IJE Advance Access originally published online on March 22, 2006
International Journal of Epidemiology 2006 35(2):466-467; doi:10.1093/ije/dyl040
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Commentary |
Commentary: Childhood education and disparities in adult health—the need for improved theories and better data
Department of Mental Health, Institute of Applied Health Sciences, University of Aberdeen, Forresterhill, Aberdeen, AB25 2ZH, UK.
E-mail: l.j.whalley{at}abdn.ac.uk
Contemporary theories of social inequalities in health seek to elucidate the core principles determining disease distributions and individual susceptibilities to specific disorders. An extensive literature supports the roles of specific insults and buffers, each derived from careful observational studies, many of which reliably identify associations at a population level between specific factors and disease incidence. Amongst these factors, many acting and interacting in complex ways at multiple levels, the role of childhood education (gauged by duration or attainment) is consistently shown to be a major and pervasive influence on health inequalities.1 The influence of education, in some studies, acts independently of socioeconomic status and initial intelligence.2,3 Thus, there seems to be some aspect of education that uniquely captures individual differences not detected by other means. The predictive power of ‘education’ is a key fact in social epidemiology requiring exploration and analysis. Two questions press those who work in this area: what aspect of individual differences is approximated by the variable ‘education’? And why should this predictive power of education be so constant over time and between cultures?
Education does not stand alone among the many influences on childhood development. It is closely related to other powerful formative influences on the acquisition of later health-related behaviours through imitation and peer group pressures to adult understanding and acceptance of health education. These pressures can be both positive and negative. Amongst the latter, social disadvantage, poor social support, and inferior social position may steer children along one of the many pathways to poor health from childhood adversity to adult disease. Alone or together, diversity of these positive and negative influences presents considerable challenges to understanding disparities of health.
Identification and quantification of the role of education may resolve some of these problems. Exposure to education can be judged by its duration and by its effectiveness in terms of educational goals achieved. The philosophical foundations of educational systems are not, however, immune to major social and political change, and throughout the 20th century these foundations were affected by the powerful arguments of educational theorists.4 When the content and purpose of childhood education may have changed so substantially over time, study of adult health in those whose education differs markedly from what is currently provided following contemporary guidelines might seem almost archaic or even purposeless, offering no fresh insights into the determinants of disease.
Nevertheless, study of the effects of education on disparities in health remains compelling to epidemiologists largely because the consistency of its associations with health seem so robust and its principal components remain relevant to causal psychosocial theories of disease.5 Perhaps too, because the content of education, its delivery, and academic effectiveness were all so carefully recorded and archived. When the identity and type of school is known, when the school is associated with specific locality-based levels of material deprivation or advantage and the achievements of its pupils are in the public record, then it seems potentially informative to make comparisons between schools in terms of their associations with later adult health. If individual schools could be associated with different adult health outcomes, then this might facilitate the identification within the broad term ‘education’ the most influential of its components.
This was the purpose leading to the paper in this issue of the Journal by Dundas et al.6 Their aim was to examine whether different primary schools (where Scottish children were educated from age 5 to 12 years) differ in terms of adult health outcomes or behaviours.
Although simple comparisons seem useful, Dundas et al. also considered whether any differences might be explained by differences in school composition or by factors present in adulthood, which might also be associated with different types of primary school (for example, material advantage). These aims reflect our need to know in contemporary terms whether schools cause specific types of disease (for example substance misuse) or prevent it. If schools differed in these ways, then it might provide fertile ground on which to identify the psychosocial insults and buffers provided by some schools that are open to modification and later inform educational policy.
Dundas et al. could not relate the type of primary school attended to later adult health and this is an important but puzzling negative finding. First, it points to the need to consider how the opportunities to conduct this type of research between places and times might be better exploited. Second, it asks if factors specific to Aberdeen might have reduced the likelihood of detecting associations between school type and adult self-reported health. The most obvious difference between Aberdeen and other seaports in decline is the rapid economic growth experienced in the Aberdeen following the discovery of major oil deposits in the Northern North Sea. This discovery coincided with the majority of the children of the fifties entering the adult workforce and may have been a sufficiently powerful influence to reduce health differences between adults who had attended different schools.
