Background Measures of population health indicate poorer outcomes in the U.S. compared with other high-income countries. The difference has been shown to be most evident at the bottom of the income distribution. This study extends prior research by focusing on physical and cognitive functioning outcomes for low vs. high-income working-age adults in the U.S. compared to 11 European countries.

Methods Using a pooled cross-sectional analysis, the study estimated differences in comparably measured outcomes of activities of daily living (ADLs), instrumental activities of daily living (IADLs), and word recall assessment, with adjustment for survey design aspects, demographic characteristics, and socioeconomic status. The study used the Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA), and the Survey of Health, Ageing, and Retirement in Europe (SHARE) for 2011-2018 to compare differences in the outcomes across countries, by income groups. The analytical sample included community-dwelling adults aged 55 to 64 years in the U.S. and 11 countries in Europe. Income groups were determined based on the distribution within each country, year, and age.

Results Overall, older working-age adults from the U.S. were significantly more likely to have difficulty with ADLs and IADLs compared to all other European countries examined in the study, with the exception of having a similar outcome with England for having difficulty with ADLs. Those from the lowest income group (bottom 20%) in the U.S. had a substantially higher risk of having difficulty with ADLs and IADLs, compared to most European countries; for example, the adjusted prevalence of ADL limitation was 30% in the US vs. 4%-13% in 10 European countries. Those from the highest income group (top 20%) in the U.S. had a similar risk of having difficulty with ADLs to most countries examined in the study but had a greater risk of having difficulty with IADLs compared to the majority of the countries in the study (England, Austria, Sweden, Spain, Netherland, Denmark, and Switzerland). Word recall scores from the lowest income group were poorer in the U.S. compared to many European countries, while those from the highest income group performed better in the U.S.

Conclusion Overall, the risk of having limitations in daily living is greater for U.S. older working-age adults compared to their peers in other European countries, especially amongst the poorest in society. Targeting the poorest in the U.S. at risk of disability through intervention, which appears to work in selected European countries, should be a priority.