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American Journal of Epidemiology Advance Access originally published online on August 23, 2007
American Journal of Epidemiology 2007 166(9):1059-1067; doi:10.1093/aje/kwm185
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American Journal of Epidemiology Published by the Johns Hopkins Bloomberg School of Public Health 2007.

ORIGINAL CONTRIBUTIONS

Childhood Social and Economic Well-Being and Health in Older Age

Sandra Moody-Ayers1,2, Karla Lindquist2, Saunak Sen1,3 and Kenneth E. Covinsky1,2

1 San Francisco VA Medical Center, San Francisco, CA
2 Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA
3 Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, CA

Correspondence to Dr. Sandra Moody-Ayers or Dr. Kenneth Covinsky, San Francisco VA Medical Center (181G), 4150 Clement Street, San Francisco, CA 94121 (e-mail: sandra.moody{at}va.gov or Ken.Covinsky{at}ucsf.edu).

Received for publication April 14, 2006. Accepted for publication May 17, 2007.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Childhood socioeconomic status (SES) acts over a lifetime to influence adult health outcomes. Whether the impact of childhood SES differs by age or race/ethnicity is unclear. The authors studied 20,566 community-living US adults aged ≥50 years. Parental education was the main predictor. Outcomes evaluated (1998–2002) included self-reported health and functional limitation. The influence of childhood SES on later-life health was also examined in groups stratified by age and race/ethnicity, with adjustment for demographic factors and current SES. Participants' mean age was 67 years; 57% were women. By race/ethnicity, 76% were White, 14% were Black, and 8% were Latino. The relation between low parental education and fair/poor self-rated health declined with advancing age (age 50–64 years: adjusted odds ratio (AOR) = 1.42, 95% confidence interval (CI): 1.24, 1.63; age ≥80 years: AOR = 1.14, 95% CI: 0.96, 1.36). The relation between low parental education and fair/poor self-rated health differed across racial/ethnic groups and was significant in White (AOR = 1.33, 95% CI: 1.21, 1.47) and Black (AOR = 1.37, 95% CI: 1.14, 1.64) participants but not Latinos. These findings suggest that childhood SES affects health status through midlife but the effects may abate in late life; its effects also may be weaker in Latinos than in Whites or Blacks.

activities of daily living; frail elderly; health status; mobility limitation; social class

Abbreviations: ADL, activities of daily living; CI, confidence interval; OR, odds ratio; SES, socioeconomic status


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Studies show that racial/ethnic disparities in health status exist across the life cycle, persisting throughout most of old age (1). Older minority adults, particularly African Americans, experience a higher rate and earlier onset of functional disability and chronic diseases than White adults, resulting in longer exposure to the negative impact of disability and disease (2–10). It is well known that poverty negatively affects health throughout life and is implicated in racial/ethnic disparities in health outcomes (1, 11). Despite documentation, the mechanisms of these disparities are not clear (12).

A growing body of literature shows an association between childhood socioeconomic status (SES) and health outcomes in adulthood (13–38). This approach, termed the study of "life-course SES," assesses SES at multiple points throughout life to evaluate the documented social inequalities in health that exists across social classes (13, 17, 20, 22, 24, 26, 35, 38). Investigators have found that low SES in infancy/childhood is associated with higher morbidity and mortality in adulthood (14, 18, 19, 27–30, 35, 38). Hayward and Gorman (32), for example, found that mortality in men aged 45–85 years was associated with several factors, including childhood SES and living arrangements and mother's work status. Achieved SES and lifestyle in adulthood, however, mediated these effects. Luo and Waite (36) noted similar findings in older adults. James et al. (38) showed that low SES in childhood and adulthood was associated with greater odds of hypertension in African-American men aged 25–50 years.

