儿童期社会经济地位与中老年健康状况的关系研究
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摘要
研究背景
大量研究发现利用收入、教育或职业衡量的不同社会阶层中,健康是不平等分布的。早期关于健康的社会经济梯度的研究集中于阐述这些梯度的存在,很少去研究社会经济梯度背后的原因。理论模型和实证研究都致力于解释成年期出现健康差异的原因,但没有一个因素,无论是单独的还是结合的,能完全地解释健康的社会经济梯度。研究者认为,社会经济地位对健康的影响并非是一时的,而是持续的、累积的,人生早期的生活经历会对未来健康产生长远的影响。在生命周期的各个阶段中,儿童期非常关键。儿童期的社会经济地位以及生活环境对成年期社会经济地位以及疾病风险有着长期的影响,这种影响将可能持续一生。
近年来研究者开始关注儿童期的社会经济地位与成年期健康以及长寿的关系,致力于从源头探究健康差异。现有的相关研究主要集中在欧美等发达国家,来自发展中国家的研究非常有限。多数研究的健康指标集中在死亡率以及心血管疾病,部分文献利用了比较单一的健康指标如自评健康、认知功能等,全面综合地从生理、心理等方面评价中老年人健康状况的研究较少,并且在使用不同的指标以及在不同地区的人群中开展研究的时候,得出的结论并不一致。我国作为发展中国家,社会经济水平、人们的健康状况、行为生活方式和发达国家相比都存在较大差异。并且,我国中老年人的生活轨迹可能更为复杂,不可避免地会影响到中老年群体的儿童期及当前的社会经济地位,进而对健康状况造成影响。
研究目的
本研究的总目标是通过理论研究和实证分析,探讨儿童期社会经济地位与中老年健康的关系以及生命历程里社会经济地位的变动对中老年健康状况的影响,为减少健康差异、促进健康公平政策的制定提供理论基础和科学依据。
具体研究目的包括：构建儿童期社会经济地位与中老年健康关系的理论和实证模型；揭示儿童期社会经济地位与中老年自评健康、日常活动能力、认知功能、抑郁症状等健康指标之间的关系；探讨社会经济地位的变动对中老年健康状况的影响；分析儿童期社会经济地位、儿童期健康、中老年期社会经济地位及中老年健康之间的相互关系；提出减少健康差异、促进健康公平的政策建议。
研究方法
本研究数据来源于“中国健康与养老追踪调查(CHARLS)"2011-2012年全国基线调查,CHARLS的抽样方法为多阶段分层概率比例规模抽样。最终抽取28个省(直辖市),150个县(区),450个行政村(社区),本文的研究对象为参与问卷调查及体检的45岁及以上的中老年人,删除关键变量缺失及异常值的样本,本研究最终纳入的家户数为8520,样本量为13516。
在分析方法上,本研究首先对样本的基本情况以及社会经济特征进行了描述和比较；然后利用单因素和多因素分析探讨了儿童期社会经济地位与不同健康指标的关系,通过构建Logistic回归模型,在模型中逐步纳入儿童期社会经济地位、儿童期健康、中老年期社会经济地位,分析逐步控制上述因素后模型的变化；随后通过主成分分析构建儿童期社会经济地位及中老年期社会经济的综合指标,分析生命历程里社会经济地位的变动与健康状况的关系；最后是构建PLS路径分析模型,探讨了儿童期社会经济地位、儿童期健康、中老年期社会经济地位以及不同健康指标之间的关系。资料的统计分析由SPSS16.0软件和Smart PLS2.0软件完成。
主要研究结果
(1)儿童期社会经济地位与中老年健康状况的关系
研究对象自评健康为很好、好、一般、不好、很不好的比例分别为6.9%、15.3%、47.7%、27.4%和2.6%,日常活动能力的受损率为16.8%,抑郁症状的发生率为37.7%,高血压的患病率为40.9%,认知均分为12.73分。除了高血压患病之外,单因素分析均显示,儿童期SES处于劣势的研究对象,中老年期的健康状况较差。在多因素分析中,控制了中老年当前的SES之后,儿童期SES与自评健康、日常活动能力受损、抑郁症状以及高血压患病的关系消失,但与认知功能的关系存在统计学意义,儿童期居住于城镇、父母亲接受过教育的研究对象,中老年期的认知功能更好。
(2)儿童期到中老年期社会经济地位的变动与中老年健康状况的关系
研究对象的年龄、婚姻状况以及地区不同,儿童期SES综合得分存在差异(P<0.001),低龄、在婚、东中部的研究对象,儿童期SES综合得分较高；研究对象的性别、年龄、婚姻状况以及地区不同,中老年期SES的综合得分存在差异(P<0.001),男性、低龄、在婚、东部的研究对象,中老年期SES的综合得分较高。研究对象从儿童期到中老年期SES的变动“保持低水平”、“由高到低”、“由低到高”、“保持高水平”的比例分别为37.4%、12.6%、21.6%和28.4%。低龄组、在婚组“保持高水平”的比例更高,和男性相比,女性的社会经济地位更难上升。SES变动形式不同,自评健康不良率、ADL受损率、高血压患病率、抑郁症状发生率、认知功能均存在统计学差异。儿童期SES较低但经历了SES上升的研究对象与SES未经历上升的相比,健康状况更好；相反,儿童期SES较高但后期经历了SES下降的研究对象与未经历SES下降的相比,健康状况更差。但高血压患病未呈现类似的变化趋势,SES“保持高水平”的研究对象高血压患病风险最高,“保持低水平”的患病风险最低。
(3)儿童期社会经济地位与中老年健康关系的路径分析
所有的PLS路径模型均显示,儿童期SES与中老年SES的标准化路径系数最大,儿童期SES越高,中老年期SES越高；儿童期SES越高,儿童期健康状况越好；儿童期健康状况越好,中老年SES越高；中老年SES越高,自评健康越好,日常活动能力受损越小,抑郁症状发生风险越低,认知功能越好。儿童期SES与不同健康指标的关系有差异,儿童期SES对中老年认知具有直接影响,儿童期SES越高,中老年期认知功能越好,但与其他健康指标的关系,未见统计学意义,儿童期SES与其他健康指标的关系更多是通过儿童期健康及中老年SES的间接作用。另外,儿童期健康与不同健康指标的关系也有差异,儿童期健康状况越好,中老年自评健康越好,抑郁症状发生风险越低,但与ADL、高血压患病以及认知功能的关系未见统计学意义。
结论及建议
根据研究结果,本研究得出如下结论：
(1)儿童期SES对中老年健康具有长远的影响,儿童期SES处于劣势,会增加中老年健康状况不良的风险。但对于不同的健康指标,这种关系的强度不一样,对于自评健康、日常活动能力、高血压患病和抑郁症状,主要是通过儿童期健康及中老年当前的社会经济地位发挥中介作用,证实了“路径模型”；对于认知功能,则更多体现了儿童期SES直接的作用,证实了“累积劣势模型”。(2)儿童期到中老年期SES上移,能部分补偿儿童期不良SES的负面影响,儿童期到中老年期SES下移,早期良好SES的影响会被下移的SES所抵消。(3)儿童期SES处于劣势的研究对象,中老年期SES更为低下。社会经济地位具有代际转移的特点,证实了“地位获得模型”。(4)儿童期健康状况不良的研究对象,中老年期SES更为低下,体现在受教育程度和家庭人均收入较低,验证了“健康选择学说”。(5)儿童期健康状况不良,中老年期的自评健康较差,日常活动能力和抑郁症状发生率较高,人生早期的健康状况产生长远影响,甚至持续终身。(6)研究对象当前的社会经济地位对健康具有重要影响。现居地为农村、受教育程度低、家庭人均收入低的研究对象,自评健康状况较差,日常活动能力受损较严重,抑郁症状发生率较高,认知功能较为低下。因此,缩小社会经济地位的差异有助于降低健康不平等。
