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What is it about education that makes us healthy? Exploring the

education-health connection
Cathie Hammond

To cite this Article Hammond, Cathie(2002) 'What is it about education that makes us healthy? Exploring the education-
health connection', International Journal of Lifelong Education, 21: 6, 551 — 571
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 INT. J. OF LIFELONG EDUCATION, VOL. 21, NO. 6 (NOVEMBER–DECEMBER 2002), 551–571

What is it about education that makes us healthy?

Exploring the education–health connection

CATHIE HAMMOND
Wider Benefits of Learning Research Centre, London, UK

Reviews of the evidence conclude that correlations exist between measures of education and
physical health and that a substantial element of this correlation results from the effects of
learning upon health. Closer examination reveals that the correlations between education and
health change across levels of education, and depend upon when during the life course
education is experienced, the type of health condition and the national context. The purpose
of this paper is to investigate these variations with a view to developing fuller understanding of
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the mechanisms through which learning affects physical and psychological health. Such an
understanding throws light upon the importance of context in relation to the impacts of
education upon health.

Correlations between education and physical health are more consistently found
amongst older adults. There is evidence that education affects the adoption of
health behaviours, and the interaction of the education–health correlation with
age reflects (in part at least) the cumulative risk that many health behaviours
carry. Health behaviours are adopted through processes of awareness raising,
empowerment and socialization. These processes also contribute to the
development of resilience. This is reflected by correlations between education
and lower rates of depression. Learning appears to play an important role in the
rehabilitation of people with mental health problems, and is especially
empowering at times of change in peoples’ lives.
Some studies report negative correlations between education and health. For
example, education and poorly understood conditions appear to be positively
associated. It is suggested that this reflects a bias in attribution of symptoms and
diagnosis, and a more general inequality in access to health services favouring
more educated individuals. This effect of education benefits individuals, but does
not benefit health at the community level. Findings that some neurotic disorders
are positively associated with education, and that education above intermediate
levels is not always associated with positive health outcomes raise issues about the
importance of the educational and national contexts in which people learn. It is
argued that in contexts that foster competition and lack social cohesion,
education can be harmful as well as beneficial to health at collective and

Cathie Hammond is a research officer at the Wider Benefits of Learning Research Centre. Publications include
Learning to be Healthy (London: Institute of Education, 2002) and with John Preston The Wider Benefits of Further
Education: Practitioner Views (London: Institute of Education, 2002).

International Journal of Lifelong Education ISSN 0260-1370 print/ISSN 1464-519X online # 2002 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/0260137022000016767
 552 CATHIE HAMMOND

individual levels. In contrast, education that takes place within a context of co-
operation, integration and challenge is empowering and promotes social cohesion.

Introduction

The government’s Green Paper entitled ‘The Learning Age’ (DfEE 1998, para. 8)
sets out the British government’s vision for learning:

Our vision of the Learning Age is about more than employment. The
development of a culture of learning will help to build a united society,
assist in the creation of personal independence, and encourage our
creativity and innovation.

This vision is complemented by investment in major programmes by the

Department of Health and Department for Education and Skills, which strive to
improve health at individual and community levels through community
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regeneration, involving educational interventions. Examples are the

establishment of Health Action Zones, Health Improvement Projects and the
National Healthy School Standard. It is in this context that this paper seeks to
explore what is already known about correlations between education and
psychological and physical health outcomes.
Almost all of the quantitative studies reviewed here use years of education or
highest qualification gained as measures of education. Such measures limit the
scope of this discussion because they do not refer to informal and non-accredited
learning. Consequently, the title of this paper refers to education rather than the
broader concept of learning. Below, the terms education and learning are used
interchangeably, but usually refer to learning at the formal end of the spectrum.
Numerous reviews have assessed the evidence for a correlation between levels of
education and physical health outcomes and concluded that the evidence is
consistent and robust (e.g. Grossman and Kaestner 1997, Hartog and Oosterbeek
1998, Ross and Mirowsky 1999). Evidence for the correlation has been found
worldwide and amongst individuals of different ethnic groups, ages and incomes.
Some of the evidence is summarized in table 1. The findings are more striking
when one considers that the magnitude of identified correlations between (more)
learning and (better) health are probably underestimates of those that exist. This
is because lower levels of education appear to be associated with the under-
reporting of illness by patients (Mackenbach et al. 1996).
The observed positive correlations between education and health can be
explained in three ways. First, individuals with better health may have a tendency
to continue learning for longer. Second, one or more factors, for example family
structure, income or parental levels of education may affect both education and
health outcomes. The third explanation is that increases in schooling result in
improvements in health. The three explanations are illustrated in figure 1.
Grossman and Kaestner (1997) and Hartog and Oosterbeek (1998) review the
relevant research and conclude that each of these explanations contributes to the
observed correlation between education and physical health, but that the effect of
learning upon health plays a major role. However, the mechanisms through
which education affects health are not altogether clear. One source of evidence
 THE EDUCATION–HEALTH CONNECTION 553

