BMC Public Health Article Summary

Gumà et al. BMC Public Health(2019) 19:699
https://doi.org/10.1186/s12889-019-7054-0
RESEARCH ARTICLE
Open Access
Examining social determinants of health:
the role of education, household
arrangements and country groups by
gender
Jordi Gumà1,2,3* , Aïda Solé-Auró1,2 and Bruno Arpino4,3
Abstract
Background: The majority of empirical studies focus on a single Social Determinant of Health (SDH) when
analysing health inequalities. We go beyond this by exploring how the combination of education (micro level) and
household arrangements (mezzo level) is associated with self-perceived health.
Methods: Our data source is the 2014 cross-sectional data from the European Survey of Living Conditions (EU-SILC)
. We calculate the predicted probabilities of poor self-perceived health for the middle-aged European population
(30–59 years) as a function of the combination of the two SDHs. This is done separately for five European country
groups (dual-earner; liberal; general family support; familistic; and post-socialist transition) and gender.
Results: We observe a double health gradient in all the country groups: first, there is a common health gradient by
education (the higher the education, the lower the probability of poor health); second, household arrangements
define a health gradient within each educational level according to whether or not the individual lives with a
partner (living with a partner is associated with a lower probability of poor health). We observe some specificity in
this general pattern. Familistic and post-socialist transition countries display large differences in the predicted
probabilities according to education and household arrangements when compared with the other three country
groups. Familistic and post-socialist transition countries also show the largest gender differences.
Conclusions: Health differences in European populations seem to be defined, first, by education and, second, by
living or not living with a partner. Additionally, different social contexts (gender inequalities, educational profile,
etc.) in European countries change the influences on health of both the SDHs for both women and men.
Keywords: Social determinants of health, Education, Household arrangements, Gender differences, Europe
Background
Studies on the social determinants of health (SDH) have
contributed to a better understanding of health inequalities within and across populations, and have given important support to the design of public health policies
[26, 27]. As Dahlgren and Whitehead [10] proposed in
their ‘Rainbow Model’, the social root of SDHs implies
that they can be classified according to the social context
* Correspondence: jordi.guma@upf.edu
1
Department of Political and Social Sciences, Universitat Pompeu Fabra
(UPF), Carrer Ramón Trias Fargas 25-27, 08005 Barcelona, Spain
2
Sociodemography Research group (DemoSoc), University Pompeu Fabra
(UPF), Barcelona, Spain
Full list of author information is available at the end of the article
to which they belong (from individual characteristics to
the general context that is common for a large population). According to the Rainbow Model, all SDHs identified by the literature can be classified into three levels,
according to whether they correspond to individual (micro level) or contextual characteristics (mezzo and
macro levels). For the latter, we should distinguish between SDHs pertaining to the mezzo level of the closest
context (e.g. household and family, place of residence,
etc.) and macro level factors of the most general context
(e.g. public policies, sociocultural characteristics, etc.).
An exhaustive review of the literature demonstrates
that the majority of empirical studies focus on a single
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Gumà et al. BMC Public Health
(2019) 19:699
SDH, which has contributed to having a detailed knowledge about how each single factor individually influences health inequalities. Among these SDHs, most
attention has been given to socioeconomic characteristics of individuals (education, activity status, salary, etc.)
[1]. However, contextual level factors such as household
arrangements (mezzo level) [22] and public health policies (macro level) [31] have also shown a high capacity
to explain health differences. In other words, a picture
defined merely by individual features cannot fully capture the complexity of modern societies when we attempt to explain health differences. The only exception
to this is a recent case study for the Spanish adult population by Gumà et al. [18] where the authors stated that
combining information from education and household
arrangements permits the definition of more precise
health profiles.
Our aim is to go beyond the study of a single SDH by
exploring the interactions between SDHs at different
levels in order to assess whether possible advantages or
disadvantages related to an individual’s context are modified depending on their individual features, and vice versa.
For this purpose we examine the combination between
educational level (as a proxy of long-term social differences beyond contextual factors like employment status
or salary) and household arrangements (the most basic
unit of socialization between relatives), two outstanding
SDHs from the micro and mezzo levels, among the
middle-aged European population (30–59 years). Furthermore, we account for the most general context by adopting a comparative perspective and analysing how the
effects of the above mentioned SDHs vary across different
European regions according to the type of family welfare
regime in those regions [34]. Welfare regimes permit us to
summarize the general context (e.g. public policies, levels
of gender equity, etc.) of European countries in some way.
