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Race by Gender Group Differences in the Protective Effects of Socioeconomic Factors Against Sustained Health Problems Across Five Domains



Despite the existing literature on the central role of socioeconomic status (SES; education and income) for maintaining health, less is known about group differences in this effect. Built on the intersectionality approach, this study compared race by gender groups for the effects of baseline education and income on sustained health problems in five domains: depressive symptoms, insomnia, physical inactivity, body mass index (BMI), and self-rated health (SRH).


Data came from waves 7, 8, and 10 of the Health and Retirement Study (HRS), which were collected in 2004, 2006, and 2010, respectively. The study followed 37,495 white and black men and women above age 50 for up to 6 years. This number included 12,495 white men, 15,581 white women, 3839 black men, and 5580 black women. Individuals reported their depressive symptoms (Center for Epidemiological Studies-Depression (CES-D) 11), insomnia, physical inactivity, BMI, and SRH across all waves. Multigroup structural equation modeling (SEM) was used to compare black men, black women, white men, and white women for the effects of education and income in 2004 on sustained health problems from 2004 to 2010.


In the pooled sample, higher education and income at baseline were associated with lower sustained health problems across all five domains. However, race by gender group differences were found in the effects of education and income on sustained insomnia, physical inactivity, and BMI, but not depressive symptoms and SRH. The protective effects of education against insomnia, physical inactivity, and BMI were not found for black men. For black women, the effect of education on BMI was not found. Income had a protective effect against sustained high BMI among white and black women but not white and black men.


The intersection of race and gender alters the protective effects of social determinants on sustained health problems such as insomnia, physical inactivity, and BMI. Social groups particularly vary in the operant mechanisms by which SES contributes to maintaining health over time. The health effects are less universal for education than income. Race by gender groups differ more in SES determinants of BMI, insomnia, and physical inactivity than depressive symptoms and SRH.

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  1. 1.

    Pampel FC, Krueger PM, Denney JT. Socioeconomic disparities in health behaviors. Annu Rev Sociol. 2010;36:349–70.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60–76. doi:10.1377/hlthaff.21.2.60.

    Article  Google Scholar 

  3. 3.

    Pamuk E, editor. Health United States 1998: with socioeconomic status and health chart book. PA, USA: DIANE Publishing; 1999.

  4. 4.

    Mare R.D.. “Socio-economic careers and differential mortality among older men in the U.S.”. In: Vallin J, D’Souza S, Palloni A, editors. Measurement and Analysis of Mortality—New Approaches. Oxford: Clarendon; 1990. p. 362–387.

  5. 5.

    Lantz PM et al. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of U.S. adults. J Am Med Assoc. 1998;279(21):1703–8.

    CAS  Article  Google Scholar 

  6. 6.

    Pappas G. et 72 Socioeconomic disparities health affairs ~ Volume 21, Number 2 SES & Health on June 16, 2016 by HW Team Health Affairs by Downloaded from al., “The Increasing Disparity in Mortality between Socioeconomic Groups in the United States, 1960 and 1986”. N Engl J Med. 1993;329(2):103–9.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Nandi A, Glymour MM, Subramanian SV. Association among socioeconomic status, health behaviors, and all-cause mortality in the United States. Epidemiology. 2014;25(2):170–7.

    Article  PubMed  Google Scholar 

  8. 8.

    Assari S, Lankarani MM. Race and urbanity alter the protective effect of education but not income on mortality. Front Public Health. 2016;4:100. doi:10.3389/fpubh.2016.00100.

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Assari S. Cross-country variation in additive effects of socio-economics, health behaviors, and comorbidities on subjective health of patients with diabetes. J Diabetes Metab Disord. 2014;13(1):36. doi:10.1186/2251-6581-13-36.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Assari S, Lankarani MM. Does multi-morbidity mediate the effect of socioeconomics on self-rated health? Cross-country differences. Int J Prev Med. 2015;6:85. doi:10.4103/2008-7802.164413.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Assari S. Cross-country differences in the additive effects of socioeconomics, health behaviors and medical comorbidities on disability among older adults with heart disease. J Tehran Heart Cent. 2015;10(1):24–33.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Adams P, Hurd MD, McFadden D, Merril A, Ribeiro T. Health, wealthy and wise. Tests for direct causal paths between health and socioeconomic status. J Econometrics. 2003;112:3–56. doi:10.1016/S0304-4076(02)00145-8.