Table 1. Summary of the evidence for a correlation between (more)

education and (better) physical health in different countries
Geographical locations where
correlations found References to studies
Worldwide McMahon (1999)
Developing countries World Bank (1993), Rodrigues-Garcia
and Goldman (1994)
Throughout the USA Desai (1987), Gilleskie and Harrison
(1998), Pappas et al. (1993), Ross and
Mirowsky (1999)
Canada Veenstra (2000)
Quebec Noreau et al. (1999)
Australia National Health Strategy (1992), Benze-
val et al. (1995), Mitchell et al. (1997)
Italy Piperno and Di Orio (1990), Benzeval et
al. (1995), Varenna et al. (1999)
Britain Montgomery and Schoon (1997)
The Netherlands Mackenbach (1993), Benzeval et al.
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(1995)
Sweden Wamala et al. (1999)
Finland Valkonen (1993), Benzeval et al. (1995),
Sihvonen et al. (1998)
Norway Sihvonen et al. (1998)

that may throw light upon them is how the correlations between measures of
education and health vary in different contexts. For example, how do the
magnitudes of correlations change depending upon attributes of the learner, such
as their previous educational and health status, their socio-economic status (SES),
age, sex and ethnic background? Are correlations between learning and health
always positive? What are the patterns of correlations for different types of
learning experience? How do they vary with the social and political contexts in
which learning takes place? And what are the different correlations between
learning and different health conditions, including psychiatric conditions?
This paper reviews some of the studies that indicate how education–health
correlations change with some of these variables and discusses the implications.
The next section presents evidence indicating how correlations between
education and health vary. There follows discussion of the ways in which these
variations reflect and contribute to understandings of the processes through
which education affects health, and the importance of context upon the impacts
of education. The final section presents conclusions and discusses policy
implications.

Variations in the magnitude and direction of the correlation

between education and health

Correlations between education and different health conditions

Many of the studies that report evidence for a correlation between (more) education
and (better) physical health use national morbidity and mortality rates as measures
 554 CATHIE HAMMOND
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Figure 1. Three explanations for the observed positive correlations

between education and health.

Table 2. Summary of the evidence for correlation between education and a

range of health conditions amongst different groups of individuals
Health outcomes that
correlate with education
Mortality rates and self-rated
health
Self-rated health and number
of days off work due to sickness
Self-rated general, physical
and mental health
Coronary heart disease
Alzheimer’s disease
Chronic fatigue
Chronic fatigue
Rates of depression
Rates of depression
Post-natal depression
Suicide attempts
Suicide attempts
Groups of individuals
amongst whom the
correlation was found References to studies
High-income group white Grossman (1975)
males in USA
Low-income working males in Desai (1987)
the USA
Men and women aged 50–94 Mitchell et al. (1997)
in Australia
Adult women in Sweden Wamala et al. (1999)
Elderly community residents Breitner et al. (1999)
in Utah, USA
USA Valdini et al. (1987)
USA Clark et al. (1995)
Cohort born in Britain in 1970 Montgomery and
Schoon (1997)
Frail elderly living alone in Burnette and Mui
the USA (1994)
Mothers in Peru Vega Dienstmaier
et al. (1999)
Young adults living in rural Ferrero et al. (1994)
and urban areas of Spain
Community sample of older Andrews and
adolescents in the USA Lewinsohn (1992)
 THE EDUCATION–HEALTH CONNECTION 555

of physical health. Others suggest correlations between (more) education and

(reduced) risks of specific health disorders, including depression. Details of some
relevant studies are summarized in table 2. For a fuller review of this evidence,
see Hammond (2002).
On the other hand, the evidence relating to the connections between learning
and anxiety disorders is inconsistent. Associations between years of schooling and
lowered rates of anxiety and phobic disorders have been reported in Amsterdam
and Iceland (Beekman et al. 1998, Arnarson et al. 1998, respectively). In contrast,
Benham and Benham (1982) report findings based on survey data of individuals
born in St Louis (USA) in the 1910s and 1920s that those with more schooling
were more likely to suffer from neuroses than their less educated counterparts. It
also appears that eating disorders are more prevalent amongst those with more
education (Toro et al. 1995, Westermeyer and Specker 1999).
Numerous studies of the epidemiology of chronic fatigue syndrome/myalgic
encephalomyelitis (or CFS/ME) suggest that prevalence rates are particularly
high amongst individuals who are more highly educated (Wessely et al. 1998). 1
Similarly, Heinrich et al. (1998) report that allergies are most frequently
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diagnosed in children of parents with higher levels of education.

