Comparing Health and Socioeconomic Status in Ohio Counties

Final Paper, Regression Analysis

Spring 2016
Jo Hanna Friend DEpiro, PA-C, MPH
Doctoral Candidate, Workforce Development and Education
Am I sick because I am poor, or am I poor because I am sick? It is both; it should be neither. (Erwin)

Abstract
Socioeconomic status has been shown to have a direct correlation with health at all levels of
income. Those with the least money and lowest social status have the poorest health. (Marmot,
2010) Poverty is common in the United States. Ohio ranks 28th in the nation for poverty and its
overall health rank is 39th. (DeNava & Proctor, 2013, Census, 2014, United Health Foundation)
Using current data available from government sources, this study examines the role of
socioeconomic status as measured by median income and education and the relationships between
health habits (tobacco use and physical inactivity) with health status as measured by years of
potential life lost (YPLL) among the population by counties of the state of Ohio (n = 88). Income
and smoking were the strongest predictors for years of life lost before age 75. Education had a
very modest moderating effect on income for years of life lost.
Introduction
15.8% of Ohios citizens live in poverty, while in the United States, as of September 2015,
14.8% of people were in poverty. (Ohio Poverty Report, 2016, US Census Bureau Quick Facts) In
Ohio, children under 18 years of age are even more greatly affected by poverty with about one in
five living in poverty (23%). (County Health Rankings, 2016) The dollar amount defined by the
US Census, which defines poverty, is irrespective of geographic location but takes age into
consideration (under or over age 65).

Different groups of people are affected by poverty at different rates. Race matters. Minorities
are disproportionately affected by poverty. In Ohio, 8.1 to 12.2 percent of non-Hispanic whites
and 13.9 to 15.9 percent of Asians/Pacific islanders were poor while poverty rates for blacks
ranged from 26.5 to 34.7 percent and Hispanics range between 20 to 25 percent. Marital status
matters. In Ohio, married couple families that were in poverty measured 5.5 percent in 2013 2014 while households headed up by women were in poverty at a whopping rate of 45.4%.
Another 18.4 percent of people in Ohio are close to being poor at less than 200 percent of
poverty level. Geography matters. Counties in southeastern Ohio, in the Appalachian region, were
hard hit with poverty at 17.8 percent. This compares to the poverty rate in the rest of Ohio, which
averaged at about 15.8 percent. Those residing in the urban areas of metropolitan cities were even
more likely to be poor at 28 percent. Education matters. Households with lower educational status
were the most likely to be in a lower quintile of income. Poverty decreased with education from
those who had not graduated from high school (29.8%); to high school degree (13.8%); to some
college (11.6%); and finally to bachelors degree or more (4.0%). (Ohio Poverty Report, 2016)
Factors that off set or mitigate the effects of poverty include education and social support.
Education can confer knowledge, problem-solving skills and a sense of control over life
circumstances.

In 2006, the life expectancy of a 25-year-old American man without a high

school degree was 9.3 years shorter than those with a Bachelors degree or higher education.
(CDC Newsroom, 2012) Education and income are linked. It is estimated that each additional year
of schooling leads to about 11% more income annually. (County Health Rankings, 2016) Higher
paying jobs are more likely than lower paying jobs to provide workers with safe work
environments and offer benefits such as health insurance and sick leave. More educated workers
also fare better in economic downturns (County Health Rankings, 2016) Education is associated

with healthy behaviors and employment and may confer a perceived higher position in a social
hierarchy. Education among young adults could influence behaviors such as accidents and drug
related mortality. (Woolf & Aron, 2013). Self-perceived social status is correlated with health
outcomes. (Boyce, 2012)
The chronic stress of poverty is felt to be a major contributor to illness. This is known as
increased allostatic load. Allostatic load refers to how resting levels of stress hormones adapt or
adjust to experience over time and has been called how experience becomes embedded in
biology or gets under your skin. Increased allostatic load refers to the wear and tear on the
body in response to the inefficient turning on or shutting off of these mechanisms. (McEwen &
Seeman, 2009) Evidence suggests that cardiovascular and metabolic risk vary by socioeconomic
status. Neighborhood poverty affects local social and physical environmental conditions (eg.
Access to food, safe places for physical activity) which influence health related behaviors. This
community poverty is significantly associated with increased allostatic load. These effects are
long lasting. Economic hardship during childhood may lead to a chronic inflammatory state that
later manifests itself with chronic diseases (eg. diabetes and cardiovascular disease.) (Miller &
Chen, 2013)

From: The Ohio Poverty Report (2016) Ohio Development Services Agency

Two modifiable health habits have dramatic impacts on overall health and life expectancy.
Smoking is the leading cause of preventable death in the United States. It affects every organ in
the body and has been attributed to about one in five deaths. (CDC Smoking) It is strongly
associated with cardiovascular disease including strokes and heart attacks and lung cancer and
disease as well as other types of cancer. Tobacco use affects individuals throughout the lifespan
from premature birth, to osteoporosis to early death.

