Introduction: Given the known female disadvantage in physical and mental health, this study aimed to investigate sex differences in self-rated health (SRH) among older adults, considering the longitudinal course by age, birth cohort, and educational level. Methods: Data from birth cohort 1911–1937 with baseline age 55–81 years (n = 3,107) and birth cohort 1938–1947 with baseline age 55–65 years (n = 1,002) from the Longitudinal Aging Study Amsterdam (LASA) were used. Mixed model analyses were used to examine sex differences in SRH (RAND General Health Perception Questionnaire [RAND-GHPQ], range 0–16) over the age course, testing for effect modification by the birth cohort and educational level (low, middle, high). Results: For both sexes, a decline in SRH was seen with increasing age. Over the age course, there was no significant sex difference in SRH within the older (1911–1937) birth cohort (0.13 lower score on SRH for women compared to men, 95% CI: −0.35 to 0.09) and only a small sex difference in the more recent (1938–1947) birth cohort (0.35 lower score on SRH for women compared to men [95% CI: −0.69 to −0.02], p = 0.04). There was no significant cohort difference in the size of the sex difference (p = 0.279). Those with a higher level of education reported a higher SRH, but between educational levels, there was no significant difference in the size of the sex difference in SRH. Discussion: In this study, no relevant sex difference in SRH over the age course was observed among older adults. Future research on SRH trajectories by sex during aging should take health-related, cognitive, psychosocial, and behavioral factors into account.

While women have a higher life expectancy, they experience more years with disabilities compared to men. This so-called male-female health-survival paradox is a well-established phenomenon, placing aging women in a disadvantaged position [1]. In order to reduce this female disadvantage and foster healthy aging for both sexes, gaining insight into sex-specific health trends in the older population is necessary.

Research has shown a consistent female disadvantage in various domains of aging, including physical and mental functioning [2, 3]. While self-rated health (SRH) has been increasingly used as a simple measure of overall subjective health status and is a predictor of mortality, independent of other health parameters [4, 5], there is limited research on sex differences in SRH and results are inconsistent [6‒9]. SRH provides a holistic view on one’s health, taking morbidities, health behavior, and social factors into account [10]. Yet, a precise definition of what SRH truly measures in old age remains a topic of ongoing debate [11]. Previous research has shown that physical and mental functioning both play an important role in shaping SRH. Given the previously reported female disadvantage in physical and mental health during aging [2, 3, 12], a female disadvantage in SRH could be expected. However, studies have shown that women generally report a lower SRH compared to men until mid-adulthood but that this difference may stabilize or even decrease with later age [6, 7]. One large-scale cross-sectional study found that across the adult lifespan (aged >18 years), women consistently report a poorer SRH compared to men [7]. Another cross-sectional study among men and women aged 25 years and over showed lower SRH for women compared to men until the age of 60 years, after which women report a slightly better SRH then men [6]. Longitudinal studies regarding sex differences in SRH are scarce; one recent longitudinal study using SHARE panel data observed a consistent female disadvantage in SRH among older European adults aged 65 years at baseline and 10 years later [8].

Besides variability by age, it has been suggested that sex differences in SRH vary over time. A US cohort study showed that the sex difference (with lower SRH for women) among older adults was only evident in the oldest birth cohort (1924–1933) and disappeared in younger birth cohorts [9]. This suggests that the female disadvantage in SRH diminishes in younger birth cohorts. Cohorts differ from each other through their distinct historical and social attributes. For women, important changes have taken place in terms of educational attainment, labor force participation, and income. These societal shifts may contribute to the attenuation of SRH.

Furthermore, there are some indications that the educational level may impact the sex difference in SRH among older adults. A low educational level has been associated with poorer disease outcomes and lower SRH compared to higher education levels in older adults [1, 13, 14]. A meta-analysis among older adults demonstrated that a higher SRH among men was to a larger extent explained by a higher educational level compared to women [14]. However, it is unknown whether sex differences in SRH differ between educational groups.

