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Understanding differences in health behaviors by education
Open accessAbstract
Using a variety of data sets from two countries, we examine possible explanations for the relationship between education and health behaviors, known as the education gradient. We show that income, health insurance, and family background can account for about 30 percent of the gradient. Knowledge and measures of cognitive ability explain an additional 30 percent. Social networks account for another 10 percent. Our proxies for discounting, risk aversion, or the value of future do not account for any of the education gradient, and neither do personality factors such as a sense of control of oneself or over one's life.
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“this finding is supported by many studies showing that social determinants of health are key drivers of mortality,50, 51, 52, 53, 54”
From Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021 (2024) · cites this paper as [51]
In the citing paper
“the prevalence of several risk behaviors is generally higher among those with fewer than nine years of formal education, begins to decline among those who have nine to 12 years of formal education, and continues to decline with additional years of education”
From Education improves public health and promotes health equity (2015) · cites this paper as [28]
In the citing paper
“There is also strong evidence of a dose response between years of education and many health-related risk and protective behaviors among US adults.”
From Education improves public health and promotes health equity (2015) · cites this paper as [28]
In the citing paper
“Similar results are found by Cutler and Lleras-Muney,28 who use different sources to assess associations between educational attainment, health behaviors, and mortality in the United States and Great Britain.”
From Education improves public health and promotes health equity (2015) · cites this paper as [28]
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BackgroundFairness and annuity divisors for notional defined contribution pension schemes
Boado‐Penas, M. D. C., Haberman, S., & Naka, P. (2020) · Journal of Pensions Economics and Finance · doi:10.1017/s1474747220000311 · Cited by 8
“Hence, this group of people are likely to live longer than those with a lower level of education attainment (Friedman et al., 1995; Kern and Friedman, 2008; Cutler and Lleras-Muney, 2010).”
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Educational differences in mortality and hospitalisation for cardiovascular diseases
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Erectile dysfunction predictors in hypertensives at a primary care clinic in Southern Nigeria
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Can Health Insurance Coverage Improve Educational Attainment? Evidence from China
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Preventing Malaria among Children in Zambia: The Role of Mother's Knowledge.
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“…college experience, those who enroll in and/or graduate from college generally have lower unemployment rates, better earnings, annual incomes, savings, home ownership rates, and health outcomes (Cutler & Lleras-Muney, 2010; Eide & Showalter, 2011; Long, 2010; Mishel, Bernstein, & Shierholz, 2009).”
BackgroundYuan, M., Chen, W., Chu, C., & Fang, Y. (2015) · PLoS ONE · doi:10.1371/journal.pone.0131331 · Cited by 7
“Many studies have found that a higher level of education is strongly associated with better health and functional status [5, 10, 12, 17].”
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Aughinbaugh, A., Pierret, C. R., & Rothstein, D. S. (2015) · Monthly labor review · doi:10.21916/mlr.2015.34 · Cited by 7
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“1 Introduction Educational differences in smoking, with lower educated individuals being more likely to smoke than higher educated individuals, have been widely documented (e.g. Kenkel et al., 2006; de Walque, 2007; Cutler and Lleras-Muney, 2010; Jürges et al., 2011; Maralani, 2013).”
BackgroundToday's decisions, Tomorrow's outcomes: Does self-control explain the educational smoking gradient?
Holmes, C. J. (2017) · Social Science Research · doi:10.1016/j.ssresearch.2017.10.009 · Cited by 7
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Huang, G., Guo, F., & Gong, C. (2019) · Educational Gerontology · doi:10.1080/03601277.2019.1678719 · Cited by 7
“Cutler and Lleras-Muney (2010) also indicate that 30% of the effect of education on health can be explained by cognitive ability.”
