effect of behavioral factors. Inequalities in SRH were found with a higher risk of reporting poor health with an OR of 2.06 (95% CI = 1.71–2.48) in the middle educational group and an OR of 3.44 (95% CI = 2.63–4.50) in the low educational group as compared to the highly educated when controlling for sex, age, employment status and chronic diseases (descriptive statistics of the study sample in Supplementary online file). Such interventions should focus on all age groups as living conditions from prior life stages are important determinants of health in later life. Health inequalities are ultimately about differences in the status of people’s health. 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. 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). . Stolz E, Mayerl H, Waxenegger A et al. [1] United Nations, World Population Ageing 2015 (ST/ESA/SER.A/390). low educational group as compared to the high educational group. Participants with missing values on the other variables (n = 152) and with a BMI lower than 18 (n = 22) were excluded, so that an analytic sample of 3246 participants resulted. This poses special challenges for the medical, nursing and psychosocial care … 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. Whereas the association between education and health in later life is well described, investigations about the underlying mechanisms of these health inequalities are scarce. Educational status and functional decline among the 1931–1941 birth cohort. Thus, further investigations should examine if the contribution of material, behavioral and psychosocial pathways to health inequalities in old age differs depending on the indicators of health and social inequality under study. 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 Such interventions should focus on all age groups as living conditions from prior life stages are important determinants of health in later life.35–37, Studies with the population of working age have identified material, behavioral and psychosocial factors as key pathways for explaining health inequalities. . . when smoking or overeating are applied to cope with psychosocial stressors.8 Therefore, the relevance of single explanatory approaches might be overestimated when only one pathway is taken into account.5. The existing studies argue for the importance of material living conditions as they are widely working through behavioral and psychosocial factors.10–14. The independent effect of behavioral factors was comparable to the independent effect of psychosocial factors (middle educational group: 9%, low educational group: 13%). 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). The relationship we have with our environments is skewed by personal characteristics such as the family we were born into, our sex and our ethnicity, leading to inequalities in health. As there were only small differences in the size of coefficient estimates and their statistical significance, we decided to rely on the dataset which maintains cases with missing values and therefore provides a less biased sample. Societal changes (such as rising education levels) and social mobility can influence how much people are affected by health conditions. 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. As described in this chapter, there are also differences in outcomes relating to socioeconomic status, ethnicity, geographical region and other social factors. These health inequalities, avoidable and unfair differences in health status between groups of people or communities1, reflect historic and present-day social inequalities in our population. Such age-specific health influences are neither theoretically conceptualized nor empirically examined in health inequalities research, so that further studies are needed. It might be reasonable that the importance of psychosocial variables is higher in mental health problems, whereas material and behavioral factors might be more relevant for inequalities in somatic health. There are also differences in outcomes relating to socioeconomic status, ethnicity, geographical area and other social factors. 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. 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. 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. 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? Unfortunately, most of the existing studies with the population of working age do not provide results on the contribution of single variables. 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. Between 2015 and 2030, the number of people aged 60 and over is expected to increase from 901 million to 1.4 billion. 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. 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. 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. Oxford University Press is a department of the University of Oxford. Published by Oxford University Press on behalf of Faculty of Public Health. 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. Additionally, psychosocial factors had an indirect effect through behavioral factors (middle educational group: 4%, low educational group: 5%). 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. [3] World Health Organization, World Report on Ageing and Health (Geneva, 2015). For instance, what is the cumulative health effect on BAME groups due to a lifetime of inequalities in 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… There is considerable evidence on active ageing and cognition in older age that shows people and communities can make changes that improve physical and mental health at 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 2006;28:375–92. The Institute for Social Research and Social Policy, Cologne, Germany. [3] Moreover, these factors are often intertwined, such that individual characteristics among older persons may hold sway over other health determinants. (eds). But is that so for all? Additionally, we ran the analysis with a dataset in which missing values were replaced by the mean score of the sample. 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). The baseline model (Model 1) included educational status and control variables (sex, age, employment status and chronic diseases). [2] Genetics are estimated to be responsible for about 25 per cent of differences in health and function in old age, with other determining factors including aspects of the natural and physical environment such as air pollution and accessibility, risky behaviors such as smoking and inactivity, and individual characteristics such as occupation and level of income or education. In: Knesebeck O, Wahrendorf M, Hyde M 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). ‘Thinking of your household’s total monthly income, would you say that your household is able to make ends meet…with great difficulty/with some difficulty/fairly easily/easily?’ 