Transcript of interview with Paula Braveman, MD, MPH, director of the Center on Social Disparities in Health at the University of California-San Francisco
Interview conducted by Natalie McGill, reporter for The Nation’s Health newspaper. Listen to this interview as a recording on our podcast page.
You authored an issue brief for the Robert Wood Johnson Foundation on Education and Health that said education affects health in three big ways: health knowledge and behaviors, employment income, and social and psychological factors. As far as health behaviors, what lessons or skills are people learning in the classroom that influence the decisions they make about their health in adulthood?
It's great that you've asked about lessons or skills because I think that there's very good reason to believe that the most important thing for health later are the skills that people acquire in the classroom rather than any particular fact or piece of knowledge that they learn.
And it's the skills that enable us to get decent jobs that pay a decent income, that come with the kind of benefits like health benefits and paid sick leave, maternity leave, and that let us be able to afford renting or buying a home in a neighborhood. That kind of health promoting characteristics let us be able to afford buying a nutritious diet.
It's a, you know, there's a long list of those advantages that come with higher income or at least adequate income as an adult. And education for the vast majority of the population, except for a few very, very wealthy people who have inheritage wealth, for the rest of us, it's our education that's going to determine our access to the jobs that determine our access to a standard of living that will promote health.
What are the ways a parent's education level can influence a child's health and perhaps ultimately their adult health?
Well, there's tremendous influence of a parent's education on a child's health.
We looked at data from the National Center for Health Statistics, and looked at the relationship between parents' educational attainment and children's health, as reported by the parents, which is an imperfect measure, admittedly. But, it has been found to correlate well enough with clinical assessments that it's very, very widely used.
And what you find when you look at educational attainment in relation to children's health, is that the children whose parents haven't finished high school are about six times as likely to be in poor or fair health as children — as the children of college graduates. We could go through a number of other health indicators in addition to this one that would underscore how important the parent's education is for the children's health.
But for example in speaking about whether it just makes sense that parents' education could affect children's health.
If you just think about it a little, the parents who are -- who have a higher level of education are much more likely…to be reading to them, doing the things we know promote the children's development. And child development then is strongly linked with their health in adulthood. Educational levels are also connected with disciplinary styles of parents. With the less educated parents tending to have a more authoritarian disciplinary style, which has been associated with poor development of children and plays out in terms of poor health later.
The social connections of the parents who are educated, maybe those that give a, you know, a tip about a good job that's to be had.
The parent's education is the big driver of the parent's income level and the income level is what determines the ability to buy or rent a home in a health promoting neighborhood where that child is experiencing safe recreational activities, less exposure to crime, less exposure to the kind of role models who we don't want them exposed to and more exposure to the role models that we want them exposed to. So, there are just all of these ways and I think they're pretty well supported in the literature. But, you have to connect the dots.
Research shows high school graduation rates are a strong indicator of future health for many reasons. Namely it's linked to employment. But dropouts are an issue and are especially prevalent among many minority groups. So, what are some of the key barriers that young adults face that makes dropout a possibility?
Well, I would say that one of the biggest barriers is a lack of hope. And if you're growing up in a community where you see that everyone like you ends up going to jail or being involved in crime, whether or not they actually go to jail, or not going to jail or involved in crime, but just desperately poor and constantly struggling to live — what that does to your sense of optimism about the future and hope. And if you don't have optimism and hope, there's not really much reason to avoid smoking and other behaviors that we know threaten health.
There have been studies done that have shown that a lot of kids growing up in very poor neighborhoods don't think they're going to survive beyond their 20s because they've seen so many of their peers die or be incarcerated.
Having the resources to lead a life that would let you incorporate healthy practices is also very important. And do you know there have been studies that show that one of the effects that indicate -- that one of the effects of education on health may very well go through how it makes us feel in relation to others in our society. And do we feel like we're at the bottom of the heap? Or are we at a decent level, somewhere there on the middle rung of the ladder or above?
Where we see ourselves in a social hierarchy seems to be strongly associated with health even after we take into account the "objective" measure of where we are in a social hierarchy, which would be like years of education or levels of education and income and the professional, that blue versus white collar status of our work.
So, I think there are just many, many ways in which the high school -- even a high school dropout can affect health. And an obvious one is the inability to get a decent job with decent benefits. Then again, along these long chains are these dots that have to be connected. If you can't get a decent job with decent pay and benefits, then that puts you at risk for a number of conditions that are either outright health damaging, or at least don't promote health.