上述结论具有如下政策含义(1)重视儿童期社会经济地位对整个生命历程的长远影响,将儿童期作为生命历程里降低健康差异的最佳时机。缩小社会经济地位的差异,不仅能缩小当前的健康差异,而且对未来健康产生潜在的长远影响。(2)改善健康状况,促进健康公平,不仅仅依赖于个人当前的社会经济地位或卫生服务因素,还有赖于早期的生活经历和健康状况。意味着完善卫生系统内的举措只是解决卫生服务本身的问题,要增进健康,促进公平,不仅需要相对完善的卫生服务,更需着力破解卫生系统之外的诸多问题。要将其置于一个宏观的社会经济制度的框架下综合考虑,注重缩小城乡社会经济差异、教育差异。
创新与不足
本研究的创新性(1)现有的关于儿童期社会经济地位与成年健康的研究主要集中在欧美国家,本研究利用我国大规模的调研数据,基于生命历程理论,从生理、心理、认知功能等方面全面探讨儿童期社会经济地位与中老年健康状况的关系,提供来自我国的证据。(2)通过构建综合性的社会经济地位指标,探讨了生命历程里社会经济地位的变动对健康状况的影响,弥补了国内该方面研究的不足。(3)构建PLS路径分析模型,对儿童期SES、儿童期健康、中老年SES以及中老年健康之间的关系进行了系统分析,有利于为减小健康差异、促进公平的政策制定找到干预点。
本研究的不足(1)只掌握了有限的儿童期信息,儿童期到中老年的时间跨度大,且利用的是横断面数据,本研究只是对儿童期社会经济地位与中老年健康之间的关系进行了探讨,难以确定因果关系的方向。(2)对于儿童期社会经济地位低下的个体来说,可能在进入中年之前就已经去世,被排除在本研究的样本之外,可能导致一定的样本选择偏倚。(3)社会经济地位的测量只包括两个时点,而出生时的情况及中期之前的工作收入等都有可能影响健康状况,由于数据的限制,并未考虑这一影响,有可能影响研究结论。
Background
A substantial amount of research has found that health is not equally distributed across social class groups stratified by income, education or occupation. Early literature related to socioeconomic gradients in health expended enormous energy in repeatedly demonstrating their pure presence, with little effort devoted to understanding reasons underlying it. Theoretical models and empirical studies that did attempt to understand the gradients focused on current influential factors in adult that could give rise to different health states across social groups, but none of the factors, either alone or in combination, could fully explain those gradients. Researchers found that the impact of socioeconomic status on health was not temporary but lasting and cumulative. The early life experience will have long-term efforts on future health. Childhood was very critical because childhood socioeconomic and living conditions might have lasting efforts on adult SES and disease risk throughout their whole life.
In recent years, researchers began to pay attention to the associations between childhood SES and adult health, as well as longevity, with the dedication to explore health disparities from the source. The existing research mainly concentrated in developed countries such as America and Europe, and studies from developing countries were very limited. Most studies focused on mortality and cardiovascular disease, and part of the literature only examined one dimension of health, such as self-rated health and cognition. The conclusions were not consistent when different indicators in different populations were measured. As a developing country, there are big differences in socioeconomic status and people's health and life style compared with developed countries. And the life trajectories of old people in our country may be more complex, which could inevitably affect both early and later SES and health outcomes.
Objective
