As illustrated in , we observed differences in the baseline distribution of material disadvantage across age, gender, racial/ethnic, and education groups in all 3 resource domains examined (health care, food, and housing). Differences between older (≥65 years) and younger (51 to 64 years) respondents were significant for all individual components in the health care and food disadvantage domains but were more modest in the housing domain. Participants under 65 years of age, most of whom were not yet eligible for Medicare, reported substantially more problems with foregone prescriptions because of cost (11.5% vs 6.6%). By contrast, uninsurance or underinsurance was more common in the older age group, which reflected a higher prevalence of underinsurance because of both higher health costs and lower incomes. Younger participants fared significantly worse than did adults 65 years and older on indicators of food disadvantage; they reported a higher occurrence of both insufficient funds to pay for necessary food and more frequent receipt of food stamps. On every individual indicator studied, women were significantly more likely than were men to be disadvantaged.
The most pronounced differences in material disadvantage occurred across racial/ethnic and educational strata. We observed consistent, substantial, and statistically significant race/ethnicity-based material resource differentials in all 3 domains, as well as for every individual indicator examined. Non-Hispanic Black and Hispanic respondents were far more likely than were non-Hispanic White respondents to report foregoing needed prescriptions because of cost and had a significantly higher prevalence of uninsurance or underinsurance. Similarly pronounced racial/ethnic differentials were observed for health care and food disadvantage. Food insufficiency and food stamp receipt were far more common for non-Hispanic Black and Hispanic respondents than they were for non-Hispanic White respondents. More than 20% of non-Hispanic Black and Hispanic respondents lived in low-quality housing compared with 7.8% of non-Hispanic White respondents. Housing was unaffordable for 23.4% of non-Hispanic Black, 26.7% of Hispanic, and 12.3% of non-Hispanic White respondents. The majority of non-Hispanic Black (60.7%) and Hispanic (53.5%) respondents reported living in unsafe neighborhoods, compared with 22.2% of non-Hispanic White respondents. Across all 3 racial/ethnic groups studied, the majority of participants reported material disadvantage in at least 1 domain. Such disadvantage was particularly common among non-Hispanic Black and Hispanic participants, who often reported multiple unmet needs.
Disparities by educational attainment also were pronounced in our study population. In the domains of health care, food, and housing, and on every individual indicator of disadvantage, respondents with less than a high school education were far more likely than were those with high school diplomas to report material deficits. Examples included the markedly higher occurrence of foregone prescriptions (13.6% vs 8.5%) and uninsurance or underinsurance (46.2% vs 27.5%), as well as large differences in the prevalence of renting rather than owning a home (21.8% vs 10.6%), living in low-quality housing (23.0% vs 7.6%), and living in an unsafe neighborhood (47.8% vs 23.4%). Food insufficiency (5.5% vs 2.0%) and food stamp receipt (13.1% vs 2.5%) were also substantially more common in respondents without a high school diploma.
As illustrated in , disadvantaged individuals were markedly more likely than were their advantaged counterparts to experience declines in self-rated health and incident walking limitations. More than 1 in 10 participants reported a decline in self-rated health (12.3%) or incident walking limitations (15.8%) between 2004 and 2006. For all individual and summary measures of health care, food, and housing disadvantage, we observed higher rates of worsening health among participants without adequate material resources.
Prevalence of Decline in Self-Rated Health (n = 14268) and Incident Walking Limitation (n = 14609) Among US Adults Aged 51 Years and Older With Specified Types of Material Disadvantage: Health and Retirement Study, 2004 and 2006
The results of logistic regression models designed to determine the independent health effects of each demographic indicator and domain of disadvantage are reported in . The analysis of declines in self-rated health () excluded participants who already reported poor health in 2004. In model 1, which predicted a decline in self-rated health with the use of only demographic characteristics, declines were more common among older, Black or Hispanic (compared with White), and unmarried respondents, as well as those with less than a high school education and those living in poverty.
Relative Odds of Decline in Self-Rated Health and Incident Walking Limitation Among US Adults Aged 51 Years and Older: Health and Retirement Study, 2004 and 2006
Next, in model 2, we assessed the association between dichotomous indicators of health care, food, and housing disadvantage and decline in self-rated health. Disadvantage in each domain was associated with significantly elevated odds of decline in self-rated health, with the strongest associations observed for food disadvantage (odds ratio [OR]=2.10; 95% confidence interval [CI]=1.65, 2.68). These results were largely unchanged after we controlled for demographic characteristics (model 3). The relations between being non-Hispanic Black and being unmarried and health declines were rendered nonsignificant after we controlled for material disadvantage, and the estimated effects of poverty, Hispanic ethnicity, and education were attenuated. Even after we further controlled for baseline self-rated health, co-morbid conditions, weight status, and smoking status (model 4), health care, food, and housing disadvantage were independently associated with the odds of a decline in self-rated health. The effect was strongest for food disadvantage (OR=1.69; 95% CI=1.29, 2.22), followed by health care (OR=1.39; 95% CI=1.23, 1.58) and housing (OR=1.20; 95% CI=1.07, 1.35) disadvantage. Effect estimates for each type of disadvantage were comparable with those observed for a range of comorbid conditions, including diabetes and stroke.
Comparable results for incident walking limitations are also shown in , again showing the strongest effect for food disadvantage (OR=1.64; 95% CI=1.31, 2.05), followed by health care disadvantage (OR=1.43; 95% CI=1.29, 1.58). Housing disadvantage was not a significant predictor of walking limitations after we controlled for baseline walking limitations, comorbid conditions, weight status, and cigarette smoking status (model 4).
We used similar models that controlled for all covariates to examine the independent contributions to both outcomes of the component indicators that constitute health care, food, and housing disadvantage (results not shown). Both indicators of health care disadvantage (foregone prescriptions because of cost and uninsurance or underinsurance) were significantly associated with self-rated health declines and incident walking limitations. We observed significantly elevated odds of decline in self-rated health among food stamp recipients (OR=1.48; 95% CI=1.10, 2.00), as well as elevations approaching statistical significance among participants reporting insufficient money for food (OR=1.47; 95% CI=0.92, 2.36; P=.104). For incident walking limitations, we observed elevated point estimates for both insufficient money for food (OR=1.47; 95% CI=0.95, 2.26; P=.082) and food stamp receipt (OR=1.26; 95% CI=0.96, 1.65; P=.095), although neither was statistically significant. In the housing domain, only living in an unsafe neighborhood was significantly associated with decline in self-rated health (OR=1.17; 95% CI=1.02, 1.34), whereas both unsafe neighborhood conditions (OR=1.17; 95% CI=1.05, 1.30) and poor housing quality (OR=1.20; 95% CI=1.03, 1.41) were associated with higher odds of incident walking limitations.
The predicted probability of declines in self-rated health and incident walking limitations are provided in . The probabilities shown are based on the number of domains disadvantaged, with control for all covariates in model 4. We observed a monotonic pattern of more frequent declines in self-rated health and walking limitations among respondents with a higher number of domains disadvantaged, such that the highest risk was observed in respondents disadvantaged in all 3 domains.
Number of domains disadvantaged and adjusted probability of decline in (a) self-rated health and (b) incident walking limitation: Health and Retirement Study, United States, 2004 and 2006.