    Article  Google Scholar 

  13. 13.

    Assari S, Lankarani RM, Lankarani MM. Cross-country differences in the association between diabetes and disability. J Diabetes Metab Disord. 2014;13(1):3. doi:10.1186/2251-6581-13-3.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Assari S, Lankarani MM. Education and alcohol consumption among older Americans; black-white differences. Front Public Health. 2016;4:–67. doi:10.3389/fpubh.2016.00067.eCollection 2016.

  15. 15.

    Mustard CA, Etches J. Gender differences in socioeconomic inequality in mortality. J Epidemiol Community Health. 2003;57(12):974–80.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Assari S. Combined racial and gender differences in the long-term predictive role of education on depressive symptoms and chronic medical conditions. J Racial Ethn Health Disparities. 2016.

  17. 17.

    Vlassoff C. Gender differences in determinants and consequences of health and illness. J Health Popul Nutr. 2007;25(1):47–61.

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Assari S, Moghani Lankarani M, Kazemi Saleh D, Ahmadi K. Gender modifies the effects of education and income on sleep quality of the patients with coronary artery disease. Int Cardiovasc Res J. 2013;7(4):141–6.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Annang L, Walsemann KM, Maitra D, Kerr JC. Does education matter? Examining racial differences in the association between education and STI diagnosis among black and white young adult females in the U.S. Public Health Rep. 2010;125(Suppl 4):110–21.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    King D. Multiple jeopardy, multiple consciousness: the context of a black feminist ideology. Signs. 1989;14:42–72.

    Article  Google Scholar 

  21. 21.

    Zajacova A, Hummer RA. Gender differences in education effects on all-cause mortality for white and black adults in the United States. Soc Sci Med. 2009;69(4):529–37. doi:10.1016/j.socscimed.2009.06.028.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Hauser RM, Willis RJ. Survey design and methodology in the health and retirement study and the Wisconsin longitudinal study. In: Waite LJ, editor. Aging, health, and public policy: demographic and economic perspectives. New York: The Population Council, Inc; 2005. p. 209–35.

    Google Scholar 

  23. 23.

    Heeringa SG, Connor JH. Technical description of the health and retirement survey sample design. 1995. Available from:

  24. 24.

    Sonnega A, Faul JD, Ofstedal MB, Langa KM, Phillips JW, Weir DR. Cohort profile: the health and retirement study (HRS). Int J Epidemiol. 2014;43(2):576–85. doi:10.1093/ije/dyu067.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Kaufmann CN, Canham SL, Mojtabai R, et al. Insomnia and health services utilization in middle-aged and older adults: results from the health and retirement study. J Gerontol A Biol Sci Med Sci. 2013;68:1512–7. doi:10.1093/gerona/glt050.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Leggett A, Pepin R, Sonnega A, Assari S. Predictors of new onset sleep medication and treatment utilization among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2016;71(7):954–60. doi:10.1093/gerona/glv227.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Feinglass J, Thompson JA, He XZ, Witt W, Chang RW, Baker DW. Effect of physical activity on functional status among older middle-age adults with arthritis. Arthritis Rheum. 2005;53(6):879–85.

    Article  PubMed  Google Scholar 

  28. 28.

    Taylor AW, Dal Grande E, Gill TK, Chittleborough CR, Wilson DH, Adams RJ, et al. How valid are self-reported height and weight? A comparison between CATI self-report and clinic measurements using a large cohort study. Aust N Z J Public Health. 2006;30(3):238–46.

    Article  PubMed  Google Scholar 

  29. 29.

