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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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Personal factors of biological aging in working and non-working respondents in late maturity period
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“The health of people of mature age is influenced by the following features of their life path: the level of education (Cutler & Lleras-Muney, 2010), a variety of interests, and hobbies that a person had during their life.”
BackgroundInfluentialFactors That Affect Maternal Mortality in Rwanda: A Comparative Study with India and Bangladesh
Patrick, M., Zaman, M. S. U., Afzal, G., Mahsud, M., & Hanifatu, M. N. (2022) · Computational and Mathematical Methods in Medicine · doi:10.1155/2022/1940188 · Cited by 13
“Education may likewise impact health through its effect on pay but not the same as that of income [4, 6].”
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“After examining the impact of growth targets management and regional competition on the ULGUE, this paper used the method of Cutler and Lleras-Muney (2010) [35] to build the following mechanism test model, and thereby identify the transmission mechanism of its impact.”
MethodSilva, D. R., Viana, V. P., Müller, A. M., Coelho, A. C., Deponti, G. N., Livi, F. P., & Dalcin, P. D. T. R. (2013) · Jornal Brasileiro de Pneumologia · doi:10.1590/s1806-37132013000200007 · Cited by 13
No free lunch, buddy: past housing transfers and informal care later in life
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“If there is no selection on unobservables relative to distance, this strategy should recover the conditional effect of interest (see Cutler and Lleras-Muney 2010, for an example in a different context).”
The Rapid Expansion of Higher Education in the New Century
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“For instance, higher levels of education may enhance one’s problem-solving skills, sense of control, or informal social networks (Cutler & Lleras-Muney, 2010).”
BackgroundLife Expectancy at Birth in Europe: An Econometric Approach Based on Random Forests Methodology
Cervantes, P. A. M., López, N. R., & Rambaud, S. C. (2020) · Sustainability · doi:10.3390/su12010413 · Cited by 13
“In addition, our findings suggest that the educational level of a population has a strong influence in determining health outcomes, as confirmed by previous empirical studies [41,42,83].”
ResultNumeracy and memory for risk probabilities and risk outcomes depicted on cigarette warning labels.
Shoots‐Reinhard, B. L., Erford, B. M., Romer, D., Evans, A. T., Shoben, A. B., Klein, E. G., & Peters, E. M. (2020) · Health Psychology · doi:10.1037/hea0000879 · Cited by 13
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Self-citationZhu, S., Liu, J., Wang, Z., & Chen, S. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-13292-6 · Cited by 12
“In discussing the factors affecting public health service supply, factors such as government fiscal expenditure [69], income, education [70], and urbanization [71] have attracted much attention.”
Yang, B., Hassan, F. A., Ahmad, W., Antohi, V. M., Forțea, C., & Pleșea-Condratovici, C. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1724402 · Cited by 12
“Higher levels of these pollutants contribute to respiratory and cardio-vascular diseases, thereby reducing LIFE (48).”
Xue, B., Wu, Y., Zheng, X., Xue, Y., Dong, F., Xiao, S., Yin, M., Wang, M., Liu, Y., & Zhang, C. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.981649 · Cited by 12
“Incomes and education were associated with people’s healthy behaviors (26, 27).”
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“Model 2 for “Poverty status” and “Health insurance coverage” additionally adjusted for “Education”, “Employ-ment”, and “Marital status”; also, Model 2 for “Health insurance coverage” adjusted for “Poverty status” to screen for breast, cervical, and colorectal cancer [18, 19].”
Educational Influences on Late-Life Health: Genetic Propensity and Attained Education
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“The relationship between education and health is commonly theorized to originate from environmental factors related to the level of attained education, such as social position, health behaviors, living conditions, and work environment (Breen et al., 2010; Cutler & Lleras-Muney, 2010).”
BackgroundPain: its prevalence and correlates among the oldest old
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Using the Internet to Support Exercise and Diet: A Stratified Norwegian Survey
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“Differences in education accounts for a substantial part of social disparities in health (7).”
Who is taking up voluntary medical male circumcision? Early evidence from Tanzania
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The Health and Libraries of Public Use Retrospective Study (HeLPURS)
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Moy, S., Kober, K. M., Viele, C. S., Paul, S. M., Hammer, M. J., Melisko, M., Wright, F., Conley, Y. P., Levine, J. D., & Miaskowski, C. A. (2020) · Cancer Nursing · doi:10.1097/ncc.0000000000000875 · Cited by 13
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“…intellectual stimulation and through the development of the foundation for later life socioeconomic status, social network quality, and healthcare resources related to brain health (Clouston et al., 2012; Cutler & Lleras-Muney, 2010; Kahn & Pearlin, 2006; Wilson et al., 2009; Zhang et al., 2016).”