Correlations between education and health at different stages in the life course

Veenstra (2000) investigated correlations between levels of education and self-rated

health status amongst adults living in Canada. The author found evidence of a
correlation for individuals who were middle-aged and older but failed to find
evidence for the correlation amongst younger individuals. Investigations of the
effects of education upon health using data from nationally representative
longitudinal datasets similarly suggest that the effects of education upon physical
health are more marked amongst older cohorts than they are amongst younger
cohorts (Bynner and Egerton 2001), and have identified primarily psychosocial as
opposed to physical effects in younger cohorts (Matthews et al. 1999).
A slightly different finding from qualitative research, but one that relates to
stages in the lifecourse, is that some individuals find learning particularly
empowering at times of transition (Antikainen 1998). These are times of high
stress relative to periods of stability. Similarly, analyses of British national
longitudinal datasets suggest that associations between higher education and
physical and psychological health are particularly marked for mature students,
for whom the educational experience is likely to represent a discontinuity in the
life course (Bynner and Egerton 2001).

Different levels of education and correlations with health

A study of a Dutch cohort born in 1940 suggests that improving physical health is
correlated with additional years of education up to an intermediate level of
education only. Additional years of education after this level are not positively
correlated with physical health, happiness, or wealth (Hartog and Oosterbeck
1998). For this cohort, the correlation between learning and health appears to be
non-linear.
 556 CATHIE HAMMOND

The importance of context in relation to associations between education and health

Veenhoven (1996) reports that whereas in poor nations the correlation between
more education and greater life satisfaction is positive and consistent, in rich
nations correlations between education and life satisfaction appear to be
weaker, or even non-existent. In addition, Clark and Oswald (1994) analysed
nationally representative British data and found a correlation between higher
levels of education and greater unhappiness amongst those who were
unemployed in 1991.

Implications for our understanding of how education affects

health

The patterns of correlations described above are by no means a full picture. For
example, how do the correlations between education and health change
depending upon the sex or ethnic background of the learner, their social and
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political contexts or the style and content of the learning? It is hoped that these
questions will be tackled in other publications. Nevertheless, the different
magnitudes and directions of the correlations between education and health that
have been identified in the studies reviewed above do beg questions such as why
and what are the implications?
This section comprises a discussion in response to these questions. Much of it is
speculative. The intention is not to provide answers but to raise awareness of certain
issues and to provoke debate. The discussions that follow centre upon the role of
health behaviours, the generation and sustaining of resilience, access to health
services and the importance of context in understanding relationships between
education and health.

The role of health behaviours in mediating effects of education upon health

Health behaviours are behaviours that are thought to have an effect upon health
outcomes. They include smoking, drinking alcohol, consumption of illegal drugs,
exercise, diet, dental hygiene, use of seat belts, use of condoms and adherence to
medical advice. Individuals tend to behave in ways that are in general either
healthy or less healthy—in other words, individuals who smoke are also more
likely to eat a less healthy diet, exercise less often and so on (e.g. Feigelman et al.
1998, Costakis et al. 1999, Kyngas and Lahdenpera 1999, Slater et al. 1999,
Thompson et al. 1999).
It appears that years of education and higher qualifications are associated with
the adoption of health behaviours. This can be explained in a number of ways.
First, background variables such as parental attitudes and family income may
affect both commitment to education and the adoption of health behaviours.
Second, adoption of health behaviours may lead to educational success. Third,
education may influence the adoption of health behaviours. Studies of the health
behaviours of children and adolescents make it clear that for this age group at
least, the relationships between education and lifestyle are complex (e.g.
Provaznikova et al. 1997, Karvonen et al. 1999, Koivusilta et al. 1999, Resnicow et
 THE EDUCATION–HEALTH CONNECTION 557

al. 1999), but that education does appear to play a role in determining the adoption
(or not) of health behaviours.

