Week 5 Educational Attainment and Health Article Discussion please see attached………………………………………….. ISSUE BRIEF 5 # EXPLORING

Week 5 Educational Attainment and Health Article Discussion please see attached………………………………………….. ISSUE
BRIEF
5
#
EXPLORING THE SOCIAL DETERMINANTS OF HEALTH
This issue brief, published in April 2011, is one in a series of 12 issue briefs on the social determinants of health. The series began as a product
of the Robert Wood Johnson Foundation Commission to Build a Healthier America.
Education and Health
1. Introduction
Everyone knows that without a good education, prospects for a good job with good
earnings are slim. Few people think of education as a crucial path to health, however.
Yet a large body of evidence strongly—and, with very rare exceptions, consistently—
links education with health, even when other factors like income are taken into
account.1-6 By “education” we mean educational attainment, or the years or level of
overall schooling a person has, rather than instruction on specific health topics like
hygiene, diet or exercise; while the quality of education also is important for health
outcomes, this information is more difficult to measure and thus typically unavailable.
People with more education are likely to live longer, to experience better health
outcomes (Figures 1 & 2), and to practice health-promoting behaviors such as
exercising regularly, refraining from smoking, and obtaining timely health care checkups and screenings.4, 7-9 Educational attainment among adults is linked with children’s
health as well, beginning early in life: babies of more-educated mothers are less likely
to die before their first birthdays, and children of more-educated parents experience
better health (Figures 3 & 4).
Education can influence health in many ways. This issue brief examines three major
interrelated pathways through which educational attainment is linked with health:
health knowledge and behaviors; employment and income; and social and
psychological factors, including sense of control, social standing and social networks.
In addition, this brief explores how educational attainment affects health across
To find out more on the integral relationship between our health and how we
live, learn, work and play, visit www.rwjf.org.
A large body of
evidence links
education with health,
even when other factors
like income are taken
into account.
generations, examining the links between parents’ education—and the social and
economic
advantages it represents—and their children’s health and social advantages,
Figure 1. For both men and women, more education typically means longer life.†
including
educational
Collegeopportunities
graduates canfor
expect
to live atattainment.
least 5 years longer than individuals who have not
finished high school.
Educational Attainment
Less than high-school graduate
60
High-school graduate
LIFE EXPECTANCY AT AGE 25
Some college
College graduate
58.5
57.4
56.4
54.7
55
Figure 1. For both men and
women, more education
typically means longer life. +
College graduates can expect
to live at least 5 years longer
than individuals who have not
finished high school.
53.4
52.2
50.6
50
47.9
45
40
MEN
WOM E N
MEN
People with more
education are likely
to live longer and
experience better
health outcomes.
WOMEN
Source: National Longitudinal Mortality Study, 1988-1998.
† This chart describes the number of years that adults in different education groups can expect to live
beyond age 25. For example, a 25-year-old man with only a high-school diploma can expect to live 50.6
more years and reach an age of 75.6 years.
Figure 2. Less education is linked with worse health.†
Across racial or ethnic groups, adults with greater educational attainment are less likely to
rate their health as less than very good.
PERCENT OF ADULTS, AGES 25-74 YEARS,
IN LESS THAN VERY GOOD HEALTH*
Educational Attainment
Less than high-school graduate
100
High-school graduate
Some college
84.1
80
72.7
70.6
70.4
67.2
62.2
60
College graduate
59.4
54.7
43.6
40
54.1
50.0
48.6
41.0
41.8
39.5
41.4
26.7
20
0
Black,
Non-Hispanic
BLACK,
NON-HISPANIC
Hispanic
HISPANIC
Asian
ASIAN
American Indian or Alaska
AMERICAN
INDIAN
Native
OR ALASKA
NATIVE
Source: Behavioral Risk Factor Surveillance System Survey Data, 2005-2007.
† Based on self-report and measured as poor, fair, good, very good or excellent.
* Age-adjusted.
page 2
69.4
60.9
57.5
Other‡
WHITE,
NON-HISPANIC
Figure 2. Less education is
linked with worse health. +
Across racial or ethnic
groups, adults with greater
educational attainment are
less likely to rate their health
as less than very good.
Figure 3. Infant mortality rates vary by mother’s education.