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Health Behaviors in Austrian Apprentices and School Students during the COVID-19 Pandemic
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“Taken together these findings support the argument that education type is an important factor for health behaviors [15], and our results suggest this also holds true in Austria.”
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Balasooriya, N. N., Bandara, J. S., & Rohde, N. (2022) · Social Science & Medicine · doi:10.1016/j.socscimed.2022.115165 · Cited by 12
Effect of widowhood on the risk of disability among the elderly in China
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“In exploring the channel of the effect of widowhood on the risk of disability, the explained variables in Equation (1) were replaced with three channel variables: sleep duration, smoking, and personal fitness expenditure, referring to existing studies (19, 33).”
MethodAndersson, M. A., & Vaughan, K. R. (2017) · SSM - Population Health · doi:10.1016/j.ssmph.2017.05.003 · Cited by 12
“Thus, educational and extra-educational resources are essentially substitutable in the production of adult health or well-being (e.g., Cutler & Lleras-Muney, 2010; Ross &Mirowsky, 2011; Schafer et al., 2013).”
BackgroundAwareness of ParticipACTION among Canadian adults: a seven-year cross-sectional follow-up
Spence, J. C., Faulkner, G., Lee, E., Berry, T. R., Cameron, C., Deshpande, S., Latimer‐Cheung, A. E., Rhodes, R. E., & Tremblay, M. S. (2018) · Health Promotion and Chronic Disease Prevention in Canada · doi:10.24095/hpcdp.38.4.04 · Cited by 12
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“This skill-based theoretical proposition aligns with the literature on the relationship between education and health (Cutler & Lleras-Muney, 2010; Hayward et al., 2015).”
The Effect of Education on Health: Evidence from the 1997 Compulsory Schooling Reform in Turkey
Baltagi, B. H., Flores‐Lagunes, A., & Karatas, H. M. (2019) · Regional Science and Urban Economics · doi:10.1016/j.regsciurbeco.2019.05.001 · Cited by 12
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Current cigarette smoking among U.S. college graduates
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Kovács, N., Pálinkás, A., Sipos, V., Nagy, A. C., Harsha, N., Kőrösi, L., Papp, M., Ádány, R., Varga, O., & Sándor, J. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16173153 · Cited by 12
“The relationship between the level of education and the use of preventive care services has been established [43,44].”
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Cutler, D., Meara, E. R., & Stewart, S. (2020) · National Bureau of Economic Research · doi:10.3386/w27974 · Cited by 12
“Our methodology for examining the impact of physical stress on knee pain is similar to Cutler and Lleras-Muney (2010).”
Self-citationThe Non-Market Benefits of Education and Ability
Heckman, J. J., Humphries, J. E., & Veramendi, G. F. (2017) · National Bureau of Economic Research · doi:10.3386/w23896 · Cited by 12
No Free Lunch, Buddy: Past Housing Transfers and Informal Care Later in LifePreprint
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A Dermatologist's Ammunition in the War Against Smoking: A Photoaging App
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“Skin damage due to smoking that is culturally associated with a decrease in attractiveness (ie, wrinkles, early hair loss, declined capillary perfusion, pale or grayish skin [7-9]) predominantly affects the self-concept of young people with low education [1], who are at significantly greater risk for tobacco addiction…”
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Estimating the Impact of Education on Household Fruit and Vegetable Purchases
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“This is in addition to the private returns on education such as increased cognitive processing, increased labor force productivity, and improved health outcomes, as laid out in this study (Cutler & Lleras-Muney, 2010; Peters et al., 2010).”
BackgroundSmoking and income distribution: Inequalities in new and old products
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“For example, Cutler and Lleras-Muney (2010) identified very large returns to many measures of health status even after controlling for income, health insurance, and family background.”
BackgroundHarhay, M. O., Harhay, J. S., & Nair, M. M. (2012) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2012.11.004 · Cited by 11
“We also hypothesized, based on prior evidence, that lower SEP more strongly and adversely impacts women and urban inhabitants [4,8,12,13,17,33].”
Beyond Income, Access, and Knowledge
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“1414 Journal of Aging and Health 25(8) Individuals with higher education may be more elastic to price changes than individuals with lower education (Cutler & Lleras-Muney, 2010).”
BackgroundMethodInfluentialGesundheitliche Ungleichheit und neue Morbidität
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“Not surprisingly then, data indicate that less-educated adults are more likely to be obese and to smoke, eat an unhealthy diet, abuse drugs, and seldom exercise [13,14,15,16].”
