995 (MIDUS I) Second wave�10 y later (MIDUS II)

National Longitudinal Study ofAdolescent Health (ADDHealth),104 NICHD

�90 000 students in grades 7–12 in 1994 at 145 schools; morethan�20 000 students and their parents interviewed at home

Reinterviewed at ages 18–26 and 24–32 y

Nurses’ Health Study (NHS),105 NIH Original cohort:�122 000 married registered nurses, aged30–55 y in 1976; NHS II: 116 686 women aged 25–42 y in 1989

Biennially to present

NIA indicates National Institute on Aging; NHLBI, National Heart, Lung and Blood Institute; NICHD, Eunice Kennedy Shriver National Institute of Child Health and Human Development; NIH,National Institutes of Health.

TABLE 4 Examples of Other Longitudinal Databases: United States

Name of Study, Lead Agency Initial Sample Follow-up

Early Childhood Longitudinal Study Birth Cohort(ECLS-B),106 Department of Education

14 000 children born in 2001 Data collection at birth, 9 mo, 2 y, preschool age,and entry to kindergarten

Early Childhood Longitudinal Study KindergartenCohort (ECLS-K),106 Department of Education

Nearly 4 million kindergartners enrolled in 1998–1999 Additional data collection in 1st, 3rd, 5th, and8th grades

National Longitudinal Survey of Youth (NLSY79),107

Bureau of Labor Statistics12 686 men and women aged 14–22 y in 1979 Interviewed annually through 1994, and

biennially to presentNLSY79 Children and Young Adults,107 Bureau ofLabor Statistics

Ongoing enrollment of NLSY79 women’s offspring,beginning in 1986

Biennially to present

NLS Original Cohorts,107 Bureau of Labor Statistics 5159 women aged 14–24 y in 1968; 5083 women aged20–44 y in 1967; 5225 men aged 14–24 y and 5020men aged 45–59 y in 1966

Women: biennially to present; men: interviewsceased in 1981

Panel Study of Income Dynamics (PSID),108

National Science Foundation4800 families in 1968 core sample;�7400 families by2005

Annually 1968–1996, biennially to present

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to study complex pathways over time,taking into account the temporal andpotential relationships at any given pointin time. In addition, previous researchtells us that socioeconomic conditions inearly life are strongly associated withlater-life socioeconomic conditions,116,117

which, in turn, have demonstrated linkswith adult health.

To tease out the “independent” impact ofearly socioeconomic circumstances onlater health (ie, to assess whether earlyadverse exposures themselves areman-ifested in later irreversible or difficult-to-reverse health damage, regardless oflater experiences), most life-coursestudies have attempted to control for so-cioeconomic circumstances later in life.Such adjustments can lead to underesti-mates of the influence of early-life fac-tors on subsequent health. For example,“overcontrolling” could mask the influ-ence of key mediators on the causalpathway from early conditions to lateradult health.

Life-course studies designed to betterunderstand health disparities have aneven greater challenge than life-course studies in general. To under-stand disparities not only in childhealth but also in adult health in rela-tion to experiences during childhood,we must examine multiple determi-nants of health and of health dispari-ties. The risk factors for disparities in

a given health indicator are not alwaysthe same as those for levels of thathealth indicator on average.

To understand the underlying basis fordisparities in a particular health out-come, we need to understand not onlythe causal exposures that occur inclose temporal proximity to the out-come but also the more fundamentalcauses or, in other words, the causesof the causes. We must consider thesocial and physical environments thatcreate great opportunities or dauntingobstacles to health, in part by con-straining choices. We must considermultiple dimensions of material depri-vation, social disadvantage, discrimi-nation, and marginalization. Thesedimensions include poverty- and race-based discrimination and their healthconsequences, as well as the health ef-fects of chronic stress that arise fromhaving inadequate resources to dealwith crushing demands. These aresome of the factors that belong in the 2outer arches of Fig 2 as examples ofeconomic and social resources andopportunities and of the living andworking conditions that they produce.These are the factors that producehealth disparities by tracking differentgroups of people into different expo-sures, different vulnerabilities to expo-sure, and different consequences of illhealth. These harmful or protective

factors should be examined atmultiplelevels of aggregation or analysis fromthe individual, family, community, andsocietal levels. A life-course study, fur-thermore, must examine these multi-ple dimensions of social advantageand disadvantage over time.