Having less then a high school education can make it harder to get a job or more likely that you'll have one that's low pay or high stress. But what effects do unemployment and underemployment have not only on physical, but psychological health?
Yes, there is some decent evidence of physical health effects of unemployment. I think the evidence is a bit more consistent and stronger on the mental health side and particularly depressive symptoms and depression. And it puts terrible strains on families, which then increases the stress level.
There's no question that unemployment and underemployment are stressors. And we have — we've made big leaps in our understanding of how stress influences health just over the last 15 to 20 years I'd say most of this knowledge comes from the field of neuroscience.
But, at that this point, I think we understand a lot about how stress how -- how it takes its toll on both mental health, but particularly on physical health.
And so, it is in ways that probably they don't play out over just a year or two. It, you know, probably doesn't play out for 20 years.
What we know about the physiology of stress is how, okay, one part of our brain registers the fact that we're stressed. And then that part of the brain sends a signal to another part of the brain, which sends the signal to our adrenal glands.
And our adrenal glands pump out cortisol and other substances, which for a short-term exposure are probably not unhealthy at all. And they even maybe health promoting.
But, it's when there's a chronic exposure to stress and then a chronic exposure of multiple organs and systems not only to cortisol but other hormone and other kind of chemical messengers in the body, that's when it looks like there's a terrible toll that's taken. And it leads to chronic disease in adulthood and premature mortality. But, this takes decades to play out. So, it's very hard to make the connection.
One of the last big ways you said education influences health is through social and psychological factors. How can education equip you to feel in control about your life course and where you rank in society?
Okay, I think that this is a very important issue to look at in understanding how education can influence health. The more we have of this, the more we feel that we have knowledge and the more skills that we've acquired in reasoning, critical thinking, and maybe most importantly, the more recognition we get as having, you know, having good reasoning power and being in control.
That there's a lot of literature, from the education field of course, linking educational attainment with something that can be called empowerment. There's a huge literature linking educational attainment with self-efficacy. And there is a huge literature linking empowerment with healthy behaviors. And the thinking is that the more we feel that we are able to control what happens to us in our lives, the more able we are to adopt healthy behaviors. And to maintain those healthy behaviors. And the more able we are to discontinue unhealthy behaviors that we have. But, if you don't have -- if you don't have a sense that you're in control, you don't feel efficacious in your self. That's a huge risk factor for having unhealthy behaviors.
The issue brief said that closing the gaps in educational attainment is key to reducing health disparities. What must public health practitioners and policymakers focus on to close these gaps across the life span?
If policymakers want to address health disparities and improve the health of the entire population, they need to focus on education, education, education. Public health practitioners could play a role here. And I think it's by as advocates for the need for investment in education and always speaking to the likely health benefits of that.
I was a part of a study that was done, the Institute of Medicine, now called the National Academies of Medicine, conducted a study, it was commissioned by NIH. The report was released in 2013. And what we were asked to do was to speak to the U.S. health disadvantage in relation to other affluent countries. And there had been evidence for a while that we ranked at or near the bottom on the -- on infant mortality and at or near the bottom among other affluent countries on life expectancy.
So our charge was to answer the question, is this across all age groups, this U.S. health disadvantage? And does it apply across a broad array of health indicators? Or is it limited?
And it was really — it was shocking, because we looked at over 100 health indicators across the entire life span. And the U.S. was the, you know, lowest on the list or within a couple of rungs, you know, low on the list for almost everything. And we did conclude that no one factor was probably the explanation. It was probably a lot of things. But, educational levels we thought were a very, very likely contributor. One out of every seven U.S. adults is illiterate. And the estimate is that the, you know, many more, a much higher percentage then that really can't read very well at all. So, it's not only that they can't read the informational leaflets that we give them in the health field, and they can't read the medication instructions. It's that they can't get decent jobs, you know, with decent benefits. Those benefits are just provided to people across the board in these other affluent nations as opposed to being tied to your getting not only a job, but a good job.
We came to believe that education was very, very likely a major piece of the puzzle. Not the only one, but that it's crucial. And if we want to see improvements not only in closing the gap of health disparities, by disparities by income and by race or ethnic groups, if we want to see a lifting up the average level of health in this country, we're going to have to do a whole lot better at education.