4. WHAT ARE THE EFFECTS OF EDUCATION ON HEALTH? – 171 4. What are the effects of education on health? By Leon Feinstein, Ricardo Sabates, Tashweka M. Anderson, ∗ Annik Sorhaindo and Cathie Hammond ∗ Leon Feinstein, Ricardo Sabates, Tashweka Anderson, Annik Sorhaindo and Cathie Hammond, Institute of Education, University of London, 20 Bedford Way, London WC1H 0AL, United Kingdom. We would like to thank David Hay, Wim Groot, Henriette Massen van den Brink and Laura Salganik for the useful comments on the paper and to all participants at the Social Outcome of Learning Project Symposium organised by the OECD’s Centre for Educational Research and Innovation (CERI), in Copenhagen on 23rd and 24th March 2006. We would like to thank the OECD/CERI, for their financial support of this project. A great many judicious and helpful suggestions to improve this report have been put forward by Tom Schuller and Richard Desjardins. We are particularly grateful for the general funding of the WBL Centre through the Department for Education and Skills whose support has been a vital component of this research endeavour. We would also like to thank research staff at the Centre for Research on the Wider Benefits of Learning for their useful comments on this report. Other useful suggestions were received from participants at the roundtable event organised by the Wider Benefits of Learning and the MRC National Survey of Health and Development, University College London, on 6th December 2005. All remaining errors are our own. MEASURING THE EFFECTS OF EDUCATION ON HEALTH AND CIVIC ENGAGEMENT: PROCEEDINGS OF THE COPENHAGEN SYMPOSIUM – © OECD 2006 172 – 4.1. EXECUTIVE SUMMARY 4.1. Executive summary Objectives This report reviews the evidence on the hypothesis that education has important social impacts on health. In reviewing the evidence, we highlight those studies that have attempted to identify causal impacts with robust estimation techniques. We have also described evidence that demonstrates the extent of the descriptive correlation of education and health. As well as reviewing the evidence on the overall effect of education, we have reviewed the evidence on potential mechanisms for this effect, in a wide range of different personal and social contexts. Overview of the structure of the report In Section 4.2 of the report we have mapped out a general conceptual framework that sets out the hypothesised mechanisms for the effect of education on health. This framework creates a structure within which evidence and theory from diverse strands of the literature can be linked coherently. It also enables us to include within the review, evidence that does not investigate the direct impact of education on health but rather investigates the relationship between education and a potential mechanism or mediator of impacts on health. We set out the methodological criteria for our review of the evidence in Section 4.3 and summarise the findings of this review in Section 4.4. The implications of these findings are discussed in Section 4.5 in relation to the development of indicators and in terms of general policy conclusions in Section 4.6. The remaining sections present a detailed review of the evidence. Section 4.7 summarises the search criteria for evidence. In Sections 4.8 and 4.9 we describe the evidence in relation to the direct effects of education on mental and physical health and health behaviours. In Sections 4.10 and 4.11 we describe the evidence in relation to the indirect mechanisms that have been emphasised in the conceptual review, namely via effects of education on the self and effects of education on contexts. Main findings Overall, we find considerable international evidence that education is strongly linked to health and to determinants of health such as health behaviours, risky contexts and preventative service use. Moreover, we find that a substantial element of this effect is causal. MEASURING THE EFFECTS OF EDUCATION ON HEALTH AND CIVIC ENGAGEMENT: PROCEEDINGS OF THE COPENHAGEN SYMPOSIUM – © OECD 2006 4.1. EXECUTIVE SUMMARY – 173 Education does not act on health in isolation from other factors. Income is another very important factor that interacts in many important ways with education as influences on health. This makes it hard to assess their independent effects. However, empirical investigations often find that the effect of education on health is at least as great as the effect of income. Those with more years of schooling tend to have better health and well-being and healthier behaviours. Education is an important mechanism for enhancing the health and well-being of individuals because it reduces the need for health care, the associated costs of dependence, lost earnings and human suffering. It also helps promote and sustain healthy lifestyles and positive choices, supporting and nurturing human development, human relationships and personal, family and community well-being For example, one study finds that for individuals born in the United States between 