Does the Type and Timing of Educational Attainment Influence Physical Health? A Novel Application of Sequence Analysis

Mid-life employment trajectories and subsequent memory function and rate of decline in rural South Africa, 2000-22

AIM

To investigate mid-life employment trajectories in relation to later-life memory function and rate of decline in rural South Africa.

METHODS

Data from the Agincourt Health and Socio-Demographic Surveillance System were linked to the 'Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa' (HAALSI) in rural Agincourt, South Africa (N = 3133). Employment was assessed every 4 years over 2000-12 as being employed (0, 1, 2 and ≥3 time points), being employed in a higher-skill occupation (0, 1, 2 and ≥3 time points) and dynamic employment trajectories identified using sequence analysis. Latent memory z-scores were assessed over 2014-22. Mixed-effects linear regression models were fitted to examine the associations of interest.

RESULTS

Sustained mid-life employment from 2000-12 (β = 0.052, 95% CI: -0.028 to 0.132, 1 vs 0 time points; β = 0.163, 95% CI: 0.077 to 0.250, 2 vs 0 time points; β = 0.212, 95% CI: 0.128 to 0.296, ≥3 vs 0 time points) and greater time spent in a higher-skill occupation (β = 0.077, 95% CI: -0.020 to 0.175, 1 vs 0 time points; β = 0.241, 95% CI: 0.070 to 0.412, 2 vs 0 time points; β = 0.361, 95% CI: 0.201 to 0.520, ≥3 vs 0 time points) were associated with higher memory scores in 2014/15, but not subsequent rate of memory decline. Moving from a lower-skill to higher-skill occupation was associated with higher memory function, but a faster rate of decline over 2014-22.

CONCLUSIONS

Sustained mid-life employment, particularly in higher-skill occupations, may contribute to later-life memory function in this post-Apartheid South African setting.

"We adjusted for race": now what? A systematic review of utilization and reporting of race in American Journal of Epidemiology and Epidemiology, 2020-2021

Race is a social construct, commonly used in epidemiologic research to adjust for confounding. However, adjustment of race may mask racial disparities, thereby perpetuating structural racism. We conducted a systematic review of articles published in Epidemiology and American Journal of Epidemiology between 2020 and 2021 to (1) understand how race, ethnicity, and similar social constructs were operationalized, used, and reported; and (2) characterize good and poor practices of utilization and reporting of race data on the basis of the extent to which they reveal or mask systemic racism. Original research articles were considered for full review and data extraction if race data were used in the study analysis. We extracted how race was categorized, used-as a descriptor, confounder, or for effect measure modification (EMM)-and reported if the authors discussed racial disparities and systemic bias-related mechanisms responsible for perpetuating the disparities. Of the 561 articles, 299 had race data available and 192 (34.2%) used race data in analyses. Among the 160 US-based studies, 81 different racial categorizations were used. Race was most often used as a confounder (52%), followed by effect measure modifier (33%), and descriptive variable (12%). Fewer than 1 in 4 articles (22.9%) exhibited good practices (EMM along with discussing disparities and mechanisms), 63.5% of the articles exhibited poor practices (confounding only or not discussing mechanisms), and 13.5% were considered neither poor nor good practices. We discuss implications and provide 13 recommendations for operationalization, utilization, and reporting of race in epidemiologic and public health research.

Education mediates the relationship of parental socioeconomic status with subjective adult oral health

BACKGROUND

Evidence shows that both socioeconomic status (SES) during childhood and education are associated with adult oral health. However, whether the range of opportunities families have regarding their children's education mediate the effect of childhood disadvantage on oral health later in life remains unknown. The aim of this study was to evaluate the mediating role of education in the association between parental SES and subjective oral health status in middle adulthood.

