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Use Slopes to Track the “Fundamental Cause” of Group Disparities in Health
Linda S. GottfredsonUniversity of DelawareNewark, DE 19716 USA
International Society for Intelligence ResearchMadrid, December 19, 2009
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“Fundamental cause”
• The relation between social class and health is so general (cannot be explained by
income, access to care, etc.) that there must be a highly generalizable “fundamental cause”
A highly generalizable cause accounting for the remarkably general relation between
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g as the “fundamental cause”
• Hypothesis: – group differences in g are the fundamental cause
of group differences in health• Common “disproof:”
– “If correct…one might have expected the relation between IQ and mortality to act through known risk factors. This does not appear to be the case. In fact, a recent analysis…shows that this relationship is abolished when education and income are in the same model” (Marmot & Kivimaki, 2009)
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4
Example: Disparities in health behavior by education; all races & sexes: % who smoke, 2006 (age adjusted)
(CDC, Health in the United States, 2008, Table 64)
0
5
10
15
20
25
30
35
40
BA+ Some college HS diploma <Diploma
%
White female
Black female
White males
Black males
%
Education LoHi
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Lung cancer mortality, Men 25-64, 1950-1998 by social class of county, USA
(age adjusted)
Gradients sometimes flip over
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6
Typical health disparities by education; in all races & sexes:% of non-ill 51-year-olds expected to have this chronic illness by age 63
(USA, ages 51-61 in 1992; Hayward et al, 2000)
010203040506070
16 12 80
10203040506070
16 12 8
HypertensionDiabetes whiteCOPD blackCancer
Men Women
%
Years
Negative gradients—rare
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7
010203040506070
16 12 80
10203040506070
16 12 8
HypertensionDiabetes whiteCOPD blackCancer
Men Women
%
Years
Race difference—hypertension
Sex difference—diabetes
Common policy goal : All gradients flat
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88
“Disparity” = group differences on health outcome X“Explaining” between-group variation
Means, rates, etc.
16 yrs12 yrs8 yrs
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99
“Disparity” = group differences on health outcome X“Explaining” between-group variation
Means, rates, etc.
16 yrs12 yrs8 yrs
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1010
a
b
c
d
d
fg
This is not about individual differences in health
Not “explaining” within-group variation
Within-group and between-group variancemay arise from different mix of causes
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1111
Many families of health disparities
HEALTH HABITS
MORTALITY
KNOWLEDGECHRONIC ILLNESSES
INJURIES
INFECTIOUS DISEASES
ADHERENCE
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Example 1(Erikson & Torssander, 2008)
Mortality in Sweden, 1991-2003 Among all individuals ages 30-59 in 1990 So– born 1930-1960; still alive 1990 died ~ ages 31-73 (N ~ 130,000 deaths) Social class = occupational level (1-6)
Universal health care Ethnically homogeneous Whole cohort (not sample) Uniform classification of deaths
Removes 2 common sources of variance in disparities
Reduces error variance
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Broad categories of death 1991-2003, Sweden Social class disparities among individuals ages 30-59 in 1990
Causes(selected)
Men (N=80,040) Women (N=49,654)
Hazards ratios by social class % Hazards ratios by social class %2 3 4 5 6
(lo)2 3 4 5 6
(lo)
Neoplasms 1.1 1.2 1.4 1.4 1.5 35 1.0 1.1 1.2 1.3 1.3 58
Infections 1.3 1.4 1.4 1.1 2.2 1 1.2 1.8 1.9 2.0 2.3 1
Nervous system 1.1 1.2 1.4 2.1 2.2 2 1.0 1.1 1.3 1.6 1.5 2
Circulatory 1.3 1.5 1.8 1.9 2.5 35 1.3 1.7 2.0 2.2 2.6 19
Musculoskeletal 1.9 2.0 1.7 3.2 2.6 <1 1.3 2.5 2.5 2.0 2.0 1
External 1.2 1.4 2.0 1.9 2.5 13 1.1 1.2 1.2 1.4 1.8 8
Respiratory 1.2 1.6 2.3 2.9 3.0 3 1.4 1.9 2.4 2.4 3.0 4
Endocrine 1.3 1.8 1.9 3.9 3.1 2 1.3 2.0 2.6 3.1 3.7 2
Mental/behav 1.4 1.7 3.8 3.1 5.3 2 1.1 1.7 1.7 2.4 2.9 1
TOTAL 1.2 1.4 1.7 1.8 2.1 100 1.1 1.3 1.4 1.6 1.7 100
