The relative importance of education and health behaviour for health and wellbeing

BACKGROUND

Indicators of socioeconomic position (SEP) and health behaviours (HB) are widely used predictors of health variations. Their relative importance is hard to establish, because HB takes a mediating role in the link between SEP and health. We aim to provide new knowledge on how SEP and HB are related to health and wellbeing.

METHODS

The analysis considered 14,713 Norwegians aged 40-63. Separate regressions were performed using two outcomes for health-related quality of life (EQ-5D-5 L; EQ-VAS), and one for subjective wellbeing (Satisfaction with Life Scale). As predictors, we used educational attainment and a composite measure of HB - both categorized into four levels. We adjusted for differences in childhood financial circumstances, sex and age. We estimated the percentage share of each predictor in total explained variation, and the relative contributions of HB in the education-health association.

RESULTS

The reference case model, excluding HB, suggests consistent stepwise education gradients in health-related quality of life. The gap between the lowest and highest education was 0.042 on the EQ-5D-5 L, and 0.062 on the EQ-VAS. When including HB, the education effects were much attenuated, making HB take the lion share of the explained health variance. HB contributes 29% of the education-health gradient when health is measured by EQ-5D-5 L, and 40% when measured by EQ-VAS. For subjective wellbeing, we observed a strong HB-gradient, but no education gradient.

CONCLUSION

In the institutional context of a rich egalitarian country, variations in health and wellbeing are to a larger extent explained by health behaviours than educational attainment.

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway

BACKGROUND

The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. efforts that - to varying extents - are within one's control. From the perspective of IOp, this paper aims to explain variations in individuals' health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents' health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents' wealth is indicated by childhood financial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an effort, and examine associations of IOp for different health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specific HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression).

METHOD

We use unique survey data (N = 20,150) from the egalitarian country of Norway to investigate if differences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifications. The first represents a narrow IOp by estimating the contributions of parents' health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an effort variable and the two sets of circumstance variables.

RESULTS

We find strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents' anxiety and depression. Our Shapley decomposition analysis suggests that parents' health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL.

CONCLUSION

We provide evidence for the presence of the lasting effect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities.

Childhood Circumstances and Health Inequality in Old Age: Comparative Evidence from China and the USA

This paper estimates the extent to which childhood circumstances contribute to health inequality in old age and evaluates the importance of major domains of childhood circumstances to health inequalities in the USA and China. We link two waves of the China Health and Retirement Longitudinal Study in 2013 and 2015 with the newly released 2014 Life History Survey, and two waves of the Health and Retirement Study in 2014 and 2016 with the newly released 2015 Life History Mail Survey in the USA, to quantify health inequality due to childhood circumstances for which they have little control. Using the Shapley value decomposition approach, we show that childhood circumstances may explain 7-16 and 14-30% of health inequality in old age in China and the USA, respectively. Specifically, the contribution of childhood circumstances to health inequality is larger in the USA than in China for self-rated health, mental health, and physical health. Examining domains of childhood circumstance, regional and rural/urban status contribute more to health inequality in China, while family socioeconomic status contributes more to health inequality in the USA. Our findings support the value of a life course approach in identifying the key determinants of health in old age. Distinguishing sources of health inequality and rectifying inequality due to early childhood circumstances should be the basis of policy promoting health equity.

Explaining subjective social status in two countries: The relative importance of education, occupation, income and childhood circumstances

In the literature on social inequalities in health, subjective socioeconomic position (SEP) is increasingly applied as a determinant of health, motivated by the hypothesis that having a high subjective SEP is health-enhancing. However, the relative importance of determinants of subjective SEP is not well understood. Objective SEP indicators, such as education, occupation and income, are assumed to determine individuals' position in the status hierarchy. Furthermore, an extensive literature has shown that past childhood SEP affects adult health. Does it also affect subjective SEP? In this paper, we estimate the relative importance of i) the common objective SEP indicators (education, occupation and income) in explaining subjective SEP, and ii) childhood SEP (childhood financial circumstances and parents' education) in determining subjective SEP, after controlling for objective SEP. Given that the relative importance of these factors is expected to differ across institutional settings, we compare data from two countries: Australia and Norway. We use data from an online survey based on adult samples, with N ≈ 1400 from each country. Ordinary least squares regression is conducted to assess how objective and childhood SEP indicators predict subjective SEP. We use Shapley value decomposition to estimate the relative importance of these factors in explaining subjective SEP. Income was the strongest predictor of subjective SEP in Australia; in Norway, it was occupation. Of the childhood SEP variables, childhood financial circumstances were significantly associated with subjective SEP, even after controlling for objective SEP. This association was the strongest in the Norwegian sample. Only the mother's education had a significant impact on subjective SEP. Our findings highlight the need to understand the specific mechanisms between objective and subjective SEP as determinants of inequalities in health, and to assess the role of institutional factors in influencing these complex relationships.

