Examining social determinants of health: the role of education, household arrangements and country groups by gender.

BACKGROUND: The majority of empirical studies focus on a single Social Determinant of Health (SDH) when analysing health inequalities. We go beyond this by exploring how the combination of education (micro level) and household arrangements (mezzo level) is associated with self-perceived health. METHODS: Our data source is the 2014 cross-sectional data from the European Survey of Living Conditions (EU-SILC). We calculate the predicted probabilities of poor self-perceived health for the middle-aged European population (30-59 years) as a function of the combination of the two SDHs. This is done separately for five European country groups (dual-earner; liberal; general family support; familistic; and post-socialist transition) and gender. RESULTS: We observe a double health gradient in all the country groups: first, there is a common health gradient by education (the higher the education, the lower the probability of poor health); second, household arrangements define a health gradient within each educational level according to whether or not the individual lives with a partner (living with a partner is associated with a lower probability of poor health). We observe some specificity in this general pattern. Familistic and post-socialist transition countries display large differences in the predicted probabilities according to education and household arrangements when compared with the other three country groups. Familistic and post-socialist transition countries also show the largest gender differences. CONCLUSIONS: Health differences in European populations seem to be defined, first, by education and, second, by living or not living with a partner. Additionally, different social contexts (gender inequalities, educational profile, etc.) in European countries change the influences on health of both the SDHs for both women and men.

Feeling good in old age: factors explaining health-related quality of life.

BACKGROUND: Sustained growth in longevity raises questions as to why some individuals report a good quality of life in older ages, while others seem to suffer more markedly the effects of natural deterioration. Health-related quality of life (HRQL) is mediated by several easily measurable factors, including socio-demographics, morbidity, functional status and lifestyles. This study seeks to further our knowledge of these factors in order to outline a profile of the population at greater risk of poor ageing, and to identify those attributes that might be modified during younger stages of the life course. METHODS: We use nationally representative data for Catalonia (Spain) to explain the HRQL of the population aged 80-plus. Cross-sectional data from 2011 to 2016 were provided by an official face-to-face survey. HRQL was measured using EQ-VAS - the EuroQol-5D visual analogue scale - which summarizes current self-perceived health. Multivariate linear regression was used to identify variables influencing the EQ-VAS score. RESULTS: Sociodemographic factors, including being older, female, poorly educated and belonging to a low social class, were related with poor HRQL at advanced ages. The presence of severe mobility problems, pain/discomfort, and anxiety/depression were highly correlated to the HRQL of the elderly, while problems of self-care and with usual activities had a weaker association. CONCLUSIONS: Encouraging the young to stay in education, as well as to adopt healthier lifestyles across the lifespan, might ensure better HRQL when individuals reach old age. More multidisciplinary research is required to understand the multifaceted nature of quality of life in the oldest-old population.

Do women in Europe live longer and happier lives than men?

Background: The article examines gender differences in happy life expectancy at age 50 (LE50) and computes the age-specific contributions of mortality and happiness effects to gender differences in happy LE50 in 16 European countries. Methods: Abridged life tables and happy LE50 were calculated using conventional life tables and Sullivan's method. Age-specific death rates were calculated from deaths and population exposures in the Human Mortality Database. Happiness prevalence was estimated using the 2010-11 Survey of Health, Ageing and Retirement in Europe. Happiness was defined using a single question about life satisfaction on a scale of 0-10. A decomposition algorithm was applied to estimate the exact contributions of the differences in mortality and happiness to the overall gender gap in happy LE50. Results: Gender differences in happy LE50 favour women in all countries except Portugal (0.43 years in Italy and 3.55 years in Slovenia). Generally, the contribution of the gender gap in happiness prevalence is smaller than the one in mortality. The male advantage in the prevalence of happiness partially offsets the effects of the female advantage in mortality on the total gender gap in happy LE50. Gender differences in unhappy life years make up the greatest share of the gender gap in total LE50 in all countries except Denmark, Germany, Netherlands, Slovenia and Sweden. Conclusion: Countries with the largest gender gap in LE are not necessarily the countries with larger differences in happy LE50. The remaining years of life of women are expected to be spent not only in unhealthy but also in unhappy state.

Educational attainment, gender and health inequalities among older adults in Catalonia (Spain).

