Health Disparities

  • Sanjay Basu
  • Mark Cullen
  • Jeremy Freese
  • David Rehkopf

Leaders: Sanjay Basu, Mark Cullen, Jeremy Freese, David Rehkopf 

The affiliates within the Health Disparities RG are using new computer modeling and statistical techniques to examine how poverty affects the health of children and adults and how some anti-poverty programs are reducing those effects. Here’s a sampling of our projects. 

Income, geography, and life expectancy: Using deidentified tax data and Social Security Administration death records, Raj Chetty and his coauthors have shown that the richest 1 percent live 14.6 years longer, on average, than the poorest 1 percent. Although poor people typically have much shorter lives, Chetty also shows that the extent of this disadvantage depends on the place of residence, thus suggesting that there may be opportunities for policy to reduce the gap in life expectancy.

Infant health and poverty: Which poor neighborhoods are associated with very low birth weights? By identifying neighborhoods that are yielding very low birth weights, we can start to target home visiting and related programs.

Biological mechanisms of disadvantage: We all know that poverty “gets under the skin” and creates lasting disadvantage. Is this because children exposed to poverty-induced stress experience epigenetic changes? We’re going to know very soon.

Income and the developing brain: The prevailing view is that poverty is especially likely to shape children’s early development because of the high plasticity and rapid growth of the brain during the first three years of life. It’s high time for a rigorous study of how income affects the brain function and development of infants and toddlers. 

Health - CPI Research

Title Author Media
The Geographic Distribution of Genetic Risk as Compared to Social Risk for Chronic Diseases in the United States David H. Rehkopf, Benjamin W. Domingue, Mark R. Cullen

The Geographic Distribution of Genetic Risk as Compared to Social Risk for Chronic Diseases in the United States

Author: David H. Rehkopf, Benjamin W. Domingue, Mark R. Cullen
Publisher: Biodemography and Social Biology
Date: 04/2016

There is an association between chronic disease and geography, and there is evidence that the environment plays a critical role in this relationship. Yet at the same time, there is known to be substantial geographic variation by ancestry across the United States. Resulting geographic genetic variation—that is, the extent to which single nucleotide polymorphisms (SNPs) related to chronic disease vary spatially—could thus drive some part of the association between geography and disease. We describe the variation in chronic disease genetic risk by state of birth by taking risk SNPs from genome-wide association study meta-analyses for coronary artery disease, diabetes, and ischemic stroke and creating polygenic risk scores. We compare the amount of variability across state of birth in these polygenic scores to the variability in parental education, own education, earnings, and wealth. Our primary finding is that the polygenic risk scores are only weakly differentially distributed across U.S. states. The magnitude of the differences in geographic distribution is very small in comparison to the distribution of social and economic factors and thus is not likely sufficient to have a meaningful effect on geographic disease differences by U.S. state.

Long-Run Impacts of Childhood Access to the Safety Net Hilary Hoynes, Diane Whitmore Schanzenbach , Douglas Almond

Long-Run Impacts of Childhood Access to the Safety Net

Author: Hilary Hoynes, Diane Whitmore Schanzenbach , Douglas Almond
Publisher: American Economic Review
Date: 04/2016

We examine the impact of a positive and policy-driven change in economic resources available in utero and during childhood. We focus on the introduction of the Food Stamp Program, which was rolled out across counties between 1961 and 1975. We use the Panel Study of Income Dynamics to assemble unique data linking family background and county of residence in early childhood to adult health and economic outcomes. Our findings indicate access to food stamps in childhood leads to a significant reduction in the incidence of metabolic syndrome and, for women, an increase in economic self-sufficiency.

