Choose one diverse population of interest as highlighted in this weeks readings and discuss what information was gained from

Substance Use & Misuse, 47:734–744, 2012 Copyright C© 2012 Informa Healthcare USA, Inc. ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2012.666312

ORIGINAL ARTICLE

Racial Differences in Co-Occurring Substance Use and Serious Psychological Distress: The Roles of Marriage and Religiosity

Celia C. Lo1, Kimberly A. Tenorio2 and Tyrone C. Cheng1

1School of Social Work, University of Alabama, Tuscaloosa, Alabama, USA; 2Florida State College at Jacksonville, Office of Open Campus, Jacksonville, Florida, USA

The study examined how marriage and religiosity can protect members of certain racial/ethnic groups against co-occurring substance use and serious psy- chological distress. Using the national dataset 2007 National Survey on Drug Use and Health, we ana- lyzed data via multinomial logistic regression, observ- ing several important results. Our findings generally support the deprivation-compensation thesis, in that religiosity elevates the mental health of racial/ethnic minority individuals more than that of Whites. We also found, however, that race/ethnicity moderates effects of education and poverty on the co-occurring behav- iors, with Whites’ mental health benefiting more from wealth and education than Blacks’ or Hispanics’ men- tal health did.

Keywords social integration, religiosity, marriage, substance abuse, serious psychological distress, co-occurring behaviors

INTRODUCTION

Co-occurring drug abuse1 and mental illness is widespread in the United States (NIDA [National Institute on Drug Abuse], 2007), as is the more specific instance of co-occurring drug use and serious psycholog- ical distress (Kessler et al., 1996; Psychiatric Services, 2006; Rosenberg, 2008). Often, one mental health prob- lem results from another, as when serious psychological distress occurs following frequent, severe drug use (Dennis, Key, Kirk, & Smith, 1995) or when drugs are used in an attempt to self-medicate (Dennis et al., 1995)

1The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. 2The reader is asked to consider that concepts and processes such as “risk” and “protective” factors are often noted in the literature, without adequately delineating their dimensions (linear, nonlinear, rates of development, sustainability, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously, micro to macro levels) which are necessary for them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to operate and whether their underpinnings are theory driven, empirically based, individual and/or systemic stake holder bound, historically bound, based upon “principles of faith” or what. This is necessary to clarify, if possible, whether these terms are not to remain as yet additional shibboleths in a field of many stereotypes. Editor’s note. Address correspondence to Celia C. Lo, School of Social Work, University of Alabama, Box 870314, Tuscaloosa, AL 35487, USA; E-mail: [email protected]

or otherwise palliate mental illness (RachBeisel, Scott, & Dixon, 1999) or, more specifically, psychological distress (Kessler et al., 1996; Manchikanti et al., 2007). Whatever their onset order, drug abuse and mental illness alike are risk factors2 for each other’s appearance (NIDA, 2007).

Racial/ethnic disparities in mental health exist because American society is organized in a way that creates and perpetuates social inequalities among its citizens, through a system of rewards and ascriptive processes (Aneshensel, 1992, 2009; Aneshensel, Rutter, & Lachenbruch, 1991; Grusky, 2001; Rothman, 2005). Social institutions de- fine what is acceptable, what is good, within a society. These social institutions then operate to ensure that only those groups they endorse are able to win the rewards available in the society. This sets up generational perpet- uation, or status crystallization, of the social inequalities created by the institutions (Grusky, 2001). Health is a re- ward that is subject to such status crystallization based on group membership. To a marked degree, the society cre- ates its citizens’ differential health statuses. While the in- dividual’s physical condition is always an influence, the relative exposure to phenomena that damage health, and to resources that enhance health, is a function of member- ship in particular social groups (Lynch & Kaplan, 2000; Marmot, Kogevinas, & Elston, 1987). Those who belong to a racial/ethnic minority are not fully endorsed by social institutions and thus constitute the groups on the social ladder’s lower rungs, where the bulk of physical and men- tal health problems are located.