BACKGROUND: Health expectancies vary worldwide according to socioeconomic status (SES), with health disadvantages being evident among lower SES groups. Using educational attainment as a proxy of SES, we seek to identify trends in SES differentials in health by gender, with a particular focus on individuals with low educational attainment in the adult Catalan population (Spain) aged 55 or older. METHODS: Using cross-sectional data for 1994 and 2010-2014 drawn from the Catalan Health Survey, we examined three health indicators to document social health inequalities: self-perceived health, functional limitations, and restrictions on activities of daily living (ADL). We applied logistic models for each indicator, controlling for sociodemographic characteristics, health coverage and health behaviours. RESULTS: Among the less-educated, females presented a greater improvement in their self-perceived health over time than did their male counterparts, there being no significant variations among the medium/high educated. Regardless of education, males showed an increase in the prevalence of functional problems (as did the women, but the increase was not statistically significant). Both genders presented a higher prevalence of limitations when performing ADL in the second time period. The gender health gap was reduced slightly both for the low and the medium/high educated, expect in the case of ADL restrictions. Health and functioning differences by education level persisted, but showed significant signs of reduction. CONCLUSIONS: Less-educated females constitute the most disadvantaged group in terms of health and personal autonomy, though there are encouraging signs that the gap is closing both in terms of gender and level of education. Health policymakers need to devote particular attention to the aging population with low SES, especially to women. Public programmes promoting greater protection and equity, while fostering preventive and healthy practices, need to target the most underprivileged.

Is Transition to Retirement Associated With Volunteering? Longitudinal Evidence from Europe.

Studies have shown that retired older adults are more likely to volunteer than their working counterparts. However, whether the transition to retirement is associated with increased volunteering frequency and whether this varies according to material and time resources of participants is unclear. We used four waves of data from the longitudinal Survey of Health, Ageing and Retirement in Europe, collected between 2011-2018 across 19 countries (n = 12,400 person-observations from 6200 individuals over 50). Within-person (or panel fixed-effect) regression analyses revealed that transition to retirement was associated with an increased volunteering frequency over time. This association was stronger among individuals with better health, higher education, improved financial situation and in countries with higher gross domestic product per capita. Overall, transition to retirement tends to open new ways of organizing everyday life and is associated with increased frequency of volunteering.

Changes in Resources and Volunteering: A Longitudinal Study of Active Engagement Among Older Europeans.

BACKGROUND AND OBJECTIVES: Volunteering is an important dimension of successful aging. Although prior studies have found that personal resources such as health and financial situations are associated with volunteering, there is a lack of research exploring the relationship between resource changes and volunteering. Here, we investigated whether changes in individuals' resources were associated with volunteer engagement among older Europeans. RESEARCH DESIGN AND METHODS: Using data from the Survey of Health, Aging, and Retirement in Europe, collected in five waves between 2011 and 2020 across 19 countries (57,410 observations from 17,498 individuals aged 50 and above), we employed asymmetric fixed-effect ordinal regression models to investigate whether positive or negative resource changes were associated with the frequency of volunteering over time. We used three resource indicators: health, financial condition, and time availability (measured by engagement in paid work, grandparenting, and family care). RESULTS: Health deterioration and worsening financial condition were associated with a decreased frequency of volunteering. A transition out of weekly paid work and beginning to provide weekly grandchild care were both associated with an increased frequency of volunteering. We did not detect any further significant effects of resource changes on volunteering. DISCUSSION AND IMPLICATIONS: Our study revealed asymmetrical associations between changes in resources and volunteering, providing new insights into their interplay. The results deepen our understanding of successful aging by emphasizing the need to consider the dynamics of all resources that either facilitate or hinder active engagements among older adults.

(Healthy) Aging Patterns in Europe: A Multistate Health Transition Approach.

We explore patterns and determinants of health transition probabilities by combining outcomes of morbidity and mortality to examine different aging patterns across Europe, and to ascertain how individual socio-demographic characteristics modify these patterns. We use panel data from the Survey of Health, Ageing and Retirement in Europe (2004- 2017) for 76,536 individuals aged 50 + in 20 European countries who participated in at least two waves. All transition probabilities were calculated applying a multistate analytical approach. Our findings show significant gender, education, and cohort differences in health transition probabilities and marked cross-country group differences. Central and Northern European countries present lower probabilities of health deterioration than Southern and, especially, Eastern European countries. Having a high level of education, living in Central Europe, and being younger are associated with lower probabilities of health deterioration and, if any, a higher probability of being restored to good health. We found less evidence of differences when transitions end in death. Our study contributes to this line of research by implementing a multistate approach using European harmonized panel dataset, to examine the effects of birth cohort, educational attainment and gender differences on health transitions. Our findings point to the need to consider the specific influence of individual factors in the aging process in different transitions according to the context and with reference to specific vulnerable groups. In the context of aging societies, such a consideration is both essential and policy relevant. Supplementary Information: The online version contains supplementary material available at 10.1007/s12062-022-09403-4.