Heterogeneity in State-Dependent Utility: Evidence from Strategic Surveys Jeffrey R. Brown , Gopi Shah Goda, Kathleen M. McGarry

Heterogeneity in State-Dependent Utility: Evidence from Strategic Surveys

Author: Jeffrey R. Brown , Gopi Shah Goda, Kathleen M. McGarry
Publisher: Economic Inquiry
Date: 04/2016

A standard result of life‐cycle models under uncertainty is that optimizing individuals equate the expected marginal utility of consumption across states of the world if insurance is available at actuarially fair rates. A small empirical literature has suggested that the marginal utility of consumption is lower in less healthy states. We use a novel survey‐based measure to document significant heterogeneity in health‐state dependence across individuals largely orthogonal to standard controls. We further show that individuals value unhealthy states of the world more when facing work‐limiting disabilities than when facing disabilities requiring long‐term care, and when facing physical rather than mental disabilities.

Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s Sanjay Basu, David H. Rehkopf, Arjumand Siddiqi, M. Maria Glymour, Ichiro Kawachi

Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s

Author: Sanjay Basu, David H. Rehkopf, Arjumand Siddiqi, M. Maria Glymour, Ichiro Kawachi
Publisher: American Journal of Epidemiology
Date: 03/2016

We studied the health of low-income US women affected by the largest social policy change in recent US history: the 1996 welfare reforms. Using the Behavioral Risk Factor Surveillance System (1993–2012), we performed 2 types of analysis. First, we used difference-in-difference-in-differences analyses to estimate associations between welfare reforms and health outcomes among the most affected women (single mothers aged 18–64 years in 1997; n = 219,469) compared with less affected women (married mothers, single nonmothers, and married nonmothers of the same age range in 1997; n = 2,422,265). We also used a synthetic control approach in which we constructed a more ideal control group for single mothers by weighting outcomes among the less affected groups to match pre-reform outcomes among single mothers. In both specifications, the group most affected by welfare reforms (single mothers) experienced worse health outcomes than comparison groups less affected by the reforms. For example, the reforms were associated with at least a 4.0-percentage-point increase in binge drinking (95% confidence interval: 0.9, 7.0) and a 2.4-percentage-point decrease in the probability of being able to afford medical care (95% confidence interval: 0.1, 4.8) after controlling for age, educational level, and health care insurance status. Although the reforms were applauded for reducing welfare dependency, they may have adversely affected health.

Alternative strategies to achieve cardiovascular mortality goals in China and India: A microsimulation of target-versus risk-based blood pressure treatment S. Basu, J.S. Yudkin, J.B. Sussman, C. Millett, R.A. Hayward

Alternative strategies to achieve cardiovascular mortality goals in China and India: A microsimulation of target-versus risk-based blood pressure treatment

Author: S. Basu, J.S. Yudkin, J.B. Sussman, C. Millett, R.A. Hayward
Publisher: Circulation
Date: 03/2016

BACKGROUND:

The World Health Organization aims to reduce mortality from chronic diseases including cardiovascular disease (CVD) by 25% by 2025. High blood pressure is a leading CVD risk factor. We sought to compare 3 strategies for treating blood pressure in China and India: a treat-to-target (TTT) strategy emphasizing lowering blood pressure to a target, a benefit-based tailored treatment (BTT) strategy emphasizing lowering CVD risk, or a hybrid strategy currently recommended by the World Health Organization.

METHODS AND RESULTS:

We developed a microsimulation model of adults aged 30 to 70 years in China and in India to compare the 2 treatment approaches across a 10-year policy-planning horizon. In the model, a BTT strategy treating adults with a 10-year CVD event risk of ≥10% used similar financial resources but averted ≈5 million more disability-adjusted life-years in both China and India than a TTT approach based on current US guidelines. The hybrid strategy in the current World Health Organization guidelines produced no substantial benefits over TTT. BTT was more cost-effective at $205 to $272/disability-adjusted life-year averted, which was $142 to $182 less per disability-adjusted life-year than TTT or hybrid strategies. The comparative effectiveness of BTT was robust to uncertainties in CVD risk estimation and to variations in the age range analyzed, the BTT treatment threshold, or rates of treatment access, adherence, or concurrent statin therapy.

