Reliability of educational attainment of survey respondents: an overlooked barrier to comparability?

Nominal comparability is not enough: (In-)equivalence of construct validity of cross-national measures of educational attainment in the European Social Survey

Background:In multiple sclerosis (MS), the educational gradient in diagnostic and disease-modifying treatment (DMT) delays is sparsely examined, and the results are mixed.Objectives:Among patients with relapsing-remitting MS (RRMS), we aimed to examine the educational gradient in diagnostic delay and delay in the initiation of the first DMT.Design:A nationwide cohort study.Methods:We linked the Danish Multiple Sclerosis Registry with other nationwide registries. Diagnostic delay was evaluated in 4344 patients ⩾20 years at clinical onset with clinical onset from January 1, 2012, onwards, diagnosed by March 1, 2023. DMT delay was evaluated in 5402 patients ⩾20 years at MS diagnosis who were diagnosed from January 1, 2012, to March 1, 2022, with DMT initiation follow-up until March 1, 2023. The highest completed education before onset and diagnosis, respectively, was categorized using the International Standard Classification of Education (ISCED) into low (ISCED 0–2), medium (ISCED 3–4) and high (ISCED ⩾5) education. Endpoints were categorized according to their duration into four groups based on a population-specific quartile split. The highest quartile comprised long duration (⩾500 days (diagnostic delay) and ⩾76 days (DMT delay)). We calculated crude and adjusted odds ratios (OR) with 95% confidence intervals (CI).Results:The mean age was 36.7 years (SD = 10.3, diagnostic delay population) and 39.2 years (SD = 10.9, DMT delay population). Most were female (67.4% and 68.3%) and of Danish origin (90.3% and 90.5%). Patients with low educational attainment did not have higher odds of diagnostic delay (OR = 1.05; 95% CI: 0.81–1.35) but had higher odds of DMT delay (OR = 1.48; 95% CI: 1.17–1.87) compared to patients with high educational attainment.Conclusion:In adult patients with RRMS, low educational attainment was associated with higher odds of DMT delay but not diagnostic delay. Targeted interventions are needed to address educational disparities in healthcare access and treatment initiation.

The International Standard Classification of Education (ISCED) is a tool for harmonising education-related information. It covers almost all countries in the world and is centrally maintained and documented by UNESCO Institute for Statistics. ISCED is commonly used in official statistics and surveys (e.g. by OECD and Eurostat), but it is also increasingly used for the measurement of educational attainment in academic cross-national surveys. ISCED has been revised between 2008 and 2011, and the new version was adopted by the UNESCO General Conference in November 2011. This research note describes ISCED 2011 and the most important changes as compared to the previous version, ISCED 1997, with a special focus on educational attainment. A brief discussion of strengths and weaknesses of the classification as well as future challenges conclude the note.

Increasing educational attainment (EA) could decrease the occurrence of depression. We investigated the relationship between EA and depressive symptoms in older individuals across four European regions. We studied 108,315 Europeans (54% women, median age 63years old) from the Survey on Health, Ageing and Retirement in Europe assessing EA (seven educational levels based on International Standard Classification of Education [ISCED] classification) and depressive symptoms (≥4 points on EURO-D scale). Logistic regression estimated the association between EA and depressive symptoms, adjusting for sociodemographic and health-related factors, testing for sex/age/region and education interactions. Higher EA was associated with lower odds of depressive symptoms, independent of sociodemographic and health-related factors. A threshold of the lowest odds of depressive symptoms was detected at the first stage of tertiary education (OR 0.60; 95% confidence interval [CI] 0.55-0.65; p<0.001; relative to no education). Central and Eastern Europe showed the strongest association (OR for high vs. low education 0.37; 95% CI 0.33-0.40; p<0.001) and Scandinavia the weakest (OR for high vs. low education 0.69; 95% CI 0.60-0.80; p<0.001). The association was strongest among younger individuals. There was a sex and education interaction only within Central and Eastern Europe. Level of EA is reflected in later-life depressive symptoms, suggesting that supporting individuals in achieving EA, and considering those with lower EA at increased risk for depression, could lead to decreased burden of depression across the life course. Further educational support in Central and Eastern Europe may decrease the higher burden of depressive symptoms in women.

