2014/ED/EFA/MRT/PI/05 Background paper prepared for the Education for All Global Monitoring Report 2013/4 Teaching and learning: Achieving quality for all Education, Literacy & Health Outcomes Findings Emmanuela Gakidou 2013 This paper was commissioned by the Education for All Global Monitoring Report as background information to assist in drafting the 2013/4 report. It has not been edited by the team. The views and opinions expressed in this paper are those of the author(s) and should not be attributed to the EFA Global Monitoring Report or to UNESCO. The papers can be cited with the following reference: Paper commissioned for the EFA Global Monitoring Report 2013/4, Teaching and learning: Achieving quality for all For further information, please contact efareport@unesco.org
Education, Literacy & Health Outcomes Findings By Emmanuela Gakidou Methods Data We used data from 139 Demographic & Health Surveys on 58 countries. Since some countries did not report literacy data, we were only able to include 39 countries in our analysis of literacy. Meta-Analysis We ran country-specific analyses on the following outcomes: Under Five Mortality (deaths under the age of five) Neonatal Mortality (deaths in the first month) Post-neonatal Mortality (deaths between the age of 1-11 months old) Infant Mortality (deaths under the age of one) Child Mortality (deaths between the age of 1 and 4 years old) Reported Cough (reported in the last two weeks) Reported Diarrhea (reported in the last two weeks) Reported Fever (reported in the last two weeks) 3 DPT Vaccinations (reported DPT 3 vaccination, including self-report and health card documentation) We ran the following logistic regression: logit (γ) ~ β0 + β1 X Child + β 2 X Parents + β 3 X Household + β 4 X Community + β 5 X Time + β6 X Exposure + ε Child: Gender, Multiple Births, Birth Order Parents: Maternal Height, Maternal Education, Paternal Education, Maternal Literacy Household: Size, Urban/Rural, Wealth Quintile Community: Average Years of Schooling among Women, Average Wealth Time: Five-Year Time Period Indicators Exposure: 6-Month Exposure Indicators Indonesia did not have data on maternal height, so we ran the analysis on Indonesia without this covariate.
We created meta-analysis graphs to visualize effects across all of these countries for maternal education and literacy. One set of graphs focuses on all data, the other is a subset of countries with literacy data. Predicted Probability Analysis We simulated predicted probabilities to estimate the probability of each outcome by education across a set of counterfactual education and literacy scenarios. We report the absolute change in the predicted probability of the outcome in one set of tables, and the proportion change in the outcome in another. We present country specific results, as well as results aggregated at the region level. We also summarize results for all developing countries, and for all countries included in the analysis. Note that we do not have data on all countries within a region, so regional, developing, and global estimates are only proxies based on the available data. For comparison, we included results for a model that only includes maternal education. We present results only at the country and global levels for the absolute difference in predicted outcomes for the model without paternal and community education, for simplicity. We interacted wealth quintile and maternal education in India, Ethiopia and Nigeria, where sample sizes are large enough to allow for this model specification. Pneumonia Analysis We utilized GBD 2010 estimates of under-five pneumonia death rates, and investigated the association between education and the log of pneumonia death rates over time and across countries. We used data on 137 countries from 1980-2011. The full list of countries is included. We ran a quantile regression at the 10 th, 25 th, 50 th, 75 th, and 90 th percentiles. We also ran a pooled regression with random effects on country and the interaction between education and region. This analysis allowed us to make estimates about the percent of the pneumonia death rate we expect to change based on a 1-year increase in education. Malaria Analysis We estimated the probability of parasitemia using maternal education, urban/rural, age of the child, sex of the child, wealth quintile, IRS and ITN use as covariates. We also used indicators on rain and lagged rain levels. We used data from the 2013 Fullman et al. paper. We estimated predicted probabilities of parasitemia across the spectrum of observed maternal education levels, and did a counterfactual analysis for the following three scenarios: if women had 1 additional year of education, if the average was at least 6 years of education, and if the average was at least 12 years of education. Findings Overall Effects of Education and Literacy Improvements in women s education are associated with significant reductions in under five mortality. The magnitude of the effects of a 1 year increase in maternal education on under five mortality are heterogeneous across countries, and range from - 0.1% to -10.0%, with a mean of -3.5% and a median of -3.6%. The magnitude of community education on under five mortality ranges from -28.6% to 12.2%,
