Race, sense of control over life, and short-term risk of mortality among older adults in the United States.

INTRODUCTION: Sense of control over life has been shown to have protective health effects in studies that have mostly enrolled White middle class individuals. It is unknown, however, whether populations differ in the protective health gain associated with sense of control over life. This study compared a nationally representative sample of Black and White older adults for protective effects of sense of control over life on short-term risk of all-cause mortality in the United States.
MATERIAL AND METHODS: This longitudinal prospective study followed 1,493 White (n = 759) and Black (n = 734) older adults (age 66 or more) from 2001 to 2004. Race, demographics, socio-economics, sense of control over life, health behaviors, and self-rated health were measured at baseline in 2001. Outcome was all-cause mortality occurring between 2001 and 2004. Logistic regression models were used for data analysis.
RESULTS: In the pooled sample, sense of control over life was protective against 3-year mortality risk above and beyond demographics, socio-economics, health behaviors, and self-rated health. We found a race by sense of control over life interaction, suggesting a stronger protective effect of control over life on mortality risk for Whites compared to Blacks. In race-specific models, sense of control over life at baseline was predictive of mortality among Whites but not Blacks.
CONCLUSIONS: In the United States, Black older adults do not gain a survival benefit associated with high levels of sense of control over life, as do their White counterparts. It is not clear why sense of control over life translates into survival for Whites but not for Blacks.

Introduction

Similar to other psychological constructs such as locus of control, self-efficacy, mastery, self-directedness, personal autonomy, instrumentalism, and helplessness, which have been used interchangeably [1], sense of control over life also predicts better health status [2]. Individuals with a high sense of control over life report higher well-being [3] and lower stress, anxiety, and depression [4]. A high level of control is also associated with better physical health outcomes such as physical functioning [5] as well as lower risk of cardiovascular disease [6]. A high level of control over life also predicts lower risk of mortality [7].

Sense of control over life – also known as perceived control, control beliefs, or sense of control – refers to subjective expectations regarding one’s ability to exert an influence over life circumstances and outcomes in the surrounding environment [2]. Sense of control over life is a cognitive style which reflects whether life outcomes are subjectively ascribed to the self vs. something external to a person. While shaped by age, gender [8], life events [9], and sociological and contextual factors such as race, education, and marriage [1], sense of control is frequently viewed as a stable personality trait [10]. In this view, individuals are located on a continuum, from having the generalized belief that one can and does master, control, and shape one’s own life, to the opposite end of the continuum, which is perceived powerlessness, accompanied by the belief that one’s life is shaped by external forces, such as luck, chance, fate, or powerful others [7, 11].

In 2014, Turiano et al. studied population variation in the protective effects of sense of control over life on mortality risk. The authors found that education level alters how sense of control over life predicts risk of all-cause mortality. Control beliefs were a predictor of mortality risk only among individuals with low but not high education. The authors also showed that such an interaction is not due to confounders such as health behaviors, mood, or health status [7]. Although in the U.S. race is a strong proxy of social class [12], it is still unknown whether race moderates the protective effect of control beliefs. In other terms, it is unknown whether Blacks and Whites differ in the health gain associated with such control beliefs.

In 2016, Assari used follow-up data of 3,361 Black (n = 1,156) or White (n = 2,205) adults for up to 25 years from 1986 to 2011. The author measured self-efficacy in 1986 and used Cox proportional hazards models to test whether the effect of self-efficacy beliefs on risk of mortality depends on race. The author found a stronger protective effect of self-efficacy on mortality for Whites compared to Blacks. In race-specific models, self-efficacy protected Whites but not Blacks against mortality. The author concluded that in the United States, long-term health gains associated with high self-efficacy are not universal but race-specific [13].

In response to the very limited knowledge on group differences in the protective effect of control beliefs on mortality, the current study compared Blacks and Whites for the effects of sense of control over life on short-term risk of mortality in the United States. To provide generalizable results, we used nationally representative data.

Material and methods

Design and setting

This was a longitudinal panel study with three years of follow-up. Data came from wave 1 and wave 2 of the Religion, Aging, and Health Survey, a household survey from 2001 until 2004 [14].

Ethics

The project received Institutional Review Board (IRB) approval from the University of Michigan. All participants provided consent.

Participants

The study only included White and Black older adults. All participants were non-institutionalized English speaking people of age more than 65 years. Geographically, the study population was restricted to individuals residing in the coterminous United States (i.e., residents of Alaska and Hawaii were not sampled). The study population was limited to Christians or those who were never associated with any faith. Older Blacks were oversampled in the survey [14].