The overall objective of the current study was to offer insights into potential sex differences in SRH over the age course among older adults in the Netherlands. Furthermore, exploring the role of demographic characteristics such as the birth cohort and educational level in these sex differences allows for a further specification of potential disparities in health, which may provide guidance in the development of prevention strategies to reduce these disparities. Moreover, knowledge about the age course of the sex difference in SRH over successive birth cohorts will identify potential trends over time, providing insights into the evolving nature of the sex difference in SRH. The aim of this exploratory study was therefore to investigate sex differences in SRH among older adults in the Netherlands, including their longitudinal course by age, and considering the role of the birth cohort and educational level in these potential differences.

Study Sample

Prospective cohort data from the Longitudinal Aging Study Amsterdam (LASA) were used. LASA is a long-term, ongoing cohort study aimed at determining predictors and consequences of aging in the Netherlands [15, 16]. The sampling and data collection procedures have been described in detail elsewhere [17]. In short, a sample of older men and women (aged 55–85 years), stratified by age and sex, was drawn from the population registries of eleven Dutch municipalities across three culturally distinct regions (Amsterdam, Zwolle, and Oss). In total, 3,107 men and women were enrolled in the baseline examination (1992/1993). Follow-up measurements were performed every 3 years and included a face-to-face main interview, a self-report questionnaire, and a medical interview. The main interview was conducted by a trained interviewer at the participant’s home. During the interview, participants were asked to fill out a written questionnaire, which was left at the participant’s home after the visit and collected during the medical interview or returned by mail. The SRH questions were included in this self-administered questionnaire [16]. Additionally, every 10 years (in 2002/2003 and 2012/2013), a new cohort of participants was added with a baseline age of 55–65 years. The LASA study has received medical ethical approval from the Medical Ethics Committee of the VU Medical Center, and all participants have provided written informed consent prior to their inclusion. Longitudinal data were used from the first birth cohort 1911–1937 (n = 3,107, baseline measurements in 1992/1993, 20-year follow-up) and the second birth cohort 1938–1947 (n = 1,002, baseline measurements in 2002/2003, 10-year follow-up).

Self-Rated Health

In order to evaluate SRH, the RAND General Health Perception Questionnaire (RAND-GHPQ) scale was used [18]. This measure consists of four statements: (1) “I am somewhat ill,” (2) “I am as healthy as anybody I know,” (3) “My health is excellent,” (4) “I have been feeling bad lately.” Participants were asked to indicate their level of agreement with each statement on a five-point Likert scale, ranging from “completely disagree” to “complete agree.” The scale provides a score ranging from poor (0) to good (16) SRH [18].

Sex, Birth Cohort, and Educational Level

During the main interview, participants were asked about their sex at birth (male/female). The birth cohort was dichotomized as birth cohort 1911–1937 and birth cohort 1938–1947. Education was categorized into three levels: low (elementary education or less), middle (lower vocational and general intermediate education), and high (intermediate vocational, general secondary, higher vocational, college, and university education).

Statistical Analyses

Data analyses were performed using mixed model analyses for repeated measurements over time with a random intercept for the participants and a random slope estimate for age of the participant. The mixed model analyses incorporated all longitudinal data of SRH, thereby not losing previous measurements of participants in case of dropout or missing values on (further) follow-up measurements. This prevents the loss of available data and creates more statistical power [19]. On average, SRH levels were missing for 24% of participants per wave in birth cohort 1911–1937 and for 10% of participants in birth cohort 1938–1947 across follow-up measurements.

Five analysis steps were taken. First, the course of SRH by age was investigated, stratified by the birth cohort or educational level. If the variable “age * age” improved the model significantly as determined by the log-likelihood test, the quadratic regression coefficient was additionally included in further analysis steps, in order to allow a better estimation of the course of the sex difference in SRH by age. Second, the overall age-adjusted sex difference in SRH was investigated for each birth cohort (variable “sex” in an age-adjusted model) and each educational level. Third, the longitudinal course of the sex difference in SRH by age was investigated for each birth cohort and educational level. In these analyses, the significance of the interaction term of age and sex (“age * sex” and “age * age * sex”) was determined. Fourth, whether the size of the age-adjusted sex difference in SRH differed by birth cohort or educational level was investigated by testing for interaction (significance of the interaction terms “birth cohort * sex” and “educational level * sex”) in the total sample. Last, whether the age course of the sex difference in SRH differed between the birth cohorts or educational levels was investigated bij testing for interaction (significance of the interaction terms “birth cohort * sex * age” and “educational level * sex * age”). To visually depict the longitudinal course of SRH by age and sex, lines were plotted based on the regression coefficients of the statistical model. All analyses were performed using Stata statistical software, version 17. Statistical significance was considered at an alpha of 5%.