Health behaviours: variations in the education–health correlation depending upon age

We have seen above that associations between education and physical health appear
to be weaker amongst younger populations than they are amongst older
populations. One explanation is that whereas some health behaviours—such as
not wearing a seat belt or condom—constitute a constant risk to health, other
health behaviours—such as smoking and excessive alcohol consumption—carry a
cumulative risk. This means that although education plays an important role in
the promotion of physical health through health behaviours, these are only
translated into observable physical health outcomes later in life.
Evidence presented in the previous section suggests that the effects of education
upon the health of younger cohorts are primarily psychosocial as opposed to
physiological (Matthews et al. 1999). These psychosocial outcomes affect health
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behaviours. They include the deeply socializing process of education, which

forms norms and attitudes about health and health behaviours; the development
of supportive social networks; empowerment through building up a sense of
personal control and critical awareness; a tendency to think in terms of future
outcomes and behave accordingly (sometimes referred to as future-orientation or
time preference); and awareness of health information. For a fuller discussion, see
Grossman and Kaestner (1997), Mirowsky and Ross (1998), Campbell (2000),
Putnam (2000) and Hammond (2002).

Health behaviours: variations in the education–health correlation depending upon

physical condition

A study of the relationships between education, income, health behaviours, and

health conditions suggests that the extent to which health behaviours account for
associations between education and physical health varies according to the health
condition. Cairney and Arnold (1998) analysed data from the Canadian 1991
general Social Survey on Health using logistic regression techniques and found
that education (having a degree as opposed to post-secondary or only some
secondary education) was correlated with the chances of suffering from a range of
health conditions, even after controlling for income. The extent to which health
behaviours mediated these correlations varied across the condition 2 .
These findings may provide useful insights into the relationships between health
behaviours and health conditions. Of more relevance here is that they highlight the
fact that although education affects health through the promotion of health
behaviours, for many conditions other mechanisms are also involved.

Education, resilience and health

Resilience refers to the dimension of individual difference that spans the ways we
deal with adversity and stressful conditions and how they affect us (e.g. Garmezy
 558 CATHIE HAMMOND

1971, Anthony 1974, Rutter 1990). The personal and social resources that
contribute to the development of resilience in children have been examined
extensively, and the relevant literature is reviewed by Howard et al. (1999). Many
of the social and psychological resources that are believed to contribute to
resilience have been identified in other studies as outcomes of education. They
include self-esteem, self-efficacy, interpersonal trust, empathy, feelings of
connectedness, supportive relationships and broader outlooks. The relationships
between education and these outcomes are discussed more fully elsewhere
(Hammond 2002), but the evidence is summarized here in table 3.
Some attributes—namely, problem-solving skills and a sense of purpose—
contribute to resilience but have not been identified empirically as outcomes
of education. Perhaps this is because they are difficult to measure. However,
authors argue that problem-solving skills and a sense of purpose are likely to
be outcomes of education. For example, Mirowsky and Ross (1998: 417)
suggest that education ‘instills the habit of meeting problems with attention,
thought, action, and persistence. Thus, education increases effort and ability,
the fundamental components of problem solving (Wheaton 1980)’. Becker and
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Mulligan (1994) argue that through the study of history, thinking about
adulthood and imagined scenarios, pupils may learn to think in a more
future-oriented manner.
By definition, an individual with more resilience will experience relatively low
levels of chronic stress in response to a given life stressor. There is considerable
evidence that high levels of chronic stress are damaging in the long term to
physical health. Consequently, it appears that one mechanism through which
learning affects physical health is through developing the resilience of learners.
In addition, resilience protects individuals from the onset and progression of
depression. We have seen that there is robust evidence that individuals with more
education are less likely to have depressive symptoms. Analyses of British
longitudinal datasets suggest that this correlation is at least partly explained by
effects of education upon psychological health (Bynner and Egerton 2000,
Feinstein 2001).
Numerous evaluations and reports indicate that people with mental health
problems experience great personal benefits from learning (Wertheimer 1997),
and some primary care practices have introduced referrals to Community
Adult Education as a prescribable option for treatment (e.g. Wheeler 1999,
James 2001).
There is also evidence that learning is particularly beneficial at stages in the
life course that are characterized by change. At these ‘turning points’, an
individual’s resilience may be of critical importance. For example, Antikainen
(1998) used qualitative biographical techniques to investigate the meaning of
learning experienced by a group of adults in Finland and found that
learning was particularly significant in terms of empowerment for individuals
during times of change, e.g. surviving widowhood, and migration from the
countryside to the city. In addition, Bynner and Egerton’s findings that the
effects of Higher Education upon physical health and malaise are
particularly strong amongst mature students (2000) may reflect the fact that
for many mature students participation in higher education represents a
greater life change than it does for the average 19-year-old who has just left
school.
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Table 3. Details of studies that demonstrate that learning leads to the development of a range of psychosocial resources
Outcome of learning Type of learning provision Details of learners Country Approach used Reference
A new sense of self- Higher education Mature women England Individual depth Cox and Pascall
evaluation and interviews (1994)
individuality
Increased self-esteem ‘New beginnings’ Adults England Interviews and Hull (1998)
courses questionnaires
Coherence Access courses and Adults England Qualitative West (1995)
higher education
Confidence, ability All types Adults aged between England and Survey plus depth Dench and Regan
THE EDUCATION–HEALTH CONNECTION