The complexity of the interplay between the SDHs
under consideration is even greater when we consider
gender inequalities. It has been proved that gender inequalities in western countries lead to different signs and
magnitudes of the effect of a particular SDH on females’
and males’ health [39] (e.g. employment status shows a
stronger association with male health, whereas educational attainment is more relevant for female health).
To the best of our knowledge, no previous study has
examined the influence on health of the combination between education and household arrangements, although
in some cases the relationship between household arrangements and health has been explored with education being included as a control variable [23, 29]. We
hypothesize that the household effect on health is moderated by education because of its ability to counteract
possible negative situations [20] (e.g. the social network
of an individual with higher education has been shown
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to be of help in finding a new job during an episode of
unemployment). Additionally, although household arrangements have displayed a higher explanatory capacity
of health variability among women [29] than among men,
we expect to find lower gender differences in health according to household arrangements in regions with higher
gender equality. Finally, we also assume that differences
between European country groups in terms of family, educational and gender inequality profiles may moderate the
effects of the SDH variables at lower levels.
Education and health
The association between health and education has been
repeatedly tested because of the capacity of the latter to
establish different levels of social stratification [20]. Population groups defined by a low educational level show a
greater disadvantage in terms of health, although there are
differences between countries according to their specificities regarding health behaviours and public policies [6,
20, 28]. Individuals with the lowest educational level have
been consistently found to report the worse health [35].
Indeed, education has been shown to influence an individual’s health at different life-course stages (from adulthood
to advanced age), as well as to mediate the long-term influence of early-life conditions on health [3].
Educational differences in health across Europe are
well documented, with a general pattern of large variations in the magnitude of the differentials across countries. In general, a high level of social transfer is
expected to reduce exposure to deprivation, and this
could be translated into reductions in the health disadvantage of poorly educated groups. For instance, for the
Spanish population with a low educational level, Alcañiz
et al. [2] found a higher prevalence of certain lifestyle indicators such as tobacco and alcohol consumption and a
sedentary lifestyle, in addition to greater problems in
performing daily activities. Additionally, the magnitude
of the influence of education on health differs between
women and men. According to the resource substitution
theory, the absence of one or more socio-economic resources can be replaced by a greater influence from
other resources [36]. As a consequence, lower female
participation in the labour market, as well as the gender
wage gap, has reinforced the importance of education
for health among women [36, 37].
Household arrangements and health
Household arrangements, as an SDH, is located at the
intermediate level of the Rainbow Model. Household arrangements represent the context in which individuals
with a family tie perform a daily exchange of resources
of diverse natures (economic, emotional, care, information, etc.) [39]. Focusing on specific family ties, those living in a couple have been found to report better health
Gumà et al. BMC Public Health
(2019) 19:699
than their counterparts who are living without a partner
[23]. This evidence has received several explanations: 1)
higher levels of social control might reduce the propensity to carry out risky behaviour, which is especially
beneficial for men; 2) there may be an optimization of
resources through scale economies; and 3) the creation
and maintenance of a larger social network can be of
help in adversity [16, 41].
Living with children is another relevant family tie that has
shown both positive and negative effects on health. The positive effects, like the increase in life satisfaction due to emotional reward, are explained because of feelings of fulfilling a
vital purpose [4, 19]. However, detrimental consequences on
well-being and health have also been found, due to changes
in the economic capacity of the household, increases in
couple conflicts or difficulties in balancing the family and
work spheres, especially for women [25, 30].
The relationship between household arrangements and
health has also been found to vary among countries. A
recent study [13] that assessed the association between
household arrangements and self-perceived health
among the adult population in 12 European countries
found that the usual health gap between partnered and
non-partnered subpopulations is smaller in countries
where the relative importance of the second group is
higher. The authors also pointed to a meaningful different explanatory capacity of household arrangements on
the health variability of women and men, with this being
an SDH that is more relevant for females.