Corrigendum: Gender Gap in Unhealthy Life Expectancy: The Role of Education Among Adults Aged 45.

[This corrects the article DOI: 10.3389/ijph.2022.1604946.].

Gender Gap in Unhealthy Life Expectancy: The Role of Education Among Adults Aged 45.

Objectives: This paper examines the gender gap in unhealthy life expectancy across education levels and age in Spain to understand the extent to which the gender paradox exists over education and across ages. Methods: Death registrations and vital status were taken from the Spanish Statistical Office, while the three health measures (chronic conditions, bad-self rated health and cognitive impairment) from the 2019 European Health Interview Survey. We used Sullivan's method to compute unhealthy life expectancy by education level. We computed the gender and the education ratios of the proportion of unhealthy life years in each health measure by education and age. Results: At almost all ages and all education levels, women significantly lived longer but in poorer health than men. Marked gender differences are seen across most age-groups, particularly among the low educated. We detected greater health inequalities by education level for women (confirming the gender paradox) and a health gradient due to aging and across the health measures charting the disablement process. Conclusion: The new education distribution might improve the unhealthy life expectancy and might reduce the gender gap in the number of years spent in poor health.

Gender differences in health: results from SHARE, ELSA and HRS.

BACKGROUND: We examine gender differences in health at ages 50 years and older in 11 European countries, England and the USA. METHODS: We use the Survey of Health, Ageing and Retirement (SHARE) for 11 Continental European countries; the English Longitudinal Study of Ageing (ELSA) and the Health and Retirement Study (HRS) for the USA to examine gender differences in health behaviours, functioning problems, disability, disease prevalence and self-rated health. RESULTS: Women in all countries are more likely than men to have disabling, non-lethal conditions including functioning problems [odds ratio (OR) indicating the effect of female is 1.57-2.43], IADL difficulties (OR 1.45-2.94), arthritis (OR 1.46-2.90) and depressive symptoms (OR 1.45-3.35). On the other hand, self-reported heart disease is more common among men (OR indicating effect of female ranges from 0.43 to 0.86). These differences are not eliminated by controlling for smoking behaviour and weight. Self-reported hypertension (OR 0.72-1.53) is generally more common among women; stroke and diabetes do not show consistent sex differences. While subjective assessment of health is poorer among women, this is not true when indicators of functioning, disability and diseases are controlled. CONCLUSION: There is remarkable consistency in direction of gender differences in health across these 13 countries. The size of the differences is affected in many cases by the similarity in behaviours of men and women.

Happiness and life expectancy by main occupational position among older workers: Who will live longer and happy?

Current concerns about aging populations are being translated into legislations to postpone the statutory age at retirement. However, if this is done without considering inequalities in longevity across occupational groups, some may face higher vulnerabilities than others. We examine differences in life expectancy and happiness by occupational position for the Spanish population aged 50 and over. We use happiness as a measure of subjective wellbeing, and compute life expectancy and happy life expectancy by sex and main occupation. Age-specific death rates are calculated using administrative data, and happiness prevalence comes from the European Social Survey. We show that both men and women in managerial positions were advantaged in terms of life expectancy, but only men record more years with happiness. In addition, women in routine jobs were the ones who could expect to live shorter and unhappier. Postponing the statutory age at retirement without considering these differences could be detrimental to women's wellbeing and health.

Does Transition to Retirement Promote Grandchild Care? Evidence From Europe.

Evolutionary theory posits that grandparents can increase their inclusive fitness by investing in their grandchildren. This study explored whether the transition to retirement affected the amount of grandchild care that European grandparents provided to their descendants. Data from five waves of the longitudinal Survey of Health, Aging, and Retirement in Europe collected between 2004 and 2015 from 15 countries were used. We executed within-person (or fixed-effect) regression models, which considered individual variations and person-specific changes over time. It was detected that transition to retirement was associated with increased grandchild care among both grandmothers and grandfathers. However, the effect of retirement was stronger for grandfathers than for grandmothers. Moreover, transition to retirement was associated with increased grandchild care among both maternal and paternal grandparents, but there was no significant difference between lineages in the magnitude of the effect of transition to retirement on grandchild care. In public debate retirees are often considered a burden to society but the present study indicated that when grandparents retire, their investment in grandchildren increased. The findings are discussed with reference to key evolutionary theories that consider older adults' tendency to invest time and resources in their grandchildren.