Studies seeking to explain co-occurring substance use and serious psychological distress are few. But many

734

SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 735

studies have shown race/ethnicity to be a correlate of, separately, substance use and psychological distress. The discrimination, stigma, and negative stereotypes associ- ated with membership in a racial/ethnic minority can be stressors for members of these groups (Aneshensel, 1992, 2009; Aneshensel et al., 1991; Gary, 2005; Williams & Rucker, 2000). Social institutions function so that, in general, these groups’ members—since they are not fully endorsed—will obtain only low incomes and lesser- quality services, including health care, but at the same time will receive relatively more interest from the legal system, which increases stress (Sachs-Ericsson, Plant, & Blazer, 2005; Williams & Rucker, 2000).

Not surprisingly, since they meet with differential stres- sors, the members of different racial/ethnic groups may respond to stress differently. Whites have been found to misuse alcohol at a greater rate than the main minor- ity groups do (Blacks, Hispanics) (Green, Freeborn, & Polen, 2001; Muthen & Muthen, 2000), although use rates for illicit drugs appear very similar among Whites, Blacks, and Hispanics3 (Mosher & Akins, 2007; NIDA, 2003; SAMHSA [Substance Abuse and Mental Health Services Administration], 2009). At least one study found a higher rate of psychological distress for Blacks than Whites (Brown & Keith, 2003), even though more gener- ally it is Whites who, of any racial/ethnic group, are likeli- est to experience serious mental illness (SAMHSA, 2009); furthermore, particular forms of mental health problems seem to typify Whites, Hispanics, and Blacks who do be- come ill (McVeigh et al., 2006; SAMHSA, 2009).

Since all racial minorities are socially disadvantaged, why should their members have lower rates of mental health disorders than Whites? The finding may reflect the many subgroups constituting a racial minority in the United States. The Hispanic minority includes Cuban, Mexican American, Puerto Rican, and other subgroups, each of which exhibits a distinct culture, has experienced a distinct acculturation process, and responds to stress in distinct behavioral ways (Balcazar, Aoyama, & Cai, 1991; Nielsen, 2000; Scribner, 1996). The cultures of the sub- groups nevertheless value certain collectivist, interdepen- dent ideals, and their members draw powerful social sup- port from one another that counteracts, to a degree, the inequity and deprivation they all face (Plant & Sachs- Ericsson, 2004).

Marriage and religiosity4 illustrate social integration’s posited protective nature and may enhance psychological well-being by several mechanisms. First, as compared to their absence, marriage and religiosity are associated with less stress and strain, two states detrimental to psychological well-being (Hackney & Sanders, 2003; Roohafza et al., 2007). Marriage is a normative life stage, so having a spouse means reduced exposure to

3The reader is reminded that the three categories of Whites, Blacks, and Hispanics, as racial or ethnic groups, represent heterogeneity and not homogeneity in each group and that the 2010 US Census greatly expanded the choices for ethnic self-identification. Editor’s note 4Religiosity is defined as an individuals’ bonding or commitment to religion and religious beliefs.

stress and strain compared with never-married, divorced, and widowed individuals. The latter groups are likely to face comparatively high levels of financial difficulty, work–family conflict, and child-care worries, increasing psychological distress and impairing mental health (Avison, Ali, & Walters, 2007; Dziak, Janzen, & Muhajarine, 2010; Roohafza et al., 2007). Similarly, according to research, those who attend church regu- larly report less exposure to stress (Ellison, Boardman, Williams, & Jackson, 2001). Believing their relationship with God to be good, and having faith that God will pro- vide love and assistance, religious individuals are more likely than others to have a low level of psychological distress (Flannelly, Koenig, Galek, & Ellison, 2007).

Second, social integration’s link to good health of- ten involves the extension of social networks that— accompanied by sufficient other psychosocial, social, health, and material resources—may work to promote healthy behaviors and neutralize stress (Aneshensel, 2009; Berkman, Glass, Brissette, & Seeman, 2000; Datta, Neville, Kawachi, Datta, & Earle, 2009; George, Elli- son, & Larson, 2002; House, Umberson, & Landis, 1988; Jackson & Neighbors, 1996; Osborne, Ostir, Du, Peek, & Goodwin, 2005). The larger the network, the more readily available the social support that enhances coping with problems (George, 2010). It should be noted, how- ever, that not all pertinent studies confirm that marriage is beneficial for coping with stress (Avison et al., 2007). As for religiosity, its health benefits may be qualified by the individual’s particular religious experiences. Experi- encing positive, collaborative relationships with God and with other believers offers the strongest benefit when it comes to coping with problems (Ano & Vasconcelles, 2005; George et al., 2002; House, Landis, & Umberson, 1988; Phillips, Pargament, Lynn, & Crossley, 2004).