METHODS

Data from 6703 members of the British Cohort Study 1970 were analyzed. Parental SES was measured using the 7-class National Statistics Socio-Economic Classification (NS-SEC) at age 10 years. Five measures of education (type of high school, highest qualification, age left full-time education, status of institution and field of study) were obtained from ages 16 and 42 years. Subjective oral health was measured with a single global item at age 46 years. Causal mediation analysis was performed, using a weighting-based approach, to evaluate how much of the effect of parental SES on subjective oral health was mediated by the measures of education separately and jointly.

RESULTS

Overall, 23.6% of individuals reported poor oral health. Parental SES was associated with every measure of education, and they were also associated with subjective oral health in regression models adjusted for confounders. The effect of parental SES on subjective oral health was partially mediated by each measure of education, with a proportion mediated of 53.2% for the institution status, 46.5% for the field of study, 42.8% for the school type, 38.9% for the highest qualification earned and 38.4% for the age when full-time education was discontinued. The proportion of the effect of parental SES on subjective oral health jointly mediated by all measures of education was 81.1%.

CONCLUSION

This study found a substantial mediating role of education in the association between parental SES and subjective oral health in middle adulthood.

Educational Attainment and Dementia: Mediation by Mid-Life Vascular Risk Factors

INTRODUCTION

Lower education is associated with higher burden of vascular risk factors in mid-life and higher risk of dementia in late life. We aim to understand the causal mechanism through which vascular risk factors potentially mediate the relationship between education and dementia.

METHODS

In a cohort of 13,368 Black and White older adults in the Atherosclerosis Risk in Communities Study, we assessed the relationship between education (grade school, high school without graduation, high school graduate or equivalent, college, graduate/professional school) and dementia among all participants and among those with incident stroke. Cox models were adjusted for age, race-center (a variable stratified by race and field center), sex, apolipoprotein E (APOE) ε4 genotype, and family history of cardiovascular disease. Causal mediation models assessed mediation by mid-life systolic blood pressure, fasting blood glucose, body mass index, and smoking.

RESULTS

More education was associated with 8 to 44% lower risk of dementia compared to grade school-level education in a dose-response pattern, while the relationship between education and post-stroke dementia was not statistically significant. Up to 25% of the association between education and dementia was mediated through mid-life vascular risk factors, with a smaller percentage mediated for lower levels of education.

INTERPRETATION

A substantial proportion of the relationship between education and dementia was mediated through mid-life vascular risk factors. However, risk factor modification is unlikely to fully address the large educational disparities in dementia risk. Prevention efforts must also address disparities in socioeconomic resources leading to divergent early-life education and other structural determinants of mid-life vascular risk factors. ANN NEUROL 2023;94:13-26.

Racial Differences in Employment and Poverty Histories and Health in Older Age

INTRODUCTION

Black Americans encounter more barriers in the job market and earn less than White Americans. However, the extent to which racial disparities in employment and poverty histories impact health is not fully understood. This study characterized employment‒poverty histories for Black and White middle-aged adults and examined their association with health.

METHODS

Respondents born in 1948-1953 and enrolled in the 2004 Health and Retirement Study (N_Black=555, N_White=2,209) were included. Sequence analysis grouped respondents with similar employment‒poverty trajectories from 2004 to 2016, and confounder-adjusted regression analyses estimated the associations between these trajectories and health in 2018. Analyses were conducted in 2021-2022.

RESULTS

More than 23% of Black respondents experienced both employment and poverty fluctuations, including bouts of extreme poverty (<50% of the federal poverty threshold), whereas no trajectory for White respondents included extreme poverty. Adversities in employment‒poverty were associated with worse health. For example, among Black respondents, those who experienced both employment and poverty fluctuations had worse cognition than those employed and not poor (β= -0.55 standardized units, 95% CI= -0.81, -0.30). Similarly, among White respondents, those who experienced employment fluctuations had worse cognition than those employed (β= -0.35, 95% CI= -0.46, -0.24). Notably, the employed and not poor trajectory was associated with worse survival among Black respondents than among White respondents.