INFANT MORTALITY RATES (PER 100,000 LIVE BIRTHS)
Babies born to mothers who have not finished high school are nearly twice as likely to die
before their first birthdays as babies born to college graduates.
Mother’s Educational Attainment
10
0-11 years
12 years
13-15 years
8.1
8
16 or more years
7.6
6.2
6
4.2
4
2
0
1
Source: Matthews TJ, MacDorman MF. Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death
Dataset. National Vital Statistics Reports, vol 55 no 15. Hyattsville, MD: National Center for Health Statistics, 2007.
page 3
Figure 3. Infant mortality
rates vary by mother’s
education. Babies born to
mothers who have not
finished high school are
nearly twice as likely to die
before their first birthdays as
babies born to college
graduates.
Adults’ educational
attainment is linked
with their children’s
health, beginning early
in life.
Figure 4. Parents’ education is linked with children’s health.†
Children whose parents have not finished high school are more than six times as likely
to be in poor or fair health as children of college graduates.
PERCENT OF CHILDREN, AGES ? 17 YEARS,
WITH POOR/FAIR HEALTH*
6
Parent’s Educational Attainment
Less than high-school graduate
High-school graduate
5
Some college
4.4
College graduate
Figure 4. Parents’ education
is linked with children’s
health. + Children whose
parents have not finished high
school are more than six
times as likely to be in poor
or fair health as children of
college gradutes.
4
3
2.4
2
1.7
1
0
0.7
1
Source: National Health Interview Survey, 2001-2005.
† Based on parental assessment and measured as poor, fair, good, very good or excellent.
* Age-adjusted.
page 4
LOW EDUCATIONAL ATTAINMENT IS A MAJOR PROBLEM IN THIS COUNTRY
In the United States overall, nearly 16 percent of adults ages 25 years and older have not completed high school, 30 percent have no
schooling beyond high school, 27 percent have attended but not completed college, and 28 percent are college graduates (Figure 5).
These overall percentages mask dramatic differences across racial or ethnic groups, however: for example, 50 percent of Asian and 31
percent of non-Hispanic white adults are college graduates, compared with 17 percent of non-Hispanic black and 13 percent of Hispanic
and American Indian or Alaska Native adults.
The United States is the
only industrialized
nation where young
people currently are
less likely than
members of their
parents’ generation to
be high-school
graduates.
Approximately 30 percent of high-school freshmen in this country—and nearly half of all freshmen in school systems in the 50 largest
U.S. cities—fail to graduate within four years.10 The likelihood of dropping out increases with decreasing income. In 2007, for example,
17 percent of 16- to 24-year-olds from families in the lowest income quartile were not enrolled in high school and had not received a
high-school credential, compared with 3 percent of those from families in the highest income quartile.11 At the same time, college has
become increasingly unaffordable for low- and middle-income families. For the 2007-2008 school year, net college costs for a family in
the lowest income quintile represented 55 percent of median family income, compared with 33 percent, 25 percent, 16 percent and 9
percent, respectively, for families in successively higher income quintiles.12 In response to budget constraints, at least 28 states cut
funding for public colleges and universities and/or substantially increased college tuitions in their 2009 fiscal year budgets.13
The United States is the only industrialized nation where young people currently are less likely than members of their parents’ generation
to be high-school graduates.14 Given the changing demography of the country and the escalating costs of college, bold action will be
needed to meet President Obama’s goal of having the highest proportion of college graduates in the world by 2020.
page 5
2. How does education influence health?
Educational
attainment
•Health knowledge
•Literacy
•Coping & problem-solving
Working
conditions
Educational
attainment
Work
Work-related
resources
Income
Control beliefs
(sense / locus of control,
powerlessness, fatalism,
mastery, self-efficacy)
Educational
attainment
Diet
Exercise
Smoking
Health & disease management
HEALTH
Figure 6. Education could
affect health through many
different pathways.
Exposure to hazards
Control / demand imbalance
Stress
Health insurance
Sick leave
Retirement benefits
Wellness programs
Stress
HEALTH
Housing
Neighborhood environment
Diet & exercise options
Stress
Work-related factors
Health-related behaviors
Coping & problem-solving
Response to stressors
Social standing
Social & economic resources
Perceived status
Stress
Social networks
Social & economic resources
Social support
Norms for health-related behaviors
Stress
HEALTH
HEALTH
Figure 6. Education could affect health through many different pathways.
