Differential associations between state-level educational quality and cardiovascular health by race: Early-life exposures and late-life health.SSM Popul Health 2019; 8:100418SP
Cardiovascular diseases (CVD) are patterned by educational attainment but educational quality is rarely examined. Educational quality differences may help explain racial disparities. Health and Retirement Study respondent data (1992-2014; born 1900-1951) were linked to state- and year-specific educational quality measures when the respondent was 6 years old. State-level educational quality was a composite of state-level school term length, student-to-teacher ratio, and per-pupil expenditure. CVD-related outcomes were self-reported (N = 24,339) obesity, heart disease, stroke, ever-smoking, high blood pressure, diabetes and objectively measured (N = 10,704) uncontrolled blood pressure, uncontrolled blood sugar, total cholesterol, high-density lipoprotein cholesterol (HDL), and C-reactive protein. Race/ethnicity was classified as White, Black, or Latino. Cox models fit for dichotomous time-to-event outcomes and generalized estimating equations for continuous outcomes were adjusted for individual and state-level confounders. Heterogeneities by race were evaluated using state-level educational quality by race interaction terms; race-pooled, race by educational quality interaction, and race-specific estimates were calculated. In race-pooled analyses, higher state-level educational quality was protective for obesity (HR = 0.92; 95%CI(0.87,0.98)). In race-specific estimates for White Americans, state-level educational quality was protective for high blood pressure (HR = 0.95; 95%CI(0.91,0.99). Differential relationships among Black compared to White Americans were observed for obesity, heart disease, stroke, smoking, high blood pressure, and HDL cholesterol. In race-specific estimates for Black Americans, higher state-level educational quality was protective for obesity (HR = 0.88; 95%CI(0.84,0.93)), but predictive of heart disease (HR = 1.07; 95%CI(1.01,1.12)), stroke (HR = 1.20; 95%CI(1.08,1.32)), and smoking (HR = 1.05; 95%CI(1.02,1.08)). Race-specific hazard ratios for Latino and Black Americans were similar for obesity, stroke, and smoking. Better state-level educational quality had differential associations with CVD by race. Among minorities, better state-level educational quality was predominately associated with poorer CVD outcomes. Results evaluate the 1900-1951 birth cohorts; secular changes in the racial integration of schools since the 1950s, means results may not generalize to younger cohorts.