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SEPTEMBER / OCTOBER 2012 :: 73(5)
Social Determinants of Health

This issue's policy forum focuses on key social determinants of health. Authors explore how health is linked with education, poverty, and housing, and discuss the role of neighborhoods and health disparities in shaping individual health status. Complementary sidebar articles describe effective and promising interventions occurring throughout the state to address these social determinants of health. Original articles examine the state of racial/ethnic diversity in North Carolina's health workforce and review dental visits to an emergency department in the state.

INVITED COMMENTARY

Educational Attainment as a Social Determinant of Health

Joseph Telfair, Terri L. Shelton

N C Med J. 2012;73(5):358-365.PDF | TABLE OF CONTENTS



A review of the current literature on the relationship between health outcomes and level of education provides points for consideration by providers and policymakers wishing to address social and economic determinants of health and health disparities.

Overview
Historically, certain groups of people (mostly minorities, poor people, and those living in regions where care is geographically sparse) have had less access to health care and have been less likely to utilize the care available to them. Figuring out how best to address such disparities in health care continues to be of importance to providers, administrators, scientists, and policymakers. Knowledge of the social and economic determinants of the disparities is critical for building evidenced-based solutions for their mitigation [1]. The Centers for Disease Control and Prevention, drawing on a World Health Organization report [2], explains that the social determinants of health are the

“complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world [3].”

The North Carolina Institute of Medicine (NCIOM) Task Force on Prevention in a 2009 report recognized that a person’s level of educational attainment is strongly related to his or her well-being and health status [4]. David M. Cutler and Adriana Lleras-Muney summarized the evidence in a policy brief for the National Poverty Center (2007) [5]: they noted that the research showed that better-educated people have lower death rates from common chronic and acute conditions, even after adjusting for demographic and employment factors. Further, the differences in life expectancy for those with and without a college education has widened over time. Differences in health behavior cannot account for all of the differences in health outcomes between those with more education and those with less. The ways in which education affects health are complex and include

“interrelationships between demographic and family background indicators, effects of poor health in childhood, greater resources associated with higher levels of education, a learned appreciation for the importance of good health behaviors, and one’s social networks [5].”

Unfortunately, our system of mass public education does not work equally well for everyone. Those with poor academic performance are likely to have lower educational attainment. This in turn decreases upward mobility and affects a person’s health status.

Early childhood education can instill lifelong beliefs and behaviors that promote good health outcomes. However, the likelihood that a child will experience interventions designed to instill those beliefs and behaviors depends on his or her social, educational, and economic circumstances [6]. Challenges to the development and implementation of effective early intervention programs and services are complex and multifactorial, but they can be mitigated by programs such as the Healthy Start program of the Department of Health and Human Services [7] and North Carolina Smart Start [8]. Access to such programs varies, and efforts to encourage greater participation are needed.

The health disparities between the more and the less educated are significant. In 1999, the age-adjusted mortality rate of high school dropouts ages 25 to 64 was more than twice that of those with some college [9]. Using data from the National Health Interview Survey and matching respondents with death certificates obtained through the National Death Index, Cutler and Lleras-Muney found that individuals with higher levels of education were less likely to die within 5 years of having been interviewed [10]. This association remained substantial and significant even after controlling for job characteristics, income, and family background. This suggests that policies that improve educational outcomes for individuals have the potential to substantially improve health.

There is a relationship between educational level and health for both chronic conditions and acute ones, but the magnitude of the relationship is generally greater for chronic conditions [1]. Among adults 25 years of age or older, an additional 4 years of education lowers 5-year mortality by 1.8 percentage points (from 11% to 9.2%); it also reduces the risk of heart disease by 2.2 percentage points (from 31% to 28.8%) and the risk of diabetes by 1.3 percentage points (from 7% to 5.7%) [5].

