Race and Ethnicity, Racism, and Population Health in the United States: The Straightforward, the Complex, Innovations, and the Future

For far too long, U.S. racialized groups have experienced human suffering and loss of life far too often and early. Thus, it is critical that the population sciences community does its part to improve the science, education, and policy in this area of study and help to eliminate ethnoracial disparities in population health. My 2022 PAA Presidential Address focuses on race and ethnicity, racism, and U.S. population health in the United States and is organized into five sections. First, I provide a descriptive overview of ethnoracial disparities in U.S. population health. Second, I emphasize the often overlooked scientific value of such descriptive work and demonstrate how such seemingly straightforward description is complicated by issues of population heterogeneity, time and space, and the complexity of human health. Third, I make the case that the population sciences have generally been far too slow in incorporating the role of racism into explanations for ethnoracial health disparities and lay out a conceptual framework for doing so. Fourth, I discuss how my research team is designing, collecting, and disseminating data for the scientific community that will have potential to, among many other purposes, create a better understanding of ethnoracial health disparities and the role of racism in producing such disparities. Finally, I close by suggesting some policy- and education-related efforts that are needed to address racism and population health within U.S. institutions.

Exposure to Family Member Deaths Across the Life Course for Hispanic Individuals

The present study documents differences in exposure to family member deaths among foreign-born and U.S.-born Hispanic individuals compared with non-Hispanic Black and non-Hispanic White individuals. We use data from the Health and Retirement Study (HRS; 1992-2016, ages 51+; N = 23,228) and the National Longitudinal Study of Adolescent to Adult Health (Add Health; Waves I-V, ages 12-43; N = 11,088) to estimate the risk of exposure to the death of a mother, father, spouse, sibling, and child across the life course. HRS results show more inequities in exposure to family deaths compared with Add Health results, suggesting differences by age or birth cohort. Compared with non-Hispanic Whites, U.S.-born Hispanic individuals in the HRS have a higher risk of experiencing a child's death throughout adulthood and a sibling's death in later life; the latter is explained by larger sibship size, indicating a greater lifetime risk of bereavement experiences. The higher risk of parental death during childhood for U.S.-born and foreign-born Hispanic individuals is explained by covariates (e.g., lower levels of educational attainment). Hispanic individuals generally have a lower risk of family deaths than non-Hispanic Black individuals, but at times a higher risk of exposure relative to non-Hispanic White individuals.

Race/ethnicity, immigrant generation, and physiological dysregulation among U.S. adults entering midlife

This study aimed to better understand racial/ethnic and immigrant generation disparities in physiological dysregulation in the early portion of the adult life course. Using biomarker-measured allostatic load, we focused on the health of child/adolescent immigrant, second-, and third-plus-generation Asian, Black, Hispanic, and White Americans in their late 30s and early 40s. We drew on restricted-access data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves I and V. The results indicate lower levels of physiological dysregulation for most racial/ethnic groups of child/adolescent immigrants relative to both third-plus-generation Whites and third-plus-generation same race/ethnic peers. Socioeconomic, social, and behavioral control variables measured in different parts of the life course had little impact on these patterns. Thus, evidence of an immigrant health advantage is found for this cohort using allostatic load as a measure of physiological dysregulation, even though immigrants in Add Health arrived at the United States during childhood and adolescence. Implications of these findings in the context of immigrant health advantages and trajectories are discussed.

"Outside the Skin": The Persistence of Black-White Disparities in U.S. Early-Life Mortality

Research on Black-White disparities in mortality emphasizes the cumulative pathways through which racism gets "under the skin" to affect health. Yet this framing is less applicable in early life, when death is primarily attributable to external causes rather than cumulative, biological processes. We use mortality data from the National Vital Statistics System Multiple Cause of Death files and population counts from the Surveillance, Epidemiology, and End Result Program to analyze 705,801 deaths among Black and White males and females, ages 15-24. We estimate age-standardized death rates and single-decrement life tables to show how all-cause and cause-specific mortality changed from 1990 to 2016 by race and sex. Despite overall declines in early-life mortality, Black-White disparities remain unchanged across several causes-especially homicide, for which mortality is nearly 20 times as high among Black as among White males. Suicide and drug-related deaths are higher among White youth during this period, yet their impact on life expectancy at birth is less than half that of homicide among Black youth. Critically, early-life disparities are driven by preventable causes of death whose impact occurs "outside the skin," reflecting racial differences in social exposures and experiences that prove harmful for both Black and White adolescents and young adults.

Skin Tone and the Health Returns to Higher Status

This study addresses two questions. First, why do Black Americans exhibit worse health outcomes than White Americans even at higher levels of socioeconomic status (SES)? Second, are diminished health returns to higher status concentrated among Black Americans with darker skin color? Novel hypotheses are tested with biosocial panel data from Add Health, a nationally representative cohort of Black and White adolescents who have transitioned to adulthood. We find that White and light-skin Black respondents report improved health after achieving higher SES, on average, while their darker-skin Black peers report declining health. These patterns persist regardless of controls for adolescent health status and unmeasured between-person heterogeneity. Moreover, increased inflammation tied to unfair treatment and perceptions of lower status helps to account for patterns of diminished health returns for dark-skin Black groups. Our study is the first to document skin tone heterogeneity in diminished health returns and one of few studies to identify life course stress processes underlying such disparities. We consider additional processes that could be examined in future studies, as well as the broader health and policy implications of our findings.

Life Course Socioeconomic Disadvantage and the Aging Immune System: Findings From the Health and Retirement Study

OBJECTIVES

Previous research has documented a consistent association between current socioeconomic status (SES) and cytomegalovirus (CMV). Early life is likely a critical period for CMV exposure and immune development, but less is known about early-life socioeconomic factors and CMV, particularly in older age populations. Using data from the Health and Retirement Study, we investigated the association between life course socioeconomic disadvantage and immune response to CMV among older adults.

METHODS

Using ordered logit models, we estimated associations between several measures of socioeconomic disadvantage and the odds of being in a higher CMV Immunoglobulin G (IgG) response category in a sample of 8,168 respondents aged older than 50 years.

RESULTS

We found a significant association between educational attainment and CMV IgG response. Those with less than a high school education had 2.00 (95% confidence interval [CI]: 1.67-2.40) times the odds of being in a higher CMV category compared to those with a college degree or greater. In addition, we also observed a significant association with parental education and CMV response. Individuals with parents having 8 years or less of schooling had 2.32 (95% CI: 2.00-2.70) times the odds of higher CMV response compared to those whose parents had greater than high school education.

