Marianne M. Hillemeier

INcome inequality, the psychosocial environment, and health: comparisons of wealthy nations.

BACKGROUND The theory that income inequality and characteristics of the psychosocial environment (indexed by such things as social capital and sense of control over lifes circumstances) are key determinants of health and could account for health differences between countries has become influential in health inequalities research and for population health policy. METHODS We examined cross-sectional associations between income inequality and low birthweight, life expectancy, self-rated health, and age-specific and cause-specific mortality among countries providing data in wave III (around 1989-92) of the Luxembourg Income Study. We also used data from the 1990-91 wave of the World Values Survey (WVS). We obtained life expectancy, mortality, and low birthweight data from the WHO Statistical Information System. FINDINGS Among the countries studied, higher income inequality was strongly associated with greater infant mortality (r=0.69, p=0.004 for women; r=0.74, p=0.002 for men). Associations between income inequality and mortality declined with age at death, and then reversed among those aged 65 years and older. Income inequality was inconsistently associated with specific causes of death and was not associated with coronary heart disease (CHD), breast or prostate cancer, cirrhosis, or diabetes mortality. Countries that had greater trade union membership and political representation by women had better child mortality profiles. Differences between countries in levels of social capital showed generally weak and somewhat inconsistent associations with cause-specific and age-specific mortality. INTERPRETATION Income inequality and characteristics of the psychosocial environment like trust, control, and organisational membership do not seem to be key factors in understanding health differences between these wealthy countries. The associations that do exist are largely limited to child health outcomes and cirrhosis. Explanations for between-country differences in health will require an appreciation of the complex interactions of history, culture, politics, economics, and the status of women and ethnic minorities.

Excess Mortality Among Blacks and Whites in the United States

BACKGROUND Although the general relations between race, socioeconomic status, and mortality in the United States are well known, specific patterns of excess mortality are not well understood. METHODS Using standard demographic techniques, we analyzed death certificates and census data and made sex-specific population-level estimates of the 1990 death rates for people 15 to 64 years of age. We studied mortality among blacks in selected areas of New York City, Detroit, Los Angeles, and Alabama (in one area of persistent poverty and one higher-income area each) and among whites in areas of New York City, metropolitan Detroit, Kentucky, and Alabama (one area of poverty and one higher-income area each). Sixteen areas were studied in all. RESULTS When they were compared with the nationwide age-standardized annual death rate for whites, the death rates for both sexes in each of the poverty areas were excessive, especially among blacks (standardized mortality ratios for men and women in Harlem, 4.11 and 3.38; in Watts, 2.92 and 2.60; in central Detroit, 2.79 and 2.58; and in the Black Belt area of Alabama, 1.81 and 1.89). Boys in Harlem who reached the age of 15 had a 37 percent chance of surviving to the age of 65; for girls, the likelihood was 65 percent. Of the higher-income black areas studied, Queens--Bronx had the income level most similar to that of whites and the lowest standardized mortality ratio (men, 1.18; women, 1.08). Of the areas where poor whites were studied, Detroit had the highest standardized mortality ratios (men, 2.01; women, 1.90). On the Lower East Side of Manhattan, in Appalachia, and in Northeast Alabama, the ratios for whites were below the national average for blacks (men, 1.90; women, 1.95). CONCLUSIONS Although differences in mortality rates before the age of 65 between advantaged and disadvantaged groups in the United States are sometimes vast, there are important differences among impoverished communities in patterns of excess mortality.

Does Young Maternal Age Adversely Affect Child Development? Evidence from Cousin Comparisons in the United States

The following issues are addressed: the need to distinguish conceptually between current maternal characteristics and family background the difficulties in using matched comparison groups to control for family background and the inability of controls for socioeconomic status to capture family background characteristics that my confound the relationship between maternal age and child development. Specifically the objective is to examine the degree to which family background characteristics preceding 1st pregnancy account for development differences between children of teen and nonteen mothers. The sample of women aged 14-21 in 1979 who are sisters with their 1st births at different ages and have 1 1st cousin was drawn from the National Longitudinal Survey of Youth (NLSY) 1979-88. The main sample was 1223 children in the 1986 and/or 1988 NLSY and the 1st cousin sample consisted of 637 mothers. Least square regressions were used to estimate cross-sectional effects on developmental scores of children of teen mothers. All children in the 1st cousins sample are categorized by whether 1) all sisters had their 1st births as teenagers 2) at least 1 sister had a 1st birth after age 19 but the mother was a teen 3) the reverse of 2 and 4) all sisters had 1st births after age 19. The within family effect compares groups 2 and 3. Analyses are conducted on the full sample of 1st cousins a subsample of firstborn children a subsample of non-Hispanic black women and a subsample of non-Hispanic white women. Conclusions may be drawn only about the effects for women from more disadvantaged families in which women have teen 1st births. The results were that young maternal age is associated with impaired child development. But in the 1st cousins comparisons the findings were that there was not an adverse effect of maternal age on measures of child development. The results are confounded by family background. The lower performance of children of teen mothers may reflect their mothers prechildbearing characteristics rather than their youth. The comparisons among cousins suggests that socioeconomic costs to women from disadvantaged backgrounds of early childbearing may be much lower than suggested in other findings. Further systematic study is needed to explain the cousins results particularly of differences in parenting skills or parenting as a shared activity.

