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Health equity means all people have a fair and just opportunity to be as healthy as possible. This requires removing economic and social, demographic or geographic obstacles to health, such as poverty and discrimination.
Progress toward achieving health equity is measured by health disparities, which can be identified by analyzing differences across such groups as race-ethnicity, gender, age, economic status and/or educational attainment. This section of America’s Health Rankings Annual Report examines health equity across the states by looking at differences in health by education.

Health and Education

Education is a very strong predictor of health disparities. Higher educational attainment is associated with better jobs and higher earnings, increased health literacy and greater access to resources to pursue a healthy lifestyle. These resources include healthier foods, regular exercise, health services and transportation, and safer housing and neighborhoods. Individuals with more education tend to have fewer negative health behaviors and better health outcomes compared with those with less education. Among adults aged 25 and older without a high school diploma, life expectancy is four to five years shorter than college graduates. This is why America’s Health Rankings Annual Report examines high school graduation rates across the states each year. Graduation rates have a profound impact on health.
This year's report continues to show wide state-level variation in high school graduation by race and ethnicity and in health measures where education-level subpopulation data are available. These include behaviors such as excessive drinking, obesity, physical inactivity and smoking; clinical care measures such as low birthweight; and outcomes measures such as diabetes, frequent mental distress and frequent physical distress.

High School Graduation

Nationally, the four-year high school graduation rate among U.S. students has increased annually since 2013, reaching its highest level in America’s Health Rankings history at 84.1 percent of students in 2018. By state, graduation rates vary 1.3-fold from 91.3 percent of students in Iowa to 71.0 percent in New Mexico. Further, graduation rates vary widely by race and ethnicity (Figure 37). The five states with the highest high school graduation rates for white students ranged from 92.6 percent in Nebraska to 94.2 percent in New Jersey. For Hispanic students, the five states with the highest graduation rates ranged from 85.7 percent in Arkansas to 89.0 percent in Vermont. For black students, the five states with the highest graduation rates ranged from 82.9 percent in North Carolina to 88.0 percent in West Virginia. The state with the highest high school graduation rate for black students, West Virginia, is lower than the graduation rate among white students in 28 states, and the state with the fifth highest graduation rate for black students, North Carolina, is lower than the graduation rate among white students in 42 states.

Health Disparities by Education

Disparities emerge among many measures across the states when analyzing health behaviors, clinical care and outcomes by education level (less than a high school education, high school graduate, some college and college graduate). Three views including national prevalence, trend over time, and state and national variation provide multiple perspectives on disparities by educational attainment for various health measures in this report.
Adults aged less than 25 were excluded from our analysis to accurately measure educational attainment with the exception of low birthweight where moms of all ages were included. For some states, not all education levels were used. Only education levels with sufficient sample size in a state were compared. Values were suppressed if the sample size was less than 50 respondents or the relative standard error was greater than 30 percent. For example, excessive drinking among adults with less than a high school education is not available for Alaska, so the state was excluded from the state comparison graphic.

Excessive Drinking

Nationally, the prevalence of excessive drinking among adults aged 18 and older is 19.0 percent. Unlike other health behaviors, higher educational attainment is associated with a greater prevalence of this negative health behavior on average. Among adults aged 25 and older, college graduates (18.5 percent) and those with some college (18.4 percent) have a significantly greater prevalence of excessive drinking compared with those who did not graduate from high school (14.5 percent) (Figure 38).



Figure 39 shows a gap in the prevalence of excessive drinking at the national level has widened over the past six years between those who did not graduate from high school and high school graduates, adults with some college and college graduates (Figure 39).


The state with the largest difference in excessive drinking by education is Massachusetts with a 13.5 percentage point difference between adults with some college (23.0 percent) and adults who did not graduate from high school (9.5 percent)(Figure 40). There is little disparity in excessive drinking by education in Mississippi, with a 1.8 percentage point difference between adults who graduated from high school (12.2 percent) and college graduates (14.0 percent).

Obesity

Nationally, the prevalence of obesity among U.S. adults aged 18 and older has increased on average 2.2 percent annually since 2012 — and it has exceeded 30 percent for the first time in 2018 at 31.3 percent of adults. Among adults aged 25 and older, obesity prevalence is significantly lower among college graduates (23.3 percent) compared with other education levels (Figure 41); however, it is increasing year-to-year for each education level (Figure 42).


Figure 42 also shows a gap has persisted over the past six years, particularly between college graduates and all other education levels (less than high school education, high school graduate and some college).


Vermont has the widest variation in obesity by education with a 28.3 percentage point difference between adults who did not graduate high school (48.1 percent) and college graduates (19.8 percent)(Figure 43). There is little disparity in obesity by education in Nebraska, with a 7.4 percentage point difference between adults who did not graduate from high school (37.4 percent) and college graduates (30.0 percent).

Physical Inactivity

Nationally, the prevalence of physical inactivity among adults aged 18 and older is 25.6 percent. Among adults aged 25 and older, prevalence of physical inactivity is 2.9 times higher among those who did not graduate from high school (44.2 percent) than among college graduates (15.5 percent). At the national level, the prevalence of physical inactivity is statistically different at each education level (Figure 44).


Over the past six years, significant gaps in the prevalence of physical inactivity have persisted between all education levels. In this time span, prevalences have increased among all levels (Figure 45).


