Background There is an inverse relation between socioeconomicstatus and mortality. Over the past several decades death ratesin the United States have declined, but it is unclear whetherall socioeconomic groups have benefited equally.
Methods Using records from the 1986 National Mortality FollowbackSurvey (n = 13,491) and the 1986 National Health Interview Survey(n = 30,725), we replicated the analysis by Kitagawa and Hauserof differential mortality in 1960. We calculated direct standardizedmortality rates and indirect standardized mortality ratios forpersons 25 to 64 years of age according to race, sex, income,and family status.
Results The inverse relation between mortality and socioeconomicstatus persisted in 1986 and was stronger than in 1960. Thedisparity in mortality rates according to income and educationincreased for men and women, whites and blacks, and family membersand unrelated persons. Over the 26-year period, the inequalitiesaccording to educational level increased for whites and blacksby over 20 percent in women and by over 100 percent in men.In whites, absolute death rates declined in persons of all educationallevels, but the reduction was greater for men and women withmore education than for those with less.
Conclusions Despite an overall decline in death rates in theUnited States since 1960, poor and poorly educated people stilldie at higher rates than those with higher incomes or bettereducations, and this disparity increased between 1960 and 1986.
In recent decades death rates in this country have fallen, butthe improvement has not been shared equally. There is a wideninggap in the death rate between blacks and whites1. Although theinverse relation between socioeconomic class and mortality hasbeen documented in the United States,2,3 less is known abouthow this relation may be changing4. Studies in a number of othercountries have demonstrated that lower socioeconomic classeshave higher death rates than upper socioeconomic classes andthat these differences have increased in the past several decades5,6,7.The Black Report and other studies record a growing disparityin death rates between occupational classes in England and Walessince 19508,9,10,11,12. Similar gaps have been noted in Franceand Hungary during the past two decades, whereas in Sweden,Norway, Denmark, and Finland the differences have remained constant7,8.In the United States, increased differences in mortality havebeen noted among older white men according to their level ofeducation13.
This study examines changes in mortality rates from 1960 through1986 according to income and level of education among persons25 to 64 years of age in the United States. Kitagawa and Hauserused the 1960 Matched Record Study to demonstrate the inverserelation between socioeconomic status and the death rate2. Wereplicated this approach with data from the 1986 National MortalityFollowback Survey and the 1986 National Health Interview Survey.
Methods
Matched Record Study
The Matched Record Study of 1960 was a collaborative effortof the Bureau of the Census and National Center for Health Statistics.A sample of the death certificates of persons 25 years of ageor older who died from May through August 1960 were matchedagainst census information collected in the same year. The 62,400matched records that included data on sex, race, family status,income, occupation, and educational attainment were used tocalculate age-adjusted death rates for various socioeconomicclasses and groups.
Kitagawa and Hauser used standardized mortality ratios, an indirectadjustment for age that is calculated by dividing the numberof observed deaths by the number of expected deaths in a specificgroup. The 1960 survey was used to estimate the number of observeddeaths. The number of expected deaths was calculated by multiplyingthe 1960 death rates by the census figures for various groupsdefined according to sex, race, family status, income, or education.Only the published data for 1960 are presented here, becausethe original data no longer exist, not having been routinelyarchived. Kitagawa and Hauser published results on the inequalityin mortality for education and income groups among whites accordingto sex and family status. Because of the small number of blacksin their study, only the results for the groups that were subdividedaccording to sex and education were published.
National Mortality Followback Survey and National Health Interview Survey
The National Mortality Followback Survey and the National HealthInterview Survey, both conducted in 1986, were used to developmeasures comparable to the 1960 figures. For the rates and ratiosshown here, the 1986 National Mortality Followback Survey providedthe numerators, and the 1986 National Health Interview Surveyprovided the denominators.
The National Mortality Followback Survey is a nationally representativesample comprising 18,733 people 25 years of age or older whodied in 198614,15; we analyzed the records of 13,491 of them(the exclusions are described below under Analytical Sampleand Variables). Information obtained from death certificateswas linked with data from questionnaires completed by next ofkin. These data included information about income, education,and family status. All the states except Oregon (which accountedfor 1 percent of the U.S. population) participated in the survey.When weighted, these records provide the estimated number ofdeaths used here as the numerators in the rates and ratios.