Participants had an average of 3.4 repeated measurements in birth cohort 1911–1937 (range 1–7) and an average of 3.2 in birth cohort 1938–1947 (range 1–4), with minimal differences between men and women in SRH (Table 1). Women had a lower educational level compared to men, especially among birth cohort 1911–1937.

Table 1.

Baseline characteristics for men and women of the LASA stratified by birth cohort

Birth cohort 1911–1937Birth cohort 1938–1947
men (n = 1,506)women (n = 1,601)men (n = 475)women (n = 527)
Age, mean (SD), years 70.9 (8.8) 70.6 (8.8) 59.9 (2.9) 60 (3.0) 
Educational level, n (%) 
 Low 501 (33.4) 875 (54.8) 89 (18.7) 124 (23.5) 
 Middle 481 (32.0) 437 (27.3) 137 (28.9) 248 (47.1) 
 High 519 (34.6) 286 (17.9) 249 (52.4) 155 (29.4) 
SRH (range 0 = −16), mean (SD) 11.4 (3.4) 11.4 (3.5) 11.4 (3.0) 11.1 (3.3) 
Birth cohort 1911–1937Birth cohort 1938–1947
men (n = 1,506)women (n = 1,601)men (n = 475)women (n = 527)
Age, mean (SD), years 70.9 (8.8) 70.6 (8.8) 59.9 (2.9) 60 (3.0) 
Educational level, n (%) 
 Low 501 (33.4) 875 (54.8) 89 (18.7) 124 (23.5) 
 Middle 481 (32.0) 437 (27.3) 137 (28.9) 248 (47.1) 
 High 519 (34.6) 286 (17.9) 249 (52.4) 155 (29.4) 
SRH (range 0 = −16), mean (SD) 11.4 (3.4) 11.4 (3.5) 11.4 (3.0) 11.1 (3.3) 

Mean SRH was assessed with the RAND-GHPQ (range 0–16) and was based on data from 1,006 men and 963 women at baseline in birth cohort 1927–1937 and on 432 men and 476 women of birth cohort 1938–1947.

A higher score indicates a better SRH.

n, number; SD, standard deviation.

Sex Differences in SRH by Age

For both men and women, a decline in SRH was observed with increasing age (Fig. 1; Table 2). This trend, as seen in both birth cohorts, had an exponential course by age. There was no sex difference in SRH in birth cohort 1911–1937 (0.13 lower score on SRH for women compared to men, 95% CI: −0.35 to 0.09) and a small sex difference in birth cohort 1938–1947. In this latter cohort, women had a 0.35 lower score on SRH compared to men (95% CI: −0.689 to −0.015), p = 0.041). There was no sex difference in the longitudinal course of SRH, except for the exponential part of the course in birth cohort 1911–1937 (sex * age * age; p = 0.015). This reflects an accelerated decline in SRH by age in men compared to women (Fig. 1; Table 2). There was no significant sex difference in SRH for all educational groups (Table 3), although women scored 0.30 lower than men in the middle-educated group compared to men (95% CI: −0.62 to 0.12, p = 0.059).

Fig. 1.

Longitudinal course of the sex difference in SRH by age and birth cohort. The longitudinal course of the sex difference in SRH by age for birth cohort 1911–1937 (solid lines) and birth cohort 1938–1947 (dotted lines).

Fig. 1.

Longitudinal course of the sex difference in SRH by age and birth cohort. The longitudinal course of the sex difference in SRH by age for birth cohort 1911–1937 (solid lines) and birth cohort 1938–1947 (dotted lines).

