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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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Health Recommendations and Selection in Health Behaviors
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“…are also less likely to smoke, for example—and they also correlate with education and income (e.g., Berrigan et al. 2003; Friel, Newell, and Kelleher 2005; Finke and Huston 2003; Kirkpatrick et al. 2012; Cutler and Lleras-Muney 2010; Cutler, Lleras-Muney, and Vogl 2008; Goldman and Smith 2002).”
BackgroundLacey, R. J., Belcher, J., & Croft, P. R. (2012) · European Journal of Public Health · doi:10.1093/eurpub/cks056 · Cited by 59
Meijer, E., Gebhardt, W. A., van Laar, C., Kawous, R., & Beijk, S. C. A. M. (2016) · Social Science & Medicine · doi:10.1016/j.socscimed.2016.06.022 · Cited by 64
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“Indeed, the effect of education on adult mortality may operate via income [45], health behaviors [46], marriage [47,48], chronic stress [49], or their combination.”
BackgroundSaving Lives at Birth: The Impact of Home Births on Infant Outcomes
Daysal, N. M., Trandafir, M., & van Ewijk, R. J. G. (2012) · American Economic Journal Applied Economics · doi:10.1257/app.20120359 · Cited by 59
Wang, H., Frasco, E., Takesue, R., & Tang, K. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06854-x · Cited by 58
Soh, Y., Whitmer, R. A., Mayeda, E. R., Glymour, M. M., Peterson, R. L., Eng, C. W., Quesenberry, C. P., Manly, J. J., & Gilsanz, P. (2023) · JAMA Neurology · doi:10.1001/jamaneurol.2022.5337 · Cited by 57
Education and health knowledge: Evidence from UK compulsory schooling reform
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“One of the key pathways by which education is thought to causally impact on health is through an improved ability of individuals to acquire and process health-related knowledge, and then to act on new knowledge (Cutler and Lleras-Muney, 2010).”
Inequalities in Premature Death From Colorectal Cancer by State
Jemal, A., Siegel, R. L., Ma, J., Islami, F., Desantis, C. E., Sauer, A. G., Simard, E. P., & Ward, E. (2014) · Journal of Clinical Oncology · doi:10.1200/jco.2014.58.7519 · Cited by 58
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The Right Stuff? Personality and Entrepreneurship
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Mulia, N. (2020) · Alcohol research · doi:10.35946/arcr.v40.2.09 · Cited by 64
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Long, Y., Jia, C., Luo, X., Sun, Y., Zuo, W., Wu, Y., Wu, Y., Kaierdebieke, A., & Lin, Z. (2022) · Sustainability · doi:10.3390/su141912142 · Cited by 69
Mulia, N., Karriker‐Jaffe, K. J., Witbrodt, J., Bond, J. C., Williams, E., & Zemore, S. E. (2016) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2016.10.031 · Cited by 58
Religiosity and Health Through the Decades: Is There a Gender Difference?
Mukerjee, S., & Venugopal, A. (2017) · American Journal of Health Promotion · doi:10.1177/0890117116687886 · Cited by 56
Phuong, D., Wang, L., & Elliott, M. R. (2013) · Social Science & Medicine · doi:10.1016/j.socscimed.2013.03.003 · Cited by 56
“Given the strong linkage between educational attainment and adult health (Adler et al., 1993; Cutler & Lleras-Muney, 2010; Kimbro et al., 2008), adjusting for educational attainment prohibits recovering the indirect effect of neighborhoods on health via education.”
BackgroundCan education rescue genetic liability for cognitive decline?
Cook, C. J., & Fletcher, J. M. (2014) · Social Science & Medicine · doi:10.1016/j.socscimed.2014.06.049 · Cited by 56
Noh, J., Kim, Y. M., Lee, L. J., Akram, N., Shahid, F., Kwon, Y. D., & Stekelenburg, J. (2019) · PLoS ONE · doi:10.1371/journal.pone.0213987 · Cited by 56
“Education not only increases women’s awareness of the importance of health services, but also gives them the ability to select the most appropriate service for their needs [26, 27].”