(Erikson & Torssander, 2008)
1=Higher managerial/professional, 2=lower managerial/professional, 3= intermediate, 4=lower supervisory/skilled manual, 5=routine non-manual, 6=unskilled manual
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Three major causes of death 1991-2003, Sweden Social class gradients for individuals ages 30-59 in 1990
0
0.5
1
1.5
2
2.5
3
1 2 3 4 5 6
Neoplasm-menNeoplasm-womenCirculatory-menCirculatory-womenExternal-menExternal-women
Hi Occupational class Lo
Hazards ratio
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Three major causes of death 1991-2003, Sweden Social class gradients for individuals ages 30-59 in 1990
0
0.5
1
1.5
2
2.5
3
1 2 3 4 5 6
Neoplasm-menNeoplasm-womenCirculatory-menCirculatory-womenExternal-menExternal-women
Hi Occupational class Lo
Hazards ratio
Slope (ß)
.18
.19
.17
.10
.08
.06
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Causes of death 1991-2003, Sweden Social class disparities among individuals ages 30-59 in 1990
Causes(selected)
Men (N=80,040) Women (N=49,654)
Hazards ratios by social class % Slope( ß )
Hazards ratios by social class % Slope( ß )2 3 4 5 6
(lo)2 3 4 5 6
(lo)
Neoplasms 1.1 1.2 1.4 1.4 1.5 35 .08 1.0 1.1 1.2 1.3 1.3 58 .06Infections 1.3 1.4 1.4 1.1 2.2 1 .10 1.2 1.8 1.9 2.0 2.3 1 .17
Nervous system 1.1 1.2 1.4 2.1 2.2 2 .16 1.0 1.1 1.3 1.6 1.5 2 .10
Circulatory 1.3 1.5 1.8 1.9 2.5 35 .17 1.3 1.7 2.0 2.2 2.6 19 .18
Musculoskeletal 1.9 2.0 1.7 3.2 2.6 <1 .17 1.3 2.5 2.5 2.0 2.0 1 .14
External 1.2 1.4 2.0 1.9 2.5 13 .19 1.1 1.2 1.2 1.4 1.8 8 .10
Respiratory 1.2 1.6 2.3 2.9 3.0 3 .24 1.4 1.9 2.4 2.4 3.0 4 .21Endocrine 1.3 1.8 1.9 3.9 3.1 2 .25 1.3 2.0 2.6 3.1 3.7 2 .26
Mental/behavioral 1.4 1.7 3.8 3.1 5.3 2 .33 1.1 1.7 1.7 2.4 2.9 1 .22TOTAL 1.2 1.4 1.7 1.8 2.1 100 .15 1.1 1.3 1.4 1.6 1.7 100 .10
(Erikson & Torssander, 2008)
1=Higher managerial/professional, 2=lower managerial/professional, 3= intermediate, 4=lower supervisory/skilled manual, 5=routine non-manual, 6=unskilled manual
Slopes = linear regression of HRs on class categories
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Distribution of all 101 class-mortality slopes (50 men, 51 women) NOT independent (includes broad categories plus high-volume sub-categories)
Slopes (ß)
Mean = .16 SD = .09
- +
But recall population—
• Universal health care• Ethnically homogeneous• Cohort born 1930-1960• Died ~ ages 31-73Need to explain
this variation (in gradients)
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Distribution of class-mortality slopes Ages 30-59 in 1990, died 1991-2003, Sweden
Men:
Women:
Men:
Women:
35 specific causes of death
15 broad categories of death
- + slopes 0.0 0.1 0.2 0.3 0.4
Variability in size of gradients across causes
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Distribution of class-mortality slopes Ages 30-59 in 1990, died 1991-2003, Sweden
Men:
Women:
Men:
Women:
35 specific causes of death
15 broad categories of death
- + slopes 0.0 0.1 0.2 0.3 0.4
More variability across specific causes
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Distribution of class-mortality slopes Ages 30-59 in 1990, died 1991-2003, Sweden
Men:
Women:
Men:
Women:
35 specific causes of death
15 broad categories of death
- + slopes 0.0 0.1 0.2 0.3 0.4
Mean SD
0.17 0.10
0.14 0.09
0.17 0.08
0.17 0.06
Sex differences in class gradients
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Plot of slopes for men vs. women, broad categories of death
0
0.05
0.1
0.15
0.2
0.25
0.3
0 0.1 0.2 0.3 0.4
Women
Men
r = .38
= all deaths
Hazards ratios range from 1.3 to 5.3
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Plot of slopes for men vs. women, specific categories of death (where N > 100, each sex)
-0.1 0 0.1 0.2 0.3 0.4
r = .86
Men
Women
0.3
0.2
0.1
0
Hazards ratios range from 0.9 to 6.3
Steeper for women
Steeper for men
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Class gradients: Specific neoplasms
-0.1 0 0.1 0.2 0.3 0.4
Neoplasms
Women
Men
0.3
0.2
0.1
0
= All neoplasms
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Class gradients: Specific neoplasms
-0.1 0 0.1 0.2 0.3 0.4
Women
Men
colonlymph
skin
pancreas
rectum
kidney
bladder
esophagusliver
stomachlung, larynx
lip/oral
0.3
0.2
0.1
0
= All neoplasms
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-0.1 0 0.1 0.2 0.3 0.4