with a mean of -4.3% and a median of -5.4%. Since the effects of maternal education and community women s education are additive, we can also look at their combined effect across countries. The combined effect ranges from -34.3% to 7.9%, with a mean of -7.8% and a median of -7.8%. In contrast, the effect of a 1 year increase in men s education ranges from -15.2% to 1.0%, with a mean of -2.3% and a median of -2.0%. The effects of women s education are greatest in Latin America and South Asia, and smallest in Sub- Saharan Africa and Central Asia. The effect of maternal education at the country level is largest for child mortality, followed by postneonatal mortality. Community women s education has a larger effect on under five mortality than either maternal or paternal education alone. Maternal education has a greater effect than paternal education. At a global level, a 1 year increase in community s female education is associated with the largest absolute decline in under five mortality of 2.2 per 1,000. If all women globally had at least six years of education, we estimated a 6.1 per 1,000 reduction in the under five mortality rate. Effects of maternal education were similar regardless of whether we controlled for paternal and community level education or not. We estimate a median effect of -7.8% of 1 additional year of women s education (both maternal and community effects) on under five mortality. This is slightly smaller than the estimate of -10.0% from Gakidou et al. 2010. There are many reasons why these two studies are not directly comparable. For example, this study does not take into account the ways in which education may change fertility preferences over time, because using individual-level data does not allow this to be estimated. The two studies also differ considerably in the composition of countries. However, despite these differences, both studies estimate relatively similar effect sizes, which suggests that the results are independent of modeling strategy. We examined the counterfactual scenarios in which education levels were increased to 6 and 12 years respectively, estimated for men and women separately and together. The median country effect if all women had at least 6 years of education is a 16.0% reduction in under five mortality, and a 42.9% reduction if all women had 12 years. Men s education at 6 years is associated with a median effect of - 0.9% and -8.9% if all men had at least 12 years. If everyone had at least 6 years, the median effect is a 20.2% reduction in under five mortality, and a 47.6 % reduction if everyone had 12 years. Investing in women s education in particular has the potential to have a large effect on reducing under five mortality. Improvement in women s education would have a greater effect, partly because the magnitude of the association with under five mortality is greater for women than for men, and partly because women are currently at lower levels of educational attainment than men in many low and lower-middle income countries. The interaction between wealth and education was significant for most mortality outcomes in India and Nigeria, but not significant in Ethiopia. In India and Nigeria, being wealthier is associated with a greater effect of education on predicted mortality. In Nigeria, neonatal mortality is undifferentiated by wealth, but the effect of education on probability of death after the first month varies by wealth quintile.
Education has a very small effect on the predicted probability of three DPT immunizations. The median country-specific estimate for a 1 year increase in maternal education is a 0.5% increase in DPT coverage. We did not find strong or significant relationships between maternal education and reported diarrhea, fever, or cough. This may in part be due to poor data quality on these measures, and on differences in reporting that may be related to a mother s education. While literacy is protective and significant for mortality outcomes in our analysis, it has a small effect on the predicted probability of under five mortality. Across all countries with literacy data, the median effect size of 100% literacy and under five mortality is -2.9%. Literacy is associated with the largest proportional decrease in child mortality, followed by post-neonatal mortality. The median countryspecific effect of literacy DPT 3 vaccinations is a 1.6% increase with 100% maternal literacy. The counterfactual scenario in which every mother is literate is associated with increases in reported diarrhea, fever, and cough. This may be due to differential reporting of these conditions based on a mother s literacy, and may also be a reflection on the way literacy data is collected in the DHS. Better instruments are needed to more accurately capture variation in literacy, as the current instrument is a rough proxy. Pneumonia Analysis At a global level, we estimate that a 1-year increase in maternal education is associated with a 14.0% decrease in the pneumonia rate. We also find that in countries with a high burden of pneumonia, education has less of an effect. In Africa a 1-year increase in maternal education is not associated with a significant change in pneumonia rates. However, in countries with a low burden of pneumonia, we find that education is associated with increasingly larger decreases in the pneumonia rate. The quantile analysis and the ordinary least squares regression demonstrate similar results. Malaria Analysis Overall, we find that education has a small but significant negative association with parasitemia. However, the country-specific analysis suggests that in countries like Angola and Senegal, the trend is relatively flat. In countries such as Cameroon and Burkina Faso, we see a much stronger trend in the negative relationship between education and parasitemia.
Some notes: We re-did the predicted probability results for the Full Model, so that if a country doesn t have literacy data we present results on the model excluding literacy as a covariate and excluding the literacy counterfactuals. Countries with a mean education greater than 6 or 12 years are indicated with a 0 in the predicted probability files. The predicted probabilities analysis includes an assessment of the proportion change in predicted probability of the outcome. Since the proportion change includes uncertainty, the confidence intervals around this estimate are wider and sometimes cross zero, even though the underlying coefficient on education is significant. This is simply a function of the measure being shown, and not an indication of the significance of education.