The County Health Rankings show us that where we live matters to our health. The health of a community depends on many different factors - ranging from health behaviors, education and jobs, to quality of health care, to the environment.

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Education

What Is It?

The relationship between higher education and improved health outcomes is well known, although the explanation for this correlation is less certain.[1] This positive relationship between health outcomes and advanced education levels is an important concept for understanding a community’s health. The County Health Rankings uses two measures to represent education: the high school graduation rate and the percent of the adults (ages 25 to 44) with some post-secondary education.

Why Do We Measure It?

Several theories attempt to explain how education affects health outcomes. First, education often results in higher incomes, on average, and more resources than a job that does not require education.[2,3] Access to health care is a particularly important resource that often is linked to jobs requiring a certain level of educational attainment.[2] However, when income and health care insurance are controlled for, the magnitude of education’s effect on health outcomes remains substantive and statistically significant. Hence income and health care insurance are only two of many contributing factors.[2] 

The labor market environment is also thought to contribute to health outcomes. People with lower educational attainment are more likely to be affected by variations in the job market. Unemployment rates are highest for individuals without a high school diploma (7%) compared with college graduates (2%).[4] Evidence shows that the unemployed population experiences worse health and higher mortality rates than the employed population.[3,5]

Third, health literacy can help explain an individual’s health behaviors and lifestyle choices.[3] There is a striking difference between health literacy levels based on education. Only 3% of college graduates have below basic health literacy skills, while 15% of high school graduates and 49% of adults who have not completed high school have below basic health literacy skills.[3,6] Adults with less than average health literacy are more likely to report their health status as poor.[3]

Not only does one’s education level affect his or her health; education can have multigenerational implications that make it an important measure for the health of future generations.[2,3] Evidence links maternal education with the health of her offspring.[2] The education of parents affects their children’s health directly through resources available to the children, and also indirectly through the quality of schools that the children attend.[3]

Finally, education influences a variety of social and psychological factors.[3] Evidence shows that the more education an individual has, the greater his or her sense of personal control. This is important to health because people who view themselves as possessing a high degree of personal control also report better health status and are at lower risk for chronic disease and physical impairment.[7] In addition, more education improves an individual’s self-perception of his or her social standing, which also predicts higher self-reported health status.[3,8]

What Is the County Health Rankings Measurement Strategy?

The County Health Rankings uses two measures in an attempt to capture the formal years of education within the population. The first measure reports the percent of the ninth grade cohort that graduates high school in four years. The measure is from the National Center for Education Statistics (NCES) as well as from some state data sources that are not represented in the NCES. The second measure reports the percentage of the population age 25-44 with some post-secondary education. These data are from the American Community Survey (ACS).

Measure Strengths & Limitations

Different aspects regarding education have been studied in an attempt to distinguish which factor plays the most significant role in the health of the population. One study looked at years of formal education, the credential of the college degree, and the selectivity of the educational experience.[9] The years of formal education had the strongest correlation with health and is thought to be related to the work and economic opportunities from more years of education, the psychological resources available to more educated individuals, and a healthier lifestyle.[9] This study supports the use of the two County Health Rankings measures for reporting on education and its links to health.

A limitation for an education measure is the lack of knowledge surrounding educational impacts on health, and the argument that we do not know definitely whether the effect of education on health is causal.[2] Additionally, there are many conflicting findings on the effect of age on education and health. Some studies have found that the relationship between education and health weakens with age.[10,11] Age of residents could also make it difficult for a county to take action surrounding the education measure so the post-secondary college education measure is only measured for adults aged 25-44 years.

Finally, education may have differential effects on individuals based on gender and the degree obtained. For example, education reduces women’s risk for obesity and depression whereas it decreases premature mortality and heavy drinking behavior among men.[2] Additionally, it appears that the type of degree obtained is important for different health behaviors. For example, a postgraduate degree decreases the likelihood of binge drinking, but a high school degree increases the likelihood for binge drinking.[1]

 

References

[1] Cowell AJ. The relationship between education and health behavior: Some empirical evidence. Health Econ. 2006;15:125-146.
[2] Cutler D, Lleras-Muney A. Education and Health: Evaluating Theories and Evidence. Cambridge, MA: National Bureau of Economic Research;2006. Working Paper Series, no. 12352.
[3] Egerter S, Braveman P, Sadegh-Nobari T, Grossman-Kahn R, Dekker M. Education Matters for Health. Princeton, NJ: RWJF Commission to Build a Healthier America; 2009. Issue Brief 6.
[4] Pizer SD, Frakt AB, Iezzoni LI. Uninsured adults with chronic conditions or disabilities: Gaps in public insurance programs. Health Aff.2009;28:w1141-w1150.
[5] Bartley M, Plewis I. Accumulated labour market disadvantage and limiting long-term illness: Data from the 1971-1991 Office for National Statistics' Longitudinal Study. Int J Epidemiol. 2002;31:336-341.
[6] Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education, U.S. Department of Education; 2006.NCES 2006-483.
[7] Leganger A, Kraft P. Control constructs: Do they mediate the relation between educational attainment and health behaviour? J Health Psychol. 2003;8:361-372.
[8] Singh-Manoux A, Adler NE, Marmot MG. Subjective social status: Its determinants and its association with measures of ill-health in the Whitehall II study. Soc Sci Med. 2003;56:1321-1333.
[9] Ross CE, Mirowsky J. Refining the association between education and health: The effects of quantity, credential and selectivity.Demography. 1999;36:445-460.
[10] Dupre ME. Educational differences in age-related patterns of disease: Reconsidering the cumulative disadvantage and age-as-leveler hypotheses. J Health Soc Behav. 2007;48:1-15.
[11] Beckett M. Converging health inequalities in later life-An artifact of mortality selection? J Health Soc Behav. 2000;41:106-119.