The overarching objective of this study was to explore the relationship between childhood SES and later health outcomes through theoretical research and empirical analysis, as well as the relationship between SES mobility in life course and health outcomes in later life, providing theoretical foundation and scientific basis for promoting health equity.
Specific objectives included that (1) establishing a theoretical and empirical model of the relationship between childhood SES and later health outcomes;(2) revealing the relationship between childhood SES and self-rated health, activities of daily living(ADL), cognition and depression, respectively;(3) exploring the association between SES mobility and later health outcomes;(4) analyzing the relationship between childhood SES and childhood health and adult SES and different health outcomes;(5) putting forward proposals to reduce health disparities and promote health equity.
Methods
Data came from2011-2012national baseline survey of "The China health and retirement longitudinal study (CHARLS)." Through multi-stage stratified probability proportionate to size (PPS) sampling, CHARLS chose10257households with individuals aged45and older from450administrative villages or communities in150counties or districts of28provinces in China. After excluding the missing and abnormal values,13516people aged45and older from8520households were included in this study.
Descriptive statistics were performed to analyze the general conditions and socioeconomic status of the sample; then univariate and multivariate analyses were used to explore the relationship between childhood SES and different health outcomes. Through Logistic regression model, childhood SES, childhood health and adult SES were included into the model step by step and compared changes in OR value. Then principal component analysis was adopted to build a comprehensive index of childhood SES and adult SES, and explored the relationship between SES mobility and health status. At last, PLS path analysis models were conducted to discuss the relationships between childhood SES, childhood health, adult SES and different health outcomes. Data was analyzed by SPSS16.0and Smart PLS2.0software.
Main results
(1) The relationship between childhood SES and later health outcomes
The proportions of self-reported health of "excellent, good, fair, poor, very poor" were6.9%,15.3%,47.7%,27.4%and2.6%respectively. The rate of damaged ADL was16.8%. The incidence rate of depression was37.7%. The prevalence of hypertension was40.9%and the mean score of cognition was12.73. Univariate analysis showed that lower childhood SES was associated with poor health outcomes except for hypertension. Multivariate analysis showed that when adult SES were controlled, the associations between childhood SES and self-rated health, ADL, depression and hypertension were not significant any more. However, the relationship between childhood SES and cognition remained significant.Those who lived in towns and whose parents'had ever received education had better cognition.
