Education attainment linked to health throughout lifespan: Exploring social determinants of health
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* Natalie McGill

*Second in a series on the role of social determinants of health. Visit [www.thenationshealth.org/sdoh](http://www.thenationshealth.org/sdoh) for related content.*

Issues such as equal access to affordable housing and income redistribution may have their political foes, but Anthony Iton said he is hard-pressed to find anyone against high-quality education for everyone.

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[Figure1](http://www.thenationshealth.org/content/46/6/1.3/F1)

Middle-school students at Knowledge is Power Program Academy take notes in October 2000 in New York City. The amount and quality of education children receive can influence how healthy they are as adults and how long they live.

Photo by Chris Hondros, courtesy Newsmakers/Getty Images

“Education is the single most important modifiable social determinant of health,” Iton, MD, JD, MPH, senior vice president for healthy communities at the California Endowment and an APHA member, told *The Nation’s Health.* “Income and education are the two big ones that correlate most strongly with life expectancy and most health status measures.”

Social determinants of health are the social, economic and physical environment factors that impact well-being, such as housing, access to health care and employment. But length and quality of education is crosscutting — it predicts employment and income, which influences where someone can live and if they can afford health care. Education is not just about what is learned in the classroom; it is also about the doors it unlocks to future well-being.

U.S. women age 25 in 2005 who never finished high school could expect to live another 52 years, compared to another 57.3 years for women who completed high school, according to a 2010 National Center for Health Statistics report. Men who never finished high school could expect to live another 46.2 years, compared with 51.5 for those with high school diplomas.

Aware of education’s influence on health, federal health officials made high school graduation a health priority in Healthy People 2020, a national blueprint of health objectives, outlining goals to boost education and quality of instruction for U.S. kids. One of those goals, boosting the number of kids who graduate in four years as of ninth grade, is a Leading Health Indicator, meaning it is a priority for U.S. health under Healthy People 2020. Seventy-nine percent of public school students completed high school in four years as of the 2010-2011 school year. The goal is to increase that to 87 percent by 2020.

## Road to good health begins early in life

The building blocks of good health have their foundation in social and emotional skills learned during early childhood.

Early childhood programs such as preschool use games and social interactions to expose children to the concepts of problem solving and thinking ahead, which forces them to think about the consequences of their actions, said W. Steven Barnett, PhD, director of the National Institute for Early Education Research at Rutgers University. That is a practice carried into adulthood that may lead to better decision making about situations that could impact health, he said.

“If we put this in a broader perspective and not just diet and exercise, it’s the avoidance of accident and injury,” Barnett told *The Nation’s Health.* “It’s the avoidance of teen pregnancy. It’s the avoidance of violence or aggression. Those are, from a public health perspective, big deals.”

One of the longest running early childhood education programs is Head Start, a federal program geared toward low-income kids that since 1965 provides school readiness to 1 million children annually across U.S. states, territories and 155 tribal communities.

Part of Head Start’s services boost language and literacy skills and social and emotional development, through playing with peers, building relationships with adults and teaching a combination of planned and spur-of-the-moment lessons, said Blanca Enriquez, PhD, director of the Office of Head Start.

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But early childhood education programs are resources for not only teaching social and emotional skills carried into adulthood, but for health-related services that keep young children and their families healthy.

Access to Head Start also means program staff and families work together to keep children up-to-date on required immunizations, as well as secure health insurance, a medical home and a dental home. Ninety-six percent of families in Head Start have insurance coverage and a medical home, and 93 percent have dental homes by the end of the school year, she said.

Access to Head Start also provides screening for developmental delays and follow-up care, as some children may have cognitive issues, hearing loss or vision problems.

“Catching these early makes a huge difference in the early years when a child is developing so quickly, and learning so much,” Enriquez said.

But a large factor in early childhood education’s influence on health is the education level of the parents themselves. According to 2014 Census Current Population Survey data, 28 percent of 3- to 5-year-olds whose parents dropped out of high school attend preprimary programs such as preschool, compared with 49 percent of kids of the same age whose parents have graduate or professional degrees.

“If you just think about it a little, the parents who have a higher level of education are much more likely to be able to give their child intellectual stimulation, to be reading to them, doing the things we know promote the children’s development,” said APHA member Paula Braveman, MD, MPH, a research director for the Robert Wood Johnson Foundation’s Commission to Build a Healthier America and director of the Center on Social Disparities in Health at the University of California-San Francisco. “And child development then is strongly linked with their health in adulthood.”

In north Minneapolis, where poverty and crime rates soar, early parent involvement and access to high-quality early childhood education are priorities of the area’s Northside Achievement Zone. The zone is a partnership of schools and more than 40 agencies and nonprofit groups which use a wraparound approach to address social factors that impede education.

Families have access to parenting classes at all stages of a child’s life, including the early childhood years, as only 28 percent of kids who live in north Minneapolis enter kindergarten school-ready. As of the 2014-2015 school year, only 18 percent of neighborhood kids whose families were not in Northside Achievement Zone programs were kindergarten-ready, compared with 50 percent of children whose parents took Northside’s classes and enrolled them in early childhood education programs.

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[Figure3](http://www.thenationshealth.org/content/46/6/1.3/F3)

A second-grader flips through a new notebook in August 2000 after his class received donated supplies at Chicago’s Stewart Elementary School. Ensuring access to quality childhood education is important, as it influences lifelong health.

Photo by Tim Boyle, courtesy Newsmakers/Getty Images

“We have a two-generation approach, because what we want to do is create a context in which children can do the only two things they should be doing: having fun and learning,” said Sondra Samuels, MBA, president and CEO of the Northside Achievement Zone. “We have to work with their parents to create those conditions at home and in the community. Our hope is that we can end multigenerational poverty in our lifetime using education and family support as the two levers.”

