Jennifer Karas Montez

Social Relationships and Health A Flashpoint for Health Policy

Social relationships—both quantity and quality—affect mental health, health behavior, physical health, and mortality risk. Sociologists have played a central role in establishing the link between social relationships and health outcomes, identifying explanations for this link, and discovering social variation (e.g., by gender and race) at the population level. Studies show that social relationships have short- and long-term effects on health, for better and for worse, and that these effects emerge in childhood and cascade throughout life to foster cumulative advantage or disadvantage in health. This article describes key research themes in the study of social relationships and health, and it highlights policy implications suggested by this research.

Trends in the educational gradient of U.S. Adult mortality from 1986 through 2006 by race, gender, and age group

The educational gradient of U.S. adult mortality became steeper between 1960 and the mid-1980s, but whether it continued to steepen is less clear given a dearth of attention to these trends since then. This study provides new evidence on trends in the education-mortality gradient from 1986 through 2006 by race, gender, and age among non-Hispanic Whites and Blacks using data from the 2010 release of the National Health Interview Survey Linked Mortality File. Results show that for White and Black men, the gradient steepened among older ages because declines in mortality risk across education levels were greater among the higher educated. The gradient steepened among White women, and to a lesser extent among Black women, because mortality risk decreased among the college-educated but increased among women with less than a high school diploma. Greater returns to higher education and compositional changes within educational strata likely contributed to the trends.

The Significance of Education for Mortality Compression in the United States

Recent studies of old-age mortality trends assess whether longevity improvements over time are linked to increasing compression of mortality at advanced ages. The historical backdrop of these studies is the long-term improvement in a population’s socioeconomic resources that fueled longevity gains. We extend this line of inquiry by examining whether socioeconomic differences in longevity within a population are accompanied by old-age mortality compression. Specifically, we document educational differences in longevity and mortality compression for older men and women in the United States. Drawing on the fundamental cause of disease framework, we hypothesize that both longevity and compression increase with higher levels of education and that women with the highest levels of education will exhibit the greatest degree of longevity and compression. Results based on the Health and Retirement Study and the National Health Interview Survey Linked Mortality File confirm a strong educational gradient in both longevity and mortality compression. We also find that mortality is more compressed within educational groups among women than men. The results suggest that educational attainment in the United States maximizes life chances by delaying the biological aging process.

Cumulative childhood adversity, educational attainment, and active life expectancy among U.S. adults.

Studies of the early-life origins of adult physical functioning and mortality have found that childhood health and socioeconomic context are important predictors, often irrespective of adult experiences. However, these studies have generally assessed functioning and mortality as distinct processes and used cross-sectional prevalence estimates that neglect the interplay of disability incidence, recovery, and mortality. Here, we examine whether early-life disadvantages both shorten lives and increase the number and fraction of years lived with functional impairment. We also examine the degree to which educational attainment mediates and moderates the health consequences of early-life disadvantages. Using the 1998–2008 Health and Retirement Study, we examine these questions for non-Hispanic whites and blacks aged 50–100 years using multistate life tables. Within levels of educational attainment, adults from disadvantaged childhoods lived fewer total and active years, and spent a greater portion of life impaired compared with adults from advantaged childhoods. Higher levels of education did not ameliorate the health consequences of disadvantaged childhoods. However, because education had a larger impact on health than did childhood socioeconomic context, adults from disadvantaged childhoods who achieved high education levels often had total and active life expectancies that were similar to or better than those of adults from advantaged childhoods who achieved low education levels.

Why Is the Educational Gradient of Mortality Steeper for Men

OBJECTIVES It is often documented that the educational gradient of mortality is steeper for men than for women; yet, the explanation remains a matter of debate. We examine gender differences in the gradients within the context of marriage to determine whether overall differences reflect gender differences in health behaviors or a greater influence of mens education on spousal health. METHODS We used data from the 1986 through 1996 National Health Interview Survey Linked Mortality Files for non-Hispanic White adults aged 55-84 years at the time of survey. We estimated Cox proportional hazards models to examine the gradients (N = 180,208). RESULTS The educational gradient of mortality is marginally steeper for men than for women when aggregating across marital statuses; yet, this reflects a steeper gradient among unmarried men, with low-educated never married men exhibiting high levels of mortality. The gradient among unmarried men is steeper than unmarried women for causes that share smoking as a major risk factor, supporting a behavioral explanation for differences in the gradient. No gender difference in the gradient is observed for married adults. DISCUSSION Low education and unmarried status exert a synergistic effect on mens mortality. Unmarried, low-educated men may lack social supports that encourage positive health behaviors.

Trends in Mortality Risk by Education Level and Cause of Death Among US White Women From 1986 to 2006

OBJECTIVES To elucidate why the inverse association between education level and mortality risk (the gradient) has increased markedly among White women since the mid-1980s, we identified causes of death for which the gradient increased. METHODS We used data from the 1986 to 2006 National Health Interview Survey Linked Mortality File on non-Hispanic White women aged 45 to 84 years (n = 230 692). We examined trends in the gradient by cause of death across 4 time periods and 4 education levels using age-standardized death rates. RESULTS During 1986 to 2002, the growing gradient for all-cause mortality reflected increasing mortality among low-educated women and declining mortality among college-educated women; during 2003 to 2006 it mainly reflected declining mortality among college-educated women. The gradient increased for heart disease, lung cancer, chronic lower respiratory disease, cerebrovascular disease, diabetes, and Alzheimers disease. Lung cancer and chronic lower respiratory disease explained 47% of the overall increase. CONCLUSIONS Mortality disparities among White women widened across 1986 to 2006 partially because of causes of death for which smoking is a major risk factor. A comprehensive policy framework should address the social conditions that influence smoking among disadvantaged women.