Close modal
Table 2.

Multivariate model of the longitudinal course of the sex difference in SRH by age stratified by birth cohort

Birth cohort 1911–1937Birth cohort 1938–1947
B [CI]p valueB [CI]p value
Age (y) −0.086 [−0.095 to −0.077] 0.000 −0.014 [−0.038 to 0.009] 0.231 
+ Age * age (y2−0.001 [−0.002 to −0.0002] 0.013 −0.006 [−0.01 to −0.003] 0.001 
+ Sex (female) −0.129 [−0.352 to 0.094] 0.256 −0.350 [−0.686 to −0.015] 0.041 
+ Sex (female) * age (y) −0.005 [−0.024 to 0.014] 0.588 −0.0003 [−0.047 to 0.047] 0.991 
+ Sex (female) * age * age (y20.002 [0.0004-0.004] 0.015 0.001 [−0.006 to 0.008] 0.792 
Birth cohort 1911–1937Birth cohort 1938–1947
B [CI]p valueB [CI]p value
Age (y) −0.086 [−0.095 to −0.077] 0.000 −0.014 [−0.038 to 0.009] 0.231 
+ Age * age (y2−0.001 [−0.002 to −0.0002] 0.013 −0.006 [−0.01 to −0.003] 0.001 
+ Sex (female) −0.129 [−0.352 to 0.094] 0.256 −0.350 [−0.686 to −0.015] 0.041 
+ Sex (female) * age (y) −0.005 [−0.024 to 0.014] 0.588 −0.0003 [−0.047 to 0.047] 0.991 
+ Sex (female) * age * age (y20.002 [0.0004-0.004] 0.015 0.001 [−0.006 to 0.008] 0.792 

B, regression coefficient, with [CI] = 95% confidence interval; p, p value at an alpha of 5%. Bold indicates statistical significance (p < 0.05).

Table 3.

Multivariate model of the longitudinal course of the sex difference in SRH by age stratified by educational level

Low educationMiddle educationHigh education
B [CI]p valueB [CI]p valueB [CI]p value
Age (y) −0.068 [−0.082 to −0.053] 0.000 −0.070 [−0.083 to −0.058] 0.000 −0.071 [−0.083 to −0.060] 0.000 
+ Age * age (y2−0.001 [−0.002 to −0.001] 0.280 −0.003 [−0.004 to −0.022] 0.000 −0.001 [−0.002 to 0.000] 0.074 
+ Sex (female) 0.004 [−0.360 to 0.369] 0.982 −0.302 [−0.616 to 0.117] 0.059 0.033 [−0.277 to 0.343] 0.836 
+ Sex (female) * age (y) −0.041 [−0.072 to −0.010] 0.009 0.009 [−0.016 to 0.034] 0.483 0.013 [−0.011 to 0.037] 0.286 
+ Sex (female) * age * age (y20.003 [0.0003-0.006] 0.027 0.002 [0.000-0.004] 0.041 −0.001 [−0.003 to 0.002] 0.617 
Low educationMiddle educationHigh education
B [CI]p valueB [CI]p valueB [CI]p value
Age (y) −0.068 [−0.082 to −0.053] 0.000 −0.070 [−0.083 to −0.058] 0.000 −0.071 [−0.083 to −0.060] 0.000 
+ Age * age (y2−0.001 [−0.002 to −0.001] 0.280 −0.003 [−0.004 to −0.022] 0.000 −0.001 [−0.002 to 0.000] 0.074 
+ Sex (female) 0.004 [−0.360 to 0.369] 0.982 −0.302 [−0.616 to 0.117] 0.059 0.033 [−0.277 to 0.343] 0.836 
+ Sex (female) * age (y) −0.041 [−0.072 to −0.010] 0.009 0.009 [−0.016 to 0.034] 0.483 0.013 [−0.011 to 0.037] 0.286 
+ Sex (female) * age * age (y20.003 [0.0003-0.006] 0.027 0.002 [0.000-0.004] 0.041 −0.001 [−0.003 to 0.002] 0.617 

Bold indicates statistical significance (p < 0.05).

