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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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“12,13 Risk factors for CVD are also strongly associated with education.”
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“Because individuals with higher levels of education are better able to access, understand, and apply health-related information and knowledge, and are better able to understand and adopt behaviors to prevent disease and maintain health (19).”
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“…been linked to health outcomes, whereby studies have shown that higher levels of education are associated to a reduction of risky behaviors (smoking or heavy drinking) and declining obesity, whereby for each extra year of study, the risk for obesity reduces by 1.4% (Cutler and Lleras-Muney, 2009).”
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“These findings are particularly important, given the association between HC and preventative behavior given that less educated individuals are less likely to engage in health behaviors.(35) Furthermore, the findings suggest that efforts to reduce cancer and promote health should focus on decreasing structural barriers…”
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“Increased levels of education also improve children’s earnings prospects, which may increase the costs of engaging in unhealthy behaviours (Fuchs, 1982; Cutler and Lleras-Muney, 2010).”
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“Cutler and Lleras-Muney (2010) find that there is a strong disparity in healthy behaviours like diet choice across education groups.”
BackgroundGalama, T. J., & van Kippersluis, H. (2013) · SSRN Electronic Journal · doi:10.2139/ssrn.2270572 · Cited by 8
Bleil, M. E., Roisman, G. I., Hamilton, D. T., Magro, S. W., Appelhans, B. M., Gregorich, S. E., Booth‐LaForce, C., & Pianta, R. C. (2024) · BMC Public Health · doi:10.1186/s12889-024-18560-4 · Cited by 8
Son, J. Y., Marriott, D. J., Struble, L. M., Chen, W., & Larson, J. L. (2024) · Journal of the American Geriatrics Society · doi:10.1111/jgs.19147 · Cited by 7
“Furthermore, education which is established in early life influences individuals ’ health behaviors and health over individuals' lifetime, 27 – 29 thereby, contributing to negative health outcomes like nursing home admission in later life.”
State cigarette taxes, smoking cessation, and implications for the educational gradient in mortality
Riley, A. R. (2024) · Social Science & Medicine · doi:10.1016/j.socscimed.2024.117398 · Cited by 6
Kazakova, Y., Leturcq, M., & Panico, L. (2024) · Child Indicators Research · doi:10.1007/s12187-024-10178-7 · Cited by 7
“The literature on the correlation between education and health behaviours is vast, identifying many potential mechanisms underscoring this relationship, such as income and other resources such as insurance, knowledge and cognitive ability, and social networks (Cutler & Lleras-Muney, 2010).”
Li, C., Zhang, Y. S., Noppert, G. A., Hazzouri, A. Z. A., Gross, A. L., & Kobayashi, L. C. (2024) · SSM - Population Health · doi:10.1016/j.ssmph.2024.101716 · Cited by 9
Controlling for polygenic genetic confounding in epidemiologic association studies
Zhao, Z., Yang, X., Dorn, S., Miao, J., Barcellos, S., Fletcher, J. M., & Lu, Q. (2024) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.2408715121 · Cited by 7
“These studies either do not adjust for genetic confounding at all ( 35 – 37 ), or use molecular genetic data to adjust for confounding ( 38 , 39 ).”
Ismail, L. C., Osaili, T. M. I., Obaid, R. S., Hashim, M., Ahmed, M. K., Al-Fayadh, F., Farah, A., Sad, H., Alghanem, H., Mohamad, M. N., et al. (2025) · BMC Public Health · doi:10.1186/s12889-024-20836-8 · Cited by 9
Social determinants of health and biological age among diverse U.S. Adults, NHANES 2011–2018
Mesa, R. A., Llabre, M. M., Lee, D., Rundek, T., Kezios, K., Hazzouri, A. Z. A., & Elfassy, T. (2025) · BMC Public Health · doi:10.1186/s12889-025-23803-z · Cited by 7
“Therefore, compared to males, females with lower levels of education may be more vulnerable to unhealthier lifestyle choices [37] and prone to stress and depression, which negatively impact their health [35] and can contribute to advanced biological aging.”
Educational inequalities in Europe: A scoping review of longitudinal studies in K-12 education
Campos, D., Koskinen, A., Munkácsy, B., Rolfe, V., Patsis, P., Tóth, E., Olsen, R. V., Scherer, R., Söldner, L., Danek, A. H., et al. (2025) · Studies In Educational Evaluation · doi:10.1016/j.stueduc.2025.101523 · Cited by 10
Au, N., Hauck, K., & Hollingsworth, B. P. (2012) · Applied Economics · doi:10.1080/00036846.2012.657353 · Cited by 7
“It is suggested that schooling may lead to healthier behaviours by improving health knowledge (Kenkel, 1991 ; Nayga, 2000 ), or by raising levels of cognitive ability (Cutler and Lleras-Muney, 2010 ).”
BackgroundThe Traveller’s Risk Perception (TRiP) questionnaire: pre-travel assessment and post-travel changes
Tardivo, S., Zenere, A., Moretti, F., Marchiori, F., Berti, D., Migliorini, M., Tomasi, A., Ferrari, S., Tognon, F., Napoletano, G., et al. (2019) · International Health · doi:10.1093/inthealth/ihz033 · Cited by 7
Pei, Y., Qi, X., Zhu, Z., Zhang, W., Tsay, R.-M., & Wu, B. (2023) · Geriatric Nursing · doi:10.1016/j.gerinurse.2023.10.023 · Cited by 7
Pai, M., & Muhammad, T. (2024) · Scientific Reports · doi:10.1038/s41598-023-50613-3 · Cited by 7
“…access to better-paying jobs and quality health care, higher education is linked to better nutrition 101 , more physical activity 102,103 , fewer instances of smoking, and moderate drinking 104,105 —all of which, separately and cumulatively, could render better muscle strength in older ages.”
BackgroundHorizontal inequity in the use of mental healthcare in Australia
Black, N., Johnston, D. W., Knapp, M. R. J., Shields, M. A., & Wong, G. H. Y. (2024) · Health Economics · doi:10.1002/hec.4910 · Cited by 7
“While several proposed mechanisms link education to health and health-behaviours, the most direct pathway is increased knowledge (Grossman, 1972; Kenkel, 1991; Cutler and Lleras-Muney, 2010).”
Educational Heterogeneity in the Association between Smoking Cessation and Health Information
Lillard, D. R. (2017) · Emerald Group Publishing Limited eBooks · doi:10.1108/s0731-219920170000025006 · Cited by 7
Socioeconomic inequality and dental caries among Thai working age population
Amornsuradech, S., & Vejvithee, W. (2019) · Journal of Health Research · doi:10.1108/jhr-03-2019-0060 · Cited by 7
Cook, W. K., Mulia, N., & Li, L. (2020) · Substance Use & Misuse · doi:10.1080/10826084.2020.1732423 · Cited by 7
“SES differences in health mortality and other outcomes are attributable, in part, to differences in health behaviors (Cutler & Lleras-Muney, 2010).”
Background
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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