CONCLUSIONS

Employment fluctuations were associated with worse health, especially cognitive function, where the association was stronger among Black Americans who experienced both employment fluctuations and poverty. Findings highlight the importance of enhancing employment stability and of antipoverty programs, especially for Black Americans.

Socioeconomic changes predict genome-wide DNA methylation in childhood

Childhood socioeconomic position (SEP) is a major determinant of health and well-being across the entire life course. To effectively prevent and reduce health risks related to SEP, it is critical to better understand when and under what circumstances socioeconomic adversity shapes biological processes. DNA methylation (DNAm) is one such mechanism for how early life adversity 'gets under the skin'. In this study, we evaluated the dynamic relationship between SEP and DNAm across childhood using data from 946 mother-child pairs in the Avon Longitudinal Study of Parents and Children. We assessed six SEP indicators spanning financial, occupational and residential domains during very early childhood (ages 0-2), early childhood (ages 3-5) and middle childhood (ages 6-7). Epigenome-wide DNAm was measured at 412 956 cytosine-guanines (CpGs) from peripheral blood at age 7. Using an innovative two-stage structured life-course modeling approach, we tested three life-course hypotheses for how SEP shapes DNAm profiles-accumulation, sensitive period and mobility. We showed that changes in the socioeconomic environment were associated with the greatest differences in DNAm, and that middle childhood may be a potential sensitive period when socioeconomic instability is especially important in shaping DNAm. Top SEP-related DNAm CpGs were overrepresented in genes involved in pathways important for neural development, immune function and metabolic processes. Our findings highlight the importance of socioeconomic stability during childhood and if replicated, may emphasize the need for public programs to help children and families experiencing socioeconomic instability and other forms of socioeconomic adversity.

The association between social determinants of health and psychological distress during the COVID-19 pandemic: a secondary analysis among four racial/ethnic groups

BACKGROUND

Racial disparities in psychological distress associated with COVID-19 remain unclear in the U.S. This study aims to investigate the associations between social determinants of health and COVID-19-related psychological distress across different racial/ethnic groups in the US (i.e., non-Hispanic Whites, Hispanic, non-Hispanic Asians, and non-Hispanic African Americans).

METHODS

This study used cross-sectional data from the 2020 California Health Interview Survey Adult Data Files (N = 21,280). Adjusting for covariates-including age, gender, COVID-19 pandemic challenges, and risk of severe illness from COVID-19-four sets of weighted binary logistic regressions were conducted.

RESULTS

The rates of moderate/severe psychological distress significantly varied across four racial/ethnic groups (p < 0.001), with the highest rate found in the Hispanic group. Across the five domains of social determinants of health, we found that unemployment, food insecurity, housing instability, high educational attainment, usual source of health care, delayed medical care, and low neighborhood social cohesion and safety were associated with high levels of psychological distress in at least one racial/ethnic group (p < 0.05).

CONCLUSION

Our study suggests that Hispanic adults face more adverse social determinants of health and are disproportionately impacted by the pandemic. Public health practice and policy should highlight social determinants of heath that are associated with different racial/ethnic groups and develop tailored programs to reduce psychological distress.

Structural racism and adverse maternal health outcomes: A systematic review

In the United States, racial disparities in adverse maternal health outcomes remain a pressing issue, with Black women experiencing a 3-4 times higher risk of maternal mortality and a 2-3 times higher risk of severe maternal morbidity. Despite recent encouraging efforts, fundamental determinants of these alarming inequities (e.g. structural racism) remain understudied. Approaches that address these structural drivers are needed to then intervene upon root causes of adverse maternal outcomes and their disparities and to ultimately improve maternal health across the U.S. In this paper, we offer a conceptual framework for studies of structural racism and maternal health disparities and systematically synthesize the current empirical epidemiologic literature on the links between structural racism measures and adverse maternal health outcomes. For the systematic review, we searched electronic databases (Pubmed, Web of Science, and EMBASE) to identify peer-reviewed U.S. based quantitative articles published between 1990 and 2021 that assessed the link between measures of structural racism and indicators of maternal morbidity/mortality. Our search yielded 2394 studies and after removing duplicates, 1408 were included in the title and abstract screening, of which 18 were included in the full text screening. Only 6 studies met all the specified inclusion criteria for this review. Results revealed that depending on population sub-group analyzed, measures used, and covariates considered, there was evidence that structural racism may increase the risk of adverse maternal health outcomes. This review also highlighted several areas for methodological and theoretical development in this body of work. Future work should more comprehensively assess structural racism in a way that informs policy and interventions, which can ameliorate its negative consequences on racial/ethnic disparities in maternal morbidity/mortality.

