[Socioeconomic inequalities in health in later life]

[How has life expectancy without functional limitations developed in Germany? An analysis with data from the German Ageing Survey (DEAS)]

INTRODUCTION

The long-term increase in life expectancy raises the question of whether the increased life expectancy is accompanied by an extension of years without health limitations. The study analyzes how life expectancy without functional and mobility limitations from the ages of 46 and 65 and their proportions of remaining life expectancy have changed since 2008.

METHODS

We analyze data from the German Ageing Survey of the 2008, 2014, and 2020/21 waves. Life expectancy without functional limitations (disability-free life expectancy-DFLE) was calculated using the Sullivan method. Severe functional limitations (using the Global Activity Limitation Indicator-GALI) and mobility limitations (climbing stairs, walking more than 1 km) were examined.

RESULTS

Compression of morbidity in the GALI has been observed in 46- and 65-year-old men since 2014, but not in women of the same age. In terms of mobility, 46- and 65-year-old men show trends towards compression when climbing stairs and 46-year-old men when walking more than 1 km since 2014. The values for women have stagnated for the first two indicators mentioned, but not for 46-year-old women since 2014 when walking more than 1 km.

DISCUSSION

Our analyses show different trends in DFLE depending on the indicator, age, and gender and do not allow a clear answer to the question of morbidity compression or expansion. We tend to see morbidity compression in men, whereas trends of stagnation or expansion tend to be seen in women. These results signal challenges in maintaining functional health, especially in women, and point to the need for targeted interventions to improve quality of life and healthy life expectancy.

Intersectionality on the perception of health in two cross-national surveys (WVS and EVS)

This article focuses on the health perceptions of people across social strata and nations using the combined dataset of the World Values Survey and the European Values Study (EVS/WVS). An intercategorical intersectional analysis model was developed to examine the social determinants underlying differences in health perceptions. Using logistic regression of the interactions between sex, age, level of educational attainment and income, we calculated the impact of these variables (main effects) and their interactions within the intersecting categories on health perceptions. The group with the best perception of their health includes men aged 16-49, with a high income and an upper-middle level of education. Comparative analysis has been carried out to identify differences in the influence of intersectional categories across countries. Of particular relevance is the number of Eastern European countries where the perception of people aged 50 and over with low income is very poor.

The association between health-promoting-lifestyles, and socioeconomic, family relationships, social support, health-related quality of life among older adults in china: a cross sectional study

Objectives

Lifestyles, accounting for 53% in determining death, play a vital role in improving the health of older adults. Thus, this study aimed to explore the influencing factors of the health-promoting-lifestyles and interaction mechanisms among older adults.

Methods

A total of 8526 elders were selected by a three-stage stratified random cluster sampling method. Socioeconomic status, family relationships, social support, health-related quality of life (QOL), and health-promoting-lifestyles (HPLP) of older adults were assessed with the Social Support Rating Scale, the short form 36 health survey (SF-36) and Health-Promoting Lifestyle Profile. A structural equation model (SEM) was conducted to test the direct and indirect association between influencing factors with HPLP.

Results

In this study, there were 4901 older adults who were empty nesters, and 3625 were non-empty nesters. Of all respondents, the average QOL score of older adults was 62.28 ± 16.51, average social support score was 78.06 ± 7.50. The HPLP score of older adults was 105.9 ± 19.6, and the average score of subscales was 2.5 ± 0.5, which was at the medium level. Social support had a positive and direct effect on HPLP of older adults (total effect, 0.34). Meanwhile, social support mediated the relationship between socioeconomic (total effect, 0.17), QOL (total effect, 0.33) and HPLP. Family relationships had a small indirect effect on HPLP via social support (0.01).

Conclusions

Social support is the strongest influencing factor in the health-promoting-lifestyles among older adults, followed by socioeconomic, health-related quality of life and family support. Thus, maintaining higher social support was important to improve the HPLP of older adults.

Occupational differences in mortality and life expectancy persist after retirement and throughout life

AIMS

There are substantial differences in remaining life expectancy at higher ages between occupational groups. These differences may be the effect of work-related exposures, lifestyle factors of workers in specific occupations, socioeconomic position or a combination of this. The scope of this paper is the extent to which occupational differences in remaining life expectancy persist after retirement, which would suggest that occupational exposures alone are not likely to explain all the difference.

METHODS

All individuals born between 1925 and 1939 who reported occupational information in the Census 1985 and were residents in Sweden to the end of 2020 or who died were included and followed for death until 2020. The Nordic Classification of Occupations was used to create nine occupational groups. Partial life expectancy and age-specific death rates were applied to examine mortality differentials.

RESULTS

This study showed substantial differences in partial life expectancy across the occupational cohorts with the biggest difference being about 2 years. The mortality differences persisted with increasing age, both when measured as absolute numbers as well as relative numbers.

CONCLUSIONS

The lack of convergence in mortality at high ages suggests that factors associated with lifestyle may play a larger role than occupational factors for the mortality differences between occupational groups at high ages. However, it cannot be ruled out that long-lasting effects of earlier occupational exposures also contribute. Regardless of the exact mechanism, we conclude that there is room for further reduction in mortality at high ages and, thus, for further improvement in life expectancy.