The National Health Interview Survey comprises a multistageprobability sample of households from the civilian, noninstitutionalizedU.S. population. The 1986 survey included 30,725 persons from25 through 64 years of age and was weighted to represent thepopulation at the middle of the year 1986,16 appropriately forthe calculation of death rates. The 1986 National Health InterviewSurvey was used to estimate the sex, race, family-status, income,and education groups used as the denominators in the rates andratios presented here.
Mortality Ratios and the Index of Inequality
The mortality ratios presented in this study measure the relativedifferences in mortality between groups with different levelsof education and income. They are ratios of standardized mortalityratios, calculated with the technique of Kitagawa and Hauser,13by dividing the observed number of deaths by the number expected.In this study the number of observed deaths was obtained fromthe 1986 National Mortality Followback Survey. We obtained thenumber of expected deaths by multiplying the age-specific deathrates for the entire U.S. population in 1960 by the age compositionof each subgroup (i.e., those defined according to age, sex,race, education, or income), using the population estimatesfrom the 1986 National Health Interview Survey.
Mortality ratios were calculated by dividing the standardizedmortality ratio for each income or education subgroup by thestandardized mortality ratio for the group of people of thatsex and race. A mortality ratio of less than 1 indicates thatthe number of observed deaths in a particular education or incomecategory was smaller than expected on the basis of age, sex,and race alone. A mortality ratio higher than 1 indicates thatthe number of observed deaths exceeds the number expected solelyon the basis of age, sex, and race.
The mortality ratios corresponding to different education andincome levels are plotted against the midpoint for the relevantpercentile of the subgroup, with the population ordered fromlow to high status (Figure 1 and Figure 2). The lowest incomelevel among white women, for example, comprises 21 percent ofthat group and is therefore plotted at 10.5 on the abscissaof the graph. The proportion of the population in each higherincome group is added and plotted at the respective midpoints.With this technique it is possible to plot on the same scalethe distributions and ranges of income and education that differboth for the two study years and between subgroups of the population.The plots make approximate adjustments for monetary inflationand increasing educational attainment by creating a relativescale for each subgroup.
Figure 1. Relative Mortality in 1960 (broken line) and 1986 (solid line) According to Percentile of Educational Attainment in Persons 25 through 64 Years of Age.
The levels of educational attainment used in the 1960 study were as follows: primary and middle school, 0 to 4 years, 5 to 7 years, and 8 years; high school, 1 to 3 years and 4 years; and college, 1 to 3 years and 4 years. The levels used in 1986 were: school, 0 to 11 years and 12 years; and college, 1 to 3 years and 4 years. See the Methods section for a discussion of the plotting of levels of educational attainment according to the percentile of the population. Mortality ratios are ratios of standardized mortality ratios, a method of indirect age adjustment. Data are from the 1960 Matched Record Study, the 1986 National Mortality Followback Survey, and 1986 National Health Interview Study.
Figure 2. Relative Mortality in 1960 (broken line) and 1986 (solid line) According to Income and Family Status in White Men and Women (25 through 64 Years of Age).
The income levels used for family members in the 1960 study were as follows: <$2,000, $2,000 to $3,999, $4,000 to $5,999, $6,000 to $7,999, $8,000 to $9,999, and $10,000. The levels used for unrelated people in 1960 were <$2,000, $2,000 to $3,999, and $4,000. The levels used for family members in 1986 were $10,999, $11,000 to $16,999, $17,000 to $18,999, $19,000 to $24,999, and $25,000. The levels used for unrelated people in 1986 were $6,999, $7,000 to $12,999, $13,000 to $24,999, and $25,000. See the Methods section for a discussion of the plotting of income levels according to the percentile of the population. Mortality ratios are ratios of standardized mortality ratios, an indirect age adjustment. Data are from the 1960 Matched Record Study, the 1986 National Mortality Followback Survey, and the 1986 National Health Interview Study.
These plots indicate the relation between social class and mortalityon the basis of the relative inequality (the divergence fromthe average) within a group. Lines that fall nearer the horizontalindicate more convergence within a group (that is, a weakerinverse relation between class and mortality). More verticallines indicate greater divergence from the average -- that is,more inequalities within the group. Comparing the lines forthe two study years permits an assessment of changes over timein inequality between classes with respect to mortality withinparticular subgroups.
To summarize the difference in mortality across educationaland income levels, we constructed an index (Figure 3) to representthe difference between levels of education or income acrossthe entire group. For each education or income subgroup, themortality ratio was subtracted from the mortality ratio forthe group (considered to be equal to 1), and the absolute valueof the difference was multiplied by the respective percentageof the population that belonged to that subgroup. The sum ofthese weighted differences in mortality ratios is the indexscore.
