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. Res Aging. Between 2015 and 2030, the number of people aged 60 and over is … We ran the analysis with missing data excluded which eliminated nearly 300 cases (in addition to the n = 152 with missing values on the other variables). 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. Introduction. Societal changes (such as rising education levels) and social mobility can influence how much people are affected by health conditions. For a detailed description of the calculation method, see Table 3. Health inequalities persist in old age, as individuals’ health status is an accumulation of lifelong socioeconomic, ethnic … First, pension schemes can worsen health inequalities in old age through increased privatization and retirement age reforms. We estimated logistic regression models using the highest educational group as the reference category. Health inequalities in the older population. effect of behavioral factors. Interventions for the reduction of health inequalities in old age should thus focus on improving material living conditions. effect of material factors—ind. 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. Regardless of the reason for social isolation, it ultimately leads to huge inequalities in the provision of health services across age groups. See Table 1 for the operationalization and coding of the variables. van Oort F, van Lenthe FJ, Mackenbach JP. 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 Analyses were performed with Stata V.13 (StatCorp, Texas, USA) using the decomposition method of Karlson, Holm and Breen (KHB) which allows a comparison of regression coefficients between same-sample nested non-linear models.32 In contrast to linear models, changes in regression coefficients in logit models cannot readily be attributed to the effect of including mediator variables as parameter rescaling by itself tends to increase the regression coefficients.32,33. Moor I, Rathmann K, Stronks K et al. 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. (eds). As we use cross-sectional data, it is not possible to determine the direction of causation between education, mediator variables and SRH. Old age is often accompanied by poor health and functional disabilities. Including death in the health outcome steepens the health trajectories at older ages, especially for manual classes, eliminating the convergence in health inequalities, suggesting that healthy survival effects are important. Schöllgen I, Huxhold O, Tesch-Römer C. Sundmacher L, Scheller-Kreinsen D, Busse R. Aldabe B, Anderson R, Lyly-Yrjänäinen M et al. Schmitz, E-mail: The causal effect of education on health: what is the role of health behaviors? 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. Socio-economic disparities in physical health in 10 European countries. 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. Furthermore, we adjusted the baseline model for several combinations of two groups of variables (Models 5–7). 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. 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. For instance, what is the cumulative health effect on BAME groups due to a lifetime of inequalities in Between 2015 and 2030, the number of people aged 60 and over is expected to increase from 901 million to 1.4 billion. 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. Hoogendijk E, van Groenou MB, van Tilburg T et al. effect of material factors—ind. In old age, lifetime savings of different forms of capital were crucial. After the first step of variable selection (χ2 test), all material factors and most of the behavioral factors remained for further analysis. Simplified causal model for educational inequalities in health with independent (direct) and indirect effects of material, behavioral and psychosocial factors. 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%). Pförtner TK, Schmidt-Catran A. Lebensstandard und Gesundheit. In: Knesebeck O, Wahrendorf M, Hyde M et al. The author used the 1992-2002 Health and Retirement Study to shed new light on this old debate. As described in previous chapters, there are differences in health outcomes for men and women, for different age groups and for different countries. 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. Health and inequalities in ageing People still grow old, but they are growing old later in life. . Age is in fact estimated to be the most important determinant of health. 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. . 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. The reduction of the effect size of the coefficient estimates for educational status was interpreted as the effect of education that is mediated by the variable group included. Additionally, we ran the analysis with a dataset in which missing values were replaced by the mean score of the sample. 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]. 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. 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). : 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. . 1, modified after Moor et al.5). But the term is also commonly used to refer to differences in the care that people receive and the opportunities that they have to lead healthy lives, both of which can contribute to their health status. 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 psychosocial factors—ind. Our analysis revealed that material factors were the most important as they exerted the largest independent effect and as they were additionally working indirectly through behavioral and psychosocial factors. economic inequalities in mortality in old age is important given the gains in longevity, increasing ageing population and expanding health expenditure as societies age. Material factors were most important as they were additionally working through behavioral and psychosocial factors whereas the independent contribution of behavioral and psychosocial factors was much lower than suggested in the separate analyses of the three explanatory pathways. 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. 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. In our analysis, the most relevant mediators were financial problems, type of health insurance (especially in the low educational group), lacking social participation, insufficient control beliefs, lacking physical activity and a BMI ≥ 30. ‘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. 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. But is that so for all? Research from Canada illustrates that the main long-term health proble… A significant proportion of the diversity in older age is due to the cumulative impact of these health inequities across the life course. 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. , 2013: 84). 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. 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). The analytic sample included 3246 participants aged 60–85 years. Whereas the association between education and health in later life is well described, investigations about the underlying mechanisms of these health inequalities are scarce. In: Börsch-Supan A, Brugiavini A, Jürges H et al. Skalická V, van Lenthe F, Bambra C et al. 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. Read our Briefing Paper on “Health Inequalities in Old Age”. 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. (eds). Psychosocial factors were civil status,25,30 parenthood,10 social participation, control beliefs and social capital. 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 Policy interventions that focus on the improvement of material living conditions might reduce health inequalities in old age. 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%). Furthermore, material factors were working through psychosocial factors with an indirect contribution of 6% in the middle educational group and 8% in the low educational group. The impact of health inequality is keenly felt by the oldest old [3] Moreover, these factors are often intertwined, such that individual characteristics among older persons may hold sway over other health determinants. 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. . Furthermore, health inequalities in old age reflect accumulated disadvantage over the life course as well as inequalities experienced at older ages associated with geographic location of residence, gender, and ageist attitudes and practices (). Oxford University Press is a department of the University of Oxford. In comparison with half a century ago, 75 today is the new 65 in terms of mortality and disability. 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). . 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 The material factors were house ownership,14,24 financial situation, material deprivation, access to healthcare and type of health insurance.14,25, Behavioral factors were smoking habits,1 alcohol consumption,26 moderate or vigorous physical activity27,28 and body mass index (BMI) as a proxy of the quantity and quality of food intake.24,29. Published by Oxford University Press on behalf of Faculty of Public Health. This study examines the relative contribution of material, behavioral and psychosocial factors to health inequalities in older Germans. Education and physical health trajectories 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. 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.
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