726390

research-article2017
JAHXXX10.1177/0898264317726390Journal of Aging and HealthArpino and Solé-Auró

Article
Journal of Aging and Health
2019, Vol. 31(1) 185­–208
Education Inequalities © The Author(s) 2017
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DOI: 10.1177/0898264317726390
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Women: The Role of

Active Aging

Bruno Arpino, PhD1 and Aïda Solé-Auró, PhD1

Abstract
Objective: We assessed whether education inequalities in health among
older people can be partially explained by different levels of active aging
among educational groups. Method: We applied logistic regression and
the Karlson, Holm, & Breen (KHB) decomposition method using the
2010 and 2012 waves of the Survey of Health, Ageing and Retirement in
Europe on individuals aged 50+ years (N = 27,579). Active aging included
social participation, paid work, and provision of grandchild care. Health
was measured by good self-perceived health, low number of depressive
symptoms, and absence of limitations because of health in activities people
usually do. Results: We found a positive educational gradient for each of
the three health measures. Up to a third of the health gaps between high and
low educated were associated with differences in engagement in active aging
activities. Discussion: Policies devoted at stimulating an active participation
in society among older people should be particularly focused on lower
educated groups.

Keywords
health measures, active aging activities, Europe, education inequalities

1Universitat Pompeu Fabra, Barcelona, Spain

Corresponding Author:
Bruno Arpino, Department of Political and Social Sciences, Universitat Pompeu Fabra, C/
Ramon Trias Fargas, 25-27, 08005 Barcelona, Spain.
Email: bruno.arpino@upf.edu
186 Journal of Aging and Health 31(1)

Introduction
Against the background of rapid population aging worldwide, reducing and
preventing health inequalities are priorities for public policies (Jagger et al.,
2013; Lagiewka, 2012; Mackenbach, Karanikolos, & McKee, 2013).
Understanding the mechanisms that contribute to create, maintain, and rein-
force health inequalities is crucial to design appropriate health policies for
individuals with different socioeconomic characteristics.
Because population aging is one of the greatest social challenges facing
the European Union in the 21st century, the aim of this study is to examine
whether different levels of active aging across educational groups explain at
least in part educational inequalities in health among the older European pop-
ulation. Promotion of active aging aims, among other goals, to reinforce the
sustainability of existing social benefits by preventing and reducing the risks
of inequalities. Indeed, it is of crucial importance to reduce these risks in mid-
and old-adult ages, when the prevalence of disability starts reaching signifi-
cant levels. And, it is also important to reduce the large and persistent social
inequalities in the chance of reaching the retirement age in good health and in
the chance of remaining active and independent in later ages. Our article
contributes to different strands of the literature by linking insights from stud-
ies on educational inequalities in health at older ages and the literature on
active aging. On one hand, it is well known that educational inequalities in
health exist and their consequences and antecedents have been the object of
numerous studies (e.g., Cambois, Solé-Auró, Brønnum-Hansen, et al., 2016;
Chiu, Hayward, & Saito, 2016; Crimmins & Saito, 2001; Laditka & Laditka,
2016). On the other hand, active aging is an increasingly important topic for
policy makers, and researchers have examined its determinants and its posi-
tive health benefits (e.g., Di Gessa & Grundy, 2014; Hank & Stuck, 2008).
Studies examining the role of engagement in activities in explaining educa-
tional inequalities are far less common. One exception is the study by Ross and
Zhang (2008) focusing on psychological distress among older Chinese. The
authors find that older Chinese with higher education show lower levels of
distress than their less educated counterparts, in part, because they engage more
in cognitively stimulating activities, such as reading. Similarly, we expect
active aging, and more specifically social participation, paid work, and grand-
child care, to mediate the effect of education on health among older Europeans.

Active Aging
Active and healthy aging is a major social challenge common to all popula-
tions, with a major social policy discourse in Organisation for Economic
Arpino and Solé-Auró 187

Co-Operation and Development (OECD) countries. Active and healthy aging

is of crucial importance especially in mid- and old-adult ages when disability
starts to be highly prevalent and implies increased need of social support and
loss of financial resources due to (early) retirement. As suggested by Kuh,
Cooper, Hardy, Richards, and Ben-Shlomo (2014), healthy aging (limited
deterioration of functioning or maintenance of good health) should be distin-
guished from active aging (participation in social and cultural activities).
Active aging is defined by the World Health Organization (WHO; 2002) as
“the process of optimising opportunities for health, participation and security
in order to enhance quality of life as people age” (p. 12), where the word
“active” also refers to continuing engagement in economic, social, cultural,
spiritual, and civic affairs. It, thus, covers activities such as participating in
associations, doing voluntary work and providing care, going beyond the
ability to be physically active, or to participate in the labor force (working
longer—retiring later; Boudiny, 2013).
In this study, we focus on engagement in three important types of active
aging activities that have been found to influence health, and examine their
role as mediators of the effect of education on health: (a) social participation,
(b) paid work, and (c) provision of grandchild care.

