Abstract
This paper estimates the extent to which childhood circumstances contribute to health inequality in old age and evaluates the importance of major domains of childhood circumstances to health inequalities in the USA and China. We link two waves of the China Health and Retirement Longitudinal Study in 2013 and 2015 with the newly released 2014 Life History Survey, and two waves of the Health and Retirement Study in 2014 and 2016 with the newly released 2015 Life History Mail Survey in the USA, to quantify health inequality due to childhood circumstances for which they have little control. Using the Shapley value decomposition approach, we show that childhood circumstances may explain 7–16 and 14–30% of health inequality in old age in China and the USA, respectively. Specifically, the contribution of childhood circumstances to health inequality is larger in the USA than in China for self-rated health, mental health, and physical health. Examining domains of childhood circumstance, regional and rural/urban status contribute more to health inequality in China, while family socioeconomic status contributes more to health inequality in the USA. Our findings support the value of a life course approach in identifying the key determinants of health in old age. Distinguishing sources of health inequality and rectifying inequality due to early childhood circumstances should be the basis of policy promoting health equity.
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Notes
The number of older persons—those aged 60 years or over—has increased substantially, from 0.61 billion (or 9.9% of the population) in 2000 to 0.90 billion (or 12.3% of the population) in 2015 in the world. This growth is projected to accelerate in the coming decades, to reach almost 1.40 billion (or 16.5% of the population) by 2030 and nearly 2.09 billion (or 21.5% of the population) by 2050 in the world (United Nations 2015).
A life course approach emphasizes a temporal and social perspective, looking back across an individual’s or a cohort’s life experiences or across generations for clues to current patterns of health and disease, while recognizing that both past and present experiences are shaped by the wider social, economic and cultural context (WHO 2000).
Inequality of Opportunity in health refers to health inequality due to circumstances that are beyond individual control (Roemer 2002). Childhood circumstances are the main factors beyond individual control, since individuals cannot be held responsible for their birth lottery. In contrast, efforts can be freely chosen by individuals according to their preferences and, hence, may contribute to health inequality.
Let us suppose there are two individuals with logarithmic values of health outcome \({\text{lnx}}_{1}\) and \({\text{lnx}}_{2}\), respectively. According to Jensen's Inequality, MLD increases with inequality \(- \left( {{\text{lnx}}_{1} + {\text{lnx}}_{2} } \right)/2 > - \ln \left[ {({\text{x}}_{1} + {\text{x}}_{2} } \right)/2]\). The MLD is nonnegative, takes the value zero when everyone has the same health status, and takes larger positive values as health becomes more unequal.
\(\varPhi_{{\left( {\mu , f} \right)}}\) has a cumulative distribution function that is a step function, with as many steps as types. This is often called the ‘smoothed’ distribution of \(F\) associated with the typology \(\left( {f,\mu } \right)\).
The 150 county-level units were randomly selected using probability proportional to size (PPS) and stratified by region, urban/rural and county-level gross domestic product (GDP). Within each county-level unit, three village-level units (villages in rural areas and urban communities in urban areas) were randomly selected using PPS as primary sampling units (PSUs). Within each PSU, 80 dwellings were randomly selected from a complete list of dwelling units generated from a map** or listing operation, using augmented Google Earth maps (Google Inc) along with considerable ground checking. In scenarios with more than one age-eligible household in a dwelling unit, one was randomly selected. From this sample for each PSU, the proportion of households with age-eligible members was determined, as was the proportion of empty residences. From these proportions and an assumed response rate, we selected households from our original PSU frame to obtain a target number of 24 age-eligible households per PSU. Thus, the final household sample size in a PSU depended on the PSU age-eligibility and empty residence rates. In each household, one person aged 45 years or older was randomly chosen as the main respondent, and the individual’s spouse was automatically included. On the basis of this sampling procedure, 1 or 2 individuals in each household were interviewed depending on the marital status of the main respondent.
The HRS sample is selected under a multi-stage area probability sample design. The first stage involves PPS selection of U.S. Metropolitan Statistical Area(MSA) and non-MSA counties. The second stage involves sampling of area segments (SSUs) within sampled PSUs. The third stage includes a complete listing (enumeration) of all housing units (HUs) that are physically located within the bounds of the selected SSUs. The final stage includes the selection of the household financial unit within a sample HU (Heeringa and Connor 1995). More information about the sample design is provided in Sonnega et al. (2014).
Specifically, in terms of the choice of cutoff, Andresen et al. (1994) proposed a 10-item CES-D (total score ranges from 0 to 30) and suggested a cutoff of 10. HRS adopts 8-item CES-D as the measurement of mental health. The possible range for 8-item CES-D is 0-8, and a value of 3 is often used as the cutoff. At a cutoff point of 3 or higher for the 8-item CES-D, Turvey et al. (1999) found high levels of both sensitivity and specificity.