Third, the kind of social integration that social net- works promote, in turn, promotes social control. The social control thus promoted is often consistent with a healthy lifestyle and with good health (George et al., 2002; House, Landis, et al., 1988; House, Umberson, et al., 1988; Umberson, 1987).

Religion and marriage, then, are social integration factors shown to promote healthy behaviors and psycho- logical adaptation (Jang et al., 2009; Umberson, 1987). However, these factors may not function uniformly to protect the health of the members of different racial/ethnic groups. Marriage’s and religiosity’s health-promoting benefits likely vary within different racial/ethnic groups, because racial/ethnic status is linked both to the quantity and quality of social relationships (House, Landis, et al., 1988).

In the present study, our interest was understanding interactions involving race/ethnicity and marital status and religiosity, which according to Link and Phelan are the social conditions that put “people at risk of risks” (1995, p. 89). By treating marriage and religiosity as social integration factors and investigating differences in co-occurring substance use and serious psychological dis- tress, we intended our study to achieve three objectives.

736 C. C. LO ET AL.

First, we sought to examine systematically whether and how marriage’s and religiosity’s effects on co-occurring behaviors differ from one racial/ethnic group to another. Diverse studies have indicated, thus far, that social inte- gration factors wield unequal effects on the mental health of individuals in different social groups (House, Landis, et al., 1988). Second, in the event we observed evidence supporting our unequal effects hypothesis, we intended to measure effects’ relative power, asking whether partic- ularly strong effects were associated with Whites or with the Black and Hispanic racial/ethnic minorities. Third, we meant to explore how the co-occurring behaviors might be differentially affected by factors beyond our pair of social integration factors, an understanding that might help min- imize group-based differences in co-occurring behaviors. Evidence of how race/ethnicity and poverty and gender interact, contributing to the development of co-occurring behaviors, could help answer questions about the proper role for research and regulatory efforts in improving mental health (Link & Phelan, 1995; Suthers, 2008).

METHODS

Design and Sample Data for our study came from the 2007 National Survey on Drug Use and Health (NSDUH), a national household survey series describing a representative sample of civil- ian, noninstitutionalized individuals aged 12 or over in the United States. NSDUH has been conducted annually since 1991 and seeks to determine the extent of the use of illicit drugs, and the rate of mental disorders, in the Amer- ican civilian population. The final sample employed in the present study excluded NSDUH respondents who iden- tified themselves as Native Americans/Alaska Natives, Asians, and Native Hawaiian/other Pacific Islanders; it also excluded those claiming more than one racial/ethnic identity. Our final sample furthermore included only adults 18 years or older. Ultimately, the sample num- bered 34,650 individuals who identified themselves as non-Hispanic White, non-Hispanic Black, or Hispanic. Our data analysis employed weighting to ensure that data collected were representative of the population as a whole and to adjust for sampling inaccuracy.

Measures The dependent variable co-occurring drug use and seri- ous psychological distress in the past year was indicated by four categories: presence of co-occurring serious psy- chological distress and substance use in the past year; presence of serious psychological distress in the past year; presence of substance use in the past year; and the refer- ence category, absence of both serious psychological dis- tress and substance use. Respondents were classified as substance use if they self-reported activities and experi- ences meeting criteria from the Diagnostic and Statistic Manual of Mental Disorders IV (DSM-IV) for drug abuse or drug dependence in the past year. NSDUH determined serious psychological distress using the K6 scale for non- specific psychological distress. The scale’s six questions

asked respondents to think back to the 1 month from the past year during which they had been at their worst emo- tionally and to report how many times in that month they felt nervous, hopeless, restless, depressed, low in energy, and worthless. Response categories were (0) none of the time/do not know/refused, (1) a little of the time, (2) some of the time, (3) most of the time, and (4) all of the time. Scores on all six questions were totaled, and respondents scoring 13 or higher were said to have had serious psy- chological distress in the past year.

