摘要：Objectives. To examine how disparities in adult disability by educational attainment vary across US states. Methods. We used the nationally representative data of more than 6 million adults aged 45 to 89 years in the 2010–2014 American Community Survey. We defined disability as difficulty with activities of daily living. We categorized education as low (less than high school), mid (high school or some college), or high (bachelor’s or higher). We estimated age-standardized disability prevalence by educational attainment and state. We assessed whether the variation in disability across states occurs primarily among low-educated adults and whether it reflects the socioeconomic resources of low-educated adults and their surrounding contexts. Results. Disparities in disability by education vary markedly across states—from a 20 percentage point disparity in Massachusetts to a 12-point disparity in Wyoming. Disparities vary across states mainly because the prevalence of disability among low-educated adults varies across states. Personal and contextual socioeconomic resources of low-educated adults account for 29% of the variation. Conclusions. Efforts to reduce disparities in disability by education should consider state and local strategies that reduce poverty among low-educated adults and their surrounding contexts. The high costs of disability for US individuals and the nation make it imperative to elucidate the risks of disability. 1 , 2 Moreover, the growing disparities in disability by educational attainment 3 make it important to understand the reasons for the disparities and identify the risks for disability disproportionately borne by lower-educated adults. This information is critical for health care policy and planning targeted at vulnerable population groups. Many studies find that educational attainment is a strong predictor of disability in mid and later life. 3–7 For instance, studies find that education prospectively predicts the disability status of older adults, after controlling for childhood health and socioeconomic conditions. 4 , 5 Education is thought to shape health outcomes, such as disability, through 3 main pathways: economic circumstances, psychosocial resources, and health behaviors. 8 , 9 Economic circumstances, particularly income, appear to be the strongest pathway through which education shapes health. 8 , 9 Disability is a unique dimension of health. Unlike other measures of health, such as diabetes, that inhere in the individual, “disability is not a personal characteristic, but is instead a gap between personal capability and environmental demand.” 10 (p1) For example, not having the capability to walk for a certain distance may become a disability for adults living alone in impoverished areas without public transportation and with fractured social networks. The importance of the environment for disability suggests that disparities in disability by educational attainment vary across place. Understanding why these disparities vary across place can shed light on the underlying causes of the education–disability association. Places differ in their demographic, socioeconomic, and policy contexts in ways that may make education more important for health in some places than in others. It is well established, for instance, that disparities in health and mortality by educational attainment vary across European countries and welfare regimes. 7 , 11–16 The contextual characteristics of places may be particularly salient for disability of lower-educated adults. Their higher-educated peers may be able to marshal their economic and psychosocial resources to garner a healthy life, 17 , 18 even in places not conducive to health. Impoverished, unequal, socially fractured places with austere economic policies 19 may have little consequence for the health of higher-educated residents but be toxic for lower-educated residents who have fewer personal resources to draw on. In other words, high education may provide a “personal firewall” to suboptimal contexts. Lacking this firewall, the health of lower-educated adults may be tightly tethered to the contexts in which they live. This suggests that variation in adult disability across place is most pronounced among lower-educated adults. A critical dimension of place is the US state. 20 The size of disparities in adult disability by education may vary across states for myriad reasons. We focused on 4 demographic and socioeconomic factors that are particularly salient for adult disability. First, low education puts individuals at greater risk for poverty, especially in contexts with weak economic safety nets. 12 Second, individuals’ race/ethnic minority status intersects with low education, and jointly they elevate the risk of disability. We also assessed 2 contextual factors: the concentration of low education and poverty in an individual’s area of residence. Low education may be more problematic for disability in states where low-educated adults tend to reside in areas of educational and economic disadvantage. We addressed 3 questions: (1) How does the size of disparities in disability by educational attainment vary across states? (2) Does the size vary across states primarily because the prevalence of disability among low-educated adults varies across states? and (3) How does the variation across states in the prevalence of disability among low-educated adults reflect differences across states in the race/ethnicity and poverty status of low-educated adults and the socioeconomic contexts in which they live? We address these questions for all adults and by gender because previous studies suggest state and local contexts may have different consequences for women and men. 21–23