Figure 3. Increases from 1960 to 1986 in the Inequality in Mortality for Selected Education and Income Groups among Persons 25 through 64 Years of Age, According to Race, Sex, and Family Status.
The index of inequality is a summary measure of differences in mortality according to level of education or income among persons of similar sex, race, and family status, based on mortality ratios. See the Methods section for a more complete discussion. Data are from the 1960 Matched Record Study, the 1986 National Mortality Followback Survey, and the 1986 National Health Interview Study.
The index score has an advantage over the comparison of extremes,a popular technique used to assess changes in the differencebetween classes. Comparisons of the mortality ratios for groupsat the top and bottom of the education and income scales aredistorted by the fact that at different times there are differingproportions of the population with the various levels of educationand income. Our index overcomes this difficulty and aggregatesthe inequality in mortality across the entire scale. The advantagesof indexes of this type have been discussed by Wagstaff et al17.
The statistical significance of the results of this study canbe tested by examining the consistency of the direction of changefrom the first study year to the second. The sign test assessesthe probability that observed increases in the index of inequalityfor all comparisons are due to chance. Because Kitagawa andHauser did not calculate standard errors for their study andthe original data are no longer available, no further statisticaltesting of the time trend is possible.
Analytical Sample and Variables
The analytical sample used in this study included the noninstitutionalized,civilian U.S. population (excluding that of Oregon) 25 to 64years of age. The deaths of persons in the military and thoseof persons who lived in institutions for more than half theyear were excluded from the numerator estimates derived fromthe National Mortality Followback Survey. The analysis was restrictedto persons 25 to 64 years old because many of those who diedover the age of 64 lived in institutions, and the National HealthInterview Survey excluded institutionalized persons from itssample.
In their studies of race, Kitagawa and Hauser used the categoriesof white and nonwhite. The composition of the populations consideredto be white and nonwhite has, however, changed since 1960. "White"now includes an increasing proportion of Hispanics, whereas"nonwhite" includes an increasing proportion of persons whoare not of African descent. To make the comparisons as accurateas possible, we compared non-Hispanic whites from 1986 withwhites of 1960 and blacks from 1986 with nonwhites of 1960.These categories are referred to here as white and black forboth 1960 and 1986.
The indicators of socioeconomic class studied here include educationallevel and income. The family income of persons living in familiesand the individual income of unrelated people were used in thedetermination of income level. Unrelated people were consideredto include persons living alone and those living with otherswho were not family members. Unmarried domestic partners wereconsidered as family members.
Results
Poor or poorly educated persons have higher death rates thanwealthier or better educated persons, and these differencesincreased from 1960 through 1986. The disparity in death ratesamong adults 25 to 64 years of age has widened in relation toincome and educational level. Although death rates improvedin the population as a whole, the benefits were not shared equally.From 1960 to 1986, the inequality in mortality related to educationallevel and income increased in each of the subgroups studiedaccording to race, sex, and family status. Among whites, whereasdeath rates declined for persons of every educational level,the decline was steeper among men and women with more educationthan among those with less.
The inverse relation between mortality and socioeconomic class(as defined by educational attainment and income) was confirmedfor adults 25 through 64 years of age in 1986 (Table 1). Withincreasing levels of education, direct age-adjusted death ratesfell among white men, black men, white women, and black womenin the United States. Similar relations were noted for income.
Table 1. Death Rates in 1986 among Persons 25 through 64 Years Old in Selected Education and Income Groups According to Race and Sex.
The mortality ratios showed the same patterns (Figure 1). Theplotted indirect age-adjusted data for 1986 indicated inverserelations between educational class and mortality for each race,sex, and family-status subgroup studied. Among white men, mortalityratios decreased consistently as educational attainment rose.The ratio for white men with 11 years or less of schooling was1.6; for white men with at least 4 years of college, it was0.6. That is, the age-adjusted mortality ratio for white menwith the lowest educational attainment was more than 2 1/2 timeshigher than the comparable ratio for white men of the highesteducational level. The education-related differential for whitewomen was only 86 percent, ranging from a mortality ratio of1.3 for white women with 11 years or less of schooling to aratio of 0.7 for white women with at least 4 years of college.Similar trends were noted for black men and women. Mortalitydecreased with increasing educational attainment across theentire distribution, not only among those at the bottom of theeducation scale.
