ArticleInternational journal for equity in health2026
Generational variation and life‑course accumulation of social inequalities in all-cause mortality in Germany: a cohort-sequential study.
Article in International journal for equity in health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundSocial inequalities in mortality persist as a public health challenge across Europe, including Germany, despite significant health gains. Research shows a lasting social gradient in survival. However, comprehensive longitudinal evidence on cohort and life-course dynamics is limited. We examine trends in social inequalities in all-cause mortality, cohort differences, and whether cumulative low-SES exposure raises mortality risk over the life course.
methodWe used longitudinal data from the German Socio-economic Panel (SOEP, 1996-2023). A cohort-sequential survival analysis included 112,037 individuals, totalling 660,480 observations and 4,974 deaths. Five birth cohorts (1925-1975) were defined. Socio-economic status (SES) was measured using education, income, and occupation, combined and modelled as both time-varying and constant exposures. Mortality was ascertained via year of death. We estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) using Cox proportional hazards models with attained age as the time scale. Analyses were adjusted for sex, migration background, and marital status. Model diagnostics and sensitivity analyses were performed.
resultsMortality declined over time. However, relative social inequalities persisted. Individuals with low SES had over twice the mortality risk of those with high SES. In our life-course analysis, we found that repeated or cumulative social disadvantage across adulthood mattered more than single episodes. Each additional year spent in low SES increased mortality risk by 16% at age 50 (HR = 1.16; 95% CI: 1.11-1.22), though this effect decreased with age. We also observed generational variations: for example, low-SES individuals born in the 1956-1965 cohort (HR = 2.03, 95% CI 1.15-3.57) and 1966-1975 cohort (HR = 2.32, 95% CI 1.03-5.30) had higher mortality hazards than the 1925-1934 reference cohort. Finally, men had a higher mortality risk than women (HR 1.84, 95% CI 1.65-2.05).
conclusionsWhile mortality has declined, social inequality in survival persists. It accumulates over the life-course and varies by generation. These findings underscore the need for sustained, life-course policies: reducing early-life disadvantage, strengthening stable working-age, and addressing structural drivers of survival inequalities.
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