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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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“Low levels of educational attainment have been associated with a wide variety of poorer health outcomes, including life expectancy (32).”
BackgroundAngerer, S. V., Waibel, C., & Stummer, H. (2018) · American Journal of Health Economics · doi:10.1162/ajhe_a_00124 · Cited by 39
Assessment of Exposure to High-Performing Schools and Risk of Adolescent Substance Use
Dudovitz, R., Chung, P. J., Reber, S., Kennedy, D. P., Tucker, J. S., SHOPTAW, S. J., Dosanjh, K. K., & Wong, M. D. (2018) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/jamapediatrics.2018.3074 · Cited by 40
“The RISE UP Study charter schools were selected based on the following criteria: (1) location in Los Angeles County; (2) most students enrolled are economically disadvantaged (qualify for free or reduced price lunch); (3) academic performance in the top tertile of public high schools in Los Angeles County based on 201…”
Educational Attainment as a Super Determinant of Diet Quality and Dietary Inequities
Olstad, D. L., & McIntyre, L. (2025) · Advances in Nutrition · doi:10.1016/j.advnut.2025.100482 · Cited by 54
“Mediation analyses have also shown that economic resources account for 20% of associations between educational attainment and health-related practices collectively, including dietary intake, physical activity, smoking, alcohol intake, and preventive care [20].”
Cavaliere, A., Marchi, E. D., & Banterle, A. (2014) · Appetite · doi:10.1016/j.appet.2014.08.011 · Cited by 38
“This may be due to the fact that more educated individuals generally have a higher inclination to healthy behaviours (Cutler & Lleras-Muney, 2010).”
Marital Disruption and Health Insurance
Peters, H. E., Simon, K. I., & Taber, J. R. (2014) · Demography · doi:10.1007/s13524-014-0317-6 · Cited by 38
“For adults and children, the past literature shows that health insurance status depends on individual, family, and social policy characteristics, such as education, health, employment, marital status, family income, state Medicaid eligibility rules, and child support policies (e.g., Currie et al. 2008; Cutler and Ller…”
Étilé, F. (2013) · Economics & Human Biology · doi:10.1016/j.ehb.2013.01.002 · Cited by 38
Vedøy, T. F. (2014) · Social Science Research · doi:10.1016/j.ssresearch.2014.05.005 · Cited by 43
“Although variations in daily cigarette smoking fit the pattern predicted by TDI, the precise mechanisms behind educational differences in cigarette smoking have been the object of much debate (Cutler and Lleras-Muney, 2010; de Walque, 2007; Tenn et al., 2010).”
BackgroundLong-term health implications of school quality
Dudovitz, R., Nelson, B. B., Coker, T. R., Biely, C., Li, N., Wu, L. C., & Chung, P. J. (2016) · Social Science & Medicine · doi:10.1016/j.socscimed.2016.04.009 · Cited by 38
Oncini, F., & Guetto, R. (2017) · Health Sociology Review · doi:10.1080/14461242.2017.1321493 · Cited by 38
“As some studies have shown, cultural capital is a good predictor of health and unhealthy behaviours such as heavy drinking, smoking, and dietary non-compliance (Cutler & Lleras-Muney, 2010; Oncini & Guetto, 2017).”
BackgroundHealth status and health disparity in China: a demographic and socioeconomic perspective
Liu, J., & Zhang, Y. (2018) · China Population and Development Studies · doi:10.1007/s42379-018-0015-y · Cited by 38
Si, H., Wang, C., Jin, Y., Tian, X., Qiao, X., Liu, N., & Dong, L. (2019) · Pain Management Nursing · doi:10.1016/j.pmn.2019.01.006 · Cited by 38
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The hindrances to perform the COVID-19 vaccination in Brazil
Boschiero, M. N., Palamim, C. V. C., & Marson, F. A. L. (2021) · Human Vaccines & Immunotherapeutics · doi:10.1080/21645515.2021.1955607 · Cited by 41
“4%,(37) which can lead to a different perception, in each region, regarding the necessity of vaccination, since higher years of study were associated with higher vaccination rate.(38) Also, the Brazilian people, as discussed before, is mixed.”
