Dr. Deniz Karaoglan got her B.A and M.A degrees from Bilkent University Economics Department in 2007 and 2009 respectively. She got her Ph.d degree from Middle East Technical University in September 2015. She worked as teaching and research assistant in Bilkent University, Yasar University, Hacettepe University and Middle East Technical University between 2007 and 2015. Now, she is working as part-time instructor in Middle East Technical University, Economics Department. She is expected to work as post-doctoral research associate in the University of York, UK, beginning from March 2016. Her main interests are health economics, education economics, microeconometrics, labor economics, applied microeconomic theory, time series and international economics. Dr. Karaoglan has publications on female labor force participation and international economics in SSCI journals.
The relationship between health and education has been examined widely in the literature. The association between health and education is simply called “education gradient of health”. Grossman (1972) is one of the earliest papers that provide formal explanations of the observed differences in health outcomes by education. Recent studies which examine the validity of education gradient of health include Eide and Showalter (2011), Brunello et al. (2015), Kemptner et al. (2011), Fonseca and Zheng (2011), Silles (2009), Cutler and Llearas Muney (2010), Grossman(2008), Conti et al. (2010), Arendt (2005), Llears-Muney (2005) and Adams (2002). All of these studies find positive association between the individual’s health outcome and education level. The possible mechanisms for the positive relationship between health and education can be listed as follows: First, education results in greater access to health care. Second, since educated people have better jobs they work in safer environments, they are provided with better health insurance. Third, education offers better futures, thus, the individuals are more likely to invest in their health to protect that future. Finally, more educated people are better informed, hence, they make use of new health related information first. (Cutler and Llears Muney, 2010). The relationship between individual’s health outcome and education level is examined widely for developed countries. However, there is less evidence on this issue for developing countries. The aim of this study is to examine the causal relationship between health and education in Turkey which is a middle-income, developing country.
In this study, a descriptive analysis is provided in order to test the validity of the education gradient of health in Turkey for the individuals who are above 25 years of age since approximately at age 25 individuals complete their schooling in Turkey. By restricting the sample to individuals who are 25 or over it is expected to circumvent the problem of individuals who have not yet completed their education. For the analysis, the Turkish Health Survey (THS) is pooled for the years 2008, 2010 and 2012 prepared by Turkish Statistical Institute (TURKSTAT). THS is a rich micro data set which consists of 46,473 observations for the three years for individuals 25 and over. The pooled sample consists of 21,015 observations for men and 25,458 observations for women. Individual’s Self-Assessed Health Status (SAH), smoking, alcohol consumption, obesity and the usage of preventative health care services are used as the health outcomes throughout the analysis.
Figure 1. How do the individuals above 25 feel themselves in Turkey?
Figure 2. SAH and Education Level in Turkey
Figure 1 reflects that 59.28 per cent of the individuals who are 25 years old or older report that their health statuses are good or very good in Turkey. Figure 2 suggests that in Turkey the prevalence of reporting very good and good health is highest among the individuals who have university or higher degree. It is observed that observe that the frequency of reporting very poor and poor health is highest among the illiterate individuals. The figure clearly reflects the fact that higher levels of education lead to increase in the frequency of reporting very good and good health and they lead to decrease in the occurrence of reporting very poor and poor health. Therefore, the descriptive statistics indicate the positive association between SAH and education level in Turkey.
Smoking is one of the most harmful health behaviors. Regular smokers are in great risk for cardiovascular disease, chronic lung disease and several types of cancer (Stewart et al., 2009; Chalupka and Warner, 2000). In THS data set smoking does not imply tobacco consumption only. It also includes other types of tobacco products such as cigars. An individual is defined as smoker if he/she reports that he/she has been a regular smoker and he/she currently smokes.
Figure 3. Prevalence of Smoking by Education Level in Turkey
Figure 3 reveals that probability of being smoker rises with education levels at the bottom education degrees and the prevalence of smoking is the highest among middle school graduates. However, the ratio of smoking decreases if the individual has higher degrees than middle school. It is observed that the ratio of the individuals who report that they are regular smokers decreases to 30.42 per cent among the university graduates. Therefore, it is possible to state that the awareness of dangers of smoking increases with higher education levels.