0 = no financial problems (easily), 1 = some financial problems (fairly easy/with some difficulty), 3 = great financial problems (with great difficulty), Several questions about problems in affording goods and amenities of daily living (replacing worn out clothes or shoes; replacing glasses; buying necessary groceries and household supplies; heating; eating meat, fish, poultry, fruits or vegetables more than once a week; doing a week long holiday once a year; paying unexpected expenses without borrowing money), 0 = not deprived (less than three items mentioned), 1 = deprived (three or more items mentioned), 0 = Private health insurance, 1 = statutory health insurance, 1 = Never / one to two times per month, 2 = one to four times per week, 3 = five times a week or more, 0 = More than once a week, 1 = less than once a week, 0 = Normal weight (18–25), 1 = overweight (25 < 30), 2 = obesity (≥ 30), 0 = Married/in a relationship, 1 = divorced/separated/widowed/single, 0 = At least one child alive, 1 = no child alive, Copyright © 2020 Faculty of Public Health. Selective mortality explains only some of the decline in health inequalities with age. Old age is often accompanied by poor health and functional disabilities. Between 2015 and 2030, the number of people aged 60 and over is … . 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]. Furthermore, different national contexts and age groups should be taken into account as the relevance of health influences might differ between countries and life stages. 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. Neglect, Abuse and Violence of Older Women, Commission for Social Development (CSocD), Open-Ended Working Group on Ageing (OEWGA), 1999 International Year of Older Persons (IYOP), Vienna International Plan of Action on Ageing, Madrid International Plan of Action on Ageing (MIPAA), Department of Economic and Social Affairs, Madrid International Plan of Action on Ageing. For instance, Ploubidis et al.25 showed that material and behavioral factors are most important in explaining socioeconomic inequalities (measured by an index of occupation, education, income and wealth) in somatic health, depression and well-being, whereas psychosocial factors exert most of their influence on depression and well-being. 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. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Pförtner TK, Schmidt-Catran A. Lebensstandard und Gesundheit. 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. 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). Address correspondence to A.L. We conclude that material factors are of major importance for explaining health inequalities as they most adequately reflect the life situation of the socially disadvantaged. According to a recent literature review,5 there are few studies that examine the contribution of all of the three explanatory pathways to the association between education and SRH. 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%). Finally, we included all variables simultaneously to estimate their total contribution (Model 8).10,13,14 For each model, we calculated the relative contribution to the association between education and SRH by: ((β(Model 1) – β(Model 2–8)/β(Model 1)) × 100). After the first step of variable selection (χ2 test), all material factors and most of the behavioral factors remained for further analysis. Research from Canada illustrates that the main long-term health proble… 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. 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%). 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, However, employing a more proximal measure of SES reduces inequalities in middle age so that convergence of inequalities is not apparent in old age. 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. When the terms ‘effect’ or ‘explain’ are used in the upcoming sections, they should be understood in a statistical sense rather than in a causal relationship sense. 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. In the context of rapid population ageing, age-related inequalities take on greater urgency. larger social health inequalities. Logistic regression models of poor SRH by education, adjusted for material, behavioral and psychosocial factors (n = 3246). Furthermore, material factors work indirectly through behavioral factors, e.g. Against the background of rapid population aging in Europe and as older people constitute the vast majority of those with health problems in developed countries, understanding the determinants of health in old age has become one major concern of policy-makers. 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. effect of psychosocial factors—ind. . Schmitz, E-mail: The causal effect of education on health: what is the role of health behaviors? Hoogendijk E, van Groenou MB, van Tilburg T et al. In: Giesselmann M, Golsch K, Lohmann H et al. Reducing inequalities shoul… effect of behavioral factors. As ill-health can be prevented and death be delayed, old age inequalities in health should also be possible to reduce. 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). In this article... A discussion of the health inequalities associated with ageing The socioeconomic influences on ageing A discussion of age discrimination. : 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. Read our Briefing Paper on “Health Inequalities in Old Age”. delayed, old age inequalities in health should also be possible to reduce. For a detailed description of the calculation method, see Table 3. Res Aging. Education was measured by the highest educational level using the International Standard Classification of Educational Degrees (ISCED-97).19 Participants were categorized into three groups: ‘low education’ (ISCED-97-levels 0–2: pre-primary, primary and lower secondary education), ‘medium education’ (ISCED-97-levels 3–4: upper and post-secondary education) and ‘high education’ (ISCED-97-levels 5–6: tertiary education).20,21, SRH was chosen as indicator of health as it is a strong predictor for morbidity and mortality that is widely used in public health research.22,23 SRH was assessed by asking ‘Would you say your health is…excellent/very good/good/fair/poor’. The author used the 1992-2002 Health and Retirement Study to shed new light on this old debate. Studies that take into account material, behavioral and psychosocial factors rely on other health indicators than SRH and other measures of social inequality than education. 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. 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. 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.