Decision letter: Nationwide participation in FIT-based colorectal cancer screening in Denmark during the COVID-19 pandemic: An observational study

BackgroundEducation, as a proxy for cognitive reserves, has been linked to dementia; however, the association between education attainment and brain health remains unclear. We aim to investigate the association between education attainment and neuroimaging based brain‐predicted age difference (BPAD, the difference between brain age and chronological age).MethodThe study included 32,322 chronic neurological disease‐free participants (mean age 54.74 ± 7.49 years, 46.58% female) who underwent brain MRI scans 9+ years after baseline. Years of education were self‐reported and categorized as low (7 and 10 years), medium (13, 15, and 19 years), and high (20 years) according to the International Standard Classification of Education. BPAD was predicted based on 1,079 multimodal imaging‐derived phenotypes (including structural and functional MRI) by a LASSO machine learning model. Alzheimer's disease‐related polygenic risk score (PRSAD) was tertiled as low, moderate and high. Data were analyzed using linear regressions.ResultAt baseline, 6,332 (19.59%), 10,872 (33.64%), and 15,118 (46.77%) participants had low, medium, and high education, separately. Compared to low education, high education (β [95% CI]: ‐0.230 [‐0.392, ‐0.067]) was related to more negative BPAD. In joint‐effect analysis, the β (95% CI) of BPAD was ‐0.542 (‐0.796, ‐0.289) among participants with high education and low‐to‐moderate PRSAD, compared to those with low education and high PRSAD.ConclusionHigh education attainment was associated with more negative BPAD, particularly among people with a low‐to‐moderate genetic susceptibility for dementia.

All social science (and many other) surveys measure respondents’ educational attainment. However, most of them do it in different ways, resulting in incoherent education variables across surveys. This complicates the cumulation of different datasets and hampers survey data reuse. For cross-national surveys that are designed to be comparative from the outset, methods for ensuring comparability in the measurement of education across countries have improved substantially over the last decades, relying on ex-ante output harmonization. For ex-post harmonization, the situation is more difficult because the data have already been collected, with education measures that only partly overlap in the amount and kind of information they store about respondents’ education. This results in aggregated measures when harmonizing data ex-post. Such aggregated measures may underestimate associations with education in multivariate analyses, leading to biased results. They also do not allow testing hypotheses on the effects of specific types of education, such as vocational programs. This paper presents a new framework for harmonizing education variables ex-post, building on the International Standard Classification of Education (ISCED) and experience from cross-national surveys using ex-ante harmonization. It includes a new coding scheme called ‘generalized ISCED’ or GISCED, and extension variables standardizing aspects of education not covered by ISCED. It proposes solutions for problems that specifically occur in ex-post harmonization, for example source categories spanning ISCED levels. The paper also shows how to apply the GISCED framework to existing data. An empirical illustration shows how detailed harmonized education measures may give insights for research and policy not possible with more aggregate measures.

This chapter covers the development of cross-national survey research in general, focusing on the evolution of the field of comparative survey research and its major components. It discusses the contemporary situation including conditions in (a) the academic, governmental, and commercial sectors, (b) data resources and archives, (c) international academic, professional, and trade associations, (d) journals, and (e) the development of international standards and guidelines. The chapter explores the methodological challenges of conducting reliable and valid cross-national research, and illustrative findings from cross-national research, and the future prospects for further growth and methodological improvement. Cross-national survey research was stimulated during and immediately after World War II by the Allies who conducted public opinion research and established local organizations in the occupied countries. Globalization has expanded both the necessity for and existence of cross-national, survey research. Academic, professional, and trade associations are another important component of the comparative, survey-research community. Keywords: academic associations; archives; cross-national survey research; data resources; international standards; professional associations; public opinion

BackgroundEducational qualifications and literacy skills are highly related. This is not surprising as it is one aim of educational systems to equip individuals with competencies necessary to take part in society. Because of this relationship educational qualifications are often used as a proxy for “human capital”. However, from a theoretical perspective, there are many reasons why this relationship is not perfect, and to some degree this is due to third variables. Thus, we want to explore the net relationship between educational attainment (harmonized according to the International Standard Classification of Education, ISCED) and literacy skills, and how much skills vary within education levels across countries.MethodsWe use data from 21 countries from the Programme for the International Assessment of Adult Competencies 2012. This paper compares the literacy skills of adults who achieved different levels of educational attainment across countries. Given the high degree of educational differentiation in most countries, we do this using a more differentiated educational attainment variable than what is commonly used. In our analyses we firstly adjust for factors that are likely to affect access to education and the acquisition of educational qualifications and literacy skills, such as parental education and language and migration background. In a second step, we also take into account factors affecting skill development after initial formal education, such as occupation and skill use at home.ResultsWe firstly find a high degree of heterogeneity of skills across countries for equivalent education categories. Secondly, we find skill similarities for equivalent education categories classified at different broad education levels, sometimes even breaking the hierarchical order of ‘higher education entails higher competencies’.ConclusionWe conclude that ISCED levels cannot be taken as a cross-nationally comparable proxy for human capital in terms of literacy skills, and that education has to be harmonized in a substantively more meaningful way in future adult literacy surveys.