This is a tall order to fill. It is impossi-ble to describe fully all of the signifi-cant social and economic influences atthe individual, family, and communitylevels at any given point in time, letalone across a lifetime. We must beaware of this limitation aswe interpretresearch findings that will inevitablybe incomplete in some regard. Wemust also be careful not to invokegenes or “culture” to explain racial orethnic disparities in health withoutconsidering the potential roles of un-measured differences in social or eco-nomic experiences and in chronicallystressful experiences related to low in-come or to racial discrimination.

The challenges in conducting life-course research are considerable,but the challenges in applying thelife-course perspective to policy andpractice are even greater. One majorobstacle is that when the costs andbenefits of proposed policies are beingweighed, the time frame for outcomemeasurement is very short (typically 3to 5 years) for the Office of Manage-ment and Budget,118 which assesses

TABLE 5 Examples of Major Longitudinal Health-Focused Databases: Europe

Name of Study Initial Sample Follow-up

Avon Longitudinal Study of Parents andChildren (ALSPAC)109

�14 000 mothers enrolled during pregnancy in Bristol, United Kingdom,during 1991 and 1992

Ongoing

1970 British Birth Cohort Study110 �17 200 infants born in England, Wales, Scotland, and North Ireland ina week in April 1970

6 follow-ups, 1975–2004

Millennium Cohort Study (MCS)111 18 818 infants born in the United Kingdom over a 12-mo period in 2000–2001 and living in selected UK wards at 9 mo of age

4 waves between June 2001 and present

National Child Development Study (NCDS)112 17 500 infants born in England, Scotland, and Wales in a week in March1958

7 waves to the present

Newcastle Thousand Families Study113 All 1142 infants born to mothers in Newcastle Upon Tyne, UnitedKingdom, May–June 1947

At ages 15, 22, 32, 50, and 54 y

Population, Cancer, Cause of Death, andHospital Discharge Registries

Population-wide registries in the Scandinavian countries, linkablethrough the personal identification code

NA

Understanding Society Study114 Household members aged�10 y in 40 000 households across theUnited Kingdom

Annually from 2009

NA indicates not applicable.



proposed federal legislation. Politi-cians typically want credit for the initi-atives they enact, but a life-course per-spective tells us that it can often take1 or more generations to realize thefull benefits of investments in earlychildhood.

Perhaps even more challenging arethe “silos” that isolate different sec-tors. In the current structures, the ed-ucation and social welfare sectors willnot receive credit for improvements inadult health that result from invest-ments in high-quality early-childhooddevelopment programs and improvedK-12 schooling. The transportation sec-tor will not receive credit for the healthbenefits that result from improvingpublic transportation in ways that pro-vide communities with more employ-ment opportunities. The agencies thatmust invest in improving early-childhood living conditions to producehealthy adults are not the same agen-cies that will receive the credit or anymonetary savings from improved adulthealth. The political and bureaucraticstructures that separate differentagencies, particularly across differentsectors, are among the greatest obsta-cles to translating knowledge fromlife-course research into effective pol-icy and practice.

AN AGENDA FOR RESEARCH ANDACTION INFORMED BY LIFE-COURSEPERSPECTIVES

We need more life-course research,which will require longitudinal studieswith extensive multilevel informationon social and physical context as wellas biology and behavior over time. TheNational Children’s Study is a step inthe right direction. However, futurefunding to follow the cohort into adult-hood is not ensured. In addition, al-though the National Children’s Studywill provide a rich source of contextualinformation, no single study can coverall important research questions, and

many items desired by researchersare not included in the study.