A 4-item index was employed to indicate religiosity. Three index questions asked how strongly respondents agreed with statements about sharing one’s religious beliefs with friends, religious beliefs shaping one’s decisions, and religious beliefs’ overall importance in one’ sexperience. Response categories ranged from (1) strongly disagree to (4) strongly agree. The index’s fourth item involved a 6-point scale measuring the number of church services a respondent had attended in the past 12 months, to gauge involvement with religion. Response categories were (1) 0 times, (2) 1 to 2 times, (3) 3 to 5 times, (4) 6 to 24 times, (5) 25 to 52 times, and (6) more than 52 times. The total index score was the sum of the 4 items’ standardized scores. The index achieved moderately high consistency (alpha = .82).

Marital status was a further variable and was recoded as a dichotomous variable; individuals not presently married provided the reference group. We similarly recoded the three-category race variable into two dichotomous vari- ables, Black and Hispanic; White provided the reference group.

Other status variables were indicated using respon- dents’ gender, income level, education, and age. Gender was a dichotomous variable, female providing the refer- ence group. We constructed two dichotomous variables from the three-category income measure. The two were (a) 100%–199% of the US Census poverty threshold and (b) equal to or greater than 200% of the poverty threshold; less than 100% of poverty threshold provided the refer- ence group. We measured education as a continuous vari- able, its response scale including (1) less than high school education, (2) high school graduate, (3) some college, and (4) college graduate. Age was measured as a continu- ous variable, the responses being (in years) (1) 18–25, (2) 26–34, and (3) 35orolder. Younger adults are likelier than older ones to use substances and also to exhibit psycho- logical distress; adults who have completed higher educa- tion are less likely to have mental health problems than those lacking such education (Mosher & Akins, 2007; Schieman, 2008; Schieman, Van Gundy, & Taylor, 2001).

Data Analysis Using multinomial logistic regression, we evaluated for Whites, Blacks, and Hispanics the effects of our two social integration factors and of gender, poverty, education, and age, on the four-category dependent variable co-occurring substance use and serious psychological distress. Eval- uation was conducted separately for each race/ethnicity. Group difference testing determined whether the

SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 737

differences observed among coefficients of marriage and religiosity for each race/ethnicity variable reached statis- tical significance. To achieve simultaneous comparison of the groups’ coefficients (as we had for the independent variables), we performed separate multinomial logistic regressions for each independent variable. During these separate regressions, we included all independent vari- ables, as well as all interactions involving the minority groups and the independent variable in question; White respondents constituted the reference category. Where an identified interaction between a minority group and a particular independent variable (e.g., between Black and education) was statistically significant, a significant difference was indicated between that group and White, in terms of the independent variable’s effect on co-occurring behaviors within the group. As we conducted the data analyses, we used STATA software to take the sample weight into account.

RESULTS

The descriptive statistics in Table 1 show that 4.3% of our respondents reported experiencing co-occurring sub- stance use and serious psychological distress, 14.8% re- ported experiencing serious psychological distress but not substance use, and a further 14.6% reported abusing a sub- stance but not experiencing serious psychological distress. Females made up the majority (54%) of the respondents; White was the majority racial/ethnic group, comprising 71% of the sample, while Blacks constituted 13% and Hispanics 16%. More than 6 in 10 respondents (63%) re- ported income of at least 200% of poverty level, 21% had income of 100%–199% of poverty level, and 14% lived below poverty level. On average, our respondents were 26–34 years old and had a high-school education.

In general, the results of correlations between our mental health variables, social status, and the two social integration factors were as expected. Co-occurring behaviors, serious psychological distress, and substance use all were likelier to be found in individuals who were living below poverty or at 100%–199% of poverty, who were unmarried, younger, less educated, and less religious. Members of the Hispanic group were less likely than Whites to report experiencing, in the past year, co-occurring behaviors or either serious psychological distress or substance use singly. In contrast, Blacks were equally likely, compared with Whites, to report co-occurring behaviors or serious psychological distress singly. Males were likelier than females to report abusing a substance; females were likelier to report experiencing serious psychological distress. Males and females were equally likely to report co-occurring behaviors. Concern- ing the two social integration factors, Whites were more likely than minority-group members to be married, and non-Whites were more likely to be religious.

