Degrees of health disparities: Health status disparities between young adults with high school diplomas, sub-baccalaureate degrees, and baccalaureate degrees

Substance Use and College Completion Among Two-Year and Four-Year College Students From a Nationally Representative Longitudinal Study

Young adults from disadvantaged populations access higher education through two-year colleges, but substance use research among young adults focuses on four-year colleges. Filling this research gap is important given recent policy changes that have increased marijuana availability for young adults. This study uses a subsample of college-enrolled participants from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to evaluate whether substance use predicts educational attainment seven years later, comparing 888 students attending a two-year college with 1,398 matched students attending a four-year college. Matched students were identified using a propensity score method so that students were comparable on 15 measures, including precollege grades, precollege test scores, and precollege substance use. Compared with similar four-year college students, two-year college students were more likely to use methamphetamines, cocaine, or marijuana; more likely to report problematic substance use; and less likely to use alcohol. Two-year college students who used methamphetamines in the past year (incidence rate ratio (IRR) = 1.51, 95% CI (1.12, 2.04), p = 0.007) or past month (IRR = 1.69, 95% CI (1.09, 2.61), p = 0.02) or completed alcohol abuse treatment (IRR = 1.58, 95% CI (1.21, 2.07), p < 0.001) were less likely to complete college than two-year college students without those risk factors. Among the matched four-year college students, students who reported that drugs interfered with school or work in the past year (IRR = 1.84 (1.28, 2.64), p = 0.001), used cocaine in the past year (IRR = 1.47 (1.04, 2.08), p = 0.03), and used marijuana in the past year (IRR = 1.30 (1.07, 1.57), p = 0.007), past month (IRR = 1.31 (1.07, 1.61), p = 0.01), or ≥5 times in the past month (IRR = 1.44 (1.12, 1.85) p = 0.005) were less likely to complete college than the matched four-year college students without those risk factors. Substance use interventions should target both two-year and four-year college students. Two-year colleges that better accommodate students who complete substance use treatment may improve these students' completion. Students who use marijuana or cocaine or whose drug use impairs functioning may benefit from an incremental approach of completing a two-year degree prior to transferring to a four-year degree rather than enrolling directly in a four-year program.

Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research

STUDY OBJECTIVES

This review aims to assess the association between socioeconomic status (SES) and sleep health in the general population and the mediating effects of lifestyle and mental and physical health in this relationship.

METHODS

Observational studies testing the independent association between objective or subjective SES indicators and behavioral/physiological or clinical sleep health variables in the general population were included. PubMed/MEDLINE was searched for reports published from January 1990 to December 2019. The direction of effect was used as the primary effect measure, testing the hypothesis that low SES is associated with poor sleep health outcomes. Results are presented in the form of direction effect plots and synthesized as binomial proportions.

RESULTS

Overall, 336 studies were identified. A high proportion of effects at the expected direction was noted for measures of sleep continuity (100% for sleep latency, 50-100% for awakenings, 66.7-100% for sleep efficiency), symptoms of disturbed sleep (75-94.1% for insomnia, 66.7-100% for sleep-disordered breathing, 60-100% for hypersomnia), and general sleep satisfaction (62.5-100%), while the effect on sleep duration was inconsistent and depended on the specific SES variable (92.3% for subjective SES, 31.7% for employment status). Lifestyle habits, chronic illnesses, and psychological factors were identified as key mediators of the SES-sleep relationship.

CONCLUSIONS

Unhealthy behaviors, increased stress levels, and limited access to health care in low-SES individuals may explain the SES-sleep health gradient. However, the cross-sectional design of most studies and the high heterogeneity in employed measures of SES and sleep limit the quality of evidence. Further research is warranted due to important implications for health issues and policy changes.

CITATION

Papadopoulos D, Etindele Sosso FA. Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research. J Clin Sleep Med. 2023;19(3):605-620.