Methods
We used the 2014 cross-sectional data from the European
Survey of Living Conditions (EU-SILC). This survey takes
the household as a sampling unit and collects information
for each member of the household, except in seven countries
(Denmark, Finland, Iceland, the Netherlands, Norway,
Sweden and Slovenia) where only one member of the household was randomly selected to answer the entire questionnaire. As a result of the influence of age on family events we
restricted our sample to individuals aged 30 to 59: for instance, in Spain, Italy, Portugal, Croatia, Greece and Bulgaria,
among others, the average age on leaving the parental home
was about 28 and 30 for women and men, respectively, in
2013 [15]. Moreover, we tried to avoid possible bias from the
association between health and age of retirement across
countries [12]. For instance, the lowest effective retirement
age for men was found in France (59.4), while the lowest age
for women was found in Slovakia (58.2) [32]. Respondents
born in a different country, and those who stated that they
were unable to work because of their health, were not included in our analysis. Cyprus was also not included because
of its political specificities. After dropping 3% of observations
with missing cases from the original sample, which were randomly distributed according to country, age and gender, the
Page 3 of 9
final sample consisted of 187,898 respondents (52% women
and 48% men).
Adopting the measure proposed by the WHO [11],
our dependent variable was self-perceived health, which
was measured with the question ‘How is your health in
general?’. This is one of the three health questions that
pertain to the Minimum European Health Module
whose reliability and comparability between European
countries has been previously confirmed [8]. This indicator was chosen on the basis of its proven capacity to give
information about a person’s general current health status as well as about any recent changes [21]. Selfperceived health is especially suitable for studying
middle-aged populations where morbidity levels are still
low but future health problems are incipient. Indeed,
self-perceived health has showed a stronger association
with mortality, an outcome of objective health, at younger ages [5, 17]. Following common practice [9], we
grouped the five possible answers into two categories:
good or very good health (good health = 0), and fair, bad
or very bad health (poor health = 1).
Education was grouped into three categories: low (primary – whether or not complete – and low secondary
studies), medium (upper secondary and post-secondary
but non-tertiary education) and high (tertiary). Household
arrangements were defined according to whether or not
the individual lived with a partner and/or with children,
resulting in four different categories: 1) living with neither
partner nor children (single-person household or living
with other people); 2) living with partner but without
children; 3) living with partner and children; and 4) living
with children but without partner (single parent).
To explore how the combination between education and
household arrangements was associated with self-perceived
health, we combined these and created a new variable with
12 categories. We opted for the combination of both variables after testing the significance of the interaction of both
variables, both overall and by gender (Additional file 1:
Table S1 and Additional file 2: Table S2). We also tested
the triple interaction between education, household arrangement and gender (Additional file 3: Table S3).
Following Oláh et al. [34], we grouped the 30 countries in
the study into five groups according to the type of family
welfare regime: dual-earner (Denmark, Finland, Iceland,
Norway and Sweden); liberal (Switzerland, United Kingdom,
Ireland and Malta); general family support (Austria, Belgium,
Germany, France and Netherlands); familistic (Greece, Spain,
Italy and Portugal); and post-socialist transition (Bulgaria,
Czech Republic, Estonia, Croatia, Hungary, Latvia, Lithuania,
Poland, Romania, Serbia, Slovenia and Slovak Republic).
We ran separate logistic regressions by country groups
and gender after assessing the significant difference between the estimates across the five European regions as
well as between women and men in a pooled model
Gumà et al. BMC Public Health
(2019) 19:699
Page 4 of 9
(easily, fairly easily, with some difficulty and with difficulties). To ease the interpretation of results, we present, separately for each country group and gender, the predicted
probabilities of poor health with 95% confidence intervals
from the logistic models including all control variables
(complete estimates of all models are available in
Additional file 5: Table S5).
(Additional file 4: Table S4). The reason for calculating
independent models according to these two factors, gender and country groups, is twofold. First, separate
models according to gender in addition to restricting individuals in our analysis aged 30–59 prevents from a
possible issue of dependency in our analysis due to the
inclusion of individuals from the same household. The
age selection prevents from analysing members of the
same family from two different generations and separate
models by gender imply that members from a couple are
in different models (same sex couples are rare in the
EU-SILC data). Second, previous research has proved
that the answer to the question about self-perception of
health is sensitive to gender and cultural context [33].
