February 13, 2015

Americans with more education live longer, healthier lives than those with fewer years of schooling (see Issue Brief #1). But why does education matter so much to health? The links are complex—and tied closely to income and to the skills and opportunities that people have to lead healthy lives in their communities.

How are health and education linked? There are three main connections:1

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The relationship between education and health has existed for generations, despite dramatic improvements in medical care and public health. Recent data show that the association between education and health has grown dramatically in the last four decades. Now more than ever, people who have not graduated high school are more likely to report being in fair or poor health compared to college graduates.2 Between 1972 and 2004, the gap between these two groups grew from 23 percentage points to 36 percentage points among non-Hispanic whites age 40 to 64. African-Americans experienced a comparable widening in the health gap by education during this time period. The probability of having major chronic conditions also increased more among the least educated.3 The widening of the gap has occurred across the country4 and is discussed in more detail in Issue Brief #1.

How important are years of school?

Research has focused on the number of years of school students complete, largely because there are fewer data available on other aspects of education that are also important. It’s not just the diploma: education is important in building knowledge and developing literacy, thinking and problem-solving skills, and character traits. Our community research team noted that early childhood education and youth development are also important to the relationship between education and health.

This issue brief, created with support from the Robert Wood Johnson Foundation, provides an overview of what research shows about the links between education and health alongside the perspectives of residents of a disadvantaged urban community in Richmond, Virginia. These community researchers, members of our partnership, collaborate regularly with the Center on Society and Health’s research and policy activities to help us more fully understand the “real life” connections between community life and health outcomes.

1. The Health Benefits of Education

Income and Resources

“Being educated now means getting better employment, teaching our kids to be successful and just making a difference in, just in everyday life.” —Brenda

Better jobs: In today’s knowledge economy, an applicant with more education is more likely to be employed and land a job that provides health-promoting benefits such as health insurance, paid leave, and retirement.5 Conversely, people with less education are more likely to work in high-risk occupations with few benefits.

Higher earnings: Income has a major effect on health and workers with more education tend to earn more money.2 In 2012, the median wage for college graduates was more than twice that of high school dropouts and more than one and a half times higher than that of high school graduates.6 Read More

Adults with more education tend to experience less economic hardship, attain greater job prestige and social rank, and enjoy greater access to resources that contribute to better health. A number of studies have suggested that income is among the main reasons for the superior health of people with an advanced education.1 Weekly earnings rise dramatically for Americans with a college or advanced degree. A higher education has an even greater effect on lifetime earnings (see Figure 1), a pattern that is true for men and women, for blacks and whites, and for Hispanics and non-Hispanics. For example, based on 2006-2008 data, the lifetime earnings of a Hispanic male are $870,275 for those with less than a 9th grade education but $2,777,200 for those with a doctoral degree. The corresponding lifetime earnings for a non-Hispanic white male are $1,056,523 and $3,403,123.7

“Definitely having a good education and a good paying job can relieve a lot of mental stress.”
—Chimere

Resources for good health: Families with higher incomes can more easily purchase healthy foods, have time to exercise regularly, and pay for health services and transportation. Conversely, the job insecurity, low wages, and lack of assets associated with less education can make individuals and families more vulnerable during hard times—which can lead to poor nutrition, unstable housing, and unmet medical needs. Read More

Economic hardships can harm health and family relationships,8 as well as making it more difficult to afford household expenses, from utility bills to medical costs. People living in households with higher incomes—who tend to have more education—are more likely to be covered by health insurance (see Figure 3). Over time, the insured rate has decreased for Americans without a high school education (see Figure 4).

Lower income and lack of adequate insurance coverage are barriers to meeting health care needs. In 2010, more than one in four (27%) adults who lacked a high school education reported being unable to see a doctor due to cost, compared to less than one in five (18%) high school graduates and less than one in 10 (8%) college graduates.9 Access to care also affects receipt of preventive services and care for chronic diseases. The CDC reports, for example, that about 49% of adults age 50-75 with some high school education were up-to-date with colorectal cancer screening in 2010, compared to 59% of high school graduates and 72% of college graduates.10

Figure 1 Figure 2 Figure 3 FIgure 4

Social and Psychological Benefits

“So through school, we learn how to socially engage with other classmates. We learn how to engage with our teachers. How we speak to others and how we allow that to grow as we get older allows us to learn how to ask those questions when we're working within the healthcare system, when we're working with our doctor to understand what is going on with us.”
—Chanel

