Influence of social determinants of health in the evolution of the quality of life of older adults in Europe: A comparative analysis between men and women

The study addresses how social determinants of health (SDH) influence the evolution of quality of life (QoL) among Europeans aged 50 years and older, and whether effects differ by sex and European region. Population aging is accelerating, creating potential health inequalities shaped by SDH such as age, education, economic status, immigrant status, and residence. The research hypothesis posits that these SDH will affect QoL trajectories differently by sex and region. The objective is to analyze the impact of these SDH on QoL in individuals 50+, stratified by sex and region, using a longitudinal design across multiple European countries.

SDH, defined by the WHO Commission as personal, social, economic, and environmental factors, underlie health inequalities shaped by power, prestige, and resource access. Prior European studies have linked objective health factors (multimorbidity, chronic disease, functional limitations, depression) to poorer QoL in older adults. Structural SDH—economic status, material resources, sex, and education—also affect QoL, with women typically reporting worse indicators, lower education, and poorer health. Family trajectories and social relationships show sex-differentiated effects on QoL (e.g., stable partnerships benefiting men more than women). However, prior research lacked a longitudinal, multi-country European analysis explicitly differentiating men and women 50+ across regions to assess how SDH shape QoL evolution.

Design: Population-based analytical prospective cohort using SHARE Waves 5, 6, and 7 (2013, 2015, 2017). Standardized CAPI interviews (~90 min) were conducted at participants’ homes. SHARE provides calibrated design weights for cross-country inference. Setting and participants: From 59,421 individuals in 13 European countries in Wave 5 (Germany, Austria, Belgium, Denmark, Slovenia, Spain, Estonia, France, Italy, Luxembourg, Sweden, Switzerland, Czech Republic), inclusion criteria were age ≥50, residence in a study country, consent, and participation in all three consecutive waves. Final sample: n=11,493 (female n=6,236; male n=5,257). Countries were grouped by welfare regime into four regions: North (Denmark, Sweden; n=2,747), Continental (Austria, Germany, Belgium, France, Luxembourg, Switzerland; n=4,443), South (Spain, Italy; n=2,770), East (Slovenia, Estonia, Czech Republic; n=1,533). Representativeness check: Noting baseline differences between participants and non-participants (participants slightly younger, fewer women, marginally higher CASP-12), the team performed a random matching of non-participants to participants by sex, age (±2 years), and region to compare CASP-12. Scores were highly similar (38.3 vs 38.2), supporting representativeness of the analytic cohort as a slightly younger fraction. Outcome: QoL measured with CASP-12 (12–48; higher=better). Cutoffs: <35 low, 35–37 moderate, 38–39 high, 39–48 very high. Scale reliability α≈0.84. Explanatory SDH variables (primarily individual-level): sex; age groups (50–64, 65–74, 75–84, ≥85); education (ISCED: low 0–2, medium 3–4, high 5–6); economic level via “making ends meet” dichotomized (no difficulty vs difficulty) and “received external financial assistance” (yes/no); nativity (born in interview country yes/no); area of residence (urban: big city/suburbs/large town vs rural: small town/rural village); European region (North, Continental, South, East). Covariates: Marital status; employment (present worker yes/no); household composition; number of children (0, 1–2, ≥3); grandchildren (0, 1–4, ≥5); self-perceived health (excellent/very good, good, fair, poor); chronic conditions (0, 1–2, ≥3); mobility difficulties (none/some/severe); physical activity (active vs inactive); depression via EURO-D (0–12; ≥4 indicates depression; α 0.62–0.78); BMI categories (WHO); smoking (current vs non-/ex-smoker); alcohol (none or <1–2/month; 1–4 days/week; almost every day). Statistical analysis: Descriptives with means/SD and frequencies/percentages; univariate tests via chi-square and t-tests. Linearity checked; children/grandchildren categorized based on spline smoothing; multicollinearity assessed via gVIF (max 1.22). Linear mixed-effects models (lme4::lmer in R) with participant ID as random intercept estimated effects. A crude model included sex only; an adjusted model added wave, region, and age groups to estimate sex effects within strata by changing reference categories. Interactions Sex×Region and Sex×Age Group were tested. Determinant-specific models (one determinant at a time) estimated differences in QoL stratified by sex. Analyses used SPSS 25 and R 4.3.0. Significance at p<0.05.