Underlying apparently simple questions of the type addressed by Dundas et al. are more complex issues concerning the nature of educational systems, the extent to which economic and political influences on education create or reduce particular tensions between individuals in terms of later economic status and social privilege, which, in turn, may be fundamental causes of disparities in adult health.7 Against such possible roles of social systems (including education) in the production of disease must be set the recognition that some schools take great pride in the development of an individual sense of responsibility. This will include a child becoming informed about and able to choose honest and healthy lifestyles and so enjoy better health. Were these factors important in Aberdeen in the 1950s? And if so, could schools be shown to differ in the ethos underpinning the development of individual children? Like other Scottish children of the time, their education was supported by public commitment to a vision of social justice widely accepted after the Second World War, which had become firmly allied to concerns about social equity and to public health, well established in the Scottish socialist tradition, the then predominant Scottish political standpoint.
Post-war Scotland was materially disadvantaged; rationing as in the rest of the U K remained in force and what few luxury goods were available were difficult to obtain. The children of the fifties studied here were yet to experience the rapid economic growth enjoyed in Aberdeen in the latter part of the 20th century. Many were more than 20 years old before the relative material disadvantages of Aberdeen were reversed by the exploitation of North Sea oil, substantial local economic growth, and huge improvements in employment opportunities. After the discovery of oil, the population decline in Aberdeen was reversed (outward migration slowed quickly). There were dramatic increases in the total of economically active individuals so that unemployment rates that, before the discovery of oil, had been higher than the Scottish national average fell to 50% of that average in subsequent decades.8
Taken together, economic growth may be sufficient to ameliorate many other economic-related factors that influence health, possibly through opportunities to make good earlier educational disadvantage, enter new trades, or acquire new work skills.9 Better theories of social inequality would help identify important influences on the association between education and health. These might place observations within frameworks as diverse as public policy in education and contrast these with current emphases on the development of individual responsibilities for matters of personal health. Such diverse theoretical frameworks might produce improved research designs that would allow us to evaluate critically the complex interconnections between social experience and biological status. When set in the context of a life course approach to the production of disease, this might produce better theories that combine social and biological observations on disease distribution. Such a contention makes the production of improved theories a necessary pre-requisite of better research design. Through these means, determinants of the association between education and inequalities of health might be better understood or even ameliorated. Potentially, the Aberdeen children of the fifties may help test the assumption that economic growth determines health.
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1 Huisman M, Kumst AE, Bopp M, Borgan JK, Borrell C, Costa G et al. Educational inequalities in cause specific mortality in middle-aged and older men and women in eight western European populations. Lancet 2005;365:493–500.[Web of Science][Medline]
2 Gottfedson LS. Intelligence: is it the epidemiologist's elusive "fundamental cause" of social class inequalities in health? J Pers Soc Psychol 2004;86:174–99.[CrossRef][Web of Science][Medline]
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4 Hirst P, Carr W. Philosophy and education—a symposium. J Philos Educ 2005;39:No 4.
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6 Dundas R, Leyland AH, MacIntyre S, Leon DA. Does the primary school attended influence self-reported health or its risk factors in later life? Aberdeen Children of the 1950's study. Int J Epidemiol 2006;35:458–65.
7 Krieger N. Theories for Social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol 2001;30:668–77.
8 Kemp A, Smith F. North Sea Oil and the Aberdeen economy in retrospect. In Starkey DJ, Hahn-Pedersen M (eds). Concentration and Dependency: The Role of Maritime Activities in North Sea Communities. Esbjerg, Denmark: Fisheries and Maritime Museum, 2002, pp. 281–305.
9 Houweling TAJ, Kunst AE, Borsboom G, Mackenbach JP. Mortality inequalities in times of economic growth: time trends in socioeconomic and regional inequalities in under five mortality in Indonesia, 1982–1997. J Epidemiol Community Health 2006;60:62–68.
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