Reduced stress: People with more education—and thus higher incomes—are often spared the health-harming stresses that accompany prolonged social and economic hardship. Those with less education often have fewer resources (e.g., social support, sense of control over life, and high self-esteem) to buffer the effects of stress. Read More

Life changes, traumas, chronic strain, and discrimination can cause health-harming stress. Economic hardship and other stressors can have a cumulative, negative effect on health over time and may, in turn, make individuals more sensitive to further stressors. Researchers have coined the term “allostatic load” to refer to the effects of chronic exposure to physiological stress responses. Exposure to high allostatic load over time may predispose individuals to diseases such as asthma, cardiovascular disease, gastrointestinal disease, and infections11 and has been associated with higher death rates among older adults.12

Social and psychological skills: Education in school and other learning opportunities outside the classroom build skills and foster traits that are important throughout life and may be important to health, such as conscientiousness, perseverance, a sense of personal control, flexibility, the capacity for negotiation, and the ability to form relationships and establish social networks. These skills can help with a variety of life’s challenges—from work to family life—and with managing one’s health and navigating the health care system. Read More

Many types of skills can be developed through education, from cognitive skills to problem solving to fostering key personality traits. Education can increase ‘learned effectiveness,’ including cognitive ability, self-control, and problem solving.13 Personality traits, otherwise known as ‘soft skills’, are associated with success in education and employment and lower mortality rates.14 One set of these personality traits has been called the ‘Big Five’: conscientiousness, openness to experience, being extraverted, being agreeable, andemotional stability.15

These various forms of human capital are an important way that education affects health. For example, education may strengthen coping skills that reduce the damage of stress. Greater personal control may also lead to healthier behaviors, partly by increasing knowledge. Those with greater perceived personal control are more likely to initiate preventive behaviors.13

Social networks: Educated adults tend to have larger social networks—and these connections bring access to financial, psychological, and emotional resources that may help reduce hardship and stress and improve health. Read More

Social networks also enhance access to information and exposure to peers who model acceptable behaviors. The relationship between social support and education may be due, in part, to the social and cognitive skills and greater involvement with civic groups and organizations that come with education.16, 17 Low social support is associated with higher death rates and poor mental health.18, 19

Education is also associated with crime. Among young male high school drop-outs, nearly 1 in 10 was incarcerated on a given day in 2006-2007 versus fewer than 1 of 33 high school graduates.20 The high incarceration rates in some communities can disrupt social networks and weaken social capital and social control—all of which may impact public health and safety.

“Being able to advocate and ask for what you want, helps to facilitate a healthier lifestyle. … If it's needing your community to have green spaces, have a park, a playground, have better trails within the community, advocating for that will help.”
—Chanel

Health Behaviors

Knowledge and skills: In addition to being prepared for better jobs, people with more education are more likely to learn about healthy behaviors. Educated patients may be more able to understand their health needs, follow instructions, advocate for themselves and their families, and communicate effectively with health providers.21 Read More

People with more education are more likely to learn about health and health risks, improving their literacy and comprehension of what can be complex issues critical to their wellbeing. People who are more educated are more receptive to health education campaigns. Education can also lead to more accurate health beliefs and knowledge, and thus to better lifestyle choices, but also to better skills and greater self-advocacy. Education improves skills such as literacy, develops effective habits, and may improve cognitive ability. The skills acquired through education can affect health indirectly (through better jobs and earnings) or directly (through ability to follow health care regimens and manage diseases), and they can affect the ability of patients to navigate the health system, such as knowing how to get reimbursed by a health plan. Thus, more highly educated individuals may be more able to understand health care issues and follow treatment guidelines.21–23 The quality of doctor-patient communication is also poorer for patients of low socioeconomic status. A review of the effects of health literacy on health found that people with lower health literacy are more likely to use emergency services and be hospitalized and are less likely to use preventive services such as mammography or take medications and interpret labels correctly. Among the elderly, poor health literacy has been linked to poorer health status and higher death rates.24

Healthier Neighborhoods

“Poor neighborhoods oftentimes lead to poor schools. Poor schools lead to poor education. Poor education oftentimes leads to poor work. Poor work puts you right back into the poor neighborhood. It's a vicious cycle that happens in communities, especially inner cities.” —Albert

Lower income and fewer resources mean that people with less education are more likely to live in low-income neighborhoods that lack the resources for good health. These neighborhoods are often economically marginalized and segregated and have more risk factors for poor health such as:

  • Less access to supermarkets or other sources of healthy food and an oversupply of fast food restaurants and outlets that promote unhealthy foods.25

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Nationwide, access to a store that sells healthier foods is 1.4 less likely in census tracts with fewer college educated adults (less than 27% of the population) than in tracts with a higher proportion of college-educated persons.26 Food access is important to health because unhealthy eating habits are linked to numerous acute and chronic health problems such as diabetes, hypertension, obesity, heart disease, and stroke as well as higher mortality rates.