Economic Inequality, Working-Class Power, Social Capital, and Cause-Specific Mortality in Wealthy Countries

This study tests two propositions from Navarros critique of the social capital literature: that social capitals importance has been exaggerated and that class-related political factors, absent from social epidemiology and public health, might be key determinants of population health. The authors estimate cross-sectional associations between economic inequality, working-class power, and social capital and life expectancy, self-rated health, low birth weight, and age- and cause-specific mortality in 16 wealthy countries. Of all the health outcomes, the five variables related to birth and infant survival and nonintentional injuries had the most consistent association with economic inequality and working-class power (in particular with strength of the welfare state) and, less so, with social capital indicators. Rates of low birth weight and infant deaths from all causes were lower in countries with more “left” (e.g., socialist, social democratic, labor) votes, more left members of parliament, more years of social democratic government, more women in government, and various indicators of strength of the welfare state, as well as low economic inequality, as measured in a variety of ways. Similar associations were observed for injury mortality, underscoring the crucial role of unions and labor parties in promoting workplace safety. Overall, social capital shows weaker associations with population health indicators than do economic inequality and working-class power. The popularity of social capital and exclusion of class-related political and welfare state indicators does not seem to be justified on empirical grounds.

Coordination between Child Welfare Agencies and Mental Health Service Providers, Children's Service Use, and Outcomes.

OBJECTIVE Interorganizational relationships (IORs) between child welfare agencies and mental health service providers may facilitate mental health treatment access for vulnerable children. This study investigates whether IORs are associated with greater use of mental health services and improvement in mental health status for children served by the child welfare system. METHODS This was a longitudinal analysis of data from a 36-month period in the National Survey of Child and Adolescent Well-Being (NSCAW). The sample consisted of 1,613 children within 75 child welfare agencies who were 2 years or older and had mental health problems at baseline. IOR intensity was measured as the number of coordination approaches between each child welfare agency and mental health service providers. Separate weighted multilevel logistic regression models tested associations between IORs and service use and outcomes, respectively. RESULTS Agency-level factors accounted for 9% of the variance in the probability of service use and 12% of mental health improvement. Greater intensity of IORs was associated with higher likelihood of both service use and mental health improvement. CONCLUSIONS Having greater numbers of ties with mental health providers may help child welfare agencies improve childrens mental health service access and outcomes. PRACTICE IMPLICATIONS Policymakers should develop policies and initiatives to encourage a combination of different types of organizational ties between child welfare and mental health systems. For instance, information sharing at the agency level in addition to coordination at the case level may improve the coordination necessary to serve these vulnerable children.

Racial and Ethnic Disparities in ADHD Diagnosis From Kindergarten to Eighth Grade

OBJECTIVE: Whether and to what extent racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis occur across early and middle childhood is currently unknown. We examined the over-time dynamics of race/ethnic disparities in diagnosis from kindergarten to eighth grade and disparities in treatment in fifth and eighth grade. METHODS: Analyses of the nationally representative Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999 (N = 17 100) using discrete-time hazard modeling. RESULTS: Minority children were less likely than white children to receive an ADHD diagnosis. With time-invariant and -varying confounding factors statistically controlled the odds of ADHD diagnosis for African Americans, Hispanics, and children of other races/ethnicities were 69% (95% confidence interval [CI]: 60%–76%), 50% (95% CI: 34%–62%), and 46% (95% CI: 26%–61%) lower, respectively, than for whites. Factors increasing children’s risk of an ADHD diagnosis included being a boy, being raised by an older mother, being raised in an English-speaking household, and engaging in externalizing problem behaviors. Factors decreasing children’s risk of an ADHD diagnosis included engaging in learning-related behaviors (eg, being attentive), displaying greater academic achievement, and not having health insurance. Among children diagnosed with ADHD, racial/ethnic minorities were less likely than whites to be taking prescription medication for the disorder. CONCLUSIONS: Racial/ethnic disparities in ADHD diagnosis occur by kindergarten and continue until at least the end of eighth grade. Measured confounding factors do not explain racial/ethnic disparities in ADHD diagnosis and treatment. Culturally sensitive monitoring should be intensified to ensure that all children are appropriately screened, diagnosed, and treated for ADHD.