Modification by Birth Cohort

For both men and women, SRH was lower in birth cohort 1937–1947 compared to birth cohort 1911–1937 (B −0.344, 95% CI: −0.563 to −0.125, p = 0.002). The course of SRH by age was also different for the two birth cohorts (cohort * age and cohort * age * age, p = 0.001 and p = 0.008, respectively), which means a more linear course in birth cohort 1911–1937. However, the interaction term birth cohort * sex was not statistically significant (p = 0.279), indicating that the size of the sex difference in SRH was not significantly different between the two birth cohorts (Table 4).

Table 4.

Interaction terms of the multivariate model of the age-adjusted sex difference in SRH and the longitudinal course thereof between birth cohorts 1911–1937 and 1938–1947

Birth cohort 1938–1947 versus birth cohort 1911–1937
B [CI]p value
Model age (y), age * age (y2), and sex (female) 
+ Cohort −0.344 [−0.563 to −0.125] 0.002 
+ Cohort * age 0.048 [0.020-0.077] 0.001 
+ Cohort * age * age −0.005 [−0.009 to −0.001] 0.008 
+ Cohort * sex −0.226 [−0.635 to 0.183] 0.279 
+ Cohort * sex * age 0.006 [−0.044 to 0.057] 0.811 
+ Cohort * sex * age * age −0.001 [−0.008 to 0.007] 0.879 
Birth cohort 1938–1947 versus birth cohort 1911–1937
B [CI]p value
Model age (y), age * age (y2), and sex (female) 
+ Cohort −0.344 [−0.563 to −0.125] 0.002 
+ Cohort * age 0.048 [0.020-0.077] 0.001 
+ Cohort * age * age −0.005 [−0.009 to −0.001] 0.008 
+ Cohort * sex −0.226 [−0.635 to 0.183] 0.279 
+ Cohort * sex * age 0.006 [−0.044 to 0.057] 0.811 
+ Cohort * sex * age * age −0.001 [−0.008 to 0.007] 0.879 

B, regression coefficient, with [CI] = 95% confidence interval; p, p value at an alpha of 5%. Bold indicates statistical significance (p < 0.05).

Modification by Educational Level

For both men and women, a higher SRH was seen in those with a higher level of education, compared to a low and middle level of education (p < 0.001 and p = 0.008, respectively) (Table 5). The sex difference in SRH did not significantly differ between the educational levels (high vs. low * sex, p = 0.998, middle vs. low * sex, p = 0.142, high vs. middle * sex, p = 0.136).

Table 5.

Interaction terms of the multivariate model of the age-adjusted sex difference in SRH and the longitudinal course thereof between educational levels