Educational Attainment and Psychological Distress Among Working-Age Adults in the United States

This study builds on a growing body of literature analyzing the education-health gradient across detailed educational categories, which documents that US working-age adults who attended college but did not earn a bachelor's degree report equal or worse health than adults with a high school diploma. This is known as the "anomaly" in the education-health gradient. The purpose of this study is to test whether this pattern extends to measures of serious psychological distress (SPD) and individual symptoms by using data from the National Health Interview Survey (NHIS, 1997-2018) and a series of logistic regression models. We find that the anomaly in the education-health gradient is present for a summary measure of SPD as well as for five of the six symptoms that make up this measure. The exception was reporting feeling sad most or all the time during the last month, where adults with "some college" were found to have lower odds than those with a high school diploma. Further stratified analysis by sex revealed that this result for feeling sad was driven by women. In terms of associate degrees, our models show that adults with a vocational/technical associate degree have statically similar odds of SPD and reporting four out of six symptoms (exceptions were feeling hopeless and sadness), while those with an academic associate degree have significantly lower odds in all outcomes. The robustness of the models used is supported by an extensive sensitivity analysis. Overall, we find evidence of the anomaly in the education-health gradient in SPD and individual symptoms of psychological distress at the sub-baccalaureate level, adding to previous studies that document the anomaly in markers of physiological dysregulation, health conditions, vision problems, functional limitations, and pain.

Socioeconomic status and sleep disturbances among pediatric population: a continental systematic review of empirical research

To this day, no consensus has been established on the definition and the conceptualization of the socioeconomic status (SES), since all the available studies on the relation between SES and health did not use the same conceptual framework and operationalization to assess SES. While literature reported that SES markers (such as income, social support networks, education, employment or occupation) influence the health of populations by shaping living conditions; empirical research does not tell us which SES markers affect more strongly the sleep components of the individuals, as well as which sleep disorders (SD) are affected and how. Even though several original studies have tried to assess how changes in socioeconomic status of parents may affect the psychosocial environment and mental health of an individual directly or through his community, no systematic reviews on the influence of SES on children's sleep are available. This systematic review make an update on the different measures of SES and sleep disturbances used for pediatric population across the different regions of the world. Recommendations for a future standardization of SES measures is proposed, for a better understanding of its influence on sleep disturbances.

The Relationship Between Education and Pain Among Adults Aged 30-49 in the United States

Pain is a major health problem among U.S. adults. Surprisingly little, however, is known about educational disparities in pain, especially among the nonelderly. In this study, we analyze disparities in pain across levels of educational attainment. Using data from the 2010 to 2017 National Health Interview Survey among adults aged 30 to 49 (N = 74,051), we estimate logistic regression models of pain prevalence using a dichotomous summary pain index and its 5 constituent pain sites (low back, joint, neck, headache/migraine, and facial/jaw). We find a significant and steep pain gradient: greater levels of educational attainment are associated with less pain, with 2 important exceptions. First, adults with a high-school equivalency diploma (GED) and those with "some college" have significantly higher pain levels than high school graduates despite having an equivalent or higher attainment, respectively. Second, the education-pain gradient is absent for Hispanic adults. After taking into account important covariates including employment, economic resources, health behaviors, physical health conditions, and psychological wellbeing, educational disparities in pain are no longer statistically significant except for the GED and "some college" categories, which still show significantly higher pain levels than high school graduates. We thus document the overall education-pain gradient in most younger U.S. adult populations, and identify groups where pain is higher than expected (certain educational categories) or lower than expected (eg, less-educated Hispanics). Understanding the causes of these anomalous findings could clarify factors shaping pain prevalence and disparities therein. PERSPECTIVE: Over 50% of U.S. adults age 30 to 49 report pain. Overall, more educated Americans report substantially less pain than the less educated. However, adults with a GED and "some college" report more pain than other groups. Understanding the causes could help illuminate the mechanisms through which social factors influence pain.