Health Inequalities
Pointing out and understanding differences regarding health and functioning
within populations have been placed on the top of the political agenda
(Marmot, 2010). Europeans live longer than ever and spend decades in
retirement, but a significant part of their life expectancy is lived with dis-
eases and disability (Solé-Auró & Alcañiz, 2015). It is also well documented
that health inequalities in Europe are associated with socioeconomic status.
Social characteristics such as employment and occupational experience con-
tribute to health status and health inequalities as well (Molarius et al., 2006).
For instance, using the Global Activity Limitation Indicator (GALI), lower
social classes have been found to be disadvantaged regarding health com-
pared with the rest of the population, whereas the higher social classes are
advantaged (Cambois, Solé-Auró, Brønnum-Hansen, et al., 2016).
Moreover, less educated females constitute the most disadvantaged group in
terms of health (Solé-Auró & Alcañiz, 2016). These health differentials
appear to be due to a combination of biological, behavioral, social, and eco-
nomic differences as well as the interaction of these factors (Robine, 2011).
In this article, we focus on the role of active aging in explaining educational
health inequalities.
188 Journal of Aging and Health 31(1)

The Influence of Educational Gradient in Active Aging on Health

Inequalities
A positive educational gradient in social participation has been documented
(Arpino & Bordone, 2015, 2017; Hank & Stuck, 2008): Higher educated people
tend to be considerably more active than lower educated people, especially in
volunteer work (see, for example, Erlinghagen & Hank, 2006; Hank & Stuck,
2008). Similarly, Whitley, Benzeval, and Popham (2016) found that socioeco-
nomic position is positively associated with productive engagement (that in
their definition encompassed both social participation and paid work). However,
previous studies have emphasized that participation in social activities is benefi-
cial for older people’s mental and physical health (Han, Tavares, Evans,
Saczynski, & Burr, 2017; Landstedt, Almquist, Eriksson, & Hammarström,
2016; Sirven & Debrand, 2008) and participation in society has become a key
pillar in the active aging discourse (WHO, 2002; Zaidi et al., 2013).
Education has been found to be positively associated also to labor force
participation at older ages (Kalwij, Kapteyn, & de Vos, 2016; Tang, Choi, &
Goode, 2013). As far as the relationship between engagement in paid work
and health is concerned, mixed evidence is found in the literature. Although
several studies point at positive effects of engagement in paid work and, sym-
metrically, at negative effects of retirement on health (Di Gessa & Grundy,
2014; Mazzonna & Peracchi, 2017), others found opposite results (see, for
example, Syse, Veenstra, Furunes, Mykletun, & Solem, 2017). These studies
also highlight that heterogeneities due to occupation, age at retirement, and
whether the retirement decision is or not voluntary can contribute explaining
the mixed findings.
The last type of active aging activity that we consider is provision of
grandchild care. This type of activity has been found to be associated with
higher educational levels, unless intensive care is considered (see, for exam-
ple, Di Gessa, Glaser, & Tinker, 2016). Recent studies using European data
and focusing on provision of supplementary care (e.g., when grandparental
help is complementary to parental care) tend to report positive effects on
health and well-being (Arpino & Bordone, 2014; Di Gessa et al., 2016).
Summarizing, a positive educational gradient has been found for each of
the three types of active aging activities we consider (social participation, paid
work, and provision of grandchild care). However, engagement in these activ-
ities has been found to produce (mainly) positive effects on health. Therefore,
we can think of active aging activities as possible mediators of the effect of
education on health. More specifically, as higher educated people are those
who are more actively engaged, we can expect that at least part of their health
advantage can be explained by their higher engagement in social activities.
Arpino and Solé-Auró 189

Estimating the effect of social participation on health is difficult because

of selection issues and reverse causality. We acknowledge that the relation-
ship between engagement in the activities we consider and health may be
bidirectional as bad health may reduce the ability to work or be active in
organizations (Di Gessa & Grundy, 2014; Landstedt et al., 2016). Therefore,
individuals with higher education may be more active because of their better
health conditions. To partially address these issues, we use longitudinal data
and measure covariates and explanatory variables at the baseline, whereas
our health outcome variables are measured at the follow-up. Still, as we also
discuss in the concluding section, our estimates should be interpreted as asso-
ciations and not in causal terms.

Data, Variables, and Methods

Data
This study uses individual-level data from the Survey of Health, Ageing and
Retirement in Europe (SHARE), a multidisciplinary longitudinal survey, rep-
resentative of the noninstitutionalized population aged 50 and above (Börsch-
Supan, Brugiavini, et al., 2005; Börsch-Supan & Jürges, 2005). All persons
aged at least 50 in the selected households were interviewed, as well as their
partners independent of their age.
Our work is based on a longitudinal analysis using data from the fourth
(2010) and fifth (2012) waves of SHARE including 13 European countries
that participated in both waves. We use information at Wave 4 to measure
independent variables (baseline wave) and information on health at the Wave
5 (follow-up wave) as outcome variables. We focus only on these two more
recent waves because there were changes in the way some of the main vari-
ables of our interest were asked in the first two waves. We also exclude the
third wave (2008) of SHARE, called SHARELIFE, because it contains
mainly retrospective information on the respondents.
Due to a low prevalence of engagement in social activities for people aged
85 and more in our sample, we restricted our analyses to women and men
aged 50 to 85 years.1 The final sample was composed of 27,579 persons
(11,595 men and 15,984 women).

Dependent Variables
We utilize three indicators of positive endorsement of health at follow-up
(Wave 5) as dependent variables. The first measure we consider is self-per-
ceived health ranging from 1 (excellent) to 5 (poor). Our second outcome
190 Journal of Aging and Health 31(1)

variable refers to depression. Depressive symptoms are measured using the

EURO-D Scale ranging from 0 to 12, higher values indicating more depres-
sion symptoms. Finally, our third dependent variable measures health related
to activity limitations with a single question captured by the GALI. We used
a binary variable taking value 1 for people who declared to be “limited, but
not severely” or “severely limited” because of health in the activities people
usually do and 0 for respondents reporting not to be limited.

