Gender differences in healthy life years within the EU: an exploration of the “health–survival” paradox

In this paper, we approach the health–survival paradox by using composite indicators, HLY and ULY, which contain information on both components of the paradox: mortality and the prevalence of (ill)-health. Mortality and disability tend to play in opposite ways on the magnitude of the gender differentials in HLY. While women’s longer life and higher disability prevalence translate into more years to be lived with disability by women, in all but two countries the disability effect compensates the mortality effect reducing the gender difference in HLY. Even more, in some countries, the disability effect overpasses the mortality effect and women live fewer years without disability. The health–survival paradox appears to be a function of the level of population health indicators and their gender difference. We observed that in populations with a high LE, the gender difference in HLY is small or even negative. Current cross-sectional analysis does not recognize that the health trajectories and the evolution of the LE during the last decades of the twentieth century were substantially different in Western European countries compared to countries of Central and Eastern Europe or the Baltic States (Leon 2011). Therefore, it is important to stress that a small or negative gender difference in HLY may mask important evolutions in the gender differences in mortality and/or activity limitations as it is a result of two opposing forces of the paradox: the survival with a smaller women’s mortality advantage and the health part with a larger women’s disability disadvantage. This observation is consistent with reports on trends in health expectancy indicators over time where more often evidence for compression of morbidity is reported among men alongside evidence for expansion among women (Robine et al. 2005; Van Oyen et al. 2008). The differences in evolution by gender in populations with a high LE may result from women having already reached extreme older ages and that changes in health are much more concentrated at the frontier of human life span. In populations with low life expectancy, we observed that the gender gap in HLY or ULY is large predominantly because of the large gender difference in mortality with the gender difference in the prevalence of activity limitations being less important. In populations with less favourable population health indicators such as low LE, low HLY and high ULY, the hardship among men is already evident at young ages (15–49 years), with men having higher mortality alongside a prevalence of activity limitations which is closer to that of women, yielding both an important mortality disadvantage and a lack of disability advantage relative to women. This confirms the double burden on men living in less healthy populations (countries of Central and Eastern Europe or the Baltic States) since together with their shorter life, they also have a shorter healthy life and a longer unhealthy life with a poorer health and higher mortality starting at young ages (Nusselder et al. 2010b).

Our analysis has several strengths. The country data were not pooled and the substantial heterogeneity in HLY and ULY among the EU member states is used (Jagger et al. 2008). The uncertainty around the estimates is accounted for in the meta-regression. The gender difference in HLY and ULY were subsequently separated into two parts to disentangle the health–survival paradox: one that can be explained by a differential age-specific mortality selection and the other that is due to a different age-specific prevalence of activity limitations.

Limitations of the study that should be considered are related to the cross-sectional design and the Sullivan method. The latter produces health expectancy indicators which are not period indicators and which may introduce bias in the absence of a steady state (Barendregt et al. 1994; Mathers and Robine 1997). The decomposition components do not represent the underlying processes of the incidence and recovery of activity limitations (Nusselder and Looman 2004). Further, the SILC survey is limited to the community dwelling population and no information is available on the health status of the institutionalized population. Not only does the proportion of the population within institutions differ between the EU countries, but the type of care-related institutions is also heterogeneous. Ignoring differences in health status between residents in the community and in institutions probably leads to an overestimation of the expected years without activity limitations. It is unknown if this bias occurs similarly in men and women in which case it would not affect gender differences. Even so, the bias may be larger in countries with a higher proportion of the population in institutions. A final limitation is related to the remaining problems in the harmonization of the GALI instrument (Van Oyen et al. 2010)

Multiple causes have been considered to explain the mechanisms which drive the health–survival paradox between the genders. The impact of methodological issues such as gender differences in survey participation or in reporting health problems have been minimized (Oksuzyan et al. 2009). Among the biological explanations most attention has been given to hormonal, autoimmune and genetic differences (Oksuzyan et al. 2008). The European LE experience during the most recent decades of last century suggests an impact of lifestyles and environmental factors including political, social and economic determinants of health, improvement of education, standards of living and health care (Leon 2011). Young men were more vulnerable to the negative health consequences of the rapid economic transition in the former communist states resulting in a high mortality of injuries, violence, cardiovascular diseases and cancers caused by high levels of alcohol consumption, especially binge drinking, smoking and poor nutrition (Mckee and Shkolnikov 2001). The lower quality of medical care in the Central and Eastern European Countries or the Baltic States may have further contributed to the more unfavourable health position of men (Newey et al. 2004). Both HLY and HLY gender gap are associated with country-specific macro-level indicators which are less favourable in countries of Central and Eastern Europe or the Baltic States (Jagger et al. 2008; Van Oyen et al. 2010). More specifically, the gender gap in HLY decreased as the gross domestic product, the expenditure on elderly care and the lifelong learning among men increased while it increased with a growing inequality in the income distribution (Van Oyen et al. 2010). Social position is an important determinant of inequality in health expectancy indictors (Bossuyt et al. 2004; Cambois et al. 2001; Crimmins and Saito 2001; Davis et al. 1999; Perenboom et al. 2005; Van Oyen et al. 2011). Women and especially older women have a lower social position as a result of a lower education or socio-economic position and this may affect the gender difference in health and functional disability (Bird and Rieker 2008). Several lifestyle factors, which have a differential uptake in men compared to women, not only affect LE, but are also associated with expected years of life without disability (Juel et al. 2008). Some of the lifestyle factors may especially influence mortality and reduce both the years lived with and without limitations; while other factors such as obesity mainly expand the years lived with disability (Reuser et al. 2009). Men have an excess of diseases which shorten life, while the disease pattern in women creates an excess in non-lethal conditions (NCHS 2009). Contributing causes of morbidity to the mortality effect of the gender difference in the disability-free life expectancy in the Netherlands were heart diseases, cancer, and COPD. Causes contributing to the disability effect of the gender difference in DFLE are heart disease, arthritis, back complaints, diabetes and COPD (Nusselder and Looman 2004). Within Europe, the wide range of gender differences in LE, HLY or ULY; the changing importance of either the mortality effect, the disability effect or the age groups contributing to the gender difference in HLY or ULY, is at the same time a statement that the health–survival paradox is not an artefact, but whatever determines the health–survival paradox is dependent on modifiable societal, social and behavioural factors.

The novelty of this paper studying the health–survival paradox is the use of HLY and the exploration of the two components of the gender difference in HLY: difference due to inequality in survival and difference due to inequality in disability. We observed large inequalities in the gender difference in health between European countries which corroborate our hypotheses. In populations with a high LE the gender difference in HLY is smaller because of the additive effect of a reduced mortality effect and a larger disability effect. In countries with a lower level of population health as indicated by a low LE, a low HLY and a large ULY, men are in the worst position having not only a higher mortality compared to women but also a high prevalence of activity limitations. Additionally, in contrast to men in populations with a better health profile, the ill-health of these men begins early in life.