All models included the combination of education and
household arrangements in order to assess possible differences in the health gradient observed in previous research
when both variables were analysed separately. In all
models we controlled for socio-economic and demographic variables that had previously been proved to have
an association with health: age, employment status
(employed, unemployed and inactive) and subjective economic capacity of the household to make ends meet
Results
Table 1 reports descriptive statistics of the educational
and household arrangements profile by gender, revealing
meaningful differences between the five country groups.
Women display higher levels of educational attainment,
with the highest gender difference in the dual-earner
countries. In general, focusing on country groups differences we observe that dual-earner, liberal and general
family support countries show higher percentages of high
education than post-socialist and familistic countries, with
the majority of the population in the post-socialist countries being concentrated at the medium educational level
and in the familistic countries at the low education level.
As for household arrangements, the two situations of
living with a partner (with or without children) are the
Table 1 Educational attainment and household arrangements by European groups of countries and gender (ages 30–59) 2014
Low education
Medium
education
High education
Dual-earner
countries
Liberal
General family
support
Familistic
Men
(%)
Women
(%)
Men
(%)
No partner-no
children
3.7
1.4
No partner-children
0.3
Partner-no children
3.4
Transition postsocialist
Women
(%)
Men
(%)
Women
(%)
Men
(%)
Women
(%)
Men
(%)
Women
(%)
7.1
3.1
3.1
2.1
9.7
4.1
3.8
1.3
1.3
0.9
4.9
0.3
1.9
0.8
4.4
0.4
2.1
3.5
4.2
4.6
2.8
3.9
5.5
6.7
1.9
2.9
Partner-children
5.0
3.4
15.4
14.5
5.4
5.5
24.2
22.7
6.7
7.9
Total
12.3
9.7
27.6
27.1
11.5
13.3
40.2
37.9
12.8
14.2
No partner-no
children
9.6
4.7
7.1
4.4
10.5
7.0
10.1
5.4
14.7
6.6
No partner-children
1.8
4.0
0.9
4.8
1.3
5.8
0.5
3.5
1.5
7.8
Partner-no children
10.8
10.1
6.8
7.3
11.7
12.1
4.8
4.8
11.2
10.8
Partner-children
24.7
17.4
18.1
20.5
25.3
25.1
20.5
20.3
40.7
33.6
Total
46.9
36.2
32.9
37.1
48.8
50.0
35.9
34.0
68.1
58.8
No partner-no
children
6.3
6.5
6.7
5.7
7.2
6.2
6.9
6.3
4.0
4.4
No partner-children
1.2
4.8
0.6
3.5
1.1
3.7
0.3
2.3
0.3
3.4
Partner-no children
8.9
11.3
9.1
7.1
8.7
7.3
3.4
4.1
3.4
4.2
Partner-children
24.3
31.4
23.2
19.6
22.6
19.7
13.4
15.4
11.4
15.0
Total
Total
N
40.7
54.1
39.6
35.9
39.6
36.8
23.9
28.1
19.1
27.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
7156
7054
9881
11,423
16,140
17,718
21,600
23,145
34,310
39,471
Data source: EU-SILC 2014
Note: Dual-earner (Denmark, Finland, Island, Norway and Sweden); Liberal (Switzerland, United Kingdom, Ireland and Malta); General family support (Austria,
Belgium, Germany, France and Netherlands); Familistic (Greece, Spain, Italy and Portugal); and Transition post-socialist (Bulgaria, Czech Republic, Estonia, Croatia,
Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovenia and Slovak Republic
Gumà et al. BMC Public Health
(2019) 19:699
Page 5 of 9
liberal countries, followed by familistic, general family support and post-socialist transition countries, which lie in the
region with the worst health outcomes.
The probabilities of poor health predicted from the logistic
models (Fig. 1) confirm the double gradient observed when
combining educational attainment and household arrangements. First, there is a common educational gradient in all
the country groups, so that the higher the education, the
lower the probability of declaring poor health. Second, there
is a health gradient within each educational level according
to household arrangements, mainly defined by whether or
not an individual lives with a partner (living with a partner is
associated with a lower probability of poor health), whereas
having children only shows a small effect when education is
taken into account. It must be noted that in the specific case
of single mothers (the low number of single fathers does not
permit us to draw conclusions for them), which is the situation that the literature indicates as the most disadvantaged
in terms of health [38], a significantly lower probability of
poor health is observed when the educational status is
higher, in all the country groups except dual-earner
countries.