CONCLUSIONS:

In model-based analyses, a simple BTT strategy was more effective and cost-effective than TTT or hybrid strategies in reducing mortality.

health - CPI Affiliates

Jack Shonkoff's picture Jack Shonkoff Director, Center on the Developing Child, Julius B. Richmond FAMRI Professor of Child Health and Development, Professor of Pediatrics, Harvard Medical School and Boston Children’s Hospital
Harvard University
Jacob Hacker's picture Jacob Hacker Stanley B. Resor Professor of Political Science; Director of the Institution for Social and Policy Studies
Yale University
Jason Beckfield's picture Jason Beckfield Professor of Sociology, Associate Director, Center for Population and Development Studies
Harvard University
Sarah Burgard's picture Sarah Burgard Associate Professor of Sociology and Epidemiology; Research Associate Professor, Population Studies Center; Director of Graduate Studies
University of Michigan
Shannon Monnat's picture Shannon Monnat Assistant Professor of Rural Sociology, Demography, and Sociology
Pennsylvania State University

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Health - Other Research

Title Author Media
Addressing the Opioid Epidemic: Is There a Role for Physician Education? Molly Schnell, Janet Currie

Addressing the Opioid Epidemic: Is There a Role for Physician Education?

Author: Molly Schnell, Janet Currie
Publisher: NBER
Date: 08/2017

Using data on all opioid prescriptions written by physicians from 2006 to 2014, we uncover a striking relationship between opioid prescribing and medical school rank. Even within the same specialty and county of practice, physicians who completed their initial training at top medical schools write significantly fewer opioid prescriptions annually than physicians from lower ranked schools. Additional evidence suggests that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools. Altering physician education may therefore be a useful policy tool in fighting the current epidemic.

 

Is It Who You Are or Where You Live? Residential Segregation and Racial Gaps in Childhood Asthma Diane Alexander, Janet Currie

Is It Who You Are or Where You Live? Residential Segregation and Racial Gaps in Childhood Asthma

Author: Diane Alexander, Janet Currie
Publisher: NBER
Date: 07/2017

Higher asthma rates are one of the more obvious ways that health inequalities between African American and other children are manifested beginning in early childhood. In 2010, black asthma rates were double non-black rates. Some but not all of this difference can be explained by factors such as a higher incidence of low birth weight (LBW) among blacks; however, even conditional on LBW, blacks have a higher incidence of asthma than others. Using a unique data set based on the health records of all children born in New Jersey between 2006 and 2010, we show that when we split the data by whether or not children live in a “black” zip code, this racial difference in the incidence of asthma among LBW children entirely disappears. All LBW children in these zip codes, regardless of race, have a higher incidence of asthma. Our results point to the importance of residential segregation and neighborhoods in explaining persistent racial health disparities.

 

An Analysis of the Memphis Nurse-Family Partnership Program James J. Heckman, Margaret L. Holland, Kevin K. Makino, Rodrigo Pinto, Maria Rosales-Rueda

An Analysis of the Memphis Nurse-Family Partnership Program

Author: James J. Heckman, Margaret L. Holland, Kevin K. Makino, Rodrigo Pinto, Maria Rosales-Rueda
Publisher: NBER
Date: 07/2017

This paper evaluates a randomized controlled trial of the Nurse-Family Partnership (NFP) program conducted in Memphis, TN in 1990. NFP offers home visits conducted by nurses for disadvantaged first-time mothers during pregnancy and early childhood. We test NFP treatment effects using permutation-based inference that accounts for the NFP randomization protocol. Our methodology is valid for small samples and corrects for multiple-hypothesis testing. We also analyze the underlying mechanisms generating these treatment effects. We decompose NFP treatment effects into components associated with the intervention-enhanced parenting and early childhood skills. The NFP improves home investments, parenting attitudes and mental health for mothers of infants at age 2. At age 6, the NFP boosts cognitive skills for both genders and socio-emotional skills for females. These treatment effects are explained by program-induced improvements in maternal traits and early-life family investments. At age 12, the treatment effects for males (but not for females) persist in the form of enhanced achievement test scores. Treatment effects are largely explained by enhanced cognitive skills at age 6. Our evidence of pronounced gender differences in response to early childhood interventions contributes to a growing literature on this topic.