to cope with Wales interviews (1999)

everyday life
Increased confidence Informal learning Older adults Britain Qualitative Carlton and Soulsby
and self-esteem (1999)
Perceived happiness Current education Older adults US Qualitative Mookherjee (1998)
Increased self-esteem Mentees in Older adults US Self-completion Koberg et al. (1998)
psychosocial support questionnaire
programme
Increased confidence, Courses provided by People experiencing England and Review of various Wertheimer (1997)
empowerment colleges in the mental health Wales studies
community difficulties
Increased confidence, Various Long-term unemployed, Gloucester, Evaluation of a McGivney (1997)
empowerment people with long-term England project
health and disability
problems or mental
health problems,
isolated, elderly
Increased self-esteem Level of previous White and Hispanic US Quantitative: Rini et al. (1999)
education pregnant women interviews and
questionnaires
Increased self- Level of Older people who are US Quantitative using Kubzansky et al.
efficacy, mastery previous physically and cognitively fit in-home interviews (1998)
and happiness education
559

continued
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560
Table 3. continued
Outcome of learning Type of learning provision Details of learners Country Approach used Reference
Empowerment All forms of planned People living in rural and Finland Qualitative Antikainen (1998)
learning urban areas and at biographical
different stages in their lives methods
Social capital Various Various Several Review Glaeser (1999)
Empathy building Mainstream Secondary school students US Analysis of Angell (1983)
and a sense of ‘intermediate’ minutes of
community level meetings
Various People with mental health Great Britain Review Wertheimer (1997)
difficulties
Participation in a People with mental health Great Britain Evaluation of a McGivney (1997)
variety of educational difficulties programme
provision
Community-based High school students US Observation and Ennis et al. (1999)
physical education interviews
programme entitled
‘Sport for Peace’
Connectedness and Attendance at a Older learners Britain Qualitative Jarvis and Walker
a broader outlook summer university (1997)
Participation in a People with mental Britain Evaluation of a McGivney (1997)
variety of educational health difficulties programme
provision
Years of formal Various Various Review Emler and Frazer
education and level (1999)
of attainment
Lower rates of Years of formal Various European Analysis of data Wagner and Zick
ethnic prejudice education countries from Eurobarometer (1995)
using subtle and qualitative
measures
Inter-personal trust Higher education Adults born in 1958 Britain Secondary analysis Bynner and Egerton
(2000)
continued
CATHIE HAMMOND
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Outcome of learning Type of learning provision
Supportive Years of schooling,
relationships college degree,
academic quality of
the school
Table 3. continued
Details of learners Country Approach used Reference
Nationally representative US Secondary analysis Ross and Mirowsky
sample of adults (1999)
THE EDUCATION–HEALTH CONNECTION

Mentoring on a People aged 55+ Netherlands Qausi-experimental Kocken and Voorham

health education evaluation using (1998)
course questionnaire
Higher education Adults born in 1958 Britain Secondary analysis Bynner and Egerton
(2000)
Voluntary activity Higher education Adults Britain Secondary analysis Parry et al. (1992)
Various Various Europe Review Frazer and Emler
(1999)
Political High vs. low Young adults Analysis of Banks et al. (1992)
engagement, activity attainment levels longitudinal surveys
and identity of 15–20-year-olds
Education of Young adults Britain Secondary analysis Bynner and Ashford
parents and of longitudinal (1994)
educational success datasets
before age of 20
Higher education Nationally representative Britain Secondary analysis Bynner and Egerton
sample of adults born in (2000)
1958
561
 562 CATHIE HAMMOND