Although this is a general pattern regardless of gender
and country groups, we also observe specificities regarding the magnitude of the probabilities in each country
group. In general terms, the highest probabilities of having poor health are observed in the post-socialist cluster,
most frequent, with the only exception being the familistic
countries, where the category of those living without a
partner or children ranks second (except for poorly educated women). Living without children is the most frequent
situation among those who do not live with a partner,
whereas in general the least frequent is living with children
but no partner. Overall, gender differences are similar within
each country group. The most meaningful difference relates
to the higher percentage of single mothers compared to single fathers, whereas men show a higher prevalence of living
with neither partner nor children.
The prevalence of poor health according to education,
household arrangements and gender by country groups
(Table 2) reveals a double health gradient according to
the combination of education and household arrangements: the higher the educational attainment, the lower
the prevalence of poor health; and, within each educational level, those who live with a partner declare better
health outcomes, which become even better when they
also live with children. However, it seems that the educational gradient prevails even for the same categories of
household arrangements: those who have a certain
household arrangement show better or worse health status depending on their educational status.
In general, we observe a general health advantage of men
compared to women [7, 40]. A country group gradient is also
evident, with better health outcomes in dual-earner and
Table 2 Prevalence of poor health according to educational attainment and household arrangements by European groups of
countries and gender (ages 30–59) 2014
Low education
Medium
education
High education
Dual-earner
countries
Liberal
General family
support
Familistic
Men
(%)
Women
(%)
Men
(%)
No partner-no
children
34.1
44.1
No partner-children
22.7
Partner-no children
30.4
Transition postsocialist
Women
(%)
Men
(%)
Women
(%)
Men
(%)
Women
(%)
Men
(%)
Women
(%)
25.3
36.3
37.6
48.9
29.1
43.3
42.2
62.1
30.9
27.1
31.1
29.8
44.9
31.8
43.1
46.7
55.8
33.2
21.5
31.5
30.9
41.5
36.9
45.1
46.5
56.8
Partner-children
22.8
24.6
17.6
21.6
27.2
32.5
28.0
34.1
36.1
44.5
No partner-no
children
26.9
28.7
20.0
22.0
28.4
30.2
13.1
18.7
28.2
39.8
No partner-children
22.1
23.6
17.6
22.0
24.0
31.6
16.5
24.1
34.9
39.4
Partner-no children
20.7
24.2
19.1
18.6
27.8
29.4
16.6
23.2
40.3
45.5
Partner-children
17.1
17.0
14.2
15.1
21.4
20.2
13.9
15.8
27.4
28.8
No partner-no
children
18.9
17.6
13.9
15.9
17.5
20.3
8.8
14.2
15.7
22.2
No partner-children
12.5
16.4
18.6
15.3
14.6
20.0
11.5
18.7
20.8
26.7
Partner-no children
10.7
14.3
10.0
11.0
15.1
18.0
10.3
13.7
24.1
28.6
Partner-children
9.0
10.7
10.0
9.8
12.5
13.1
10.4
10.4
15.4
17.0
Total
17.4
17.7
15.4
17.8
21.1
23.7
19.3
24.1
28.7
33.1
Data source: EU-SILC 2014
Note: Dual-earner (Denmark, Finland, Island, Norway and Sweden); Liberal (Switzerland, United Kingdom, Ireland and Malta); General family support (Austria,
Belgium, Germany, France and Netherlands); Familistic (Greece, Spain, Italy and Portugal); and Transition post-socialist (Bulgaria, Czech Republic, Estonia, Croatia,
Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovenia and Slovak Republic
Gumà et al. BMC Public Health
(2019) 19:699
A
B
C
D
E
Fig. 1 (See legend on next page.)
Page 6 of 9
Gumà et al. BMC Public Health
(2019) 19:699
Page 7 of 9
(See figure on previous page.)