(2) The association between SES mobility trajectories and later health outcomes
The comprehensive score of childhood SES was different across different age, marital status and area groups. The score of childhood SES was higher among those who were younger, married, lived in east and central areas. The comprehensive score of adult SES also varied across different gender, age, marital status and area groups. Those who were male, young, marreid and lived in east area were of higher score in adult SES. The mobility trajectories of SES, categorized as "stable low","downward","upward","stable high", were37.4%,12.6%,21.6%and28.4%, respectively. The proportion of "stable high" was higher among those who were young and married. Women's SES was less likely to rise. Those who had a low childhood SES and then experienced upward mobility had better health outcomes than those with similar childhood SES but limited or no upward mobility. In contrast, those who had high SES in childhood but then experienced downward mobility in adulthood had worse health outcomes than those with stable high SES. But hypertension did not follow the same gradient. Those with "stable low" SES had the highest risk of getting hypertension, while those "downward" had the lowest risk of getting hypertension.
(3) The pathway analysis of childhood SES and different health outcomes
All path analysis models showed that the standardized path coefficient between childhood SES and adult SES were the biggest. The higher childhood SES was, the higher the adult SES was. Those whose childhood SES was higher had better childhood health. Those whose childhood health was better had higher adult SES. For those whose adult SES were higher, their self-rated health, ADL, depression and cognition were better. Childhood SES had a direct effect on cognition, and those whose childhood SES were better had better cognition. But the associations between childhood SES and other health indicators were not statistically significant. The efforts of childhood SES on other health indicators were meditated mostly through the path of childhood health and adult SES. The relationships between childhood health and other health indicators were different. If childhood health was better, the better the self-rated health and the lower the risk of depression would be. But the relationships between childhood health and ADL, hypertension and cognition were not significant.
Conclusions and Recommendations
According to the results, this study came to the following conclusions:
(1) Childhood SES has long-lasting efforts on different health outcomes. People who grew up in relatively disadvantaged conditions had poor health outcomes than those with more privileged childhoods. But for different health outcomes, the associations were different. For self-rated health, ADL, hypertension and depression, a much larger proportion of the effect of childhood SES on later health operated through its effect on childhood health and later SES, which proved "pathway model"; while most of the effect of childhood SES on cognition reflected direct effect, which proved "the cumulative disadvantage model".(2) The negative impact of low childhood SES can be ameliorated if people from a low childhood SES position achieve higher status in later life. On the contrary, the objective impact of high childhood SES can be attenuated if SES deteriorates from higher status in childhood to lower status in later life.(3) Lower childhood SES was associated with lower later SES and the effect of SES could be transferred inter-generationally.(4) Poor childhood health was associated with lower adult SES, which proved "health selective hypothesis".(5) Poor childhood health was associated with worse health outcomes and the health status in early life had long-lasting efforts which would even continue in the whole life.(6) This study demonstrated the importance of current SES for health. Those who lived in rural areas, were less educated, with low income had worse health outcomes. So reducing the differences in SES can help to reduce health inequalities.
These conclusions have following policy implications (1) Attaching great importance to the long-lasting efforts of childhood SES on the whole life and make childhood period as the best opportunity to reduce health disparities. Reducing the disparities of SES could not only reduce health disparities but also has long-lasting efforts on future health.(2) Improving health status and reducing health disparities not only depend on current SES and health service, but also the living conditions of early life, which means improving health system just solve the problem of health system itself. In order to improve health and narrow disparities, more efforts outside of the health system should be taken. We should put it in a macro social economic system and pay more attention to narrow social and economic gap between urban and rural areas and the gap of education.
Innovation and limitations
The innovations includes:(1) The existing study of childhood SES and adult health mainly concentrated in Europe and the United States. Based on life-course theory, this study used large-scale survey data of China and explored childhood SES and physical&mental health comprehensively.(2) With calculating comprehensive SES score, this study explored SES mobility trajectories in life course and filled the research gap in our country.(3) By building pathway analysis model, this study investigated childhood SES, childhood health, later SES and later health outcomes systematically, which helped to reduce health disparities and promote equity.
The limitations includes:(1) Because of limited information in childhood and the changes during long period between childhood and later adulthood, it is difficult to establish possible pathways between childhood SES and health in later life. This study only discussed the association between childhood SES and later health and it was difficult to determine the causal relationships.(2) Those who grew up in disadvantage childhood SES might have died before entering middle age, which could be naturally excluded from the sample of this study and lead to sample selection bias.(3) The measurement of SES included only two points, without considering the conditions at birth and occupation and income before middle age. Because of the limitation of data, this study did not consider the effect, which might affect our conclusion.
