The impact of health and health behaviours on educational outcomes in high-income countries: a review of the evidence

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3 The impact of health and health behaviours on educational outcomes in high-income countries: a review of the evidence Marc Suhrcke, School of Medicine, Health Policy and Practice, University of East Anglia, United Kingdom Carmen de Paz Nieves, Fundación Ideas, Madrid, Spain

4 ISBN Keywords HEALTH BEHAVIOR - HEALTH STATUS - EDUCATIONAL STATUS - RISK FACTORS - SOCIOECONOMIC FACTORS - REVIEW LITERATURE Suggested citation Suhrcke M, de Paz Nieves C (2011). The impact of health and health behaviours on educational outcomes in highincome countries: a review of the evidence. Copenhagen, WHO Regional Office for Europe. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). World Health Organization 2011 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Edited by Elizabeth Goodrich Book design and layout by Marta Pasqualato Cover photo istockphoto.com/neustock The photographs in this material are used for illustrative purposes only; they do not imply any particular health status, attitudes, behaviours, or actions on the part of any person who appears in the photographs.

5 WHO European Office for Investment for Health and Development The WHO European Office for Investment for Health and Development, which coordinated the activities leading to this publication, was set up by the WHO Regional Office for Europe, with cooperation and support from the Ministry of Health and the Veneto Region of Italy. One of its key responsibilities is to provide evidence on and act upon the social and economic determinants of health. The Office systematically reviews what is involved in drawing together the concepts, scientific evidence, technology and policy action necessary to achieve effective investment for the promotion of health and synergy between social, economic and health development. The Office fulfils two interrelated main functions: to monitor, review and systematize the policy implications of the social and economic determinants of population health; and to provide services to help Member States in the WHO European Region increase their capacity to invest in health by addressing these policy implications and integrating them into the agenda for development. Acknowledgements We gratefully acknowledge the financial and other support provided by the WHO European Office for Investment for Health and Development, WHO Regional Office for Europe and the National Health Service Health Scotland (NHS Health Scotland) in its capacity of WHO collaborating centre for health promotion and public health development, in the production of this work. We have benefited greatly from the comments made by David Pattison (NHS Health Scotland) and Chris Brown (WHO European Office for Investment for Health and Development, WHO Regional Office for Europe), and the production coordination provided by Cristina Comunian (WHO European Office for Investment for Health and Development, WHO Regional Office for Europe). We are also indebted to Elizabeth Goodrich who copy-edited the text. Any errors are the sole responsibility of the authors. The views expressed in this publication do not necessarily reflect the official views of NHS Health Scotland. Marc Suhrcke, School of Medicine, Health Policy and Practice, University of East Anglia, United Kingdom Carmen de Paz Nieves, Fundación Ideas, Madrid, Spain iii

6 Contents Acknowledgements...iii Abbreviations... v Executive summary...vi 1. Introduction The association between education and health From health to education: a conceptual framework... 3 Health outcomes and conditions... 3 Mediating factors and educational outcomes... 4 External or control factors affecting both health and education... 5 Impact of health on future prospects through education and intergenerational transmission of inequalities Search methodology Results of the literature review... 9 Selected summary statistics... 9 Impact of health-related behaviours and risk factors on educational outcomes: detailed findings Impact of health conditions on educational outcomes: detailed findings Conclusions Annex 1. Online databases used References List of tables Table 1. Number of papers reviewed, by health behaviours and conditions... 9 Table 2. Number of papers reviewed, by educational outcome Table 3. Number of papers reviewed, by year of publication Table 4. Number of papers reviewed, by country Table 5. Number of papers reviewed, by methodology Table 6. Number of papers reviewed, by journal article versus working paper Table 7. Number of papers reviewed, by field Table 8. Number of papers reviewed, by findings Table 9. Alcohol drinking Table 10. Marijuana use Table 11. Smoking Table 12. Poor nutrition Table 13. Obesity and overweight Table 14. Physical exercise Table 15. Sleeping problems Table 16. Mental health and well-being Table 17. Asthma Table 18. General health List of figures Fig. 1. Analytical framework of the causal association between health and education... 3 Fig. 2. Study selection criteria and process... 8 iv