Baseline (Wave 5) patterns: - Regional and sex differences in CASP-12: Northern Europe had the highest QoL; Southern the lowest. Example: women South vs North 35.0 (SD 6.55) vs 40.7 (SD 5.17), p<0.001; this persisted in Waves 6–7. Men scored higher than women in all regions, with the smallest sex gap in the North. - Age trend: QoL decreased with age across sexes and regions (p<0.001). - Education: Lowest scores among women with low education in the South (34.3, SD 6.62) vs men 35.6 (SD 6.32), p<0.001; trend persisted. - Economic hardship showed the largest sex differences in QoL across regions and waves; especially low in South among women: 32.7 (SD 6.44) vs men 34.2 (SD 6.28), p<0.001. - Nativity: Native respondents generally had higher QoL than immigrants, except in South. - Living with a partner associated with higher QoL; difference notable in South (women 35.0, SD 6.68 vs men 36.2, SD 6.28; p=0.03). - Self-perceived health: Poor self-rated health strongly linked to lower QoL; women South vs North with poor health: 27.8 (SD 5.78) vs 32.8 (SD 7.08), p<0.001. - Lifestyle: No consistent smoking-related QoL differences except South where male nonsmokers > female nonsmokers (36.2 vs 34.9; p<0.001). Moderate alcohol intake (1–4 days/week) associated with highest QoL in all regions; in East, daily-drinking women scored 39.6 (SD 5.71) > non-consumers 36.7 (SD 6.34) and > men 38.6 (SD 6.19), p<0.001. Depression (EURO-D≥4) markedly reduced QoL in both sexes, with lowest scores in East and South. Longitudinal mixed-model estimates (selected): - Temporal change: QoL declined over time for both sexes from Wave 5. Wave 7 estimates: Women β=-0.430 (95% CI -0.580; -0.280); Men β=-0.293 (95% CI -0.455; -0.132); between-sex slope difference not significant (p=0.225). - Age effect: QoL worsened with age; strongest in ≥85. Women β=-4.311 (95% CI -4.826; -3.797) vs Men β=-2.890 (95% CI -3.446; -2.334); sex differences significant (p<0.001). - Education: Compared to low, medium and high education improved QoL; effects larger in women. Medium: Women β=1.888 (1.637; 2.139) vs Men β=1.539 (1.279; 1.800), p=0.034. High: Women β=2.862 (2.575; 3.149) vs Men β=2.480 (2.186; 2.775), p=0.033. - Economic status: No difficulty vs difficulty: Women β=3.447 (3.249; 3.646), Men β=3.265 (3.046; 3.484); sex difference not significant (p=0.100). Receiving external financial assistance associated with lower QoL (Women β=-1.074; Men β=-0.810; p=0.079 for sex difference). - Residence: For women, rural/small town β=0.266 (0.019; 0.514), suburbs β=0.590 (0.189; 0.990); not significant in men. - Region (vs South): Continental: Women β=3.461 (3.128; 3.795), Men β=3.103 (2.759; 3.447); North: Women β=5.198 (4.827; 5.569), Men β=4.360 (3.977; 4.742), p=0.002 (women>men); East: Women β=1.471 (1.041; 1.901), Men β=0.995 (0.530; 1.459). - Interactions: Sex×Region (p=0.0378) and Sex×Age Group (p<0.001) significant. In adjusted all-ages models, no significant sex difference in the North (p=0.385), but significant male>female differences in Continental, East, and South. Sex differences increased with age in all regions (e.g., South: All ages β=1.006, p<0.001; 85+ β=1.945, p<0.001). Overall, key SDH linked to poorer QoL were female sex, older age, economic hardship, lower education, and residing in Southern/Eastern Europe. Depression substantially lowered QoL, especially in South and East.

The findings confirm that SDH substantially shape QoL trajectories in Europeans aged 50+, with consistent sex and regional disparities. Women reported lower QoL than men across waves, with the smallest gap in Northern Europe, suggesting social democratic welfare regimes may mitigate sex-based inequalities. Economic strain strongly reduced QoL similarly in men and women, but its prevalence and impact were more pronounced in Southern and Eastern regions, aligning with literature on welfare-state differences. Education benefited QoL for both sexes, with a stronger effect in women, implying that educational attainment may be a pivotal lever for reducing gendered QoL gaps. Age-related declines were universal but steeper for women, particularly at 85+, pointing to compounded vulnerabilities. Being native appeared protective for women, consistent with evidence on migrant women’s multiple discrimination. Residence showed a nuanced pattern: rural/small-town or suburban living was modestly protective for women but not men, diverging from some prior meta-analytic evidence and suggesting contextual heterogeneity. Depression substantially decreased QoL across regions, with greater detriments in South and East, underscoring mental health as a critical target. Moderate alcohol intake correlated with higher QoL, possibly reflecting social integration and cultural norms, while physical inactivity—more prevalent among women—related to lower QoL. The significant Sex×Region and Sex×Age interactions indicate that policies must be tailored by welfare regime and life stage to effectively address inequalities.

This longitudinal, sex-stratified analysis across 13 European countries identified persistent and regionally variable sex inequalities in QoL among adults aged 50+. Women consistently reported lower QoL, with the smallest sex difference in Northern Europe and the largest in Southern Europe. Key SDH associated with lower QoL included older age (with sex differences widening with age), economic difficulties (especially in Southern and Eastern regions), lower education (more prevalent and impactful among women, particularly in the South), and regional location. Depression prevalence and its association with lower QoL were higher in Southern and Eastern Europe. Lower physical activity among women was linked to reduced QoL. These findings highlight the need for policies that invest in education, alleviate economic hardship, enhance mental health services, promote physical activity, and address region-specific inequities, with particular attention to older women. Future research should incorporate richer socioeconomic and contextual variables to further explain regional and sex disparities and to evaluate targeted interventions.

- Attrition and selection: Only participants present in Waves 5–7 were included, potentially limiting external validity. Matching analyses suggested similar CASP-12 among matched non-participants, but residual selection bias may remain. - Economic measures: Economic status assessed via self-reported “making ends meet” and “received external financial assistance,” which are subjective, not directly quantifiable, and may vary over time. - Alcohol measures: Cross-country differences in definitions of moderate/excessive drinking could affect comparability. - Missing sociodemographic detail: Lack of ethnicity/race and detailed country-of-origin information limits analysis of migrant heterogeneity. - Unmeasured SDH: Important variables (income percentiles, social benefits, childhood conditions, social participation, neighborhood services, digital literacy, family support) were not included. - Generalizability: Despite calibrated weights, differences in national sampling frames and requirement of three-wave participation may affect representativeness.