Socioeconomic inequalities in health after age 50: Are health risk behaviors to blame?
Introduction
Population-based research conducted in a variety of industrialized countries suggests that socioeconomic inequalities in health persist into late life (Huisman, Read, Towriss, Deeg, & Grundy, 2013). Although some evidence indicates that the magnitude of these inequalities diminishes among the oldest old (von dem Knesebeck, Lüschen, Cockerham, & Siegrist, 2003), it has now become clear that socioeconomic position plays an important role, not only in determining who reaches old age, but also in shaping risk for poor health and mortality during old age (Fors, Lennartsson, & Lundberg, 2008).
That socioeconomic inequalities in health outcomes persist during late life, despite efforts to equalize access to health care (Card, Dobkin, & Meastas, 2008) and income (Crystal, Shea, & Krishnaswami, 1992) among older adults, is troubling. Some have suggested that programs for older adults, like Medicare, are ineffective at diminishing health inequalities because they do not provide equal access to the highest quality of care (Hoffmann, 2011). Others have argued that socioeconomic inequalities in old age health and mortality are largely a function of inequalities that were established much earlier in life, with the negative effects accumulating over time (Ferraro, Shippeee, & Schafer, 2009).
The persistence of socioeconomic inequalities in health into late life may also be an indication that the individual lifestyles of older adults in different socioeconomic positions play a large role in maintaining health inequalities. Several studies have shown that health behaviors partially mediate socioeconomic inequalities in health among middle-aged adults (Lantz et al., 2001, Stringhini et al., 2011), and others have examined age differences in the health risks associated with socioeconomic and behavioral factors (Lantz, Golberstein, House, & Morenoff, 2010); however, few studies have examined the role of behaviors in maintaining socioeconomic inequalities in health among older adults (Fors, Agahi, & Shaw, 2012). Thus, it is currently not clear how much focus should be placed on reducing hazardous lifestyles among older adults as a means towards eliminating socioeconomic inequalities in late life health.
With the aim of gauging the role that health behaviors play in producing or maintaining socioeconomic inequalities in late life health, this study examines: a) how the prevalence of key health risk behaviors - including smoking, alcohol misuse, physical inactivity, and unhealthy body mass index (BMI) - differs across socioeconomic status among older adults; b) the extent to which these key health risk behaviors impact mortality and the initial onset of disability among older adults, and account for socioeconomic differences in these health indicators; and c) whether there are age and gender differences in the contribution of these health risk behaviors to socioeconomic inequalities in health among adults in later life. To follow is a brief review of our current knowledge pertaining to each of these areas.
Health behaviors are suspected mediators of socioeconomic inequalities in health, in part due to their socioeconomic stratification. The socioeconomic stratification of health behaviors is thought to be either due to indirect selection (Mackenbach, 2012), or the result of socioeconomic circumstances shaping the motivations and means of individuals to maintain a healthy lifestyle (Pampel, Krueger, & Denney, 2010). Indirect selection refers to a process whereby both socioeconomic achievement and health behaviors are determined by individual characteristics, like intelligence and personality. Alternatively, the influence of socioeconomic circumstances may be more direct; for example, psychological stress resulting from financial deprivation may motivate socioeconomically disadvantaged individuals to engage in unhealthy behaviors, such as smoking and alcohol abuse, as a way of providing immediate relief from feelings of distress (Shaw, Agahi, & Krause, 2011). Similarly, socioeconomically disadvantaged individuals may be less motivated than advantaged individuals to invest the time and money necessary for engaging in healthy behaviors, such as physical activity or consuming a balanced diet, as these behaviors may be recognized as offering limited short-term, and inadequate long-term, payoff (e.g., in terms of longevity) (Blaxter, 1990). Furthermore, socioeconomic position can determine one's access to psychological, social, and environmental resources that facilitate the adoption and maintenance of healthy lifestyles (Ross & Mirowsky, 2011). Still, while the socioeconomic stratification of health behaviors in the general population has been well studied, the extent to which hazardous lifestyles are also more prevalent among socioeconomically disadvantaged groups of older adults is not well known.
The role of health behaviors in mediating socioeconomic inequalities in health among older adults is also a function of the degree to which health risk behaviors are associated with health outcomes during later life, and the nature by which the socioeconomic stratification of health outcomes and health risk behaviors may change with advancing age. The powerful health effects of certain health risk behaviors, such as smoking, alcohol misuse, physical inactivity, and weight management, are well known (Mokdad, Marks, Stroup, & Gerberding, 2004). However, their effects on health during older ages are less clear, perhaps in part due to the selective survival into old age of only the most resilient individuals. This could result in a population of older adults who are relatively resistant to the negative health effects of traditional behavioral risks. Such a "survivor effect" has been cited as one possible explanation for the "reverse epidemiology" of obesity among older adults, whereby the relative mortality risks of overweight and obesity decline with age (Oreopoulos, Kalantar-Zadeh, Sharma, & Fonarow, 2009).