7 Abbreviations ADHD ANOVA BMI CE ESS ETS GATOR GEE GPA HI MAP MLDA NBER NHANES III NLSCY NLSY NLSY79 NTDS NSL OECD OEO PDSS PIAT PIATR PPVT-R PSID PUMS SOEP TSIV WIC WISC-III attention deficit hyperactivity disorder analysis of variance body mass index coordinative exercise Epworth Sleepiness Scale environmental tobacco smoke Georgetown Adolescent Tobacco Research generalized estimating equation grade point average hyperactivity-impulsivity Missouri Assessment Program minimum legal drinking age National Bureau of Economic Research Third National Health and Nutrition Examination Survey Canadian National Longitudinal Survey of Children and Youth National Longitudinal Surveys of Youth ( America) 1979 National Longitudinal Surveys of Youth (United States) National Public School-Head Start Transition Demonstration Study normal sports lesson Organisation for Economic Co-operation and Development Office of Equal Opportunity (United States) paediatric daytime sleepiness scale Peabody Individual Achievement Test Peabody Individual Achievement Test Revised Peabody Picture Vocabulary Test Revised Panel Survey of Income Dynamics Public-Use Microdata Sample German Socioeconomic Panel Two-Sample Instrumental Variables Special Supplement Nutrition Program for Women, Infants, and Children (United States) Weschler Intelligence Scale for Children III v

8 Executive summary While the importance of education is widely appreciated as a public policy priority in industrialized countries and cross-country comparative rankings of educational performance typically provoke major national debates, comparably little attention, outside of health, is paid to the impact of child and adolescent health on education. Part of the reason could be the perception that child health is but a by-product of education rather than a factor that could determine educational outcomes. This report casts doubt on this perception by critically examining the evidence on the effect of health on education in industrialized countries. Based on seemingly underrecognized evidence, our overall finding is that there is reason to believe health does have an impact on education. This finding should serve as a basis for raising the profile of child health in the public policy debate, and by illustrating the potential for mutual gains, it should help stimulate cross-sectoral collaboration between the health and education sectors. Education and health are known to be highly correlated that is, more education indicates better health and vice versa but the actual mechanisms driving this correlation are unknown. The effect of health on education has been well researched in developing countries, as has the effect of education on health in both developing and industrialized countries. Such imbalance could signal lack of attention not only in research but also in the public policy debate. While children in developing countries face more serious health challenges than those in industrialized ones, the potentially relevant effect of health on their educations (and perhaps on labour force participation) cannot be ruled out. The analytical framework we used to guide our research posits a path leading from health behaviours (e.g. smoking) and health conditions (e.g. asthma) to educational attainment (level of education) and educational performance (e.g. grades). We searched literature in the fields of health, socioeconomic research, and education and ultimately narrowed our selected publications to 53, all of them based in countries belonging to the Organisation for Economic Co-operation and Development. Based on the evidence reviewed, some of our more important findings are the following. Overall child health status positively affects educational performance and attainment. For example, one study found that very good or better health in childhood was linked to a third of a year more in school; another concluded that the probability of sickness significantly affected academic success: sickness before age 21 decreased education on average by 1.4 years. The evidence indicates that the negative effect on educational outcomes of smoking or poor nutrition is greater than that of alcohol consumption or drug use. Initial research has found a significant positive impact of physical exercise on academic performance. Obesity and overweight are associated negatively with educational outcomes. Sleeping disorders can hinder academic performance. Particularly underresearched, especially considering their growing significance, is the effect of anxiety and depression on educational outcomes. Asthma on average has not been shown to affect school performance. The preponderance of research was based in the America, but overall this field has grown markedly since 2001, including in Europe. From a methodological perspective it is important to note that several papers undertake serious efforts to tackle the challenge of proving causality in the relationship. In light of the comparative lack of European evidence, there is a genuine need to undertake further targeted research in this somewhat neglected area. Nevertheless, the evidence that already exists should be actively disseminated across both education and health ministries and agencies. Academics and practitioners should be encouraged to share the wide range of evidence sources they have; doing so may contribute to a greater understanding of this area of work. This evidence should include recognition of the value of qualitative evidence and grey literature. vi