Previously published data from 1960 on death rates for peopleof various educational levels are shown with the 1986 mortalityratios in Figure 1. This mode of presentation allows comparisonsdespite the increases in educational attainment over the 26-yearperiod and the changes in the proportion of the population tohave attained various educational levels.
When the 1960 data and the 1986 data are compared, it is apparentthat the inverse relation between mortality and education hasbecome stronger. Among whites and blacks of both sexes, thedifferences in mortality according to educational level weregreater for 1986 than for 1960; the slopes of the lines for1986 were steeper than those for 1960. This widening of differencesin mortality with educational level was also observed amongwhite family members and unrelated persons of both sexes. (Morecomplete data are available elsewhere.*)
The patterns in the data for income level were similar to thosefor educational level. As shown in Figure 2, higher-income groupshad lower mortality ratios in 1986. Among white men from familieswith incomes under $10,999, the mortality ratio of 2.5 was morethan four times higher than the ratio of 0.6 for white men fromfamilies with incomes of $25,000 or more. From 1960 through1986, the differences in mortality widened between income groups.Among white family members, there were larger differences inmortality ratios between income levels in 1986 than in 1960;the slopes of the lines for 1986 were steeper than those for1960. The same was true for unrelated people of both sexes.
An index of inequality was calculated to summarize and quantifythe inequality in mortality rates across the entire group. Theindexes for education (Figure 3) showed that from 1960 through1986, inequality in mortality increased 30 percent for blackwomen and 23 percent for white women. For both black and whitemen, inequality in mortality according to educational leveldoubled. The changes in the inequality index according to incomewere larger than the changes in the index according to education.The index of inequality in mortality rates for income groupsmore than doubled among unrelated people (both white men andwhite women) and more than tripled among white men and womenwho were family members.
This measure of cumulative inequality in mortality in a grouprevealed greater inequality in 1986 than in 1960 for each availablecomparison. The application of a two-sided sign test againsta null hypothesis that there was no change in inequality determinedthe significance of this consistent direction of change. Theconsistent difference in sign for the six independent subgroups(sex, race, and family status) for education resulted in a significancelevel of P = 0.031. The consistent difference in sign for thefour independent subgroups (sex and race) for income resultedin a significance level of P = 0.13.
Although death rates declined over the 26-year period in allgroups, the decline was steeper for men and women of high educationalattainment than for those with low levels of education (Figure 4).The study of absolute differences according to educationalattainment was restricted to whites because no comparable datafrom 1960 were available for other groups. The direct age-adjusteddeath rate for white men 25 to 64 years of age declined by 50percent (from 5.7 to 2.8 per 1000) among men of high educationalattainment from 1960 through 1986 and dropped only 15 percent(from 9 to 7.6) among white men of low education. Comparisonof the slopes suggested less dramatic changes among white womenover the same period. The differing proportions of the populationin the different educational groups and the changes in the socialmeaning of particular educational levels complicated comparisonsof the direct age-adjusted rates. The mortality ratios previouslypresented avoid these complexities and support similar conclusions.
Figure 4. Death Rates in 1960 and 1986 among Whites 25 through 64 Years of Age, According to Sex and Educational Level.
Death rates shown are per 1000 population after direct adjustment for age to the 1940 U.S. population. Low level of education was defined in 1960 as <8 years of schooling and in 1986 as <11 years of schooling. High level of education was defined in 1960 as 1 year of college and in 1986 as 4 years of college. Data are from the 1960 Matched Record Study, the 1986 National Mortality Followback Survey, and the 1986 National Health Interview Study.
Discussion
This study confirms the well-known inverse relation betweensocioeconomic class and mortality18,19 and documents that inthe United States the relation between the two has become stronger.The presence of widening differences in mortality rates accordingto income and educational level should come as no surprise,given the broad social changes in this country since 1960. Increasinginequalities in income, education, and housing and a fallingstandard of living for a large segment of the U.S. populationhave been reported20,21. Access to health care is a problemfor a growing number of Americans22. Although Medicaid may haveimproved access and health outcomes for a portion of the population,it appears to have been insufficient to equalize the chancesfor survival among the poorest and least educated23,24. Thesocial distribution of behavior that presents health risks maybe important in explaining the widening gap25. It may be thatpeople of higher socioeconomic status have adopted healthy lifestylesmore rapidly26,27,28.