Examining socio-spatial mobility patterns among colon cancer patients after diagnosis

Given the growing number of cancer survivors, it is important to better understand socio-spatial mobility patterns of cancer patients after diagnosis that could have public health implications regarding post-diagnostic access to care for treatment and follow-up surveillance. In this exploratory study, residential histories from LexisNexis were linked to New Jersey colon cancer cases diagnosed from 2006 to 2011 to examine differences in socio-spatial mobility patterns after diagnosis by stage at cancer diagnosis, sex, and race/ethnicity. For the colon cancer cases, we summarized and compared the number of residences and changes in the residential census tract and neighborhood poverty after the diagnosis. We found only minor changes in neighborhood poverty among the cases during the follow-up period after diagnosis. During the follow-up period of up to 10 years after diagnosis, 67% of the patients did not move to a different residential census tract, and 10.8% moved from New Jersey to another state. Cases that moved to a different census tract changed after diagnosis were generally less wealthy than non-movers, but the destination of relocation varied by race/ethnicity and socioeconomic status. We also found a significant association between residential mobility and stage at diagnosis, whereby patients diagnosed with colon cancer at an early stage were more likely to be movers. This study contributes to understanding of the socio-spatial mobility patterns in colon cancer patients and may help to inform cancer research by summarizing the extent to which colon cancer patients move after diagnosis.

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Post-diagnosis socio-spatial mobility is relatively low among colon cancer patients.

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Post-diagnosis, ∼67% of all colon cancer patients in NJ did not change residence.

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Movers spent more time living in high-poverty neighborhoods than non-movers.

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Approximately 10% of all patients left New Jersey for other states.

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Geographic destinations vary by race/ethnicity and socioeconomic status.

The Effect of Adult Children's Education Attainment on Their Parents' Cognitive Health: An Intergenerational Support Perspective

The purpose of this study is to examine the relationship between adult children's education attainment and their parents' cognitive health, and to further explore the mechanism of intergenerational support. Based on empirical analysis of data from China Health and Retirement Longitudinal Survey, our study finds a positive association between children's educational attainment and parents' cognitive health. This correlation is provided for by emotional communication of informal caregiving, financial support, and healthy behaviors shaped in the parents by adult children. The strength of the effect varied by the adult child's gender. While sons' education attainment significantly improves parental cognitive parameters through informal caregiving, financial support, and development of healthy behaviors, the effect of daughters' education derives from financial support and healthy behaviors, not being related to informal caregiving. The study enriches the evidence on the mobility of children's human capital toward their parents and provides practical insights for advancing children's participation in family caregiving.

Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis

BACKGROUND

Higher educational attainment predicts lower hypertension. Yet, associations between nontraditional educational trajectories (eg, interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories.

METHODS

In National Longitudinal Survey of Youth 1979 cohort data (N = 6 317), we used sequence and cluster analyses to identify groups of similar educational sequences-characterized by timing and type of terminal credential-that participants followed from age 14-48 years. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status [cSES]).

RESULTS

Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR: 1.32; 95%CI: 1.04, 1.66) or Associate degree after

CONCLUSIONS

Both type and timing to terminal credential matter for hypertension but effects may vary by experiences of structural marginalization. Documenting the nuanced ways in which complex educational trajectories are associated with health could elucidate underlying mechanisms and inform systems-level interventions for health equity.

