Stolz E, Mayerl H, Waxenegger A et al. Thus, a growing proportion of older people in the population is likely to put a strain on the health and social care systems. Thus, the aim of this study was to examine contribution of these explanatory pathways to the association between education and SRH in old age. The existing studies on the underlying mechanisms of educational inequalities in health with a special focus on the older population are of limited comparability due to differences in the statistical methods, health indicators and the included explanatory pathways. Skalická V, van Lenthe F, Bambra C et al. . Additionally, material factors were indirectly working through health behaviors with an additional effect of 4% in the middle educational group and 6% in the low educational group. The Institute for Social Research and Social Policy, Cologne, Germany. studies show that socioeconomic inequalities in old age exist, but that the magnitude depends on the indicator of socioeconomic status that is used, on the age group and gender that is studied, on the country for which they are examined, and on the health outcome that is used. This poses special challenges for the medical, nursing and psychosocial care … 2006;28:375–92. Although the past 50 years have seen substantial improvements in the average level of health as measured by mortality rates in many countries, health inequalities have remained static or widened.1 Against this background, in 2000 WHO declared the reduction of health inequalities between and within countries to be a priority. Logistic regression models of poor SRH by education, adjusted for material, behavioral and psychosocial factors (n = 3246). Selective mortality explains only some of the decline in health inequalities with age. Independent effect of material factors net of behavioral factors: Independent effect of behavioral factors net of material factors: Indirect effect of material factors via behavioral factors: Model 7–ind. Over 80% of all deaths in England and Wales occur among people aged 65 and over, with a further 8% among people aged 55-64. Furthermore, study results might depend on the age group under study as the relevance of single variables could differ between people in middle adulthood as compared to the older population. Independent effect of psychosocial factors net of behavioral factors: Independent effect of behavioral factors net of psychosocial factors: Indirect effect of psychosocial factors via behavioral factors: Model 6–ind. But is that so for all? United Nations. Germany with its conservative welfare state in which the living conditions in old age are strongly influenced by resources from prior life stages (such as education) offers an interesting opportunity for studying health inequalities in old age. By comparing the models with two groups of variables with the corresponding models with each one group of explanatory factors we distinguished between the independent and indirect effects. In old age, the available material resources reflect to a certain extend the accumulation of (dis-)advantage over the life course so that their contribution to health inequalities is of particular relevance.34, Interventions for the reduction of health inequalities in old age should thus focus on improving material living conditions. However, after around the age of 70 years, the results suggest that this gap in the trajectories of healthy … After the second step of variable selection (logistic regression), all of the remaining factors except of a BMI 25 <30 were included in the mediator analysis as they were significantly associated with SRH (results of variable selection in Supplementary online file). As we use cross-sectional data, it is not possible to determine the direction of causation between education, mediator variables and SRH. effect of psychosocial factors. The baseline model (Model 1) included educational status and control variables (sex, age, employment status and chronic diseases). . In: Börsch-Supan A, Brugiavini A, Jürges H et al. The higher contribution in the low educational group is due to the higher prevalence of health risks which hints at the fact that there are health risks especially relevant in the middle educational group that we did not consider. Between 2015 and 2030, the number of people aged 60 and over is … Life expectancy has increased globally over the past century, with the number of people aged 65 years or over increasing at a faster rate than total population growth (Kaneda et al, 2011). Laaksonen M, Roos E, Rahkonen O et al. We examined the independent and indirect contribution of material, behavioral and psychosocial factors to the association between education and self-rated health based on logistic regression models. Operationalization and coding of explanatory variables, Several questions that inquire if the participants could not see a doctor or dentist because of costs or long waiting times in the past 12 months, or if they had difficulties to get to their general practitioner, the nearest health center or pharmacy, 0 = no problems, 1 = at least one problem, ‘How often in the past 12 months…did you do voluntary or charity work/have you attended an educational or training course/did you go to a sport, social or other kind of club/haven you taken part in a political or community-related organization/have you played cards or games such as chess?’, 0 = any of these activities at least once a week, 1 = none of these activities at least once a week, ‘How often do you feel that what happens to you is out of your control?’; ‘How often do you feel left out of things?’, (both coded 1 = often, 2 = sometimes, 3 = rarely, 4 = never), Index summing up the two scores (range 2–8) with 0 = sufficient control beliefs (index values 5–8), 1 = insufficient control beliefs (index values 2–4), ‘I really feel part of this area.’; ‘If I were in trouble, there are people in this area who would help me.’, (both coded 1 = agree, 2 = agree, 3 = disagree, 4 = strongly disagree), Index summing up the two scores (range 2–8) with 0 = sufficient social capital (index values 2–4), 1 = insufficient social capital (index values 5–8). 