Explanatory Variables
To assess whether educational inequalities in health outcomes among older
Europeans exists, we consider three educational groups based on the level of
education achieved using the International Standard Classification of
Education2: low (corresponding to ISCED 0-1, no or primary education, and
ISCED 2, lower secondary education—reference), medium (ISCED 3-4,
higher secondary education), and high (ISCED 5-6, tertiary education).
Education is our exposure variable.
We consider three dimensions of active aging that refer to the level and
intensity of participation in social activities, paid employment, and provision
of grandchild care, which were measured at the baseline (Wave 4). As for
social participation, the SHARE questionnaire includes the following ques-
tion: “Have you done any of these activities in the last 4 weeks?” Respondents
could tick several activities from a list including voluntary or charity work;
attending educational or training course; participation in a sport, social, or
other kind of club; taking part in a religious organization (church, synagogue,
mosque, etc.); and taking part in a political or community-related organiza-
tion. Respondents were also asked about the frequency of participation in the
activities they mentioned (“almost daily,” “almost every week,” “less often”).
For each of the five activities, first we computed the frequency of involve-
ment (in days) in each social activity, and then, we created a numerical vari-
able that gave us an approximation of the total involvement in social activities
in the year preceding the interview. Therefore, we distinguished the involve-
ment into three categories: (a) “no involvement,” (b) “not intensive” (<70
days per year), and (c) “intensive” (≥70 days per year). As a second indicator
of active aging, we consider a variable indicating participation in the labor
market. We also take into account the intensity of the involvement by incor-
porating the number of hours usually worked in a week. We distinguished
between intensive and not intensive involvement, dividing the respondents in
three categories: (a) not working, (b) working part time, and (c) working full
time (at least 37 hr per week).
Arpino and Solé-Auró 191

Figure 1.  Visualization of the breakdown of the total (unadjusted) effect of

education on health into direct (adjusted) and indirect components.

Finally, we account for provision of grandchild care as a third indicator of

active aging. Information on grandchild care in SHARE is obtained through
a question asking “During the last 12 months, have you regularly or occasion-
ally looked after your grandchild/your grandchildren without the presence of
the parents?” If “yes,” a second question asked the frequency of such grand-
child care for each respondent’s child (“almost daily, almost every week,
almost every month, less often”). Based on the information on the frequency
of grandchild care provided by the respondent to each of his or her children,
we created a new variable with three categories: (a) “no grandchild care,” (b)
“not intensive grandchild care” (<70 days per year), and (c) “intensive grand-
child care” (≥70 days per year). Individuals without grandchildren are
included in the reference category together with grandparents who did not
provide grandchild care because our goal here is to assess the effect of the
grandchild-care activity and not of having grandchildren per se. It has to be
noticed that in SHARE, we do not have information on grandchild care pro-
vided to each grandchildren separately but the information refers to all chil-
dren of each of the respondent’s child. So, SHARE underestimates grandchild
care for the respondents who provide care to grandchildren with the same
parent. The three active aging variables play the role of mediators of the
effect of education in our analyses (see Figure 1).
To assess the robustness of the results to the operationalization of our
explanatory variables, we used different measures of the social participation
variable (number of activities, number of activities with an “almost weekly”
frequency, and a dummy variable indicating an “almost weekly” participation
in at least one of the activities), and the results were similar to those reported
here. As for grandchild care, we also considered a simple binary variable
indicating intensive grandchild care provision (“almost weekly” or more)
192 Journal of Aging and Health 31(1)

provided to at least one child versus the rest, and results were not affected
significantly. These analyses are available upon request.

Control Variables
In all multivariate analyses, we control for a set of variables that have been
found to be related to education, social participation, and health outcomes and,
therefore, may confound the associations under study (Crimmins, Kim, &
Solé-Auró, 2011; Di Gessa & Grundy, 2014; Han et al., 2017). Sociodemographic
control variables include age as a continuous variable, marital status (married
or in partnership—reference, never married, divorced, or widowed), number of
children, number of grandchildren, and type of living area (“rural” = 1 for
respondents living in rural areas, 0 = otherwise).3 These control variables are
added into the model due to their association with education and health.
We then control for a binary variable indicating whether the respondent
provided or not regular help during the 12 months before the interview to
someone living in his or her household with personal care (such as washing,
getting out of bed, or dressing). We also control for a dummy variable taking
value 1 for respondents engaged in vigorous physical activity (such as sports,
heavy housework, or a job that involves physical labor) at least once a week
and taking value 0 for those who are engaged in physical activities less often
than once a week or are not engaged at all.
We also control for several measures of health status at the baseline (Wave
4, 2010) to account for the initial health status of our respondents. First, we
consider information on the experience of chronic diseases reported in response
to the question, “Has a doctor ever told you that you had any of the following
conditions: hypertension, diabetes, cancer, lung disease, heart disease, stroke
and arthritis?” For each of these conditions, we include a dummy variable as
control. Second, we use grip strength, an indicator of measured functional per-
formance. More specifically, we used the maximum of the grip strength mea-
sures taken during the interview. Finally, in all regression analyses, we control
for differences across the 13 European countries (Austria, Belgium, Czech
Republic, Denmark, Estonia, France, Germany, Italy, the Netherlands, Slovenia,
Spain, Sweden, Switzerland) by including country fixed effects.
To address concerns of overcontrolling, we implemented a sensitivity
check where in turn the block of health conditions and sociodemographic
variables, both measured at baseline, are excluded from the set of control
variables. Although of course numerical estimates were different, these anal-
yses (available upon request) gave similar patterns of results as those pre-
sented in the article. Importantly, the conclusions from a qualitative point of
view would remain the same.
Arpino and Solé-Auró 193