Fig. 1 Predicted probability of declaring poor health with 95% confidence intervals as function of combining educational attainment and
household arrangement by gender and European groups of countries. 2014. A Dual-earner. A1. Women. A2.Men. B Liberal. B1.Women. B2.Men. C
General Family Support. C1.Women. C2. Men. D Familistic. D1.Women. D2. Men. E Sovietic post-transition. E1. Women. E2. Men. Panel A for Dualearner countries, panel B for Liberal countries, panel C for General Family Support, panel D for Familistic countries, and panel E for Sovietic posttransition countries. Sub-panel 1 for Women and Sub-panel 2 for Men. Data source: EU-SILC 2014. Note1: Low (Low educational attainment);
Medium (Medium educational attainment); High (High educational attainment). Note2: Dual-earner (Denmark, Finland, Island, Norway and
Sweden); Liberal (Switzerland, United Kingdom, Ireland and Malta); General family support (Austria, Belgium, Germany, France and Netherlands);
Familistic (Greece, Spain, Italy and Portugal); and Transition post-socialist (Bulgaria, Czech Republic, Estonia, Croatia, Hungary, Latvia, Lithuania,
Poland, Romania, Serbia, Slovenia and Slovak Republic
whereas the liberal and dual-earner countries display the
lowest values. When we focus on the combination of education and household arrangements, familistic and postsocialist transition countries display large differences in the
predicted probabilities when compared with dual-earner, liberal and general family support countries. Familistic countries show the widest gap between the lowest educational
level and the other two levels, whereas in the post-socialist
transition countries the most noticeable difference is observed between the highest educational level and the level of
low and medium education. On the other hand, the other
three country groups (dual-earner, liberal and general family
support) follow the general pattern described above, with
progressive differences in the probability of poor health according to educational status.
By gender, the probability of poor health is higher for
women in general, with the largest gender difference being found in the familistic and post-socialist transition
countries, whereas general family support, dual-earner
and liberal countries show the lowest differences. More
specifically, the most striking gender differences are
found among poorly educated individuals in familistic
and post-socialist transition countries.
Discussion
This study explores the differences in self-perceived
health among middle-aged (30–59) Europeans, by combining information on educational attainment and
household arrangements, two well-studied SDHs from
the micro and the mezzo levels that have been considered separately in previous studies. We show different
specificities according to gender and groups of European
countries (dual-earner, liberal, general family support,
familistic and post-socialist transition).
Our results display a double health gradient defined
according to the combination of education and household arrangements. Specifically, at the micro level the
educational health gradient prevails (the higher the educational status, the better the health outcomes), but we
also observe an additional health gradient within each
educational level according to the type of household arrangement. This health gradient is located at the mezzo
level and seems to be mainly defined by whether or not
the individual lives with a partner, whereas living with
children does not seem to be relevant when education is
controlled for. When taking into account both SDHs together, we see that not only do individuals declare better
or worse health outcomes within the same educational
level depending on their household arrangement, but also
that health differences between educational levels depend
on the type of household arrangement. The case of single
mothers stands out (there are too few single fathers to
draw conclusions), showing the highest probabilities of
poor health among poorly educated individuals (together
with single childless people), whereas their probabilities
are not significantly different from those of people in
other household arrangements among highly educated individuals. The fact that single mothers do not display significant differences regarding the other household
arrangements within the same educational level points to
the fact that previous results on health differences by
household arrangements were importantly moderated by
education.
The separate models by country groups contribute to
the discovery of certain specificities within the general
pattern in the association between the two SDHs and
self-perceived health. The most outstanding health difference is the sharp gap between those with low educational attainment and the rest of the population in the
familistic countries, and between those with high education and the rest of the population in the post-socialist
transition countries. Additionally, these two country groups
show the largest gender differences in the health gradient according to education and household arrangements. Although
men usually show better health outcomes than women [33],
dual-earner, liberal and general family support countries display the lowest gender difference, whereas familistic and
post-socialist transition countries show the highest. Indeed,
in the first three country groups there is almost no gender
difference within the same combination of education and
household arrangements, whereas this is not the case in the
last two groups of countries. Therefore, the worse aggregated
health profile in these countries [14] seems to be basically
defined by their specific educational profile as well as by their
lower level of gender equality [24].
Overall, the main contribution of this paper is twofold.
First, we have shown that combining information from
two SDHs, representing the micro and the mezzo levels,
Gumà et al. BMC Public Health
(2019) 19:699
leads to more accurate insights into the most vulnerable
socio-demographic profiles in terms of health. Second,
although both SDHs contribute towards explaining health
differences among European populations, education (micro
level) seems to explain a greater amount of health variability
than whether or not an individual lives with a partner
(mezzo level). Additionally, we have uncovered meaningful
gender differences in the association between education,
household arrangements and health in the five country
groups, pointing out that current gender inequalities in western societies mean that the influence of SDHs on health for
women and men is different.