As we have noted, better-educated persons have lower morbidity from the most common acute and chronic diseases (heart condition, stroke, hypertension, high cholesterol, emphysema, diabetes, asthma, and ulcers) [5, 10]. Educational attainment has been shown to have a significant protective effect on the risk for stroke and myocardial infarction, independent of socioeconomic status and other cardiovascular risk factors. Researchers in the Department of Neurosurgery and Toshiba Stroke Research Center at State University of New York, Buffalo, evaluated the relationship between education level (12 years or more of education versus less than 12 years) and the incidence of fatal stroke, ischemic stroke, intracerebral hemorrhage, and myocardial infarction [11] in a cohort of 21,443 United States adults who had participated in 1 of 2 large survey follow-up studies. During a mean follow-up period of 15.2 years, the risk for all fatal strokes increased in persons who reported less than 12 years of education; those with less education also had higher risks of myocardial infarction and of fatal intracerebral hemorrhage [11]. In combination with higher income, higher levels of education can also protect against risk factors for atherothrombotic (coronary, cerebrovascular, and/or peripheral arterial) disease: In a large multinational study, Goyal and colleagues [12] found that attained education level was protective against risk factors such as obesity, smoking, hypertension, and baseline burden of vascular disease in high-income countries such as the United States, but not in countries where income was low or moderate.

People with more education are less likely to have diabetes [5, 10]. Diabetes is especially common among disadvantaged groups, including persons without a high school diploma. A study by Reither and colleagues [13] using Utah data from the Behavioral Risk Factor Surveillance System between 1996-1999 and 2004-2007 found significant inverse associations between educational attainment and the odds of having diabetes. Women with a college education were found to be 27% less likely than women with a high school education to have diabetes. Well-educated men and women exhibit lower rates of diabetes than those with less education, and these disparities have not changed appreciably over the past decade [13].

Those with more education are healthier both mentally and physically. They are substantially less likely to report that they are in poor health or are experiencing anxiety or depression [5]. Having an additional 4 years of education lowers the probability of reporting oneself to be in fair or poor health by 6 percentage points (from 12% to 6%) and reduces the number of days of work lost to sickness each year by 2.3 days (from 5.2 days to 2.9 days) [5]. Better-educated people report spending fewer days in bed or not at work because of disease, and they have fewer functional limitations [10]. In short, higher levels of education yield better health, and with each increase in level of education (eg, from high school to college, or college to graduate school), there appears to be a positive change in health status [5].

The fact that people who are better educated have lower morbidity rates from the most common acute and chronic diseases is due in part to the fact that education level and educational achievement play a role in determining what sort of job or career one has, which in turn directly correlates with one’s financial or socioeconomic status. Education is perhaps the most basic component of socioeconomic status, because it shapes future occupational opportunities and earning potential. Education also provides knowledge and life skills that allow better-educated persons to more readily gain access to information and resources that promote health [9].

Individuals 25 years of age or older who have an additional 4 years of education also report more positive health behaviors [5]. Cutler and Lleras-Muney note that having an additional 4 years of education reduces the risk that one will smoke from 23% to 12%. People with the additional education also are less likely to report excessive drinking (5 or more drinks in 1 day). Those with more education report drinking to excess 4 days per year on average, compared with 11 days per year for those with less education. The risk of obesity is also reduced for those with more education, from 23% to 18%, and they are at slightly less risk of using illegal drugs (4.9% versus 5.0%) [5]. The authors note that differences in health behaviors alone cannot explain all of the disparities in health outcomes between the better educated and the less educated. Nevertheless, Cutler and Lleras-Muney point out, “an almost linear negative relationship exists between mortality and years of schooling and between self-reported fair/poor health status and years of schooling” [5]. And for some outcomes (functional limitations and obesity, for instance) the positive impact of education is even greater for those with some postsecondary education [5].

The correlation between educational achievement and health declines after a person reaches about age 50 or 60 [5, 10]. Cutler and Lleras-Muney suggest several possible reasons for this [5, 10]. Although less educated people are less likely to survive into older age, those who do survive are relatively healthy. Therefore, they may have been more similar to those who are better educated. It is also possible that education has become more important to health outcomes only in recent years. Further, the association between education and health may decrease after adults retire.

There are multiple reasons for these associations between level of education and health outcomes, although it is likely that they are in part the result of differences in behavior across education groups. The relationships that have been found between level of education and various health risk factors—smoking, drinking, diet/exercise, use of illegal drugs, household safety, use of preventive medical care, and care for hypertension and diabetes—suggest very strongly that people who are better educated have healthier behaviors, although some of these healthier behaviors may also reflect differential access to care. As we have mentioned, those with more years of schooling are less likely to smoke, to drink heavily, to be overweight or obese, or to use illegal drugs [5]. Interestingly, although they report having tried illegal drugs more frequently than do the less educated, they also report having given up using illegal drugs more readily [9, 10].