Aberrant Nocturnal Cortisol and Disease Progression in Women with Breast Cancer Jamie M. Zeitzer, Bita Nouriani, Michelle B. Rissling, George W. Sledge, Katherine A. Kaplan, Linn Aasly, Oxana Palesh, Booil Jo, Eric Neri, Firdaus S. Dhabhar, David Spiegel

Aberrant Nocturnal Cortisol and Disease Progression in Women with Breast Cancer

Author: Jamie M. Zeitzer, Bita Nouriani, Michelle B. Rissling, George W. Sledge, Katherine A. Kaplan, Linn Aasly, Oxana Palesh, Booil Jo, Eric Neri, Firdaus S. Dhabhar, David Spiegel
Publisher: Breast Cancer Research and Treatment
Date: 06/2016

While a relationship between disruption of circadian rhythms and the progression of cancer has been hypothesized in field and epidemiologic studies, it has never been unequivocally demonstrated. We determined the circadian rhythm of cortisol and sleep in women with advanced breast cancer (ABC) under the conditions necessary to allow for the precise measurement of these variables. Women with ABC (n = 97) and age-matched controls (n = 24) took part in a 24-h intensive physiological monitoring study involving polysomnographic sleep measures and high-density plasma sampling. Sleep was scored using both standard clinical metrics and power spectral analysis. Three-harmonic regression analysis and functional data analysis were used to assess the 24-h and sleep-associated patterns of plasma cortisol, respectively. The circadian pattern of plasma cortisol as described by its timing, timing relative to sleep, or amplitude was indistinguishable between women with ABC and age-matched controls (p′s > 0.11, t-tests). There was, however, an aberrant spike of cortisol during the sleep of a subset of women, during which there was an eightfold increase in the amount of objectively measured wake time (p < 0.004, Wilcoxon Signed-Rank). This cortisol aberration was associated with cancer progression such that the larger the aberration, the shorter the disease-free interval (time from initial diagnosis to metastasis; r = −0.30, p = 0.004; linear regression). The same aberrant spike was present in a similar percent of women without ABC and associated with concomitant sleep disruption. A greater understanding of this sleep-related cortisol abnormality, possibly a vulnerability trait, is likely important in our understanding of individual variation in the progression of cancer.

A Wearable Social Interaction Aid for Children with Autism Peter Washington, Catalin Voss, Nick Haber, Serena Tanaka, Jena Daniels, Carl Feinstein, Terry Winograd, Dennis Wall

A Wearable Social Interaction Aid for Children with Autism

Author: Peter Washington, Catalin Voss, Nick Haber, Serena Tanaka, Jena Daniels, Carl Feinstein, Terry Winograd, Dennis Wall
Publisher: Proceedings of the 2016 CHI Conference Extended Abstracts on Human Factors in Computing Systems
Date: 05/2016

Over 1 million children under the age of 17 in the US have been identified with Autism Spectrum Disorder (ASD). These children struggle to recognize facial expressions, make eye contact, and engage in social interactions. Gaining these skills requires intensive behavioral interventions that are often expensive, difficult to access, and inconsistently administered. We have developed a system to automate facial expression recognition that runs on wearable glasses and delivers real time social cues, with the goal of creating a behavioral aid for children with ASD that maximizes behavioral feedback while minimizing the distractions to the child. This paper describes the design of our system and interface decisions resulting from initial observations gathered during multiple preliminary trials.