Reproductive coercion sometimes works: evaluating whether young African-American women who experience reproductive coercion or birth control sabotage are more likely to become pregnant

Men engaging in reproductive coercion may coerce, force, or deceive female partners into pregnancy. This study evaluates whether the 3-month incidence of pregnancy is higher among women reporting reproductive coercion than similar women reporting no reproductive coercion. We tested this hypothesis in longitudinal data from a sample of African-American women ages 18–24 recruited from community settings in Atlanta, Georgia, US, in 2012–2014 (n = 560). Participants were surveyed at baseline, 3 months, 6 months, 9 months, and 12 months. To reduce selection bias, we used full matching on 22 baseline variables related to demographics, economic power, risky alcohol use, and gender-based power inequality. We used logistic regression in the matched sample with outcome pregnancy 3 months later, controlling for baseline fertility intentions (n = 482, n = 458, n = 452 at respectively 3, 6, 9 months). At 3 months, 15% of women reported reproductive coercion. At 6 months, 11.3% of women reporting coercion were pregnant vs. 4.6% of matched women reporting no coercion (p = 0.06). Women reporting coercion had 3 times the odds of pregnancy as matched women reporting no coercion (AOR 2.95, 95% CI (1.16, 6.98), p = 0.02). Among women pregnant after coercion, only 15% wanted to be pregnant then or sooner. Women reporting reproductive coercion are at greater risk of unwanted or mistimed pregnancies, and the semen exposure that caused these pregnancies could also transmit STI/HIV. Clinicians should screen patients for reproductive coercion; consider using semen exposure biomarkers such as PSA or Yc-PCR to identify condom sabotage or stealthing; and refer women experiencing reproductive coercion to supportive services.

Does E-cigarette Use at Baseline Influence Smoking Cessation Rates among 2-Year College Students?

INTRODUCTION

This study evaluates the impact of baseline e-cigarette use on smoking cessation rates in a national sample of two-year college student smokers.

METHODS

Participants were 1400 students from over 60 two-year colleges across 25 states who were current smokers enrolled in a web-assisted tobacco intervention (WATI) trial. Survey data were collected at baseline, 1-, 6-, and 12-months, with primary outcomes evaluated at 6-months.

RESULTS

At 6-months, baseline e-cigarette users were more likely to report cessation of traditional cigarettes compared to non-users (OR 1.39, 95% CI 1.002-1.92). Cessation was also associated with higher baseline confidence in quitting and greater time to first cigarette in the morning. Baseline e-cigarette use was not found to be associated with self-reported cessation of all nicotine/tobacco products (OR 1.09, 95% CI 0.75-1.58) nor biochemically verified cessation of all nicotine/tobacco products (OR 0.83, 95% CI 0.47-1.47). Higher confidence was again associated with both self-reported and biochemically verified cessation of all nicotine/tobacco products. Female gender was associated only with biochemically verified cessation of all nicotine/tobacco products at 6-months.

CONCLUSIONS

Two-year college students represent a priority population for cessation interventions. The findings from this study highlight the complexities of evaluating the impact of e-cigarette use on cessation.

The Relationship Between Education and Health: Reducing Disparities Through a Contextual Approach

Adults with higher educational attainment live healthier and longer lives compared with their less educated peers. The disparities are large and widening. We posit that understanding the educational and macrolevel contexts in which this association occurs is key to reducing health disparities and improving population health. In this article, we briefly review and critically assess the current state of research on the relationship between education and health in the United States. We then outline three directions for further research: We extend the conceptualization of education beyond attainment and demonstrate the centrality of the schooling process to health; we highlight the dual role of education as a driver of opportunity but also as a reproducer of inequality; and we explain the central role of specific historical sociopolitical contexts in which the education-health association is embedded. Findings from this research agenda can inform policies and effective interventions to reduce health disparities and improve health for all Americans.

Disabilities and Degrees: Identifying Health Impairments that Predict Lower Chances of College Enrollment and Graduation in a Nationally Representative Sample

OBJECTIVE

Community colleges have increased post-secondary educational access for youth, including individuals with disabilities, but completion rates remain low. This study tests the hypothesis that health conditions that reduce social integration predict lower educational attainment among community college students.

METHODS

Our sample from the nationally representative Add Health data (1995, 2001, 2008) comprised respondents in 2001 whose highest degree was a high school diploma (n=9909), focusing on subsamples of students enrolled in 2-year colleges and 4-year colleges (n=1494, n=2721). For each of 57 health conditions in 2001, we estimated the relative risk of earning certificate, associates degree (AA), or bachelors degree (BA) in 2008, controlling for pre-college factors, including high school grades, test scores, parents' household income, and full-time enrollment.