The effects of education upon access to health services

The observed class gradient in prevalence rates of CFS/ME and allergies may arise
because the conditions are difficult to diagnose. The diagnosis (and treatment) of
these conditions differs from the diagnosis of other conditions in that it relies less
upon observable symptoms and more upon how the patient presents their
experience of the condition to the medical practitioner and how the medical
practitioner interprets the information that is provided by the patient.
Consequently, the patient’s understanding of their symptoms, their ability to
describe these symptoms, their confidence in dealing with the medical
practitioner, and the medical practitioner’s respect for the patient play
particularly crucial roles in the diagnosis of these conditions. Each of these
factors is likely to be affected by the patient’s level of education.
Studies of the epidemiology of CFS/ME that suggest a class gradient in
prevalence rates rely upon samples drawn from hospital clinics (Wessely et al.
1998), in which more educated individuals are over-represented. In contrast,
community-based studies investigating the epidemiology of CFS/ME present a
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different picture, the class gradient being entirely absent (Lawrie and Pelosi
1975, Buchwald et al. 1995, Shefer et al. 1997). Presumably, many individuals
with CFS/ME are receiving inaccurate diagnoses or not receiving any
diagnosis at all. Indeed, there are numerous reports from individuals later
diagnosed to have CFS/ME who were initially given inaccurate diagnoses of
depressive conditions (e.g. ME Association 1998, 1999). Since those with more
education appear to be more readily referred to hospital clinics, as indicated
by the class gradient in clinic-based epidemiological studies, those who are not
referred because they receive inaccurate diagnoses will include a relatively high
proportion of people of lower socio-economic status. A proportion of these
individuals will receive a diagnosis of depression, which may partly account for
the correlation between lower levels of education and higher rates of medically
diagnosed depression.
These correlations between level of education and poorly understood conditions
highlight two important issues. The first is that they are examples of a more general
inequality—that availability of and access to medical care tends to be lower amongst
populations that are more socio-economically deprived. The inequality is
compounded by the fact that these same (socially and economically deprived)
populations are characterized by relatively poor health (e.g. Hart 1971, Saul and
Payne 1997). Studies in Scotland suggest that patients who are socio-
economically deprived are thought to be particularly likely to develop coronary
heart disease and are also less likely to be investigated and treated than their
more socio-economically advantaged counterparts (MacLeod et al. 1999, Pell et al.
2000). 3 The ironic paradox that those most in need of medical support are least
likely to receive it has been termed the ‘inverse care law’ (Hart 1971).
The second and related issue that is highlighted by the relationships between
education, illness attribution and diagnostic bias is that education may be good
for the individual, but it reinforces inequalities within communities. If
education enables an individual to obtain services and treatments, then this
helps them, and probably their family and close friends as well. However, it
may be at the expense of somebody whose need is greater, but whose
education is less adequate.
 THE EDUCATION–HEALTH CONNECTION 563

The importance of context

Some studies suggest that more education is not associated with better health at the
level of the individual. Higher levels of education appear to be associated with the
onset and progression of eating disorders (Toro et al. 1995, Westermeyer and
Specker 1999), and Benham and Benham (1982) report a correlation between
educational level and neurotic disorders. In addition, findings that years of
schooling correlate with health and happiness up to an intermediate level of
education only (Hartog and Oosterbeck 1998, Feinstein 2001) raise questions
about associations between education and health at higher levels of education.
These findings do not reconcile easily with preceding discussions pertaining to
the roles of education in the adoption of healthy behaviours, development of
psychological and social resources central to resilience, and access to appropriate
health care. Neither do they reconcile with the well-established relationships
between educational success and higher socio-economic status (e.g. Joseph
Rowntree Foundation 1995, Asplund and Pereira 1999), which is known to
correlate positively with health outcomes (Black et al. 1982, Marmot et al. 1991,
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Acheson 1998). The explanation for these apparent contradictions may lie in the
effects that contexts have upon impacts of education upon health.
The context of education refers to the whole society, the labour market and work
contexts, educational institutions, families and the individual. Of course, the effects
of each context upon relationships between education and health outcomes will
operate together. But for conceptual simplicity, the effects of each context are
discussed separately.

A competitive world and cognitive dissonance

Education raises aspirations as well as prospects. If they are not met,

disappointment will follow. The greater the discrepancy between aspirations and
actual outcome, the greater the disappointment and the more difficult it is to
cope with. Psychologists refer to this phenomenon as cognitive dissonance.
In a competitive world, some individuals fail to meet their aspirations. Findings
that amongst the unemployed, it is those with higher levels of education who are
more prone to depressive conditions and other physical health problems (Clark
and Oswald 1994, Turner 1995) may reflect the relatively high levels of cognitive
dissonance that these individuals struggle to cope with. Similarly, Veenhoven’s
finding that correlations between education and well-being are greater in
magnitude and more consistently found in less wealthy nations may reflect a lack
of appropriate high-status employment opportunities in wealthy nations.