While these studies strongly suggest that early-life SES affects health well into adulthood, few have examined whether the effects decrease with advancing age. Further, while the important interactions between SES and race/ethnicity are well known, few studies have examined the association of these interactions with childhood SES. Therefore, our goal was to examine the relation between childhood SES and health status in different age and racial/ethnic groups in an ethnically diverse, population-based, nationally representative sample of community-living older adults.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Study population
Participants (n = 20,566) were drawn from the 1998 wave of the Health and Retirement Study, an ongoing, population-based, nationally representative sample of community-dwelling US adults aged ≥50 years. The study's objective was to examine the relations between health, income, and wealth over time (39). In 1998, two previously existing study cohorts—wave 4 of the Health and Retirement Study (persons aged 57–67 years in 1998) and wave 3 of the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD; persons aged ≥75 years in 1998)—were merged with two newly created cohorts—War Babies (aged 50–56 years in 1998) and Children of the Depression (aged 68–74 years in 1998)—to incorporate the missing age groups. Interviews were conducted by telephone or, when participants had health limitations or no telephone, face-to-face (40), and did not differ by race/ethnicity. Interviews were conducted in English or Spanish, depending upon the preference of the participant. The overall survey response rate was nearly 90 percent and did not vary significantly by age or race/ethnicity. The study included oversampling of Blacks, Latinos, and Florida residents.

Measures
Childhood SES.
We used three measures of childhood SES: self-reported perception of childhood family financial status (i.e., "well-off," "about average," or "poor"), experience of family hardship in childhood (having or not having moved because of financial difficulties), and parental education (<8, 8–11, or ≥12 years of schooling) (39).

Covariates.
Additional variables included age, sex, self-identified race/ethnicity (White, Black, Latino, or other), and current SES as measured by the participant's highest year of schooling, total household income, and total net worth (including individual retirement accounts, stocks or mutual funds, checking and savings accounts, and real estate). Household income and net worth were log-transformed to normalize the distributions.

Health status measures.
Our primary measures of health status were self-rated health, which is strongly predictive of morbidity and mortality and incorporates participants' perceptions of their physical and psychological health (41–45), and functional limitation, a key health outcome in aging adults (12, 46), defined as difficulty with mobility or activities of daily living (ADL). ADL difficulty is a commonly used index of disability in older patients; it is more sensitive than ADL dependence and clearly precedes ADL dependence, which is strongly associated with nursing home placement (46). This combination of health measures gives a global picture of health status.

We assessed health status by asking participants to rate their health as excellent, very good, good, fair, or poor. Difficulty with ADL and mobility were defined as difficulty in eating, dressing, bathing, transferring, and toileting and in walking several blocks or climbing one flight of stairs without resting.

The Institute for Social Research at the University of Michigan (Ann Arbor, Michigan) managed data collection and obtained informed consent and institutional review board approval for the Heath and Retirement Study.

Statistical analyses
We used bivariate logistic regression to examine the relations between self-rated health and functional limitation and each measure of childhood SES (family financial status, family hardship, and parental education).

We then examined the association between childhood SES and health status in adulthood for consistency across age and race/ethnicity categories, and we conducted a series of stratified analyses, first by age (50–64, 65–79, and ≥80 years) and then by race/ethnicity (White, Black, and Latino). Within each stratum, we examined the bivariate associations for each measure and then examined these associations using logistic regression to adjust for current SES and demographic characteristics. When zero-inflated Poisson regression was performed, our results were unchanged. We created interaction terms to determine whether the relation between each childhood SES measure and each health status measure differed across age or racial/ethnic strata. Because rates of missing data were very low, we did not use imputation procedures.

We examined whether childhood SES measures were associated with a decline in self-rated health or new onset of functional limitation over 4 years of follow-up (1998–2002). These analyses were deemed exploratory, because most theoretical models view the effect of childhood SES on later health outcomes to be progressive over a lifetime. Therefore, we would expect childhood SES to affect outcomes over a 4-year period only if the effect were very large. While our primary analyses were cross-sectional, since data on measures of childhood SES and adult health status were collected simultaneously, the childhood SES measures reflected the experience of the participants many decades previously. Therefore, modest but important relations between childhood SES and adult health status were more likely to be observed.