Educational levels: low, middle, and high
B [CI]p value
Model age (y), age * age (y2), and sex (female) 
+ Educational level (high vs. low) 0.527 [0.291-0.764] 0.000 
Or + educational level (middle vs. low) 0.309 [0.080-0.538] 0.008 
Or + educational level (high vs. middle) 0.218 [−0.009 to 0.446] 0.060 
+ Educational level (high vs. low) * age −0.012 [−0.032 to 0.008] 0.244 
Or + educational level (middle vs. low) * age −0.009 [−0.029 to 0.011] 0.379 
Or + educational level (high vs. middle) * age −0.003 [−0.022 to 0.016] 0.765 
+ Educational level (high vs. low) * age * age −0.0002 [−0.002 to 0.005] 0.809 
Or + educational level (middle vs. low) * age * age −0.003 [0.004 to −0.0001] 0.002 
Or + educational level (high vs. middle) * age * age 0.002 [0.001-0.004] 0.004 
+ Educational level (high vs. low) * sex 0.001 [−0.476 to 0.477] 0.998 
Or + educational level (middle vs. low) * sex −0.349 [−0.816 to 0.117] 0.142 
Or + educational level (high vs. middle) * sex 0.350 [−0.110 to 0.809] 0.136 
+ Educational level (high vs. low) * sex * age 0.057 [0.015-0.099] 0.008 
Or + educational level (middle vs. low) * sex * age 0.050 [0.009-0.091] 0.018 
Or + educational level (high vs. middle)* sex * age 0.007 [−0.033 to 0.046] 0.740 
+ Educational level (high vs. low) * sex * age * age 0.000 [0.000-0.000] 0.014 
Or + educational level (middle vs. low) * sex * age * age 0.000 [0.000-0.000] 0.021 
Or + educational level (high vs. middle) * sex * age * age 0.000 [0.000 to −0.000] 0.855 
Educational levels: low, middle, and high
B [CI]p value
Model age (y), age * age (y2), and sex (female) 
+ Educational level (high vs. low) 0.527 [0.291-0.764] 0.000 
Or + educational level (middle vs. low) 0.309 [0.080-0.538] 0.008 
Or + educational level (high vs. middle) 0.218 [−0.009 to 0.446] 0.060 
+ Educational level (high vs. low) * age −0.012 [−0.032 to 0.008] 0.244 
Or + educational level (middle vs. low) * age −0.009 [−0.029 to 0.011] 0.379 
Or + educational level (high vs. middle) * age −0.003 [−0.022 to 0.016] 0.765 
+ Educational level (high vs. low) * age * age −0.0002 [−0.002 to 0.005] 0.809 
Or + educational level (middle vs. low) * age * age −0.003 [0.004 to −0.0001] 0.002 
Or + educational level (high vs. middle) * age * age 0.002 [0.001-0.004] 0.004 
+ Educational level (high vs. low) * sex 0.001 [−0.476 to 0.477] 0.998 
Or + educational level (middle vs. low) * sex −0.349 [−0.816 to 0.117] 0.142 
Or + educational level (high vs. middle) * sex 0.350 [−0.110 to 0.809] 0.136 
+ Educational level (high vs. low) * sex * age 0.057 [0.015-0.099] 0.008 
Or + educational level (middle vs. low) * sex * age 0.050 [0.009-0.091] 0.018 
Or + educational level (high vs. middle)* sex * age 0.007 [−0.033 to 0.046] 0.740 
+ Educational level (high vs. low) * sex * age * age 0.000 [0.000-0.000] 0.014 
Or + educational level (middle vs. low) * sex * age * age 0.000 [0.000-0.000] 0.021 
Or + educational level (high vs. middle) * sex * age * age 0.000 [0.000 to −0.000] 0.855 

B, regression coefficient, with [CI] = 95% confidence interval; p, p value at an alpha of 5%.

Bold indicates statistical significance (p < 0.05).

This study aimed to longitudinally investigate sex differences in SRH among older adults. Over the age course, there was no significant sex difference in SRH within the older birth cohort 1911–1937 and only a small sex difference in birth cohort 1938–1947, in which women had a 0.35 lower score on the RAND-GHPQ (range 0–16) compared to men. Furthermore, men in birth cohort 1911–1937 showed a slightly steeper decline in SRH at higher age compared to women. Sex differences in SRH were not modified by the birth cohort or educational level.

Previous cross-sectional studies have shown a female disadvantage in SRH among older adults, which seems to become smaller around the age of 60 years [6, 7]. As our study included older persons aged 55 years and older, the absence of a clear sex difference in SRH might be attributable to this previously reported age effect. In line with a meta-analysis [14], we observed a lower SRH among older adults with a lower educational level. However, we did not observe a sex difference in SRH within educational groups. A marginal sex difference in SRH within the youngest birth cohort (1937–1947) was found in our study. This contrasts a previous study that observed a sex difference within the oldest birth cohort only [9]. However, that study included five birth cohorts spanning a larger timeframe (from 1924 until 1973), which makes direct comparisons with our findings difficult. As we only observed a 0.35 lower score on a total score ranging from 0 to 16, it is unlikely that these findings will have substantial implications for clinical decision-making or interventions.