Method
The first two health outcome measures we consider are numerical variables and
the third one is binary. All of them are measured at the follow-up wave (Wave
5, 2012). We estimate two linear and a logistic regression model, to assess the
effect of education on health and the mediating role of active aging activities.
To this end, we estimate and compare results from two types of regression
models. In a first step, Model 1 estimates the effect of education on health out-
comes controlling for all the control variables explained above but excluding
the active aging variables (unadjusted model). In a second step, Model 2 repli-
cates Model 1 adding the three active aging indicators, building our final
adjusted model. Both models are run separately for women and men.
To quantify what part of the effect of education on health can be attributed
to the active aging variables, we use the “KHB” method (Karlson, Holm, &
Breen, 2011; Kohler, Karlson, & Holm, 2011). This method appropriately
compares the unadjusted and adjusted models and allows decomposing the
total effect of education on health in its direct and indirect components (see
the visualization of the model in Figure 1). Therefore, we can quantify the
change in the association between the exposure variable (level of education)
and the outcome (health measures) before and after controlling for one or
more potential mediators (active aging activities). This change corresponds
to the indirect effect of the mediator. In our case, the indirect effect is the part
of the effect of education on health that is explained by active aging differen-
tials across educational groups, that is, the part of the effect of education that
is mediated by the considered active aging activities. The KHB method also
allows decomposing the indirect effect in the part due to each one of the
mediators separately, that is, each of the three active aging activities. The
direct effect of education corresponds, instead, to the effect of education that
is left after active aging variables are also controlled for in the adjusted
model. Note that this direct effect may be in part mediated by other variables
others than our mediators. The total effect is the sum of the direct and indirect
effects. The contribution of active aging activities to the educational differ-
ences in health, which is the quantity of our main interest, corresponds to
ratio of the indirect effect to the total effect.

Results
Descriptive Statistics
Table 1 presents the sample size and the weighted summary statistics on the
three health measures by education and gender. Table 1 demonstrates large
health inequalities by education levels. For each of the three health measures
194 Journal of Aging and Health 31(1)

Table 1.  Summary Statistics (Mean and %) on the Three Health Measures, by
Education Level for Men and Women.

Men Women
Self-perceived health (M)
 Total 3.1 3.2
 Low 3.4 3.5
 Medium 3.2 3.1
 High 2.8 2.8
Depressive symptoms (M)
 Total 2.0 2.9
 Low 2.4 3.4
 Medium 2.0 2.7
 High 1.5 2.2
GALI—limited (%)
 Total 41.1 46.5
 Low 45.0 51.2
 Medium 41.9 42.9
 High 34.1 36.2
Sample size (N) 11,595 15,984

Source. SHARE (2010-2012).

Note. “Low,” “medium,” and “high” refer to the level of educated. Education is measured at
baseline (Wave 4, 2010) and health measures are measured at follow-up (Wave 5, 2012).
Appropriate weights are used. GALI = Global Activity Limitation Indicator; SHARE = Survey
of Health, Ageing and Retirement in Europe.

and for both men and women, we observe a positive educational gradient:
Health tends to be better with increased education. Adults with high educa-
tion tend to have lower mean values of self-perceived health, lower mean
values of depressive symptoms, and lower prevalence of GALI limitations
than those with lower levels of education. The group with a medium level of
education is more similar to the high educated than to the low educated one.
Differences are particularly striking between high and low educated and for
self-perceived health.
Table 2 reports weighted descriptive statistics on the control and mediat-
ing variables for men and women by level of education. The educational
gradient varies for men and women: Less men than women are low educated
(34.5% and 43.4%, respectively), and more men than women are medium or
high educated. People with low education tend to be on average older than
individuals with high education. More high educated men compared with low
educated report being married or in partnership, probably due to their younger
 Table 2.  Sample Characteristics by Gender and Level of Education.
Men Women

Low Medium High Low Medium High

Variables Prevalence 95% CI Prevalence 95% CI Prevalence 95% CI Prevalence 95% CI Prevalence 95% CI Prevalence 95% CI