Outcome was determined by a report of fair/poor self-rated health or functional limitation in 2002 but not in 1998. Functional limitation was defined as nursing home placement or death, before which functional decline often occurs (46), and difficulty with ADL/mobility.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Baseline characteristics of the participants are presented by race/ethnicity and age in table 1. The mean age of the participants was 67 years. Most were female (57 percent) and White (76 percent). Black and Latino participants were slightly younger than White participants. Assessment of current SES revealed a mean of 12 years of education, a median income of $30,000, and a median net worth of $117,000 and striking differences in these variables by race/ethnicity. White participants had 2 more years of education, on average, than Black participants and 5 more years than Latino participants. White participants also had twice as much household income and a four- to fivefold greater net worth than either Black or Latino participants. For childhood SES, nearly 70 percent of participants indicated parental education of 11 years or less, and one third rated their family financial status as poor. Approximately one third of the participants rated their health as fair or poor, and 35 percent reported functional limitation (figure 1), the prevalence of which ranged from 25 percent (age 50–64 years) to 66 percent (age ≥80 years). Although most participants (66 percent) reported no functional limitation, 34 percent reported difficulty in at least one ADL/mobility function, ranging from 19.2 percent (one limitation) to 1.6 percent (six limitations).


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  		TABLE 1. Characteristics of 20,566 community-living US adults aged ≥50 years participating in the Health and Retirement Study, 1998

 

Figure 1
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  		FIGURE 1. Distribution of the number of difficulties in activities of daily living (ADL) and/or mobility reported by study participants, Health and Retirement Study, 1998.

 
Fair/poor self-rated health and functional limitations were strongly associated with parental education, poor family financial status, and family hardship (table 2). While adjustment for current SES and demographic characteristics attenuated these relations, the association remained and was strongest for low parental education. Participants whose parents had less than an 8th-grade education, as compared with a 12th-grade education or more, were more likely to have fair/poor self-rated health (odds ratio (OR) = 1.61, 95 percent confidence interval (CI): 1.45, 1.79) and more likely to have functional limitations (OR = 1.30, 95 percent CI: 1.17, 1.44).


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  		TABLE 2. Odds ratios for fair/poor self-rated health and functional limitation in adulthood according to childhood socioeconomic status among community-living US adults aged ≥50 years (n = 20,566), Health and Retirement Study, 1998*

 
We examined age and race/ethnicity for the relation between childhood SES and fair/poor self-rated health and functional limitation (table 3). Both fair/poor self-rated health and functional limitation increased with age, and the prevalence of each was highest in Black and Latino participants and lowest in White participants. We tested the interactions for these relations and found that the associations were strongest for the interaction between parental education and health status in adulthood. In unadjusted analyses, younger participants (age 50–64 years) were more likely to rate their health as fair/poor than older participants (age ≥80 years) when their parents had less than 8 years of education. After adjustment for race/ethnicity, sex, and current SES, the association remained significantly stronger in younger participants but not in the oldest (age 50–64 years: OR = 1.42, 95 percent CI: 1.24, 1.63; age ≥80 years: OR = 1.14, 95 percent CI: 0.96, 1.36). When the relation between parental education and functional limitation was examined, the results were similar to those obtained in unadjusted analyses; after adjustment, it did not differ across age categories. Findings for poor family financial status were consistent with the results observed above for parental education across age and racial/ethnic groups.