35 – 37 Old age is often accompanied by poor health and functional disabilities. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Because findings of declining health inequalities in old age are often dismissed as a product of mortality selection and cohort effects, this study primarily aimed to Indeed, additional findings from the ELSA study show that in 2006 approximately one in ten people aged 50-years and over in England did not have anyone strongly supporting them when in need (Hyde et al., 2003). Simplified causal model for educational inequalities in health with independent (direct) and indirect effects of material, behavioral and psychosocial factors. We limited our analysis to only one country as previous research has shown that, besides individual characteristics, there are also macro-level influences on health inequalities,17,18 which speaks against examining the pooled sample of all participating countries. In studies on the underlying mechanisms of health inequalities, material, behavioral and psychosocial factors should be modeled as inter-related predictors as the separate analysis does not reveal their actual contribution so that the relevance of single explanatory pathways might be overestimated. This article uses data from SHARE Waves 1, 2, 4 and 5 (DOIs:10.6103/SHARE.w1.600, 10.6103/SHARE.w2.600, 10.6103/SHARE.w4.600, 10.6103/SHARE.w5.600), see Börsch-Supan et al.15 for methodological details. In the separate analyses (Models 2–4), the contribution of material factors was the highest (middle educational group: 18%, low educational group: 23%), followed by behavioral factors (middle educational group: 13%, low educational group: 19%) and psychosocial factors (middle educational group: 12%, low educational group: 17%). effect of behavioral factors. Second, we did not consider lifetime exposure to health relevant factors, although health in later life is related to living conditions in earlier adulthood37 and even childhood.35,36 Besides influences from prior life stages, there may be health risks especially relevant for the old aged such as care-giving for relatives or an inadequate intake of prescribed drugs. A detailed description of the survey methodology can be found elsewhere.15 For this study, the German sample aged 60–85 years was selected. The most relevant variables were financial problems, type of health insurance (especially in the low educational group), low social participation, insufficient control beliefs, lacking physical activity and a BMI ≥ 30. The independent effect of behavioral factors was comparable to the independent effect of psychosocial factors (middle educational group: 9%, low educational group: 13%). When material and behavioral factors were included simultaneously (Model 7), the independent effect of material factors amounted to 14% in the middle educational group and to 17% in the low educational group. In comparison with half a century ago, 75 today is the new 65 in terms of mortality and disability. . The elderly, and especially the oldest old, have generally been overlooked in research on social class inequalities in health. By comparing the models with two groups of variables with the models with each one group of explanatory factors it became obvious that the independent contribution of material factors was higher than that of behavioral and psychosocial factors. See Table 1 for the operationalization and coding of the variables. First, pension schemes can worsen health inequalities in old age through increased privatization and retirement age reforms. Between 2015 and 2030, the number of people aged 60 and over is expected to increase from 901 million to 1.4 billion. The authors show that health differences in older age might be due to the disadvantage accumulated in early life among those with low education and wealth. For some variables relevant for our analysis (material deprivation, access to healthcare and social capital), the number of missing values was much higher than for others. Conclusions: socioeconomic inequality in developing new health problems persist into old age for certain illnesses, particularly functional impairment, but not for heart disease. Although many older persons retain overall good health and functioning well into old age, the process of ageing entails an increasing risk of poor health.