Association of Childhood Exposure to School Racial Segregation with Late-Life Cognitive Outcomes among Older Americans
Authors: Lin Zhuoer , Wang Yi , Gill Thomas M. , Chen Xi 
Published: June 2024

AbstractIMPORTANCEDisparities in cognition, including dementia occurrence, persist between White and Black older adults, and are possibly influenced by early educational differences stemming from structural racism. However, the relationship between school racial segregation and later-life cognition remains underexplored.OBJECTIVETo investigate the association between childhood contextual exposure to school racial segregation and cognitive outcomes in later life.DESIGN, SETTING, AND PARTICIPANTSData from 16,625 non-Hispanic White (hereafter, White) and 3,335 non-Hispanic Black (hereafter, Black) Americans aged 65 or older were analyzed from the Health and Retirement Study.EXPOSURESState-level White-Black dissimilarity index for public elementary schools in the late 1960s (range: 0-100) was used to measure school segregation. States were categorized into high segregation (≥83.6) and low segregation (<83.6) based on the top quintile.MAIN OUTCOMES AND MEASURESCognitive scores, cognitive impairment (with or without dementia), and dementia were assessed using the Telephone Interview for Cognitive Status (TICS) and proxy assessment. Multilevel regression analyses were conducted, adjusting for demographic covariates, socioeconomic status, and health factors. Stratified analyses by race were performed.RESULTSThe mean (SD) age of participants was 78.5 (5.7) years, and 11,208 (56.2%) were female. Participants exposed to high segregation exhibited lower cognitive scores (12.6 vs. 13.6;P<0.001) and higher prevalence of cognitive impairment (50.8% vs 41.4%;P<0.001) and dementia (26.0% vs. 19.5%;P<0.001), compared to those with low segregation exposure. Multilevel analyses revealed a significant negative association between school segregation and later-life cognitive even after adjusting sequentially for potential confounders, and these associations were stronger among Black than White participants. Notably, in the fully adjusted model, Black participants exposed to high segregation displayed significantly lower cognitive scores (−0.51; 95% CI: −0.94, −0.09) and higher likelihood of cognitive impairment (adjusted Odds Ratio [aOR]: 1.45, 95% CI: 1.22, 1.72) and dementia (aOR: 1.31, 95% CI: 1.06, 1.63).CONCLUSIONS AND RELEVANCEOur study underscores that childhood exposure to state-level school segregation is associated with late-life cognition, especially for Black Americans. Given the rising trend of school segregation in the US, educational policies aimed at reducing segregation are crucial to address health inequities. Clinicians can leverage patients’ early-life educational circumstances to promote screening, prevention, and management of cognitive disorders.Key PointsQuestionsIs state-level school racial segregation during childhood associated with cognitive outcomes in later life among non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) Americans?FindingsIn this nationally representative sample, older adults exposed to high levels of school segregation had lower cognitive scores and an increased likelihood of cognitive impairment and dementia compared to those with low levels of exposure. These associations remained significant after adjusting for a comprehensive array of factors over the life course, and were more pronounced for Black than White participants.MeaningThese findings suggest that investments to reduce school racial segregation could have lasting benefits for cognition and racial equity, spotlighting school racial segregation as an important form of structural racism in the US. Ascertainment of school racial segregation during childhood could help to promote more efficient and equitable screening, prevention, and management of cognitive impairment in clinical settings.