Adverse childhood circumstances and cognitive function in middle-aged and older Chinese adults: Lower level or faster decline?

We examine the long-term relationship between childhood circumstances and cognitive aging. In particular, we differentiate the level of cognitive deficit from the rate of cognitive decline. Applying a linear mixed-effect model to three waves of China Health and Retirement Longitudinal Surveys (CHARLS 2011, 2013, 2015) and matching cognitive outcomes to CHARLS Life History Survey (2014), we find that key domains of childhood circumstances, including family socioeconomic status (SES), neighborhood cohesion, friendship, and health conditions, are significantly associated with both the level of cognitive deficit and the rate of decline. In contrast, childhood neighborhood safety only affects the level of cognitive deficit. Childhood relationship with mother only affects the rate of cognitive decline. The effects of adverse childhood circumstances are generally larger on level of cognitive deficit than on rate of cognitive decline. Moreover, education plays a more important role in mediating the relationships compared to other later-life factors. These findings suggest that exposure to disadvantaged childhood circumstances can exacerbate cognitive deficit as well as cognitive decline over time, which may be partially ameliorated by educational attainment.

Intergenerational educational mobility and smoking: a study of 20 European countries using diagonal reference models

OBJECTIVES

Intergenerational educational mobility can be particularly relevant for smoking because it implies moving from individuals' family background to a new position in the social hierarchy. Existing research, however, does not provide an answer as to how the process of mobility, per se, is associated with the likelihood of smoking.

STUDY DESIGN

We used cross-nationally comparable survey data for 20 countries collected within the health module of the European Social Survey in 2014. The analytical sample consisted of 22,336 respondents aged 25-64 years.

METHODS

Smoking was operationalized by daily and occasional smoking, while the intergenerational educational mobility variable was derived from a comparison of respondents' and their parents' highest levels of educational attainment. We employed diagonal reference models to examine the association of intergenerational educational mobility and smoking.

RESULTS

In the country- and age-adjusted analysis, intergenerational downward mobility was associated with odds ratios of 1.34 (CI95 1.07, 1.68) and 1.61 (CI95 1.34, 1.93) for smoking, respectively, among men and women. Intergenerational upward mobility, on the other hand, was negatively associated with smoking but only among women.

CONCLUSION

Our findings provide new evidence that the process of intergenerational educational mobility is associated with individuals' likelihood of smoking and that this effect cannot be explained by conventional covariates of smoking.

How community resources mitigate the association between household poverty and the incidence of adverse childhood experiences

OBJECTIVES

To assess what proportion of the association between household low income and incidence of adverse childhood experiences (ACE) would be eliminated if all households had access to housing, transportation and childcare services, breastfeeding counselling, and parks.

METHODS

Using Growing Up in Scotland birth cohort data (N = 2816), an inverse probability-weighted regression-based mediation technique was applied to assess associations between low-income status (< £11,000 in 2004/5), resource access, and cumulative 8-year ACE incidence (≥ 1, ≥ 3 ACEs). Resource access was measured based on households' self-reported difficulties (yes/no) in accessing housing, transportation, childcare, and breastfeeding counselling, and park proximity (within 10 min from the residence).

RESULTS

The protective effects of resources were heterogeneous. Only access to transportation was associated with lower ACE incidence in both low- and higher-income households. If all had access to transportation, 21% (95% CI 3%, 41%) of the income-based inequality in incidence of 3 or more ACEs could be eliminated.

CONCLUSIONS

While second best to the elimination of child poverty, measures to improve families' access to community resources such as transportation may mitigate the effects of poverty on ACE incidence.

Growing up in wartime: Evidence from the era of two world wars

We document the association between war-related shocks in childhood and adult outcomes for Europeans born during the first half of the twentieth century. Using a variety of data, at both the macro- and the micro-level, we address the following questions: What are the patterns of mortality among Europeans born during this period? Do war-related shocks in childhood and adolescence help predict adult health, human capital and wellbeing of the survivors? Are there differences by sex, socio-economic status in childhood, and age when the shocks occurred? At the macro-level, we show that the secular trend towards lower mortality was interrupted by dramatic increases in mortality during World War I, the Spanish Flu, the Spanish Civil War, and World War II, and we quantify the size of these mortality shocks. Different patterns characterize these high-mortality episodes, with substantial variation by country, sex and age group. At the micro-level, we show that war-related hardship in childhood or adolescence, in particular exposure to war events and experience of hunger, is associated with worse physical and mental health, education, cognitive ability and subjective wellbeing at older ages. The strength of the association differs by sex and type of hardship, with war exposure being more important for females and experience of hunger for males. We also show that hardships matter more if experienced in childhood, and have stronger consequences if they last longer.