[1]. socioeconomic inequalities in mortality rate in old age suggest that a low socioeconomic position continues to increase the risk of death even among the oldest old” (Huisman et al. Results from the SHARE study in non-institutionalised men and women aged 50+, Health, Ageing and Retirement in Europe: First Results from the Survey of Health, Ageinge and Retirement in Europe, Forschungsinstitut Ökonomie und Demographischer Wandel, Educational differences in functional limitations: comparisons of 55-65-year-olds in the Netherlands in 1992 and 2002, Explaining socioeconomic inequality in mortality among South Koreans: an examination of multiple pathways in a nationally representative longitudinal study, Psychosocial and behavioural factors in the explanation of socioeconomic inequalities in adolescent health: a multilevel analysis in 28 European and North American countries, Comparing regression coefficients between same-sample nested models using logit and probit: a new method, Lebensbedingungen in Deutschland in der Längsschnittperspektive, Trajectories of functional health: the ‘long arm’ of childhood health and socioeconomic factors, Tracing the origins of successful aging: the role of childhood conditions and social inequality in explaining later life health, The association between mid-life socioeconomic position and health after retirement—exploring the role of working conditions, Impact of socioeconomic position on frailty trajectories in 10 European countries: evidence from the Survey of Health, Ageing and Retirement in Europe (2004–2013), Gender-specific responses to social determinants associated with self-perceived health in Taiwan: a multilevel approach, Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health, © The Author(s) 2017. One such determinant is a person’s educational attainment and numerous studies have documented an educational gradient in health: the higher the educational level, the lower the risk of long-standing illness, functional limitations, low self-rated health (SRH) and mortality.1–3 These health inequalities are even present in the oldest old although it is less clear if and how these relationships change during the aging process as compared to middle adulthood.2,4, Several studies have identified material, behavioral and psychosocial factors as key pathways for explaining health inequalities.5 The materialist explanation underlines the importance of financial resources, working and housing conditions or access to goods, services and healthcare.6,7 The behavioral explanation claims that health inequalities result from the higher prevalence of smoking, excessive alcohol consumption, physical inactivity and inadequate nutrition in lower educational groups.1 Psychosocial explanations stress the unequal distribution of risk factors such as a lack of social support and social participation or insufficient control beliefs which affect health through various pathways.7–9, Current explanatory approaches postulate that material, behavioral and psychosocial factors exert an independent influence on health (direct effect), while also being interrelated and working through one another (indirect effect) (Fig. As described in this chapter, there are also differences in outcomes relating to socioeconomic status, ethnicity, geographical region and other social factors. In accordance with previous studies, a mediator analysis was performed to investigate the relative contribution of material, behavioral and psychosocial factors to the association between education and SRH.13,14,31 Only those variables were selected for mediator analysis which (i) had a negative and significant association with education (bivariate analysis, χ2-test) and (ii) were significantly associated with SRH (logistic regression controlled for sex, age, employment status and chronic diseases).10,14,31 Several models were estimated to calculate the contribution of the different explanatory pathways. Avendano M, Aro AR, Mackenbach JP. The analytic sample included 3246 participants aged 60–85 years. [3] Moreover, these factors are often intertwined, such that individual characteristics among older persons may hold sway over other health determinants. After the first step of variable selection (χ2 test), all material factors and most of the behavioral factors remained for further analysis. Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C) and from various national funding sources is gratefully acknowledged (see www.share-project.org). Socio-economic factors, such as poor education, unemployment, poor housing, level of income, ethnicity, and gender, influence a person’s health and their access to and use of healthcare services. Only alcohol consumption was excluded as there was an inverse social gradient (excessive alcohol consumption was less common in the middle and low educational group). Inequalities in Old Age i85 grounds enjoy a clear health advantage in later life.21Evidence for class differences in psychological functioning is rathe22Americar sketchy.n researchers have consistently found a direct relationship between Conclusion: The existence of health inequalities in old age indicates that older people from disadvantaged social groups have a particular need for healthcare and support. The independent contribution of behavioral and psychosocial factors was much lower than suggested by the separate analyses. One hopeful lesson about addressing inequalities in later life is that it is never too late. Hoogendijk E, van Groenou MB, van Tilburg T et al. The SHARE data collection has been primarily funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812) and FP7 (SHARE-PREP: N°211909, SHARE-LEAP: N°227822, SHARE M4: N°261982). As