大量研究发现利用收入、教育或职业衡量的不同社会阶层中,健康是不平等分布的。早期关于健康的社会经济梯度的研究集中于阐述这些梯度的存在,很少去研究社会经济梯度背后的原因。理论模型和实证研究都致力于解释成年期出现健康差异的原因,但没有一个因素,无论是单独的还是结合的,能完全地解释健康的社会经济梯度。研究者认为,社会经济地位对健康的影响并非是一时的,而是持续的、累积的,人生早期的生活经历会对未来健康产生长远的影响。在生命周期的各个阶段中,儿童期非常关键。儿童期的社会经济地位以及生活环境对成年期社会经济地位以及疾病风险有着长期的影响,这种影响将可能持续一生。
近年来研究者开始关注儿童期的社会经济地位与成年期健康以及长寿的关系,致力于从源头探究健康差异。现有的相关研究主要集中在欧美等发达国家,来自发展中国家的研究非常有限。多数研究的健康指标集中在死亡率以及心血管疾病,部分文献利用了比较单一的健康指标如自评健康、认知功能等,全面综合地从生理、心理等方面评价中老年人健康状况的研究较少,并且在使用不同的指标以及在不同地区的人群中开展研究的时候,得出的结论并不一致。我国作为发展中国家,社会经济水平、人们的健康状况、行为生活方式和发达国家相比都存在较大差异。并且,我国中老年人的生活轨迹可能更为复杂,不可避免地会影响到中老年群体的儿童期及当前的社会经济地位,进而对健康状况造成影响。
研究目的
本研究的总目标是通过理论研究和实证分析,探讨儿童期社会经济地位与中老年健康的关系以及生命历程里社会经济地位的变动对中老年健康状况的影响,为减少健康差异、促进健康公平政策的制定提供理论基础和科学依据。
具体研究目的包括：构建儿童期社会经济地位与中老年健康关系的理论和实证模型；揭示儿童期社会经济地位与中老年自评健康、日常活动能力、认知功能、抑郁症状等健康指标之间的关系；探讨社会经济地位的变动对中老年健康状况的影响；分析儿童期社会经济地位、儿童期健康、中老年期社会经济地位及中老年健康之间的相互关系；提出减少健康差异、促进健康公平的政策建议。
研究方法
本研究数据来源于“中国健康与养老追踪调查(CHARLS)"2011-2012年全国基线调查,CHARLS的抽样方法为多阶段分层概率比例规模抽样。最终抽取28个省(直辖市),150个县(区),450个行政村(社区),本文的研究对象为参与问卷调查及体检的45岁及以上的中老年人,删除关键变量缺失及异常值的样本,本研究最终纳入的家户数为8520,样本量为13516。
在分析方法上,本研究首先对样本的基本情况以及社会经济特征进行了描述和比较；然后利用单因素和多因素分析探讨了儿童期社会经济地位与不同健康指标的关系,通过构建Logistic回归模型,在模型中逐步纳入儿童期社会经济地位、儿童期健康、中老年期社会经济地位,分析逐步控制上述因素后模型的变化；随后通过主成分分析构建儿童期社会经济地位及中老年期社会经济的综合指标,分析生命历程里社会经济地位的变动与健康状况的关系；最后是构建PLS路径分析模型,探讨了儿童期社会经济地位、儿童期健康、中老年期社会经济地位以及不同健康指标之间的关系。资料的统计分析由SPSS16.0软件和Smart PLS2.0软件完成。
主要研究结果
(1)儿童期社会经济地位与中老年健康状况的关系
研究对象自评健康为很好、好、一般、不好、很不好的比例分别为6.9%、15.3%、47.7%、27.4%和2.6%,日常活动能力的受损率为16.8%,抑郁症状的发生率为37.7%,高血压的患病率为40.9%,认知均分为12.73分。除了高血压患病之外,单因素分析均显示,儿童期SES处于劣势的研究对象,中老年期的健康状况较差。在多因素分析中,控制了中老年当前的SES之后,儿童期SES与自评健康、日常活动能力受损、抑郁症状以及高血压患病的关系消失,但与认知功能的关系存在统计学意义,儿童期居住于城镇、父母亲接受过教育的研究对象,中老年期的认知功能更好。
(2)儿童期到中老年期社会经济地位的变动与中老年健康状况的关系
研究对象的年龄、婚姻状况以及地区不同,儿童期SES综合得分存在差异(P<0.001),低龄、在婚、东中部的研究对象,儿童期SES综合得分较高；研究对象的性别、年龄、婚姻状况以及地区不同,中老年期SES的综合得分存在差异(P<0.001),男性、低龄、在婚、东部的研究对象,中老年期SES的综合得分较高。研究对象从儿童期到中老年期SES的变动“保持低水平”、“由高到低”、“由低到高”、“保持高水平”的比例分别为37.4%、12.6%、21.6%和28.4%。低龄组、在婚组“保持高水平”的比例更高,和男性相比,女性的社会经济地位更难上升。SES变动形式不同,自评健康不良率、ADL受损率、高血压患病率、抑郁症状发生率、认知功能均存在统计学差异。儿童期SES较低但经历了SES上升的研究对象与SES未经历上升的相比,健康状况更好；相反,儿童期SES较高但后期经历了SES下降的研究对象与未经历SES下降的相比,健康状况更差。但高血压患病未呈现类似的变化趋势,SES“保持高水平”的研究对象高血压患病风险最高,“保持低水平”的患病风险最低。
(3)儿童期社会经济地位与中老年健康关系的路径分析
所有的PLS路径模型均显示,儿童期SES与中老年SES的标准化路径系数最大,儿童期SES越高,中老年期SES越高；儿童期SES越高,儿童期健康状况越好；儿童期健康状况越好,中老年SES越高；中老年SES越高,自评健康越好,日常活动能力受损越小,抑郁症状发生风险越低,认知功能越好。儿童期SES与不同健康指标的关系有差异,儿童期SES对中老年认知具有直接影响,儿童期SES越高,中老年期认知功能越好,但与其他健康指标的关系,未见统计学意义,儿童期SES与其他健康指标的关系更多是通过儿童期健康及中老年SES的间接作用。另外,儿童期健康与不同健康指标的关系也有差异,儿童期健康状况越好,中老年自评健康越好,抑郁症状发生风险越低,但与ADL、高血压患病以及认知功能的关系未见统计学意义。
结论及建议
根据研究结果,本研究得出如下结论：
(1)儿童期SES对中老年健康具有长远的影响,儿童期SES处于劣势,会增加中老年健康状况不良的风险。但对于不同的健康指标,这种关系的强度不一样,对于自评健康、日常活动能力、高血压患病和抑郁症状,主要是通过儿童期健康及中老年当前的社会经济地位发挥中介作用,证实了“路径模型”；对于认知功能,则更多体现了儿童期SES直接的作用,证实了“累积劣势模型”。(2)儿童期到中老年期SES上移,能部分补偿儿童期不良SES的负面影响,儿童期到中老年期SES下移,早期良好SES的影响会被下移的SES所抵消。(3)儿童期SES处于劣势的研究对象,中老年期SES更为低下。社会经济地位具有代际转移的特点,证实了“地位获得模型”。(4)儿童期健康状况不良的研究对象,中老年期SES更为低下,体现在受教育程度和家庭人均收入较低,验证了“健康选择学说”。(5)儿童期健康状况不良,中老年期的自评健康较差,日常活动能力和抑郁症状发生率较高,人生早期的健康状况产生长远影响,甚至持续终身。(6)研究对象当前的社会经济地位对健康具有重要影响。现居地为农村、受教育程度低、家庭人均收入低的研究对象,自评健康状况较差,日常活动能力受损较严重,抑郁症状发生率较高,认知功能较为低下。因此,缩小社会经济地位的差异有助于降低健康不平等。