We follow the most adopted rule in existing studies to divide China into 6 regions and the USA into 11 regions to facilitate comparisons with the mainstream literature. While the set of regional and urban/rural status in the CHARLS is smaller than in the HRS, our findings are robust to alternative divisions of regions not reported here.
Overall, all seven domains of childhood circumstances are comparable between the USA and China. These domains range from macro-level regional circumstances to micro-level family circumstances. However, due to the differences in economic development, institutions and culture between the USA and China, some of the specific variables within the circumstances domains differ. For example, parents’ political affiliation (e.g. communist party membership) is an important indicator of family SES in China, but is less important and not provided in America’s HRS survey. The range of number of books at home in childhood is an important circumstances variable in the USA, but not surveyed in China’s CHARLS. Therefore, the subset of circumstances in the robustness check exclude all variables that could not be well matched between CHARLS (China) and HRS (USA), including being inconsistently measured or nonexistent in one country.
The sample sizes of age cohort 60 +, 50–59, and 45–49 are 8255, 6062 and 3219 in the CHARLS 2013/2015.
Since the age cohort 50–59 in HRS only includes about 700 respondents, we use the age cohort 50–64 with about 1400 persons to enlarge the sample size. The sample sizes of age cohort 60 + and 50–59 are 14,167 and 4542 in the HRS 2014/2016 without life history data, and 3014 and 713 in the HRS 2014/2016 with life history data. Therefore, there seems little sample bias between age cohort 60 + and 50–59.
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Acknowledgements
Dr. Yan is supported by the Natural Science Foundation of China (71974097, 71503129) and the Fundamental Research Funds for the Central Universities (SKCX2019006), a project funded by the Priority Academic Program Development of Jiangsu Higher Education Institute (PAPD), a research grant by China Center for Food Security Studies at Nan**g Agricultural University, and Jiangsu Center of Agricultural Modernization. Dr. Gill is the recipient of an Academic Leadership Award (K07AG043587) from the National Institute on Aging. Drs. Gill and Chen are supported by the Yale Claude D. Pepper Older Americans Independence Center (P30AG21342). Dr. Chen acknowledges financial support from the James Tobin Research Fund at Yale Economics Department, NIH/NIA grants (R03AG048920; K01AG053408), and faculty research grant awarded by Yale Macmillan Center (2017–2019). We are grateful to Maya Mahin for research assistance. The authors declare that there is no conflict of interest regarding the preparation of this manuscript.
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Appendices
Appendix 1
Appendix 2: Measuring Relative Contribution of Each Domain of Childhood Circumstances
The overall contribution \(\hat{r}\) can be neatly decomposed into components \(\hat{r}^{j}\) for each category j in childhood circumstances C with the idea of the Shapley approach.
where j, k=1, 2, … are categories of childhood circumstances. \(\alpha_{j}\) and \(\alpha_{k}\) are coefficients of categories j and k. Equation (4) presents an example of a Shapley Value Decomposition. This approach provides an appropriate way to assign roles to sources in generating health inequality (Björklund et al. 2012; Ferreira and Gignoux 2013; Jusot et al. 2013; Shorrocks 2013; Roemer and Trannoy 2016).
A particular category j’s overall contribution to the variance in Y—\(\hat{r}^{j}\)—corresponds to an average between two channels. Intuitively, childhood circumstances may not only directly impact health in old age, but exert their effects indirectly through sha** other childhood circumstances and adulthood efforts. Formally, all \(C_{j \ne J}^{j}\) are held constant in the direct contribution of category j, i.e. \(a_{j}^{2} \left( {var Y} \right)^{ - 1} var C^{j}\). Regarding the indirect contribution, category j itself is held constant, and its indirect contribution, i.e. \(\frac{1}{2}\left( {var\,Y} \right)^{ - 1} \sum\nolimits_{k} {a_{k} a_{j} cov\left( {C^{k} ,C^{j} } \right)}\), is taken as the difference between the total variance and the ensuing variance.
To compute the Shapley value decomposition, we first estimate the inequality measure for all possible permutations of the circumstance variables. In a second step, the average marginal effect of each circumstance variable on the measure of IOP is computed (Juarez and Soloaga 2014). This procedure is very computationally intensive as 2 K (K= number of circumstances) must be computed.
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Chen, X., Yan, B. & Gill, T.M. Childhood Circumstances and Health Inequality in Old Age: Comparative Evidence from China and the USA. Soc Indic Res 160, 689–716 (2022). https://doi.org/10.1007/s11205-020-02436-2
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DOI: https://doi.org/10.1007/s11205-020-02436-2