Sampling frame

The study used a random sampling strategy. The sampling frame for this study consisted of all eligible persons contained in the Medicare Beneficiary list maintained by the Centers for Medicare and Medicaid Services (CMS). A five-step process was used to draw a sample from the CMS file (54).

Interviews

Data collection was performed by Louis Harris and Associates (now Harris Interactive, New York). Interviewing began in March 2001 and concluded in August 2001 [14].

Measures

Age, race, family income, number of chronic medical conditions (13 chronic medical conditions), perceived financial difficulty, self-rated health, perceived control over life, and death anxiety were measured.

Perceived control over life. The following four items were used to measure control over life. 1) I have a lot of influence over most things that happen in my life. 2) I can do just about anything I really set my mind to. 3) When I make plans, I’m almost certain to make them work. 4) When I encounter problems, I don’t give up until I solve them. Responses ranged from 4 (Strongly Agree) to 1 (Strongly Disagree). A higher score reflected higher control over life. (Cronbach’s α = 0.743) [15].

Self-rated health (poor). Individuals were asked three questions. 1) How would you rate your overall health at the present time? Would you say your health is excellent, good, fair, or poor? 2) Would you say your health is better, about the same, or worse than most people your age? 3) Do you think your health is better, about the same, or worse than it was a year ago? Responses to the first item included: 1) Excellent, 2) Good, 3) Fair, 4) Poor. Responses to the second and third items included 1) Better, 2) About the same, and 3) Worse (Cronbach’s α = 0.678).

Mortality. Information on occurrence of death from 2001 to 2004 was obtained through the informants, death certificates, and national death index. Mortality during the follow-up was treated as a dichotomous variable, independent of time and cause of death. Overall, 208 deceased Black or White participants were detected. From this number, 112 were Black and 96 were White.

Statistical analysis

We used SPSS 20.0 for data analysis. We fitted logistic regressions in the pooled sample, and specific to race, with sense of control as the independent variable, mortality as the outcome, and demographics, socio-economics, health behaviors, and self-rated health as covariates, and race as the focal moderator. Odds ratios with 95% confidence intervals (CI) were reported.

Results

The study followed 1,493 Black (n = 734) and White (n = 759) older adults (age 65 or more) for 3 years. Overall, 208 deceased participants were detected. From this number, 112 (54%) individuals were Blacks and 96 (56%) individuals were Whites.

Table I presents descriptive statistics overall and also based on race. While age was not significantly different between Blacks and Whites, Blacks were more often female, had lower education, were less frequently married, more frequently smoked, less frequently drank, and reported worse self-rated health. Sense of control over life was also lower among Blacks compared to Whites.

Table I

Descriptive statistics for the analytic sample, stratified by race and overall

Parameter	All	Whites	Blacks
Age, mean ± SD	75.14 ±6.66	75.37 ±6.82	74.91 ±6.49
Control over life, mean ± SD*	1.98 ±0.51	2.02 ±0.47	1.93 ±0.54
Gender, n (%):*
Male	570 (38.2)	314 (41.4)	256 (34.9)
Female	923 (61.8)	445 (58.6)	478 (65.1)
Education (high school diploma):
Yes	872 (59.0)	552 (73.4)	320 (44.0)
No	607 (41.0)	200 (26.6)	407 (56.0)
Marital status (married), n (%):*
No	773 (52.2)	306 (40.5)	467 (64.3)
Yes	708 (47.8)	449 (59.5)	259 (35.7)
Current smoking, n (%):*
Yes	155 (10.4)	60 (7.9)	95 (13.0)
No	1336 (89.6)	698 (92.1)	638 (87.0)
Drinking (lifetime), n (%):*
Yes	466 (31.3)	307 (40.5)	159 (21.7)
No	1025 (68.7)	451 (59.5)	574 (78.3)
Self-rated health (poor), n (%):*
No	1316 (88.4)	694 (91.8)	622 (84.9)
Yes	173 (11.6)	62 (8.2)	111 (15.1)
Mortality, n (%):
Survived	1285 (86.1)	663 (87.4)	622 (84.7)
Deceased	208 (13.9)	96 (12.6)	112 (15.3)

P < 0.05.

Table II shows the results of six logistic regressions in the pooled sample. While sense of control over life was a predictor of mortality (Model 2), we also found significant interaction effects between race and sense of control over life on mortality, suggesting larger effect for Whites compared to Blacks (Model 3). This interaction remained significant in models that controlled for covariates (Models 4 to 6).