上述结论具有如下政策含义(1)重视儿童期社会经济地位对整个生命历程的长远影响,将儿童期作为生命历程里降低健康差异的最佳时机。缩小社会经济地位的差异,不仅能缩小当前的健康差异,而且对未来健康产生潜在的长远影响。(2)改善健康状况,促进健康公平,不仅仅依赖于个人当前的社会经济地位或卫生服务因素,还有赖于早期的生活经历和健康状况。意味着完善卫生系统内的举措只是解决卫生服务本身的问题,要增进健康,促进公平,不仅需要相对完善的卫生服务,更需着力破解卫生系统之外的诸多问题。要将其置于一个宏观的社会经济制度的框架下综合考虑,注重缩小城乡社会经济差异、教育差异。
创新与不足
本研究的创新性(1)现有的关于儿童期社会经济地位与成年健康的研究主要集中在欧美国家,本研究利用我国大规模的调研数据,基于生命历程理论,从生理、心理、认知功能等方面全面探讨儿童期社会经济地位与中老年健康状况的关系,提供来自我国的证据。(2)通过构建综合性的社会经济地位指标,探讨了生命历程里社会经济地位的变动对健康状况的影响,弥补了国内该方面研究的不足。(3)构建PLS路径分析模型,对儿童期SES、儿童期健康、中老年SES以及中老年健康之间的关系进行了系统分析,有利于为减小健康差异、促进公平的政策制定找到干预点。
本研究的不足(1)只掌握了有限的儿童期信息,儿童期到中老年的时间跨度大,且利用的是横断面数据,本研究只是对儿童期社会经济地位与中老年健康之间的关系进行了探讨,难以确定因果关系的方向。(2)对于儿童期社会经济地位低下的个体来说,可能在进入中年之前就已经去世,被排除在本研究的样本之外,可能导致一定的样本选择偏倚。(3)社会经济地位的测量只包括两个时点,而出生时的情况及中期之前的工作收入等都有可能影响健康状况,由于数据的限制,并未考虑这一影响,有可能影响研究结论。
Background
A substantial amount of research has found that health is not equally distributed across social class groups stratified by income, education or occupation. Early literature related to socioeconomic gradients in health expended enormous energy in repeatedly demonstrating their pure presence, with little effort devoted to understanding reasons underlying it. Theoretical models and empirical studies that did attempt to understand the gradients focused on current influential factors in adult that could give rise to different health states across social groups, but none of the factors, either alone or in combination, could fully explain those gradients. Researchers found that the impact of socioeconomic status on health was not temporary but lasting and cumulative. The early life experience will have long-term efforts on future health. Childhood was very critical because childhood socioeconomic and living conditions might have lasting efforts on adult SES and disease risk throughout their whole life.
In recent years, researchers began to pay attention to the associations between childhood SES and adult health, as well as longevity, with the dedication to explore health disparities from the source. The existing research mainly concentrated in developed countries such as America and Europe, and studies from developing countries were very limited. Most studies focused on mortality and cardiovascular disease, and part of the literature only examined one dimension of health, such as self-rated health and cognition. The conclusions were not consistent when different indicators in different populations were measured. As a developing country, there are big differences in socioeconomic status and people's health and life style compared with developed countries. And the life trajectories of old people in our country may be more complex, which could inevitably affect both early and later SES and health outcomes.
Objective