Educational attainment and adult health: under what conditions is the association causal?

The positive association between an individuals educational attainment and their health and longevity is one of the strongest, pervasive, and most robust in the social sciences (Hummer and Lariscy, 2011; Mirowsky and Ross, 2003). For example, in the United States in the year 2000 life expectancy at age 25 among adults with at least one year of college was an impressive five years longer for women, and eight years longer for men, than their less-educated peers (Meara et al., 2008). In addition to life expectancy, education is associated with numerous mental and physical health outcomes, such as depression (Miech and Shanahan, 2000), dementia (Ngandu et al., 2007), disability (Freedman et al., 2008), cancer incidence (Mouw et al., 2008), and heart disease and diabetes (Cutler and Lleras-Muney, 2008). The association between education and these outcomes exists across vastly different sociopolitical and economic contexts, spanning countries as diverse as the United States, Sweden, South Korea, Taiwan, and Ghana (Baker et al., 2011; Peters et al., 2010; Zimmer et al., 1998). Moreover, the association has persisted over time, even though some of the mechanisms that purportedly explain why education influences health and longevity have changed. For all of these reasons, educational attainment is often referred to as a “fundamental cause” of disparities in health and longevity (Link and Phelan, 1995; Masters et al., 2012; Montez and Hayward, 2014). Interestingly, educational attainment has become an increasingly stronger predictor of adult health and longevity in recent decades, particularly within the United States (e.g., Goesling, 2007; Masters et al., 2012; Miech et al., 2011; Montez et al., 2011) and several European countries (e.g., Kunst et al., 2005; Strand et al., 2010). For instance, during the 1990s the gap in life expectancy at age 25 between U.S. adults with at least one year of college and their less-educated peers widened by 1.3e1.9 years depending on race and gender, while the gap between men and women and between blacks and whites narrowed (Meara et al., 2008). The widening inequalities in health and longevity across education levels have raised concern among scholars, the media, and funding agencies. Why has education become an increasingly important predictor of these outcomes? Are the widening inequalities “real” and “causal”? In other words, has higher education become more critical for accessing health-enhancing resources, such as fulfilling jobs, economic security, social ties, and safe neighborhoods? Or do the widening inequalities reflect compositional changes within the education distribution? In other words, has the least-educated segment of the population become more negatively selected on health-related characteristics? Or are both of these processes occurring (see discussion in Montez and Zajacova,

Early Life Conditions and Later Life Mortality

Although the idea that early life conditions shape mortality is not new, there has been a resurgence of studies on the topic in the last two decades. In our review of this work, we weigh the evidence for the major causal mechanisms, i.e., biological imprint and pathway processes, thought to underlie the associations between childhood conditions and adult mortality. We also examine the evidence on how key social and physical exposures in early life are associated with adult mortality through these mechanisms. Drawing on the Health and Retirement Study, we then offer additional evidence on these associations and mechanisms. While our results reinforce the importance of early life conditions for understanding adult mortality, they, as well as previous literature, also highlight key conceptual and analytical challenges. Associations and mechanisms are sensitive, for example, to particular social and physical exposures, the period of manifestation, and the type of health problem. Nonetheless, the body of evidence strongly points to childhood conditions having an enduring influence on adult mortality through both imprint and pathway processes. We argue that variability in these associations and mechanisms should be expected both historically and within populations, as variability reflects sociohistorical differences in life-course exposures.

Explaining the Widening Education Gap in Mortality among U.S. White Women

Over the past half century the gap in mortality across education levels has grown in the United States, and since the mid-1980s, the growth has been especially pronounced among white women. The reasons for the growth among white women are unclear. We investigated three explanations—social-psychological factors, economic circumstances, and health behaviors—for the widening education gap in mortality from 1997 to 2006 among white women aged 45 to 84 years using data from the National Health Interview Survey Linked Mortality File (N = 46,744; 4,053 deaths). Little support was found for social-psychological factors, but economic circumstances and health behaviors jointly explained the growing education gap in mortality to statistical nonsignificance. Employment and smoking were the most important individual components. Increasing high school graduation rates, reducing smoking prevalence, and designing work-family policies that help women find and maintain desirable employment may reduce mortality inequalities among women.

Trends in the Educational Gradient of Mortality Among US Adults Aged 45 to 84 Years: Bringing Regional Context Into the Explanation

OBJECTIVES We investigated trends in the educational gradient of US adult mortality, which has increased at the national level since the mid-1980s, within US regions. METHODS We used data from the 1986-2006 National Health Interview Survey Linked Mortality File on non-Hispanic White and Black adults aged 45 to 84 years (n = 498,517). We examined trends in the gradient within 4 US regions by race-gender subgroup by using age-standardized death rates. RESULTS Trends in the gradient exhibited a few subtle regional differences. Among women, the gradient was often narrowest in the Northeast. The regions distinction grew over time mainly because low-educated women in the Northeast did not experience a significant increase in mortality like their counterparts in other regions (particularly for White women). Among White men, the gradient narrowed to a small degree in the West. CONCLUSIONS The subtle regional differences indicate that geographic context can accentuate or suppress trends in the gradient. Studies of smaller areas may provide insights into the specific contextual characteristics (e.g., state tax policies) that have shaped the trends, and thus help explain and reverse the widening mortality disparities among US adults.