1914 and 1939, an additional year of schooling reduces the probability of dying in the next 10 years by 3.6 percentage points (Lleras-Muney, 2005). Another study finds that for the cohort of Swedish men born between 1945 and 1955, an additional year of schooling reduces the risk of bad health by 18.5% (Spasojevic, 2003). Breierova and Duflo (2004) use the Indonesian government’s implementation of a primary school construction project in the years 1973-79 to identify the causal effect of education. They find that an increase in the average number of years of education in the household reduces child mortality by approximately 10 percentage points from a mean level of 22.5%. For women in the United States at the margin of college enrolment, being able to enrol in college and stay for a minimum of two years decreases the probability of smoking during pregnancy by 5.8 percentage points. This is a large effect given that on average only 7.8% of the women in the sample smoked during pregnancy (Currie and Moretti, 2002). Not all of the effects of education on health costs are positive. Education can increase uptake of preventative care which may lead to long-run savings but short-term increases in health care costs. Those with more education are also more likely to take advantage of health care provision. Moreover, the association of education and some forms of illicit drug use and sometimes alcohol use is found to be positive, i.e. education is associated with increased use. Finally, although education appears to be protective against depression it has been found to have much less substantial impacts on general happiness or well-being. It is also important to emphasise that to the extent that education effects on health occur as a result of impacts on features of the self, particularly self-concepts and attitudes, then if the quality of education is not appropriate to the developmental needs of the individual education can have directly injurious effects. Findings on the mechanisms for education effects The finding that education affects health is not new. An innovation of this review is the breadth of features of health that have been shown to be impacted on by education, linked to a clear conceptual model to explain that effect in terms of benefits for individuals in multiple contexts at different levels of social aggregation. MEASURING THE EFFECTS OF EDUCATION ON HEALTH AND CIVIC ENGAGEMENT: PROCEEDINGS OF THE COPENHAGEN SYMPOSIUM – © OECD 2006 174 – 4.1. EXECUTIVE SUMMARY Our central hypothesis is that education impacts on health because: • individuals exist in multiple, multi-layered and interacting contexts, • each of these contexts is a domain of social relations and environmental health; and • education impacts on individuals and on each context at each level. As well as finding direct effects of education on health outcomes and on the health behaviours that lead to health outcomes, we also assess the evidence in relation to the mechanisms for these education effects. There is substantive evidence to suggest that education has direct impacts on features of the individual that have direct benefits for health as well as supporting individuals in moderating the impacts of the contexts they inhabit. For example, there is good evidence that beliefs about health and health care, shaped and influenced by socio-demographic factors including education, determine health behaviours. Randomised controlled trials testing the efficacy of interventions has demonstrated that education has the potential to change health beliefs and behaviours if designed and delivered to appropriately address particular notions about health and illness. Self-concepts are associated with learning across the lifespan, though a causal link has not been determined through rigorous testing. There is also some evidence that self- concept and self-esteem provide protection against some adverse health outcomes through fostering resilience. This finding has not been consistent. We find that there are important channels for effects of education on health in all of the contexts considered, at every level of social aggregation from the household to the nation. To some extent these different contexts mediate education effects because of the effects of education on the physical and chemical environments that people come to inhabit and to some extent education effects are channelled through social and economic relations in each of these contexts. For example in relation to the workplace, education reduces the likelihood that individuals will work in the most hazardous jobs. As well as this direct effect of physical hazards, education impacts on social and economic relations in the workplace to improve the relative health of those with autonomy and authority in the workplace and reduce that of individuals with less autonomy and authority. There may also be an aggregate effect by which increasing average levels of education may improve the overall balance of risk through these channels.