Regarding the question of how socioeconomic differences in health and health risk behaviors may change across the adult life course, two opposing theoretical perspectives inform our understanding. On the one hand, cumulative inequality theory (Ferraro et al., 2009) proposes that experiencing social disadvantages at one point in time increases one's future likelihood of exposure to health risks, while experiencing social advantages increases future chances for exposure to opportunities for health promotion. When applied to health behaviors, this suggests that with advancing age, the personal and environmental resources necessary for maintaining a healthy lifestyle are likely to be increasingly accessible to the socioeconomically advantaged, and increasingly inaccessible to the disadvantaged. Some support for the idea that socioeconomic inequalities in the prevalence of healthy behaviors accumulate with age has been reported, particularly with respect to physical activity (Shaw & Spokane, 2008).
On the other hand, the age-as-leveler perspective suggests that during later life, normative physical and social changes become stronger determinants of health than socioeconomic circumstances (Wray, Alwin, & McCammon, 2005). As a result, at advanced ages, the prevalence of risk behaviors, like smoking, may be expected to be universally low, as rates of cessation increase with age across the entire socioeconomic spectrum (Husten et al., 1997). In addition, the age-as-leveler perspective suggests that the role of health risk behaviors in mediating socioeconomic inequalities in health may diminish with advancing age, as the relative risk of some behaviors wanes in later life. This could occur because an adult's remaining life span is not sufficiently long to experience the negative consequences of unhealthy behaviors. For instance, prior research has shown that quitting smoking during midlife can increase life expectancy by as much as 8 years, but the benefits of quitting decline progressively with increasing age (Taylor, Hasselblad, Henley, Thun, & Sloan, 2002). Similarly, Janssen and Bacon (2008) found that becoming obese during late life is not associated with elevated mortality risk. Still, the health impacts of other behaviors, like physical activity, may continue to be strong during late life (Petersen et al., 2012).
In order to assess these competing hypotheses regarding the role of health behaviors in accounting for socioeconomic inequalities in health during later life, the current study uses data from a nationally representative sample of U.S. adults over the age of 50 to examine the potentially differential role that health risk behaviors may play across four subgroups: late middle aged and older adults, as well as among men and women. If health risk behaviors play a role in accounting for socioeconomic inequalities in health in adults over age 50, and if this role is greater among the older segments of this population, then cumulative inequality theory would be supported. If, however, health risk behaviors play a minimal role, and less of a role in the older segments of the population, then the age-as-leveler perspective would be supported.
Additionally, recognizing that health behaviors may play a different role in explaining socioeconomic inequalities in health for men and women, gender comparisons are made as well. The primary justification for expecting gender differences is that many of the variables and associations in the current study are known to vary by gender, including a) health risk behaviors tending to be more common among men than women (Berrigan, Dodd, Troiano, Krebs-Smith, & Barbash, 2003); b) the socioeconomic gradient tending to be stronger in men than women (Koskinen & Martelin, 1994); and c) rates of mortality and disability differing significantly between older men and women (Gorman & Read, 2006).
Section snippets
Data source
Data for this study came from the Health and Retirement Study (HRS), a nationally representative panel survey of community-dwelling older Americans (http://hrsonline.isr.umich.edu). The original HRS sample, born between 1931 and 1941, was selected in 1992. In 1998, this sample was merged with cohorts born between 1890 and 1930, and between 1942 and 1947. Baseline data for the current study come from respondents to the 1998 survey who were at least 51 years old. After excluding individuals with
Results
Table 1 presents descriptive data on the demographic characteristics, health risk behaviors, and health status of the HRS sample, as well as the lowest and highest wealth groups. The sample has a larger proportion of women (55.4%) than men (44.6%), and is predominately white (88.7%). The average age at baseline is 65.4.
Discussion
The primary aim of this study was to examine the role of health risk behaviors in accounting for these disparities in risk observed after age 50, and persisting beyond age 65. With a focus on what are widely regarded as the most important behavioral risks in the U.S. population, we found that these behavioral risk factors account for approximately one-quarter or more of the elevated mortality risk among the least wealthy in each gender and age subgroup, with the exception of women over the age
Conclusions
This study sought to examine whether health risk behaviors continue to shape socioeconomic inequalities in health during later life, or whether the impact of behaviors is relatively trivial during this stage of life, when many of the least healthy members of the population have already died, and when virtually every member of the population has access to basic health care services. Our findings indicate that prevalence rates of key behavioral risks are relatively high among the most
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