BackgroundGreco, A., Brugnera, A., D’Αddario, M., Compare, A., Franzelli, C., Maloberti, A., Giannattasio, C., Fattirolli, F., & Steca, P. (2020) · Journal of Public Health · doi:10.1007/s10389-020-01369-x · Cited by 7
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“Poorer SES, whether measured by education, income, occupation, race and ethnicity, or locality, has been associated a variety of negative health outcomes including shorter life expectancy [1], worse mental health [2], higher mortality from a wide-range of diseases [3], worse health behaviors [4], and most recently, hi…”
BackgroundOlivera, J. (2020) · Socio-Economic Review · doi:10.1093/ser/mwaa044 · Cited by 8
“For example, individuals with low levels of education also tend to show poorer health and lower incomes and life expectancy (Cutler et al., 2006; Cutler and Lleras-Muney, 2010).”
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Hand-to-Mouth Consumption and Calorie Consciousness: Consequences for Junk-Food Taxation
Mathieu‐Bolh, N. (2019) · Public Finance Review · doi:10.1177/10911421211000465 · Cited by 8
“This is consistent with the observed positive relationship between schooling a health behavior (Cutler and Lleras-Muney 2010; Fuchs 1982).”
Baltagi, B. H., Flores‐Lagunes, A., & Karatas, H. M. (2023) · Economic Modelling · doi:10.1016/j.econmod.2023.106286 · Cited by 7
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“The strong positive relation between health outcomes and cognitive abilities might be also explained by the fact that individual with better cognitive functions are more informed about health risks and sharper critical thinking ( Cutler and Lleras-Muney 2010 ).”
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Jack-of All-Trades? The Effect of Balanced Skills on Team Performance
Huber, L. R., Sloof, R., & van Praag, M. (2014) · Academy of Management Proceedings · doi:10.5465/ambpp.2014.16024abstract · Cited by 7
“2More in general, there is convincing evidence that cognitive ability affects performance outcomes (Cutler and Lleras-Muney, 2010; Dohmen et al., 2010; Grinblatt et al., 2011), and determines — at the aggregate level — economic growth (Hanushek and Woessmann, 2008; Gennaioli et al., 2013).”
BackgroundInvited Commentary: Multigenerational Social Determinants of Health—Opportunities and Challenges
Cohen, A. K., & Lê‐Scherban, F. (2015) · American Journal of Epidemiology · doi:10.1093/aje/kwv145 · Cited by 8
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Malleability of Alcohol Consumption: Evidence from MigrantsPreprint
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Malleability of Alcohol Consumption: Evidence from Migrants
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Interrogating Theories and Mechanisms Underlying Educational Inequities in Diet Quality
Olstad, D. L., & McIntyre, L. (2025) · Journal of Nutrition · doi:10.1016/j.tjnut.2025.09.015 · Cited by 7
“As such, they tend to be more futur-e-oriented — focusing less on immediate needs and more on longer term rewards [52,55 – 57].”
InfluentialMuñoz, I. G., Baker, D. P., & Peters, E. M. (2020) · International Perspectives on Sexual and Reproductive Health · doi:10.1363/46e9320 · Cited by 7
“For example, in a comprehensive analysis of health behavior and safety measures (e.g., smoking, drinking, overeating, and automobile and household safety) in the United States and the United Kingdom, Cutler and Lleras-Muney 28 estimated that cognitive ability and knowledge account for 30% of the education–health behav…”
BackgroundRisk factors for musculoskeletal-related occupational disability among US Army soldiers
Clifton, D. R., Nelson, D. A., Choi, Y. S., Edgeworth, D. B., Nelson, K. J., Shell, D., & Deuster, P. A. (2021) · BMJ Military Health · doi:10.1136/bmjmilitary-2021-001900 · Cited by 6
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“…choices impact health) as well as through its association with higher socioeconomic status, including (depending on the health system) improved financial access to quality health care and health insurance (Cutler and Lleras-Muney 2010; Leopold and Engelhartdt 2012; Basu, Jones, and Dias 2018).”