BackgroundINCOME INEQUALITY AND MENTAL HEALTH—EMPIRICAL EVIDENCE FROM AUSTRALIA
Bechtel, L., Lordan, G., & Rao, D. S. P. (2012) · Health Economics · doi:10.1002/hec.2814 · Cited by 38
“The health economics literature has many contributions that aim to quantify the determinants of health (Ruhm, 2000; Frijters and Ulker, 2008; Berry and Welsh, 2010; Cutler and Lleras-Muney, 2010).”
BackgroundBehavior change and reducing health disparities
Kaplan, R. M. (2014) · Preventive Medicine · doi:10.1016/j.ypmed.2014.04.014 · Cited by 37
The Roots of Health Inequality and The Value of Intra-Family Expertise
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“…of medical doctors in the Netherlands.10 More generally, our findings contribute to the literature documenting a positive association between educational attainment and own health and health behaviors (see, e.g., Cutler and Lleras-Muney, 2008; Cutler and Lleras-Muney, 2010; Meghir et al., 2018).”
Ma, H., Liu, F., Li, J., Chen, J., Cao, J., Chen, S., Liu, X., Yang, X., Huang, K., Shen, C., et al. (2023) · Hypertension · doi:10.1161/hypertensionaha.122.20061 · Cited by 38
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“An advantage of video messages is the fact that these do not require abstract text to be translated into concrete actions [27], which lower educated individuals often find harder to do [25,28].”
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Self-citationIs there a cannabis epidemic model? Evidence from France, Germany and USA
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Neurocognitive processes underlying academic difficulties in very preterm born adolescents
Twilhaar, E. S., de Kieviet, J. F., van Elburg, R. M., & Oosterlaan, J. (2019) · Child Neuropsychology · doi:10.1080/09297049.2019.1639652 · Cited by 44
“Academic performance is a domain of particular interest for long-term follow-up studies as it is related to life chances, health, and life expectancy (Cutler & Lleras-Muney, 2010; McMahon & Oketch, 2013).”
BackgroundCOVID-19 Sources of Information, Knowledge, and Preventive Behaviors Among the US Adult Population
Shafiq, M., Elharake, J. A., Malik, A. A., McFadden, S. M., Aguolu, O. G., & Omer, S. B. (2021) · Journal of Public Health Management and Practice · doi:10.1097/phh.0000000000001348 · Cited by 39
“Knowledge and adherence disparity may be a result of lack of access to socioeconomic resources among those with a lower educational background.(18,19) This, then, impacts affordability of certain items, such as”
BackgroundMaternal Education and Perinatal Outcomes Among Spanish Women Residing in Southern Spain (2001–2011)
Juárez, S., Revuelta-Eugercios, B., Fariñas, D. R., & Viciana, F. (2013) · Maternal and Child Health Journal · doi:10.1007/s10995-013-1425-4 · Cited by 37
“Higher education contributes with knowledge-related assets, agency and efficacy skills [25, 26] that are expressed in the adoption of healthy lifestyles and avoidance of acknowledged risk factors [27].”
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Agénor, P. (2014) · Journal of Economics · doi:10.1007/s00712-014-0418-0 · Cited by 37
Educational inequalities in smoking over the life cycle: an analysis by cohort and gender
Bricard, D., Jusot, F., Beck, F., Khlat, M., & Legleye, S. (2015) · International Journal of Public Health · doi:10.1007/s00038-015-0731-6 · Cited by 38
García‐Gómez, P., Schokkaert, E., Ourti, T. V., & d’Uva, T. B. (2014) · Health Economics · doi:10.1002/hec.3092 · Cited by 36
“Again, particularly interesting questions arise with respect to the effect of education —it has been argued by Cutler and Lleras-Muney (2010) that, correcting for income, the effect of education on lifestyles is mainly related to differences in cognitive abilities.”
Frisvold, D., & Golberstein, E. (2013) · Demography · doi:10.1007/s13524-013-0227-z · Cited by 35
“…enabling individuals to make better health care choices, respond more quickly to new information and technological advances, more effectively gather information, and more effectively communicate with medical care providers (Cutler and Lleras-Muney 2010; Glied and Lleras-Muney 2008; Lochner 2011).”