Older People's Nonphysical Contacts and Depression During the COVID-19 Lockdown.

BACKGROUND AND OBJECTIVES: With the goal of slowing down the spread of the SARS-CoV-2 virus, restrictions to physical contacts have been taken in many countries. We examine to what extent intergenerational and other types of nonphysical contacts have reduced the risk of increased perceived depressive feelings during the lockdown for people aged 50+. RESEARCH DESIGN AND METHODS: We implemented an online panel survey based on quota sampling in France, Italy, and Spain in April 2020, about 1 month after the start of the lockdown. Our analyses are based on logistic regression models and use post-stratification weights. RESULTS: About 50% of individuals aged 50+ felt sad or depressed more often than usual during the lockdown in the 3 considered countries. Older people who increased or maintained unchanged nonphysical contacts with noncoresident individuals during the lockdown were at a lower risk of increased perceived depressive feelings compared to those who experienced a reduction in nonphysical contacts. The beneficial effect of nonphysical contacts was stronger for intergenerational relationships. The effects were similar by gender and stronger among individuals aged 70+, living in Spain and not living alone before the start of the lockdown. DISCUSSION AND IMPLICATIONS: In the next phases of the COVID-19 pandemic, or during any future similar pandemic, policy makers may implement measures that balance the need to reduce the spread of the virus with the necessity of allowing for limited physical contacts. Social contacts at a distance may be encouraged as a means to keep social closeness, while being physically distant.

Educational Inequalities in Life and Healthy Life Expectancies among the 50-Plus in Spain.

This study computes educational inequalities in life expectancy (LE), healthy life expectancy (HLE), and unhealthy life expectancy (ULE) by gender and education level in Spain in 2012. Death registrations and vital status by level of education were obtained from Spain's National Institute of Statistics. Health prevalences were estimated from the National Health Survey for Spain. We used Sullivan's method to compute HLE, ULE, and the proportion of time lived with health problems. Our results reveal that Spanish women live longer than men in all education groups, but a higher proportion of women report poor health. We detect substantial differences in unhealthy life by gender and education, with higher effect for women and for those with low levels of education. Poor self-perceived health shows the largest educational gradient; chronic diseases present the lowest. This is the first work that provides evidence on health inequalities by education level in Spain. Our findings seem to be in line with reports of the smaller social inequalities experienced in Southern Europe and highlight the importance of education level on extending the proportion of years spent in good health in a Mediterranean country.

"When I Retire, I'll Move Out of the City": Mental Well-being of the Elderly in Rural vs. Urban Settings.

This study examines the influence of risk factors on mental well-being at older ages focusing on the level of rurality of the living environment. We used cross-sectional, nationally representative survey data for Catalonia (Spain) from 2015 to 2017 to explain the mental well-being of the population aged 65 years and over. Based on a sample of 2621 individuals, we created a score of current mental well-being using the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). Using logistic regression and non-parametric tests, we identified the sociodemographic, health and lifestyle variables which, in combination with the features of the rural and urban settings of the living space, were associated with poor SWEMWBS scores. Our results reveal that adequate social support is linked to expectations of good mental well-being in later life. Poor self-perceived health and ageing limitations are associated with less deterioration of the well-being for the elderly living in rural areas, whereas living in urban areas is linked to a higher risk of suffering from emotional distress attributable to economic difficulties or low educational attainment. Incentivizing older people to live in rural environments could result in greater well-being in the last stages of life; appropriate prospective studies are needed to test this positive outcome.

[Scenarios for the impact of immigration on longevity and dependency among the elderly in the Spanish population]. / Escenarios del impacto de la inmigración en la longevidad y la dependencia de los mayores en la población española.

