It is now widely recognized that health outcomes are deeply influenced by a variety of social factors outside of health care. The dramatic differences in morbidity, mortality, and risk factors that researchers have documented within and between countries are patterned after classic social determinants of health, such as education and income,1,2 as well as place-based characteristics of the physical and social environment in which people live and the macrostructural policies that shape them.
A 2013 report from the National Research Council and Institute of Medicine cited these socioecological factors, along with unhealthy behaviors and deficiencies in the health care system, as leading explanations for the “health disadvantage” of the United States. In a comparison of 17 high-income countries, age-adjusted all-cause mortality rates for 2008 ranged from 378.0 per 100,000 in Australia to 504.9 in the United States. The report documented a pervasive pattern of health disadvantages across diverse categories of illness and injury that existed across age groups, sexes, racial and ethnic groups, and social class.3
Recent attention has focused on the substantial health disparities that exist within the United States, where life expectancy varies at the State level by 7.0 years for males and 6.7 years for females,3 but mortality and life expectancy vary even more substantially across smaller geographic areas such as counties4,5 and census tracts. In many U.S. cities, life expectancy can vary by as much as 25 years across neighborhoods.6 The same dramatic geographic disparities can be seen for other outcomes, such as infant mortality, obesity, and the prevalence of diabetes and other chronic diseases.
Of the various social determinants of health that explain health disparities by geography or demographic characteristics (e.g., age, gender, race-ethnicity), the literature has always pointed prominently to education. Research based on decades of experience in the developing world has identified educational status (especially of the mother) as a major predictor of health outcomes, and economic trends in the industrialized world have intensified the relationship between education and health. In the United States, the gradient in health outcomes by educational attainment has steepened over the last four decades7,8 in all regions of the United States,9 producing a larger gap in health status between Americans with high and low education. Among white Americans without a high school diploma, especially women,10 life expectancy has decreased since the 1990s, whereas it has increased for others.8 Death rates are declining among the most educated Americans, accompanied by steady or increasing death rates among the least educated.11The statistics comparing the health of Americans based on education are striking:
- At age 25, U.S. adults without a high school diploma can expect to die 9 years sooner than college graduates.12
- According to one study, college graduates with only a Bachelor’s degree were 26 percent more likely to die during a 5-year study followup period than those with a professional degree. Americans with less than a high school education were almost twice as likely to die in the next 5 years compared to those with a professional degree.13
- Among whites with less than 12 years of education, life expectancy at age 25 fell by more than 3 years for men and by more than 5 years for women between 1990 and 2008.8
- By 2011, the prevalence of diabetes had reached 15 percent for adults without a high school education, compared with 7 percent for college graduates.14
What accounts for the growing health disadvantages that exist among people with lower educational attainment? Is it what they learn in school, such as how to live a healthy lifestyle, or the socioeconomic advantages that come from an education? Or is the cross-sectional association between education and health more complex, involving nuanced contextual covariables in our society that provide a fuller back story?
This chapter explores the relationship between education and health from the perspective of the peer-reviewed literature and that of community members, engaged through a research exercise, to blend insights from lived experience with the empirical data accumulated from scholarly research. Unpacking the reasons for the connection between education and health is not just an exercise in scientific inquiry, it is also essential to setting policy priorities. As increasing attention is focused on the need to address social inequity in order to address health inequities, understanding the links between broad upstream factors such as education and health outcomes becomes a critical challenge. Awareness of the importance of education might help drive investment in education and improvements in education and educational policy.
An overarching theoretical framework for the impact of social determinants on health is provided by an ecological model in which individuals and their behavior are embedded, across the lifespan, within a framework of nested institutional contexts (Figure 1).15 The individual and his or her characteristics are situated within and affected by the family and household, the community and its institutions (e.g., school, workplace, civil institutions), and policies of the larger society. Each level brings access to opportunities, as well as constraints on actions and opportunities. Furthermore, these levels interact with one another, such that family resources, for example, may mediate or moderate the resources available within the community. Social scientists widely agree that unequal social status creates unequal access to resources and rewards. Social structure, as embodied in social position, structures individual behaviors and values and therefore affects many of the mediators in the relationship between education and health.
Education is one of the key filtering mechanisms that situate individuals within particular ecological contexts. Education is a driving force at each ecological level, from our choice of partner to our social position in the status hierarchy. The ecological model can therefore provide a context for the numerous ways in which education is linked to our life experiences, including health outcomes. It also provides a framework for understanding the ways in which educational outcomes themselves are conditioned on the many social and environmental contexts in which we live and how these, in turn, interact with our individual endowments and experiences.