A competitive labour market and job-related stress

It is well established that more education increases the chances that individuals
enter white-collar occupations including occupations in the professional
managerial employee strata (e.g. Esping-Anderson 1993, Joseph Rowntree
Foundation 1995). So how does entry into a white-collar professional managerial
occupation affect health outcomes?
 564 CATHIE HAMMOND

The health inequalities literature clearly indicates that higher status

occupations are associated with better health outcomes. Possible explanations
include material security and occupational fulfilment. It has been suggested by
authors in the USA that those occupations requiring higher qualifications allow
more self-direction, which is related to self-efficacy and well-being and protects
against depression (Kohn and Schooler 1983, Kohn et al. 1990). English
findings from a 20(+)-year follow-up to the Whitehall studies 4 (Marmot et al.
1991) found that civil service employment grade was positively associated with
greater self-efficacy and self-direction at work, more variety and challenge at
work and greater job satisfaction. Those in higher grades also tended to report
lower levels of hostility, fewer difficult life events, healthier lifestyles, and lower
rates of morbidity. One explanation for these associations is that employment
in higher grades was more fulfilling than employment in lower grades, and that
this sense of fulfilment led to lower levels of experienced stress and
consequently lower rates of morbidity.
In contrast to these findings, analysis of the British Household Panel Survey
between 1991 and 1997 suggests that the professional managerial jobs that are
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associated with high levels of job satisfaction are also associated with high levels
of stress (Rose 2000). Occupations associated with low levels of stress include
craft skill groups, such as electricians, carpenters and plumbers, and other blue-
collar workers. 5
Occupational stress may partly account for findings of a study in which level of
education and level of earnings correlated positively with rates of neurotic
disorder (Benham and Benham 1982). The authors report that neither education
nor earnings appeared to provide protection against the onset and progression of
neurotic disorders. The data used for the study relates to a 43-year-old cohort
born in St Louis (USA) in the 1910s and 1920s, and identifies neurotic disorders
if individuals had received a diagnosis of a neurotic disorder since the age of 18.
One hypothesis that would explain these findings—and it is the hypothesis of
interest here—is that educational success increases the chances of obtaining high
earnings, and that the type of employment that is associated with high earnings
contributes to the onset and progression of neurotic disorders. Another
hypothesis, referred to as a selection hypothesis, is that predisposition towards
neurosis also predisposed individuals to success in both education and earnings.
Unfortunately, the analyses do not enable one to distinguish between these two
explanations.
Success in education in a competitive labour market will be good for the health of
the individual so long as it does not lead to occupations and lifestyles that are overly
stress-inducing. However, it is not necessarily good for the community because it
does not change it. It just means that this individual, as opposed to another
individual, obtained the high status, fulfilling, challenging, and possibly highly
stressful job.

Competitive schools and families and academic stress

The experience of academic stress results from a combination of sources, which are
themselves interrelated: the educational institution, the family and the individual,
all of which will be affected by society. Parents and teachers often impose on
 THE EDUCATION–HEALTH CONNECTION 565

children stringent academic demands that are hard to fulfil, and fail to recognize
achievements and efforts that they consider to be less than the child’s ‘best’.
Failure to meet targets may result in peer devaluation. To add further to the
stress, some students place high standards upon themselves.
Bandura (1997: 235–236) suggests that students who have low self-efficacy (that
is, who feel that they have little control over the things that are important to them)
are especially vulnerable to academic stress:

Rather than concentrate on how to master the knowledge and cognitive skills
being taught, they [the students] magnify the formidableness of the tasks and
their personal inadequacies, ruminate about their past failures, worry about
the calamitous consequence of failing, imagine perturbing scenarios of
things to come, and otherwise think themselves into emotional distress and
faulty performances (Sarason 1975, Wine 1982).

Bandura quotes a number of studies which show that it is not academic failure that
causes academic stress, but rather a low sense of personal and academic efficacy
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(Wortman et al. 1976, Meece et al. 1990, Solberg et al. 1993).

Bandura suggests that parental and peer support bolsters personal efficacy to
cope with college pressures. However, educational environments need not induce
academic stress. Wertheimer’s (1997) review of the value of education for people
experiencing and recovering from mental health difficulties describes education
as challenging, stimulating and broadening, but at the same time, supportive.
Preliminary findings from a large fieldwork project involving 145 biographical
interviews suggest that challenge and stimulation in a supportive and socially
cohesive setting are important for all learners, but what this means in practice
varies depending upon the characteristics of the learner (Schuller et al. 2002). In
addition, studies of the development of resilience in children suggest that these
resources are best developed most effectively within learning contexts that are
integrated, co-operative, challenging, inclusive, heterogeneous, and encourage
participation and independent learning (Benard 1995, Frieberg et al. 1995, Wang
et al. 1997).

