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
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