The overarching objective of this study was to explore the relationship between childhood SES and later health outcomes through theoretical research and empirical analysis, as well as the relationship between SES mobility in life course and health outcomes in later life, providing theoretical foundation and scientific basis for promoting health equity.
Specific objectives included that (1) establishing a theoretical and empirical model of the relationship between childhood SES and later health outcomes;(2) revealing the relationship between childhood SES and self-rated health, activities of daily living(ADL), cognition and depression, respectively;(3) exploring the association between SES mobility and later health outcomes;(4) analyzing the relationship between childhood SES and childhood health and adult SES and different health outcomes;(5) putting forward proposals to reduce health disparities and promote health equity.
Methods
Data came from2011-2012national baseline survey of "The China health and retirement longitudinal study (CHARLS)." Through multi-stage stratified probability proportionate to size (PPS) sampling, CHARLS chose10257households with individuals aged45and older from450administrative villages or communities in150counties or districts of28provinces in China. After excluding the missing and abnormal values,13516people aged45and older from8520households were included in this study.
Descriptive statistics were performed to analyze the general conditions and socioeconomic status of the sample; then univariate and multivariate analyses were used to explore the relationship between childhood SES and different health outcomes. Through Logistic regression model, childhood SES, childhood health and adult SES were included into the model step by step and compared changes in OR value. Then principal component analysis was adopted to build a comprehensive index of childhood SES and adult SES, and explored the relationship between SES mobility and health status. At last, PLS path analysis models were conducted to discuss the relationships between childhood SES, childhood health, adult SES and different health outcomes. Data was analyzed by SPSS16.0and Smart PLS2.0software.
Main results
(1) The relationship between childhood SES and later health outcomes
The proportions of self-reported health of "excellent, good, fair, poor, very poor" were6.9%,15.3%,47.7%,27.4%and2.6%respectively. The rate of damaged ADL was16.8%. The incidence rate of depression was37.7%. The prevalence of hypertension was40.9%and the mean score of cognition was12.73. Univariate analysis showed that lower childhood SES was associated with poor health outcomes except for hypertension. Multivariate analysis showed that when adult SES were controlled, the associations between childhood SES and self-rated health, ADL, depression and hypertension were not significant any more. However, the relationship between childhood SES and cognition remained significant.Those who lived in towns and whose parents'had ever received education had better cognition.