9 1. Introduction The relationship between health and education is doubtless a close one. In particular, the public health literature has widely documented the correlation between these two dimensions of human capital in both developing and industrialized countries. More often than not, this association is interpreted or even shown to represent, especially in industrialized countries, a causal effect running from education to health: a better education leads to better health. This publication explores, specifically in high-income countries, the extent to which a causal link may also run the other way, from health to education. That is, does better health lead to a better education? We start with the hypothesis that this direction of the relationship has been somewhat ignored both in research and, arguably, in the public policy debate. To date, far more attention has been paid to the importance of health for education in the research on developing countries, documenting in particular very clearly the importance of child and adolescent health for educational attainment and performance. While there is obvious reason to believe that the health challenges children face in rich countries affect education to a lesser extent than the more life-threatening health challenges in poor countries, a potentially relevant effect of health on education in the industrialized world cannot be automatically ruled out. This study aims to systematically review the current knowledge of the effect that different health conditions and unhealthy behaviours can have on educational outcomes in the context of rich countries. Specifically, we examine research on the following questions. Does poor health during childhood or adolescence have a significant impact on educational achievement or performance? Does the engagement of children and adolescents in unhealthy behaviours determine their educational attainment and academic performance? As it turns out, although these questions have not been a major research focus, the evidence that does exist offers a lot to suggest a causal contribution of health to various educational outcomes. While gaps in the research do remain, its results already bear relevant policy implications both for the wider importance of child health in rich countries (extending beyond the health benefits per se) and for the ways in which educational outcomes might be improved. The publication is structured as follows. In section 2 we review briefly some of the evidence and hypotheses behind the linkage between health and education in general. Section 3 presents a conceptual framework to organize the different ways in which health may impact education. Section 4 describes the literature search methodology. Section 5 presents the core results of the literature review, first in terms of basic summary statistics and second in a more detailed, synthesis format. The final section draws together our conclusions. 1

10 2. The association between education and health A fairly large body of evidence both in the economics and public health literature documents a positive correlation between health and education. Due to the empirical challenges involved in assessing causality in the relationship, there is less agreement on what the precise mechanisms are that drive this correlation. As first highlighted by Grossman (1973) and more recently by other authors including Cutler and Lleras-Muney (2006); Ding et al. (2006); Gan and Gong (2007), health and education may interact in three not mutually exclusive ways: 1) education may determine health; 2) one or more other factors may determine both health and education simultaneously; and 3) health may determine education. Education may determine health. The predominant view appears to be that the effect of education on health is primarily driving the correlation in high-income countries. A set of quasi-experimental studies across different countries confirmed this view and was summarized, for instance, by Cutler and Lleras-Muney (2006). Similarly, a recent study by Lundborg (2008), using data on identical twins to estimate the health returns to education, concluded that higher educational levels positively affect self-reported health and reduce the number of chronic conditions. The link between education and health has different potential explanations. First, education as a long-term investment provides an incentive to individuals to stay healthy and reap the benefits of such investment. Cutler and Lleras-Muney (2006) in this regard highlight differences in preferences and an individual s valuation of his or her future that may both be affected by the level of education as relevant factors explaining health outcomes. Second, as a key input in the health production function, education may also help individuals maintain or improve their health, mostly by means of their enhanced knowledge of health issues, information availability and cognitive skills (Grossman, 1973; Cutler and Lleras-Muney, 2006). Finally, educational achievement is correlated with higher earnings through access to better job opportunities and social networks, which in the long term is expected to translate into higher health expenditure and thus better health (Grossman, 1975; Kenkel, 1991; Rosenzweig and Schultz, 1991 as cited in Gan and Gong, 2007; Lleras-Muney, 2006). One or more other factors may determine both health and education simultaneously. Some researchers suggest that it is mostly external factors that simultaneously affect both education and health. For instance, Case, Fertig and Paxson (2005), using panel data from the United Kingdom, found that children s health was significantly affected by the socioeconomic status of their family. Currie et al. (2004) concluded similarly that around 60% of the variation in children s health in a sample of English siblings was explained by unobserved family characteristics, i.e. not investments in health or education. In line with these findings from the United Kingdom, Smith (2008) concluded on the basis of a sample in the United States that significant differences existed in the estimated impact of health outcomes on education between regular and within-sibling models, reinforcing the hypothesis that family background likely plays a key role in both children s health and education. Health may determine education. Last but not least and in accordance with the prime focus of this study, health may also be a determinant of educational outcomes (Gan and Gong, 2007). Of the three potential mechanisms this one appears to be the least researched in high-income countries. The subsequent section describes in more detail the potential mechanisms that might explain such a causal impact. Parts of the relevant literature in this field were recently reviewed by Currie (2008) and Taras and Potts-Datema (2005 a, b, c and d). Our review builds on these efforts and complements them in various ways. Currie s (2008) excellent review did not comprehensively cover all the available literature on the topic. Neither her nor the Taras and Potts-Datema (2005 a, b, c, and d) reviews exhaustively covered the evidence on the impact of different health behaviours on educational outcomes. In addition, since Taras and Potts- Datema s reviews were published in 2005, they could not capture the notably growing research output albeit from a low base in more recent years. To the best of our knowledge, this is the first effort to comprehensively study the effect of health behaviours and health conditions on educational outcomes within a common analytical framework. 2