This study has also some limitations. First, the crosssectional nature of our data does not allow to go further
than only stating associations between variables. This does
not permit us to explore possible mechanisms like selection into marriage and fertility due to different levels of
educational attainment. Longitudinal data would also
allow to compare the results from different generations in
order to assess whether the association between our variables of interest and self-perceived health varies over time.
Second, separate models according to country clusters
only confirm the existence of contextual differences but
do not permit to identify their origin. For this reason, we
plan to incorporate information about SDHs from the
macro level (e.g., public health expenditure in each country, general levels of gender equity, etc.) in future research
in order to better understand how these factors interplay
with SDHs from the micro and the mezzo levels to establish health differences.
Conclusion
To conclude, this study contributes to confirm the idea
that SDHs are interrelated, as it was already pointed out
in a similar case study using only data for Spain [18],
and that the analysis of their interactions could complement the current knowledge that we have about their
separate influences on health.
Additional files
Additional file 1: Table S1 Odds ratio of poor self-perceived health of
the interaction between education and household arrangements from
the pooled logistic regression model for middle-aged Europeans (30–59
years old). This file confirms the statistical significance of the interaction
between education and household arrangements for the whole working
sample. (DOCX 15 kb)
Additional file 2: Table S2 Odds ratio of poor self-perceived health of
the interaction between education and household arrangements from the
pooled logistic regression model for middle-aged Europeans (30–59 years
old) by gender. This file contains the results from the model that confirms
the statistical significance of the interaction between education and household arrangements for women and men separately. (DOCX 17 kb)
Additional file 3: Table S3 Odds ratio of poor self-perceived health for
the interaction between education, household arrangements and gender
from the pooled logistic regression model for middle-aged Europeans
Page 8 of 9
(30–59 years old). This file shows the results from the triple interaction
between education, household arrangement and gender. (DOCX 15 kb)
Additional file 4: Table S4 Odds ratio of poor self-perceived health
from the pooled logistic regression model for middle-aged Europeans
(30–59 years old). This file confirms the significant difference between the
estimates across the five European regions as well as between women
and men. (DOCX 15 kb)
Additional file 5: Table S5 Odds ratio of poor self-perceived health for
middle-aged population (30–59 years old) by country cluster and gender
This file contains the complete estimates of all models included in the
Results section. (DOCX 16 kb)
Abbreviations
EU-SILC: European Survey of Living Conditions; SDH: Social determinants of
health
Acknowledgements
Not applicable.
Authors’ contributions
JG led on the design of the analysis, the analysis of EU-SILC data & drafting
the manuscript; ASA and BA led on the analysis of EU-SILC & drafting the
manuscript. All authors participated in several rounds of manuscript redrafting. All authors read and approved the final manuscript.
Funding
JG has got financial support for this research from the Spanish Ministry of
Economy and Competitiveness under the program “Juan de la Cierva” (FJCI2015-25066). This manuscript is part of the project INTERSOC-HEALTH
(RTI2018–099875-J-I00; PI: JG) founded by the Spanish Ministry of Science,
Innovation and Universities. This manuscript is also part of the multi-country
project CREW (PCIN-2016-005; PI: ASA) founded by the Spanish Ministry of
Economy and Competitiveness within the second Joint Programming Initiative “More Years Better Lives”.
Availability of data and materials
The data that support the findings of this study are available from third
parties: for EU-SILC this is Eurostat (http://ec.europa.eu/eurostat/web/microdata/european-union-statistics-on-income-and-living-conditions).
Ethics approval and consent to participate
Not applicable (this paper uses secondary data; ethics approval & consent
were obtained by the original EU-SILC team).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Political and Social Sciences, Universitat Pompeu Fabra
(UPF), Carrer Ramón Trias Fargas 25-27, 08005 Barcelona, Spain.
2
Sociodemography Research group (DemoSoc), University Pompeu Fabra
(UPF), Barcelona, Spain. 3Research and Expertise Centre for Survey
Methodology (RECSM), Barcelona, Spain. 4Department of Statistics, Computer
Science, Applications, University of Florence, Florence, Italy.
Received: 26 March 2019 Accepted: 27 May 2019
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