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“Indeed, knowledge, attitudes, and behavior constitute a continuum in health promotion efforts [13–15] and are also associated with social determinants [16]; for example, education is associated with higher knowledge and engagement in health promoting behaviors [17,18].”
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“For example, education correlates positively with the size of individuals’ social networks, which provide essential financial, psychological, and emotional resources that reduce stress exposure and improve health (Cutler & Lleras-Muney, 2010; Mirowsky & Ross, 2003).”
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“Then, in the second step, in testing a particular theory, we learn from the existing literature [59] and re-estimate Equation (1) by adding a set of exogenous explanatory variables, Z′, which is shown in Equation (6).”
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“Second, education raises cognitive skills that foster health-promoting decisions [23, 26].”
BackgroundInequalities at birth: stable socioeconomic differences in birth outcomes in three British cohorts
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“…to harsh life conditions, stress, peer-influence, and lack of medical knowledge may play a role in generating SES disparities in health behaviors (Cutler & Lleras-Muney, 2010). in birth weight at the population level, research investigating socioeconomic differences in birth weight has reported…”
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Liu, Q., Tooki, T., Di, D., Zhou, H., Cui, Z., Zhang, R., Zhang, J., Yuan, T., Zhou, T., Luo, X., et al. (2023) · Archives of Osteoporosis · doi:10.1007/s11657-023-01329-4 · Cited by 7
“Several studies have shown that more educated people have better health behaviors than less educated ones [30, 31].”
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“The particular mechanisms through which maternal education translates into better reproductive outcomes are hard to track, but some studies suggest that maternal education is linked to LBW due to the knowledge-related assets and effi cacy skills that are acquired with education (Lynch and Kaplan, 2000; Cutler and Ller…”
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“Prior work has shown that education and personality traits impact health behaviors and obesity (Webbink et al., 2010; Cutler and Lleras-Muney, 2010; Conti and Hansman, 2013).”
BackgroundTrostel, P. A. (2017) · Change The Magazine of Higher Learning · doi:10.1080/00091383.2017.1321425 · Cited by 6
“Some recent examples are Grossman (2006), Groot and Massen van den Brink (2007), Cutler and Lleras-Muney (2010), Conti, Heckman and Urzua (2010), Lochner (2011), and Oreopouos and Salvances (2011).”
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“The later life sensitive period and SEP mobility models were adjusted for sex and age (20-29, 30-39, 40-49, 50-63), which are frequently associated with SAH(7,42,43) and education(44).”
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“Education could improve health behaviors in different ways (see for example, Grossman 2006; Cutler and Lleras-Muney 2010; Cawley and Ruhm 2012).”
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Leach, M. J., Ward, B., Kippen, R. J., Quinn, B., Agius, P. A., Sutton, K., Peterson, J., & Dietze, P. (2022) · Health & Social Care in the Community · doi:10.1111/hsc.13907 · Cited by 6
“Whilst international evidence suggests that education is associated with greater social support in general populations (Cutler & Lleras-Muney, 2010 ; Lee et al., 2021 ), our null finding for education is consistent with that observed in a past sample of people who used methamphetamine (Jalali et…”
ResultRalston, M. L., Schatz, E. J., Naidoo, N., & Kowal, P. R. (2017) · The Journal of Development Studies · doi:10.1080/00220388.2017.1311406 · Cited by 7
“The relationship between education and health is thought to be positive, as more education is thought to lead to better health behaviours (Cutler & Lleras-Muney, 2010).”