Researchers have found supporting evidence for each of the following interrelated
pathways (Figure 6):
A. EDUCATION CAN LEAD TO IMPROVED HEALTH BY INCREASING HEALTH
KNOWLEDGE AND HEALTHY BEHAVIORS
This is the pathway that many people think of first to explain the strong links between
education and health. Education can increase people’s knowledge, problem-solving,
and coping skills, enabling them to make better-informed choices among the healthrelated options available for themselves and their families, including those related to
obtaining and managing medical care.4, 15-20 Greater educational attainment has been
associated with health-promoting behaviors including increasing consumption of fruits
and vegetables and other aspects of healthy eating, engaging in regular physical activity
and refraining from smoking (Figure 7).21-25 In addition, changes in health-related
behaviors in response to new evidence, health advice and public health campaigns
(about the risks of smoking, for example) tend to occur earlier among more-educated
people.4, 26
As discussed in the section below on employment, more education is typically linked
with higher-paying jobs providing the necessary income to live in neighborhoods that
are less stressful, have stores with affordable healthy foods, and provide access to
recreational facilities. In other words, people with more education are more likely to
live in health-promoting environments that encourage and enable them to adopt and
maintain healthy behaviors.
page 6
Education is linked
with health through
three major
interrelated pathways:
health knowledge and
behaviors, employment
and income, and social
and psychological
factors.
Figure 7. Persistent education gaps in smoking.
PERCENT OF ADULTS, AGES ? 25 YEARS, WHO
ARE CURRENT SMOKERS*
Education disparities in cigarette smoking have persisted over decades. While rates of
smoking have declined in every education group, the gaps between college graduates and
those with less education appear to have widened.
Educational Attainment
50
Less than high-school graduate
High-school graduate
Some college
40
College graduate
Figure 7. Persistent
education gaps in smoking.
Education disparities in
cigarette smoking have
persisted over decades.
While rates of smoking have
declined in every education
group, the gaps between
college graduates and those
with less education appear to
have widened.
30
20
10
1976
1980
1984
1988
1992
1996
2000
2004
19
74
19
75
19
76
19
77
19
78
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
0
Source: National Center on Health Statistics. Health, United States, 2006 with Chartbook on Trends in the
Health of Americans. Hyattsville, MD.
*Age-adjusted.
The links between education and health through health knowledge and behaviors are
likely to be explained at least in part by literacy.27, 28 Low literacy is common in the
United States (a 2003 survey found that 30 million or 14 percent of U.S. adults had
literacy levels below the level needed to perform “simple and everyday” literacy
activities), with higher prevalence among people with fewer years of education.29 More
specifically, average health literacy (i.e., the degree to which individuals have the
capacity to obtain, process and understand basic health information and services needed
to make appropriate health decisions and adhere to sometimes complex disease
management protocols) increases with educational attainment. The proportion of
American adults with “below basic” health literacy, for example, ranges from 3 percent
of college graduates to 15 percent of high-school graduates and 49 percent of adults
who have not completed high school.29 Levels of health literacy in turn have been
associated with self-reported overall health, which correlates strongly with objective
clinical assessments:30, 31 compared with adults who have adequate functional health
literacy, adults with inadequate functional health literacy are more likely to rate their
health as poor.32
B. GREATER EDUCATIONAL ATTAINMENT LEADS TO BETTER EMPLOYMENT
OPPORTUNITIES AND HIGHER INCOME, WHICH ARE LINKED WITH BETTER HEALTH.
Education provides the knowledge and skills necessary for employment, which can
shape health in many ways. More education generally means a greater likelihood of
being employed at all, and of having a job with healthier working conditions, better
employment-based benefits and higher wages (see the “Work and Health” issue brief in
this series).