Table 2 presents the data outlining marriage’s role and religiosity’s role as a protective factor, along with data on how other social status factors may contribute to substance abuse, serious psychological distress, and co-occurring

behaviors within all three racial/ethnic groups. Table 2 also presents results derived from statistical significance tests we conducted to evaluate group differences in our independent variables’ particular effects on co-occurring behaviors; Whites provided the reference group. Group differences proving to be significant are indicated in the table by underscoring of the odds ratio of the specific independent variable. We did not generally observe that race/ethnicity moderated effects of the two social integra- tion factors on co-occurring behaviors. Neither did we find significant differences between Whites and the minori- ties in terms of marriage’s or religiosity’s effects on seri- ous psychological distress singly and substance use singly. However, only among Whites were marriage and religios- ity found to significantly affect all three categories of the outcome variable co-occurring behaviors; among Blacks and Hispanics, only 1 and 2 categories were significantly affected by the social integration factors.

We obtained interesting results with our independent variables beyond marriage and religiosity. Increasing edu- cation was, for Whites, associated with lower likelihood of serious psychological distress and of co-occurring behav- iors; no such association was observed for the two minori- ties. In addition, we found significant differences between Whites and Hispanics in terms of education’s effects on co-occurring behaviors as well as on serious psychologi- cal distress.

In general, age was observed to have a negative effect on substance use, serious psychological distress, and co-occurring behaviors within all three groups. For Blacks and Hispanics, however, age’s negative effects on serious psychological distress were not statistically sig- nificant. Moreover, tests of significance applied to group differences indicated that age’s effects on co-occurring behaviors and on substance use singly were significantly stronger among Whites versus Blacks. Again for all three groups, being male was linked to increased (versus females) likelihood of reporting substance use singly; females, however, were more likely than males to report serious psychological distress. Hispanic males (but not Black or White males) were significantly more likely than females in their group to report co-occurring behaviors. In general in our study, gender’s effect on co-occurring serious psychological distress and substance was significantly stronger for Hispanics than for Whites.

In our study, poverty affected reporting of co-occurring behaviors very differently for members of the three dif- ferent groups. We observed a lower likelihood of co- occurring behaviors among Whites and Hispanics in the 200% and 100%–199% poverty categories, versus poorer Whites and Hispanics. Among Blacks, in contrast, being poor was not found to significantly increase co-occurring behaviors; moreover, among respondents in the 200% poverty category, Whites were better protected by their relative wealth than Blacks were, against co-occurring be- haviors. In addition, Whites in the 200% poverty category were much better protected against serious psychologi- cal distress than Hispanics in that category were. Among Hispanics, those in the two lowest income categories and

738 C. C. LO ET AL.

T A B L E 1.

M ea ns ,s ta nd

ar d de vi at io ns ,a nd

co rr er la ti on

s of

al l in cl ud

ed va ri ab le s

(1 )

(2 )

(3 )

(4 )

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(1 1)

(1 2)

(1 3)

M ea n

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C o- oc cu rr in g be ha vi or s (1 )

1. 00

0. 04

0. 20

34 ,6 50

P sc yh

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(2 )

0. 51

1. 00

0. 15

0. 36

34 ,6 50

S ub

st an ce

ab us e (3 )

0. 51

0. 17

1. 00

0. 15

0. 35

34 ,6 50

M al e (4 )

0. 01

a −0

.1 0

0. 14

1. 00

0. 46

0. 50

34 ,6 50

W hi te (5 )

0. 02

0. 03

0. 04

0. 01

1. 00

0. 71

0. 45

34 ,6 50

B la ck

(6 )

0. 00

a −0

.0 1a

−0 .0 3

−0 .0 3

−0 .6 0

1. 00

0. 13

0. 33

34 ,6 50

H is pa ni c (7 )

−0 .0 2

−0 .0 3

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0. 02

−0 .6 9

−0 .1 7

1. 00

0. 16

0. 37

34 ,6 50

10 0%

po ve rt y (8 )

0. 04

a 0. 08

0. 03

−0 .0 7

−0 .1 9

0. 14

0. 11

1. 00

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0. 37

33 ,9 81

10 0%

–1 99 %

po ve rt y (9 )

0. 01

0. 03

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−0 .1 1

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1. 00

0. 21

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33 ,9 81

20 0%

+ po ve rt y (1 0)

−0 .0 4

−0 .0 9

−0 .0 3

0. 07

0. 24

−0 .1 4

−0 .1 7

−0 .5 8

−0 .6 6

1. 00

0. 63

0. 48

33 ,9 81

M ar ri ed

(1 1)