Conclusions and discussion

Research suggests that education and health are connected by a pattern of

correlations that varies depending upon the health outcome measured, stage of
the life course, level of education, and the national, social and economic context.
It is likely that the education–health correlations also vary according to the
values of other variables than those discussed in this paper, for example, the sex
and ethnic background of the learner, and across different forms of learning.
Clearly there is a need for further work in these areas.
The variations that have been identified have led to discussions of
relationships between health behaviours and health outcomes, and the effects
of education upon the development and maintenance of resilience, and access
to health services. They also highlight the importance of social, economic
and educational contexts upon the ways in which education impacts upon
health.
 566 CATHIE HAMMOND

An important point relating to context is that in societies that foster

competition—and most, if not all, societies do—education reinforces existing
power structures and inequalities. Studies too numerous to mention have shown
that individuals who are educationally successful tend to come from families that
are socio-economically advantaged, and that educational success leads to further
social and economic benefits. Findings reported here indicate that those with
more education tend to be not only advantaged economically and socially, and
therefore less likely to become ill, but they are also better able to access
appropriate health services and treatments. Education, therefore, is useful to the
individual because it gives him or her advantages over others. This aspect of
education is not so useful to the community as a whole because it does not
challenge existing inequalities.
But do inequalities matter to health? What are the effects of structural hierarchies
upon health at collective levels? Wilkinson (1996) presents convincing evidence that
amongst nations that enjoy a basic level of national or regional security (referring
mostly to developed as opposed to developing countries), health outcomes at
national and regional levels are best predicted by relative as opposed to absolute
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levels of poverty. In other words, nations, states and communities characterized

by high levels of financial inequality are characterized also by poorer general
health outcomes and vice versa.
Wilkinson suggests that an important characteristic that healthy egalitarian
societies share is social cohesion. Social cohesion contributes to health at a
collective level primarily because it reduces experiences of psycho-social stress,
such as insecurity, anxiety, hostility and resentment, all of which have negative
effects upon psychological health more immediately, and physical health over the
longer term. Findings that educational success is negatively associated with well-
being amongst those who are unemployed, and positively associated with the
chances of suffering from neurotic disorders such as eating disorders, suggest that
it is not only those who are disadvantaged who suffer in terms of well-being and
health as a result of living within such societies. Educational advantage under
some conditions may lead to aspirations that are hard to meet and lifestyles and
occupations that are highly stress-inducing.
Consequently, we see that within a context of social and economic inequalities,
education serves to reinforce existing power structures. This role of education
benefits individuals who are successful in educational terms because it leads to
more advantages. However, where social cohesion is lacking, even educational
success carries with it increased risks of neurotic disorders, and depression where
aspirations engendered through educational success are not met.
This is a rather negative take on the role of education in society, and it is by no
means the whole story. Education has other important roles, including the potential
to challenge existing inequalities through promoting individual empowerment and
social cohesion.
An implication of Wilkinson’s argument is that reducing income inequalities and
thereby increasing social cohesion will contribute to health at national levels.
Layard (1999) and Birdsall et al. (1995) have suggested that reducing inequalities
in education may have effects upon reducing income disparities. Provision of
education that is equally accessible to all members of society would challenge
existing power structures rather than reinforce them, and would have a knock-on
beneficial effect upon health at national levels.
 THE EDUCATION–HEALTH CONNECTION 567

Perhaps more fundamentally, education can be of enormous benefit to the well-

being and health of individuals and to communities because it serves as a role model
for the generation of a more socially cohesive society. Where education leads to
positive health outcomes, it does so through the interrelated processes of
empowerment and socialization in a context that celebrates challenge, awareness,
co-operation, inclusion, heterogeneity, participation and independent learning.
This form of education is good for both the individual and the community.

Notes

1. In contrast to chronic fatigue.

2. The health behaviours included in the analyses were smoking, alcohol consumption, body mass index and
level of exercise. The health conditions for which the association with level of education was entirely mediated by
health behaviours were respiratory problems, stomach ulcers and blood pressure. Those for which the association
was partially mediated by health behaviours were self-rated health and arthritis. The chances of having diagnosed
digestive problems were correlated with level of education, but this correlation was not mediated by the health
behaviours included in the study.
3. But see Richards et al. (2000), who found no evidence for social differences in patient presentation or gen-
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eral practitioner diagnoses that might have explained differential uptakes of cardiovascular services.
4. The Whitehall study of British civil servants began in 1967.
5. Levels of experienced stress are measured using self-report and this measure is validated against other
more objective measures such as blood pressure, digestion, rates of acute episodes of anxiety and depression,
and migraine.

Acknowledgements

I would like to thank John Bynner for his encouragement and advice. The research
described here was undertaken during the initial phase of the work of the Centre for
Research on the Wider Benefits of Learning and was funded by the Department for
Education and Skills. The views expressed in this work are those of the author and do
not necessarily reflect the views of the Department for Education and Skills. All errors
and omissions remain those of the author.

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