According the OECD (2014) Health Data set, only 1.4 per cent of adult population in Turkey consumes alcohol. This amount is very low compared to other OECD countries. The low percentage of alcohol consumption in Turkey is most probably due to religious traditions which prohibit alcohol consumption. Similarly, in THS the proportion of daily alcohol drinkers is very low, less than one percent (0.5 per cent, 0.4 per cent and 0.2 per cent in 2008, 2010 and 2012 respectively). In order to capture the variation in alcohol consumption, the daily and occasional alcohol drinkers are combined and call them as “alcohol drinkers” in our analysis. In other words, an individual is referred as alcohol drinker if the individual states that he/she currently consumes alcohol regularly or occasionally.
Figure 4. Prevalence of Alcohol Consumption by Education Level in Turkey
Figure 4 reveals that the occurrence of alcohol consumption increases as level of education increases and it is highest among the university or higher graduates. This interesting result can be explained by three facts: First, people who have higher degrees are more involved in social networking activities, and they can drink more in these kinds of activities. Second, the people who have higher degrees of education can be more comfortable to state that they are regular or occasional alcohol consumers. Third, as Kenkel (1991) suggests, more educated people may know that some drink is good for health, hence they drink more than the others.
Obesity is an increasing health problem in Turkey. It is important to analyze the determinants of obesity as it is a major source of certain diseases such as cardiovascular diseases, diabetes, and joint problems (Stewart et al., 2009). OECD (2012) Health Data indicate that 17.2 percent of working age population in Turkey is considered to be obese. BMI is used as a tool for determining if an individual is overweight or obese. An individual is considered as obese if his/her BMI is greater than 30, overweight if his/her BMI is greater than 25 and underweight if his/her BMI is under 18.5 according to World Health Organization (WHO) criteria. The BMI in our study is computed from the self-reported height (in centimeters) and weight (in kilograms) in the THS. An individual’s BMI is calculated by dividing the self-reported weight of respondent (in kilograms) to the square of the self-reported height in meters.
Figure 5. Prevalence of Obesity by Education Level in Turkey
Figure 6 reveals that the prevalence of obesity decreases by education level and it is higher among illiterate and non-graduate individuals. The figure shows that the occurrence of obesity is lowest among the university graduates. Hence, it is possible to say that the awareness of dangers of obesity increases with higher education levels. Of course, one should note that people with lower education levels generally have lower earnings. Therefore, they cannot purchase foods with protein easily, instead they have to buy foods with high glycemic indices such as bread, sugar, patato, etc…These kinds of foods cause them to gain weight. In addition, those people do not have enough chance to exercise, which can fasten their metabolism.
Cutler and Llears-Muney (2010) claim that people with higher education are more careful about the usage of preventative services. They prove their claim by using the US data set. The same result is expected for Turkey also, since it is widely acceptable that higher educated individuals are making more investments to their health, so take care of themselves more than the others. In this study measuring the blood pressure, cholesterol and blood sugar as well as having regular controls of prostate (for males) and mammography and smear (for females) are considered as preventative health care services.
Figure 6. The Usage of Preventative Health Care Services by Education Level in Turkey (Blood Pressure, Blood Sugar and Cholesterol)
Figure 7. The Usage of Preventative Health Care Services by Education Level in Turkey (Prostate (Males), Mammography and Smear (Females))
Figure 6 reveals that the prevalence of measuring the blood pressure, blood sugar and cholesterol is highest among the individuals with lowest degrees of education and it decreases by education level. However, the ratio of using these services increases if the individual has higher than middle school degree. In fact, the investigation of the correlation between the usage of these services and SAH indicates that it is negative, which implies, people who are already ill make use of preventative health care services. It is not surprising that people who have lower levels of education (thus, most probably lower earnings) have worse health conditions. Nevertheless, the increase in usage of these services among higher educated individuals reflects the increase in awareness.
Regarding the other controls, it is observed that the awareness of the importance of having regular mammography and smear controls increases as the education level increases among females. Related to males, it is observed that having prostate control is higher among the males who are illiterate or do not have degree. However, the prevalence of prostate control increases if the male has university or higher degree. Similar to the other controls, a negative association between having the genital controls and SAH is observed. Therefore, having higher levels of prostate controls among lower educated groups can be attributed to the having health problems. Therefore, in Turkey it is possible to conclude that people prefer to use preventative health care services when they are ill, however higher individuals are more likely to use these services due to higher awareness.
As a conclusion, the frequency of reporting very good and good SAH increases by education level in Turkey. It is also observed that having higher levels of education has preventative effects on reducing the risky behaviors such as smoking and having high levels of BMI. However, it is concluded that alcohol consumption increases by education level in Turkey. Lastly, it is possible to state that the awareness of using the preventative health care services is highest among the individuals who have university or higher degrees.
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