Trends and group differences in the association between educational attainment and U.S. adult mortality: implications for understanding education's causal influence

Has the shape of the association between educational attainment and U.S. adult mortality changed in recent decades? If so, is it changing consistently across demographic groups? What can changes in the shape of the association tell us about the possible mechanisms in play for improving health and lowering mortality risk over the adult life course? This paper develops the argument that societal technological change may have had profound effects on the importance of educational attainment - particularly advanced education - in the U.S. adult population for garnering health advantages and that these changes should be reflected in changes in the functional form of the association between educational attainment and mortality. We review the historical evidence on the changing functional form of the association, drawing on studies based in the United States, to assess whether these changes are consistent with our argument about the role of technological change. We also provide an updated analysis of these functional form patterns and trends, contrasting data from the early 21st Century with data from the late 20th Century. This updated evidence suggests that the shape of the association between educational attainment and U.S. adult mortality appears to be reflecting lower and lower adult mortality for very highly educated Americans compared to their low-educated counterparts in the 21st Century. We draw on this review and updated evidence to reflect on the question whether education's association with adult mortality has become increasingly causal in recent decades, why, and the potential research, policy, and global implications of these changes.

The Relationship Between Duration of U.S. Residence, Educational Attainment, and Adult Health Among Asian Immigrants

There is substantial educational heterogeneity among Asian immigrants to the United States, suggesting that the association between duration of U.S. residence with their health outcomes and behaviors may vary considerably by educational attainment. Using data from the 2003 New Immigrant Survey (N=2,373), we find strong evidence that the detrimental associations between duration of U.S. residence and self-reported health, activity limitation status, chronic health conditions and current smoking are concentrated among Asian immigrants with less than a high school education; in contrast, the health outcomes and behaviors of Asian immigrants who have at least a high school degree exhibit very few differences by duration of U.S. residence. These distinct duration-health patterns by educational attainment are not explained by duration related differences in country of origin, class of admission, or English speaking skills. We also find a stronger duration relationship with current smoking than those with the health status measures among the least educated Asian men, indicating a potential behaviorally-based explanation for poorer health among Asian immigrant men with longer duration of residence.

Racial disparities in self-rated health: trends, explanatory factors, and the changing role of socio-demographics

This paper uses data from the U.S. National Health Interview Surveys (N = 1,513,097) to describe and explain temporal patterns in black-white health disparities with models that simultaneously consider the unique effects of age, period, and cohort. First, we employ cross-classified random effects age-period-cohort (APC) models to document black-white disparities in self-rated health across temporal dimensions. Second, we use decomposition techniques to shed light on the extent to which socio-economic shifts in cohort composition explain the age and period adjusted racial health disparities across successive birth cohorts. Third, we examine the extent to which exogenous conditions at the time of birth help explain the racial disparities across successive cohorts. Results show that black-white disparities are wider among the pre-1935 cohorts for women, falling thereafter; disparities for men exhibit a similar pattern but exhibit narrowing among cohorts born earlier in the century. Differences in socioeconomic composition consistently contribute to racial health disparities across cohorts; notably, marital status differences by race emerge as an increasingly important explanatory factor in more recent cohorts for women whereas employment differences by race emerge as increasingly salient in more recent cohorts for men. Finally, our cohort characteristics models suggest that cohort economic conditions at the time of birth (percent large family, farm or Southern birth) help explain racial disparities in health for both men and women.

Is acculturation always adverse to Korean immigrant health in the United States?

This study examined the association between individuals' proportion of life spent in the United States and the health status and health behaviors among Korean immigrants aged 25 and above. The analysis is stratified by level of education to test whether a higher proportion of time spent in the United States is associated with poorer health among both less educated and highly educated Korean immigrants. California health interview survey data from 2005 to 2007 were used to estimate logistic regression models of health and health behaviour among Korean immigrants, stratified by educational attainment. The health and health behaviour of less educated Korean immigrants tended to be worse among those with a higher proportion of residence in the United States. However, more highly educated Korean immigrants tended to exhibit lower odds of being unhealthy and lower odds of poor health behavior with a higher proportion of life spent in the United States. Acculturation is not always associated with poorer immigrant health outcomes. A higher proportion of life spent in the United States tends to be associated with more favorable health and health behavior among highly educated Korean immigrants.

Does the Hispanic Paradox in U.S. Adult Mortality Extend to Disability?