DISCUSSION

CMV IgG levels in older adults are associated with both early-life and adult SES. Life course socioeconomic disadvantage may contribute to disparities in immunological aging.

Social status differences in allostatic load among young adults in the United States

Allostatic load refers to wear and tear on the body due to repeated activation of the stress response and, thus, may be an early subclinical indicator of future disease and mortality risk. To date, few studies of allostatic load have focused on young adults, racial/ethnic comparisons that include Mexican Americans, or the interplay between race/ethnicity, gender, and educational attainment. To fill these gaps, we used data on non-Hispanic Black, non-Hispanic White, and Mexican-origin respondents from Waves I (1994-1995) and IV (2007-2008) of the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 11,807). We calculated allostatic load scores based on respondents' values for 10 metabolic, cardiovascular, and inflammatory biomarkers measured at Wave IV, when respondents were 24-34 years old. We then used negative binomial regression models to assess the combined effects of race/ethnicity, gender, and educational attainment on allostatic load, while controlling for key covariates. We found that Black women had significantly higher allostatic load scores than White women and Black men, net of educational attainment and other covariates. Yet, education modified the relationship between race/ethnicity, gender, and allostatic load. Obtaining a college education was protective for White males and females but no more or less protective for other women and deleterious for Black males. In other words, by the time they reach young adulthood, the cumulative physiological burden of stress on Black women and college-educated Black men is already greater than it is among their similarly or less educated White counterparts. These findings provide important information about the intermediate physiological dysregulation that underlies social inequalities in stress-related health outcomes, especially those that occur at the intersections of race/ethnicity, gender, and educational attainment. They also suggest that research on its antecedents should focus on earlier life periods.

Social Inequality and the Future of U.S. Life Expectancy

Despite decades of progress, the future of life expectancy in the United States is uncertain due to widening socioeconomic disparities in mortality, continued disparities in mortality across racial/ethnic groups, and an increase in extrinsic causes of death. These trends prompt us to scrutinize life expectancy in a high-income but enormously unequal society like the United States, where social factors determine who is most able to maximize their biological lifespan. After reviewing evidence for biodemographic perspectives on life expectancy, the uneven diffusion of health-enhancing innovations throughout the population, and the changing nature of threats to population health, we argue that sociology is optimally positioned to lead discourse on the future of life expectancy. Given recent trends, sociologists should emphasize the importance of the social determinants of life expectancy, redirecting research focus away from extending extreme longevity and towards research on social inequality with the goal of improving population health for all.

Is educational attainment associated with young adult cardiometabolic health?

Educational disparities in health and mortality are well-documented and evidence suggests that they may be widening. Yet, there is much unknown about when educational disparities begin to emerge and for whom. This paper investigates the association between educational attainment and cardiometabolic health in young adults with critical attention paid to differences across racial/ethnic and sex subgroups. We focus on cardiometabolic health in young adulthood as it is particularly relevant for understanding current population health trends. We used data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) when participants were aged 12-19 years (Wave I) and aged 24-32 years (Wave IV). Using a series of logistic regression models, we first estimated the association between education and five markers of cardiometabolic health (high-risk blood pressure, high-risk waist circumference, diabetes/pre-diabetes, hyperlipidemia, and high-risk inflammation). We then examined the extent to which this association was explained by adolescent health and both adolescent and young adult socioeconomic status (SES) (including parental education, participant educational attainment, household income, and employment status). Finally, we investigated whether the association between educational attainment and cardiometabolic health differed by race/ethnicity and sex. We found evidence of an association between educational attainment and cardiometabolic health that persisted net of adolescent health, adolescent SES, and young adult SES. We also found some evidence of modest differences in this association by race/ethnicity and sex. Our findings suggest that even as early as young adulthood there are disparities in cardiometabolic health by educational attainment, which may lead to even larger disparities in late life health.

Patterns of black and white hysterectomy incidence among reproductive aged women

OBJECTIVE

To investigate the intersection of race and economic context in treatment with hysterectomy among reproductive aged women with noncancerous gynecologic conditions.

DATA SOURCES

We combined administrative billing records of inpatient and outpatient hysterectomy procedures (N = 28 301) occurring in North Carolina between 2011 and 2014 with census data to calculate county-level hysterectomy rates.

STUDY DESIGN

Spatial analysis techniques examined the distribution of black and white hysterectomy rates across counties, and county-level black and white rate differences were compared across economic contexts.

DATA COLLECTION/EXTRACTION

We restricted to those of premenopausal age identifying as non-Hispanic black or white, undergoing hysterectomy for nonemergent causes (N = 28 301 procedures).

PRINCIPAL FINDINGS

County-level hysterectomy rates were spatially patterned (Moran's I, P < .05) and similarly so for black and white women (LISA, P < .005). The black-white difference in hysterectomy rates was the largest in the high economic tier counties (22/10 000 person-years [PY], P < .05) and smallest in the mid and low economic tier counties (11/10 000 PY, P > .05 and 10/10 000 PY, P > .05, respectively).

CONCLUSION

Socioeconomic context is important to understand, particularly for black-white disparities in hysterectomy. Efforts should be made to understand the causes of higher rates of hysterectomy among blacks than whites, especially in counties in the highest economic tier.

A gender framework for understanding health lifestyles

PURPOSE

A health lifestyles approach holds promise for understanding change in women's and men's health behaviors and reducing gendered health disparities. The emerging theoretical and empirical literature on health lifestyles (individuals' bundled health behaviors that are shaped by group-based identities and norms) helps elucidate complex disparities in health behaviors, but research is needed on how gender shapes the development of health lifestyles. This study proposed and assessed a dynamic multilevel framework for understanding health lifestyles that draws on insights from contemporary gender and life course scholarship.

DATA

Using the transition from adolescence into adulthood as an empirical case, we analyzed US data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 6605), which followed adolescents through young adulthood, collecting information on their health behaviors and social contexts.

FINDINGS

Latent class analyses showed that health lifestyles differed significantly by gender. Results supported the dynamic multilevel framework, finding more variation in health lifestyle behaviors within genders than between, high levels of change across ages, intersections of gender with age, and socioeconomic status as a structural pathway for gender's influence.

CONCLUSION

Taken together, these findings suggest that conceptualizing gender as a dynamic multilevel system intersecting with other social statuses is fruitful for understanding how health lifestyles form and change. These findings can inform more effective policies to change health behaviors.

