摘要：Objectives. We tested whether self-rated health has improved over time (1972–2002) for women and men. We also considered the degree to which historical gains in educational attainment help to explain any observed trends. Methods. Using 21 years of repeated cross-sectional data from the General Social Survey, we estimated a series of ordered logistic regression models predicting self-rated health. Results. Our results show that women’s health status has steadily improved over the 30-year period under study, and these improvements are largely explained by gains in educational attainment. We also found that the health trend for men is nonlinear, suggesting significant fluctuations in health status over time. Conclusions. Based on the linear health status trend and strong mediation pattern for women, and the nonlinear health status trend for men, women have benefited more than men, in terms of self-rated health, from increased educational attainment. The National Center for Health Statistics recently issued a report showing that the overall health of the US population has improved over the past 50 years. 1 This report confirms that the health of the nation has improved across a range of outcomes, including health behaviors (e.g., smoking), self-rated health, and all-cause and cause-specific mortality. If the health of the US population has improved over the years, what factors might mediate or explain this trend? Some of the trend may be attributable to health education, public health programs, health research, and health care; however, it is unlikely that these factors alone have driven the trend toward better health. We used 21 years of repeated cross-sectional data to test whether self-rated health status has indeed improved over time and whether historical gains in educational attainment help to explain this trend. Aggregate gains in educational attainment over the past 30 years have been well documented. 2 , 3 In 1975, for example, 63% of adults aged 25 years and older had a high school diploma, and 14% had a bachelor’s degree or higher. By 2000, 84% of adults had completed high school, and 26% had a bachelor’s degree or higher. If educational attainment has improved over time, could this trend be responsible for changes in the health of the US population? Our central proposition that trends in educational attainment could explain trends in health is largely based on research that shows that higher education predicts better health. In general, there are two explanations for the association between socioeconomic status (SES) and health. One explanation is that SES determines health status. The other explanation is that health status determines SES. Although there is some evidence to suggest that poor health might undermine SES, the majority of studies report that SES predicts health. 4 Numerous studies show that the well educated tend to be healthier, both mentally and physically, than the less-well educated. 5 – 11 Education indirectly affects health through its association with economic resources and productive activities. Education increases household income and reduces financial hardship, which negatively impacts health. The well educated tend to work full time and to have jobs that are safe and intrinsically rewarding, which contributes to better health. 5 Education also shapes resources that promote health and well-being. For example, education enhances a sense of personal control, which facilitates a healthy lifestyle, characterized by regular exercise, moderate alcohol use, and the avoidance of obesity and smoking. Formal schooling develops skills and abilities that can be used to solve a variety of problems, including those related to productivity and health. 5 In general, education serves as a fundamental determinant of health because it influences access to important resources (e.g., money, power, and prestige) that can be used to avoid risks and to minimize the consequences of ill health. 12 Although both women and men have experienced gains in educational attainment over the past 30 years, these gains may have benefited the health of women and men differently. Mirowsky and Ross’ theory of resource substitution proposes that individuals who have multiple material and/or psychosocial resources at their disposal may benefit less from the addition of any specific resource. 5 , 13 Conversely, resource substitution implies that the effect of having any specific resource is greater for individuals who have fewer resource alternatives. Because women have been historically disadvantaged in terms of socioeconomic position, status, and power, 14 it is reasonable to expect that gains in educational attainment have had a greater influence on the trend toward better health for women than for men. Preliminary evidence already suggests that the effect of education on depression is stronger for women than for men. 13 We examined three important research questions. First, has self-rated health actually improved over the past 30 years for women and men? Second, do historical gains in educational attainment over this period help to mediate or explain these improvements? Finally, does the mediating influence of education differ for women and men?