Backgroundvan Walsem, M. R., Howe, E. I., Iversen, K., Frich, J. C., & Anđelić, N. (2015) · Orphanet Journal of Rare Diseases · doi:10.1186/s13023-015-0324-8 · Cited by 36
“One possible explanation for this finding can be related to trends in the general population; people with higher education are more resourceful and have a better understanding and awareness of what healthcare and social support services are available or that they are entitled to, as well as more resources to follow up…”
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“enables healthier lifestyle choices, especially for behaviours that involve the medical care system.(26) In addition, results from a”
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“These demographic variables were selected due to their potential relationship with mindsets and health-relevant outcomes, as has been reported elsewhere in the literature (Cutler and Lleras-Muney, 2010; Deeks et al., 2009; Grossman et al., 2020; Mezuk et al., 2010).”
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“…which reveals significant gains, may be an underestimation of the benefit, as it ignores the nonmonetary gains from improved academic outcomes, such as reduced crime (Machin, Marie, and Vujić 2011) and improved health prospects (Currie 2009; Cutler and Lleras-Muney 2010).13 Fiscal costs.”
Too Much of a Good Thing? Exploring the Impact of Wealth on Weight
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“In a more indirect way, education could positively influence the development and maintenance of cognitive abilities throughout life, and such cognitive abilities could in turn lead to healthier behaviors [46].”
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“Given this notion of the return to education, the results presented below fit nicely with the empirical evidence on cognitive ability and health behavior (Cutler and Lleras-Muney, 2010).”
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“Higher levels of education have been associated with a number of factors that favour healthy behaviours related to lifestyle, such as having health insurance, higher income level and, above all, the cognitive capacity required for an in-depth understanding of information on health.(15) With respect to professional sta…”
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“In addition, social networks partially account for the association between education and health behaviors [4].”
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Feng, J., Xie, Q., & Zhang, X. (2020) · World Development · doi:10.1016/j.worlddev.2020.105344 · Cited by 34
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Give Us This Day Our Daily Breadth
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“Education may influence work and economic conditions, enhance social and psychosocial resources, and enable a healthy lifestyle and healthy behaviours [56–58], with a potentially stronger effect during bad economic times [57], but with a link to general cognitive ability or intelligence [58, 59].”
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Which indicator of income distribution explains crime better? Evidence from China
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“Education is associated broadly with health behaviors and improved access to health-promoting economic, physical and psychosocial resources (Cutler & Lleras-Muney, 2010; Ross & Wu, 1995).”
BackgroundMortality Change among Less Educated Americans
Novosad, P. M., Rafkin, C., & Asher, S. (2022) · American Economic Journal Applied Economics · doi:10.1257/app.20190297 · Cited by 36
Malaria: An Early Indicator of Later Disease and Work Level
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“…has suggested that the effect on ater health outcomes of human capital accumulates over a lifetime Conti et al., 2010; Currie, 2009; Cutler and Lleras-Muney, 2010). onsequently, a low level of socioeconomic status, which is thought o be partially driven by early exposure to a malarial…”
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“2While there is a large literature in economics on the relationship between socioeconomic status and various health behaviors (e.g., Cutler and Lleras-Muney (2010); Jones (1997)), grocery purchases are one health behavior which has received surprisingly little attention.”
BackgroundSantaolalla, A., Sollie, S., Rislan, A., Josephs, D. H., Hammar, N., Walldius, G., Jungner, I., Garmo, H., Karagiannis, S. N., & Hemelrijck, M. V. (2021) · BMC Immunology · doi:10.1186/s12865-021-00448-2 · Cited by 32
Educational attainment and psychological distress among working-age adults in the United States
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The role of time and risk preferences in smoking inequalities: A population-based study
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“None of the two studies from the United States, one based on a small non representative sample (Guthrie et al., 2009), the other on very large nationally representative samples (Cutler & Lleras-Muney, 2010), found evidence for a role of time preference or perspective as mediators of the education gradient in smoking.”
BackgroundMethodResultInfluentialDo working conditions at older ages shape the health gradient?