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Chojnicki, X., & Rabesandratana, P. E. (2017) · Review of Income and Wealth · doi:10.1111/roiw.12306 · Cited by 6
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Hudson, E. M., Madden, D., & Mosca, I. (2014) · Arrow@dit (Dublin Institute of Technology) · Cited by 6
Ability Dispersion and Team Performance: A Field ExperimentPreprint
Hoogendoorn, S., Parker, S. C., & van Praag, M. (2012) · SSRN Electronic Journal · doi:10.2139/ssrn.2183095 · Cited by 5
“Cognitive ability shapes individuals’ behavior, decision-making and performance outcomes (Cutler and Lleras-Muney, 2010; Dohmen et al., 2010; Grinblatt et al., 2011), and is a major determinant of individual earnings, income distribution and (cid:22) at the aggregate level (cid:22) economic growth…”
Healthy(?), Wealthy, and Wise Birth Order and Adult HealthPreprint
Black, S. E., Devereux, P. J., & Salvanes, K. G. (2016) · SSRN Electronic Journal · doi:10.2139/ssrn.2740226 · Cited by 6
Editorial for the special issue on behavior change, health, and health disparities 2017
Higgins, S. T. (2017) · Preventive Medicine · doi:10.1016/j.ypmed.2017.10.026 · Cited by 6
“…behaviors is overrepresented among socioeconomically disadvantaged and other vulnerable populations, they are also important contributors to the unsettling problems of health disparities (Cutler and Lleras-Muney, 2010; Higgins and Chilcoat, 2009; Issacs and Schroeder, 2004; Kumanyika, 2012).”
BackgroundHealth Shocks, Human Capital, and Labor Market Outcomes
Parro, F., & Pohl, R. V. (2018) · doi:10.17848/wp18-290 · Cited by 6
Galama, T. J., Lleras‐Muney, A., & van Kippersluis, H. (2017) · SSRN Electronic Journal · doi:10.2139/ssrn.3081283 · Cited by 6
Self-citationHealthy(?), Wealthy and Wise: Birth Order and Adult Health
Black, S., Devereux, P. J., & Salvanes, K. G. (2015) · National Bureau of Economic Research · doi:10.3386/w21337 · Cited by 6
Is Being in School Better? The Impact of School on Children's BMI When Starting Age is Endogenous
Anderson, P., Butcher, K. F., Cascio, E., & Schanzenbach, D. W. (2011) · National Bureau of Economic Research · doi:10.3386/w16673 · Cited by 6
A Unified Model of Cohort Mortality for Economic AnalysisPreprint
Lleras‐Muney, A., & Moreau, F. (2020) · SSRN Electronic Journal · doi:10.2139/ssrn.3765182 · Cited by 6
Self-citationThe Developmental Approach to Child and Adult Health
Conti, G., & Heckman, J. J. (2012) · National Bureau of Economic Research · doi:10.3386/w18664 · Cited by 7
The Causal Effect of Education on Health Behaviors: Evidence from TurkeyPreprint
Tansel, A. (2016) · SSRN Electronic Journal · doi:10.2139/ssrn.2798089 · Cited by 6
“Both de Walque (2007) and Grimard and Parent (2007) find that as individual’s education level increases, probability of smoking decreases in the USA.”
BackgroundInfluentialThe Impact of Social Activities on Cognitive Ageing: Evidence from Eleven European CountriesPreprint
Christelis, D., & Dobrescu, L. I. (2012) · SSRN Electronic Journal · doi:10.2139/ssrn.2141386 · Cited by 6
Predictors of Social Distancing and Mask-Wearing Behavior: Panel Survey in Seven U.S. StatesPreprint
Nikolov, P., Pape, A., Tonguc, O., & Williams, C. (2021) · medRxiv · doi:10.1101/2021.05.04.21256574 · Cited by 6
“The three most crucial traits for more social distancing are higher positive reciprocity, higher openness, and being more agreeable.34 31 Cutler and Lleras-Muney (2010) find a large and persistent positive association between education and health.”
BackgroundAdolescent Cognitive and Non-Cognitive Correlates of Adult Health. NBER Working Paper No. 14924.
Kaestner, R. J. (2009) · National Bureau of Economic Research · Cited by 6
Has Mortality Risen Disproportionately for the Least Educated?