The effect of level of education on health seems to be the same for both men and women across most outcomes; depression is one of the few exceptions [5]. It is not known whether such exceptions are the result of biological sex differences, or of differences in the behavior of men and women. The effect of level of education on health also appears to the same for both whites and blacks, again with a few exceptions. Whites tend to experience more positive health benefits from educational advancement in reported health status; they are less likely to report being in fair or poor health than are blacks with the same level of education. Cutler and Lleras-Muney also found that the impact of additional years of education was greater for those not living in poverty than for those who were poor [5]. This highlights the interrelationships among those variables considered to be social determinants. Educational attainment alone is not an independent driving factor for improved health status. An individual with a 4-year college degree who is living in poverty might have considerably worse health than an individual with such a degree who is well off financially.

Many of the social factors that affect health have both independent and interactive effects. For example, people with higher incomes are more likely to live in safe, healthy homes in good communities with high-quality schools. Persons who are poor are more likely to live in substandard housing or in unsafe communities. Their communities may lack grocery stores that sell fresh fruits and vegetables or lack access to outdoor recreational facilities where people can exercise. Children who grow up in poverty generally fare worse in school and end up, on average, with fewer years of education than those in families with higher incomes [1]. Health-related factors such as hunger, physical and emotional abuse, and chronic illness can lead to poor school performance [14]. All of these factors combine to shape a person’s health experience across the lifespan.

What is known is that mitigation of many of the social determinants of health disparities and their consequences results from ongoing proactive efforts aimed at improving the overall quality of life of persons in at-risk groups, beginning early in life [15-17]. Some types of improvement efforts, such as the creation of jobs or the placement of parks or grocery stores, are beyond the scope of clinicians and other health care providers. However, ongoing efforts are being made to improve access to health care. For example, resources can be provided to expand health insurance coverage and health care in under-resourced communities.

Academic success is an excellent indicator for the overall well-being of youth and is a primary predictor and determinant of adult health outcomes [18-20]. Addressing the role of educational attainment early in a person’s life is critical, and the earlier this begins the better. The Community Preventive Services Task Force, created by the US Department of Health and Human Services to evaluate evidence and make recommendations about effective community-based interventions, has recommended the establishment of comprehensive, center-based programs for low-income children ages 3 to 5 years. Effective and evidence-based early childhood programs that support early learning opportunities result in improved school readiness, less grade retention, and fewer placements in special education classes [21]. Cutler and Lleras-Muney [10] and others [22, 23] also recommend that the quality of schools be improved. In addition, Cutler and Lleras-Muney promote policies to expand college attendance [5].

Schools can play an important role in promoting the health and safety of young people and helping them establish lifelong healthy behaviors. Studies suggest that school health programs can have positive effects on educational outcomes, health-risk behaviors, and health outcomes [22, 24]. Similarly, programs that are primarily designed to improve academic performance are increasingly recognized as being important public health interventions [11, 13]. Leading national education organizations recognize the close relationship between health and education, as well as the need to foster health and well-being within the educational environment for all students [19-21, 25, 26].

Acknowledgments
The authors would like to thank Ms. Yanica Faustin, Ms. Alexsandra Babic, and Ms. Holly Sienkiewicz for their background research and editorial assistance in the development of this manuscript.

Potential conflicts of interest. J.T. and T.L.S. have no relevant conflicts of interest.

References
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26. Basch CE. Healthier Students Are Better Learners: A Missing Link in School Reforms to Close the Achievement Gap. A Research Initiative of the Campaign for Educational Equity. Equity Matters: Research Review No. 6. New York, NY: Columbia University; 2010. http://www.equitycampaign.org/i/a/document/12557_EquityMattersVol6_Web03082010.pdf. Accessed June 29, 2012.


Joseph Telfair, DrPH, MSW, MPH director, Center for Social, Community and Health Research and Evaluation, The University of North Carolina at Greensboro, Greensboro, North Carolina.
Terri L. Shelton, PhD vice chancellor for Research and Economic Development, The University of North Carolina at Greensboro, Greensboro, North Carolina.

Address correspondence to Dr. Joseph Telfair, Center for Social, Community and Health Research and Evaluation, The University of North Carolina at Greensboro, PO Box 26170, Greensboro, NC 27402 (j_telfai@uncg.edu).