    Simon GE, Von Korff M, Saunders K, Miglioretti DL, Crane PK, van Belle G, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63(7):824–30. doi:10.1001/archpsyc.63.7.824.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Gavin AR, Rue T, Takeuchi D. Racial/ethnic differences in the association between obesity and major depressive disorder: findings from the comprehensive psychiatric epidemiology surveys. Public Health Rep. 2010;125(5):698–708.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Steffick DE. Documentation of affective functioning measures in the health and retirement study. HRS AHEAD documentation report. Ann Arbor, MI: University of Michigan; 2000.

    Book  Google Scholar 

  32. 32.

    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.

    Article  Google Scholar 

  33. 33.

    Allison PD. Structural equation modeling with Amos: basic concepts, applications, and programming. 2 ed. New York, NY: Taylor and Francis Group; 2002.

    Google Scholar 

  34. 34.

    Arbuckle JL. Amos 18 user's guide. Chicago, IL: Amos Development Corporation; 2009.

    Google Scholar 

  35. 35.

    Kline RB. Principles and practice of structural equation modeling. 3 ed. New York: Guilford press; 2011.

    Google Scholar 

  36. 36.

    Hu G, Bouchard C, Bray GA, Greenway FL, Johnson WD, Newton RJ, et al. Trunk versus extremity adiposity and cardiometabolic risk factors in white and African American adults. Diabetes Care. 2011;34(6):1415–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Dion PA. Interpreting structural equation modeling results: a reply to Martin and Cullen. J Bus Ethics. 2008;83(3):365–8.

  38. 38.

    Lei M, Lomax RG. The effect of varying degrees of nonnormality in structural equation modeling. Struct Equ Modeling. 2005;12(1):1–27.

    Article  Google Scholar 

  39. 39.

    Tabachnick BG, Fidell LS. Using multivariate statistics. 3 ed. New York: Harper Collins; 1996.

    Google Scholar 

  40. 40.

    King M. Occupational segregation by race and gender, 1940–1989. Monthly Labor Rev. 1992;115(4):30–7.

    Google Scholar 

  41. 41.

    Kmec J. Minority job concentration and wages. Soc Probl. 2003;50:38–59.

    Article  Google Scholar 

  42. 42.

    Spalter-Roth R. Race and ethnicity in the labor market; employer practices and worker strategies. In: Hernan V, Feagin JR, editors. Handbooks of the Sociology of Racial and Ethnic Relations. USA: Springer; 2007. p. 263–83.

  43. 43.

    Altonji JG, Blank RM. Race and gender in the labor market. In: Ashenfelter O, Card D, editors. Handbook of labor economics, vol. Vol. 3C. Amsterdam: Elsevier Science; 1999. p. 3143–259.

    Google Scholar 

  44. 44.

    Proudford KL, Nkomo S. Race and ethnicity in organizations. In: Konrad A, Prasad P, Pringle J, editors. Handbook of workplace diversity. London: SAGE; 2006. p. 323–44.

    Google Scholar 

  45. 45.

    Grodsky E, Pager D. The structure of disadvantage: individual and occupational determinants of the black-white wage gap. Am Sociol Rev. 2001;66(4):542–67.

    Article  Google Scholar 

  46. 46.

    Huffman ML, Cohen PN. Racial wage inequality: job segregation and devaluation across US labor markets. AJS. 2004;109(4):902–36. doi:10.1086/378928.

    Google Scholar 

  47. 47.

    Mintz B, Daniel Krymkowski D. The ethnic, race, and gender gaps in workplace authority: changes over time in the United States. Sociol Q. 2010;51:20–45.

    Article  Google Scholar 

  48. 48.

    McCall L. The complexity of intersectionality. Signs. 2005;30:1771–800.

    Article  Google Scholar 

  49. 49.

    England P, Karen C, Reid L. Gender, race, ethnicity, and wages. In: Browne I, editor. Latinas and African American women at work: race, gender, and economic inequality. New York: Russell Sage Foundation; 1999. p. 139–82.

    Google Scholar 

  50. 50.