“If the best thing that you see in the neighborhood is a drug dealer, then that becomes your goal. If the best thing you see in your neighborhood is working a 9 to 5, then that becomes your goal. But if you see the doctors and the lawyers, if you see the teachers and the professors, then that becomes your goal.” —Marco

“It's a lot of things going on [in this community], a lot of challenges. It's just hard sometimes to try and get people to come together, as one, just so we can solve the problem.” —Toni

  • Less green space, such as sidewalks and parks to encourage outdoor physical activity and walking or cycling to work or school.
  • Rural and low-income areas, which are more populated by people with less education, often suffer from shortages of primary care physicians and other health care providers and facilities.
  • Higher crime rates, exposing residents to greater risk of trauma and deaths from violence and the stress of living in unsafe neighborhoods. People with less education, particularly males, are more likely to be incarcerated, which carries its own public health risks.
  • Fewer high-quality schools, often because public schools are poorly resourced by low property taxes. Low-resourced schools have greater difficulty offering attractive teacher salaries or properly maintaining buildings and supplies.
  • Fewer jobs, which can exacerbate the economic hardship and poor health that is common for people with less education.
  • Higher levels of toxins, such as air and water pollution, hazardous waste, pesticides, andindustrial chemicals.27
  • Less effective political influence to advocate for community needs, resulting in a persistent cycle of disadvantage.

2. Poor Health That Affects Education (Reverse Causality)

“Things that happen in the home can definitely affect a child being able to even concentrate in the classroom. … If you're hungry, you can't learn with your belly growling. … If you’re worried about your mom being safe while you're at school, you're not going to be able to pay attention.” —Chimere

The relationship between education and health is never a simple one. Poor health not only results from lower educational attainment, it can also cause educational setbacks and interfere with schooling.

For example, children with asthma and other chronic illnesses may experience recurrent absences and difficulty concentrating in class.28 Disabilities can also affect school performance due to difficulties with vision, hearing, attention, behavior, absenteeism, or cognitive skills. Read More

Health conditions, disabilities, and unhealthy behaviors can all have an effect on educational outcomes. Illness, poor nutrition, substance use and smoking, obesity, sleep disorders, mental health, asthma, poor vision, and inattention/hyperactivity have established links to school performance or attainment.25, 29, 30 For example, compared to other students, children with attention deficit/hyperactivity disorder (ADHD) are three times more likely to be held back (retained a grade) and almost three times more likely to drop out of school before graduation.31 Children who are born with low birth weight also tend to have poorer educational outcomes,32, 33 and higher risk for special education placements.34, 35 Although the impact of health on education (reverse causality) is important, many have questioned how large a role it plays.1

3. Conditions Throughout the Life Course—Beginning in Early Childhood—That Affect Both Health and Education

A third way that education can be linked to health is by exposure to conditions, beginning in early childhood, which can affect both education and health. Throughout life, conditions at home, socioeconomic status, and other contextual factors can create stress, cause illness, and deprive individuals and families of resources for success in school, the workplace, and healthy living. Read More

Contextual factors throughout one’s life can affect education and health. For example, biological characteristics can affect educational success and health outcomes, as can socioeconomic and environmental conditions such as poverty or material deprivation. These influences appear to be particularly acute during early childhood, when children’s physical health and academic success can be influenced by biologic risk factors (e.g., low birth weight, chronic health conditions) and socioeconomic status (e.g., parents’ education and assets, neighborhood socioeconomic resources, such as day care and schools).36 School readiness is enhanced by positive early childhood conditions—e.g., fetal wellbeing, social-emotional development, family socioeconomic status, neighborhood socioeconomic status, and early childhood education—but some of these same assets also appear to be vital to the health and development of children and their future risk of adopting unhealthy behaviors and adult diseases.3740 Early childhood is a period in which health and educational trajectories are shaped by a nurturing home environment, parental involvement, stimulation, and early childhood education, which can foster the development of social skills, adjustment and emotional regulation as well as learning skills.41

What about social policy?