Occupation, employment status, and "despair"-associated mortality risk among working-aged U.S. adults, 1997-2015

The recent rise in U.S. midlife mortality has been conceptualized as a "working-class" crisis, defined by increasing mortality among blue-collar and/or unemployed workers and the decline of manual labor; yet research on the topic overwhelmingly focuses on educational attainment as the key socioeconomic determinant of midlife mortality, especially among "despair"-related deaths. The present study addresses this gap by using data on 360,146 adults ages 25-64 from restricted-use National Health Interview Survey-Linked Mortality Files (1997-2015; average follow-up 9.87 years) to estimate associations between individuals' occupation and employment status and alcoholic liver disease, suicide, or accidental poisoning mortality risk, net of confounders. Adults in service, manual labor, and transport occupations exhibited two-to-three times the risk of mortality from accidental poisonings compared to those in managerial/administrative positions. Notably, health professionals exhibited the highest accidental poisoning mortality risks. Relative to managerial/administrative professionals, adults not in the labor force had double the suicide risk and nearly seven times the accidental poisoning risk, net of confounders. Unemployed adults and those having never worked also had elevated risks from accidental poisoning mortality. Critically, the fact that individuals' occupations and employment status are independently associated with midlife mortality due to deaths of despair - especially accidental poisoning - highlights the need for measures of socioeconomic status beyond educational attainment and income in understanding rising midlife mortality. Moreover, policies addressing working-aged mortality must target particular workplace contexts and the consequences of unemployment, both of which affect a large and growing segment of the working-aged U.S. population.

Lung cancer mortality among never-smokers in the United States: estimating smoking-attributable mortality with nationally representative data

PURPOSE

Lung cancer mortality among never-smokers is an often overlooked yet important cause of adult mortality. Moreover, indirect approaches for estimating smoking-attributable mortality use never-smoker lung cancer death rates to approximate smoking burden. To date, though, most studies using indirect approaches import rates from the Cancer Prevention Study II (CPS-II), which is not representative of the U.S.

POPULATION

METHODS

We use the nationally representative 1985-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) to calculate lung cancer death rates among never-smokers aged 50 years or older. We then import rates from NHIS-LMF and CPS-II into the Preston-Glei-Wilmoth indirect method to determine whether smoking-attributable fractions differ.

RESULTS

Never-smokers account for 16% of U.S. lung cancer deaths among women and 11% among men. Lung cancer death rates among never-smokers are higher in NHIS-LMF than CPS-II for several age groups. Smoking-attributable fractions of mortality are slightly lower with NHIS-LMF rates (19% of male deaths and 16% of female deaths) than with CPS-II rates (21% of male deaths and 17% of female deaths).

CONCLUSIONS

Fractions based on nonrepresentative CPS-II data may modestly overestimate smoking-attributable mortality. Thus, indirect methods should use never-smoker lung cancer death rates from such nationally representative datasets as NHIS-LMF.

Race, death of a child, and mortality risk among aging parents in the United States

The death of a child is a stressful and traumatic life event that has been linked to increased mortality risk among parents. Tragically, black parents are significantly more likely than white parents to lose a child in the United States; however, prior research has not addressed this racial disadvantage in relation to parents' mortality risk. In this study, we focus on the racial context of the United States to suggest that black parents already face higher mortality rates compared to white parents, and the unequal burden of child death adds to their mortality risk. Using discrete-time event history models, we consider whether the death of a child by midlife is associated with increased mortality risk for black parents and for white parents in mid- to later-life using longitudinal data from the Health and Retirement Study (HRS; 1996-2016). Descriptive results show that by midlife, black parents, especially black mothers, experience substantially higher child mortality compared with white parents. At the same time, we find that losing a child prior to midlife is associated with heightened mortality risk for aging black mothers and white mothers. Controlling for educational attainment explains the association between child death and parental mortality risk among white mothers, whereas heightened biopsychosocial and behavioral risk factors explain the association for black mothers. Overall, the death of a child is associated with increased mortality risk for black mothers and for white mothers, but the processes linking child death to parental mortality seem to differ for black and white parents. These findings have implications for policies and interventions that address increased mortality risk for parents following the death of a child.

Race/Ethnicity, Gender, and Trajectories of Depressive Symptoms Across Early- and Mid-Life Among the Add Health Cohort

While disparities in depressive symptoms by race/ethnicity and gender have been documented, left unclear is how such status characteristics intersect to influence mental health, particularly across early life and among a diverse set of population subgroups. This study investigates how intra- and inter-individual trends in depressive symptoms unfold across a 30-year span (ages 12-42) and are structured by the intersection of race/ethnicity and gender among White, Black, Hispanic, and Asian American young adults (N = 18,566). Analyses use data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of adolescents who have been followed through their fourth decade of life. We draw on Waves I-IV and a representative subsample of the brand new Wave V data. Growth curve models indicated depressive symptoms decreased across adolescence and young adulthood before increasing in the early 30s. Racial/ethnic minorities reported more depressive symptoms than Whites. Women reported more depressive symptoms than men and experienced especially steep increases in their late 30s. Racial/ethnic-gender disparities remained stable with age, except for Hispanic-White disparities among women and Asian American-White disparities among men, which narrowed with age. Overall, findings demonstrate dynamic inequalities across a longer period of the life span than was previously known, as well as heterogeneity in trajectories of poor mental health within and between racial/ethnic-gender groups. Results also suggest that Black and Asian American women experience the highest mental health risks and that interventions for reducing disparities in depressive symptoms should focus on adults in their late 20s/early 30s, particularly women of color.

Which Aspects of Education Matter for Early Adult Mortality? Evidence from the High School and Beyond Cohort

What dimensions of education matter for people's chances of surviving young adulthood? Do cognitive skills, non-cognitive skills, course taking patterns, and school social contexts matter for young adult mortality, even net of educational attainment? We analyze data from High School & Beyond-a nationally representative cohort of ~25,000 high school students first interviewed in 1980. Many dimensions of education are associated with young adult mortality, and high school students' math course taking retain their associations with mortality net of educational attainment. Our work draws on theories and measures from sociological and educational research and enriches public health, economic, and demographic research on educational gradients in mortality that has almost exclusively relied on ideas of human capital accumulation and measures of degree attainment. Our findings also call on social and education researchers to engage together in research on the life-long consequences of educational processes, school structures, and inequalities in opportunities to learn.

