Educational inequalities and avoidable mortality

Spain is one of the countries with the highest life expectancy in the world. However, this collective achievement hides a less visible reality: not everyone benefits equally from living more years. Educational attainment continues to mark substantial differences in the risk of dying, the age at which death occurs, and the causes that explain it.

That is, people with lower educational attainment have higher mortality rates and a significantly lower life expectancy compared to those with higher levels of education; this phenomenon is known as educational inequalities in mortality.

These inequalities are not an exclusively Spanish phenomenon. Comparative European evidence shows that, even in countries with universal health systems and high levels of longevity, differences in survival by educational attainment persist (e.g., Mackenbach et al. 2018).

The most recent estimates for the 2016–2021 period, assuming that all educational groups had the same mortality as those with the highest levels of education, indicate that close to one in five deaths in Spain can be attributed to educational inequalities. In absolute terms, this is equivalent to around 80,000 deaths per year. Although most of these deaths are concentrated at older ages, where more deaths occur overall, the relative impact is especially large at young and middle ages, where the gap in the risk of dying is proportionally greater.

Risk factors matter

Educational inequalities do not affect all causes of death equally. Among women, cardiovascular diseases account for a substantial share of deaths associated with lower educational attainment, followed by metabolic and respiratory diseases and mental and neurological disorders, including dementias. Among men, cancers stand out, especially those related to smoking, as do cardiovascular and respiratory diseases and external causes. This places educational inequality as a structural determinant of population health, comparable in magnitude, at the aggregate scale, to some of the classic risk factors most studied in epidemiology, such as smoking among men.

A large part of mortality inequalities between groups with higher and lower educational attainment is linked to differences in sustained exposure over the life course to several factors, including more demanding working conditions, greater economic insecurity, less favorable residential environments, lower access to preventive resources, or lower health literacy. Education not only influences income or employment; it shapes entire life trajectories that generate the accumulation of inequalities over the life course. Therefore, the mortality inequalities observed at older ages are, to a large extent, the result of cumulative processes that begin decades earlier.

Socioeconomic inequalities, a central public health problem

Reducing inequalities is not only a matter of social equity; it is a fundamental public health strategy. Educational, social, and integration policies are also long-term health policies. Reducing early school leaving, improving vocational training, strengthening job stability, and reinforcing prevention policies targeted at the most vulnerable groups can improve lifestyles and quality of life and, consequently, have effects that are reflected decades later in lower mortality rates.

Spain faces a sustained process of demographic aging in the coming decades. It is true that younger generations have, on average, higher levels of education. However, inequalities accumulated over the life course continue to leave their mark, especially among the cohorts that are reaching older ages today. The challenge is twofold: not only to add years to life, but to reduce the social gap in survival and ensure that those additional years are lived with greater equity in health (see here and here).

In conclusion, if socioeconomic inequality were a clinical risk factor, it would occupy a prominent place in any national prevention strategy. Addressing inequalities in health and mortality is not a peripheral issue, but an essential condition for ensuring increases in longevity, quality of life, and socially inclusive progress.

References

Mackenbach, J. P., Valverde, J. R., Artnik, B., Bopp, M., Brønnum-Hansen, H., Deboosere, P., ... & Nusselder, W. J. (2018). Trends in health inequalities in 27 European countries. Proceedings of the National Academy of Sciences, 115(25), 6440-6445.

Trias-Llimós, S., Riffe, T., & Martín, U. (2025). All-cause and cause-specific mortality attributable to educational inequalities in Spain. BMC Public Health, 25(1), 2486.