Older women being active in fitness gyms: benefits or constraints? Results from a qualitative interview study (southern Germany and East Coast of USA)

In the course of demographic change, the notion of age(ing) seen as something unavoidable has changed into something more adaptable. Through a healthy lifestyle, which aims at the self-responsible management of physical risks through fitness and discipline, individuals can expand their independence. However, the chances of doing so depend largely on one’s social position. In addition, the shift in health ideology towards the individual and the trend towards active ageing may lead to social pressure for some individuals. This qualitative interview study attempts to shed more light on this field of tension: What are the benefits and constraints of working on the body in the gym? Furthermore, what similarities and differences can be identified in identity constructions in the two samples with regard to the different underlying healthcare systems? The evaluation of the interviews was based on qualitative content analysis and was carried out with technical support (MAXQDA). It appears that for the respondents creating a fit body results primarily in self-empowerment gains. At the same time, submissions to Western body and fitness norms are also evident. Inequalities in health opportunities exist in both countries: While the respondents in the German sample (26 interviews) rely on public health services, the privileged American women (14 interviews) are covered by private insurance. They indicate that claiming government benefits appears as a stigmatisation of one’s own way of life. Consequently, a lack of resources in the form of cultural and economic capital prevents successful age(ing).

Socioeconomic inequalities in lung cancer - a time trend analysis with German health insurance data

BACKGROUND

Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany.

METHODS

The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006-2009, 2010-2013 and 2014-2017.

RESULTS

Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position.

CONCLUSION

The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

Compression, expansion, or maybe both? Growing inequalities in lung cancer in Germany

BACKGROUND

Lung Cancer (LC) is one of the most common malign diseases worldwide. So far, it is unclear if the development of LC incidence and mortality leads to morbidity compression or expansion and whether these developments differ by socioeconomic characteristics. This study analyses time trends in social and gender inequalities in life years with and without LC in Germany.

METHODS

The study is based on data of a large German statutory health insurance provider (N = 2,511,790). Incidence and mortality risks were estimated from multistate survival models. Trends in life years with and without LC were analysed using multistate life table analyses. All analyses were performed separately for gender, time period (2006-2009 and 2014-2017), and income group (<60% and ≥60% of the German average income).

RESULTS

Among men, declining LC incidence rates resulted in gains of life years free of LC and declining LC- affected life years and led to a relative compression, which was strongest in men with higher incomes. Among women, a clear increase in life years with LC led to an expansion of the lifespan affected by LC. This expansion was mainly driven by increasing incidence rates in women with low incomes. Overall, income inequalities in LC increased in both genders.

CONCLUSIONS

Our analyses reveal that developments in the length of life affected by LC differed substantially by gender and income and led to widening health inequalities over time. Public health efforts should mainly focus on vulnerable groups to reduce the persisting social inequalities in LC.

Equity impacts of interventions to increase physical activity among older adults: a quantitative health impact assessment

BACKGROUND

Behavioural interventions may increase social inequalities in health. This study aimed to project the equity impact of physical activity interventions that have differential effectiveness across education groups on the long-term health inequalities by education and gender among older adults in Germany.

METHODS

We created six intervention scenarios targeting the elderly population: Scenarios #1-#4 applied realistic intervention effects that varied by education (low, medium high). Under scenario #5, all older adults adapted the physical activity pattern of those with a high education. Under scenario #6, all increased their physical activity level to the recommended 300 min weekly. The number of incident ischemic heart disease, stroke and diabetes cases as well as deaths from all causes under each of these six intervention scenarios was simulated for males and females over a 10-year projection period using the DYNAMO-HIA tool. Results were compared against a reference-scenario with unchanged physical activity.

RESULTS

Under scenarios #1-#4, approximately 3589-5829 incident disease cases and 6248-10,320 deaths could be avoided among males over a 10-year projection period, as well as 4381-7163 disease cases and 6914-12,605 deaths among females. The highest reduction for males would be achieved under scenario #4, under which the intervention is most effective for those with a high education level. Scenario #4 realizes 2.7 and 2.4% of the prevented disease cases and deaths observed under scenario #6, while increasing inequalities between education groups. In females, the highest reduction would be achieved under scenario #3, under which the intervention is most effective amongst those with low levels of education. This scenario realizes 2.7 and 2.9% of the prevented disease cases and deaths under scenario #6, while decreasing inequalities between education groups. Under scenario #5, approximately 31,687 incident disease cases and 59,068 deaths could be prevented among males over a 10-year projection period, as well as 59,173 incident disease cases and 121,689 deaths among females. This translates to 14.4 and 22.2% of the prevented diseases cases among males and females under scenario #6, and 13.7 and 27.7% of the prevented deaths under scenario #6.

CONCLUSIONS

This study shows how the overall population health impact varies depending on how the intervention-induced physical activity change differs across education groups. For decision-makers, both the assessment of health impacts overall as well as within a population is relevant as interventions with the greatest population health gain might be accompanied by an unintended increase in health inequalities.

[Health inequalities in old age : Theoretical perspectives and methodological challenges]

While it has been long known that health inequalities persist until higher ages, less is known about the underlying mechanisms and health trajectories over the life course. This article gives an overview on recent developments regarding theoretical concepts and methodological considerations in this field of research. It can be concluded that studies on the explanation of the social gradient in health are scarce and even less is known about societal contexts that enable healthy aging irrespective of the socioeconomic position. The existing evidence on causal mechanisms and developments over the life course warrants cautious interpretation due to selective study samples and cross-sectional study designs.