11 3. From health to education: a conceptual framework This section presents the framework we use to conceptualize the causal association between health and education (see Fig. 1 for a graphical illustration). Fig. 1. Analytical framework of the causal association between health and education Child and adolescent health-related behaviours Alcohol drinking Drug use Smoking Nutritional deficiencies Obesity and overweight Physical activity Child and adolescent health conditions Sleeping disorders Mental problems Asthma Mediating factors Cognitive abilities development Discrimination in classroom Self-esteem Learning skills Physical energy How teachers and peers treat children and adolescents Educational attainment Level or year of education Dropping out College enrolment Academic performance Grade point average (GPA) scores Grade repetition Truancy Other adult outcomes Health Marital status Fertility control Future children s schooling Criminal activity Income (through labour market outcomes) External factors and controls Micro: family socioeconomic background, personal ability, perceived value of the future, gender, ethnicity Meso: community and school environment, geographical location, friends habits, social networks Macro: national income, national policies Health outcomes and conditions The two boxes on the left of the diagram represent the main explanatory variables in the model, i.e. children and adolescents health indicators, which we classify into health conditions and health behaviours (or risk factors ). In our review we took into account the following health-related behaviours: alcohol drinking drug use 3

12 smoking nutritional deficiencies obesity and overweight physical activity. The health conditions we systematically studied in this review included: sleeping disorders mental health and well-being (comprising anxiety and depression) asthma. These health conditions and risk factors tend to coincide with and affect each other, as indicated by the double-headed arrow connecting the left-hand boxes. One study illustrated this clearly: studying adolescents in the United States, Ding et al. (2006) found striking differences in the estimated impacts of depression and obesity when examining a single health state in isolation. That research also concluded that individuals with health disorders such as obesity or depression were significantly more likely to smoke. Confirming these findings, students reporting higher levels of sleepiness during the day tended to also report more frequent illness (Drake et al., 2003), and several studies reviewed here highlight a relevant association between nutritional deficiencies and mental health problems (Alaimo, Olson and Frongillo, 2001; Datar and Sturm, 2006). Students who binge drank were more likely than both non-drinkers and drinkers who did not binge to report involvement in other risky health behaviours according to Cutler, Miller and Norton (2007). In addition, Ellickson et al. (2004) found that early smokers were at least three times more likely by grade 12 than non-smokers to regularly use marijuana and hard drugs. Sleepiness has also been associated with a higher incidence of anxiety and behavioural problems (Gibson et al., 2006). Therefore, in assessing the impact of health behaviours on education, it is important to avoid considering the health behaviours and/or health conditions in isolation of each other. Mediating factors and educational outcomes The focus of this review and the main question to be addressed within the framework is the extent to which the selected risk factors and health conditions have a significant effect on educational outcomes. This core link is highlighted in the central, blue-background box in the figure. However, health can influence education not only directly but also through the mediating mechanisms listed in the mediating factors box in the diagram. Guo and Harris (2000), for instance, demonstrated that cognitive stimulation is one of the main mechanisms through which poverty affects children s intellectual development and thus school achievement. Mediating factors include all those aspects determined by health that in turn can have an impact on educational outcomes e.g. (Ding et al., 2006): cognitive and learning skills development treatment received by children in the classroom in connection with their health condition(s) discrimination by peers self-esteem students physical energy. Educational outcomes are classified for the purpose of this review into longer and shorter term indicators. The longterm outcome considered is educational attainment, proxied by: level or years of education achieved dropping out college enrolment. Academic performance is the shorter term educational indicator, measured by: 4