PRECONCEPTION PREDICTORS OF WEIGHT GAIN DURING PREGNANCY Prospective Findings from the Central Pennsylvania Women's Health Study

OBJECTIVES We examined preconception (prepregnancy) predictors of pregnancy weight gain and weight gain that exceeds the 2009 Institute of Medicine (IOM) recommendations based on pre-pregnancy body mass index (BMI), in a prospective study. METHODS Data are from a population-based cohort study of 1,420 women who were interviewed at baseline and 2 years later. The analytic sample includes 103 women who were not pregnant at baseline and gave birth to full-term singletons during the follow-up period. Preconception maternal weight category as well as health behaviors, psychosocial stress, parity, and age were examined as predictors of pregnancy weight gain and of weight gain in excess of the IOM recommendations using multiple linear and logistic regression analysis. RESULTS Pregnancy weight gain averaged 33.01 pounds, with 51% of women gaining weight in excess of the 2009 IOM recommendations for their preconception weight category. Preconception overweight (BMI = 25-29.9) increased the odds of excessive pregnancy weight gain nearly threefold, whereas preconception physical activity levels meeting activity guidelines reduced the odds of excessive weight gain but was marginally statistically significant. CONCLUSION Although future research examining the role of physical activity in relation to pregnancy weight gain is needed, preconception overweight and physical activity levels are prime targets for interventions to avoid excessive pregnancy weight gain.

Minorities Are Disproportionately Underrepresented in Special Education: Longitudinal Evidence Across Five Disability Conditions

We investigated whether minority children attending U.S. elementary and middle schools are disproportionately represented in special education. We did so using hazard modeling of multiyear longitudinal data and extensive covariate adjustment for potential child-, family-, and state-level confounds. Minority children were consistently less likely than otherwise similar White, English-speaking children to be identified as disabled and so to receive special education services. From kindergarten entry to the end of middle school, racial- and ethnic-minority children were less likely to be identified as having (a) learning disabilities, (b) speech or language impairments, (c) intellectual disabilities, (d) health impairments, or (e) emotional disturbances. Language-minority children were less likely to be identified as having (a) learning disabilities or (b) speech or language impairments.

Racial differences in parental reports of attention-deficit/hyperactivity disorder behaviors.

Objective: Accurate assessment of racial disparities in attention-deficit/hyperactivity disorder (ADHD) depends on measurement that is equally valid for all groups. This study examines differences among African American and white children in ADHD measurement with a widely used parental report instrument, the Diagnostic Interview Schedule for Children (DISC). Methods: Data come from 1070 children in the Fast Track Project, a longitudinal study of predominantly low-income children at risk of emotional and/or behavioral problems. Item Response Theory (IRT) methodology is used to determine whether ADHD screening items provide comparable information for African American and white children or whether differential item function (DIF) exists. IRT scores and race/ethnicity are entered in logistic regression models predicting use of ADHD medication. Results: Seven of 39 DISC items performed differently among African Americans and whites. In most cases, parents of white children were more likely to endorse these items than were parents of African American children at comparable underlying levels of childrens hyperactivity. When items exhibiting differential functioning were deleted, race disparities predicting underlying need as indicated by ADHD medication use decreased and were no longer statistically significant. Conclusions: Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of white children, and screening instruments relying on parent report may yield different results for African American and white children with similar underlying treatment needs. Gathering information from additional sources including teachers and school counselors can provide a more complete picture of the behavioral functioning and therapeutic needs of children in all race/ethnic groups.

Science Achievement Gaps Begin Very Early, Persist, and Are Largely Explained by Modifiable Factors

We examined the age of onset, over-time dynamics, and mechanisms underlying science achievement gaps in U.S. elementary and middle schools. To do so, we estimated multilevel growth models that included as predictors children’s own general knowledge, reading and mathematics achievement, behavioral self-regulation, sociodemographics, other child- and family-level characteristics (e.g., parenting quality), and school-level characteristics (e.g., racial, ethnic, and economic composition; school academic climate). Analyses of a longitudinal sample of 7,757 children indicated large gaps in general knowledge already evident at kindergarten entry. Kindergarten general knowledge was the strongest predictor of first-grade general knowledge, which in turn was the strongest predictor of children’s science achievement from third to eighth grade. Large science achievement gaps were evident when science achievement measures first became available in third grade. These gaps persisted until at least the end of eighth grade. Most or all of the observed science achievement gaps were explained by the study’s many predictors. Efforts to address science achievement gaps in the United States likely require intensified early intervention efforts, particularly those delivered before the primary grades. If unaddressed, science achievement gaps emerge by kindergarten and continue until at least the end of eighth grade.