Studies consistently document a Hispanic paradox in U.S. adult mortality, whereby Hispanics have similar or lower mortality rates than non-Hispanic whites despite lower socioeconomic status. This study extends this line of inquiry to disability, especially among foreign-born Hispanics, since their advantaged mortality seemingly should be paired with health advantages more generally. We also assess whether the paradox extends to U.S.-born Hispanics to evaluate the effect of nativity. We calculate multistate life tables of life expectancy with disability to assess whether racial/ethnic and nativity differences in the length of disability-free life parallel differences in overall life expectancy. Our results document a Hispanic paradox in mortality for foreign-born and U.S.-born Hispanics. However, Hispanics' low mortality rates are not matched by low disability rates. Their disability rates are substantially higher than those of non-Hispanic whites and generally similar to those of non-Hispanic blacks. The result is a protracted period of disabled life expectancy for Hispanics, both foreign- and U.S.-born.

The Importance of Spousal Education for the Self-Rated Health of Married Adults in the United States

Education's benefits for individuals' health are well documented, but it is unclear whether health benefits also accrue from the education of others in important social relationships. We assess the extent to which individuals' own education combines with their spouse's education to influence self-rated health among married persons ages 25 and older in the United States (N = 337,846) with pooled data from the 1997-2010 National Health Interview Survey. Results from age and gender-specific models revealed that own education and spouse's education each share an inverse association with fair/poor self-rated health among married men and women. Controlling for spousal education substantially attenuated the association between individuals' own education and fair/poor self-rated health and the reduction in this association was greater for married women than married men. The results also suggest that husbands' education is more important for wives' self-rated health than vice versa. Spousal education particularly was important for married women ages 45-64. Overall, the results imply that individuals' own education and spousal education combine to influence self-rated health within marriage. The results highlight the importance of shared resources in marriage for producing health.

New estimates of racial/ethnic differences in life expectancy with chronic morbidity and functional loss: evidence from the National Health Interview Survey

This study documents the mortality, chronic morbidity and physical functioning experiences of U.S. Hispanics, non-Hispanic whites, and non-Hispanic blacks 50 years of age and older in the United States. Hispanics are classified by nativity to better assess an important source of heterogeneity in population health within that population. Drawing on mortality and morbidity data from the National Health Interview Survey, demographic models of healthy life expectancy are used to derive estimates of life expectancy, life expectancy with and without chronic morbidity conditions, and life expectancy with and without functional limitations. The results not only highlight the mortality advantages of foreign-born Hispanics, but also document their health advantages in terms of morbidity and physical functioning beyond age 50. Nativity is a highly important factor differentiating the health and mortality experiences of Hispanics: U.S.-born Hispanics have a health profile more indicative of their minority status while foreign-born Hispanics have much more favorable mortality and health profiles. Differences in smoking across racial/ethnic/nativity groups is suggested as an important reason behind the apparent health advantages of foreign-born Hispanics relative to whites as well as relative to their U.S.-born counterparts.

Race/Ethnicity, nativity, and tobacco use among US young adults: results from a nationally representative survey

INTRODUCTION

A growing body of research documents racial/ethnic disparities in U.S. cigarette smoking. To date, however, few studies have examined the influence of nativity, in addition to race/ethnicity, on current and ever use of cigarettes as well as other tobacco products among young adults. Here, racial/ethnic and nativity disparities in tobacco use and self-identified smoking status are documented for U.S. women and men aged 18-34, both unadjusted and adjusted for socioeconomic status.

METHODS

The Legacy Young Adult Cohort Study (N = 3,696) was used to examine gender-specific tobacco use and smoking status differences among foreign-born Hispanics, U.S.-born Hispanics, U.S.-born non-Hispanic Blacks, and U.S.-born non-Hispanic Whites. Prevalence estimates and multivariable models of ever tobacco use, current tobacco use, and self-identified smoking status were calculated.

RESULTS

U.S.-born Hispanics, Blacks, and Whites exhibit the highest levels of ever and current use across a range of tobacco products, whereas foreign-born Hispanics, particularly women, exhibit the lowest ever and current use of most products and are least likely to describe themselves as smokers. Controlling for socioeconomic covariates, current tobacco use is generally lower for most minority groups relative to Whites. Social or occasional smoking, however, is higher among U.S.-born Hispanics and Blacks.

CONCLUSIONS

The high level of tobacco use among U.S.-born young adults foreshadows substantial tobacco-related morbidity and mortality in the coming decades. Foreign-born Hispanic young adults, particularly women, exhibit the lowest levels of tobacco use. Future studies of tobacco use must differentiate racial/ethnic groups by nativity to better understand patterns of tobacco use.