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“Cutler argued that well-educated people are less likely to smoke, less likely to be obese, and less likely to drink; this leads to better elderly health status [25].”
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Cohort Profile: The National Longitudinal Survey of Youth 1979 (NLSY79)
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“Lower educated people are known to eat less fruits and vegetables [33,34], are less physically active [30,35], consume alcohol more often in unhealthy quantities [36], use more tobacco [37-39], and have a higher likelihood of being obese [40] compared to highly educated people.”
Springvloet, L., Lechner, L., de Vries, H., Candel, M. J. J. M., & Oenema, A. (2015) · Journal of Medical Internet Research · doi:10.2196/jmir.3837 · Cited by 54
“One explanation may be that high-educated people are better able to process information [69]; therefore, they may be better able to integrate and apply the environmental-level information, making the plus version more effective for this group.”
Alcohol ExposureIn Uteroand Child Academic Achievement
von Hinke, S., Wehby, G. L., Lewis, S. J., & Zuccolo, L. (2014) · The Economic Journal · doi:10.1111/ecoj.12144 · Cited by 54
“15 Although the majority of these explore the social gradient in alcohol consumption in general; see e.g. Cutler and Lleras-Muney (2010) using the National Health and Interview Survey, the Health and Retirement Study, the National Longitudinal Survey of Youth 1979 and the National Child Development…”
MethodIs Smoking Inferior? Evidence from Variation in the Earned Income Tax Credit
Kenkel, D., Schmeiser, M. D., & Urban, C. (2014) · National Bureau of Economic Research · doi:10.3386/w20097 · Cited by 54
The Relationship between Health and Schooling: What’s New?
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“21 Table 3 Classification and Inventory of Studies, 2010-2014 Direct Inclusion of Third Variables (8) Conti and Hansman (2013); Conti and Heckman (2010); Conti et al. (2010); De Walque (2010); Kaestner and Callison (2011); Savelyev (2014); Savelyev and Tan (2014); Van Der Pol (2011) Twin Studies…”
Gaalema, D. E., Higgins, S. T., Shepard, D. S., Suaya, J. A., Savage, P. D., & Ades, P. A. (2014) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000059 · Cited by 53
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The Contribution of Smoking to Educational Gradients in U.S. Life Expectancy
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Offspring schooling associated with increased parental survival in rural KwaZulu-Natal, South Africa
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“…health knowledge and skills acquired at or after under the CC BY license (http://creativecommons.org/licenses/by/4.0/). school to parents, positively affecting their health behavior (Berkman et al., 2000; Cutler and Lleras-Muney, 2010; Field and de la Roca, 2005; Rowa-Dewar et al., 2014).”
BackgroundInfluentialThe Role of Public Participation in Environmental Governance: Empirical Evidence from China
Jin, G., & Bai, J. (2019) · Sustainability · doi:10.3390/su11174696 · Cited by 53
“Moreover, due to its good performance in analyzing functional routes between economic variables, the mediation model has also been applied to recent economic studies [66,67].”
MethodScientific Education and Innovation: From Technical Diplomas to University Stem Degrees
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“By implementing interventions such as education and occupational training programmes for vulnerable groups their social position can be improved with tangible health benefits [26,27].”
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Колосницына, М. Г., Тальгатович, С. М., & Алексеевна, Х. Н. (2014) · The International Journal of Alcohol and Drug Research · doi:10.7895/ijadr.v3i3.154 · Cited by 49
“In line with previous research on alcohol consumption (Andrienko & Nemtsov, 2006; Cerdá, Johnson-Lawrence, & Galea, 2011; Contoyannis & Jones, 2004; Cutler & Lleras-Muney, 2010; Gottlieb & Baker, 1986; Le, Ahern, & Galea, 2010; Leonard & Mudar, 2003; Livingstone & Room, 2008; Neufeld, Peters, Rani,…”
Educational Attainment and Life Expectancy
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“Health habits may play an important role (Cutler & Lleras-Muney, 2010).”
