Sex differences in life-course social disadvantage and all-cause mortality: evidence from a longitudinal study from...

Social inequalities in mortality persist in Germany despite high universal health coverage. Yet no study has simultaneously examined sex-specific differences in accumulation, age modification, and life-stage variation in the association between social disadvantage and all-cause mortality across the adult life-course.

We conducted a longitudinal life-course study using 28 years of data from the German Socioeconomic Panel (SOEP; 1996-2023), comprising 112,006 adults and 660,480 person-wave observations. Low socioeconomic status (low-SES), an indicator of social disadvantage, was measured as the number of years spent in the lowest 20% of a composite SES index of education, occupation, and income. Cox proportional hazards models were fitted to estimate (1) accumulation, (2) age-modification, and (3) life-stage variation in the social disadvantage-mortality association for women and men. Results are reported as adjusted hazard ratios (HRs) with 95% confidence intervals (CIs).

Over 684,295 person-years of follow-up, 4,974 deaths occurred. Cumulative social disadvantage was associated with higher mortality risk for both sexes. Among women, each additional year spent in social disadvantage at age 50 was associated with a 13% higher mortality hazard (HR = 1.13; 95% CI: 1.07-1.19). The accumulation gradient was steeper among men (15%; interaction HR = 1.02; 95% CI: 1.01-1.04). The age-modification model indicated that the strength of the social disadvantage-mortality association attenuated with age, but more gradually for men than for women. In the life-stage model, stronger associations were observed in emerging adulthood for women (ages 16-29: HR = 1.34; 95% CI: 1.05-1.71) and in mid-adulthood (ages 45-64: HR = 1.13; 95% CI: 1 .03-1.24) and late adulthood ( ages 65 + : HR = 1.14; 95%CI: 1.00-1.29) among men.

An accumulation of social disadvantage increases mortality hazard for both sexes, but is higher for men. Association decreases with age, strongest in emerging adulthood for women and mid-to-late adulthood for men. These findings underscore the importance of life-course-informed and gender-responsive public health actions to reduce persistent social inequalities in mortality in Germany.