RESULTS

Health conditions associated with social stigma predicted lower educational attainment among community college students, including stuttering, being overweight, and health that restricts engaging in vigorous sports. A broader range of health conditions predicted lower educational attainment among 4-year college students, including restrictions on climbing one and several flights of stairs and walking one and several blocks.

CONCLUSIONS

Stigmatized health conditions may disproportionately reduce educational attainment by impacting students' social integration in community college. Improved awareness may reduce the impact of unconscious stigma. Until four-year colleges improve accommodations, students with activity restrictions may benefit by earning degrees at community college before transferring to four-year institutions.

Graduating into Lower Risk: Chlamydia and Trichomonas Prevalence among Community College Students and Graduates

BACKGROUND

Community colleges enable youth from economically disadvantaged and minority populations to access college and may enable social mobility including improved health outcomes. However, educational health disparities studies rarely assess the health outcomes for community college graduates.

METHODS

Chlamydia and trichomonas prevalence were assessed with nucleic acid based tests in a nationally representative sample of 6233 high school graduates (ages 18-25) from five educational levels: young adults without post-secondary credentials who were not enrolled in college, community college students, 4-year college students, associate's degree, and bachelor's degree. To reduce confounding between educational attainment and STI status, we used full matching to balance on 22 measures of demographics, socioeconomic status, educational factors, and sexual risk-taking. Estimates of associations between educational attainment and STI status were obtained from multivariate regression in the full (n=6233) and matched (n=1655) samples.

RESULTS

Four-year college students (adjusted incidence rate ratio (IRR) = 0.41, 95% CI [0.27, 0.61], p<0.001), associate's degree holders (IRR = 0.38 [0.15, 0.98], p=0.05), and bachelor's degree holders (IRR = 0.45 [0.23, 0.90], p=0.02) were less than half as likely to test positive for chlamydia than non-college-enrolled high school graduates in multivariate regression. After full matching, associate's degree holders were also less likely to test positive for chlamydia (IRR 0.46 (0.23, 0.85), p=0.03) than community college students. Four-year college students (IRR = 0.52 [0.24, 1.12], p=0.10) and associate's degree holders (IRR = 0.34 [0.12, 0.97], p=0.04) were half as likely to test positive for trichomonas than nonstudents/non-graduates in multivariate regression but did not differ after full matching.

CONCLUSIONS

Community college students come from populations with greater health risks than 4-year college students, but community college graduation may reduce the likelihood of chlamydia infection. STI interventions can meet the needs of young adults who access college through community college by partnering with community college health clinics to encourage continued STI prevention, testing, and treatment after the intervention ends. Public health studies that use inclusive educational attainment measures that incorporate sub-baccalaureate credentials will better capture health disparities.

Life Expectancy Gain Due to Employment Status Depends on Race, Gender, Education, and Their Intersections

PURPOSE

Despite the well-established health effects of socioeconomic status (SES), SES resources such as employment may differently influence health outcomes across sub-populations. This study used a national sample of US adults to test if the effect of baseline employment (in 1986) on all-cause mortality over a 25-year period depends on race, gender, education level, and their intersections.

METHODS

Data came from the Americans' Changing Lives (ACL) study, which followed 2025 Whites and 1156 Blacks for 25 years from 1986 to 2011. The focal predictor of interest was baseline employment (1986), operationalized as a dichotomous variable. The main outcome of interest was time to all-cause mortality from 1986 to 2011. Covariates included baseline age, health behaviors (smoking, drinking, and exercise), physical health (obesity, chronic disease, function, and self-rated health), and mental health (depressive symptoms). A series of Cox proportional hazard models were used to test the association between employment and mortality risk in the pooled sample and based on race, gender, education, and their intersections.