Social policy—decisions about jobs, the economy, education reform, etc.—is an important driver of educational outcomes AND affects all of the factors described in this brief. For example, underperforming schools and discrimination affect not only educational outcomes but also economic success, the social environment, personal behaviors, and access to quality health care. Social policy affects the education system itself but, in addition, individuals with low educational attainment and fewer resources are more vulnerable to social policy decisions that affect access to health care, eligibility for aid, and support services.

A growing body of research suggests that chronic exposure of infants and toddlers to stressors—what experts call “adverse childhood experiences”—can affect brain development and disturb the child’s endocrine and immune systems, causing biological changes that increase the risk of heart disease and other conditions later in life (see Graphic 1). For example:

“The connection that I will say between education and health would be a healthy mind produces a healthy person. A motivated mind produces a motivated person. A curious mind produces a curious person. When you have those things it drives you to want to know more, to want to have more, to want to inquire more. And when you want more, you will get more. You know where the mind goes the person follows… and that includes health.” —Marco

  • The adverse effects of stress on the developing brain and on behavior can affect performance in school and explain setbacks in education. Thus, the correlation between lower educational attainment and illness that is later observed among adults may have as much to do with the seeds of illnessand disability that are planted before children ever reach school age as witheducation itself.
  • Children exposed to stress may also be drawn to unhealthy behaviors—such as smoking or unhealthy eating—during adolescence, the age when adult habits are often first established.

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Instability in home and community life can have a negative impact on child development and, later in life, such outcomes as economic security and stable housing, which can also affect the physical and mental health of adults. Children exposed to toxic stress, social exclusion and bias, persistent poverty, and trauma experience harmful changes in the architecture of the developing brain that affect cognition, behavioral regulation, and executive function.42, 43 These disruptions can thereby shape educational, economic, and health outcomes decades and generations later.44 Dysfunctional coping skills as well as changes in parts of the brain associated with reward and addiction may draw children to unhealthy behaviors (e.g., smoking, alcohol or drug use, unsafe sex, violence) as teenagers.

Focusing on seven categories of adverse childhood experiences (ACEs)*, researchers in the 1990s reported a “graded relationship” for poor health and chronic disease: the higher the exposure to ACEs as children, the greater the risk as adults of having ischemic heart disease, cancer, stroke, chronic lung disease, and diabetes45 (see Figure 5). Chronic exposure to ACEs is now believed to disrupt children’s developing endocrine and immune systems, causing the body to produce stress hormones and proteins that produce chronic inflammation and lead later in life to heart disease and other adult health problems.46 Chronic stress can also cause epigenetic changes in DNA that “turn on” genes that may cause cancer and other conditions.47

Not surprisingly, exposure to ACEs also can stifle success in employment.38, 48, 49 In one study, the unemployment rate was 13.2% among respondents with 4 or more ACEs, compared to 6.5% for those with no history of ACEs.50

People who begin life with adverse childhood experiences can thus end up both with greater illness and with difficulties in school and the workplace, thereby contributing to the link between socioeconomic conditions, education, and health. An important way to improve these outcomes is to address the root causes that expose children to stress in the first place.

*The adverse childhood experiences explored were: psychological, physical, or sexual abouse; violence against mother; and living with household members who are substance abusers, mentally ill/suicidal, or ever imprisoned.

“We now know that adversity early in life can not only disrupt brain circuits that lead to problems with literacy; it can also affect the development of the cardiovascular system and the immune system and metabolic regulatory systems, and lead to not only more problems learning in school but also greater risk for diabetes and hypertension and heart disease and cancer and depression and substance abuse." —J Shonkoff (The Poverty Clinic, The New Yorker, March 21, 2011)

Graphic 1 Figure 5

What about individual characteristics?

Characteristics of individuals and families are important in the relationship between education and health. Race, gender, age, disability and other personal characteristics often affect educational opportunities and success in school (see Issue Brief #1). Discrimination and racism have multiple links to education and health. Racial segregation reduces educational and job opportunities51 and is associated with worse health outcomes.52, 53

 

How does education impact health in your community?

The Center on Society and Health (CSH) worked with members of Engaging Richmond, a community-academic partnership that included residents of the East End, a disadvantaged neighborhood of Richmond, Virginia. This inquiry into the links between education and health was a pilot study to learn how individuals could add to our understanding of this complex issue using the lens of their own experiences.

What does your community have to say about the links between education and health – or other health disparities? Learn more about community research partnerships and community engagement:

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