by Sanna Read, Emily Grundy and Else Foverskov
Poorer people are more likely to have a poorer health. Socioeconomic inequality in health extends worldwide and remains persistent in Europe despite increases in wealth, educational attainment, proportions of working in non-manual jobs, and expenditure on health services. All age groups are affected. We reviewed the evidence on health inequalities in Europe, focusing on older people, a group which is growing fast and is vulnerable to adverse socioeconomic circumstances.
Previous work has mostly investigated negative health outcomes such as mortality but it is important to also consider inequalities in positive dimensions of health. Our review focused on subjective health and well-being, such as self-rated health, life satisfaction and quality of life. Positive aspects have been often overlooked, even though how people rate and report their health and well-being may be a better indicator of quality of life than objective health measures such as death rate or physical measures of function. To date, there has only been one review on socioeconomic factors and subjective health in older population covering studies up until spring 1999. We both updated and expanded on it.
We were especially interested in studies that investigated the mechanisms underlying socioeconomic differences in health among older people. In other words, could some potentially modifiable factors such as health-related behaviours and social support explain the association between low socioeconomic status and poorer health? We were also interested in age and gender differences: were health inequalities weaker in very old people compared to younger-old people? Was the association stronger in men than women, or vice versa? We tried to identify common factors between the studies that could explain age or gender differences.
We carried out a systematic literature search on original articles using seven bibliographic databases. The studies were included in the review if they 1) reported results for socioeconomic position and indicators of subjective health and well-being (self-rated health, life satisfaction, quality of life); 2) were conducted since 1991 and used population based samples of people aged 60+ in Europe; and 3) were published between 1995 and 2013. We identified 71 relevant studies. Most studies were conducted in Northern, Western and Southern European countries, but only a few in Eastern Europe.
The papers reviewed indicated strong evidence of an association between socioeconomic position and the subjective health and well-being of older Europeans. Inequalities were found in all regions of Europe.
The association between socioeconomic position and health was to some extent mediated by health related behaviour and social support. This points to some potential mechanisms of why a higher socioeconomic status helps to maintain good subjective health, i.e. wealthier people choose a healthier diet, exercise, quit smoking, use alcohol moderately and have a broad and supportive social network. The interesting question is to what extent this pathway reflects the increased personal freedom to choose and make one’s life meaningful, and whether can this be achieved by anyone regardless of socioeconomic differences once their basic needs are met. In our review, very few studies investigated underlying mechanisms, and most of them used regression methods to study the pathways through health behaviours and social support (mediation). More longitudinal studies using path modelling are needed to assess mediation properly and also establish the extent of possible selection due to earlier poorer health.
Socioeconomic inequalities were more evident in self-rated health than in quality of life and life satisfaction. Possibly this is because life satisfaction and quality of life assess the psychological dimension of well-being, and this may be less affected by external circumstances such as wealth and more by internal factors such as personality.
Although the previous review mentioned above suggested that measures of current circumstances (e.g. income) had a stronger association with subjective well-being than indicators of past circumstance (e.g. education), our review suggests that this may depend on health measures. Education was frequently associated with self-rated health but the association between education and quality of life or life satisfaction was less consistent. Income, in turn, was less frequently associated with self-rated health and quality of life than other socioeconomic measures.
The effect of socioeconomic factors may be a life time process of accumulation of different factors or certain periods of life may have more impact than others. However, there is a lack of suitable longitudinal data that would make it possible to look at the impact and accumulation of different factors over time. A small number of studies investigated whether, in addition to low personal socioeconomic position, living in a deprived area was associated with the subjective health and well-being in older people. They suggested that area deprivation is a strong predictor of poorer subjective health. This warrants more work on well-being and area factors among older population.
Socioeconomic inequality in health seemed to get weaker in older age groups. One explanation may be low numbers in the oldest age groups, which reduces the power of statistical tests. However, a weakening association by age was also reported in some studies that had relatively large and equivalent numbers in different age groups. This suggests that there may be other explanations, for instance the decreased salience of factors related to working life for those in the oldest groups, possible selection effects and the changing sensitivity of socioeconomic measures over the life time.
Health inequality did not seem to be larger in men compared to women, or vice versa. If any gender differences were found, they tended to diminish after adjusting for health and life circumstances. Fluctuation in results by gender was especially evident in studies including several countries which may indicate that gender effects are context specific. Small numbers of men in the oldest age groups in some studies and the related differential survival of men and women to advanced ages may also play a role. Older people, and women especially, may be less differentiated on socioeconomic indicators, such as level of education, than mid-life groups. This may impact both age and gender patterns in the association between socioeconomic position and later life health.
In summary, the results of this systematic narrative review of the literature demonstrate the importance of social influences on later life subjective health and well-being. The paper also indicates areas which need further investigation, such as more studies from Eastern Europe, more longitudinal studies and more research on the role of mediating and moderating factors. Health inequalities are not only unnecessary and avoidable, but also unfair and unjust. Although ageing has sometimes been seen as an irreversible downward spiral of functional decline, a growing number of studies demonstrate the plasticity of ageing and the responsiveness of health indicators to current circumstances as well as events earlier in the life course. Individual variation in health is large in the second half of life: an 80-year-old may be fitter and feeling healthier than a 50-year old. The well-preserved health of some older people shows what might be achieved if material and non-material resources were accessible and personal motivation to promote good health was attractive to everyone. Recognising this and the potentials of change may encourage people to tackle persisting health inequalities in older ages.
Read S, Grundy E, Foverskov E (2015) Socioeconomic position and subjective health and well-being among older people in Europe: a systematic narrative review, Aging and Mental Health, Published online 25 March 2015.
About the authors
Sanna Read is a Research Fellow at the Department of Social Policy and the Personal Social Services Research Unit at the LSE. At the time of writing the review she was also a lecturer at London School of Hygiene and Tropical Medicine.
Emily Grundy is a Professor of Demography at the Department of Social Policy and Director of the ALPHA (Ageing, Lifecourse and Population Health Analysis) Research Group at the LSE.
Else Foverskov is a Research Assistant at the Department of Social Policy at the LSE.