Virginia has the widest variation in physical inactivity by education with a 37.6 percentage point difference between adults who did not graduate from high school (51.7 percent) and college graduates (14.1 percent)(Figure 46). In Alaska, the state with the smallest gap, there is a 13.3 percentage point difference between high school graduates (27.1 percent) and college graduates (13.8 percent). Compared with other education levels, there is more variation in physical inactivity prevalence by state among adults who did not graduate from high school.

Smoking

Nationally, the prevalence of smoking among U.S. adults aged 18 and older has decreased over the past six years from 21.2 percent in 2012 to 17.1 percent in 2017 and 2018. Among adults aged 25 and older, the prevalence of smoking is significantly lower among college graduates (6.5 percent) compared with all other education levels (Figure 47). The prevalence in 2018 was 4.2 times higher among those who did not graduate from high school than among college graduates. At the national level, the prevalence of smoking is statistically different at each education level.


While smoking has decreased across all education groups over the past six years, significant gaps remain between levels with the most pronounced gap being between college graduates and those who did not graduate from high school. This gap has widened from a 3.5-fold difference in 2012 to a 4.2-fold difference in 2018 (Figure 48).


Tennessee has the widest variation in smoking by education level with a 35.8 percentage point difference between adults who did not graduate from high school (42.7 percent) and college graduates (6.9 percent)(Figure 49). In California, the state with the smallest gap, there is an 11.7 percentage point difference between high school graduates (16.9 percent) and college graduates (5.2 percent). Compared with other education levels, there is more variation in smoking prevalence by state among adults who did not graduate from high school.

Low Birthweight

Nationally, the prevalence of low birthweight has increased on average 0.69 percent annually since 1993. It reached its highest level in 2018 at 8.2 percent of live births, a high that had previously occurred only between 2008 to 2011. The prevalence of low birthweight is lower among college graduates (6.9 percent) compared with other education levels (Figure 50). While low birthweight has been stable among college graduates it has increased over this time period among other maternal education levels (Figure 51).


Figure 51 also shows a gap has widened over the past nine years, particularly between college graduates and all other education levels (less than high school education, high school graduate, and some college). This gap has widened from a 1.2-fold difference in 2009 to a 1.4-fold difference in 2018.


West Virginia has the widest variation in low birthweight by education with a 6.3 percentage point difference between moms who did not graduate from high school (13.8 percent) and the group with the lowest prevalence, college graduates (7.5 percent)(Figure 52). In California, the state with the smallest gap, there is a 0.7 percentage point difference between moms who did not graduate from high school (7.1 percent) and college graduates (6.4 percent). Compared with other education levels, there is more variation in low birthweight prevalence by state among moms who did not graduate from high school.

Diabetes

Nationally, the prevalence of diabetes among adults aged 18 and older is 10.5 percent. Among adults aged 25 years and older, diabetes prevalence is significantly lower among college graduates (7.3 percent) compared with all other education levels (Figure 53). Prevalence in 2018 was 2.6 times higher among those who did not graduate from high school than among college graduates. At the national level, the prevalence of diabetes is statistically different at each education level.


Over the past six years, significant gaps in the prevalence of diabetes have persisted between all education levels (Figure 54).


Massachusetts has the widest variation in diabetes by education with a 19.3 percentage point difference between adults who did not graduate from high school (24.5 percent) and college graduates (5.2 percent)(Figure 55). In Nevada, the state with the smallest gap, there is a 4.4 percentage point difference between adults with some college education (12.8 percent) and college graduates (8.4 percent). Compared with other education levels, there is more variation in diabetes prevalence by state among adults who did not graduate from high school.

Frequent Mental Distress

Nationally, the prevalence of frequent mental distress among adults aged 18 and older is 12.0 percent. Among adults aged 25 and older, the prevalence of frequent mental distress is 2.4 times higher among those who did not graduate from high school (17.2 percent) than among college graduates (7.1 percent) (Figure 56).


Over the past six years significant gaps in the prevalence of frequent mental distress have persisted, most prominently between those who did not graduate from high school and college graduates. This gap has narrowed from a 2.9-fold difference in 2012 to a 2.4-fold difference in 2018 (Figure 57).


Arkansas has the widest variation in frequent mental distress by education with a 22.6 percentage point difference between adults who did not graduate from high school (30.4 percent) and college graduates (7.8 percent)(Figure 58). In South Dakota, the state with the smallest gap, there is a 4.8 percentage point difference between adults who did not graduate from high school (10.9 percent) and college graduates (6.1 percent). Compared with other education levels, there is more variation in frequent mental distress prevalence by state among adults who did not graduate from high school.

Frequent Physical Distress

Nationally, the prevalence of frequent physical distress among adults aged 18 and older is 12.0 percent. Among adults aged 25 and older, prevalence of frequent physical distress is 3.3 times higher among those who did not graduate from high school (22.6 percent) than among college graduates (6.9 percent)(Figure 59). At the national level, the prevalence of frequent physical distress is statistically different at each education level.


Over the past six years, significant gaps in the prevalence of frequent physical distress have persisted, most prominently between those who did not graduate from high school and college graduates (Figure 60).


Kentucky has the widest variation in frequent physical distress by education with a 31.6 percentage point difference between adults who did not graduate from high school (39.7 percent) and college graduates (8.1 percent)(Figure 61). In Nevada, the state with the smallest gap, there is a 9.4 percentage point difference between adults with some college education (17.4 percent) and college graduates (8 percent). Compared with other education levels, there is more variation in frequent physical distress prevalence by state among adults who did not graduate from high school at the state level.

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