Previous studies using LASA data have shown a consistent female disadvantage in mental health and physical performance during aging [2, 3], which seems to contradict the current findings regarding SRH within the same study sample. This inconsistency could be attributed to the better cognitive health observed in older women compared to men [20]. This cognitive advantage in women may compensate for the negative impact of the female disadvantage in mental health and physical performance, which is reflected in SRH ratings. It has indeed been demonstrated that cognitive functioning plays an important role in SRH in older adults [21, 22].

It is also possible that the lack of a female disadvantage in comparison to the presence of this disadvantage in outcomes such as mental health and physical performance is (partly) due to other personal and situational factors that older men and women take into account when they are asked to assess their own health. This was beyond the scope of the current paper but should be further explored in future research. For instance, it has been proposed that as people age, their coping strategies may shift from (active) problem-solving and social support strategies to relying more on (passive) emotional coping strategies [23]. Women are known to use more emotional coping strategies throughout their life as compared to men [23], which may enhance their ability to positively cope with adverse changes during aging. Data from a large European survey among adults below the age of 65 years showed that women reported poorer health when they worked in a female-dominated workplace compared to women in a male-dominated workplace [24]. It could therefore be argued that gender-based social norms could also play a role in how people perceive and rate their health. Furthermore, it has been hypothesized that men and women attribute a different meaning to the concept of health and consider different health-related and behavioral factors when assessing their own health [25], although in a more recent study, no such difference was found [6]. Lastly, in a study by Benyamini et al. [26], it was shown that older women’s SRH was associated with major as well as mild diseases, while in men, only major diseases were associated with SRH. However, other studies have shown that women are less likely to report a poor health compared to men when functional disabilities are taken into account [27].

To our knowledge, this is the first study to longitudinally explore sex differences in SRH among older adults and investigate the role of age, birth cohorts, and educational levels in which these sex differences may be more apparent. The focus on older adults and the use of two successive birth cohorts provides an important insight into the interplay between sex and SRH during aging. One limitation is that the SRH measurement was missing in approximately 10–24% of the participants per wave in this study. This could be related to differences in health and life expectancy between men and women, which may have affected our results. We did not observe any sex differences in the number of missing data on SRH in our study.

To conclude, no consistent sex differences in SRH by age, by birth cohort, or by educational level were found in older adults in the Netherlands. In order to obtain a comprehensive understanding of sex-specific SRH trajectories during aging, future studies should take physical, cognitive, and mental health into account. Furthermore, sex- and gender-specific psychological, social, and behavioral factors that influence SRH should be explored in order to gain insight into key areas for improving health and well-being for both sexes.

The authors are grateful to all LASA participants for their valued contributions.

The LASA has been approved by the Medical Ethics Committee of the VU University Medical Center (Reference No. 92/138, 2002/141 and 2012/361), and all participants have provided written informed consent prior to their inclusion. All methods were carried out in accordance with relevant guidelines and regulations.

The authors have no conflicts of interest to declare.

This work was supported by the Netherlands Organization for Health Research and Development (ZonMw) [849200005].

Laura A. Schaap: supervision, conceptualization, and writing – original draft. Lena D. Sialino: methodology, formal analysis, visualization, and writing – review and editing. Feline de la Court: formal analysis, visualization, and writing – review and editing. Sandra H. van Oostrom and Hanneke A.H. Wijnhoven: supervision, conceptualization, and writing – review and editing. H. Susan J. Picavet, W.M.Monique Verschuren, and Marjolein Visser: conceptualization and writing – review and editing.

Additional Information

Laura A. Schaap and Lena D. Sialino shared first authorship.

Data cannot be shared publicly because of confidentiality. Data are available from the LASA Institutional Data Access/Ethics Committee (contact via https://www.lasa-vu.nl/index.htm) for researchers who meet the criteria for access to confidential data. The data underlying the results presented in the study are available from the Longitudinal Aging Study Amsterdam (https://www.lasa-vu.nl/index.htm). The LASA Steering Group will review all requests for data to ensure that proposals for the use of LASA data do not violate privacy regulations and are in keeping with informed consent that is provided by all LASA participants. The authors of this study do not have any special access privileges to the data underlying this study that other researchers would not have. Further inquiries can be directed to the corresponding author.

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