Educational inequalities in disability at the end of life across European welfare regimes

Individuals with higher levels of educational attainment experience lower levels of disability than their lower educated counterparts, but it remains unclear how this educational gradient manifests at the end of life. We propose two competing perspectives that offer contrasting expectations. The cumulative dis/advantage hypothesis suggests that educational differences in disability continue to widen at the end of life, whereas the terminal convergence hypothesis postulates diminishing differences as proximity to death overrides prior social advantages through universal mortality related decline. We test these hypotheses using harmonized end-of-life interviews from 6957 deceased participants in the Survey of Health, Ageing and Retirement in Europe. Additionally, we examine whether educational inequalities vary across welfare regimes. Multilevel beta-binomial models are used to capture individual- and country-level variation in limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). During the final year of life, medium-educated and high-educated decedents were predicted to have 0.22-0.37 (8-10%) fewer ADL limitations and 0.50-0.63 (17-18%) fewer IADL limitations than low-educated decedents. Conditioning on the disability status at the last observation alive attenuated inequalities, though it did not eliminate them. This suggests that educational inequalities in disability continue to widen in the final phase of life. Welfare regimes moderated these inequalities, with strong evidence for ADL disability and limited evidence for IADL disability. Within-regime differences showed significant educational inequalities in Bismarckian and Eastern European regimes, but not in Southern European or Nordic regimes. Overall, the findings support the cumulative dis/advantage hypothesis and highlight the role of institutional context in shaping inequalities in end-of-life disability.