Age 63.6 [63.3, 63.9] 61.5 [61.3, 61.8] 62.8 [62.5, 63.1] 66.4 [66.2, 66.6] 62.5 [62.3, 62.7] 60.7 [60.5, 61.0]
Marital status
  Married or in partnership 71.8 [70.3, 73.2] 71.0 [69.7, 72.3] 76.4 [74.8, 77.9] 56.9 [55.7, 58.1] 61.3 [60.1, 62.5] 58.5 [56.9, 60.2]
  Never married 11.8 [10.7, 12.8] 10.5 [9.7, 11.4] 9.4 [8.3, 10.5] 6.3 [5.7, 6.9] 7.5 [6.8, 8.1] 10.2 [9.2, 11.2]
 Divorced 9.3 [8.3, 10.2] 12.7 [11.8, 13.6] 8.2 [7.2, 9.3] 7.6 [6.9, 8.2] 13.9 [13.1, 14.8] 19.7 [18.4, 21.1]
 Widowed 7.2 [6.3, 8.0] 5.8 [5.1, 6.4] 6.0 [5.1, 6.8] 29.3 [28.0, 30.2] 17.3 [16.3, 18.2] 11.6 [10.5, 12.6]
Nª of children (M) 2.0 [1.98, 2.07] 1.9 [1.84, 1.91] 1.9 [1.87, 1.96] 2.3 [2.26, 2.34] 2.0 [1.94, 2.00] 1.9 [1.87, 1.95]
Nª of grandchildren (M) 1.6 [1.55, 1.71] 1.2 [1.09, 1.20] 1.3 [1.25, 1.42] 2.8 [2.72, 2.88] 1.8 [1.75, 1.88] 1.3 [1.26, 1.42]
Provision of help with personal care 6.4 [5.5, 7.3] 5.4 [4.7, 6.1] 4.3 [3.5, 5.1] 10.3 [9.4, 11.2] 8.1 [7.3, 8.9] 5.8 [4.9, 6.8]
Rural vs. urban 30.9 [29.2, 32.6] 34.7 [33.2, 36.1] 26.2 [24.5, 28.0] 32.0 [30.8, 33.3] 32.1 [30.9, 33.4] 26.4 [24.7, 28.0]
Chronic conditions
  Heart attack 12.9 [11.8, 13.9] 10.0 [9.2, 10.9] 9.4 [8.3, 10.4] 10.6 [9.8, 11.3] 5.7 [5.1, 6.2] 3.3 [2.7, 3.9]
 Stroke 3.2 [2.6, 3.8] 3.0 [2.5, 3.4] 2.2 [1.7, 2.8] 2.4 [2.0, 2.7] 3.0 [2.6, 3.5] 1.1 [0.8, 1.5]
 Lung 7.6 [6.8, 8.5] 4.2 [3.6, 4.8] 6.1 [5.2, 7.0] 7.3 [6.7, 8.0] 7.1 [6.4, 7.7] 2.9 [2.4, 3.6]
 Cancer 3.9 [3.3, 4.5] 3.1 [2.6, 3.6] 3.4 [2.7, 4.0] 4.2 [3.7, 4.7] 5.3 [4.7, 5.8] 5.8 [5.0, 6.5]
 Arthritis 21.1 [19.8, 22.4] 13.0 [12.1, 13.9] 10.4 [9.3, 11.5] 38.5 [37.4, 39.7] 26.0 [24.9, 27.1] 15.4 [14.2, 16.6]
 Hypertension 36.1 [34.6, 37.6] 35.3 [33.9, 36.6] 34.2 [32.4, 35.9] 43.0 [41.7, 44.2] 37.7 [36.5, 38.9] 34.6 [33.0, 36.2]
Grip strength (M) 42.3 [42.0, 42.6] 45.8 [45.6, 46.1] 45.9 [45.6, 46.2] 24.9 [24.7, 25.0] 28.0 [27.9, 28.2] 28.6 [28.4, 28.8]
Vigorous physical activities 45.6 [44.0, 47.2] 59.4 [58.1, 60.8] 66.0 [64.3, 67.8] 35.0 [33.9, 36.2] 50.1 [48.9, 51.4] 62.5 [60.9, 64.2]
Active aging activities
  Social participationa—not intensive 9.9 [8.9, 10.8] 18.2 [17.1, 19.3] 22.2 [20.7, 23.8] 10.1 [9.4, 10.8] 15.5 [14.6, 16.4] 19.8 [18.5, 21.2]
  Social participation—intensive 24.4 [23.1, 25.8] 31.2 [29.9, 32.5] 48.2 [46.4, 50.0] 27.8 [26.7, 28.9] 36.9 [35.7, 38.1] 53.1 [51.5, 54.8]
  Working—part time 7.1 [6.3, 7.8] 10.8 [9.9, 11.7] 10.3 [9.2, 11.4] 9.2 [8.5, 9.9] 23.6 [22.6, 24.7] 26.3 [24.8, 27.8]
  Working—full time 23.7 [22.3, 25.0] 33.5 [32.2, 34.8] 39.5 [37.8, 41.3] 6.9 [6.3, 7.6] 14.6 [13.7, 15.4] 28.7 [27.2, 30.3]
  Grandchild care—not intensive 7.8 [6.9, 8.6] 10.9 [10.0, 11.8] 16.4 [15.0, 17.7] 11.2 [10.5, 12.0] 13.3 [12.5, 14.2] 13.7 [12.6, 15.0]
  Grandchild care—intensive 11.6 [10.6, 12.6] 8.6 [7.8, 9.4] 7.9 [15.0, 17.7] 19.7 [18.7, 20.7] 15.0 [14.1, 15.9] 11.2 [12.6, 12.3]
Total 34.5 [33.6, 35.3] 40.9 [40.0, 41.8] 24.6 [23.8, 25.4] 43.3 [42.5, 44.1] 35.9 [35.2, 36.7] 20.8 [20.1, 21.4]
Sample size (N) 3,809 4,885 2,899 6,418 6,161 3,404  

Source. SHARE (2010).