We also need to incorporate more in-formation on life-course social con-text into routine cross-sectional datasources as well as special studies.More investment is needed for devel-oping measures that can, despite longrecall periods, capture important in-formation about past experiences. Weneed more research on the early-lifeorigins of adult chronic disease. Un-derstanding birth outcome disparitiesshould receive special priority, givenhow powerfully low birth weight andpreterm birth predict developmentand health across the life course.

In addition to more research, we needto apply the knowledge that we cur-rently have; the available knowledgegives considerable guidance. Currentevidence tells us that we need to give ahigher priority to identifying and im-plementing policies that will ensure fa-vorable living conditions in early child-hood and that health care is importantbut not sufficient for achieving goodhealth and reducing health dispari-ties.119–121 Available evidence alsoshows that we must reduce child pov-erty and its social consequences if weare to improve adult health. We knowthat we must reduce multiple dimen-sions of disadvantage. We also knowthat effective interventions are avail-able, including high-quality programsmodeled on the most effective earlyHead Start approaches, high-qualitychild care, and support for par-ents.122,123 In the United Kingdom, the1998 Report of the Independent Inquiryinto Inequalities in Health, chaired bySir Donald Acheson, recommended39 actions that are intended to ame-liorate health inequalities primarilyby improving living conditions forvulnerable groups such as children,pregnant women, older people, andethnic minorities. On the basis of theAcheson Commission’s findings, the

Labor government enacted policies de-signed to reduce poverty and adversityin early childhood, targeting improve-ments in housing, schools, and childcare in deprived areas, as well aswage, tax, and welfare reform.114,124,125

Figure 4 is useful not only for elucidat-ing the relationships involved in theproduction of health or disease acrossa lifetime and generations but also forcalling our attention to the multiplepoints at which society can intervenethrough policies to interrupt the vi-cious cycles leading to health dispari-ties that begin in early childhood. Poli-cies can reduce social stratification,for example, by reducing poverty, ra-cial discrimination, or both. Policiescan reduce harmful exposures forthosewho aremost disadvantaged, forexample, by creating affordable andadequate housing, improving neigh-borhood environments, and enforcingantidiscrimination measures that af-fect access to health-promoting hous-ing and neighborhoods. Policies canalso reduce susceptibility to develop-ing ill health once people are exposedto risk factors by, for example, sup-porting after-school programs for at-risk youth. Policies can markedly alterthe social consequences of ill healththrough, for example, programs suchas Social Security and Medicaid.

The life-course perspective tells usthat we must change the time framefor evaluating policy outcomes andimpact, and we must break down thesector-specific silos, which will re-quire action at the highest levels ofgovernment. Child health advocatesmust recognize that children livewith adults. As a result, we cannotimprove children’s experiences with-out addressing the needs and im-proving the experiences of theiradult caregivers.

Child health advocates should under-stand that a life-course perspectiveoffers a very powerful argument for

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more investment in childhood be-cause of the impact of childhood ex-periences on later adult health. Theyshould understand, however, that theevidence indicates that investment inmedical care alone will not achievethe desired effect;119–121 investmentin children’s living and learning con-ditions is required. Adult health ef-fects might be more compelling thanchild health effects to many policymakers, because adults can vote and

adult health translates into economicproductivity.

The current economic crisis could cre-ate even more barriers to enactingbold new initiatives that require sub-stantial resources, such as efforts todrastically reduce childhood poverty.Perhaps this is also a time of uniqueopportunity, when we might be willingto reexamine many of our most funda-mental assumptions in the face of evi-dence that the course we have been

following is not working. That evidenceincludes our country’s low standing onkey health indicators compared withother affluent nations, although wespend more on medical care.96 The ev-idence also includes our rates of childpoverty, which are among the highestamong affluent nations.126 Can we af-ford to address child poverty in theUnited States? The life-course perspec-tive indicates that we cannot afford notto address it.

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Paula Braveman and Colleen BarclayHealth Disparities Beginning in Childhood: A Life-Course Perspective

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