Race/ethnicity, maternal educational attainment, and infant mortality in the United States

This study examines patterns of and explanations for racial/ethnic-education disparities in infant mortality in the United States. Using linked birth and death data (2007-2010), we find that while education-specific infant mortality rates are similar for Mexican Americans and Whites, infants of college-educated African American women experience 3.1 more deaths per 1,000 live births (Rate Ratio = 1.46) than infants of White women with a high school degree or less. The high mortality rates among infants born to African American women of all educational attainment levels are fully accounted for by shorter gestational lengths. Supplementary analyses of data from the National Longitudinal Study of Adolescent to Adult Health show that college-educated African American women exhibit similar socioeconomic, contextual, psychosocial, and health disadvantages as White women with a high school degree or less. Together, these results demonstrate African American-White infant mortality and socioeconomic, health, and contextual disparities within education levels, suggesting the role of life course socioeconomic disadvantage and stress processes in the poorer infant health outcomes of African Americans relative to Whites.

The persistent southern disadvantage in US early life mortality, 1965-2014

BACKGROUND

Recent studies of US adult mortality demonstrate a growing disadvantage among southern states. Few studies have examined long-term trends and geographic patterns in US early life (ages 1 to 24) mortality, ages at which key risk factors and causes of death are quite different than among adults.

OBJECTIVE

This article examines trends and variations in early life mortality rates across US states and census divisions. We assess whether those variations have changed over a 50-year time period and which causes of death contribute to contemporary geographic disparities.

METHODS

We calculate all-cause and cause-specific death rates using death certificate data from the Multiple Cause of Death files, combining public-use files from 1965-2004 and restricted data with state geographic identifiers from 2005-2014. State population (denominator) data come from US decennial censuses or intercensal estimates.

RESULTS

Results demonstrate a persistent mortality disadvantage for young people (ages 1 to 24) living in southern states over the last 50 years, particularly those located in the East South Central and West South Central divisions. Motor vehicle accidents and homicide by firearm account for most of the contemporary southern disadvantage in US early life mortality.

CONTRIBUTION

Our results illustrate that US children and youth living in the southern United States have long suffered from higher levels of mortality than children and youth living in other parts of the country. Our findings also suggest the contemporary southern disadvantage in US early life mortality could potentially be reduced with state-level policies designed to prevent deaths involving motor vehicles and firearms.

Maternal Educational Attainment and Child Health in the United States

PURPOSE

To identify how child health status differs by mother's educational attainment for the overall US population and by race/ethnicity and to assess whether these disparities have changed from 2000 to 2017.

DESIGN

Repeated cross-sectional data from the 2000-2017 National Health Interview Survey (NHIS).

SETTING

United States.

PARTICIPANTS

Children aged 1 to 17 years from a nationally representative sample of the noninstitutionalized US population (N = 199 427).

MEASURES

Reported child health status, mother's educational attainment, child's race/ethnicity, and control variables were measured using the NHIS.

ANALYSIS

Using logistic regression models, we assessed the relationship between maternal education and child health. Missing data were imputed.

RESULTS

Children whose mothers had less than a high school education (odds ratio [OR] = 3.84, 95% confidence interval [CI]: 3.62-4.07), high school diploma or equivalent (OR = 2.57, 95% CI: 2.44-2.70), or some college (OR = 1.90, 95% CI: 1.80-2.00) had worse reported health status compared to children whose mothers graduated college. These associations were strongest among non-Hispanic white children, with significantly (P < .05) smaller associations observed for non-Hispanic black, Mexican origin, and other Hispanic children. The associations were smaller but persisted with inclusion of controls. From 2000 to 2017, child health disparities slightly narrowed or remained stagnant among white, non-Hispanic black, and other Hispanic children but widened for Mexican origin children (P < .05).

CONCLUSION

Maternal education disparities in child health are wide and have persisted.

The Depths of Despair Among US Adults Entering Midlife

OBJECTIVES

To test whether indicators of despair are rising among US adults as they age toward midlife and whether this rise is concentrated among low-educated Whites and in rural areas.

METHODS

We used data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of US adolescents in 1994. Our sample was restricted to individuals who participated in 1 or more of 5 waves (1994-2017) and self-identified as non-Hispanic White, non-Hispanic Black, or Hispanic (n = 18 446). We examined change in indicators of despair from adolescence to adulthood using multilevel regression analysis, testing for differences by race/ethnicity, education, and rurality.

RESULTS

We found evidence of rising despair among this cohort over the past decade. This increase was not restricted to low-educated Whites or to rural areas.

CONCLUSIONS

Results suggest that generally rising despair among the young adult cohort now reaching midlife that cuts across racial/ethnic, educational, and geographic groups may presage rising midlife mortality for these subgroups in the next decade.

Longer-but Harder-Lives?: The Hispanic Health Paradox and the Social Determinants of Racial, Ethnic, and Immigrant-Native Health Disparities from Midlife through Late Life

Though Hispanics live long lives, whether a "Hispanic paradox" extends to older-age health remains unclear, as do the social processes underlying racial-ethnic and immigrant-native health disparities. Using data from the Health and Retirement Study (2004-2012; N = 6,581), we assess the health of U.S.- and foreign-born Hispanics relative to U.S.-born whites and blacks and examine the socioeconomic, stress, and behavioral pathways contributing to health disparities. Findings indicate higher disability, depressive, metabolic, and inflammatory risk for Hispanics relative to whites and similar health profiles among Hispanics and blacks. We find limited evidence of a healthy immigrant pattern among foreign-born Hispanics. While socioeconomic factors account for Hispanic-white gaps in inflammation, disparities in other outcomes persist after adjustment for socioeconomic status, due in part to group differences in stress exposure. Hispanics may live long lives, but their lives are characterized by more socioeconomic hardship, stress, and health risk than whites and similar health risks as blacks.

Family Socioeconomic Status and Early Life Mortality Risk in the United States

OBJECTIVES

We examine the association between several dimensions of parental socioeconomic status (SES) and all-cause and cause-specific mortality among children and youth (ages 1-24) in the United States.

METHODS

We use Cox proportional hazard models to estimate all-cause and cause-specific mortality risk based on data from the 1998 to 2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMFs), restricted to children and youth ages 1-17 at the time of survey followed through age 24, or the end of the follow-up period in 2015 (N = 377,252).

RESULTS

Children and youth in families with lower levels of mother's education, father's education, and/or family income-to-needs ratio exhibit significantly higher all-cause mortality risk compared with children and youth living in higher SES families. For example, compared to children and youth living with mothers who earned college degrees, those living with mothers who have not graduated high school experience 40% higher risk of early life mortality over the follow-up period, due in part to higher mortality risks of unintentional injuries and homicides. Similarly, children/youth whose fathers did not graduate high school experience a 41% higher risk of dying before age 25 compared to those with fathers who completed college.