Table II

Association between sense of control over life (2001) and mortality (2001–2004) using logistic regression in the pooled sample (n = 1439)

Parameter	Model 1		Model 2Model 1 + Control Beliefs		Model 3Model 2 + Interaction		Model 4Model 3 + SES		Model 5Model 4 + Behaviors		Model 6Model 5 + Health
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Age	1.09***	1.06–1.11	1.08***	1.06–1.11	1.08***	1.06–1.11	1.08***	1.05–1.10	1.08***	1.05–1.10	1.07***	1.05–1.10
Gender (female)	0.88	0.65–1.21	0.88	0.65–1.20	0.89	0.65–1.22	0.78	0.56–1.10	0.72#	0.51–1.03	0.71#	0.50–1.02
Race (Blacks)	1.34#	0.99–1.82	1.39*	1.02–1.88	5.70*	1.49–21.86	4.93*	1.27–19.14	4.46*	1.14–17.41	4.67*	1.19–18.31
Education (high school diploma)							0.99	0.71–1.37	0.94	0.68–1.32	0.83	0.59–1.17
Marital status (married)							0.74#	0.52–1.05	0.75	0.52–1.06	0.74	0.52–1.06
Current smoking									1.05	0.60–1.83	1.13	0.64–1.99
Drinking (lifetime)									1.38#	0.94–2.03	1.28	0.87–1.89
Self-rated health (poor)											3.65***	2.45–5.43
Control over life (poor)			1.59**	1.17–2.15	2.40***	1.47–3.93	2.36***	1.44–3.87	2.29***	1.39–3.76	1.93**	1.17–3.18
Control over life (poor)* Race (Blacks)					0.51*	0.27–0.95	0.53*	0.29–1.00	0.55#	0.29–1.03	0.52*	0.27–0.97

p < 0.1

p < 0.05

p < 0.01

p < 0.001

SES – socioeconomic status.

Table III presents race-specific models to estimate the associations between sense of control over life and subsequent risk of mortality among Blacks and Whites. Model 1 only included age and gender, Model 2 added control beliefs, Model 3 added SES factors, Model 4 also added health behaviors (smoking and drinking), and Model 5 also controlled for health status. These models suggest that sense of control over life at baseline was predictive of mortality among Whites but not Blacks. The significant association between control over life and risk of mortality among Whites did not change across models, suggesting that the association was not due to SES, behaviors, or health. Among Blacks, in all five models, control over life failed to predict risk of mortality.

Table III

Association between sense of control over life (2001) and mortality (2001–2004) using logistic regression among Whites (n = 759) and Blacks (n = 734)

Variable	Model 1		Model 2Model 1 + Control Beliefs		Model 3Model 2 + SES		Model 4Model 3 + Behaviors		Model 5Model 4 + Health
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Whites:
Age	1.09***	1.06–1.12	1.08***	1.05–1.12	1.07***	1.04–1.11	1.07***	1.04–1.11	1.07***	1.03–1.10
Gender (female)	0.90	0.57–1.41	0.92	0.59–1.46	0.75	0.46–1.23	0.76	0.45–1.28	0.75	0.44–1.26
Education (high school diploma)					1.13	0.68–1.85	1.06	0.64–1.77	0.99	0.59–1.66
Marital status (married)					0.60*	0.36–0.99	0.63#	0.38–1.05	0.63#	0.37–1.05
Current smoking							0.57	0.25–1.29	0.61	0.27–1.38
Drinking (lifetime)							1.21	0.73–2.02	1.13	0.67–1.90
Self-rated health (poor)									3.06***	1.61–5.79
Control over life (poor)			2.40***	1.47–3.94	2.35***	1.43–3.85	2.40***	1.45–3.95	2.08***	1.25–3.45
Blacks:
Age	1.09***	1.05–1.12	1.08***	1.05–1.12	1.08***	1.05–1.12	1.08***	1.04–1.11	1.08***	1.04–1.11
Gender (female)	0.87	0.57–1.33	0.86	0.56–1.32	0.81	0.51–1.28	0.70	0.43–1.13	0.68	0.42–1.12
Education (high school diploma)					0.88	0.57–1.35	0.84	0.54–1.30	0.70	0.44–1.10
Marital status (married)					0.92	0.57–1.48	0.88	0.55–1.43	0.89	0.54–1.45
Current smoking							1.61	0.74–3.51	1.77	0.79–3.94
Drinking (lifetime)							1.56	0.86–2.83	1.42	0.77–2.63
Self-rated health (poor)									4.20***	2.50–7.06
Control over life (poor)			1.23	0.83–1.80	1.27	0.85–1.88	1.26	0.85–1.87	0.96	0.63–1.46

Discussion

Based on our findings, race alters how sense of control over life translates into survival benefit, with a weaker protective effect of sense of control over life on short-term mortality risk for Blacks compared to Whites. In race-specific models, self-efficacy was only protective against mortality among Whites but not Blacks.