RESULTS

Baseline employment in 1986 was associated with a lower risk of mortality over a 25-year period, net of covariates. In the pooled sample, baseline employment interacted with race (HR = .69, 95% CI = .49-.96), gender (HR = .73, 95% CI = .53-1.01), and education (HR = .64, 95% CI = .46-.88) on mortality, suggesting diminished protective effects for Blacks, women, and individuals with lower education, compared to Whites, men, and those with higher education. In stratified models, the association was significant for Whites (HR = .71, 95%CI = .59-.90), men (HR = .60, 95%CI = .43-.83), and individuals with high education (HR = .66, 95%CI = .50-.86) but not for Blacks (HR = .77, 95%CI = .56-1.01), women (HR = .88, 95%CI = .69-1.12), and those with low education (HR = .92, 95%CI = .67-1.26). The largest effects of employment on life expectancy were seen for highly educated men (HR = .50, 95%CI = .32-.78), White men (HR = .55, 95%CI = .38-.79), and highly educated Whites (HR = .63, 95%CI = .46-.84). The effects were non-significant for Black men (HR = 1.10, 95%CI = .68-1.78), Whites with low education (HR = 1.01, 95%CI = .67-1.51), and women with low education (HR = 1.06, 95%CI = .71-1.57).

CONCLUSION

In the USA, the health gain associated with employment is conditional on one's race, gender, and education level, along with their intersections. Blacks, women, and individuals with lower education gain less from employment than do Whites, men, and highly educated people. More research is needed to understand how the intersections of race, gender, and education alter health gains associated with socioeconomic resources.

Anomaly in the education-health gradient: Biomarker profiles among adults with subbaccalaureate attainment levels

This Short Communication builds on recent findings that documented an anomaly in the education–health gradient: adults who attended college but did not earn a BA (the subbaccalaureate group) reported an equal or higher level of health problems than adults with high school (HS) diploma. Our aim is to test whether this anomaly holds when we eliminate potential reporting differences, by examining biomarker levels in the subbaccalaureate vs HS groups.

Using the restricted 1999–2012 NHANES, we estimate models of biomarkers for cardiovascular and metabolic diseases as a function of educational attainment, including three subbaccalaureate levels: “some college”, vocational associate degree (AA), and academic AA.

The data show that adults with “some college” or vocational AA have no systematic advantage over HS graduates in most biomarker indices while academic AA is associated with a significantly better risk profile compared to HS. The findings indicate that the adults with some college and vocational AA degrees do not benefit from their college experience in terms of improved physiological risk profile.

This pattern underscores the need to understand and explain the anomalous health pattern that concerns 28% of American adults in the subbaccalaureate group among whom many reap little health payoffs to postsecondary schooling.

Money isn't everything: job satisfaction, nonmonetary job rewards, and sub-baccalaureate credentials

Some researchers and reformers have raised doubts about whether sub-BA credentials lead to good jobs. This study finds that young working adults (ages 25-32) report that nonmonetary rewards such as autonomy and career relevance are more strongly related to job satisfaction than earnings is. Controlling for background differences, young adults with BA and graduate degrees have the greatest nonmonetary job rewards, followed by those with associate's degrees and certificate credentials, all of whom have significantly greater nonmonetary job rewards than high school graduates. Students who attend college without earning credentials report few job rewards, and no better autonomy and career-relevance than high school graduates. Parents, advisors, and policymakers should inform students of nonmonetary job rewards they likely will value as young adult workers in addition to earnings, and which credentials lead to these job rewards.

Combined Racial and Gender Differences in the Long-Term Predictive Role of Education on Depressive Symptoms and Chronic Medical Conditions

BACKGROUND

Despite a well-established literature on the protective effect of education on health, less is known about group differences in the mechanisms underlying this association. Using a life course approach and cumulative advantage theory, this study compared Black men, Black women, White men, and White women to assess the long-term gradient (education as a continuous measure) and threshold (>12 years) effects of baseline education on change in chronic medical conditions (CMC) and depressive symptoms (DS) from baseline to 25 years later.

METHODS

Data came from the Americans' Changing Lives Study, 1986-2011. The study followed Black and White respondents for up to 25 years, among whom 1271 individuals who had survived and were under follow-up were interviewed in 2011 and reported their number of chronic medical conditions and depressive symptoms (Center for Epidemiological Studies-Depression; CES-D 11). Multi-group structural equation modeling was used to compare gradient and threshold effects of education on change in chronic medical conditions and depressive symptoms from baseline (1986) to 25 years later (2011) among Black men, Black women, White men, and White women.