CONCLUSIONS

Today's children and youth experience clear disparities in mortality risk across several dimensions of parental SES. As the U.S. continues to lag behind other high-income countries in health and mortality, more attention and resources should be devoted to improving children's health and well-being, including the family and household contexts in which American children live.

Would the elimination of obesity and smoking reduce U.S. racial/ethnic/nativity disparities in total and healthy life expectancy?

Obesity and smoking are the two leading causes of preventable death and disability in the United States. Both of these health risks are socially patterned in ways that likely produce racial/ethnic/nativity disparities in total and healthy life expectancy. The current study simulates the extent to which the hypothetical elimination of smoking and obesity would change disparities in longevity and disability by analyzing data from 19,574 U.S.-born white, black, Hispanic and foreign-born Hispanic men and women in the 1999-2000 through 2009-2010 National Health and Nutrition Examination Survey and linked mortality files. Results suggest that the elimination of both obesity and smoking would significantly narrow disparities in total and healthy life expectancy between black and white adults and remaining differences are statistically non-significant. The longstanding life expectancy advantage of Hispanic immigrants over whites is reduced, but remains large. The life expectancy advantage of U.S.-born Hispanics is reduced as well, though to a smaller extent than what is observed for Hispanic immigrants. There were no significant observed healthy life expectancy differences between white and U.S.-born Hispanic adults. Overall study results suggest that the elimination of obesity and smoking would change the shape of racial/ethnic/nativity disparities in ways that would result in greater health equity.

Smoking and Variation in the Hispanic Paradox: A Comparison of Low Birthweight Across 33 US States

The Hispanic Paradox in birth outcomes is well documented for the US as a whole, but little work has considered geographic variation underlying the national pattern. This inquiry is important given the rapid growth of the Hispanic population and its geographic dispersion. Using birth records data from 2014 through 2016, we document state variation in birthweight differentials between US-born white women and the three Hispanic populations with the largest numbers of births: US-born Mexican women, foreign-born Mexican women, and foreign-born Central and South American women. Our analyses reveal substantial geographic variation in Hispanic immigrant-white low birthweight disparities. For example, Hispanic immigrants in Southeastern states and in some states from other regions have reduced risk of low birthweight relative to whites, consistent with a "Hispanic Paradox." A significant portion of Hispanic immigrants' birthweight advantage in these states is explained by lower rates of smoking relative to whites. However, Hispanic immigrants have higher rates of low birthweight in California and several other Western states. The different state patterns are largely driven by geographic variation in smoking among whites, rather than geographic differences in Hispanic immigrants' birthweights. In contrast, US-born Mexicans generally have similar or slightly higher odds of low birthweight than whites across the US. Overall, we show that the Hispanic Paradox in birthweight varies quite dramatically by state, driven by geographic variation in low birthweight among whites associated with white smoking disparities across states.

Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990-2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.

Contemporary Geographic Variation and Sociodemographic Correlates of Hysterectomy Rates Among Reproductive-Age Women

OBJECTIVE

For decades hysterectomy rates have famously demonstrated unexplained geographic variation. The aim of this study was to identify county-level correlates of hysterectomy rates among reproductive-age women.

METHODS

Using county-level data from multiple sources, linked with claims-based surveillance data of every hysterectomy performed among women ages 20 to 44 in North Carolina from 2011 to 2013 (N = 7180), we explored social, economic, and healthcare factors associated with county-level rates.

RESULTS

After accounting for spatial autocorrelation, county-level hysterectomy rates were negatively associated with county-level median household income, positively associated with the proportion married, and not associated with measures of healthcare capacity or access.

CONCLUSIONS

This analysis provides preliminary evidence that contemporary hysterectomy use in North Carolina occurs along socioeconomic lines.

Wide educational disparities in young adult cardiovascular health

Widening educational differences in overall health and recent stagnation in cardiovascular disease mortality rates highlight the critical need to describe and understand educational disparities in cardiovascular health (CVH) among U.S. young adults. We use two data sets representative of the U.S. population to examine educational disparities in CVH among young adults (24-34) coming of age in the 21st century: the National Health and Nutrition Examination Survey (2005-2010; N= 689) and the National Longitudinal Study of Adolescent to Adult Health (2007-2008; N=11,200). We employ descriptive statistics and regression analysis. The results show that fewer than one in four young adults had good CVH (at least 5 out of 7 ideal cardiovascular indicators). Young adults who had not attained a college degree demonstrate particularly disadvantaged CVH compared with their college-educated peers. Such educational disparities persist after accounting for a range of confounders, including individuals' genetic propensity to develop coronary artery disease. The results indicate that the CVH of today's young adults is troubling and especially compromised for individuals with lower levels of educational attainment. These results generate substantial concern about the future CVH of the US population, particularly for young adults with a low level of education.

The Other Side of the Paradox: The Risk of Low Birth Weight among Infants of Migrant and Nonmigrant Households within Mexico

The main aim of this study is to understand how the international migration process affects the risk of low birth weight among Mexican-born infants using the ENADID 1997 (Encuesta Nacional de la Dinámica Demográfica), a nationally representative survey of the Mexican population. The total sample includes 23,607 infants. We employ logistic regression to estimate models in which migration status is included as a risk factor for low birth weight. The analysis demonstrates that membership in a migrant household provides protection from the risk of low birth weight largely through the receipt of remittances. In light of this evidence, it is particularly important that international migration be recognized as one of the processes that has a positive and significant effect on perinatal outcomes in both countries of origin and in countries of destination.

Nativity, Duration of Residence, and the Health of Hispanic Adults in the United States

This article examines subgroup differences in the health status of Hispanic adults in comparison to non-Hispanic whites and non-Hispanic lacks. We pay particular attention to the influences of nativity and duration of residence in the United States. Data are pooled from the National Health Interview Survey (NHIS) for 1989–94. Puerto Ricans exhibited the worst health outcomes of any group (including whites and blacks) for each of the three health measures. Persons of Central/South American origin exhibited the most favorable outcomes for activity limitations and bed sick days, advantages that were eliminated when controlled for nativity/duration. For two of the three health status variables, Mexican Americans were very similar to non-Hispanic whites in baseline models and were more favorable than non-Hispanic whites once socioeconomic factors were controlled; this was not the case, however, for self-reported overall health. Immigration also helped to explain the relatively positive outcomes among Central/South American origin individuals, Cubans, and Mexican Americans. For most Hispanic groups (as well as non-Hispanic whites and non-Hispanic blacks), immigrants reported better health than the U.S. born, which is consistent with a selectivity hypothesis of immigrant health. In addition, this advantage tended to be significantly smaller among immigrants with ten or more years’ duration in the United States. Although the latter finding is consistent with the negative acculturation hypothesis, alternative interpretations, including the generally more limited access of immigrants to the formal health care system, are suggested.