Schmitz, L. (2016) · Journal of Health Economics · doi:10.1016/j.jhealeco.2016.10.002 · Cited by 32
Viinikainen, J., Bryson, A., Böckerman, P., Elovainio, M. J., Pitkänen, N., Pulkki-Råbäck, L., Lehtimäki, T. J., Raitakari, O. T., & Pehkonen, J. (2018) · Preventive Medicine · doi:10.1016/j.ypmed.2018.08.026 · Cited by 34
Acceptability of receiving lifestyle advice at cervical, breast and bowel cancer screening
Stevens, C., Vrinten, C., Smith, S. G., Waller, J., & Beeken, R. J. (2018) · Preventive Medicine · doi:10.1016/j.ypmed.2018.12.005 · Cited by 32
Shi, Z., Rundle, A., Genkinger, J. M., Cheung, Y. K., Ergas, I. J., Roh, J. M., Kushi, L. H., Kwan, M. L., & Greenlee, H. (2019) · Breast Cancer Research and Treatment · doi:10.1007/s10549-019-05457-9 · Cited by 32
Clements, L., Frazier, S. K., Lennie, T. A., Chung, M. L., & Moser, D. K. (2022) · Western Journal of Nursing Research · doi:10.1177/01939459221141296 · Cited by 38
“…can confer a sense of perceived control through the giving of important information, fostering skills, habits, and attitudes that enhance people’s beliefs that they can accomplish their goal, eliminating their sense of uncertainty in assisting patients in self-care (Cutler & Lleras-Muney, 2010).”
BackgroundEARLY ENDOWMENTS, EDUCATION AND HEALTHPreprint
Conti, G., Heckman, J. J., & Urz, S. S. (2009) · RePEc: Research Papers in Economics · Cited by 32
Self-control, future orientation, smoking, and the impact of Dutch tobacco control measures
Daly, M., Delaney, L. D., & Baumeister, R. F. (2015) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2015.07.002 · Cited by 31
“Highly educated individuals and those on high incomes were also less likely than others to smoke as is typical (Cutler & Lleras-Muney, 2010).”
BackgroundRosenbaum, J. E. (2012) · Health Services and Outcomes Research Methodology · doi:10.1007/s10742-012-0094-x · Cited by 31
Global Sustainable Development priorities 500 y after Luther: Sola schola et sanitate
Lutz, W. (2017) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1702609114 · Cited by 33
Who can predict their own demise? Heterogeneity in the accuracy and value of longevity expectations☆
d'Uva, T. B., O'Donnell, O., & van Doorslaer, E. V. (2017) · The Journal of the Economics of Ageing · doi:10.1016/j.jeoa.2017.10.003 · Cited by 23
Satyanarayana, S., Thekkur, P., Kumar, A. M. V., Lin, Y., Dlodlo, R. A., Khogali, M. A., Zachariah, R., & Harries, A. D. (2020) · Tropical Medicine and Infectious Disease · doi:10.3390/tropicalmed5020101 · Cited by 34
“Incorporating health within the ambit of ‘quality education’ builds knowledge, skills, and positive attitudes about health and all other determinants of health, which can directly or indirectly have a considerable impact on efforts to End TB [42].”
BackgroundMontez, J. K., Zhang, W., Zajacova, A., & Hamilton, T. G. (2018) · Social Science & Medicine · doi:10.1016/j.socscimed.2018.01.005 · Cited by 30
Black, N., Johnston, D. W., Shields, M. A., & Suziedelyte, A. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.08.032 · Cited by 30
Neve, J. D., Karlsson, O., Canavan, C. R., Chukwu, A. U., Adu‐Afarwuah, S., Bukenya, J. N., Darling, A. M., Harling, G., Moshabela, M., Killewo, J., et al. (2019) · Tropical Medicine & International Health · doi:10.1111/tmi.13328 · Cited by 30
“Such benefits may include changing fertility preferences [7,11,46–48,61], fewer unhealthy behaviours such as smoking and alcohol consumption [8,62], and particularly for young women, increased bargaining power within relationships [63–65] and improved economic independence [16,49].”
BackgroundCancer Screening Participation and Gender Stratification in Europe
Willems, B., Cullati, S., Prez, V. D., Jolidon, V., Burton‐Jeangros, C., & Bracke, P. (2020) · Journal of Health and Social Behavior · doi:10.1177/0022146520938708 · Cited by 30
“In the same vein, it has been argued that education enhances engagement in more preventive and risk control behaviors, such as participation in cancer screening (Cutler and Lleras-Muney 2010).”