Note. CI = confidence interval; SHARE = Survey of Health, Ageing and Retirement in Europe.
aSocial participation includes volunteering, education, sport or other club, religious organization, and political organization. Explanatory and control variables are

195
measured at baseline (Wave 4, 2010). Appropriate weights are used.
196 Journal of Aging and Health 31(1)

age (no significant differences for women). Almost 20% of high educated
women are divorced, whereas for high educated men, this percentage
decreases to 8.3%. About a third of the women with low education reported
being widowed, as they are also older. The mean number of children and
grandchildren significantly differs by educational groups being larger for low
educated women compared with the other groups. Regular help with personal
care significantly differs among the extreme educational groups for men, and
among all educational groups for women, being the high educated the least
likely to provide care. The proportion of people living in rural areas is highest
among those with lower levels of education. We also notice some statistically
significant variations in the prevalence of six chronic conditions, mean grip
strength, and vigorous physical activities for both genders. We observe a
positive educational gradient: Lower prevalences are seen with increased
education for chronic conditions and higher prevalences at higher levels of
education for mean grip strength and vigorous physical activities.
Finally, we report the prevalence for the intensity of the three active aging
activities we consider. First, as for health, we notice a positive educational
gradient also in engagement in active aging activities. The prevalence of
engagement in each of the three activities increases with education, both for
men and women. The only exception is the provision of intensive grandchild
care, for which we observe an opposite pattern for women: Low educated
women are more likely to provide intensive grandchild care (19.7%) than
their high educated counterpart (11.2%). We need to recall that low educated
women also have more grandchildren (2.8 vs. 1.3). In all other cases, high
educated men and women show prevalences of engagement (intensive and
not intensive) about twice as high as those observed among low educated.
The most striking educational gap is observed among women for intensive
engagement social participation: 27.8% versus 53.1% for low and high edu-
cated, respectively.

Multivariate Results
Tables 3 and 4 report, for men and women, respectively, the estimated coef-
ficients from two sets of regression models (unadjusted and adjusted) for
each of the dependent variable: self-perceived health, depressive symptoms,
and GALI limitations (limited vs. not limited). In each case, the unadjusted
model includes education, and all the control variables listed above but
excludes active aging variables. The subsequent adjusted model adds the
active aging activities. Complete estimates of our regression models includ-
ing the coefficients of the control variables are provided in the online appen-
dix (Table A1).
 Table 3.  Estimated Linear and Logistic Regression Coefficients and Contributions of Active Aging Variables to the Effect of
Education on Three Measures of Health, Men.
Self-perceived health Depressive symptoms GALI—limited

Adjusted Indirect Adjusted Adjusted

Variables Unadjusted (direct) effect Unadjusted (direct) Indirect effect Unadjusted (direct) Indirect effect
Education
 Medium −0.12*** −0.09*** −0.02 −0.15*** −0.12*** −0.03 −0.14*** −0.11** −0.03
  (–0.02) (–0.02) (0.03) (0.04) (0.04) (0.03) (0.05) (0.05) (0.05)
 High −0.36*** −0.29*** −0.06** −0.33*** −0.26*** −0.07** −0.46*** −0.38*** −0.09*
  (0.02) (0.02) (0.03) (0.05) (0.05) (0.03) (0.06) (0.06) (0.05)
Active aging Coefficients Contribution Coefficients Contribution Coefficients Contribution
Social participation—not −0.09*** 1.74*** −0.12** 2.71** −0.00 0.05
intensive
  (0.02) (0.05) (0.06)  
Social participation— −0.18*** 8.65*** −0.20*** 10.09*** −0.21*** 7.81***
intensive
  (0.02) (0.04) (0.05)  
Working—part time −0.18*** 1.67*** −0.17** 1.74** −0.21** 1.51**
  (0.04) (0.07) (0.09)  

(continued)

197
198
Table 3. (continued)

Active aging Coefficients Contribution Coefficients Contribution Coefficients Contribution

Working—full time −0.26*** 5.45*** −0.25*** 5.74*** −0.59*** 9.47***
  (0.02) (0.05) (0.06)  
Grandchild care—not −0.08*** 0.68** −0.18*** 1.65** −0.15** 0.92*
intensive
  (0.03) (0.06) (0.07)  
Grandchild care—intensive −0.10*** −0.32 −0.16*** −0.56 −0.13** −0.33
  (0.03) (0.06) (0.07)  
Total contribution active 18.2*** 21.9*** 19.7***
aging

Note. A logistic regression model was estimated for GALI, whereas linear regression models were employed for the other two measures. Unadjusted and adjusted refer to
a regression model without and with the inclusion of active aging variables, respectively. GALI = Global Activity Limitation Indicator.
*p < .1. **p < .05. ***p < .01.
 Table 4.  Estimated Linear and Logistic Regression Coefficients and Contributions of Active Aging Variables to the Effect of
Education on Three Measures of Health, Women.
Self-perceived health Depressive symptoms GALI—limited

Adjusted Indirect Adjusted Adjusted

Variables Unadjusted (direct) effect Unadjusted (direct) Indirect effect Unadjusted (direct) Indirect effect

Education
 Medium −0.20*** −0.16*** 0.03 −0.39*** −0.35*** −0.04 −0.18*** −0.14*** −0.04
  (0.02) (0.02) (0.02) (0.04) (0.04) (0.03) (0.04) (0.04) (0.04)
 High −0.39*** −0.30*** −0.09*** −0.54*** −0.45*** 0.09*** −0.33*** −0.21*** −0.12***
  (0.02) (0.02) (0.02) (0.05) (0.05) (0.03) (0.05) (0.05) (0.04)

Active aging Coefficients Contribution Coefficients Contribution Coefficients Contribution

Social participation— −0.15*** 3.18*** −0.15*** 2.34*** −0.13** 3.10**

not intensive
  (0.02) (0.05) (0.05)  
Social participation— −0.21*** 10.13*** −0.26*** 8.98*** −0.25*** 13.53***
intensive
  (0.02) (0.04) (0.04)  
Working—part time −0.19*** 2.39*** −0.12** 1.12** −0.29*** 4.31***
  (0.02) (0.06) (0.06)  
Working—full time −0.29*** 6.80*** −0.26*** 4.32*** −0.58*** 15.79***