INTRODUCTION: The composition of the Spanish population has recently changed due to immigration. The present study aimed to estimate the magnitude of change in the calculation of healthy life expectancy and life expectancy in disability, taking the population of foreign residents into account. For this population, there is no information on mortality or the prevalence of disability. MATERIAL AND METHODS: Data were extracted from the 1999 Survey on Disabilities, Handicaps and Health Status to estimate healthy life expectancy and life expectancy in disability using the Sullivan method. Data were taken from the Spanish Statistical Institute and the World Health Organization, Sullivan's method was adapted to the case of two different populations, and possible scenarios were established. RESULTS: The differences between the mortality table estimated for the foreign resident population and that estimated for the Spanish population were considerable and were more evident in women. At 65 years of age and in the worst scenario, which occurs when all the members of the foreign resident population are disabled, life expectancy in disability would be 2 more years for men and 3 more years for women than when the foreign population was not considered. CONCLUSIONS: Our scenarios reveal that the impact of immigration on the calculation of healthy life expectancy and life expectancy in disability is moderate.

Education Inequalities in Health Among Older European Men and Women: The Role of Active Aging.

OBJECTIVE: We assessed whether education inequalities in health among older people can be partially explained by different levels of active aging among educational groups. METHOD: We applied logistic regression and the Karlson, Holm, & Breen (KHB) decomposition method using the 2010 and 2012 waves of the Survey of Health, Ageing and Retirement in Europe on individuals aged 50+ years ( N = 27,579). Active aging included social participation, paid work, and provision of grandchild care. Health was measured by good self-perceived health, low number of depressive symptoms, and absence of limitations because of health in activities people usually do. RESULTS: We found a positive educational gradient for each of the three health measures. Up to a third of the health gaps between high and low educated were associated with differences in engagement in active aging activities. DISCUSSION: Policies devoted at stimulating an active participation in society among older people should be particularly focused on lower educated groups.

[Social determinants of health at distinct levels by gender: education and household in Spain]. / Determinantes sociales de la salud de distintos niveles por género: educación y hogar en España.

OBJECTIVE: To explore from a gender perspective the association with subjective health of the interaction between education and household arrangements within the framework of social determinants of health placed at the micro and mezzo levels. METHODS: The data comes from the Spanish sample of the European Union Statistics on Income and Living Conditions for 2014. Independent logistic regression models for men and women were run to analyze the association with subjective health of the interaction between education and household arrangements. An additive model was run to assess possible advantages over the interaction approach. RESULTS: The interaction models show a lower or even no significant effect on health of household arrangements usually negatively associated with health among individuals with high education, displaying specific patterns according to sex. CONCLUSIONS: Health profiles of women and men are more precisely drawn if both social determinants of health are combined. Among the women, the important role was confirmed of both social determinants of health in understanding their health inequalities. Among the men, mainly those with low educational achievement, the interaction revealed that the household was a more meaningful social determinant of health. This could enable the definition of more efficient public policies to reduce health and gender inequalities.

Gender Differences in Disability and Economic Hardship in Older Europeans.

European women live longer, but they experience more old age-related disability than men. Disability is related to social factors, among which is poverty, through various pathways. While women's poverty has been pointed up as a challenge for Europe, our study investigates to what extent and in which countries a greater exposure to economic hardship is associated with older women's disability disadvantage. We used the 2014 EU-SILC data in 30 European countries for men and women aged 50-79 years (N = [1179-17,474]). Disability was measured by self-reported activity limitation and economic hardship by difficulties in "making both ends meet" and "facing unexpected expenses". Country-specific nested logistic regressions measured the women's disability disadvantage and its association with economic hardship. We found that activity limitations and economic hardship varied substantially across Europe, being the lowest in Sweden and Norway. We found gender gaps in activity limitations in 23 countries, always to women's disadvantage. After adjusting for age, this disadvantage was significant in 19 countries. In 11 of these countries, women's excess disability is associated with excess economic hardship in women, especially in Iceland, France, Sweden, and Austria. Women's excess disability and social factors such as economic hardship are linked, even in protective countries. These situations of double disadvantage for women deserve attention when designing policies to reduce health inequalities and to promote healthy ageing.

Health of Immigrants in European countries.

The health of older immigrants can have important consequences for needed social support and demands placed on health systems. This paper examines health differences between immigrants and the native-born populations aged 50 years and older in 11 European countries. We examine differences in functional ability, disability, disease presence and behavioral risk factors, for immigrants and non-immigrants using data from the Survey of Health, Aging and Retirement in Europe (SHARE) database. Among the 11 European countries, migrants generally have worse health than the native population. In these countries, there is a little evidence of the "healthy migrant" at ages 50 years and over. In general, it appears that growing numbers of immigrants may portend more health problems in the population in subsequent years.