13 GPA or grades grade repetition days of class missed or skipped (truancy). Although most articles included here analyse the direct relationship between health conditions and behaviours and educational outcomes, some go a step further and attempt to assess this relationship through the impact of certain policies and programmes related to different health aspects on education. External or control factors affecting both health and education As highlighted in the previous section, both health and education outcomes of children and adolescents can be determined by a set of external or third factors, represented in the box at the bottom of the diagram. The presence of both observable and (in particular) unobservable common determinants of health and education tends to complicate the empirical estimation of the relationship between health and education, as discussed in subsequent sections. Aspects such as family background and individual characteristics of children (e.g. preferences) play an important role in shaping the relationship between health and education. Hence failure to take those often hard to observe factors into account would seriously bias any coefficients on the health variable. Most studies try to mitigate this problem by controlling for as many additional and relevant observable variables as possible through multivariate regression analysis. However, this effort in itself is mostly not sufficient to entirely rule out the influence of unobservable characteristics. Other studies attempt to control for unobservable factors that do not vary over time or within a family, e.g. through the use of siblings and/or twins data ( fixed-effects models ). Still others attempt to overcome endogeneity problems through the use of alternative methodologies such as instrumental variables, difference-in-differences, matching estimates and discontinuity design. The external factors that published studies have considered (or have suggested as important) in their analyses of the relationship between health and education may operate at the micro, meso and macro levels. At the micro level some of the main determinant factors include (Cutler and Lleras Muney 2006; Fuchs 1982; Smith, 2008; Currie, 2008): family socioeconomic status ethnic factors gender order among siblings value associated with the future or discount rate personal ( innate ) ability. Smith (2008), for instance, emphasized the possibility of large biases from unobserved family effects in studies assessing the potential interdependence between health and education. Other research has illustrated the gender difference in the impact of obesity (Cawley and Spiess, 2008) or mental health (Fletcher, 2008) on educational outcomes. Factors that can determine children s and adolescents development at the meso level include (Klingeman, 2003): community, neighbourhood and school characteristics access to information and social networks friends habits. Pate et al. (2006) demonstrated the importance of girls living environments to their physical activity. Other meso factors seem to be particularly relevant in the development of health-related behaviours: Duarte, Escarioa and Molina (2006), for instance, found that individual marijuana use was positively correlated with adolescents nightlife and friends smoking habits, but inversely related to school information campaigns. Finally, the macro-level policy framework may also affect both health and education. Cross-country or cross-regional 5