−0 .1 1

−0 .1 1

−0 .1 8

−0 .0 3

0. 12

−0 .1 4

−0 .0 2

−0 .1 8

−0 .0 8

0. 20

1. 00

0. 38

0. 49

34 ,6 50

E du ca ti on

(1 2)

−0 .0 4

−0 .0 6

−0 .0 3

−0 .0 6

0. 23

−0 .0 8

−0 .2 1

−0 .2 1

−0 .1 9

0. 32

0. 14

1. 00

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34 ,6 50

R el ig io si ty

(1 3)

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−0 .1 2

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a 0. 00

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(1 4)

−0 .1 0

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2. 88

0. 91

34 ,6 50

N o te : A ll co rr el at io ns

re ac h st at is ti ca l si gn ifi ca nc e at .0 5 le ve l ex ce pt in g fo r th os e si gn ifi ed

w it h a .

SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 739

TABLE 2. Determinants of the log-odds of co-occurring substance abuse and psychological distress for three racial/ethnic groups

White Black Hispanic

Variables b Odds ratio (95% CI) b Odds ratio (95% CI) b Odds ratio (95% CI)

Co-occurring behaviors Age −0.63∗∗ 0.53 (.47–.61) −0.32∗ 0.73 (.53–.99) −0.73∗∗ 0.48 (.34–.68) Male 0.22 1.25 (.99–1.56) 0.16 1.17 (.63–2.19) 0.90∗∗ 2.46 (1.41–4.27) 100%–199% poverty −0.56∗∗ 0.57 (.40–.83) −0.45 0.64 (.35–1.16) −0.80∗ 0.45 (.21–.98) 200%+ poverty −0.68∗∗ 0.51 (.36–.72) 0.01 1.01 (.57–1.80) −0.74∗ 0.48 (.22–1.05) Education −0.26∗∗ 0.77 (.69–.87) −0.17 0.84 (.58–1.23) 0.09 1.10 (.79–1.51) Married −1.05∗∗ 0.35 (.25–.48) −0.83 0.44 (.16–1.21) −0.65 0.52 (.23–1.19) Religiosity −0.11∗∗ 0.90 (.87–.93) −0.18∗∗ 0.83 (.77–.90) −0.02 0.98 (.90–1.07) Constant 0.21 −1.55∗ −1.41∗

Psychological distress Age −0.24∗∗ 0.78 (.73–.84) −0.15 0.86 (.72–1.04) −0.09 0.91 (.73–1.13) Male −0.80∗∗ 0.45 (.39–.52) −0.44∗ 0.64 (.44–.95) −0.92∗∗ 0.40 (.27–.58) 100%–199% poverty −0.16 0.85 (.68–1.07) 0.06 1.06 (.69–1.64) −0.21 0.81 (.50–1.30) 200%+ poverty −0.64∗∗ 0.53 (.43–.65) −0.56∗ 0.57 (.37–.88) 0.08 1.09 (.71–1.67) Education −0.13∗∗ 0.88 (.82–.95) −0.18 0.83 (.69–1.01) −0.01 0.99 (.84–1.18) Married −0.37∗∗ 0.69 (.59–.81) −0.40 0.67 (.43–1.06) −0.50∗∗ 0.61 (.41–.91) Religiosity −0.06∗∗ 0.94 (.92–.96) −0.09∗∗ 0.92 (.87–.96) −0.05 0.96 (.86–1.03) Constant 0.01∗∗ −0.80∗ −1.35∗∗

Substance Abuse Age −0.61∗∗ 0.54 (.50–.59) −0.21∗ 0.81 (.67–.99) −0.42∗∗ 0.66 (.50–.86) Male 1.04∗∗ 2.81 (2.41–3.29) 1.37∗∗ 3.94 (2.66–5.87) 1.26∗∗ 3.53 (2.29–5.45) 100%–199% poverty −0.06 0.95 (.70–1.27) 0.11 1.12 (.68–1.82) −0.08 0.92 (.55–1.55) 200%+ poverty −0.12 0.88 (.70–1.12) 0.10 1.10 (.72–1.70) −0.12 0.89 (.55–1.44) Education 0.05 1.05 (.98–1.13) 0.01 1.01 (.82–1.24) 0.11 1.12 (.93–1.34) Married −0.59∗∗ 0.55 …