Dissertation

Measuring and explaining the educational gradient in health across Europe: the role of individual and contextual factors

Abstract

Educational attainment is a powerful determinant of health in later life, operating through multiple channels including access to material resources, health literacy, and social and cognitive reserves. Although the associations between low levels of education and poorer health outcomes are well documented, the extent to which these associations vary across health domains, demographic subgroups, and institutional contexts remains insufficiently understood. In this dissertation, I investigate the magnitude and heterogeneity of educational health inequalities across Europe, with particular attention to functional, sensory, and cognitive health dimensions. Using harmonized data from the Survey of Health, Ageing and Retirement in Europe and comprehensive Finnish population registers, in the dissertation I applied complementary analytical frameworks to examine how health outcomes vary in relation to education, and how these patterns further differ across demographic and national contexts. This dissertation has been assembled from four papers accepted or published in scholarly journals. Study I examines educational differences in disability-free life expectancy across ten European countries, focusing on gendered and regional disparities. Study II assesses educational disparities in the prevalence of age-related hearing loss and hearing aid use across 28 countries, analysing variations by age, gender, and welfare regime. Study III explores educational disparities in cognitive health expectancy, with a focus on variations in these disparities by gender and contextual setting. Finally, Study IV uses multistate life table analysis to estimate years lived with and lifetime risk of hearing loss and dementia, as well as their comorbidity, by sex and educational attainment in Finland. Across functional limitations, sensory impairment, and cognitive impairment, education consistently emerged as a fundamental stratifier. Individuals with lower levels of educational attainment were not only more likely to experience adverse health outcomes, but they also spent a larger proportion of their remaining life with health impairments. These educational differences extended beyond survival to encompass the duration of life lived with or without impairment. However, Finnish registry data revealed somewhat unexpected findings: a positive association between education and lifetime risks of morbidity, which was stronger among men. This pattern likely results from education being a stronger determinant of survival in males rather than in females, with this differential survival shaping the male population exposed to dementia at older ages more strongly. In contrast, survey-based studies consistently showed the greatest health disadvantages among low-educated women. Women generally lived longer but spent more years in poor health, reflecting the female-male health-survival paradox. Educational health disparities were often greater among women, reflecting both their survival advantage and structural factors that affect how education translates into health resources. Age-related patterns suggest convergence of educational disparities in later life. Educational disparities in hearing loss narrowed with age, particularly for women, pointing to biological ageing processes becoming increasingly dominant over socially stratified exposures. Similarly, sex differences in hearing loss and dementia risk converged in the oldest age groups. This age-levelling likely reflects selective mortality alongside the convergence of health risks as biological deterioration becomes more universal. Contextual setting was central to interpreting the findings. Educational gradients in disability-free and cognitive health expectancy, as well as hearing loss prevalence, were steeper in Central and Eastern European countries, while region was substantially more important than education in hearing aid use. The extent of educational disparities was mostly driven by the concentration of disadvantage among low-educated women. These findings highlight the role of welfare regimes in buffering or exacerbating educational health inequalities. This dissertation advances demographic and ageing research through several original contributions. It offers new scholarly insights into how diverse European contexts, with a particular focus on Central and Eastern Europe, shape health inequalities. The work introduces novel estimation approaches for disability-free and cognitive health expectancy. Conceptually, it offers a new interpretation of education as a double-edged sword: while higher education extends longevity, it may also increase the time lived with morbidity, reframing assumptions about social advantage and health. It also demonstrates that hearing loss at age 60 redistributes the remaining years towards dementia without reducing total life expectancy. Finally, it situates education, gender, and age within historical and institutional contexts, demonstrating how educational effects vary by gender and evolve across the life course. Collectively, these studies move the field beyond isolated national studies and towards a more comparative and theoretically informed understanding of how education, gender, age, and context shape health in later life across Europe.