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Education Systems and Inequalities
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“…variable (age, gender, education, socioeconomic status, or residential area) as they can reflect unmeasured exposure to the parasite or knowledge of hygiene measures (Cutler and Lleras-Muney 2010); and (2) if authors controlled for other source of exposure to T. gondii other than raw meat.”
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“Furthermore, people who obtain college degrees tend to lead healthier lifestyles (Cockerham, 2005; Cutler and Lleras-Muney, 2010; Mirowsky and Ross, 2003).”
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BackgroundThe behavioral economics of drunk driving
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Montague, C. T., Ngcobo, N., Mahlase, G., Frohlich, J., Pillay, C., Yende‐Zuma, N., Humphries, H., Dellar, R. C., Naidoo, K., & Karim, Q. A. (2014) · PLoS ONE · doi:10.1371/journal.pone.0096468 · Cited by 42
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Adult Children’s Education and Physiological Dysregulation Among Older Parents
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“…have more knowledge of the harms of health-related behaviors, for example, smoking and heavy drinking, and are more likely to have access to material resources that promote health, including gym memberships, smoking cessation methods, and advanced health information (Cutler & Lleras-Muney, 2010).”
BackgroundHuman Capital and Per Capita Income Linkage in South Asia: A Heterogeneous Dynamic Panel Analysis
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Delayed HIV diagnosis and initiation of antiretroviral therapy
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“Members of disadvantaged socioeconomic groups face barriers to health services [2,4], even in European countrieswith universal and public health insurance [5].”
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“Lastly, an important but less examined pathway focuses on human capabilities and the role of education in enhancing women’s competence and decision-making abilities overall (Cutler & Lleras-Muney, 2010).”
BackgroundEducation and health: evidence on adults with diabetes
Ayyagari, P., Grossman, D. S., & Sloan, F. A. (2011) · International Journal of Health Care Finance and Economics · doi:10.1007/s10754-010-9087-x · Cited by 47
Caloric Beverage Intake Among Adult Supplemental Nutrition Assistance Program Participants
Todd, J. E., & Ploeg, M. V. (2014) · American Journal of Public Health · doi:10.2105/ajph.2014.301970 · Cited by 44
“Previous literature has documented the positive gradient of education and income on health and behaviors such as smoking, alcohol consumption, and diet and exercise.(18,19) Disparities in health and health behaviors across racial and ethnic subgroups that cannot be explained completely by income, education, and other…”
BackgroundBosdriesz, J. R., Mehmedovic, S., Witvliet, M. G., & Kunst, A. E. (2014) · International Journal for Equity in Health · doi:10.1186/1475-9276-13-14 · Cited by 43
Advancing Health Literacy Among Hispanic Immigrants: The Intersection Between Education and Health
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Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking
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The influence of education on the access to childhood immunization: the case of Spain
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BMI Trends, Socioeconomic Status, and the Choice of Dataset
Grabner, M. (2012) · Obesity Facts · doi:10.1159/000337018 · Cited by 46
“Ezzati et al. (2006) calculate corrected BRFSS prevalence rates by comparing height and weight in the NHANES and BRFSS for certain age/gender cells.”
MethodThe long run health returns to college quality
Fletcher, J. M., & Frisvold, D. (2012) · Review of Economics of the Household · doi:10.1007/s11150-012-9150-0 · Cited by 41
Education, cognition, health knowledge, and health behavior
Mocan, N. H., & Altindag, D. T. (2013) · The European Journal of Health Economics · doi:10.1007/s10198-013-0473-4 · Cited by 40
“Our study differs from Kenkel [20] and Cutler and Lleras-Muney [7] in two important ways.”
BackgroundMethodResultInfluentialMaurer, J. (2015) · Medical Decision Making · doi:10.1177/0272989x15608379 · Cited by 42
Li, K., & Wen, M. (2013) · Race and Social Problems · doi:10.1007/s12552-013-9087-9 · Cited by 49
“Evidence to date has consistently shown that SES measured by education and income is positively correlated with LTPA participation among adults (Ahmed et al. 2005; Cutler and Lleras-Muney 2010; Droomers et al. 1998; Sternfeld et al. 1999).”
