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
State of the Union 2017: Health Rucker C. Johnson

State of the Union 2017: Health

Author: Rucker C. Johnson
Publisher: Stanford Center on Poverty and Inequality
Date: 06/2017

Racial and ethnic minorities experience higher-than-average rates of illness, have higher age-specific death rates throughout the life course, and are more likely to suffer from early onset of illnesses and more severe diseases than whites. In this article, I examine these and other differences in health outcomes for whites and blacks in the United States and show that black-white health disparities are large and appear to widen over the life cycle. I also discuss several policy changes that served to narrow racial health disparities in the past and consider how future policies might help ameliorate racial inequities in health.

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers Rita Hamad , Sepideh Modrek, Mark R. Cullen

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers

Author: Rita Hamad , Sepideh Modrek, Mark R. Cullen
Publisher: Health Services Research
Date: 06/2016

Objective

To examine the impacts of job insecurity during the recession of 2007–2009 on health care utilization among a panel of U.S. employees.

Data Sources/Study Setting

Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N = 9,486).

Study Design

We employed segmented regressions to examine temporal discontinuities in utilization during 2006–2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects.

Principal Findings

We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p = .002) and emergency (0.4 visits/month/10,000 individuals, p = .05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (−4.0 visits/month/10,000 individuals, p = .008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p = .08).

Conclusions

These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

Beyond Income: What Else Predicts Very Low Food Security Among Children? Patricia M. Anderson, Kristin F. Butcher, Hilary W. Hoynes, Diane Whitmore Schanzenbach

Beyond Income: What Else Predicts Very Low Food Security Among Children?

Author: Patricia M. Anderson, Kristin F. Butcher, Hilary W. Hoynes, Diane Whitmore Schanzenbach
Publisher: Southern Economic Journal
Date: 06/2016

We examine characteristics and correlates of households in the United States that are most likely to have children at risk of inadequate nutrition – those that report very low food security (VLFS) among their children. Using 11 years of the Current Population Survey, plus data from the National Health and Nutrition Examination Survey and American Time Use Survey, we describe these households in great detail with the goal of trying to understand how these households differ from households without such severe food insecurity. While household income certainly plays an important role in determining VLFS among children, we find that even after flexibly controlling for income-to-poverty rates some household characteristics and patterns of program participation have important additional explanatory power. Finally, our examination of the NHANES and ATUS data suggests an important role for both mental and physical health in determining the food security status of children.

Family Ruptures, Stress, and the Mental Health of the Next Generation Petra Persson, Maya Rossin-Slater

Family Ruptures, Stress, and the Mental Health of the Next Generation

Author: Petra Persson, Maya Rossin-Slater
Publisher: NBER
Date: 05/2016

This paper studies how in utero exposure to maternal stress from family ruptures affects later mental health. We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood. Further, family ruptures during pregnancy depress birth outcomes and raise the risk of perinatal complications necessitating hospitalization. Our results suggest large welfare gains from preventing fetal stress from family ruptures and possibly from economically induced stressors such as unemployment. They further suggest that greater stress exposure among the poor may partially explain the intergenerational persistence of poverty.

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.

health - CPI Affiliates

Jeremy Freese's picture Jeremy Freese Health Disparities Research Group Leader, Professor of Sociology
Stanford University
Mark Cullen's picture Mark Cullen Health Disparities Research Group Leader, Director of Stanford Center for Population Health Sciences, Professor of Medicine
Stanford University
Sanjay Basu's picture Sanjay Basu Health Disparities Research Group Leader, Assistant Professor of Medicine
Stanford University
David Rehkopf's picture David Rehkopf Health Disparities Research Group Leader, Assistant Professor of Medicine
Stanford 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

Pages

Health - Other Research

Title Author Media
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.

Examining Rural/Urban Differences in Prescription Opioid Misuse Among US Adolescents Monnat SM, Rigg KK

Examining Rural/Urban Differences in Prescription Opioid Misuse Among US Adolescents

Author: Monnat SM, Rigg KK
Publisher: Journal of Rural Health
Date: 03/2016

PURPOSE:

This study examines differences in prescription opioid misuse (POM) among adolescents in rural, small urban, and large urban areas of the United States and identifies several individual, social, and community risk factors contributing to those differences.

METHODS:

We used nationally representative data from the 2011 and 2012 National Survey on Drug Use and Health and estimated binary logistic regression and formal mediation models to assess past-year POM among 32,036 adolescents aged 12-17.

RESULTS:

Among adolescents, 6.8% of rural, 6.0% of small urban, and 5.3% of large urban engaged in past-year POM. Net of multiple risk and protective factors, rural adolescents have 35% greater odds and small urban adolescents have 21% greater odds of past-year POM compared to large urban adolescents. The difference between rural and small urban adolescents was not significant. Criminal activity, lower perceived substance use risk, and greater use of emergency medical treatment partially contribute to higher odds among rural adolescents, but they are also partially buffered by less peer substance use, less illicit drug access, and stronger religious beliefs.

CONCLUSIONS:

Researchers, policy makers, and treatment providers must consider the complex array of individual, social, and community risk and protective factors to understand rural/urban differences in adolescent POM. Potential points of intervention to prevent POM in general and reduce rural disparities include early education about addiction risks, use of family drug courts to link criminal offenders to treatment, and access to nonemergency medical services to reduce rural residents' reliance on emergency departments where opioid prescribing is more likely.

The Health Effects of Income Inequality: Averages and Disparities Beth C. Truesdale, Christopher Jencks

The Health Effects of Income Inequality: Averages and Disparities

Author: Beth C. Truesdale, Christopher Jencks
Publisher: Annual Review of Public Health
Date: 03/2016

Much research has investigated the association of income inequality with average life expectancy, usually finding negative correlations that are not very robust. A smaller body of work has investigated socioeconomic disparities in life expectancy, which have widened in many countries since 1980. These two lines of work should be seen as complementary because changes in average life expectancy are unlikely to affect all socioeconomic groups equally. Although most theories imply long and variable lags between changes in income inequality and changes in health, empirical evidence is confined largely to short-term effects. Rising income inequality can affect individuals in two ways. Direct effects change individuals' own income. Indirect effects change other people's income, which can then change a society's politics, customs, and ideals, altering the behavior even of those whose own income remains unchanged. Indirect effects can thus change both average health and the slope of the relationship between individual income and health.

Factors Associated With Ocular Health Care Utilization Among Hispanics/Latinos Laura A. McClure, D. Diane Zheng, Byron L. Lam, Stacey L. Tannenbaum, Charlotte E. Joslin, Sonia Davis, Daniel López-Cevallos, Marston E. Youngblood Jr, Zhu-Ming Zhang, Claudia Pulido Chambers

Factors Associated With Ocular Health Care Utilization Among Hispanics/Latinos

Author: Laura A. McClure, D. Diane Zheng, Byron L. Lam, Stacey L. Tannenbaum, Charlotte E. Joslin, Sonia Davis, Daniel López-Cevallos, Marston E. Youngblood Jr, Zhu-Ming Zhang, Claudia Pulido Chambers
Publisher: JAMA Opthalmology
Date: 03/2016

Our findings suggest that increasing insurance coverage, decreasing the costs of care, and increasing the availability of care for Hispanics/Latinos with poor self-rated eyesight are relevant issues to address to improve ocular health care use among Hispanics/Latinos of diverse backgrounds.