(continued)

199
200
Table 4. (continued)
Active aging Coefficients Contribution Coefficients Contribution Coefficients Contribution

  (0.02) (0.06) (0.06)  

Grandchild care—not −0.03* 0.04 −0.18*** 0.13 −0.13** 0.16
intensive
  (0.02) (0.05) (0.05)  
Grandchild care— −0.08*** 0.14 −0.14*** 0.17 −0.15*** 0.30
intensive
  (0.02) (0.05) (0.05)  
Total contribution 22.5*** 16.8*** 36.7***
active aging

Note. A logistic regression model was estimated for GALI, whereas linear regression models were employed for the other two measures. Unadjusted and adjusted refer
to a regression model without and with the inclusion of active aging variables, respectively. GALI = Global Activity Limitation Indicator.
*p < .1. **p < .05. ***p < .01.
Arpino and Solé-Auró 201

To correctly interpret the direction of associations, it should be kept in

mind that because higher values of the outcomes correspond to worse health,
a negative coefficient actually indicates a positive association with better
health. Tables 3 and 4 provide the unadjusted (total), adjusted (direct), and
indirect effects (regression coefficients). The top part of Tables 3 and 4 show
that education is negatively associated with (bad) self-perceived health. Both
older people with medium and high levels of education report significantly
better self-perceived health on average as compared with low educated indi-
viduals. This is true for both genders.
In the adjusted model, the coefficients of the active aging variables are
negative and statistically significant for both men and women. This confirms
our expectation about a positive association between active aging and good
health. The effect of education on health is reduced when controlling for the
active aging activities (adjusted model). Therefore, education inequalities in
self-perceived health can be partly explained by different levels of active
engagement of older people.
A similar pattern of results emerge for the other two outcome variables:
The higher the education level, the better is the health. Also, for depressive
symptoms and being limited by GALI, participation in paid and unpaid activ-
ities is associated with better health. We can notice that the effect of educa-
tion is particularly strong when comparing high and low educated groups.
The coefficient of medium education, measuring the gap in health between
medium and low educated, is always considerably lower than the same coef-
ficient estimated for high educated.
Tables 3 and 4 also report the results from the KHB method that aims at
disentangling the direct and indirect (through active aging activities) effects
of education on health. For each outcome, the third column in the top part of
the tables shows the indirect effect of education (as mediated by all active
aging activities jointly). The bottom part of the third column provides the
decomposition of the significant indirect effects in the contribution of each
active aging activity category.
First, for both men and women, we notice that the indirect effects for each
health dimension are significant only for high education. Said in other words,
only for high versus low educated people, we find a statistically significant
difference in the estimated coefficients in the unadjusted and adjusted mod-
els. This means that only for the health gaps between high and low educated,
we can affirm that a significant part is attributable to differences in engage-
ment in active aging activities. As indicated in the last row of Table 3, for
men, the significant contribution of all active aging activities taken jointly in
explaining educational inequalities in health is 18.2% for self-perceived
health, 21.9% for depressive symptoms, and 19.7% for being limited with
202 Journal of Aging and Health 31(1)

activities (GALI). For women, these contributions are 22.5%, 16.8%, and
36.7%, respectively (last row of Table 4).
The bottom part of Tables 3 and 4 shows the decomposition of the signifi-
cant total contribution of the indirect effect that can be attributed to the inten-
sity of each active aging activity. The mediators that weigh the most in the
contribution of the effect of education on health are always intensive social
participation and paid work (full time), although variation exists across the
health measures. In the case of men, for self-perceived health, out of the total
indirect effect of 18.2% about two thirds of the contribution is due to social
participation (10% not intensive and 48% intensive) and over a third to work-
ing (9% working part time and 30% working full time). Only 4% is signifi-
cantly due to not intensive grandchild care. The contribution is similar for
high educated women where both intensive social participation and working
full time contributes to a larger extent (45% and 30%, respectively). For high
educated men with depressive symptoms, the largest significant contribution
is due to social participation (12% not intensive and 46% intensive); working
represents about a third of the total contribution for high educated men; for
women, social participation contributes the most (68%), followed by work-
ing (32%). The largest overall indirect effects of high education are found for
being limited in activities (GALI; 36.7%). For high educated men, working
contributes to 56% (8% working part time and 48% working full time) and
intensive social participation to 40% of the differences between high and low
educated people on being limited in activities. For women, almost two thirds
of the total contribution (36.7%) is due to working (12% part-time work and
43% full-time work) and a third due to social participation (8% not intensive
and 37% intensive). Despite being positively and significantly associated
with health, grandchild care does not contribute much to the significant edu-
cational differences in health.