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“While much of the literature has focused on the importance of education for health (Cutler & Lleras-Muney, 2010; Ross & Mirowksky, 2010; Schnittker, 2004), some scholars have argued that differences in income (McDonough et al., 1999; Wilkinson, 1990) and occupational standing (Marmot, 2004; Marmot…”
InfluentialSaw, G. K. (2015) · Educational Research for Policy and Practice · doi:10.1007/s10671-015-9175-2 · Cited by 16
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“Moreover, well-educated people have more social psychological resources such as better self-control and more social support, which are all protective factors of hypertension (36).”
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Social Policies and Health Inequalities
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“In both cases, however, the education gradient is almost a straight line, which corresponds nicely with the observation that the relationship between education and health is roughly linear after 10 years of school (Cutler and Lleras-Muney, 2010).”
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Bhalotra, S. R., Karlsson, M., & Nilsson, T. (2015) · SSRN Electronic Journal · doi:10.2139/ssrn.2598909 · Cited by 11
“The effects we identify will tend to include a behavioural component over and above the biological mechanism referred to earlier to the extent that infant health improvements raise adult education and income (Almond and Currie, 2011a), and education and income are effective in averting and treating morbidities (Cutler…”
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Social Policies and Health Inequalities
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Xue, X., & Li, Y. (2023) · Healthcare · doi:10.3390/healthcare11020219 · Cited by 10
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“[9] used six datasets from the US and the UK to examine the possible explanations for the association between education and health behaviors and found that knowledge and measures of cognitive ability could explain up to 30% of the educational gradient in health behaviors, whereas the impact of nutrition education on d…”
MethodZhu, H., Ma, S., Li, Z., & Hui-qin, X. (2023) · Economics & Human Biology · doi:10.1016/j.ehb.2023.101281 · Cited by 10
Bhattacharyya, K. K., Liu, Y., Gupta, D. D., Molinari, V., & Fauth, E. B. (2023) · Journal of Aging and Health · doi:10.1177/08982643231209482 · Cited by 11
“Lastly, we considered depressive symptoms that lasted more than two weeks in the past 12 months based on a mean score of a 7-item DEPCON scale that was administered by telephone (Cutler & Lleras-Muney, 2010).”
Social and Systemic Barriers to Transition-Related Surgical Procedures for Transgender Americans
Marano, A. A., Miller, A. S., Castillo, W., Reisner, S. L., Schechter, L. S., & Coon, D. (2024) · LGBT Health · doi:10.1089/lgbt.2023.0341 · Cited by 11
Chen, H., Deng, K., & SCHNEIDER, F. G. (2024) · Pacific Economic Review · doi:10.1111/1468-0106.12446 · Cited by 11
Li, Y., & Zhang, J. (2024) · Sustainability · doi:10.3390/su16219572 · Cited by 10
Huang, Y., Wang, S., Tian, L., Zhang, X., Liu, S., Zhu, Z., Wang, W., Shi, D., He, M., & Shang, X. (2025) · The journal of nutrition health & aging · doi:10.1016/j.jnha.2025.100525 · Cited by 11
“IndividualswithlowerEA are less informed [36], and may respond more positively to lifestyle modifications, such that targeting lifestyle interventions within this population subset could prove more effective in reducing health and mortality disparities related to EA.”
Secondary Education and Health Outcomes in Young People from the Cape Area Panel Study (CAPS)
Ward, J., & Viner, R. (2016) · PLoS ONE · doi:10.1371/journal.pone.0156883 · Cited by 10
“”[11] Although there is evidence of a dose response effect of education on health[11], there is less agreement as to he shape of this relationship.”
BackgroundYang, Y. J., Li, S., Zhang, K., Xiang, X., Li, Z., Ahn, S., & Murphy, J. G. (2020) · Journal of Aging and Physical Activity · doi:10.1123/japa.2019-0222 · Cited by 9
Can Wealth Buy Health? A Model of Pecuniary and Non-Pecuniary Investments in Health
Margaris, P., & Wallenius, J. (2023) · Journal of the European Economic Association · doi:10.1093/jeea/jvad044 · Cited by 11
Psychological safety of students in interaction with virtual reality
Litvinova, A., Berezina, T. N., Kokurin, A. V., & Ekimova, V. I. (2022) · Journal of Modern Foreign Psychology · doi:10.17759/jmfp.2022110309 · Cited by 11
The Impact of Higher Education on Health Behavior during the COVID-19 Pandemic: Evidence from China
Liu, S., Zhang, Y., Liu, H., & Yan, C. (2023) · Sustainability · doi:10.3390/su152416644 · Cited by 12
Milieu d’origine, situation sociale et parcours tabagique en France
Bricard, D., & Jusot, F. (2012) · Économie publique/Public economics · doi:10.4000/economiepublique.8916 · Cited by 10
Zalmanovitch, Y., & Vashdi, D. R. (2014) · Health Expectations · doi:10.1111/hex.12238 · Cited by 12
Population health status and economic growth in Chinese provinces: some policy implications
Murthy, V. N. R., & Okunade, A. A. (2014) · Applied Economics Letters · doi:10.1080/13504851.2013.859369 · Cited by 10
“The economic literature confirms that literacy rate and education play important roles in prolonging life expectancy (Lleras-Munley, 2005; Cutler and Lleras-Muney, 2010).”