Still, experts realize that not all U.S. children have access to high-quality early childhood education. Head Start provides services for only about 40 percent of eligible U.S. preschoolers and Early Head Start is only available to less than 5 percent of eligible infants and toddlers, Enriquez said.

“Ideally, we as a nation would develop and finance a system for comprehensive high-quality services for all of our youngest and most vulnerable citizens,” Enriquez said. “Such a system would help maintain America’s role in leading the world in so many ways.”

## High school crucial for future health

Lacking access to quality early childhood education has the potential to set kids on the wrong foot as they move through the remainder of their kindergarten through 12th-grade instruction — especially as they enter the middle and high school years.

And even though U.S. high school graduation rates have increased, disparities still remain among racial and ethnic groups.

The overall U.S. high school graduation rate was 82 percent in the 2013-2014 school year, according to the National Center for Education Statistics. Yet compared with white students, who had an 87.2 percent graduation rate, Hispanics lagged behind at 76.3 percent, followed by blacks at 72.5 percent and nearly 70 percent for American Indian and Alaska Natives.

Minority groups may be more likely to live in areas known for violence, teen pregnancy, unsafe housing and less access to health care, which drives those disparities, said Terri Wright, PhD, MPH, director of APHA’s Center for School, Health and Education. The center’s work is particularly focused on the most vulnerable teens in schools known as “dropout factories,” where less than 60 percent of students complete high school.

“We know those who drop out of high school are most likely to practice risky behaviors as adults and are most likely to have multiple health issues as adults,” Wright said.

One way public health has stepped in is by integrating public health practices and approaches into the primary care provided by school-based health centers, resources co-located in schools that help address the social factors school-wide. Strategies include but are not limited to physical and mental health services, and assistance with mitigating social issues such as hunger and safety. Such strategies and services remove the barriers that make it challenging for teens to complete high school. The use of school-based health centers is linked with higher GPAs and a greater likelihood to finish school, she said. For example, Wright noted that black male teens are more likely to use mental health services provided in a school-based health center rather than those located in the community.

When it came to education, Iton said the minds behind the California Endowment’s Building Healthy Communities thought that the schools’ work would focus primarily on topics such as increasing physical activity, nutrition and access to health care. The endowment launched Building Healthy Communities in 2010, which targets 14 low-income California areas with low-income, high-minority populations to build coalitions addressing social determinants.

But as endowment leaders spent more time with local school groups, they realized punitive school policies had an influence on health, as expulsion and suspension rates were disproportionately higher for minority boys and “the new superhighway from schools to prison.”

“These same kids were having extreme adverse health outcomes, not to mention the fact that the kids most likely to get suspended and expelled came from the most traumatized backgrounds,” Iton told *The Nation’s Health.* “They experience violence, are victims of violence, have parents who were incarcerated. They were bringing to school a lot of that emotional injury. The schools’ response was to further traumatize them by exacting these highly punitive discipline policies.”

Part of Building Healthy Communities’ work is to advocate for schools to become trauma-informed, which means recognizing students’ struggles and answering with positive reinforcement for good behaviors and strategies that hold students accountable for their actions instead of separating them from the school community, which could increase their risk of leaving school altogether.

One of those accountability strategies is restorative justice, which asks students to take steps to repair harm they caused, and reinforces that they are a part of a community and if they hurt one person, they hurt everyone.

Iton said there has been a 70 percent reduction in suspensions and a rise in academic test scores in California school districts that adopt trauma-informed practices for its students.

Disparities in education and health last beyond childhood and high school, extending into the adulthood as well.

For example, for U.S. young adults ages 20 to 24 in 2015, the unemployment rate was 12 percent overall, but 20 percent for people with less than a high school education and 16 percent for people who only had a high school education, according to the U.S. Bureau of Labor Statistics. In comparison, unemployment was 5 percent for people who had a bachelor’s degree or higher and 10 percent for people who had some college education but lacked a degree.

“These are the very people who don’t have access to care,” Wright said. “They don’t have insurance or employer-sponsored insurance, and have less access to care to take advantage of preventive health care strategies.”

While having a job is better than unemployment, having less than a high school education makes a person more likely to work jobs with lower wages, resulting in only being able to afford living in areas that are more impoverished and have less infrastructure to support healthy behaviors, such as grocery stores with fresh produce, Braveman said.

The stress of chronic unemployment or underemployment can also raise levels of the hormone cortisol and other hormones in the body, which over time can wreak havoc on organs and result in chronic diseases such as heart disease and diabetes, she said.

In addition, lower-paying jobs may be accompanied by fewer benefits, such as a lack of paid sick leave, less room for advancement, and work in areas with a higher risk of occupational injury, according to a Robert Wood Johnson Foundation Commission issue brief.

Addressing social determinants of health is a focus of APHA’s growing movement, Generation Public Health. APHA is encouraging advocates to work together on issues such as education, income mobility, community design and social justice. Find out more at [www.apha.org/healthiestnation](http://www.apha.org/healthiestnation).

To learn more about public health and social determinants, visit [www.cdc.gov/socialdeterminants](http://www.cdc.gov/socialdeterminants). For more on Healthy People 2020’s role, visit [www.healthypeople.gov](http://www.healthypeople.gov).

*For more information on social determinants of health, including a new infographic on how education can influence health, visit [www.thenationshealth.org/sdoh](http://www.thenationshealth.org/sdoh).*

*   Copyright The Nation’s Health, American Public Health Association