•
Education, unemployment, financial instability and health. Americans with lower
educational attainment are more likely to be affected by fluctuations in the
economy. While current unemployment rates are higher now than in more than a
quarter-century, increases in unemployment rates over the past year have been
greatest for adults who have not completed high school—6.9 percentage points,
compared with 2.2 percentage points for college graduates.33 In June 2009,
page 7
More education
generally means a
greater likelihood of
being employed at all,
and of having a job
with healthier working
conditions, better
employment-based
benefits and higher
wages.
unemployment rates were 15.5 percent for adults who had not graduated from high
school, 9.8 percent for high-school graduates, 8.0 percent for those who had
attended but not completed college, and 4.7 percent for college graduates. 33 These
differences have major health implications; compared with their employed
counterparts, people who are unemployed experience poorer health and higher
mortality rates.34-37
•
Education, working conditions and health. Workers with less formal education and
training are more likely to hold lower-paying jobs with more occupational hazards,
including environmental and chemical exposures (e.g., pesticides, asbestos) and
poor working conditions (e.g., shift work with few breaks, potentially harmful tools)
that put them at higher risk of injury and fatality.38 Less-educated workers are also
likely to experience more psychosocial stress at work39-41—for example, to have
jobs that make high demands yet offer few opportunities for control and skill
utilization. Such psychosocial aspects of work—including perceived balance
between a worker’s efforts and rewards, perceived justice and discrimination in the
workplace, and social support among co-workers—have been shown to have both
short- and longer-term impacts on health, particularly through pathways related to
stress.
•
Education, work-related benefits and health. Less-educated workers in lower-wage
jobs also are less likely to have health-related benefits including paid sick and
personal leave, workplace wellness programs, child and elder care resources, and
retirement benefits, in addition to employer-sponsored health insurance. Although
most Americans receive their health insurance through their jobs, not all workers
have access to this benefit. Employers with lower-wage workers offer health
insurance less frequently, and, even if employment-sponsored benefits are available,
low-wage workers may be unable to afford the premiums, copayments or
deductibles.42, 43
•
Education, income and health. For the vast majority of Americans, employment is
the sole or main source of income?a work-related resource that affects health
through multiple well-documented direct and indirect pathways.7 With limited
exceptions, greater educational attainment generally corresponds with higher-paying
employment. A recent study estimated that on average each additional year of
schooling represents an 11 percent increase in income;44 median yearly earnings in
2007 were $32,862 for a full-time year-round worker with only a high-school
degree, $40,769 for a worker with some college, and $56,118 for a worker with a
bachelor’s degree.45 These differences are particularly dramatic when compounded
over a person’s lifetime: lifetime earnings (in 1999 dollars, and based on a 40-year
full-time work life) for adults who have graduated from high school but not attended
college have been estimated at $1.2 million, compared with $2.1 million for those
with bachelor’s degrees and $4.4 million for those with post-baccalaureate
professional degrees.46
Higher-paying jobs offer greater economic security and increased ability to accumulate
wealth, enabling individuals to obtain health care when needed, to provide themselves
and their families with more nutritious foods, and to live in safer and healthier homes
and neighborhoods with supermarkets, parks and places to exercise47, 48—all of which
can promote good health by making it easier to adopt and maintain healthy behaviors.
Work-related income may also affect health through pathways involving stress. Lowerpaid workers experience greater stress because they have fewer financial resources to
cope both with everyday challenges, including child care and other family
responsibilities, and with unexpected challenges such as illness.7
page 8
More education can
lead to higher-paying
jobs, which enable
people to obtain health
care when needed,
provide themselves and
their families with more
nutritious foods, and
live in safer and
healthier homes and
neighborhoods with
supermarkets, parks
and places to
exercise—all of which
can promote good
health by making it
easier to adopt and
maintain healthy
behaviors.
STRESS AND HEALTH
Much has been learned recently about physiologic pathways that help explain the links between education and health. Coping with the
constant challenges of daily living?balancing the demands of work and family, for example?can be particularly stressful for people
whose financial and social opportunities and resources have been limited by low educational attainment. Stressful experiences have
been linked repeatedly with many adverse health outcomes across the life course, through physiological mechanisms including
neuroendocrine, immune and vascular responses to stressors. Stress can trigger the body to release hormones and other substances that
over time can damage immune defenses and vital organs. The physiologic chain of events can accelerate aging and lead to serious
chronic illnesses including cardiovascular disease.49
C.
EDUCATION IS LINKED WITH SOCIAL AND PSYCHOLOGICAL FACTORS THAT AFFECT
HE…
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