The Social Determinants of Health:
Education as a Determinant of Health

This summary is primarily based on papers and presentations by Charles Ungerleider, Professor, Sociology of Education, University of British Columbia and former Deputy Minister of Education for the Province of Briti sh Columbia, and Daniel Keating, Atkinson Professor of Early Child Development and Education, Department of Human Development and Applied Psychology at the Ontario Institute for Studies in Education/University of Toronto. The presentations were prepared for The Social Determinants of Health Across the Life-Span Conference, held in Toronto in November 2002.

The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of Health Canada.

Current Situation

The educational attainment of Canadians is rising steadily:

• From 1951 to 1991, the proportion of Canadians with less than grade 9 declined from 52% to 14%; and the proportion of Canadians with university degrees increased five fold (Statistics Canada, 2002)

• More Canadians are graduating from secondary school and continuing to post secondary education (66% of the population are high school graduates) (Statistics Canada, 2002)

• Canada has the highest percentage of the population (48%) with some postsecondary education for the members of the Organization for Economic Cooperation and Development (OECD) (23%) (Statistics Canada, 1998).

Canadian students perform well on national and international assessments in reading, mathematics and science, but disparities exist among provinces and territories, and between boys (who perform better in math) and girls (who perform better in reading) (McCall, 1998; Bowlby and McMullen, 2002).

Disadvantaged children and youth do not perform as well in school as advantaged young people. For Aboriginal people, rates of high school graduation and attendance at post-secondary schools are well below the rest of Canada. Children in low-income families are more likely to:

• be in the top 10% in terms of frequency of delinquent behaviours

• have a problem with one or more basic abilities such as vision, hearing, speech or mobility

• exhibit delayed vocabulary development (Ross, Roberts and Scott, 2000).

Children born in Canada of immigrant parents do at least as well as the children of Canadian-born parents. For children whose parents native tongue is neither English nor French, the longer the child is in the school system the less the difference in performance (Lipps and Yiptong-Avila, 1999).

Public schools are facing high levels of stress and challenges, including:

• increases in levels of aggression: in 1997, 20% of students in grades one to eight admitted to being involved as either a bully or victim more than once or twice during a school term (Pepler and Craig, 1997)

• an increasing prevalence of learning disabilities and demands for special education

• increases in cultural and language diversity and in the number of students who do not speak English or French

• budget cutbacks and labour conflicts between governments with teachers and other educators (Ungerleider, 2002).

Factors that Affect the Issue

Genetics and the environment around the infant and young child affect early child development and readiness for school. Vulnerable children in poor families begin life in stressful households and may have less opportunities for nurturing, early stimulation, a healthy diet, safe housing, and other conditions needed for successful development. Relative level of disadvantage is also important. Societies with larger gradients in socioeconomic status are more likely to encounter developmental problems in disadvantaged children (Keating, 2002).

Socioeconomic status has indirect effects on levels of academic achievement, as well as direct ones. Low income is associated with higher levels of parental depression. This can lead to hostile or withdrawn parenting, which in turn affects academic focus and higher achievement (Ryan and Adams, 1999). Disadvantaged children are more likely to live in neighbourhoods where drugs and alcohol are readily accessible and where crime levels are high. If they drop out of school, they are unlikely to find meaningful jobs or community supports in their neighbourhoods. Double disadvantage occurs when low socioeconomic status is worsened by prejudice. Until recently, public schools have done relatively little to address racism, low expectations and the neglect that produces low academic achievement for Aboriginal learners and some other groups (Ungerleider and Burns, 2002).

Aggressive behaviour and poor school performance are linked. Children who do not learn alternatives to aggression early in life are more likely to feel rejected or isolated, to be disruptive, to leave school early, to engage in violent behaviour and to be charged under Canada's Young offenders Act (Tremblay, 2000).

There has been a widespread decline in Canadians' confidence in all public institutions, including schools. This may be related to the gap between the performance of a school system under stress and heightened public expectations of what schools should do (Guppy and Davies, 1999). This has led to calls for tougher standards and heightened accountability (Bricker and Greenspoon, 2001), as well as an increased interest in private schools and schools for special groups.

While school dropout rates are decreasing, students at-risk fit a well-established profile (Bowlby and McMullen, 2002).

• School dropouts are more likely than graduates to live in "mixed" (versus nuclear) families and single parent households.

• Twice as many graduates have had at least one parent who completed postsecondary education and three times as many graduates had at least one parent who completed a university degree.

• Dropouts are more likely to have worked at a job for more than 30 hours a week in their last year of high school.

• For women, 28% of dropouts have children and half of them are single parents.

Effect of Low Levels of Education on Health

People with low levels of education suffer poorer health and well-being. Compared to non-graduates, high school graduates:

• use preventative medical services 11% more frequently

• make 2% fewer multiple visits to doctors

• have 23% better knowledge of health behaviours

• have 13% better general health status

• have 26% better family functioning (Federal, Provincial and Territorial Advisory Committee on Population Health, 1999).

Society also pays a high price when its citizens have low levels of education.

• Non-graduates from high school are much more likely to be jailed than graduates. Non-graduates represent 34% of the population but make up 74% of the prison population (Ungerleider, 2002).