Decreases in physical activity as measured

by walking have been showed to decrease insulin sensitivity, decrease lean body and increase fat.
In turn, these changed are associated with the progress of chronic health disorders and premature
death. More than 35 illnesses have been attributed to lack of physical activity and active
individuals have an approximately 30% lower risk of dying than their sedentary counterparts.
(Booth, Roberts & Laye, 2012)
This paper will examine the prospective effects of socioeconomic status as measured by
income and education and the poor health habits of smoking and lack of exercise on the ultimate
measure of health, untimely death. Education is a vital factor in potentially mitigating the effects
of poverty on health. Combined with income, socioeconomic status and these potent health habits
are expected to be strong predictors of years of potential life lost.
Method
This study was done using existing county level data from the County Health Rankings and
Roadmaps website (County, 2016) which is supported by the Robert Wood Johnson Foundation.
Population
Data about the 88 Ohio counties was accessed from County Health Rankings and Roadmaps
website. Using the Census Bureaus Population Estimates program, this website estimates the

population of Ohio as 11,570,808. In this estimate, 22.8% were below 18 years of age and 15.5%
were older than 65 years. The percent of non-Hispanic whites in Ohio was 80.1%; 12.3% nonHispanic African American; 3.5% Hispanic; 2% Asian; 0.3% American Indian and Alaska Native.
In 2014, 51.1% were estimated to be female and 22.1% of the population lived in rural areas.
(Census, Pop Est)
Measures
Years of Potential Life Lost (YPLL)
Years of potential life lost (YPLL) is a measure of premature death before age 75. The YPLL
measure is the rate of deaths before age 75 per 100,000 population and is age-adjusted to the 2000
US population. This data was from 2011 2013 and derived from the National Center for Health
Statistics - Mortality Files using CDC WONDER.

Tobacco Use

Tobacco use is the percentage of the adult population that currently smokes every day or most
days and has smoked at least 100 cigarettes in their lifetime. The data about smoking was taken
from the 2014 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a state-based
random digit dial (RDD) telephone survey that is conducted among adults over 18 years annually
in all states, the District of Columbia, and U.S. territories. It has included more than 400,000
annual respondents and is age-adjusted to the 2000 U.S. standard population. For the County
Health Rankings, data from the BRFSS are used to measure various health behaviors and healthrelated quality of life (HRQoL) indicators. The measures are self reported and cannot be validated
with medical records.

Physical Inactivity
Physical Inactivity is the percentage of adults aged 20 and over reporting no leisure-time
physical activity. The data was from the 2012 CDC Diabetes Interactive Atlas, which in turn was
derived from the The National Diabetes Surveillance System. This provides county-level
estimates of obesity, physical inactivity, and diabetes using three years of data from CDC's
Behavioral Risk Factor Surveillance System (BRFSS) and data from the U.S. Census Bureaus
Population Estimates Program. (County, 2016)
Education
High school graduation is defined as the percentage of the ninth grade cohort that graduates
from high school in four years. The County Health Rankings data was derived from the 20122013 Department of Educations graduation rates. Some college estimated the percentage of the
populations ages 25-44 with some post-secondary education and was from the 2011 2014
American Community Survey rendered by the U.S. census bureau. The American Community
Survey randomly samples addresses and conducts surveys by mail, phone calls or visits.
Median Income
The median household income data came from the Small Area Income and Poverty Estimates
program through the US Census Bureau. The estimates come from combined data from
administrative records, intercensal population estimates and the decennial census with direct
estimates from the American Community Survey.
Results
Descriptive Statistics
Using SPSS software, correlations among the variables from Ohio county level data on

socioeconomic status as defined by a combination of median income and education level with
smoking and physical inactivity and years of potential life lost were examined first. Overall, there
was significant correlation among most of the variables. Median household income was
moderately negatively correlated with years of potential life lost. (r = -.70, p <.001). Smoking was
moderately positively correlated with years of potential life lost (r = .77, p <.001). Education was
negatively correlated on a short continuum regarding years of potential life lost with the
percentage of adults with secondary education moderately negatively correlated (r = -.48, p < .001)
and high school graduates weakly negatively correlated (r = -.27, p < .001).

Not surprisingly, ill

health habits of smoking (r = -.534, p < .001) and physical inactivity (r = -.563, p < .001) were
negatively correlated with college experience. Smoking (r = -.77, p < .001) and physical
inactivity (r = .50, p < .001) were moderately negatively correlated to income. All correlation,
means and standard deviations of observed means can be found in Table 1.