Women
Men
colonlymph
skin
pancreas
rectum
kidney
bladder
esophagusliver
stomachlarynx
lip/oral
0.3
0.2
0.1
0
= All neoplasms
breast, ovary
prostate
other uterus
cervix
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Class gradients: Specific circulatory causes
-0.1 0 0.1 0.2 0.3 0.4
Circulatory
Women
Men
0.3
0.2
0.1
0
= All circulatory
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Class gradients: Specific circulatory causes
-0.1 0 0.1 0.2 0.3 0.4
Circulatory
Women
Men
other heart
stroke
heart attack
0.3
0.2
0.1
0
= All circulatory
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Class gradients: Specific external causes
-0.1 0 0.1 0.2 0.3 0.4
External
Women
Men
0.3
0.2
0.1
0
= All external injuries & accidental poisoning
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Class gradients: Specific external causes
-0.1 0 0.1 0.2 0.3 0.4
External
Women
Men
homicide
suicide
falls
accidental poisoning
undetermined intent
traffic accidents
0.3
0.2
0.1
0
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30
0%
20%
40%
60%
80%
100%
1-4 5-9 10-17
18-24
25-44
45-54
55-64
65+
Illness
Suicide
Homicide
"Accidents"
20062003-2005
Sudden cause (“external”)
Age of sample mattersCauses of death differ by age: males in USA
(CDC, Health data interactive)
Incubating cause (“internal”)Swedish sample
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Specific causes in other broad categories (digestive, endocrine, mental, respiratory)
-0.1 0 0.1 0.2 0.3 0.4
Women
Men
diabetesalcohol
ulcer
asthma
pneumoniachronic liver
disease
chronic lower respiratory
Other specific causes0.3
0.2
0.1
0drug dependence
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Most frequent specific internal causes of death:All are “entirely preventable” by patient (Eurostat report)
-0.1 0 0.1 0.2 0.3 0.4
Women
Men
ulcer
asthma
pneumonia
chronic liver disease
0.3
0.2
0.1
0
esophagus
lung, larynxlip/oral
colon
pancreas
kidney
bladder
skin
stomach
breast, ovary
other uterus
cervix
prostate
chronic lower respiratory
diabetes
stroke
alcohol
drug dependence
5 8
17%other heart
heart attack
homicide
suicide
falls
accidental poisoning
undetermined intent
traffic accidents
5
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Example 2(Gottfredson, 2004)
Mortality in US, 1980-1986 All ages External causes only Social class = neighborhood income level (1-6)
Differential access to health care Ethnically diverse
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Slopes (ß)
Mean = .12 SD = .20- +
Class-mortality gradients, for 55 specific external causes, US population, 1980-1986
classes = 6 levels of neighborhood income
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Suicide
Drugs, alcohol, poisons
Falls
Homicide
Undetermined intent: firearm, poison
Vehicles/pedestrian, drowning
Burns, cold, choke, neglect, firearm
Cut, crushed, machines, electric
Slope
Class-mortality gradients, by general type of external cause, US population, 1980-1986
classes = 6 levels of neighborhood income
Mean
-.15
-.04
.02
.12
.10
.15
.30
.29
elderly
Working-age men
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Suicide
Drugs, alcohol, poisons
Falls
Homicide
Undetermined intent: firearm, poison
Vehicles/pedestrian, drowning
Burns, cold, choke, neglect, firearm
Cut, crushed, machines, electric
Slope
Class-mortality gradients, by general type of external cause, US population, 1980-1986
classes = 6 levels of neighborhood income
Mean
-.15
-.04
.02
.12
.10
.15
.30
.29
M
F
F
M
M
MF
F
F, M = Swedish mean slopes
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Changes in:
Options & information:• preventability (don’t smoke)• detection (pap smear)• controllability (diet, insulin)
Population composition:• age• cohort• ethnicity
Slope
Source of hypotheses I: Migration of slopes over time and cohorts
Meta-analysis of slopes
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Predictors Distribution of:
Host exposure Passive (hazards) Active Personal choice
Host susceptibility BiologicalCognitive g (or surrogates)
Vector burden Biological (virulence) Cognitive Task complexity
Statistical artifacts Sampling errorMeasurement errorRestriction in range
38
Source of hypotheses II: g theory + epidemiological perspective
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Thank you