Education and health in 22 European countries

Abstract

This study investigates educational health inequalities in 22 European countries. Moreover, age and gender differences in the association between education and health are analysed. The study uses data from the European Social Survey 2003. Probability sampling from all private residents aged 15 years and older was applied in all countries. The European Social Survey includes 42,359 cases. Persons under age 25 were excluded to minimise the number of respondents whose education was not complete. Education was coded according to the International Standard Classification of Education. Self-rated health and functional limitations were used as health indicators. Results of multiple logistic regression analyses show that people with low education (lower secondary or less) have elevated risks of poor self-rated health and functional limitations. Inequalities are relatively small in Austria, Norway, Sweden, and the United Kingdom, large inequalities were found for Hungary, Poland, and Portugal. Analyses of age differences reveal that health effects of education are stronger at ages 25–55 than in the higher age groups. However, age differences in the education–health association vary between countries, sexes, and health indicators. In conclusion, our results confirm that educational inequalities in health are a generalised though not invariant phenomenon. Variations between countries, sexes and health indicators might be one explanation for the inconsistent results of other studies on age differences in the association between socioeconomic position and health.

Introduction

The positive association between education and health is well established. People with higher education generally experience lower morbidity and mortality rates than the poorly educated (Becker, 1998; Cavelaars et al., 1998; Huisman et al., 2005; Mackenbach, Kunst, Cavelaars, Groenhof, & Guerts, 1997; Manor, Eisenbach, Friedlander, & Kark, 2004; Ross & Wu, 1995; Silventoinen & Lahelma, 2002). Education as a measure of social stratification reflects people's social position in a broad manner and is related to their material and non-material resources. Not only is education a strong predictor of health when occupation and income are adjusted, but a direct effect of education (net of occupation and income) underestimates the total effect of education that works indirectly through occupation and income (Lahelma, 2001; Ross & Wu, 1995). Education is the key to one's position in the stratification system. It shapes the likelihood of being unemployed, the occupational class, and the income level.

Research on explanations for health inequalities (including educational health inequalities) documented that the following factors are of major importance: first, unequal distribution of unhealthy lifestyles (Lantz et al., 2001); secondly, unequal access to and quality of health care (van der Meer, 1998); and thirdly, differential exposure to material deprivation (Blane, Bartley, & Davey-Smith, 1997) and a stressful psychosocial environment (Marmot & Siegrist, 2004).

International studies suggest that the size of health inequalities according to education varies between countries (Cavelaars et al., 1998; Huisman, Kunst, & Mackenbach, 2003; Silventoinen & Lahelma, 2002). Comparison of varied types of societies can provide new insights into the sensitivity of social inequalities within different societal contexts. However, many of these comparative studies focused on a few countries only and thus lacked comprehensiveness.

Despite the progress in research on health inequalities according to education, there is not much known about the way in which the education-based gap in health varies with age and among countries. In general, the relationship between age and inequality might be characterised by continuation, divergence or convergence (O’Rand & Henretta, 1999). In this respect, several studies have confirmed the hypothesis that socioeconomic differences in morbidity and mortality converge with age (Beckett, 2000; House et al., 1994; Huisman et al., 2003; Manor et al., 2004; Phelan, Link, Diez-Roux, Kawachi, Levin, 2004). However, contrary to this evidence, a number of investigations have documented a continuation of the social gradient of morbidity and mortality into old age (Huisman et al., 2004; Liao, McGee, Kaufman, Cao, & Cooper, 1999; Marmot & Shipley, 1996) and Ross and Wu (1996) found a divergence in the health gap with age. The inconsistencies between investigations might be due to the different measures of socioeconomic and health status used and due to the different countries under study (Knesebeck, Lüschen, Cockerham, & Siegrist, 2003; Robert & House, 1996).

This study investigates educational health inequalities in Europe in the following way. First, international differences in the association between education and health in 22 European countries are analysed. Comparing inequalities in health in different countries is important because the magnitude of such differences depends on the country in which they are studied. As indicated, former studies show that the pattern of inequalities differs between countries (Cavelaars et al., 1998; Huisman et al., 2003; Knesebeck et al., 2003; Mackenbach, Bakker, Kunst, & Diderichsen, 2002). In this regard, the European Social Survey data set used here offers the opportunity to give a comprehensive overview of social inequalities in health in Europe. Secondly, we analyse age differences in the association between education and health to find out, whether the relationship between age and inequality is characterised by continuation, divergence or convergence.