Regression Analyses
Hierarchical multiple regression was then conducted to examine the main effects of adverse
health habits of smoking and physical inactivity on socioeconomic status. Smoking and physical

inactivity were regressed on baseline socioeconomic variables of median income (square root) and
college and high school education. Because the median income was skewed far to the right, the
square root of income was substituted for this variable in the regression model. The interaction of
education level X square root of median income was examined in separate models by college and
high school education respectively. Significant interactions were conditioned at high (+1 SD) and
low (-1 SD) levels of the moderator to determine the nature of the interaction.
Years of Potential Life Lost (YPLL)
First-order effects of income indicated a close relationship with health as measured by
diminishing years of potential life lost (YPLL) ( = -47.74, p < .001). Income remained a
significant predictor in the second regression ( = -20.09, p = .04) even with the added risk factors
of smoking and physical inactivity. Education, either college ( = -16.47, p > .28; = -5.20, p = >
.72) or high school ( = -23.21, p > .17; = -15.70, p > .30) completion, were not significant
predictors of years of life lost in either regression. Smoking dramatically diminished years of
potential life lost ( = 413.49, p < .001) while physical inactivity was not a significant predictor (
= 11.78, p > .74) For first order effects for socioeconomic status and years of life lost, please see
Table 2.

Income and Education

Although not statistically significant, there was a trend for high school education to moderate
the relationship between income and years of life lost. ( = .4037, p > .71). The higher the level
of high school graduation rates, the greater the effect (high = -8.65, p >.54); (moderate = -5.70,
p > .45) and (low = -2.7, p >.68). College experience played a greater role in years of life lost (
= .9391, p = .03). The percentage of college experience in moderating years of life lost was
statistically significant at the low and moderate percentage of college attendance ( = -27.24, p = .
03; = -18.07, p = .04) but not at the highest rates of college educated adults ( = -8.89, p > .15).

Fig. 1 Relationship between income and years

of potential life lost at high, moderate and
low levels of high school graduation rates.

Fig. 1 Relationship between some income and years

of potential life lost at high, moderate and
low levels of percentages of college experience.

Discussion
The primary purpose of this study was to examine the effect of socioeconomic status and poor
health habits on health and the moderating effect of education on income and health. Income was
a strong predictor of socioeconomic status and consequently life lost despite poor health habits.
Combined with education, income was able to predict a large percentage of potential years of life
lost. Among the independent variable, smoking was the strongest predictor of years of life lost
before age 75. Education has some potential to moderate years of life lost. Physical inactivity was
a poor predictor in this study for years of life lost.
The effect of income on health is profound. Although establishing causality is challenging, the
Institute of Medicine (IOM) in a 2013 document asserts that there are links between social factors
and health. (Woolf & Aron, 2013) Sir Michael Marmot, who chaired the World Health
Organisations Commission on Social Determinants of Health, asserts that The two (SES status
and health) are linked: the more favoured people are socially and economically, the better their
health. (Marmot, 2010) In the United States, those in the lowest income quartile had a mortality
rate 2.66 times greater than of those in the highest quartile during the 1990s. (Wolfe, 2011)
Unhealthy behaviors such as smoking and overweight tend to be associated with poverty and that
was true in our data. However, the IOM study notes that over time, the association between
adverse economic conditions and mortality persist even after adjusting for these unhealthy
behaviors. (Woolf & Aron, 2013) Using income as a marker of socioeconomic status, this study
was consistent with the literature. However, using this data, education was a weak predictor.
There are several limitations to this study. Using aggregated data from counties does not reflect
the diversity either between the counties or within an individual Ohio county. This was reflected

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by the striking outlier of Holmes county that shelters a large Mennonite and Amish community
who would not be able to be contacted by telephone and although physically active, would not
necessarily participate in physical activity outside work related concerns. The income level in
Holmes count was close to the median ($50.069) but its higher education rate was very low (23%)
while its YPLL was 5500. There was a wide disparity in median income among the counties with
the range from $34,116 to $97,802. The population of the counties also varied greatly from the
least populous, Vinton county, (population 13,276) to Cuyahoga county, (population 1,263,154).
Some Ohio counties are primarily urban while others are rural in nature reflecting very different
lifestyles.
Using years of potential life lost as a measurement of health has some drawbacks. Public health
professionals use it in order to develop strategies to prevent deaths but it does not reflect health
among specific age groups and emphasizes risk of death for younger persons. Deaths at younger
ages are essentially weighted in this measurement so it is probably not useful in examining chronic
causes of death, which are more likely to affect the elderly. Deaths that occur after age 75 are not
accounted for.
This was an interesting topic and would be worthwhile evaluating for our state and even more
localized areas. Many other variables affecting health such as food environment, alcohol use,
access to care, physical environment and crime could account for even more causes of years of life
lost. Combining a more discrete study in a small area with a more homogenous population using
one countys data or even zip codes could refine this examination further.

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