Within this rich contextual framework, educational attainment (the number of years of schooling completed) is important but is far from the whole story. Educational attainment is often a key indicator in research studies, not least because it is often measured and recorded; life expectancy is compared by educational attainment because it is the only information about education recorded on death certificates. Besides obvious measures of the quality of education such as proficiency scores and understanding of mathematics, reading, science, and other core content, other dimensions of education are clearly important in the ecological context as well; cognitive development, character development, knowledge, critical thinking, and problem solving are a few examples.
Additionally, the relationship between years of education and health is not a purely linear function. As part of a literature attempting to clarify the functional form of the relationship between education and health, Montez et al. have documented a negative relationship between years of education and mortality risk for attainment less than high school graduation, a steep decline for high school graduates (with reduction of risk five times greater than attributable to other years of education), and a continued yet steeper negative relationship for additional years of schooling (Figure 2).16 The drop at high school graduation points to the importance of obtaining credentials in addition to other benefits of educational attainment.
In order to present a nuanced picture of the relationship between education and health, this chapter is presented in two parts. First, we review the health benefits associated with education, focusing on the primary mechanisms, both distal and proximate, by which education may be considered a driving force in health outcomes. We take a socioecological approach by presenting these concepts in a hierarchy, moving from the level of the person to the community/institution and then the larger social/policy context. Next, we turn to issues of causality that can make it difficult to draw conclusions about the relationship between education and health. These include reverse causality and selection, in which education may actually be impacted by ill health, and confounding, where both education and health are affected by some other causal factor(s) that may also provide important clues about the root causes of poor education and poor health.
Finally, this chapter moves beyond abstract academic models to discuss alternate ways of understanding and prioritizing these mechanisms. We look at preliminary results from a project to garner a “view from the inner city” based on the lived experiences of residents of a disadvantaged neighborhood and how their insights may highlight, broaden, or reinterpret our understanding of the mechanisms presented earlier in the chapter. Our goal is not to settle the question of which are the most important mechanisms by which education and health are related, but rather to call attention to the value of engaging people within communities in enabling researchers and policymakers to better understand and operationalize the importance of education in everyday life and the meaning of empirical evidence from the literature. Our work is part of a larger trend in community-based participatory research (CBPR) that is invigorating a dialogue that incorporates community engagement into the important discussions surrounding social and health inequalities.17
Readers are cautioned that this chapter touches on a diverse spectrum of factors—all linked to education—that vary from urban design to psychosocial characteristics, access to health care, air pollution, and economic policy. These very diverse domains are each the subject of large literatures that cannot be systematically catalogued in this space. Rather than offering a systematic review, our goal is to draw attention to these factors as part of the education-health relationship and to cite representative sources where readers can explore these topics in more detail; we encourage this research because the quality of evidence linking these factors to health outcomes is uneven and in some cases speculative. Education is linked to established health determinants supported by extensive evidence, such as tobacco use and poverty, but also to factors with less developed evidence, such as allostatic load and social cohesion. Research on methods for improving educational outcomes and learning is not catalogued here due to space constraints but is of vital importance. Finally, the individual elements of the socioecological model exist in a context, and disciplinary and transdisciplinary research is highly relevant in understanding the interplay of contextual factors in a complex systems relationship.18,19
Health Benefits Associated with Education
Among the most obvious explanations for the association between education and health is that education itself produces benefits that later predispose the recipient to better health outcomes. We may think of these returns from education, such as higher earnings, as subsequent “downstream” benefits of education (later in the chapter we will discuss “upstream” factors that may influence both education and health throughout the life course, especially before children ever reach school age). Following the socioecological framework presented in the introduction, we describe a range of potential downstream impacts of education on health, starting with the ways individuals experience health benefits from education, but then going on to discuss the health-related community (or place-based) characteristics that often surround people with high or low education, and closing with the larger role of social context and public policy.
Impact at the Individual Level
Education can impart a variety of benefits that improve the health trajectory of the recipient. Below we discuss its role in enhancing non-cognitive and cognitive skills and access to economic resources, and we highlight the impacts of these on health behaviors and health care usage. Although this section focuses specifically on the health benefits of education, we do so in full knowledge that education is impacted by health, development, and a host of personal, community, and contextual factors.