Background: Low educational attainment is frequently associated with poorer health and increased mortality, but evidence in this field has been dominated by research conducted in Europe and North America. For this reason, there is a severe lack of data in the High-Income Asia Pacific region despite the increased political attention on health inequalities in recent decades. Therefore, there is a need for a comprehensive synthesis of available data to allow for the monitoring of inequalities across time and to provide a foundation for policy decisions. As a result, this study aims to analyze the relationship between educational attainment and all-cause mortality of adults in the High-Income Asia Pacific region.
Methods: This study is a comprehensive systematic review and meta-analysis including available literature on the effect of educational attainment on adult all-cause mortality in the High-Income Asia Pacific region. A global literature search of 7 databases was completed in November and December 2019. Independent reviewers screened abstracts and full-texts for eligibility and the presence of individual-level data on educational attainment and adult mortality. Individual-level data from included studies were used to calculate risk ratios (RR) and 95% confidence intervals (CI) for three harmonized educational groups: Primary, Secondary, and Tertiary. Random-effects meta-analyses using tertiary education as the reference group were conducted to evaluate the overall effect of education on mortality, and stratified analyses were conducted to assess this effect by sex and age group.
Results: Literature searches resulted in over 15,000 sources screened for inclusion. A total of 30 articles meeting inclusion criteria with data from the High-Income Asia Pacific region were included for this review. Individual-level data from 10 studies were included in the meta-analyses. Results from the meta-analyses showed an overall risk ratio of 2.72 (95% CI 2.01-3.69) for primary education and an estimate of 1.30 (95% CI 1.10-1.53) for secondary education. In stratified analyses, females with primary education had an increase in the risk of mortality (RR 2.85, p ˂ 0.01), as did secondary educated females (RR 1.33, p = 0.03). Males with primary and secondary education had a 129% (p ˂ 0.01) and 34% (p = 0.01) increase in risk, respectively. Those aged 30-64 with primary education displayed a 211% increase (p ˂ 0.01), while those with secondary education showed a 92% increase in risk (p ˂ 0.01). Conversely, those aged 65+ with primary education had a slight increase in risk (RR 1.23, p = 0.02), while those with secondary education did not show a significant increase (RR 1.14, p = 0.32).
Conclusion: The results indicate that lower educational attainment is associated with an increase in the risk of all-cause mortality for adults in the High-Income Asia Pacific region. We found no significant difference in risk between males and females but a significantly larger risk for younger cohorts. This study offers empirical support for the development of policies to reduce health disparities across the educational gradient and universal access to all levels of education.
Keywords: education, Asia Pacific, inequality, mortality, life-expectancy, health inequalities, inequity, educational attainment