BackgroundSocioeconomic factors and the risk for sarcoma
Hampras, S. S., Moysich, K. B., Marimuthu, S. P., Ravi, V., & Jayaprakash, V. (2013) · European Journal of Cancer Prevention · doi:10.1097/cej.0000000000000004 · Cited by 10
“Education is thought to influence lifestyle factors such as smoking, BMI, alcohol consumption, and disease preventive behaviors such as health exams (Cutler and Lleras-Muney, 2010), which in turn affect health status.”
BackgroundMortensen, L. H., & Torssander, J. (2017) · SSM - Population Health · doi:10.1016/j.ssmph.2017.01.008 · Cited by 10
“Education precedes occupation and income - two potentially health-generating resources - but it may also influence health through a greater avoidance of unhealthy behaviors, access to health related information, and increased conceptual thinking (Cutler & Lleras-Muney, 2010).”
BackgroundPiao, X., Ma, X., Zhang, C., & Managi, S. (2020) · Sustainability · doi:10.3390/su12114623 · Cited by 10
Görgens, M., Longosz, A. F., Ketende, S. C., Nkambule, M., Dlamini, T., Mabuza, M. P., Sikwibele, K., Tsododo, V., Dlamini, M., Dennis-Langa, F., et al. (2020) · BMC Public Health · doi:10.1186/s12889-020-09680-8 · Cited by 10
Mechanisms linking teenage mothers’ educational attainment with self-reported health at age 50
Maslowsky, J., Hendrick, C. E., & Stritzel, H. (2021) · BMC Women s Health · doi:10.1186/s12905-020-01150-y · Cited by 16
“regular physical activity may have direct positive impacts on women’s health later in life, such as reducing risk for obesity and stress-related diseases and increasing cardiovascular health, it can also serve as a marker of women’s health behaviours in adulthood [29].”
BackgroundComplementary medicine use in US adults with hypertension: A nationally representative survey
Kohl-Heckl, W. K., Schröter, M., & Cramer, H. (2022) · Complementary Therapies in Medicine · doi:10.1016/j.ctim.2022.102812 · Cited by 17
Wang, T., & Lu, J. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.829716 · Cited by 17
“So, it is beneficial to the physical and mental health of the educated (20, 23).”
BackgroundEducation Externalities on Longevity
Ricci, F., & Zachariadis, M. (2012) · Economica · doi:10.1111/ecca.12013 · Cited by 9
Racial disparities in the cognition-health relationship
Thompson, O. (2011) · Journal of Health Economics · doi:10.1016/j.jhealeco.2011.01.008 · Cited by 10
“…studies contain any empirical analysis of the relationship between cognition and health (Grossman 1975; Hartog & Oosterbeek 1998; Gottfredson & Deary 2004; Auld & Sidhu 2005; Heckman 2007; Cutler & Lleras-Muney 2010) and none of these address potential racial differences in this association.”
BackgroundMethodThe impact of preventive health behaviour and social factors on visits to the doctor
Din, G. Y., Zugman, Z., & Khashper, A. (2014) · Israel Journal of Health Policy Research · doi:10.1186/2045-4015-3-41 · Cited by 10
Reiner, M., Niermann, C. Y. N., Krapf, F., & Wöll, A. (2015) · International Journal of Child Youth and Family Studies · doi:10.18357/ijcyfs.61201513479 · Cited by 12
“Health behavior is associated with personal educational level (Baum, Garofalo, & Yali, 2006; Cutler & Lleras-Muney, 2010) and with the educational level of other family members (Chen & Li, 2009).”
BackgroundComplementarity in dietary supplements and foods: are supplement users vegetable eaters?
Kang, H., Joo, H. H., Choi, K. D., Lee, D., & Moon, J. (2017) · Food & Nutrition Research · doi:10.1080/16546628.2017.1361769 · Cited by 12
Alcaraz, K. I., Riehman, K. S., Vereen, R. N., Bontemps-Jones, J. E., & Westmaas, J. L. (2018) · Ethnicity & Disease · doi:10.18865/ed.28.3.161 · Cited by 10
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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