Owolabi, E. O., Goon, D. T., Adeniyi, O. V., & Seekoe, E. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-014349 · Cited by 45
“Cutler and Lleras-Muney 46 reported that education increases knowledge.”
BackgroundBaker, D. P., Smith, W. C., Muñoz, I. G., Jeon, H., Fu, T., León, J., Torres‐Salinas, D., & Horvatek, R. (2017) · Demography · doi:10.1007/s13524-017-0608-9 · Cited by 41
Hoffmann, R., & Lutz, S. U. (2018) · The European Journal of Health Economics · doi:10.1007/s10198-017-0950-2 · Cited by 42
“2 For example, not knowing that smoking causes bladder cancer, as asked in the 1990 US National Health Interview Survey [14], does not mean that one does not know that smoking is harmful.”
BackgroundMethodResultInfluentialThe average and distributional effects of teenage adversity on long-term health
Gong, J., Lu, Y., & Xie, H. (2020) · Journal of Health Economics · doi:10.1016/j.jhealeco.2020.102288 · Cited by 45
Egan, B. M., Li, J., Sutherland, S. E., Jones, D. W., Ferdinand, K. C., Hong, Y., & Sánchez, E. (2020) · Ethnicity & Disease · doi:10.18865/ed.30.4.637 · Cited by 42
Rising up with shoe leather? A comment on Fair Society, Healthy Lives (The Marmot Review)
Chandra, A., & Vogl, T. (2010) · Social Science & Medicine · doi:10.1016/j.socscimed.2010.07.006 · Cited by 43
“Education does appear to improve adult health, although the mechanism is not clear (Cutler & Lleras-Muney, 2009).”
BackgroundJones, A. M., Rice, N., & Dias, P. R. (2011) · Journal of Human Capital · doi:10.1086/662441 · Cited by 46
Koivusilta, L. K., West, P., Saaristo, V., Nummi, T., & Rimpelä, A. (2013) · BMC Public Health · doi:10.1186/1471-2458-13-711 · Cited by 41
Mapping the biopolitics of school dropout and youth resistance
Ruglis, J. (2011) · International Journal of Qualitative Studies in Education · doi:10.1080/09518398.2011.600268 · Cited by 42
Association Between Race, Place, and Preventive Health Screenings Among Men
Thorpe, R. J., Bowie, J. V., Wilson‐Frederick, S. M., Coa, K. I., & LaVeist, T. A. (2012) · American Journal of Men s Health · doi:10.1177/1557988312466910 · Cited by 44
Moser, A., Panczak, R., Zwahlen, M., Clough‐Gorr, K. M., Spoerri, A., Stuck, A. E., & Egger, M. (2014) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2014-204352 · Cited by 41
Gheorghe, M., Wubulihasimu, P., Peters, F., Nusselder, W. J., & van Baal, P. H. M. (2016) · European Journal of Public Health · doi:10.1093/eurpub/ckw043 · Cited by 41
The Roots of Health Inequality and the Value of Intrafamily Expertise
Chen, Y., Persson, P., & Polyakova, M. (2022) · American Economic Journal Applied Economics · doi:10.1257/app.20200405 · Cited by 41
Janowski, K., Kurpas, D., Kusz, J., Mroczek, B., & Jedynak, T. (2013) · Stress and Health · doi:10.1002/smi.2493 · Cited by 40
The Impact of Rural Health Care Accessibility on Cancer-Related Behaviors and Outcomes
Belasco, E. J., Gong, G., Pence, B. C., & Wilkes, E. (2014) · Applied Health Economics and Health Policy · doi:10.1007/s40258-014-0099-4 · Cited by 40
“’’ More recently, Cutler and Lleras-Muney [11] identified that income, health insurance, family background, and cognitive ability explain nearly 60 % of the relationship between education and health behaviors.”
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
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