TIME-USE AND HEALTH STATUS: AN ANALYSIS OF TIME-USE ASSIMILATION AND SELF-RATED HEALTH AMONG MEXICAN IMMIGRANTS IN THE U.S. Introduction Disparities in health across race/ethnicity and socioeconomic status (SES) have been documented and studied in the U.S. (Isaac, 2013). The importance of these dimensions of disparities was stated in the Healthy People 2020 program, where disparities are defined as any type of health difference that is interrelated to social, economic, and/or environmental disadvantage, recognizing the importance of social determinants of health outcomes (Office of Disease Prevention and Health Promotion, n.d.). The social determinants of health regulate access to sufficient social and economic resources and their role in health outcomes (The Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020, 2008), resulting in what Link & Phelan (1995) identified as the fundamental cause of diseases. This perspective establishes that population in the lower SES categories have fewer resources to develop their human capital, are less competitive in the labor market, less employable, and their wages tend to be lower, which directly affects their health status (LaVeist, 2005). Some other mechanisms by which SES affects health are explained by the social causation theory. This approach explains the relationship between SES and health outcomes through the differential exposure to risk factors, the attenuation of the impact of health risks, preferences for healthier lifestyles, and the availability of resources for pursuing those healthier preferences (LaVeist, 2005; Rogers, Hummer, & Krueger, 2005). 1
Failing to control for SES might result in the wrong interpretation of the relationships found between race/ethnicity and health. For instance, some health disparities have been explained by the longstanding differences in SES between racial and ethnic groups and the enduring experience of racial discrimination of the least advantaged group (Williams & Collins, 2013a). However, failing to control for the correct SES dimension in the analyses of racial/ethnic disparities in health could result in the overestimation of the effect that race/ethnicity has and fostering emphasis in biological differences (Adler & Rehkopf, 2008). According to Galobardes, Shaw, Lawlor, Smith and Lynch (2006), one single indicator of SES will not capture the experiences of all the groups in a society, given that the social circumstances among different ethnic groups can be different and specific stratification for one group in a particular SES indicator could not capture the experiences of other groups. For this reason, including new dimensions of SES in this analysis will allow for a better identification of the specific mechanisms resulting in differences in health outcomes. The role of dimensions of SES on health Educational attainment is among the most commonly used indicators of SES in the study of mortality and health disparities. Most studies have concluded that higher levels of educational attainment are associated with lower mortality risk explained by the role of education in increasing earning power, access to resources, improved individual agency, developing social connections and promoting healthy behaviors and healthier life trajectories (Elo, 2009; Hummer & Lariscy, 2011). Other commonly used indicators of SES are income, wealth and poverty. The underlying principle attached to these indicators is that health is related to them by material deprivation, 2
restrictions in social participation and lack of control over one’s life (Marmot, 2002). For instance, income can be used for accessing health care, better food, housing and education, as well as protecting individuals from financial stress (Adler & Newman, 2002; Elo, 2009). All these indicators for different dimensions of SES have been found of fundamental importance for explaining racial/ethnic differences in health outcomes. An important resource that has not been explored in detail in the study of health outcomes is time. In the following section I examine the role that time allocation has for health outcomes. Time-use and health Time allocation has been studied from the economic perspective in explaining the decision- making processes in households to maximize their utility (Becker, 1965; Hamermesh & Pfann, 2005). According to Becker’s original framework on time allocation, time has to be divided between income producing activities, household reproduction, and time consuming activities (Becker, 1965). Time allocation has also been used in the gender literature to identify imbalances in workload between men and women (Anxo et al., 2011; Razavi, 2011; Sayer, 2005) and to measure trends in free time behaviors (Robinson & Godbey, 1997). However, links between time- use and health outcomes remains relatively unexplored. Research in health promoting behaviors usually highlights the importance of exercising and other leisure activities in reducing obesity and improving health (Adler & Newman, 2002; Adler & Stewart, 2010; Elo, 2009). The participation in activities promoting social integration and engagement in social institutions — such as church and clubs — has been suggested as an important connection with health improvement (Adler & Newman, 2002). For instance, lack of social interaction is related to low self-rated health and increased mortality among older adults 3
(Luo, Hawkley, Waite, & Cacioppo, 2012). Also, religious attendance has been found to provide protective effects on mortality and health (Dupre, Franzese, & Parrado, 2006; Ellison & Levin, 1998; Hummer, Rogers, Nam, & Ellison, 1999). This relationship is likely to operate through the facilitation of coping mechanisms and social support, as well as control over unhealthy behaviors (Ellison & Levin, 1998; George, Ellison, & Larson, 2002; George, Larson, Koenig, & McCullough, 2000; Rogers et al., 2005). Poverty of time and health Poverty is a dimension that is highly related to health outcomes. New perspectives on the measure of poverty suggest that indicators should go beyond the material perspective, including not having leisure activities or not participating in social activities or accounting for unfair division between work and leisure (Harvey & Mukhopadhyay, 2007; Marmot, Friel, Bell, Houweling, & Taylor, 2008). The mechanisms linking time allocation to leisure, exercise and social engagement assume that the population has time available to spend in these activities, but that is not always the case. The way in which individuals and households allocate their time and the constraints they face have implications for the ability to overcome poverty (Bardasi & Wodon, 2006). Poverty of time refers to the lack of time for leisure, rest and social activities, after the time in work, housework and other activities necessary for household survival are taken into account (Bardasi & Wodon, 2006). Time poverty, as well as income poverty, constrains the access to the necessary resources needed to achieve a basic standard of living. Some individuals and households can compensate for the lack of time for household reproduction by market purchases — such as domestic workers, food, and day care— with income from paid work (Zacharias, Antronopoulos, 4
& Masterson, 2012), while some others will have monetary income below poverty thresholds, limiting their ability to purchase household services (Kalenkoski & Mahrick, 2012). Not having sufficient time available or the freedom to allocate time to the activities the individuals want to conduct has direct implications for their well-being. For instance, Spinney and Millward (2010) found that income and time poverty represent constraints to engagement in physical activities, but the effect of time poverty was higher than that of income in explaining the intensity of exercise. Also, time spent in leisure has been found to be more beneficial for women than for men, while time in paid work resulted in greater gains in health for men (Bird & Fremont, 1991), although general demands from paid work and family obligations are usually associated with increasing high risk of illness reports (Krantz, Berntsson, & Lundberg, 2005). Time poverty also has implications for the mechanisms for dealing with diseases. Access to primary care among minorities is limited by the availability of total time, waiting times and transportation to the physician’s office (Joyce & Stewart, 1999; Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2013; Mechanic, 2002). As a consequence, minority populations can delay or forgo timely treatment, resulting in adverse effects on their health status. Hispanic paradox and the role of poverty of time The Hispanic population in the U.S. does not seem to follow the traditional pattern of SES- health outcomes, with a better health status than their SES should predict (Williams & Collins, 2013). This apparent Hispanic epidemiological paradox has been documented and explored, with the evidence suggesting that Hispanics, predominantly of Mexican origin, have health outcomes closer to that of whites than to the outcomes for blacks (Markides & Coreil, 1986; Markides & Eschbach, 2005). 5
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