RESULTS

There were group differences in the long-term association between education measured as a gradient and the change in depressive symptoms and chronic medical conditions during the follow-up, and in the association between education measured at the threshold of 12 years on change in depressive symptoms from baseline to follow-up. However, the association between education measured at this threshold and change in chronic medical conditions did not differ across race-gender groups. With the exception of Black men, who showed a gradient protective effect for baseline education against increase in the number of chronic medical associations (threshold or gradient) with change in chronic medical conditions. Among White men and White women, education had a threshold protective effect against increase in depressive symptoms from baseline to 25 years later. Black men and women showed a gradient protective effect of baseline education against an increase in depressive symptoms over the 25-year follow-up period, but unexpectedly, a threshold effect of education was also found to be associated with an increase in depressive symptoms over the follow-up period among Black men. This finding suggests that although Black men benefit from each incremental increase in education, those who graduated from high school were at an additional risk of depressive symptoms over a 25-year period.

CONCLUSION

Findings suggest that the intersection of race and gender influences how education is associated with long-term changes in physical and mental health of individuals from baseline to 25 years later. As the shape of the association between education and health depends on the intersection of race and gender, these groups may vary for operant mechanisms by which education operates as a main social determinant of health.

Race and Urbanity Alter the Protective Effect of Education but not Income on Mortality

Background

Although the effects of socioeconomic status (SES) on mortality are well established, these effects may vary based on contextual factors such as race and place. Using 25-year follow-up data of a nationally representative sample of adults in the U.S., this study had two aims: (1) to explore separate, additive, and multiplicative effects of race and place (urbanity) on mortality and (2) to test the effects of education and income on all-cause mortality based on race and place.

Methods

The Americans’ Changing Lives (ACL) Study followed Whites and Blacks 25 years and older from 1986 until 2011. The focal predictors were baseline SES (education and income) collected in 1986. The main outcome was time until death due to all causes from 1986 until 2011. Age, gender, behaviors (smoking and exercise), and health (chronic medical conditions, self-rated health, and depressive symptoms) at baseline were potential confounders. A series of survey Cox proportional hazard models were used to test protective effects of education and income on mortality based on race and urbanity.

Results

Race and place had separate but not additive or multiplicative effects on mortality. Higher education and income were protective against all-cause mortality in the pooled sample. Race and urbanity significantly interacted with baseline education but not income on all-cause mortality, suggesting that the protective effect of education but not income depend on race and place. While the protective effect of education were fully explained by baseline health status, the effect of income remained significant beyond health.

Conclusion

In the U.S., the health return associated with education depends on race and place. This finding suggests that populations differently benefit from SES resources, particularly education. Differential effect of education on employment and health care may explain the different protective effect of education based on race and place. Findings support the “diminishing returns” hypothesis for Blacks.

Socioeconomic status and survival from ventricular fibrillation out-of-hospital cardiac arrest

PURPOSE

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the United States. How individual-level socioeconomic status (SES) influences survival is uncertain.

METHODS

The investigation is a retrospective cohort study of adults who suffered OHCA and presented with a shockable rhythm in a metropolitan county from January 1, 1999-December 31, 2005. Individual-level measures of SES were obtained from vital records and surveys. SES measures included education and occupation. We used multivariable logistic regression to assess the independent association between SES measures and survival to hospital discharge.

RESULTS

Of the 1390 eligible OHCA patients, 374 (27%) survived to hospital discharge. Compared to those with less than high school diploma, the multivariable-adjusted odds ratio of survival was 1.36 (95% confidence interval [CI], 0.87-2.14) for high school graduates, 1.54 (95% CI, 0.95-2.48) for those with some college, and 1.96 (95% CI, 1.17-3.27) for those with college degrees (test for trend across the categories P < .001). We did not observe an independent association between occupation and survival.

CONCLUSIONS

Higher education was associated with greater survival after OHCA. This relationship was not explained by key demographic or clinical characteristics. A better understanding of the mechanism by which individual-level SES characteristics influence prognosis may provide opportunities to improve survival.