Educational Disparities in Adult Disability: Person, Place, Policies, and Family

Declines in functioning, both mental and physical, and subsequent inability to live independently are key concerns of older people as they age. Over the past few decades, the United States and the United Kingdom have seen increases in the prevalence of mild disability, especially among women, leading to reductions in years spent disability-free.^1,2 In addition to this overall worsening situation, socioeconomic disparities in disability remain large in both countries.

At a national level, the United Kingdom has tended to use occupation- or neighborhood-based measures to explore differences in health and disability between socioeconomic groups; however, education, which generally changes little after early adulthood, suffers less from reverse causation. Nevertheless, there is a strong correlation between education and both middle- and later-life socioeconomic status measures given that increased education leads to greater job opportunities and higher incomes, as well as healthier lifestyles and better health outcomes.

Over the past two decades in England, the change in the compulsory school-leaving age from 14 years to 15 years and greater opportunities for university education have resulted in decreases in the prevalence and incidence of dementia³ and a real reduction of years with cognitive impairment among women² in more older, recent cohorts. Furthermore, education was the sole socioeconomic measure differentiating disability pathways among individuals aged 85 to 90 years in the Newcastle 85+ Study.⁴

PLACE

If there is evidence for the far-reaching effects of education through to very old age, it seems obvious that we have to maximize educational opportunities for all individuals. However, education is not only executed at an individual level. In this issue of AJPH, Montez et al. (p. 1101) demonstrate that, across the United States as a whole, gaps in disability prevalence between individuals at low and high levels of education are wide, varying from 12 to 20 percentage points across states. Individual-level factors such as race and poverty explain approximately 13% of this variation, with a further 16.5% being explained by two wider contextual factors relating to an individual’s local area: the percentage of low-educated residents and the percentage of residents living below the poverty line.

Montez et al. found that, among those with a university-level education, where they lived had little impact on their probability of disability at the age of 65 years. However, the probability of disability among those with no high school education varied from less than 0.15 (in North Dakota) to 0.23 (in Wyoming). That the probability of disability among low-educated North Dakota residents was on a par with that among residents in other states with a high school education or some college education was even more telling.

These findings concur with the World Health Organization’s view of how healthy aging plays out and how environmental factors may interact with people’s intrinsic capacity “to be and to do what they have reason to value.”⁵ Education may appear in multiple places in this process. Innate educational ability could be thought of as part of a person’s intrinsic capacity. Education may also act through improving economic circumstances, providing psychosocial resources, and increasing the likelihood that people will act on healthy lifestyle advice. At a higher level, initiatives that encourage more young people from low-income families to attend universities (and facilitate their doing so) represent an enabling extrinsic or environmental factor. Such initiatives are already being played out at the local and state levels in the United States.

RAISING EDUCATIONAL LEVELS

Montez et al. suggest three strategies for reducing socioeconomic disparities in adult health and disability: raising educational levels, reducing poverty in low-educated adults, and targeting areas and communities of socioeconomic disadvantage. Raising educational levels per se does not necessarily improve adult disability outcomes unless other measures are put into place that allow individuals to use their improved education (e.g., measures that expand job opportunities).

In our first comparison of healthy life-years (disability-free life expectancy) across the 25 countries of the European Union in 2005, my colleagues and I found that level of education (assessed according to the percentage of the population aged 25–64 years with at most a lower secondary education) was negatively associated with number of healthy life-years at the age of 50 years among men and that numbers of healthy life-years were lowest in countries with higher percentages of low-educated residents.⁶

When we analyzed the original and new member states separately, the relationship was positive in the 10 new member states; individuals in these countries, which had smaller percentages of low-educated residents, had the fewest healthy life-years. This at first sight seems contradictory; however, in these previously communist countries, although education itself was valued and available to all, the ability to translate this circumstance into better jobs and higher incomes was lacking.

REDUCING POVERTY IN LOW-EDUCATED ADULTS

Perhaps the most important strategy is to ensure that individuals better recognize the link between education and job opportunities, higher incomes, and health. Although these links might seem obvious, to many with low education they are not, as they see only their families and friends also struggling on the poverty line. Strategies such as providing greater job opportunities, reducing neighborhood segregation, and offering incentives for businesses to locate in disadvantaged areas are all likely to help; however, there is also a need for better career mentoring and neighborhood advocates who have succeeded in breaking the cycle.

Unfortunately, proper evaluations of community programs are rarely thought of when schemes are being developed and put into place, including those initiated at the governmental level, and they are much more likely to be process evaluations than true outcome evaluations. The gold-standard randomized controlled trial is not usually appropriate or feasible in these settings; other designs can be employed, however, and we must encourage greater use of them to enable the evidence base to be built more rigorously.

THE ROLE OF FAMILY

Finally, educational attainment is influenced both positively and negatively by parents as well as peers and current policies. For many, low education is passed down through the generations. Some parents who did not benefit themselves from higher education do provide opportunities for their offspring, and the benefits are seen not only in the health of their offspring but also in their own aging, with lower levels of functional limitations and mortality linked to unhealthy lifestyles.⁷ Thus, an intergenerational approach to reducing social disparities in health over the life course, rather than simply an individual, local, or state approach, is necessary.