14 variation in health- and/or education-related policies and programmes can provide natural experiments that help us more reliably identify the causal pathways between health and education. Studying data from the United States, where minimum legal drinking ages varied over time, Dee and Evans (1997) used an instrumental variable approach to exploit within-state variations in alcohol availability to estimate the impact of drinking on education. Ludwig and Miller (2006) used a discontinuity in the funding of the United States Head Start (early education) programme providing schooling and health support to poor counties to find a parallel discontinuity in educational attainment among participants. Impact of health on future prospects through education and intergenerational transmission of inequalities Taken together, children s education, health and third factors account for differences in employment status and income when they become adults, as well as their adult health outcomes, marital status, fertility control and engagement in criminal activities and in the educational achievement of their own children. Using within-sibling models on panel data in the United States, Smith (2008) found that good health during childhood increased adult family incomes by 24%, when compared to poor health. 1 Case, Fertig and Paxson (2005) also support the main hypothesis of lifecourse models that childhood health conditions have a lasting impact on health and socioeconomic status in middle adulthood. According to these authors, health at ages 23 and 33 was a significant predictor of health at age 42, as were indicators of socioeconomic status at the younger ages. These adult outcomes in turn are likely to influence the health conditions and behaviours of the next generation, which would affect educational outcomes and overall future prospects in a self-reinforcing cycle. Health differences affecting the intergenerational transmission of poverty through educational outcomes may therefore explain a significant share of the existing socioeconomic inequalities in developing but also in industrial countries (Currie, 2008). Currie and Stabile (2007) specifically suggest that variations in the incidence of health insults during childhood may be important in explaining the gap in the long-term health status between rich and poor. The inter-generational transmission of health is represented by the connection through the external factors and controls at the bottom of the diagram between the boxes representing adult outcomes at the right-hand side of the diagram and, on the left, child and adolescent health behaviours and conditions. The above, conceptual inter-linkages by themselves pose important challenges for any empirical test of the conceptual model, in particular for the assessment of the true causal impact of health on education. There are at least three major difficulties in estimating the contribution of individual health to educational outcomes: reverse causality, omitted variable bias and measurement error. If a standard single equation regression is applied, those problems can lead to biased estimates of the coefficient of the health variable (and of the other independent variables), because they lead to the error term being correlated with the health variable, a feature known as endogeneity of the health variable. As discussed below, several studies explicitly recognized this challenge and adopted econometric techniques that can at least in principle help reduce or eliminate the otherwise resulting bias. 1 The health measure in Smith (2008) is based on a five-point scale, including the categories poor, fair, good, very good and excellent. The last two categories were defined as good health and all other categories taken together as poor health. 6

15 4. Search methodology Online databases were the primary source of the reviewed literature. The search was conducted in three main thematic areas: health and public health, socioeconomic studies and research, and education. 1. Under the category of health and public health we used both general online databases, such as ScienceDirect, InterScience and Scirus, and health-specific databases, mainly PubMed, BioMed and Cochrane. A further online search of all issues between 2005 and 2008 was conducted to ensure exhaustiveness in the case of specific online journals, i.e. the American Journal of Public Health, Journal of Health Economics, Journal of School Health and The Journal of Pediatrics. 2. For socioeconomic studies and research, IngentaConnect, RePec, JSTOR, Palgrave, SagePub, SpringerLink and ISI were the most important databases. Other specific online resources included the National Bureau of Economic Research (NBER) database and the Journal of Health Economics. 3. For education, we conducted an exhaustive online search of the British Journal of Educational Psychology and the Economics of Education Review. The essential search criteria for the main databases used are detailed in Annex 1. A recent literature review by Currie (2008) and four reviews by Taras and Pott-Datemas (2005a, b, c and d) provide a comprehensive, initial picture mainly concerning specific chronic conditions such as sleeping disorders, mental health problems, asthma and some health-related behaviours, including deficient nutrition, obesity and physical exercise. Other relevant reviews used included that of Murray et al. (2008) on the literature assessing the impact of school health programmes on academic achievement, Cueto (2001) reviewing the effect of breakfast programmes on educational outcomes and Trudeau and Shephard (2008) on the relationship between physical education and physical activity and academic performance. While the main conclusions of those reviews have been considered and are indeed referred to frequently throughout this study, we did not review the original literature covered in those previous reviews. We adopted the so-called snowballing process in our search. Relevant references in the most significant papers were searched and, when appropriate, included in the review, and in every database we always searched readings related to those that were pre-selected, typically yielding relevant results. We initially selected 273 articles on the basis of the research topic, broadly considered. The selection was narrowed to 123 using the specific relevant indicators (discussed in the subsequent section) as the main inclusion criteria. The search was further restricted to 70 based on the age range of the study subjects, the country and the publication year. All papers were stored in an Endnote database, and in the process their abstracts and in most cases the entire paper were screened and a final selection on the basis of the source and methodology used was carried out. In the end, 53 papers remained (Fig. 2). 7