BackgroundHealth Lifestyles and the Transition to Adulthood
Lawrence, E., Mollborn, S., Goode, J. A., & Pampel, F. C. (2020) · Socius Sociological Research for a Dynamic World · doi:10.1177/2378023120942070 · Cited by 30
“Research has demonstrated a strong and robust association between health behaviors and socioeconomic status (Cutler and Lleras-Muney 2010; Lawrence 2017; Pampel, Krueger, and Denney 2010).”
BackgroundEffects of walking on self-assessed health status: Links between walking, trip purposes and health
Pae, G., & Akar, G. (2020) · Journal of Transport & Health · doi:10.1016/j.jth.2020.100901 · Cited by 30
The impact of road infrastructure on economic circulation: Market expansion and input cost saving
Wan, G., Wang, X., Zhang, R., & Zhang, X. (2022) · Economic Modelling · doi:10.1016/j.econmod.2022.105854 · Cited by 34
Cesur, R., & Mocan, N. H. (2013) · National Bureau of Economic Research · doi:10.3386/w19769 · Cited by 30
“Education has a causal impact on productivity in the labor market as well as productivity outside the labor market (Oreopoulos 2006, Card 2001, Grossman 1972, Grossman 2008, Cutler and Lleras-Muney, 2010).”
BackgroundThe Impact of Education on Health and Health Behavior in a Middle-Income, Low-Education Country
Cesur, R., Dursun, B., & Mocan, N. H. (2014) · National Bureau of Economic Research · doi:10.3386/w20764 · Cited by 32
Cause-effect analysis for sustainable development policy
Cucurachi, S., & Suh, S. (2017) · Environmental Reviews · doi:10.1139/er-2016-0109 · Cited by 29
“Instrumental variables have also been used to test the effects of education on health (Cutler et al. 2008; Grossman 2008; Conti et al. 2010; Cutler and Lleras-Muney 2010; Heckman et al. 2014), education on wellbeing (Oreopoulos and Salvanes 2011; Oreopoulos and Petronijevic 2013), and social connections on well-being…”
MethodBose, B., & Heymann, J. S. (2019) · Social Science & Medicine · doi:10.1016/j.socscimed.2019.112478 · Cited by 29
Rest-activity rhythms in emerging adults: implications for cardiometabolic health
Hoopes, E. K., Witman, M. A., D’Agata, M. N., Berube, F. R., Brewer, B. C., Malone, S. K., Grandner, M. A., & Patterson, F. (2021) · Chronobiology International · doi:10.1080/07420528.2020.1868490 · Cited by 29
“Young adults who do not go to college are often less healthy: they are more likely to smoke, less likely to engage in regular physical activity, and less likely to eat a healthful diet (Cutler and Lleras-Muney 2010; Lawrence 2017).”
BackgroundPersonality, Education, and Health-Related Outcomes of High-Ability Individuals
Savelyev, P. A., & Tan, K. T. K. (2014) · American Journal of Health Economics · doi:10.1162/ajhe_a_00116 · Cited by 33
“Both cognitive and socioemotional skills were shown to be important sources of bias for estimates of education’s effect on health (Conti and Hansman, 2013; Conti et al., 2010).”
InfluentialAuditor University Education: Does it Matter?
Chu, J., Florou, A., & Pope, P. F. (2021) · European Accounting Review · doi:10.1080/09638180.2020.1866633 · Cited by 29
“Education also increases general knowledge and the ability to apply theory and concepts in different situations (Cutler & Lleras-Muney, 2010; Eraut, 2009).”
Parental preference for boys in childhood and the health of the elderly: Evidence from China
Liu, Y., Su, Y., & Yin, Y. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2022.114986 · Cited by 29
Social Networks and Health Inequalities
Klärner, A., Gamper, M., Keim-Klärner, S., Moor, I., von der Lippe, H., & Vonneilich, N. (2022) · Springer eBooks · doi:10.1007/978-3-030-97722-1 · Cited by 36
Polenick, C. A., Leggett, A. N., & Kales, H. C. (2017) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2017.05.001 · Cited by 29
Early education and health outcomes of a 2001 U.S. Birth Cohort
Belfield, C., & Kelly, I. R. (2012) · Economics & Human Biology · doi:10.1016/j.ehb.2012.05.001 · Cited by 28
Maughan‐Brown, B., Lloyd, N., Bor, J. H., & Venkataramani, A. S. (2016) · Journal of the International AIDS Society · doi:10.7448/ias.19.1.20658 · Cited by 28
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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