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Level of education and injecting drug use among African Americans1

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Abstract

Drawing upon a nationally representative survey sample of African American (AA) drug injectors and non-injectors, this study tests for a suspected causal association between dropping out of school and the occurrence of injecting drug use (IDU), which remains a major cause of human immunodeficiency virus (HIV) transmission in this population. The data are from public use files of the National Household Surveys on Drug Abuse (NHSDA) conducted between 1991 and 1995. From within the NHSDA’s nationally representative sample of adult household residents, a total of 389 AA adults with a history of IDU were matched on neighborhood of residence with 2253 AA adults with no history of IDU. The conditional form of multiple logistic regression was used to estimate the relative risk of having injected a drug for school dropouts relative to a reference category of AA who received the high school diploma but did not go to college. AAs who dropped out of high school were an estimated two times more likely to have injected drugs. With statistical adjustment for age, sex, and Hispanic background, the estimated association was 1.9 (95% confidence interval (C.I.)=1.3–2.6, P<0.001). Contrary to our advance hypothesis, earning the graduate equivalency certificate (GED) did not seem to affect the magnitude of excess risk for having started IDU (adjusted odds ratio (aOR)=2.3, 95% C.I.=1.4–3.8, P<0.001). Hence, school dropout prevention might reduce the risk of IDU per se, in addition to the many other general benefits of educational attainment. The issue of GED-associated reduced risk of IDU remains open for future study.

Introduction

This study examines the relationship between level of education and occurrence of injecting drug use (IDU) in a sample of African American (AA) adults. The problem of IDU has been a subject of intense interest for over 20 years because of its association with a variety of health and social problems, one of the most serious being the transmission of human immunodeficiency virus (HIV), and AIDS (Vlahov et al., 1990, Anthony et al., 1991, Nelson et al., 1995). In spite of tremendous efforts at controlling the AIDS epidemic, the disease remains one of the leading causes of morbidity and mortality in the United States. Among AAs, the estimated number of persons living with AIDS increased from 31 200 in 1991 to 92 200 in 1996 (Centers for Disease Control and Prevention, 1997). Even though the most prevalent means of HIV transmission in the US general population is homosexual contact, injecting drug use has remained the most significant exposure category among AA males and females (Centers for Disease Control and Prevention, 1997, Crum et al., 1993, Crum et al., 1996).

One of the persistent challenges facing researchers who investigate IDU and HIV/AIDS is to identify potentially modifiable risk factors that can form the basis of a prevention program. Among the suspected factors associated with initiation of injecting drug use is level of educational achievement. No study exists that has sought to show how education and injecting drug use are related, but several studies have tested the association between level of education and alcohol dependence. For example, Crum et al. (1992), Crum et al. (1993, 1996)have used data from the Epidemiologic Catchment Area (ECA) study to show that people who dropped out of high school were six times more likely to develop alcohol abuse and dependence than a comparison group of adults with the Associate of Art degree or higher. Dropping out of college was associated with a 3-fold increase in the risk of developing alcohol dependence even when potentially confounding variables like age of first initiation, marital and employment status, and household composition were held constant. In another study, Mensch and Kandel (1988)tested the relationship between dropping out of school and drug involvement using a national longitudinal sample of Americans aged 19–27 years. Among other findings, dropping out of high school was associated with increased risk of drug use. Both male and female dropouts were at least 1.3 times more likely to have used cocaine than those who did not drop out of high school. A rather surprising finding of this study was that the risk of drug use was highest among dropouts who went on to obtain the Graduate Equivalency Diploma (GED). Because recipients of the GED are of intermediate academic ability when compared with high school graduates and terminal dropouts (Mensch and Kandel, 1988), their risk of drug use might be expected to be less than that of dropouts and higher than the risk for graduates.

The relationship between school dropout and drug use might stem from a sense of failure secondary to an inability to complete a socially expected task. This failure to meet a major social role expectation (i.e. completing high school or college) is, in fact, associated with other behavioral problems (Jessor and Jessor, 1977, Lewis et al., 1983, Helzer et al., 1991). From this problem behavior perspective, dropping out of school can be treated both as a consequence of early onset drug involvement and as a predictor of drug use (Krohn et al., 1995).

This study was designed to investigate the relationship between educational achievement and injecting drug use among AAs sampled by using a multistage probability area sample. With data from the National Household Survey on Drug Abuse (NHSDA), we tested the hypothesis that dropping out of school would be associated with increased risk of having initiated injecting drug use. We also hypothesized that getting the GED after dropping out of high school would be associated with reduced risk of IDU. Thus, we were concerned less with the number of years spent in school, and more on whether a high school diploma was earned.

Section snippets

Study population

Data for this study came from the public use files of the National Household Surveys on Drug Abuse conducted between 1991 and 1995 (US Department of Health and Human Services, Substance Abuse and Mental Health Administration, 1993–1997). The NHSDA has become an annual survey of licit and illicit drug use in the non-institutionalized US civilian population aged ≥12 years. The study design is cross-sectional with a multistage area probability sampling. Over the period from 1991 through 1995, a

Results

Table 1 shows selected characteristics of the 389 injectors and 2253 non-cases in 313 risk sets. AAs who dropped out of high school were an estimated two times more likely to have injected a drug than high school graduates (95% C.I.=1.4–2.8, P<0.001). With adjustment for age, sex, and Hispanic background, the strength of association was maintained (aOR=1.9, 95% C.I.=1.3–2.6, P<0.001). The unadjusted and adjusted relative odds estimates are shown in Table 2.

Contrary to our second hypothesis,

Discussion

In this analysis of NHSDA data we found that AA adults who had dropped out of high school were about two times more likely to have started injection drug use when compared with neighborhood-matched adults who had completed high school. Contrary to the hypothesis that earning the GED would be associated with attenuated risk for high school dropouts, there was no such reduction in the occurrence of IDU for this group.

Before discussing these findings in detail, it is necessary to mention some

Acknowledgements

This project was supported by grants T32-DA07292 and DA09592 from the National Institute on Drug Abuse.

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