16 Fig. 2. Study selection criteria and process First selection Research topic, broadly considered Second stage 273 Specific, selected health and education indicators Excluded Third stage 123 Age range, country and publication year Excluded Final selection Source, methodology 70 Excluded 53 8

17 5. Results of the literature review In this core section of the publication, we present the findings of our review, first at a very generic, descriptive level and subsequently in a more detailed, analytical format. Selected summary statistics The most basic characteristics according to which the papers reviewed can be disaggregated in a fairly simple manner are as follows: health and education indicators used; publication date; country of study; age range of study subjects; source; methodology; and qualitative result of the research. Health and education indicators The focus of the review and therefore of the literature search was the impact of health behaviours and health conditions on educational outcomes. Table 1 shows that most reviewed papers (n=30) explored the connections between alcohol drinking, marijuana use, smoking, nutrition and physical exercise, and educational outcomes. Evidence was particularly profuse in the case of alcohol drinking (n=9) and marijuana use (n=7) compared to the other healthrelated behaviours. A total of 23 papers studied the effect of three health conditions sleeping disorders, anxiety and depression, and asthma on education as well as the impact of overall health on educational outcomes. The numbers in Table 1 do not imply that there has necessarily been less research on health conditions than health behaviours. Taras and Potts-Datema (2005 a, b, c and d) and Currie (2008) have already included in their review a considerable number of studies, and to avoid duplication we excluded those studies from our review. Table 1. Number of papers reviewed, by health behaviours and conditions Health risk factors 30 Alcohol drinking 9 Marijuana use 7 Smoking 4 Nutritional problems and obesity 6 Physical exercise 4 Health conditions 23 Sleeping disorders 5 Mental health problems 6 Respiratory problems 4 Overall health 8 TOTAL 53 Table 2 shows the distribution of the studies by outcome variable considered. Most studied the relationship between different health indicators and academic performance, mainly measured through scores, both self-reported and actual. Only 12 of the 53 papers looked at the effect of health on what we call mediating factors, typically cognitive skills development, as measured, for instance, through the Peabody Individual Achievement Test (PIAT). 2 2 PIAT is an individually administered measure of academic achievement that is norm-referenced. Designed to provide a wide-range screening measure in five content areas that can be used with students in kindergarten through 12th grade, its content areas are mathematics, reading recognition, reading comprehension, spelling and general information. 9

18 Table 2. Number of papers reviewed, by educational outcome Educational attainment 22 School readiness 1 High school dropout 5 High school completion 6 Years of education achieved 4 Level of education achieved 6 Academic performance 35 Scores 15 Self-reported performance 7 Grade repetition 5 Missed days, truancy 8 Mediating factors 12 Note: Total exceeds 53 because some papers reported more than one educational outcome. Date of publication We considered only studies published between 1 January 1995, and 30 June Sophisticated econometric analysis of the relationship between the factors of interest was barely conducted before the 1990s, and its relevance today would be questionable if only due to changes in perceptions, habits and health and educational standards in the countries studied. Over two thirds of the papers we reviewed were conducted after 2001, further indicating a recent upsurge in the academic interest in this topic (see Table 3). Table 3. Number of papers reviewed, by year of publication The country of study 1 January December January June TOTAL 53 Only literature on countries in the Organisation for Economic Co-operation and Development (OECD) was reviewed. As highlighted in the introduction, the relevance and implications of the relationship between health and education are likely to differ between developing and high-income contexts. The role of health in determining educational outcomes has been more extensively studied in developing countries, while remaining comparatively scarce in highincome countries. As seen in Table 4, most of the studies focus on the United States and make use of their datasets (40 of 53), indicating a clear gap in research on the topic in European and other OECD countries. The most common data sources are longitudinal or panel data from official surveys, such as the National Longitudinal Survey of Youth (NLSY), the National Youth Risk Behaviour Survey and the United States Third National Health and Nutrition Examination Survey. Additionally, narrower samples and data from small natural and randomized experiments are used. Age range of study subjects The ages of the sample of children and adolescents studied were to be between 1 and 18 years. Literature on pre-natal health factors and their impact on child development (see e.g. Currie, 2008), although profuse, was excluded from this review mainly due to the rather different set of policy implications it relates to. 10