• Most income assistance (85%) is spent on people who have not completed high school: 33.6% of those who do not graduate from high school receive income assistance compared to 6.7% of those who graduate (Ungerleider, 2002).

Implications for Policy, Practice and Research

Canadians can take pride in the accomplishments of their public schools and the role that universal education has played in the development of healthy citizens and a productive country. At the same time, they should be worried about current vulnerabilities and the inequalities among students distinguished by socioeconomic, ethno-cultural, and gender differences.

As technology and learning advance, it is most likely that the growth economies of the 21st Century will be the knowledge economies, in which innovation is the key ingredient. Innovation is fundamentally a human resource, strongly influenced by both human development and social capital (Keating, 2002). Therefore, increased support for high quality universal public education and for helping young people stay in school is important for the future of the country as well as for the health and well-being of individuals, families and communities.

The role of leaders in health in supporting public education is largely one of advocate, knowledge broker and partner with the education system. Ensuring that public education remains accessible for all Canadians, and that it effectively serves those most in need, implies the need for a number of broad income, social and educational policies and programs that:

• Reduce income disparities

• Strengthen social capital: confront and rectify prejudice, racism and social exclusion; support mentoring programs, sport, arts, culture and recreation programs for all in school and community settings; support community development and crime prevention initiatives

• Support public schooling: increase funding and support for public schooling and educators; advocate political support for high quality public schooling for the benefit of all, as opposed to transferring support to private and fractured schooling that serves the wealthy and special interest groups

• Reduce disparities for disadvantaged groups of students: support stay-inschool initiatives with vulnerable young people and school re-entry programs for dropouts; provide special education opportunities and resource teachers for all students who need extra help

• Increase access to early childhood education (e.g., kindergartens) and postsecondary school education (i.e., colleges and universities) for all

• Provide for community control of schools for Aboriginal students on-reserve

• Provide lifelong learning opportunities and English/French -as-a-second language courses for parents and adults.

The Canadian Learning Institute will help to fill fill the void of a lack of a national education department. It is funded by government, but run independently by a board of directors representing government, business, labour and learning organizations. The Institute will provide leadership as Canada's clearinghouse for new ideas, research and trends about learning from preschool to retirement. The institute is built around lifelong learning, in support of the knowledge economy.

The health sector has a more direct role to play in building healthy schools that help young people stay in school, in making the links between early child development and academic achievement, and in making early child development opportunities available across the country. This includes policies and practices that:

• prevent adolescent pregnancy and help teen parents return to school

• prevent substance misuse and abuse in school and community settings

• prevent racism, discrimination, bullying and violence in school and community settings

• support partnerships in schools between health, recreation and social service workers, and educators

• provide universal access to early childhood development programs in communities and schools (e.g., community resource centres, parent support programs, preschool programs, head start programs and kindergarten)

• support the integration of and help for students with learning disabilities, speech and language delays and other health problems.

Research priorities include:

• a better understanding of the relationship between teachers' expectations and classroom performance

• clearer data on the correlation between teacher evaluation, parent evaluation and future academic and work performance

• best practices in early childhood interventions that enhance school readiness and academic performance

• a better understanding of the relationships between education, literacy, income and health status.

References

Bowlby J.W. and McMullen K. (2002). At a Crossroads: First Results for the 18 to 20 Year Old Cohort of the Youth in Transition Survey. Human Resources Development Canada.

Bricker D. and Greenspoon E. (2001). Searching for Certainty: Inside the New Canadian Mindset. Doubleday Canada, 149.

Federal, Provincial and Territorial Advisory Committee on Population Health (1999). Calculated from data in Statistical Report on the Health of Canadians , 1999.

Guppy N. and Davies S. (1999). Understanding Canadians' declining confidence in education. Canadian Journal of Education, 24, 3: 265-80.

Keating D. (2002). Developmental Health: Research, Policy and Practice. A presentation given at The Social Determinants of Health across the Life-Span Conference held in Toronto in November 2002.

Lipps G. and Yiptong-Avila J. (1999). From Home to School-How Canadian Children Cope. Initial Analysis Using Data from the Second Cycle of the School Component of the National Longitudinal Survey of Children and Youth. Canada: Culture, Tourism and the Centre for Education Statistics.

McCall D. (1998). Transitions Into and Through the School Systems. Third National Forum on Education. Councils of Ministers of Education Canada.

Pepler DJ. and Craig WM. (1997). Bullying: Research and Interventions. Youth Update, Institute for the Study of Antisocial Youth.

Ross D., Roberts P. and Scott K. (2000). Family income and child well-being. ISUMA, Autumn: 51-4.

Ryan B.A. and Adams G.R. (1999). How do families affect children's success in school? Education Quarterly Review, 6(1): 30- 43.

Statistics Canada (1998). The Daily, April 14.

Statistics Canada (2002). The Daily, January 23.

Tremblay R.E. (2000). The origins of youth violence. ISUMA, 1(2): 19-24.

Ungerleider C. and Burns T. (2002). The State and Quality of Canadian Public Elementary and Secondary Education. A presentation and paper given at The Social Determinants of Health across the Life-Span Conference held in Toronto in November 2002.