title: Race and Urbanity Alter the Protective Effect of Education but not Income on Mortality.
abstract: BACKGROUND
  Although the effects of socioeconomic status (SES) on mortality are well established, these effects may vary based on contextual factors such as race and place. Using 25-year follow-up data of a nationally representative sample of adults in the U.S., this study had two aims: (1) to explore separate, additive, and multiplicative effects of race and place (urbanity) on mortality and (2) to test the effects of education and income on all-cause mortality based on race and place.
  
  
  METHODS
  The Americans' Changing Lives (ACL) Study followed Whites and Blacks 25 years and older from 1986 until 2011. The focal predictors were baseline SES (education and income) collected in 1986. The main outcome was time until death due to all causes from 1986 until 2011. Age, gender, behaviors (smoking and exercise), and health (chronic medical conditions, self-rated health, and depressive symptoms) at baseline were potential confounders. A series of survey Cox proportional hazard models were used to test protective effects of education and income on mortality based on race and urbanity.
  
  
  RESULTS
  Race and place had separate but not additive or multiplicative effects on mortality. Higher education and income were protective against all-cause mortality in the pooled sample. Race and urbanity significantly interacted with baseline education but not income on all-cause mortality, suggesting that the protective effect of education but not income depend on race and place. While the protective effect of education were fully explained by baseline health status, the effect of income remained significant beyond health.
  
  
  CONCLUSIONS
  In the U.S., the health return associated with education depends on race and place. This finding suggests that populations differently benefit from SES resources, particularly education. Differential effect of education on employment and health care may explain the different protective effect of education based on race and place. Findings support the "diminishing returns" hypothesis for Blacks.
authors.affiliation: Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Center for Research on Ethnicity, Culture and Health, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Shervin
authors.initials: S
authors.lastname: Assari
authors.affiliation: Medicine and Health Promotion Institute , Tehran , Iran.
authors.forename: Maryam Moghani
authors.initials: MM
authors.lastname: Lankarani
keywords: Blacks; Whites; education; ethnic groups; income; mortality; socioeconomic status; urbanity