Our finding is in line with a recent study by Assari showing a stronger protective role of self-efficacy on risk of mortality over 25 years for Whites compared to Blacks. In race-specific models, self-efficacy at baseline was predictive of mortality among Whites but not Blacks. The author concluded that in the United States, race modifies long-term health gains associated with high self-efficacy [13]. The current study suggests that, similar to self-efficacy, sense of control over life better predicts risk of mortality for Whites compared to Blacks. Our study also suggests that Black-White differences in gain associated with such control beliefs and psychological and cognitive styles are not seen in either long-term [13] or short-term outcomes.

The protective role of having a sense of control over life against risk of mortality has already been shown [6, 7]. Such an effect may be due to protective effects of control beliefs on developing psychological distress, as well as metabolic [16] and cardiovascular [17] disease. Such beliefs also reflect lower symptoms [18], better wellbeing [18], and higher physical functioning [18, 19]. Low control beliefs reflect feeling of powerless and low efficacy in dealing with stress [20] as well as high levels of exposure to stress [21]. Among individuals of low socioeconomic status, those with higher control beliefs have better self-rated health, fewer acute health symptoms, and better physical functioning compared to those with lower levels of control beliefs [22]. The protective effect of self-efficacy is shown to hold above and beyond confounders such as SES and health [23, 24].

Several mechanisms have been proposed to explain the protective effects of control beliefs on health. Health behaviors and mental health are major mediators of the effects of control beliefs on health [4, 7]. Control beliefs may mitigate the negative health effects of stress or structural and material limitations that often accompany low socioeconomic status [22]. According to the Lazarus and Folkman theory of stress and coping, at least some of the negative health effects of stress are because of reduced individuals’ perception of control over life [25]. While some of the deleterious effects of stress on health are direct, some of the negative effects may be due deterioration of positive appraisals such as mastery, self-efficacy, and sense of control over life [25].

Our findings on racial differences in protective effects of sense of control may be due to different meanings of control beliefs across population groups. Control beliefs may reflect different aspects of life of Blacks and Whites [13, 26, 27]. The differential roles of other psychosocial and subjective measures such as depressive symptoms and self-rated health for Blacks and Whites are already known [28-33]. Thus group differences in the predictive role of psychosocial outcomes are rules rather than exceptions and are found regardless of population, setting, type of predictor, and outcome [29-33].

The low sense of control over life among Whites and Blacks may reflect different aspects of life. Given the social and economic conditions that Blacks face on a daily basis, low control beliefs may reflect a healthy sensitivity to the real world (realistic system-blame). For Blacks, low sense of control over time may be an attribute of their racial group, rather than their individual characteristic. Among Blacks, low sense of control may be secondary to realization of the existing social and economic inequalities in the U.S. Thus, such control beliefs may not similarly reflect passive beliefs, external locus of control or fatalism among Blacks and Whites [34].

According to our findings, high sense of control does not result in similar survival gains for Black and White older adults. Under certain environmental circumstances, high level of control beliefs has predicted poor health outcomes [35, 36]. Thus, control beliefs may even harm the individual, particularly when high expectations for control coexist with constrained opportunities [36, 37]. In uncontrollable or difficult to control situations, endorsement of high control beliefs can lead to high cardiovascular reactivity [38, 39], which is associated with higher risk of metabolic and cardiovascular conditions, via neuroendocrine and immune mechanisms [38-40]. While societal structural conditions prevent Blacks who endorse high control beliefs from actualization of their control beliefs, Blacks with high control beliefs may be at higher risk of cardiovascular disease due to experiencing high levels of physiological reactivity [35]. For Blacks a combination of constrained opportunities and high control beliefs may do more harm than good. This phenomenon may also be related to the role of John Henryism for Blacks, which results in effortful coping, and is a risk factor for several adverse health outcomes [41].

Our study has a number of limitations. It is unclear how such control beliefs reflect coping styles, coping resources and life environment across diverse populations. Validity of control over life may differ based on race and ethnicity. In addition, the study did not control for baseline medical conditions and stressful life events, or access to and use of health care. Finally, due to the limited sample size and short follow-up period, the number of deaths was low. However, a major strength of this study was the use of a nationally representative sample.

In conclusion, Black and White older adults differ in benefits of high levels of control beliefs in preventing short-term all-cause mortality. Control beliefs may reflect different aspects of life across minority and oppressed populations. For American Blacks, a high level of self-efficacy may reflect a low level of awareness of blocked opportunities and racism, which may not be a healthy realization. Such psychosocial constructs may have race-specific – rather than universal – health effects.