Heterogeneity in educational pathways and the health behavior of U.S. young adults

An increasing number of U.S. adults are progressing through college in decidedly more complex ways. Little is known, however, about how this growing heterogeneity may be associated with the health behaviors and ultimately health of young adults. Using a life course perspective, we investigate whether and why different educational pathways - that is, variation in when people attend and complete school - are associated with daily smoking and binge drinking among U.S. young adults. We use 14 waves (1997-2011) of data from the National Longitudinal Survey of Youth 1997 cohort (n=7,359) that enable us to identify the most common educational pathways, as well as their association with young adult health behaviors. Bachelor's degree recipients who enrolled immediately after high school but did not attain their degree within 4 years were more likely to smoke daily in early adulthood (i.e., ages 26 to 32) than those who enrolled in college immediately after high school and attained a bachelor's degree within 4 years. Conversely, bachelor's degree recipients who delayed college enrollment were less likely to binge drink in early adulthood than individuals who enrolled in college immediately after high school and attained a bachelor's degree within 4 years. Marital status and household income in young adulthood accounted for some of the relationships between educational pathways and health behavior. These findings highlight the complexity of education's relationship to health behavior and strongly suggest that heterogeneity in educational pathways should be explicitly examined in population health research. Word Count: 241.

Reservation Lands as a Protective Social Factor: An Analysis of Psychological Distress among Two American Indian Tribes

The unique physical, cultural, and ecological location of U.S. American Indian reservations simultaneously presents risks for mental health and offers sources of resilience to Native peoples. Using survey data from two American Indian tribes, we explore whether the length of one's life spent on a reservation is associated with lower odds of psychological distress. In both tribes, we find that individuals who live a vast majority of their lives on the reservation have lower odds of psychological distress than individuals who spent portions of their life off or near the reservation. These findings suggest a need to reframe the perception of life experience on tribal reservations but also call for a more nuanced investigation of the life experience of American Indians. This study illustrates the importance of deeply exploring the relationship that American Indians have with their tribal reservation lands.

The Cardiovascular Health of Young Adults: Disparities along the Urban-Rural Continuum

U.S. young adults coming of age in the early 21^st Century are the first cohort to grow up during the obesity epidemic; justifiably, there is much concern about their cardiovascular health. To date, however, no research has examined the extent to which there are disparities in young adult cardiovascular health across the urban-rural continuum. We examine this topic using data from the National Longitudinal Study of Adolescent to Adult Health. We find that young adults who live in metropolitan core areas exhibit more favorable cardiovascular health than individuals who live in smaller types of communities, and that population density largely accounts for this association. Further, individuals living in more densely populated areas in young adulthood relative to adolescence have better cardiovascular health than those who live in areas similar or less dense than their adolescent residence. Our results strongly suggest that the physical and social features of communities represent important contexts for young adult cardiovascular health.

Gender and Health Behavior Clustering among U.S. Young Adults

U.S. trends in population health suggest alarming disparities among young adults, who are less healthy across most measureable domains than their counterparts in other high-income countries; these international comparisons are particularly troubling for women. To deepen our understanding of gender disparities in health and underlying behavioral contributions, we document gender-specific clusters of health behavior among U.S. young adults using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health. We find high levels of poor health behavior, but especially among men; 40 percent of men clustered into a group characterized by unhealthy behavior (e.g., poor diet, no exercise, substance use), compared to only 22 percent of women. Additionally, women tend to age out of unhealthy behaviors in young adulthood more than men. Further, we uncover gender differences in the extent to which sociodemographic position and adolescent contexts inform health behavior clustering. For example, college education was more protective for men, whereas marital status was equally protective across gender. Parental drinking mattered for health behavior clustering among men, whereas peer drinking mattered for clustering among women. We discuss these results in the context of declining female advantage in U.S. health and changing young adult social and health contexts.

Racial/Ethnic Differences in Early-Life Mortality in the United States

U.S. early-life (ages 1-24) deaths are tragic, far too common, and largely preventable. Yet demographers have focused scant attention on U.S. early-life mortality patterns, particularly as they vary across racial and ethnic groups. We employed the restricted-use 1999-2011 National Health Interview Survey-Linked Mortality Files and hazard models to examine racial/ethnic differences in early-life mortality. Our results reveal that these disparities are large, strongly related to differences in parental socioeconomic status, and expressed through different causes of death. Compared to non-Hispanic whites, non-Hispanic blacks experience 60 percent and Mexican Americans 32 percent higher risk of death over the follow-up period, with demographic controls. Our finding that Mexican Americans experience higher early-life mortality risk than non-Hispanic whites differs from much of the literature on adult mortality. We also show that these racial/ethnic differences attenuate with controls for family structure and especially with measures of socioeconomic status. For example, higher mortality risk among Mexican Americans than among non-Hispanic whites is no longer significant once we controlled for mother's education or family income. Our results strongly suggest that eliminating socioeconomic gaps across groups is the key to enhanced survival for children and adolescents in racial/ethnic minority groups.

Racial Disparities in Functional Limitations Among Hispanic Women in the United States

This article assesses whether there are race differences in functional health among Hispanic women in the United States; ascertains whether the race differences in functional health vary by age; and examines the extent to which race differences in functional health are attributable to key dimensions of demographic, geographic, and socioeconomic heterogeneity. The analysis is based on 15 years of aggregated data from the National Health Interview Survey. Both U.S.- and foreign-born Black and other race Hispanic women display a higher level of functional limitations than their White Hispanic counterparts. There is little evidence that such health differences widen with age. U.S.-born Black Hispanic women, however, suffer from a high burden of functional limitations across the adult age range. This research speaks to the need for greater attention to racial differences in health among Hispanics and particularly so within the U.S.-born segment of this rapidly aging population.