Racial/Ethnic and Nativity Patterns of U.S. Adolescent and Young Adult Smoking

We document racial/ethnic and nativity differences in U.S. smoking patterns among adolescents and young adults using the 2006 Tobacco Use Supplement to the Current Population Survey (n=44,202). Stratifying the sample by nativity status within five racial/ethnic groups (Asian American, Mexican American, other Hispanic, non-Hispanic black, and non-Hispanic white), and further by sex and age, we compare self-reports of lifetime smoking across groups. U.S.-born non-Hispanic whites, particularly men, report smoking more than individuals in other racial/ethnic/nativity groups. Some groups of young women (e.g., foreign-born and U.S.-born Asian Americans, foreign-born and U.S.-born Mexican Americans, and foreign-born blacks) report extremely low levels of smoking. Foreign-born females in all of the 25-34 year old racial/ethnic groups exhibit greater proportions of never smoking than their U.S.-born counterparts. Heavy/moderate and light/intermittent smoking is generally higher in the older age group among U.S.-born males and females whereas smoking among the foreign-born of both sexes is low at younger ages and remains low at older ages. Taken together, these findings highlight the importance of considering both race/ethnicity and nativity in assessments of smoking patterns and in strategies to reduce overall U.S. smoking prevalence and smoking-attributable health disparities.

Educational differentials in US adult mortality: An examination of mediating factors

We use human capital theory to develop hypotheses regarding the extent to which the association between educational attainment and US adult mortality is mediated by such economic and social resources as family income and social support; such health behaviors as inactivity, smoking, and excessive drinking; and such physiological measures as obesity, inflammation, and cardiovascular risk factors. We employ the NHANES Linked Mortality File, a large nationally representative prospective data set that includes an extensive number of factors thought to be important in mediating the education-mortality association. We find that educational differences in mortality for the total population and for specific causes of death are most prominently explained by family income and health behaviors. However, there are age-related differences in the effects of the mediating factors. Higher education enables individuals to effectively coalesce and leverage their diverse and substantial resources to reduce their mortality and increase their longevity.

Education and the gender gaps in health and mortality

The positive associations between education and health and survival are well established, but whether the strength of these associations depends on gender is not. Is the beneficial influence of education on survival and on self-rated health conditioned by gender in the same way, in opposite ways, or not at all? Because women are otherwise disadvantaged in socioeconomic resources that are inputs to health, their health and survival may depend more on education than will men's. To test this hypothesis, we use data from the National Health Interview Survey-Linked Mortality Files (NHIS-LMF). We find that education's beneficial influence on feeling healthy and on survival are conditional on gender, but in opposite ways. Education has a larger effect on women's self-rated health than on men's, but a larger effect on men's mortality. To further examine the mortality results, we examine specific causes of death. We find that the conditional effect is largest for deaths from lung cancer, respiratory disease, stroke, homicide, suicide, and accidents. Because women report worse health but men's mortality is higher, education closes the gender gap in both health and mortality.

Trends in US older adult disability: exploring age, period, and cohort effects

OBJECTIVES

We elucidated how US late-life disability prevalence has changed over the past 3 decades.

METHODS

We examined activities of daily living (ADL) and instrumental activities of daily living (IADL) disability trends by using age-period-cohort (APC) models among older adults aged 70 years or older who responded to the National Health Interview Survey between 1982 and 2009. We fitted logistic regressions for ADL and IADL disabilities and for each of the 3 APC trends with 2 models: unadjusted and fully adjusted for age, period, cohort, and sociodemographic variables.

RESULTS

The unadjusted and adjusted period trends showed a substantial decline in IADL disability, and ADL disability remained stable across time. Unadjusted cohort trends for both outcomes also showed continual declines across successive cohorts; however, increasing cohort trends were evident in the adjusted models.

CONCLUSIONS

More recent cohorts of US older adults are becoming more disabled, net of aging and period effects. The net upward cohort trends in ADL and IADL disabilities remain unexplained. Further studies should explore cohort-specific determinants contributing to the increase of cohort-based disability among US older adults.