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Key Words

• Education
• GED
• Health inequity
• Hypertension

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MESH Headings

• Adolescent
• Black People
• Child
• Educational Status
• Humans
• Hypertension/epidemiology
• Male
• Sequence Analysis
• Social Class

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Grants

• R01 AG056360 NIA NIH HHS
• R01AG056360 NIH HHS
• National Institute on Aging
• National Institutes of Health

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Affiliation(s)

Catherine dP Duarte Division of Epidemiology, School of Public Health, University of California Berkeley, USA
S Rae Wannier Department of Epidemiology and Biostatistics, University of California San Francisco, USA
Alison K Cohen Department of Epidemiology and Biostatistics, University of California San Francisco, USA
M Maria Glymour Department of Epidemiology and Biostatistics, University of California San Francisco, USA
Robert K Ream Graduate School of Education, University of California Riverside, USA
Irene H Yen Department of Public Health, School of Social Sciences, Humanities, and Arts, University of California Merced, USA
Anusha M Vable Department of Family and Community Medicine, University of California San Francisco, USA

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Associations between indicators of socioeconomic position and DNA methylation: a scoping review

BACKGROUND

Socioeconomic position (SEP) is a major determinant of health across the life course. Yet, little is known about the biological mechanisms explaining this relationship. One possibility widely pursued in the scientific literature is that SEP becomes biologically embedded through epigenetic processes such as DNA methylation (DNAm), wherein the socioeconomic environment causes no alteration in the DNA sequence but modifies gene activity in ways that shape health.

METHODS

To understand the evidence supporting a potential SEP-DNAm link, we performed a scoping review of published empirical findings on the association between SEP assessed from prenatal development to adulthood and DNAm measured across the life course, with an emphasis on exploring how the developmental timing, duration, and type of SEP exposure influenced DNAm.

RESULTS

Across the 37 identified studies, we found that: (1) SEP-related DNAm signatures varied across the timing, duration, and type of SEP indicator; (2) however, longitudinal studies examining repeated SEP and DNAm measures are generally lacking; and (3) prior studies are conceptually and methodologically diverse, limiting the interpretability of findings across studies with respect to these three SEP features.

CONCLUSIONS

Given the complex relationship between SEP and DNAm across the lifespan, these findings underscore the importance of analyzing SEP features, including timing, duration, and type. To guide future research, we highlight additional research gaps and propose four recommendations to further unravel the relationship between SEP and DNAm.

Understanding the benefits of different types and timing of education for mental health: A sequence analysis approach

OBJECTIVES

Individuals increasingly experience delays or interruptions in schooling; we evaluate the association between these non-traditional education trajectories and mental health.

METHODS

Using year-by-year education data for 7,501 National Longitudinal Survey of Youth 1979 participants, ages 14-48 (262,535 person-years of education data), we applied sequence analysis and a clustering algorithm to identify educational trajectory groups, incorporating both type and timing to credential. Linear regression models, adjusted for early-life confounders, evaluated relationships between educational trajectories and mental health component scores (MCS) from the 12-item short form instrument at age 50. We evaluated effect modification by race, gender, and race by gender.

RESULTS

We identified 24 distinct educational trajectories based on highest credential and educational timing. Compared to high school (HS) diplomas, < HS (beta=-3.41, 95%CI:-4.74,-2.07) and general educational development credentials (GEDs) predicted poorer MCS (beta=-2.07,95%CI:-3.16,-0.98). The following educational trajectories predicted better MCS: some college immediately after High School (beta=1.52, 95%CI:0.68,2.37), Associate degrees after long interruptions (beta=1.73, 95%CI:0.27,3.19), and graduate school soon after Bachelor's completion (beta=1.13, 95%CI:0.21,2.06). Compared to White men, Black women especially benefited from educational credentials higher than HS in predicting MCS.

CONCLUSIONS

Both type and timing of educational credential predicted mental health. Black women's mental higher especially benefited from higher educational credentials.