We examined the relationship between educational attainment (EA) and anxiety symptoms in a sample of 77,792 individuals (median age = 64 years, 55% female) from the Survey of Health, Ageing and Retirement in Europe. Using logistic regression, we estimated odds ratio (OR) with 95% confidence interval (CI) for the association between EA (7 educational levels based on International Standard Classification of Education) and anxiety symptoms (12 or more points from the shortened 5-item version of the Beck Anxiety Inventory), adjusting for sociodemographic and health-related factors. We further explored whether the relationship varied by region, sex and age group. Independent of sociodemographic and health-related factors, higher levels of EA were associated with lower odds of anxiety symptoms. The magnitude of this association plateaued at first stage of tertiary education (OR 0.40; 95% CI 0.35–0.47, p < 0.001). The association was stronger in females, middle-aged individuals and in Central and Eastern Europe while not apparent in Northern Europe. Our findings suggest that individuals with higher education might be protected against anxiety throughout life. The protective effect of education against anxiety symptoms is more pronounced in less egalitarian regions and in females.

Background: Low educational attainment and income are associated with a higher risk of adverse cardiovascular (cv) outcomes. Research Question: The impact of lower education and income levels on the risk of cv death defined as ischemic heart disease, ischemic stroke, or peripheral artery disease associated mortality, and how this compares to traditional cv risk factors including overweight/obesity, hypertension, type 2 diabetes, smoking history, frequent alcohol consumption, physical activity, and family history for heart disease. Methods: In this prospective study involving 396,614 participants of the United Kingdom Biobank (UKB) with no history of ischemic heart disease, ischemic stroke, or peripheral artery disease at enrollment, we divided participants into five groups according to annual household income as defined in UKB, and six groups of educational attainment created using the International Standard Classification of Education. Five BMI (kg/m2) categories were created (&lt;25; 25-29.9; 30-34.9; 35-39.9, ≥40). The association of education and income with cv death was assessed using Fine-Gray sub-distribution hazard models including covariate adjustment for age, sex, race, number of people in the household, spatial socioeconomic deprivation, plasma lipids, and traditional cv risk factors. Results: Mean age was 55.8 years, 46% were men, and mean time of follow-up was 14.3 years. There were 3,930 cv deaths. One level lower in income was associated with a higher risk for cv death (aHR 1.28, 95% CI 1.22-1.34, p &lt;0.0001). One level lower in education was non-significantly associated with cv death (aHR 1.02, 95% CI 1.00-1.04, p=0.06). One level lower in income was associated with a higher risk for cv death compared to one group higher in BMI categories (aHR 1.15, 95% CI 1.10-1.21, p &lt;0.0001) and was comparable to the risk associated with having a father, mother, or sibling with heart disease. Conclusion: The risk for cv death associated with one level lower in income as assessed in the UKB is higher than the risk associated with one group higher in BMI categories and comparable with a family history for heart disease, highlighting the importance to assess socioeconomic factors in cardiovascular risk assessments.

The increase in non-marital childbearing has coincided with educational expansion, although non-marital childbirths are more common among the low-educated population. This article quantifies the contribution of changes in education-specific rates of non-marital childbearing and educational distribution of parents to increases in non-marital childbearing among Finnish first-time parents over the period 1970–2009. Using Finnish register data on first-time mothers ( N = 112,730) and fathers ( N = 108,812), the study decomposes changes in the proportion of non-marital first childbearing in pairwise comparisons of successive decades for four educational segments: low educated (International Standard Classification of Education (ISCED) 0–2), medium educated (ISCED 3–4), lower tertiary educated (ISCED 5–6) and upper tertiary educated (ISCED 7–8). The findings show that the increase in non-marital first-time births was mainly attributable to the large population of medium-educated women and men and the growing segment of lower tertiary-educated women. The highest proportion of non-marital first-time childbearing remained among the low-educated population, but diminishing group size meant their overall contribution was small. The growing upper tertiary-educated population increased its contribution to non-marital childbearing but still exhibited the lowest non-marital childbearing rates. We conclude that the medium-educated population merits increased scholarly attention for its important contribution to population-level changes.