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  		TABLE 3. Odds ratios for fair/poor self-rated health and functional limitation in adulthood among persons with a low childhood socioeconomic status (poor family financial status, family hardship, and low parental education), by participant age and race/ethnicity, Health and Retirement Study, 1998

 
Additionally, we examined the relation between parental education, poor family financial status, and family hardship and health status in adulthood between 1998 and 2002. None of the longitudinal associations were statistically significant in adjusted analyses. For example, the adjusted odds ratio for the association between low parental education and decline in self-rated health among participants aged 50–64 years was 1.01 (95 percent CI: 0.85, 1.21); among those aged 65–79 years, it was 1.12 (95 percent CI: 0.99, 1.28); and among those aged ≥80 years, it was 1.14 (95 percent CI: 0.95, 1.36), comparing participants in the lowest and highest categories of parental education. The relation between low parental education and functional decline was 0.93 (95 percent CI: 0.78, 1.10) in participants aged 50–64 years, 1.13 (95 percent CI: 1.00, 1.28) in those aged 65–79 years, and 1.09 (95 percent CI: 0.91, 1.31) in those aged ≥80 years.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
It is well established that SES is a powerful explanatory factor for health inequalities. In this multiethnic, population-based sample of older adults, we found that poor childhood SES was significantly associated with poorer health status in adulthood in cross-sectional analysis. These associations were attenuated, but not fully explained, when demographic characteristics and current SES (education, income, and net worth) were considered. Thus, our findings confirm those of other studies suggesting that childhood poverty exerts long-term effects on health status and that these effects persist even if SES improves later in life (34, 36).

Our findings suggest that demographic characteristics are also important. The relation between childhood SES and health status in adulthood differed according to age and race/ethnicity. We found, for example, that parental education and poor family financial status are associated with lower self-rated health well into later life but have diminished effects in advanced old age. As functional limitation and chronic disease increase, it is possible that the effect of age-associated diseases dominates earlier socioeconomic factors.

Survivorship bias may also explain why persons with less-educated parents who survive into old age may be either resistant to the effects of low parental education or particularly resilient. Addressing the possibility of survivorship bias will require longitudinal studies of sufficient follow-up. Although we did not examine the relation between childhood SES and mortality, we examined self-rated health, which is strongly predictive of morbidity and mortality, incorporates participants' perceptions of their physical and psychological health (41–45), and may be an indicator of global health (44).

The fact that the childhood SES measure parental education had the greatest effect on health in our study may be an indicator of the potential societal benefits of better-educated parents, including access to quality education, which would probably affect employment and produce higher economic achievement in adulthood and perhaps better health. This phenomenon is probably one of the most important factors explaining socioeconomic-based racial/ethnic differences in health outcomes among older adults and may be of particular interest for studies of these disparities. For instance, we found that low parental education was associated with lower self-rated health for White and Black participants but not for Latino participants. However, parental education was most strongly associated with functional limitations in later life for Black participants, had a smaller but statistically significant association for White participants, and had no association for Latino participants. This finding differs from Luo and Waite's (36) conclusion that the effects of childhood SES were remarkably similar for Whites and non-Whites.

The fact that Latino participants seemed to be less affected by low parental education may be related to the "Hispanic [or Latino] paradox," in which Mexican Americans (the predominant Latino group in this sample) of low SES have been shown to have better health status than Whites and other ethnic groups of the same or higher SES when they maintain strong social ties and community connections (47–49). Other possible explanations are that current SES may override the effects of childhood SES for Latinos or that our study lacked sufficient power to detect the associations.

We examined markers of childhood SES and adult net worth to obtain a more robust view of long-term effects of SES on health. Studies have shown that sustained financial hardship over time, even starting in early adulthood, is associated with increased risk of chronic disease and mortality in early-to-middle adulthood (17, 18). We demonstrated similar findings using measures of global adult health in middle-aged and elderly participants and extensive measures of adulthood SES (e.g., income measures from more than 12 potential sources and net worth from eight major categories, inheritances, and gifts). Our finding that adjustment for net worth weakens the association between childhood SES and adult health suggests that achieved net worth attenuates the effect of childhood SES. Nevertheless, the differences across racial/ethnic groups were substantial and therefore likely to influence health status significantly. Further study is needed on how different trajectories in SES from childhood to adulthood relate to health outcomes in different racial/ethnic groups.