Discussion
This study aimed to examine to what extent engagement in active aging
activities can explain educational gaps in health at older ages. We found a
strong positive educational gradient in health for each of the three health
measures we considered. Older people with high education tend to show
higher prevalence of good self-perceived health, of low depressive symp-
toms, and of absence of limitations (GALI) as compared with people with
lower levels of education. Educational inequalities in health were particularly
strong between the two extreme educational groups. All active aging activi-
ties that we considered (social participation, working and provision of grand-
child care) were found to be positively associated with each of the three
Arpino and Solé-Auró 203

health outcomes. Moreover, high educated older people reported higher

engagement in these activities.
Putting all these findings together, our multivariate analyses using the
KHB decomposition method quantified the part of the effect of education on
health that can be attributed to active aging activities. We found that a sub-
stantive part of the gap in health between high and low educated can be attrib-
uted to different active aging levels. Active aging activities explained between
12% and 33% of the gap in health between high and low educated women.
For men, these percentages ranged between 16% and 21%. Among the active
aging activities, working had often the highest weight in explaining educa-
tional inequalities in health. Social participation also played an important
role, whereas provision of grandchild care, though being positively associ-
ated with health, did not contribute noticeably to the effect of education on
health. Differences between medium and low educated groups were lower
and engagement in active aging activities had no statistically significant
effect in explaining this gap.
Consistent with previous studies using European data, our results also
show that educational inequalities are stronger among women than among
men (Solé-Auró & Alcañiz, 2016). However, the pattern of results is
somehow similar for both genders: Engagement in active aging activities
is similarly important for men and women; working and social participa-
tion mediate the effect of (high) education on health in a comparable man-
ner by gender, but the working contribution is especially relevant for the
absence of limitations due to health in activity people usually do for
women.
Despite these important findings, our study also has some limitations.
First, because SHARE excludes the nursing home population, our results
cannot be generalized to the entire population. The nursing home population
in Europe includes persons with relatively high risk of mortality and morbid-
ity. However, nursing home residence is generally relatively low in European
countries at ages below 80 (Huber, Rodrigues, Hoffmann, Gasior, & Marin,
2009).
Second, the provision of care to adults and older people could have been
considered as another type of active aging activity (as in the Active Ageing
Index definition; see Zaidi et al., 2013). However, we decided not to do so
because this variable is quite restrictive in the SHARE questionnaire as it
refers only to personal care and it is limited to persons within the household.
Yet, we controlled for it in our multivariate analyses because caregiving
activities may compete with other activities subtracting time to them and it
can also influence health outcomes (Arpino & Bordone, 2015; Carmichael &
Ercolani, 2016).
204 Journal of Aging and Health 31(1)

Finally, we pooled data from 13 countries and, even though we adjusted

for country differences by using country fixed effects, we were not able to
analyze each country separately. This is because our analyses were stratified
by gender, and we examined differences among three levels of education.
Therefore, implementing separate analyses by country would have implied
having too small sample sizes in some groups. However, to follow-up these
results, in future studies, we will examine how the gap in active aging activi-
ties changes across groups of countries.
Our article bridges the extensive literature on educational inequalities in
health (e.g., Cambois, Solé-Auró, & Robine, 2016; Cambois, Solé-Auró,
Brønnum-Hansen, et al., 2016; Chiu et al., 2016; Crimmins & Saito, 2001;
Laditka & Laditka, 2016) and the growing literature on the consequences of
active aging (e.g., Di Gessa & Grundy, 2014; Hank & Stuck, 2008). Our find-
ings indicate that different engagement levels in active aging activities
between high and low educated people may contribute to explain health dis-
parities. In particular, working full time, that among older people is most
common for those with high education, seems to be the activity that mostly
contributes explaining educational inequalities in health, particularly for
women. Intensive social participation also has an important role.
All in all, this study points to the important role of engagement in paid
work and social activities for maintaining good health at older ages and high-
lights significant differences in engagement in these activities among educa-
tional groups. This suggests that policies devoted at stimulating an active
participation in society among older people should be particularly focused on
lower educated groups that reported the lowest levels of engagement. An
increased engagement of low educated people may help to reduce educa-
tional inequalities in health. However, as we also noticed in the article, a
higher engagement in active aging activities may not only positively influ-
ence health but also may be encouraged by better health (see, for example, Di
Gessa & Grundy, 2014; Landstedt et al., 2016). To partially deal with this
reverse causality problem, we used longitudinal data and measured covari-
ates and explanatory variables (education and active aging) at the baseline
wave, controlling also for several health indicators, and we measured health
outcomes at the follow-up wave. This, however, does not solve completely
the reverse causality issues in case of highly stable engagement in activities.
Therefore, our results cannot be understood as causal and should be inter-
preted with care. For example, continued participation in the labor market
could not be always beneficial for older people’s health. Some studies point,
in fact, to a strongly heterogeneous effect of retirement on health that may
depend also on the type of job from which individuals retire (Coe, von
Gaudecker, Lindeboom, & Maurer, 2012). An interesting avenue for future
Arpino and Solé-Auró 205

research is to analyze more in depth the causal effect of work and social par-
ticipation more, in general, on health for different educational groups.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study belongs to the multi-country
project “Care, Retirement & Wellbeing of Older People Across Different Welfare
Regimes ” (CREW). The authors acknowledge funding from the Spanish Ministry of
Economy, Industry and Competitiveness (PCIN-2016-005; PI: Bruno Arpino) within
the second Joint Programming Initiative “More Years Better Lives”.

Notes
1. Missing values in each of the dependent, explanatory variables, and most of the
control variables used in the statistical analyses were other criteria for the exclu-
sion of cases. For three control variables that reported higher percentage of miss-
ing values (around 10%), we retained missing values and used a flag indicator as
additional control variable in the multivariate analyses.
2. http://www.uis.unesco.org/education/pages/international-standard-classifica-
tion-of-education.aspx
3. We used the question on the type of area where the building is located and we
coded as “rural” respondents in the category “rural area or village,” whereas all
other categories (“big city,” “suburbs or outskirts of a big city,” “large town,” and
“small town”) were included in the reference group.

Supplemental Material
Supplemental material for this article is available online.

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