described in previous chapters, there are differences in health outcomes between males and females, for different age groups and for different countries. In other words, disparities in old age in health and other areas often reflect accumulated disadvantage, due to factors such as one’s location, gender and socio-economic status, as well as to ageist attitudes and practices and to lacking or inadequate laws and policies—or their enforcement—that provide for equality and the rights to health and social security. The data are collected in computer-assisted personal interviews supplemented by self-completion questionnaires. Search for other works by this author on: Faculty of Human Sciences and Faculty of Medicine, The Institute of Medical Sociology Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany. Additionally, we use beta-coefficients as odds ratios (OR) are not symmetric on a linear scale which results in a biased interpretation of the relative contribution of mediator variables. However, employing a more proximal measure of SES reduces inequalities in middle age so that convergence of inequalities is not apparent in old age. The influence of poverty and disadvantage on health inequalities in later life is broadly consistent over time: a person’s early life continues to shape their health in later life. Unfortunately, most of the existing studies with the population of working age do not provide results on the contribution of single variables. The data were drawn from the fifth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), a multidisciplinary panel study on the living conditions of people aged 50+. Impact of surgical treatment of pectus carinatum on cardiopulmonary function: a prospective study. Martijn Huisman, Sanna Read, Catriona A. Towriss, Dorly J. H. Deeg, Emily Grundy, Socioeconomic Inequalities in Mortality Rates in Old Age in the World Health Organization Europe Region, Epidemiologic Reviews, Volume 35, Issue 1, 2013, Pages 84–97, Evidence from the Survey of Health, Ageing and Retirement in Europe (SHARE), The effect of educational attainment on adult mortality in the United States, Socioeconomic status and health in the second half of life: findings from the German Ageing Survey, Explaining socioeconomic inequalities in self-rated health: a systematic review of the relative contribution of material, psychosocial and behavioural factors, The wider determinants of inequalities in health: a decomposition analysis, Socioeconomic disparities in health behaviors, Mechanisms linking social ties and support to physical and mental health, Contribution of material, occupational, and psychosocial factors in the explanation of social inequalities in health in 28 countries in Europe, Examining cultural, psychosocial, community and behavioural factors in relationship to socioeconomic inequalities in limiting longstanding illness among the Arab minority in Israel, Educational inequalities in general and mental health: differential contribution of physical activity, smoking, alcohol consumption and diet, Material, psychosocial, behavioural and biomedical factors in the explanation of relative socio-economic inequalities in mortality: evidence from the HUNT study, Material, psychosocial, and behavioural factors in the explanation of educational inequalities in mortality in the Netherlands, Data resource profile: The Survey of Health, Ageing and Retirement in Europe (SHARE), Health differences between European countries, Societal determinants of productive aging: a multilevel analysis across 11 European countries, International Standard Classification of Education 1997, The long lasting effects of education on old age health: evidence of gender differences, Socio-economic position and quality of life among older people in 10 European countries: results of the SHARE study, The increasing predictive validity of self-rated health, What is self-rated health and why does it predict mortality? Emily Grundy and Gemma Holt. . After 11 years, however, less than 20% of them remained in the civil service. A significant proportion of the diversity in older age is due to the cumulative impact of these health inequities across the life course. larger social health inequalities. : Towards a unified conceptual model, Influence of material and behavioural factors on occupational class differences in health, Health differentials in the older population of England: an empirical comparison of the materialist, lifestyle and psychosocial hypotheses. In the low educational group the three explanatory pathways together contributed by 42% to the association between education and SRH with material factors being most important (16%), followed by behavioral factors (14%) and psychosocial factors (13%). Societal changes (such as rising education levels) and social mobility can influence how much people are affected by health conditions. Mohd Hairi F, Mackenbach JP, Andersen-Ranberg K et al. Does socio-economic status predict grip strength in older Europeans? For instance, what is the cumulative health effect on BAME groups due to a lifetime of inequalities in Schöllgen I, Huxhold O, Tesch-Römer C. Sundmacher L, Scheller-Kreinsen D, Busse R. Aldabe B, Anderson R, Lyly-Yrjänäinen M et al. in the case of an unhealthy nutrition as paying for high quality foods cannot be afforded.8 Psychosocial factors exert an indirect effect through health