Education and health in 46 countries: modeling the mediating role of social factors and health behaviors
Using causal mediation analysis to account for multiple mediators and possible interactions between education and downstream behaviors, we examined health disparities in education and the contributions of pathways through social mediating factors and health behaviors. We analyzed the World Health Survey data on 164,743 participants aged 25 or older from 46 countries. G-computation algorithm implemented using Monte Carlo simulation of generalized linear mixed models was used to estimate natural and controlled direct effects, and mediated effects of ‘lower educational attainment’ compared to ‘high school or beyond’ (reference) education. Lower educational attainment had an overall negative impact on health (b ranging from –1.06 for secondary school completed to –4.05 for no formal education), the largest proportion of which was not mediated by social factors nor health behaviors. A substantial amount of the observed education-related health disparities would be eliminated if everyone had healthy behaviors — the proportion eliminated ranging from 48% for those that completed secondary school to 72% for those with no formal education. Simultaneously intervening on education, health behaviors and social factors will be more effective in reducing health disparities than intervening on education alone, since these mediating factors are important effect modifiers for the health effects of education.