The potential contribution of marital-cohabitation status to racial, ethnic, and nativity differentials in birth outcomes in Texas

Disparities in infant mortality by race/ethnicity and nativity are widely known. Patterns of marriage and union formation also vary by race, ethnicity and nativity and may contribute to disparities in birth outcomes. Using population level data, we build on previous research of race/ethnic disparities in birth outcomes by investigating the role of union status. Data come from the 2006 Birth Record from Texas Vital Statistics. The final sample size included 369,839 births to Texas women aged 18 and older. Birth outcomes were constructed from indicators of low birth weight and preterm birth. Logistic regression estimates odds of low birth weight and preterm birth by race/ethnicity and nativity and union status. Race/ethnicity/nativity and union status are significant and independent predictors of birth outcomes. US born Black and Mexican Origin mothers had higher odds of preterm birth and low birth weight babies compared to US born White mothers. Unmarried mothers had higher odds of adverse birth outcomes compared to married women. There was only modest support that the association between race/ethnicity/nativity status and birth outcomes could be explained by divergent patterns in union status. Though disparities in birth outcomes are persistent across race, ethnicity and nativity, the results suggest that union status at birth is a very weak factor in accounting for these disparities. Differing patterns in union status did not account for the Black-White and Mexican Origin-White gaps in infant health outcomes. Additional research aimed at uncovering the processes that put these mothers and infants at higher risk is needed.

The significance of education for mortality compression in the United States

Recent studies of old-age mortality trends assess whether longevity improvements over time are linked to increasing compression of mortality at advanced ages. The historical backdrop of these studies is the long-term improvement in a population's socioeconomic resources that fueled longevity gains. We extend this line of inquiry by examining whether socioeconomic differences in longevity within a population are accompanied by old-age mortality compression. Specifically, we document educational differences in longevity and mortality compression for older men and women in the United States. Drawing on the fundamental cause of disease framework, we hypothesize that both longevity and compression increase with higher levels of education and that women with the highest levels of education will exhibit the greatest degree of longevity and compression. Results based on the Health and Retirement Study and the National Health Interview Survey Linked Mortality File confirm a strong educational gradient in both longevity and mortality compression. We also find that mortality is more compressed within educational groups among women than men. The results suggest that educational attainment in the United States maximizes life chances by delaying the biological aging process.

Educational Differences in U.S. Adult Mortality: A Cohort Perspective

We use hierarchical cross-classified random-effects models to simultaneously measure age, period, and cohort patterns of mortality risk between 1986 and 2006 for non-Hispanic white and non-Hispanic black men and women with less than a high school education, a high school education, and more than a high school education. We examine all-cause mortality risk and mortality risk from heart disease, lung cancer, and unpreventable cancers. Findings reveal that temporal reductions in black and white men's and women's mortality rates were driven entirely by cohort changes in mortality. Findings also demonstrate that disparate cohort effects between education groups widened the education gap in all-cause mortality risk and mortality risk from heart disease and lung cancer across this time period. Educational disparities in mortality risk from unpreventable cancers, however, did not change. This research uncovers widening educational differences in adult mortality and demonstrates that a cohort perspective provides valuable insights for understanding recent temporal changes in U.S. mortality risk.

Educational attainment and adult mortality in the United States: a systematic analysis of functional form

A vast literature has documented the inverse association between educational attainment and U.S. adult mortality risk but given little attention to identifying the optimal functional form of the association. A theoretical explanation of the association hinges on our ability to describe it empirically. Using the 1979-1998 National Longitudinal Mortality Study for non-Hispanic white and black adults aged 25-100 years during the mortality follow-up period (N = 1,008,215), we evaluated 13 functional forms across race-gender-age subgroups to determine which form(s) best captured the association. Results revealed that the preferred functional form includes a linear decline in mortality risk from 0 to 11 years of education, followed by a step-change reduction in mortality risk upon attainment of a high school diploma, at which point mortality risk resumes a linear decline but with a steeper slope than that prior to a high school diploma. The findings provide important clues for theoretical development of explanatory mechanisms: an explanation for the selected functional form may require integrating a credentialist perspective to explain the step-change reduction in mortality risk upon attainment of a high school diploma, with a human capital perspective to explain the linear declines before and after a high school diploma.

Effects of timing and level of degree attained on depressive symptoms and self-rated health at midlife

OBJECTIVES

We examined whether attaining a higher educational degree after 25 years of age was associated with fewer depressive symptoms and better self-rated health at midlife than was not attaining a higher educational degree.

METHODS

We analyzed data from National Longitudinal Survey of Youth, restricting our sample to respondents who had not attained a bachelor's degree by 25 years of age (n = 7179). We stratified all regression models by highest degree attained by 25 years of age.