    Cotter D, Hermsen J, Vanneman R. Systems of gender, race, and class inequality: multilevel analyses. Social Forces. 1999;78:433–60.

    Article  Google Scholar 

  51. 51.

    Pager D, Western B, Sugie N. Sequencing disadvantage: barriers to employment facing young black and white men with criminal records. Ann Am Acad Pol Soc Sci. 2009;623(1):195–213.

    Article  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Montez JK, Hummer RA, Hayward MD, Woo H, Rogers RG. Trends in the educational gradient of US adult mortality from 1986 through 2006 by race, gender, and age group. Res Aging. 2011;33(2):145–71.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Everett BG, Rehkopf DH, Rogers RG. The nonlinear relationship between education and mortality: an examination of cohort, race/ethnic, and gender differences. Popul Res Policy Rev. 2013;32(6):893–917.

    Article  Google Scholar 

  54. 54.

    Crimmins EM, Hayward MD, Seeman TE. Race/ethnicity, socioeconomic status, and health. Critical perspectives on racial and ethnic differences in health in late life. Washington, DC: National Academies Press; 2004. p. 310–52.

    Google Scholar 

  55. 55.

    Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010;1186(1):69–101.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Assari S. Racial disparities in the link between education and mortality in United States. JAMA. Under review. 2016.

  57. 57.

    Montez JK, Hayward MD, Brown DC, Hummer RA. Why is the educational gradient of mortality steeper for men? J Gerontol B Psychol Sci Soc Sci. 2009;64(5):625–34. doi:10.1093/geronb/gbp013.

    Article  PubMed  Google Scholar 

  58. 58.

    Zajacova A, Hummer RA. Gender differences in education effects on all-cause mortality for white and black adults in the United States. Soc Sci Med. 2009;69(4):529–37.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Amin V, Behrman JR, Spector TD. Does more schooling improve health outcomes and health related behaviors? Evidence from U.K. twins. Econ Educ Rev. 2013;35:134–48.

    Article  Google Scholar 

  60. 60.

    Marmot M. The health gap: the challenge of an unequal world. Bloomsbury Publishing; 2015 Sep 10.

  61. 61.

    Mintz B, Krymkowski DH. The intersection of race/ethnicity and gender in occupational segregation: changes over time in the contemporary United States. Int J Sociol. 2010;40(4):31–58.

    Article  Google Scholar 

  62. 62.

    Stainback K, Robinson C, Tomaskovic-Devey D. Race and workplace integration: a politically mediated process? Am Behav Sci. 2005;48:1200–28.

    Article  Google Scholar 

  63. 63.

    Pager D, Western B, Bonikowski B. Discrimination in a low-wage labor market: a field experiment. Am Sociol Rev. 2009;74(5):777–99.

    Article  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Tomaskovic-Devey D. The gender and race composition of jobs and the male/female, white/black pay gaps. Soc Forces. 1993;72(1):45–76. doi:10.1093/sf/72.1.45.

    Article  Google Scholar 

  65. 65.

    IWPR. Importance of social security by gender, race/ethnicity, and marital status. The Institute for Women’s Policy Research (IWPR). 2010. Available from: Accessed March 2016

  66. 66.

    Jencks C, Mayer SE. Residential segregation, job proximity, and black job opportunities. Inner-City poverty in the United States. Washington, DC: National Academy Press; 1990. p. 187–222.

    Google Scholar 

  67. 67.

    Grogger J. Does school quality explain the recent black/white wage trend? J Labor Econ. 1996;14(2):231–53. doi:10.1086/209810.

    Article  Google Scholar 

  68. 68.

    Kalleberg A, Knoke D, Marsden P, Spaeth J. Organizations in America: analyzing their structures and human resources practices. Thousand Oaks, CA: Sage; 1996.

    Google Scholar 

  69. 69.

    Tomaskovic-Devey D, Stainback K, Taylor T, Zimmer C, Robinson C, McTague T. Documenting desegregation: segregation in American workplaces by race, ethnicity, and sex, 1966–2003. Am Sociol Rev. 2006;71:565–88.