Educational and Gender Differences in Health Behavior Changes After a Gateway Diagnosis

OBJECTIVE

Hypertension represents a gateway diagnosis to more serious health problems that occur as people age. We examine educational differences in three health behavior changes people often make after receiving this diagnosis in middle or older age, and test whether these educational differences depend on (a) the complexity of the health behavior change and (b) gender.

METHOD

We use data from the Health and Retirement Study and conduct logistic regression analysis to examine the likelihood of modifying health behaviors post diagnosis.

RESULTS

We find educational differences in three behavior changes-antihypertensive medication use, smoking cessation, and physical activity initiation-after a hypertension diagnosis. These educational differences in health behaviors were stronger among women compared with men.

DISCUSSION

Upon receiving a hypertension diagnosis, education is a more important predictor of behavior changes for women compared with men, which may help explain gender differences in the socioeconomic gradient in health in the United States.

Body Mass, Smoking, and Overall and Cause-Specific Mortality Among Older U.S. Adults

The authors examine the relationships between body mass, smoking, and overall and cause-specific mortality among U.S. adults aged 60 and older, using data from the National Health Interview Survey linked to the Multiple Cause of Death file and Cox proportional hazard models. The authors find that, compared to those who are normal weight, obese individuals have higher risks of overall, circulatory disease, and diabetes mortality. Furthermore, smoking status suppresses the relationships between obesity and overall, circulatory disease, and cancer mortality, and interacts with lowbody weight to increase mortality risks. Finally, underweight individuals initially face increased risks of death over the follow-up period, although over time their mortality risks diminish to those of normal-weight individuals, likely due to the presence of unobserved illness. Researchers and health practitioners must account for smoking status, body mass, and specific causes of death to understand and improve the health of our increasingly obese elderly population.

Religious Involvement and Mortality Risk among African American Adults

This article examines the effects of religious involvement on mortality risk among African Americans. The authors use a relatively new and innovative nationally representative data set—the National Health Interview Survey matched to the National Center for Health Statistics’ multiple cause of death file—to model this relationship. The results show that, compared with African Americans who attend religious services more than once a week, those who never attend are more than twice as likely to die during the nine-year follow-up period, even net of a large number of confounding and mediating factors. The strong effect of nonattendance on mortality risk is robust, pervasive, and remarkably strong across all subgroups of the population, whereas a moderate level of attendance is associated with higher mortality risk among young adults, men, and Southerners, but not among older adults, women, and non-Southerners. Among African Americans, lack of religious involvement appears to be associated with risk of premature death, whereas frequent religious involvement stands out as a critical protective factor that contributes to lower mortality and longer life.

The Living Conditions of U.S.-Born Children of Mexican Immigrants in Unmarried Families

Recent research has brought attention to the hardship faced by children of immigrants in the United States, particularly in the Mexican-origin population. In this study, the authors are concerned with the extent to which U.S.-born children of Mexican immigrants who live in unmarried families may face exceptional risks. Using data from the Fragile Families and Child Wellbeing Study, the authors find that young children of Mexican immigrants in unmarried families face significant disadvantages on a variety of levels compared with children of U.S.-born mothers. Mexican immigrant mothers have significantly lower levels of education and employment and much higher rates of poverty, as well as less access to social services. Although characterized by low rates of low birth weight and more positive maternal health behaviors, their poor socioeconomic and social service profile suggests that even when healthy at the starting gate, they may potentially face poor outcomes during childhood and beyond.

The Role of Discrimination and Acculturative Stress in the Physical Health of Mexican-Origin Adults

The authors propose that perceived discrimination has an effect on self-reported health statuses, which are known to affect future morbidity and mortality. A sample of 3,012 Mexican-origin adults from the Mexican American Prevalence and Services Study in California is utilized to test this hypothesis. Dependent variables include a self-rating of health and a count of self-reported chronic conditions; the key independent variable is a scale of overall discrimination specific to one’s Mexican origin. Results indicate that discrimination is related to poor physical health—net of controls for acculturation stress, national heritage, sociodemographic variables, and social support. Depression is identified as a major mechanism through which discrimination may affect physical health. Notably, job market stress/discrimination has a very strong association with poorer physical health, net of depression. Individual-level effects of discrimination found in this study, as well as institutional-level conditions and contextual effects, should be treated as crucial to future studies of individual-level physical health differentials.

Educational attainment and the clustering of health-related behavior among U.S. young adults

OBJECTIVE

We documented health-related behavior clustering among US young adults and assessed the extent to which educational attainment was associated with the identified clusters.

METHODS

Using data from Wave IV of the National Longitudinal Study of Adolescent to Adult Health (Add Health), we performed latent class analysis on 8 health-related behaviors (n=14,338), documenting clustering of behavior separately by gender. Subsequently, we used multinomial logistic regression and estimated associations between educational attainment and the health-related behavior clusters.

RESULTS

Twenty-eight percent of young women grouped into the most favorable health behavior cluster, while 22% grouped into a very high-risk cluster. A larger percentage of young men (40%) grouped into the highest risk cluster. Individuals with educational attainment at the college and advanced degree levels exhibited much lower risk of being in the unhealthy behavioral clusters than individuals with lower educational attainment, net of a range of confounders.

CONCLUSION

Substantial fractions of US young adults, particularly those with less than college degrees, exhibit unhealthy behavior profiles. Efforts to improve health among young adults should focus particular attention on the clustering of poor health-related behavior, especially among individuals who have less than a college degree.

Hispanic-White Differences in Lifespan Variability in the United States

This study is the first to investigate whether and, if so, why Hispanics and non-Hispanic whites in the United States differ in the variability of their lifespans. Although Hispanics enjoy higher life expectancy than whites, very little is known about how lifespan variability-and thus uncertainty about length of life-differs by race/ethnicity. We use 2010 U.S. National Vital Statistics System data to calculate lifespan variance at ages 10+ for Hispanics and whites, and then decompose the Hispanic-white variance difference into cause-specific spread, allocation, and timing effects. In addition to their higher life expectancy relative to whites, Hispanics also exhibit 7 % lower lifespan variability, with a larger gap among women than men. Differences in cause-specific incidence (allocation effects) explain nearly two-thirds of Hispanics' lower lifespan variability, mainly because of the higher mortality from suicide, accidental poisoning, and lung cancer among whites. Most of the remaining Hispanic-white variance difference is due to greater age dispersion (spread effects) in mortality from heart disease and residual causes among whites than Hispanics. Thus, the Hispanic paradox-that a socioeconomically disadvantaged population (Hispanics) enjoys a mortality advantage over a socioeconomically advantaged population (whites)-pertains to lifespan variability as well as to life expectancy. Efforts to reduce U.S. lifespan variability and simultaneously increase life expectancy, especially for whites, should target premature, young adult causes of death-in particular, suicide, accidental poisoning, and homicide. We conclude by discussing how the analysis of Hispanic-white differences in lifespan variability contributes to our understanding of the Hispanic paradox.

