Intergenerational educational trajectories and premature mortality from chronic diseases: A registry population-based study

The tracking of educational gradients in mortality across generations could create a long shadow of social inequality, but it remains understudied. We aimed to assess whether intergenerational educational trajectories shape inequalities in early premature mortality from chronic diseases. The study included 544 743 participants of the Swiss National Cohort, a registry population-based study. Individuals were born between 1971–1980 and aged 10–19 at the start of the study (1990). Sex-specific inequalities in mortality were quantified via standardized cumulative risk differences/ratios between ages 20 and 45. We triangulated findings with a negative outcome control. For women, inequalities were negligible. For men, while inequalities in cancer deaths were negligible, inequalities in CVD mortality were associated with low individual education regardless of parental education. Excess CVD deaths for Low–High was negligible while High–Low provided 234 (95% confidence intervals: 100 to 391) and Low–Low 185 (115 to 251) additional CVD deaths per 100 000 men compared to High–High. That corresponded to risk ratios of 2.7 (1.6 to 4.5) and 2.3 (1.6 to 3.4), respectively. Gradients in substance use mortality were observed only when education changed across parent-offspring. Excess substance use deaths for Low–Low was negligible while High–Low provided 225 (88 to 341) additional and Low–High 80 (23 to 151) fewer substance use deaths per 100 000 men compared to High–High. That corresponded to risk ratios of 1.8 (1.3 to 2.5) and 0.7 (0.5 to 0.9), respectively. Inequalities in premature mortality were driven by individual education and by parental education for some chronic diseases. This could justify the development of intergenerational prevention strategies.

• Higher premature mortality rates have been consistently observed in individuals with lower educational attainment compared to those with higher education across Western societies. According to the theory of fundamental causes of inequalities in health and mortality, education provides material and non-material resources encompassing accrued knowledge, healthy behaviors, higher job market return, and beneficial social relations, which all act on health in a protective way. Additionally, the putative causal effect of education on mortality has been corroborated by natural experiments leveraging compulsory schooling laws, and by experimental and twin studies. Notably, a review of all these studies points to some differences by context and sex, suggesting that men experience larger educational inequalities in health than women.

  While the relationship between individual education and premature mortality has been extensively documented, little is known about how intergenerational educational trajectories, that is the sequence of both parental and individual attained education, may impact mortality. Socialization theory predicts that health-related behaviors, social norms, and beliefs are transmitted across generations whilst being also influenced by the schooling environment. Thus, the familial environment may contribute to the amount of cultural and social capital a person has access to, and eventually to social inequalities in health. This hypothesis is particularly relevant for inequalities in chronic. Consequently, by assessing the effect of both parental and individual educational exposure via intergenerational trajectories we may expand our knowledge about the processes underlying educational inequalities in mortality related to CDs and inform public health actions. While the education attained by an individual is partly affected by that of their parents, various social theories endow different predictions of how these two educational exposures may impact health. A theory of cumulative advantage or resource multiplication predicts that both parental and individual education drive inequalities; a theory of resource substitution predicts that only individual education drives inequalities; and finally a theory of social mobility predicts that only the direction of change – upward or downward – across the two matters. Disentangling these alternative models with empirical data is important for public health, as each theory provides a set of different entry points – identification of groups at higher risk or prioritization of family and/or institution-related educational exposure – for informing actions to reduce educational inequalities in premature mortality due to CDs.

  • Three studies, two from Finland and one from Belgium, have explicitly investigated the parental/individual educational inequalities in premature mortality related to CDs.
  • Despite the heterogeneity in the examined CDs and birth cohorts, overall these studies broadly supported the resource substitution theory, with some exceptions. Specifically, Elo et al. reported that among Finns born before 1950, inequalities in cardiovascular-related deaths were consistent with the resource multiplication theory.
  • To corroborate these findings, more research is needed in other contexts, that is in other countries and birth periods, while discerning among different categories of CDs. The study from De Grande et al. included Belgian young adults born after 1971 and examined only one category of CD-related mortality, which is cancer.
  • In this study, we aimed to utilize population-based multi-generational registry data to assess the role of parental and individual educational attainment in driving inequalities in mortality due to specific categories of chronic diseases among contemporary Swiss young adult men and women.
  • Importantly, the mortality of young adults may help to identify early-life risk factors to intervene upon for delaying or reducing the burden of mortality in older life, to which chronic diseases such as cancers and cardiovascular diseases are the largest contributors.
  • We implemented a counterfactual-based framework to assess inequalities and ran a negative outcome control to triangulate findings.