behaviors, e.g. . Can we observe significant inequalities in health and A L Schmitz, T -K Pförtner, Health inequalities in old age: the relative contribution of material, behavioral and psychosocial factors in a German sample, Journal of Public Health, Volume 40, Issue 3, September 2018, Pages e235–e243, https://doi.org/10.1093/pubmed/fdx180. . Of the psychosocial factors, parenthood and social capital were excluded as they were not significantly associated with education. All pathways together (Model 8) contributed by 31% to the association between education and SRH in the middle educational group, with material factors (12%) being slightly more important than behavioral factors (9%) and psychosocial factors (9%). . In contrast, Stolz et al.38 showed that the impact of income and poverty on frailty was mediated by material and especially by psychosocial factors, whereas the contribution of behavioral factors was only marginal. We investigated trends in relative risk (rate ratios) and absolute risk (rate differences) of educational inequalities in old age mortality in Norway in the period 1961 to 2009 during which considerable changes in mortality, health policy, and expansion of a comprehensive welfare state … As described in previous chapters, there are differences in health outcomes for men and women, for different age groups and for different countries. Most previous studies on the underlying mechanisms of educational inequalities in health are based on study samples including the population of working age only, whereas studies on the older population are scarce. These health inequalities, differences in health between people or groups of people that may be considered unfair, reflect historic and present-day social inequalities in our population. The three explanatory pathways together contributed by 31% to the association between education and SRH in the middle educational group and by 42% in the low educational group. [3] World Health Organization, World Report on Ageing and Health (Geneva, 2015). Moor I, Rathmann K, Stronks K et al. All rights reserved. Afterwards, we separately added material factors, behavioral factors and psychosocial factors (Models 2–4). Intersecting disparities of age, ethnicity, sex, occupation or deprivation and the drivers behind these inequalities, are topics that deserve greater attention. Research from Canada illustrates that the main long-term health proble… Börsch-Supan A, Brandt M, Hunkler C et al. 1, modified after Moor et al.5). , 2013: 84). This development, in turn, begs the question on whether the Nordic countries can afford to maintain their universal provision of largely tax-funded, welfare programmes. van Oort F, van Lenthe FJ, Mackenbach JP. (eds). Res Aging. In old age, lifetime savings of different forms of capital were crucial. Ageing involves biological changes, but also reflects the accumulated effects of one’s exposure to external risks, such as poor diet, and can further be influenced by social changes, such as isolation and loss of loved ones. Read our Briefing Paper on “Health Inequalities in Old Age”. It aims to use health inequality – in addition to the average level of health, average level and distribution of responsiveness and fairness in financial contributions – as a distinct p… effect of material factors—ind. As ill-health can be prevented and death be delayed, old age inequalities in health should also be possible to reduce. Schmitz, E-mail: The causal effect of education on health: what is the role of health behaviors? The independent effect of behavioral factors net of material factors amounted to 9% in the middle educational group and 13% in the low educational group (Table 3). delayed, old age inequalities in health should also be possible to reduce. economic inequalities in mortality in old age is important given the gains in longevity, increasing ageing population and expanding health expenditure as societies age. Table 2 shows the results of the mediator analysis. When adjusting for material and psychosocial factors simultaneously (Model 5), the independent effect of psychosocial factors net of material factors contributed by 6% in the middle educational group and by 9% in the low educational group whereas the independent effect of material factors was higher (middle educational group: 12%, low educational group: 15%). In the context of rapid population ageing, age-related inequalities take on greater urgency. Furthermore, we adjusted the baseline model for several combinations of two groups of variables (Models 5–7). (eds). All of the existing studies focus on the population of working age and they highlight the importance of material factors as they are also working through behavioral and psychosocial factors.11,12 The results are similar with regard to educational inequalities in other health indicators such as mortality14 or chronic diseases.11, This study is the first that provides insights in the underlying mechanisms of educational inequalities in SRH in old age by including material, behavioral and psychosocial factors. Do functional health inequalities decrease in old age? Health inequalities are ultimately about differences in the status of people’s health. Regardless of the reason for social isolation, it ultimately leads to huge inequalities in the provision of health services across age groups. 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