Duty, Honor, Country, Disparity: Race/Ethnic Differences in Health and Disability among Male Veterans

Given their unique occupational hazards and sizable population, military veterans are an important population for the study of health. Yet veterans are by no means homogeneous, and there are unanswered questions regarding the extent of, and explanations for, racial and ethnic differences in veterans' health. Using the 2010 National Survey of Veterans, we first documented race/ethnic differences in self-rated health and limitations in Activities of Daily Living among male veterans aged 30-84. Second, we examined potential explanations for the disparities, including socioeconomic and behavioral differences, as well as differences in specific military experiences. We found that Black, Hispanic, and other/multiple race veterans reported much worse health than White veterans. Using progressively adjusted regression models, we uncovered that the poorer self-rated health and higher levels of activity limitations among minority veterans compared to Whites was partially explained by differences in their socioeconomic status and by their military experiences. Minority veterans are a vulnerable population for poor health; future research and policy efforts should attempt to better understand and ameliorate their health disadvantages relative to White veterans.

Mortality Attributable to Low Levels of Education in the United States

BACKGROUND

Educational disparities in U.S. adult mortality are large and have widened across birth cohorts. We consider three policy relevant scenarios and estimate the mortality attributable to: (1) individuals having less than a high school degree rather than a high school degree, (2) individuals having some college rather than a baccalaureate degree, and (3) individuals having anything less than a baccalaureate degree rather than a baccalaureate degree, using educational disparities specific to the 1925, 1935, and 1945 cohorts.

METHODS

We use the National Health Interview Survey data (1986-2004) linked to prospective mortality through 2006 (N=1,008,949), and discrete-time survival models, to estimate education- and cohort-specific mortality rates. We use those mortality rates and data on the 2010 U.S. population from the American Community Survey, to calculate annual attributable mortality estimates.

RESULTS

If adults aged 25-85 in the 2010 U.S. population experienced the educational disparities in mortality observed in the 1945 cohort, 145,243 deaths could be attributed to individuals having less than a high school degree rather than a high school degree, 110,068 deaths could be attributed to individuals having some college rather than a baccalaureate degree, and 554,525 deaths could be attributed to individuals having anything less than a baccalaureate degree rather than a baccalaureate degree. Widening educational disparities between the 1925 and 1945 cohorts result in a doubling of attributable mortality. Mortality attributable to having less than a high school degree is proportionally similar among women and men and among non-Hispanic blacks and whites, and is greater for cardiovascular disease than for cancer.

CONCLUSIONS

Mortality attributable to low education is comparable in magnitude to mortality attributable to individuals being current rather than former smokers. Existing research suggests that a substantial part of the association between education and mortality is causal. Thus, policies that increase education could significantly reduce adult mortality.

Hispanic older adult mortality in the United States: new estimates and an assessment of factors shaping the Hispanic paradox

Hispanics make up a rapidly growing proportion of the U.S. older adult population, so a firm grasp of their mortality patterns is paramount for identifying racial/ethnic differences in life chances in the population as a whole. Documentation of Hispanic mortality is also essential for assessing whether the Hispanic paradox--the similarity in death rates between Hispanics and non-Hispanic whites despite Hispanics' socioeconomic disadvantage--characterizes all adult Hispanics or just some age, gender, nativity, or national-origin subgroups. We estimate age-/sex- and cause-specific mortality rate ratios and life expectancy for foreign-born and U.S.-born Hispanics, foreign-born and U.S.-born Mexican Americans, non-Hispanic blacks, and non-Hispanic whites ages 65 and older using the 1989-2006 National Health Interview Survey Linked Mortality Files. Results affirm that Hispanic mortality estimates are favorable relative to those of blacks and whites, but particularly so for foreign-born Hispanics and smoking-related causes. However, if not for Hispanics' socioeconomic disadvantage, their mortality levels would be even more favorable.

Hispanic Older Adult Health & Longevity in the United States: Current Patterns & Concerns for the Future

The Hispanic population aged sixty-five and over - the most socioeconomically disadvantaged subset of America's elderly - is projected to quintuple between 2012 and 2050. While current longevity patterns for Hispanics relative to whites are favorable, old-age functioning and disability patterns for Hispanics are unfavorable and have serious implications for caregivers; families; and local, state, and federal governments. Troubling signs for the future Hispanic population (which are shared to varying degrees with other vulnerable groups) include the unresolved legal status of unauthorized immigrants, continued low levels of insurance coverage even after health care reform, some unfavorable trends in health behaviors, and continued disadvantages in educational attainment and income relative to whites. We urge policy-makers to deal with these potentially problematic health and well-being issues. Not doing so could have detrimental consequences for the future of the Hispanic population as well as other at-risk groups and, by extension, the U.S. elderly population as a whole.

Long-term trends in adult mortality for U.S. Blacks and Whites: an examination of period- and cohort-based changes

Black-white differences in U.S. adult mortality have narrowed over the past five decades, but whether this narrowing unfolded on a period or cohort basis is unclear. The distinction has important implications for understanding the socioeconomic, public health, lifestyle, and medical mechanisms responsible for this narrowing. We use data from 1959 to 2009 and age-period-cohort (APC) models to examine period- and cohort-based changes in adult mortality for U.S. blacks and whites. We do so for all-cause mortality among persons aged 15-74 as well as for several underlying causes of death more pertinent for specific age groups. We find clear patterns of cohort-based reductions in mortality for both black men and women and white men and women. Recent cohort-based reductions in heart disease, stroke, lung cancer, female breast cancer, and other cancer mortality have been substantial and, save for breast cancer, have been especially pronounced for blacks. Period-based changes have also occurred and are especially pronounced for some causes of death. Period-based reductions in blacks' and whites' heart disease and stroke mortality are particularly impressive, as are recent period-based reductions in young men's and women's mortality from infectious diseases and homicide. These recent period changes are more pronounced among blacks. The substantial cohort-based trends in chronic disease mortality and recent period-based reductions for some causes of death suggest a continuing slow closure of the black-white mortality gap. However, we also uncover troubling signs of recent cohort-based increases in heart disease mortality for both blacks and whites.

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.