(2) The association between SES mobility trajectories and later health outcomes
The comprehensive score of childhood SES was different across different age, marital status and area groups. The score of childhood SES was higher among those who were younger, married, lived in east and central areas. The comprehensive score of adult SES also varied across different gender, age, marital status and area groups. Those who were male, young, marreid and lived in east area were of higher score in adult SES. The mobility trajectories of SES, categorized as "stable low","downward","upward","stable high", were37.4%,12.6%,21.6%and28.4%, respectively. The proportion of "stable high" was higher among those who were young and married. Women's SES was less likely to rise. Those who had a low childhood SES and then experienced upward mobility had better health outcomes than those with similar childhood SES but limited or no upward mobility. In contrast, those who had high SES in childhood but then experienced downward mobility in adulthood had worse health outcomes than those with stable high SES. But hypertension did not follow the same gradient. Those with "stable low" SES had the highest risk of getting hypertension, while those "downward" had the lowest risk of getting hypertension.
(3) The pathway analysis of childhood SES and different health outcomes
All path analysis models showed that the standardized path coefficient between childhood SES and adult SES were the biggest. The higher childhood SES was, the higher the adult SES was. Those whose childhood SES was higher had better childhood health. Those whose childhood health was better had higher adult SES. For those whose adult SES were higher, their self-rated health, ADL, depression and cognition were better. Childhood SES had a direct effect on cognition, and those whose childhood SES were better had better cognition. But the associations between childhood SES and other health indicators were not statistically significant. The efforts of childhood SES on other health indicators were meditated mostly through the path of childhood health and adult SES. The relationships between childhood health and other health indicators were different. If childhood health was better, the better the self-rated health and the lower the risk of depression would be. But the relationships between childhood health and ADL, hypertension and cognition were not significant.
Conclusions and Recommendations
According to the results, this study came to the following conclusions:
(1) Childhood SES has long-lasting efforts on different health outcomes. People who grew up in relatively disadvantaged conditions had poor health outcomes than those with more privileged childhoods. But for different health outcomes, the associations were different. For self-rated health, ADL, hypertension and depression, a much larger proportion of the effect of childhood SES on later health operated through its effect on childhood health and later SES, which proved "pathway model"; while most of the effect of childhood SES on cognition reflected direct effect, which proved "the cumulative disadvantage model".(2) The negative impact of low childhood SES can be ameliorated if people from a low childhood SES position achieve higher status in later life. On the contrary, the objective impact of high childhood SES can be attenuated if SES deteriorates from higher status in childhood to lower status in later life.(3) Lower childhood SES was associated with lower later SES and the effect of SES could be transferred inter-generationally.(4) Poor childhood health was associated with lower adult SES, which proved "health selective hypothesis".(5) Poor childhood health was associated with worse health outcomes and the health status in early life had long-lasting efforts which would even continue in the whole life.(6) This study demonstrated the importance of current SES for health. Those who lived in rural areas, were less educated, with low income had worse health outcomes. So reducing the differences in SES can help to reduce health inequalities.
These conclusions have following policy implications (1) Attaching great importance to the long-lasting efforts of childhood SES on the whole life and make childhood period as the best opportunity to reduce health disparities. Reducing the disparities of SES could not only reduce health disparities but also has long-lasting efforts on future health.(2) Improving health status and reducing health disparities not only depend on current SES and health service, but also the living conditions of early life, which means improving health system just solve the problem of health system itself. In order to improve health and narrow disparities, more efforts outside of the health system should be taken. We should put it in a macro social economic system and pay more attention to narrow social and economic gap between urban and rural areas and the gap of education.
Innovation and limitations
The innovations includes:(1) The existing study of childhood SES and adult health mainly concentrated in Europe and the United States. Based on life-course theory, this study used large-scale survey data of China and explored childhood SES and physical&mental health comprehensively.(2) With calculating comprehensive SES score, this study explored SES mobility trajectories in life course and filled the research gap in our country.(3) By building pathway analysis model, this study investigated childhood SES, childhood health, later SES and later health outcomes systematically, which helped to reduce health disparities and promote equity.
The limitations includes:(1) Because of limited information in childhood and the changes during long period between childhood and later adulthood, it is difficult to establish possible pathways between childhood SES and health in later life. This study only discussed the association between childhood SES and later health and it was difficult to determine the causal relationships.(2) Those who grew up in disadvantage childhood SES might have died before entering middle age, which could be naturally excluded from the sample of this study and lead to sample selection bias.(3) The measurement of SES included only two points, without considering the conditions at birth and occupation and income before middle age. Because of the limitation of data, this study did not consider the effect, which might affect our conclusion.
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