RESULTS

Among respondents with no degree, a high school diploma, or a post-high school certificate at 25 years of age, attaining at least a bachelor's degree by midlife was associated with fewer depressive symptoms and better self-rated health at midlife compared with respondents who did not attain a higher degree by midlife. Those with an associate's degree at 25 years of age who later attained a bachelor's degree or higher reported better health at midlife.

CONCLUSIONS

Attaining at least a bachelor's degree after 25 years of age is associated with better midlife health. Other specifications of educational timing and its health effects across the life course should be studied.

Education and health among U.S. working-age adults: a detailed portrait across the full educational attainment spectrum

This article presents detailed estimates of relative and absolute health inequalities among U.S. working-age adults by educational attainment, including six postsecondary schooling levels. We also estimate the impact of several sets of mediating variables on the education-health gradient. Data from the 1997-2009 National Health Interview Survey (N = 178,103) show remarkable health differentials. For example, high school graduates have 3.5 times the odds of reporting "worse" health than do adults with professional or doctoral degrees. The probability of fair or poor health in mid-adulthood is less than 5 percent for adults with the highest levels of education but over 20 percent for adults without a high school diploma. The probability of reporting excellent health in the mid-forties is below 25 percent among high school graduates but over 50 percent for those adults who have professional degrees. These health differences characterize all the demographic subgroups examined in this study. Our results show that economic indicators and health behaviors explain about 40 percent of the education-health relationship. In the United States, adults with the highest educational degrees enjoy a wide array of benefits, including much more favorable self-rated health, compared to their less-educated counterparts.

Trends in the Educational Gradient of U.S. Adult Mortality from 1986 to 2006 by Race, Gender, and Age Group

The educational gradient of U.S. adult mortality became steeper between 1960 and the mid 1980s, but whether it continued to steepen is less clear given a dearth of attention to these trends since that time. This study provides new evidence on trends in the education-mortality gradient from 1986 to 2006 by race, gender, and age among non-Hispanic whites and blacks using data from the 2010 release of the National Health Interview Survey Linked Mortality File. Results show that, for white and black men, the gradient steepened among older ages because declines in mortality risk across education levels were greater among the higher educated. The gradient steepened among white women, and to a much lesser and only marginally significant extent among black women, largely because mortality risk decreased among the college-educated but increased among women with less than a high school degree. Greater returns to higher education and compositional changes within educational strata likely contributed to the trends.

RACE/ETHNICITY AND U.S. ADULT MORTALITY: Progress, Prospects, and New Analyses

Although there have been significant decreases in U.S. mortality rates, racial/ethnic disparities persist. The goals of this study are to: (1) elucidate a conceptual framework for the study of racial/ethnic differences in U.S. adult mortality, (2) estimate current racial/ethnic differences in adult mortality, (3) examine empirically the extent to which measures of socioeconomic status and other risk factors impact the mortality differences across groups, and (4) utilize findings to inform the policy community with regard to eliminating racial/ethnic disparities in mortality. Relative Black-White differences are modestly narrower when compared to a decade or so ago, but remain very wide. The majority of the Black-White adult mortality gap can be accounted for by measures of socioeconomic resources that reflect the historical and continuing significance of racial socioeconomic stratification. Further, when controlling for socioeconomic resources, MexicanAmericans and Mexican immigrants exhibit significantly lower mortality risk than non-Hispanic Whites. Without aggressive efforts to create equality in socioeconomic and social resources, Black-White disparities in mortality will remain wide, and mortality among the Mexican-origin population will remain higher than what would be the case if that population achieved socioeconomic equality with Whites.

Education inequality in mortality: The age and gender specific mediating effects of cigarette smoking

A debate within the mortality literature centers around the impact of health behaviors on the prospects of disadvantaged groups. Meanwhile, a growing body of work illustrates the social processes that shape changes in smoking levels by socioeconomic status (SES), especially educational attainment. These literatures are merged by examining the mediating effects of cigarette smoking on education gaps in U.S. adult mortality by age and gender. Findings reveal that cigarette smoking is an important mediator of the education-mortality gap for all males and for younger females. In particular, education-mortality gaps for young men narrow considerably when cigarette smoking is accounted for, while older women experienced no reduction in the education-mortality gap with controls for smoking. These results are consistent with diffusion arguments that describe SES differences in smoking adoption by age and gender and provide strong evidence that smoking is an important differentiator of mortality risks by education.