19 Table 4. Number of papers reviewed, by country Empirical methodology United States 40 Europe 9 Germany 3 Italy 1 Spain 2 United Kingdom 3 Others 4 TOTAL 53 We gave priority to studies that performed some form of more advanced econometric analysis, by which we mean the application of at least single equation multivariate regression analysis. As Table 5 indicates, the majority of studies used this methodology, implying that most studies did not undertake specific efforts to overcome the endogeneity problem mentioned above. 3 A significant minority undertook efforts to correct for endogeneity issues, mainly by using quasi-experimental techniques and in rare occasions through randomized experimental design of the study. While not visible in Table 5, we did note a trend towards the increased use of more sophisticated approaches in attempts to adjust for endogeneity, such as via instrumental variables, fixed effects, difference-in-differences, matching and discontinuity design. Table 5. Number of papers reviewed, by methodology Single-equation multivariate 26 analysis Instrumental variables 8 Fixed effects 6 Matching estimates 1 Discontinuity design 1 Difference-in-differences 1 Other 12 Note: Total exceeds 53 because some studies used more than one analytic method. Source The selected readings were mostly journal articles, all peer-reviewed. We did however take into account specific working paper series that meet certain quality criteria, mostly NBER working papers. The decision to include these papers was driven by the impression that in most recent years there has been a growing interest in this field of research, the insights of which would be missed if we limited ourselves to journal articles. The journal versus working paper ratio is in Table 6. While it can sometimes be hard to unambiguously attribute a given journal to a specific subject, most of the journals in which the articles appeared were health related, although a significant number came from economic sources, including the NBER working papers (see Table 7). 3 That said, there are of course cases in which a single equation multivariate regression is sufficient to assess causality but this cannot be assumed as given and would need to be tested. 11

20 Table 6. Number of papers reviewed, by journal article versus working paper Journal 43 Working papers and discussion 10 papers TOTAL 53 Table 7. Number of papers reviewed, by field Health 32 Economics 20 Education 3 Policy 3 Sociology 2 Demography 2 Note: Total number of reviewed papers by field exceeds 53 because some sources address more than one field. Qualitative findings All relevant evidence on the relationship between health and education outcomes was to be examined in the review. However, the existing research overwhelmingly suggests, as shown in Table 8, that health conditions and risk factors are significantly and negatively correlated with educational achievement and academic performance, while physical exercise appears to be positively correlated with educational outcomes. At least on the face of it, this is a rather impressive result, even with the caveat that most empirical research may bear a bias in published work. Table 8. Number of papers reviewed, by findings Significant impact 49 No significant impact 4 TOTAL 53 Impact of health-related behaviours and risk factors on educational outcomes: detailed findings Underage drinking, increasing marijuana use since the 1990s, smoking and obesity are some of the key public health concerns in high-income countries (Chatterji, 2006; Miller, 2007; Yolton et al., 2005, Datar and Sturm, 2006). Despite the general association between these risky behaviours during childhood and adolescence and poorer long-term developmental outcomes, it is only recently that researchers have attempted to accurately estimate this effect, particularly with regard to education. To the best of our knowledge, this is the first systematic review conducted to date of the literature assessing the impact of these health-related behaviours on educational outcomes. Potential endogeneity issues, sample representativeness and measurement problems account for the main difficulties faced in estimating the causal impact of health-related behaviours on education. As mentioned in the description of the framework, all these health risk factors are often correlated between them, plus there may be a third set of unobservable factors that influence both education and health. Recent research attempts to overcome these confounding problems using panel data and methodological techniques such as instrumental variables. While the need remains for further research that allows establishing causality with certainty, the existing literature does provide a fair amount of good-quality evidence with relevant policy implications. Overall, there is an additional need to further explore these linkages in OECD countries other than the United States, since such research is lacking in the former. 12

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