This study had a number of strengths. Our study sample was ethnically diverse and nationally representative. In addition, the data source we used is unique in that it has comprehensive measures of current SES. Thus, in this study, we were better able than investigators in previous studies to separate the effects of adulthood SES from those of childhood SES. However, several measures of current SES may be strongly related to childhood SES. In particular, net worth partially represents assets transferred from parents to children through inheritance (21). Thus, our analyses adjusting for current SES probably represented overadjustment; therefore, our estimates of the effect of current SES are likely to have been conservative.

Several limitations should be considered in interpreting these findings. First, in our primary analyses, measures of childhood SES were obtained simultaneously with measures of adult health status; therefore, these analyses may be viewed as cross-sectional because subjects were assessed at only one time point, whereas effects of childhood SES may have accumulated over decades, which may limit inferences we can make about causal relations. Regardless, the cross-sectional nature of the data collection introduces a fundamental limitation: It is not possible to know whether differing relations between childhood SES and health outcomes across age categories reflect the effects of age (i.e., childhood SES having progressively less impact with age) or cohort effects (i.e., factors associated with an earlier birth era). Although these differences significantly affect public health regardless of the explanation, the inability to distinguish between them is a major limitation of this study. To address it, we conducted subsidiary analyses to examine associations between childhood SES and health changes over 4 years of follow-up. We found that the relation was attenuated in unadjusted analysis and no longer significant in adjusted analysis. The lack of a longitudinal association may support the hypothesis of a cohort effect; however, our follow-up was too short to fully address this question. Since the impact of childhood SES is probably progressive, we believe that studies with longer follow-up will be needed.

A second limitation is that the measures of childhood SES were based on recall, and thus potentially subject to recall bias. Nevertheless, previous work has validated the use of recall in the estimation of childhood SES (50). Third, we did not measure health behaviors, including physical activity and tobacco use, that could further explain the link between childhood SES and adult health status. However, in a study carried out by Lantz et al. (51), major health-risk behaviors across socioeconomic strata did not fully account for poor health status and were not the predominant explanatory factors when economic hardship was considered. Fourth, participants who died prior to interview were excluded, which may have caused underestimation of the possible impact of low childhood SES on mortality. Fifth, some of the participants had face-to-face interviews and others telephone interviews, which may have introduced bias. However, our predictor or outcome measure is not likely to have been biased by the mode of interview, because it did not affect responses to the ADL measures (40). Sixth, we did not have fully comprehensive measures of current SES. For example, the MacArthur Scale of Subjective Social Status (52), a relatively new measure designed "to capture the common sense of social status across SES indicators ([education, income, wealth, occupation])" (53), was not used in the Heath and Retirement Study (39). Future studies, in addition to examining objective measures of childhood SES, such as parental education, should also examine subjective measures of adulthood SES, which have been shown to be powerful determinants of health outcomes.

The relation between parental education and self-rated health and functional limitation in older adults is strong. It is somewhat mitigated by current SES, diminishes across the range of increasing age, and manifests differently in different racial/ethnic groups. These findings extend what is already known about the impact of parental education or childhood SES on health in older adults. Because chronic disease and disability often develop during middle age, particularly in ethnic minority groups, earlier intervention may decrease the incidence and prevalence of disease and disability across socioeconomic and racial/ethnic groups. These findings suggest that definitions of vulnerability to health disparities should include lower childhood SES to allow clinical identification of at-risk patients for closer care and follow-up and to allow future studies to illuminate the causal links between childhood SES, race/ethnicity, and health status.


   ACKNOWLEDGMENTS
 
This work was supported by a Veterans Affairs Career Development Award and a National Institute on Aging Minority Research Supplement grant (1R01AG019827-01) and by a pilot investigator grant obtained through the Resource Centers for Minority Aging Research/Center for Aging in Diverse Communities, funded by the National Institute on Aging and the National Institute on Nursing Research. The sponsors were not involved in the design, methods, analysis, or preparation of this paper.

Conflict of interest: none declared.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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