Using data from the 1990 U.S. Census and the 2006–2007 American Community Survey (ACS) and a synthetic cohort method, this article examines the labor market performance of young men during their initial transition to work and how it differs by educational attainment and race. The article looks at young men between the ages of 16 to 26 in 1990 who were no longer enrolled in school and men between the ages of 32–33 and 42–43 in the 2006–2007 period. Strong patterns in the results confirm conventional wisdom that economic and labor market outcomes are superior with increased levels of educational attainment. However, outcomes were more dramatic for those with college degrees than others (relative to those who dropped out of high school), confirming the disproportionate value of obtaining a college degree. Graduating from high school, going to community college, or receiving an associate's degree also improved outcomes. The data revealed that not acquiring a high school degree, especially for domestic-born racial minorities, generates very poor labor market outcomes during the initial transition to work. Racial inequality in labor market and economic outcomes widened as educational attainment levels increased. These results strongly suggest that efforts to boost academic achievement and educational attainment of racial/ethnic minority men, although they may improve labor market and economic performance, will probably not narrow racial inequalities in outcomes. Programs and policies should target factors that limit the potential gains in the labor market from educational attainment for these men.

BackgroundDeaths due to medical care appear common. Individuals with low socioeconomic position seem to be at a higher risk for sustaining a medical adverse event and premature death. This time series analysis aimed to assess educational gradients behind adverse event deaths in the US over the period 2010–2019.MethodsPublicly available mortality and census data were retrieved from official sources. The data included age, sex, educational attainment, and underlying cause of death. Adverse event deaths were identified by ICD-10 codes Y40—Y84 and Y88. Four education categories were created in accordance with the International Standard Classification of Education 2011 coding scheme [No high school or General Educational Development (GED); High school or GED; Some college; Bachelor's degeree or higher]. To capture also highly educated individuals, the analysis was delimited to ≥30-year-olds. Age-adjusted mortality rates (AMRs) were compared between education categories by means of mortality plots and linear mixed models.ResultsA total of 25,897,334 certified deaths occurred among ≥30-year-olds during the study period. The underlying cause of death was an adverse event in a rarity of cases (0.12%, n = 31,997). Individuals with Bachelor's degeree or higher had the lowest adverse event AMRs (6.1–12.4 per million per year), followed by the Some college category (9.6–18.6), the High school or GED category (17.1–35.4), and finally the No high school or GED category (20.0–36.0). AMRs showed a gradual increase as education level decreased (p ≤ 0.001 against those with Bachelor's degeree or higher). Moreover, the temporal increase in adverse event AMRs was more pronounced among individuals with low than high education; the contrasts between categories were greatest toward the end of the study period.ConclusionThe findings of this study suggest that the widening socioeconomic gradients in mortality extend also to fatal adverse events. Future studies should aim to analyze whether access to care, severity of the condition at presentation, quality of care, and social determinants of health may drive the gradients.

Background: Health literacy challenges significantly impact the adult population in Nigeria across multiple dimensions. Current research indicates that health literacy and structured health education remain underdeveloped, with only 38% of adults having access to formal education. While the relationship between health literacy and health-related behaviours has been widely studied in global contexts, there is a notable lack of research specific to Nigerian populations. This study explores the interrelationship between health literacy, levels of educational attainment, and health-related behaviours among adults in Nigeria, aiming to better understand how these factors influence one another and impact health outcomes. Methods: A quantitative research design was employed, utilizing standardized questionnaires adapted from the Health Literacy Survey North Rhine-Westphalia. Education levels were classified according to the International Standard Classification of Education. Data were collected from a purposive sample of 50 men and women aged 30–60 and analysed using computer-assisted descriptive statistics and frequency distributions.Results: Findings revealed that participants with a high level of education (100%) were significantly more likely to seek out and utilize health information compared to those with medium (71%) and low (50%) education attainment. Additionally, 91% of highly educated participants obtained health information from healthcare professionals, whereas participants with medium (33%) and low (62%) education levels relied more on family and friends. Similarly, all participants in the high education group reported practicing health-conscious behaviours, compared to 75% in the medium group and 65% in the low education group. Despite these differences, a majority across all education levels reported difficulties in understanding written health information and a general underutilization of preventive health services. Conclusion: The findings demonstrate that although education level and health literacy significantly influence health behaviours, formal education alone does not guarantee the ability to comprehend and apply health information effectively. To improve health outcomes, it is essential to expand access to both formal and informal education, promote structured health education, and support lifelong learning opportunities. Achieving this goal requires increased investment in both the education and health sectors, alongside targeted training for health professionals. Further research on health literacy in Nigeria is recommended to address existing knowledge gaps and to inform the design of context-specific, evidence-based interventions.