Leive, A. A., & Ruhm, C. J. (2020) · National Bureau of Economic Research · doi:10.3386/w27512 · Cited by 6
COVID-19 Health Precautions: Examining Demographic and Socioeconomic DisparitiesPreprint
Jehn, A., & Zajacova, A. (2020) · doi:10.31235/osf.io/fdswk · Cited by 6
Socioemotional Skills, Education, and Health-Related Outcomes of High-Ability IndividualsPreprint
Savelyev, P., & Tan, K. T. K. (2017) · SSRN Electronic Journal · doi:10.2139/ssrn.2450869 · Cited by 2
Chudzicka-Czupała, A. E., Zhou, N., Tay, A., Chiang, S., Capińska, M., Pomyluiko, V., Ostafińska-Molik, B. P., Czupała, M., Żywiołek‐Szeja, M., Yen, C., et al. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1731764 · Cited by 10
“This protective effect is likely explained in part by greater health literacy, which enables individuals to better understand and navigate healthcare systems, adhere to treatments, and adopt healthier behaviors more effectively (38).”
State-level Legislative Efforts to Improve Diabetes Care and thereby Mitigate Complications
Fitzner, K. A., BS, J. M. N. F., Heckinger, E. A., & Morrone, M. (2016) · Journal of Diabetic Complications & Medicine · doi:10.4172/2475-3211.1000105 · Cited by 5
Understanding the Impact of Social Networks on the Spread of Obesity
Tuson, M., Harper, P., Gärtner, D., & Behrens, D. A. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20156451 · Cited by 5
“• Attitudes—these are the sum of our knowledge, attitudes, and prejudices and result in the cognitive decision making processes described by [36], which in turn are moderated by the education level attained by the individual.”
BackgroundStonkute, D., Lorenti, A., & Spijker, J. (2023) · SSM - Population Health · doi:10.1016/j.ssmph.2023.101470 · Cited by 5
Higher Education and Mortality: Legacies of an Authoritarian College Contraction
González, F., Martínez, L. R., Muñoz, P., & Prem, M. (2023) · Journal of the European Economic Association · doi:10.1093/jeea/jvad066 · Cited by 5
Cohort study of early literacy and childbearing over the reproductive lifecourse.
Seymour, J. W., Frasso, R., Shofer, F. S., & Bennett, I. M. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-013522 · Cited by 4
“of health studies.(34) 35 This measure of early-life literacy was used to construct an ordinal variable for literacy based on commonly accepted RGL cut-points (<5th grade, 5–6th grade, 7–8th grade, 9–11th grade and ≥12th grade).”
Method
Metadata
- Authors
- Cutler, D. M., & Lleras-Muney, A.
- Affiliations
- National Bureau of Economic Research (US)
- ORCID
- Cutler, David M.
- Venue
- Journal of Health Economics
- Publisher
- Elsevier BV
- Published
- 2010-01
- Volume
- 29
- Issue
- 1
- Pages
- 1-28
- ISSN
- 0167-6296 (ISSN-L)
- PMC
- PMC2824018
- OpenAlex
- W2164662768
- Cited by
- 1,920
- References
- 72
- Citations by year
- 2026: 137 · 2025: 153 · 2024: 120 · 2023: 124 · 2022: 142 · 2021: 142 · 2020: 139 · 2019: 130 · 2018: 130 · 2017: 119 · 2016: 101 · 2015: 127 · 2014: 121 · 2013: 79 · 2012: 79
- FWCI
- 52.18
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Health Economics (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Funders
- National Institute on Aging (P01AG005842)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R24HD041022)
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Social Sciences › Sociology and Political Science › Intergenerational and Educational Inequality Studies
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Keywords
- education gradient, health behavior, income, health insurance, family background, health knowledge, cognitive ability, social networks, risk aversion, discounting, perceived control, cross-national comparison
- MeSH terms
- Adult, Educational Status, Female, Humans, Health Knowledge, Attitudes, Practice, Male, Middle Aged, United States, Health Behavior, Databases, Factual, Risk Reduction Behavior
About these checks
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