    Article  Google Scholar 

  70. 70.

    Tomaskovic-Devey D, Stainback K. Discrimination and desegregation: equal opportunity progress in U.S. private sector workplaces since the civil rights act. Ann Am Acad Polit Soc Sci. 2007;609:49–84.

    Article  Google Scholar 

  71. 71.

    Mackenbach JP, Kulhánová I, Bopp M, Deboosere P, Eikemo TA, Hoffmann R, et al. Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the “fundamental causes” theory of social inequalities in health. Soc Sci Med. 2015;127:51–62. doi:10.1016/j.socscimed.2014.05.021.

    Article  PubMed  Google Scholar 

  72. 72.

    Assari S. Distal, intermediate, and proximal mediators of racial disparities in renal disease mortality in the United States. J Nephropathol. 2016;5(1):51–9. doi:10.15171/jnp.2016.09.

    Article  PubMed  Google Scholar 

  73. 73.

    Assari S. Race and ethnic differences in additive and multiplicative effects of depression and anxiety on cardiovascular risk. Int J Prev Med. 2016;7(1):22. doi:10.4103/2008-7802.173931.

    Article  PubMed  PubMed Central  Google Scholar 

  74. 74.

    Watkins DC, Assari S, Johnson-Lawrence V. Race and ethnic group differences in comorbid major depressive disorder, generalized anxiety disorder, and chronic medical conditions. J Racial Ethn Health Disparities. 2015;2(3):385–94.

    Article  PubMed  Google Scholar 

  75. 75.

    Assari S, Lankarani MM. Association between stressful life events and depression; intersection of race and gender. J Racial Ethn Health Disparities. 2016;3(2):349–56. doi:10.1007/s40615-015-0160-5.

    Article  PubMed  Google Scholar 

  76. 76.

    Assari S, Lankarani MM. Stressful life events and risk of depression 25 years later: race and gender differences. Front Public Health. 2016:4–49. doi:10.3389/fpubh.2016.00049.

  77. 77.

    Assari S, Moazen-Zadeh E, Lankarani MM, Micol-Foster V. Race, depressive symptoms, and all-cause mortality in the United States. Front Public Health. 2016:4–40. doi:10.3389/fpubh.2016.00040.

  78. 78.

    Assari S, Sonnega A, Pepin R, Leggett A. Residual effects of restless sleep over depressive symptoms on chronic medical conditions: race by gender differences. J Racial Ethn Health Disparities. 2016. doi:10.1007/s40615-015-0202-z.

  79. 79.

    Assari S, Lankarani MM, Burgard S. Black-white difference in long-term predictive power of self-rated health on all-cause mortality in United States. Ann Epidemiol. 2016;26(2):106–14. doi:10.1016/j.annepidem.2015.11.006.

    Article  PubMed  Google Scholar 

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A public use dataset was used, available at the study website at University of Michigan. The Health and Retirement Study (HRS) is conducted by the Survey Research Center, Institute for Social Research, University of Michigan. The National Institute on Aging (NIA) provided funding for the Health and Retirement Study (U01 AG09740).

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Correspondence to Shervin Assari.

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Source of Support

Shervin Assari is supported by the Heinz C. Prechter Bipolar Research Fund and the Richard Tam Foundation at the University of Michigan Depression Center.

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All authors declare that they do not have any conflicts of interest.

Ethical Approval

The study received IRB approval from University of Michigan. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) with the Helsinki Declaration of 1975, as revised in 2000.

Informed Consent

Informed consent was obtained from all participants included in the study.

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No animal studies were carried out by the authors for this article.

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Assari, S., Nikahd, A., Malekahmadi, M.R. et al. Race by Gender Group Differences in the Protective Effects of Socioeconomic Factors Against Sustained Health Problems Across Five Domains. J. Racial and Ethnic Health Disparities 4, 884–894 (2017).

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  • Ethnic groups
  • Blacks
  • Whites
  • Gender
  • Depression
  • Activity
  • Obesity
  • Body mass index
  • Education
  • Income