These findings of increasing class differences in mortalityamong adults 25 through 64 years of age are generally confirmedby other work in this area. Duleep found no narrowing of differencesin mortality according to income or education among white men25 through 64 in a study comparing 1960 with the mid-1970s29.Inspection of those data suggests, however, that widening ofthe gap may have occurred. Using a longitudinal national survey,Feldman et al. reported increased differences according to educationallevel between the mortality rate for 1960 and the average ratefor the period 1971 through 1984 among white men 55 years ofage or older13. The differences among older white women showedno change. The changes we report here were weaker for womenthan for men. Our study examined a longer period than was assessedby either Duleep or Feldman et al. The widening gap betweenblacks and whites also supports our findings. Race has oftenbeen understood as a proxy for social class; among blacks, lowincome and poor education have an important effect on survivalfor both adults and infants30,31. It should be noted, however,that the results of this study suggest that the gaps in mortalityhave widened for both blacks and whites.
This and other studies of social disparities shed light on theimportance of class for an understanding of the gap in lifeexpectancy between blacks and whites32. In the 1986 NationalMortality Followback Survey, the differences in overall mortalityaccording to race were eliminated after adjustment for income,marital status, and household size. Examining cause-specificmortality while controlling for these socioeconomic factorsreveals that blacks have lower risks than whites for death fromrespiratory disease, accidents, and suicide; that they havethe same risk for cancer and circulatory diseases; and thatthey have higher risks for infectious disease, homicide, anddiabetes33.
The general pattern of improvement in death rates among whitesof all socioeconomic classes is less clear among blacks. Nocomparisons of absolute changes among blacks were possible inthis study. Community-based studies suggest that death ratesamong blacks in areas of low socioeconomic status have changedvery little since 196034,35. From 1960 through 1980, the age-adjusteddeath rate in Harlem has been static, although in the whiteand nonwhite populations overall this rate has fallen35.
The causes of death that explain the time trend we have describedhave yet to be studied. A steeper decline in rates of deathsdue to heart disease among men of higher socioeconomic statushas been reported for similar periods36,37,38. Before 1986,the acquired immunodeficiency syndrome was not a major causeof death. Cause-specific studies of mortality and morbidityare needed for the dynamics of the changes described here tobe better understood.
The findings of this study must be interpreted with severalcaveats. We examined data from only 2 years over a 26-year periodduring which differences in mortality may have varied. Furtherresearch with additional sets of data is necessary. The 1986National Mortality Followback Survey contains limited informationon income at the high end of the socioeconomic scale. The highestcategory in the 1986 survey was for income of at least $25,000,the median U.S. income for that year. A departure from the overallinverse relation between mortality and socioeconomic class wasobserved in the United Kingdom, where the death rate for thehighest income group was slightly higher than the rate for thenext highest income group39. The limitations of the 1986 datado not permit assessment of this phenomenon in the United States.
Artifact must be considered in explaining the described trends.It is known that undercounting by the census inflates deathrates among blacks to a small extent40. The problem of undercountingmay also affect people in groups of low income or low educationallevels, heightening class relations such as those we describe3.
Finally, Kitagawa and Hauser attribute a small part of the differencein socioeconomic class to the decline in status as a personapproaches death (i.e., with a declining income and occupationalstatus) -- the drift hypothesis2. There is no evidence to suggesta stronger tendency toward downward mobility in 1986. Furthermore,the association between education and mortality would not beaffected by such factors.
Despite the important decline in death rates in this countrysince 1960, we have identified a greater disparity in mortalityrates between people of different incomes and educational levels.As death rates have declined, poor and less educated peoplehave not benefited equally in comparison with those who arewealthier and better educated. These differences are not confinedto persons in extreme poverty but are seen across the socioeconomicspectrum. Improvements in life expectancy can be achieved withprograms that address the underlying causes of the differentialmortality. The results of this study raise serious questionsabout disparities in opportunity and equity in our nation.
We are indebted to Lester Curtin for statistical consultation;to Nelma Keen, Luong Tonthat, Janice Tandler, and Amy Gattonfor assistance with the production of this analysis; and tothe Poverty and Health Work Group for suggestions at variousstages of the project.
* See NAPS document no. 05038 for three pages of supplementarymaterial. To order, contact NAPS c/o Microfiche Publications,248 Hempstead Tpk., West Hempstead, NY 11552.
Source Information
From the National Center for Health Statistics, Office of Planning and Extramural Programs, Rm. 1100, 6525 Belcrest Rd., Hyattsville, MD 20782, where reprint requests should be addressed to Dr. Pappas.
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A correction has been published: N Engl J Med 1993;329(15):1139.
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