Multilevel determinants of palliative care access in 27 European countries
Abstract
Background: Europe is experiencing population ageing with increasing “slow dying” and serious health-related suffering becoming a major public health challenge. Despite being a recognised right, palliative care (PC) remains unevenly implemented. This study examines factors influencing PC access across micro-, meso-, and macro-levels, assessing whether inequalities persist beyond clinical need.
Methods: Data from SHARE (Waves 7–9) were analysed, including decedents with a completed end-of-life proxy interview and a cause of death consistent with PC needs. The outcome was self-reported PC access in the last month of life. Given the hierarchical structure (individuals nested within 27 EU countries), multilevel logistic regression models were estimated. We fitted a null model, a micro/meso-level model assessing compositional effects (including age, sex, education, income, household size, cause of death, symptom burden, and area of residence), and a full model adding a macro-level predictor (welfare regime).
Results: A total of 5,320 individuals were included. The null model attributed 9.4% of the variance to country-level differences, which did not decrease after adjustment for individual determinants (ICC = 0.11), but declined to 0.06 after including welfare regimes. Compared with Nordic systems, Eastern regimes showed lower access (OR 0.39, 95% CI 0.21–0.74).Symptom burden was the strongest predictor (OR 3.52, 2.74–4.52), and diagnosis-based disparities persisted, (organ failure vs cancer: OR 0.27, 0.23–0.31). Socioeconomic factors were not significant, whereas rural residence was associated with lower access (OR 0.78, 0.61–0.99).
Conclusions: Inequalities in European end-of-life care appear to be driven less by socioeconomic status than by geopolitical context, geography, and diagnostic labelling. Addressing these gaps requires shifting to needs-based eligibility and strengthening community-based services to support non-cancer trajectories and mitigate geographic barriers
Key messages: • Palliative care access in Europe is shaped more by welfare systems, geography and diagnosis than by socioeconomic status, highlighting structural inequalities in end-of-life care.
• Non-cancer and rural patients face lower access to palliative care, supporting a shift toward needs-based eligibility and stronger community services.
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BibTeX
@article{bellini2026multilevel,
title = {{Multilevel determinants of palliative care access in 27 European countries}},
author = {A Bellini and P Grassi and C Seghieri and D Vignoli},
journal = {The European Journal of Public Health},
year = {2026},
month = oct,
doi = {10.1093/eurpub/ckag169.128},
url = {https://doi.org/10.1093/eurpub/ckag169.128},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Multilevel determinants of palliative care access in 27 European countries
AU - A Bellini
AU - P Grassi
AU - C Seghieri
AU - D Vignoli
PY - 2026
DA - 2026/10/01
JO - The European Journal of Public Health
DO - 10.1093/eurpub/ckag169.128
UR - https://doi.org/10.1093/eurpub/ckag169.128
AB - Background: Europe is experiencing population ageing with increasing “slow dying” and serious health-related suffering becoming a major public health challenge. Despite being a recognised right, palliative care (PC) remains unevenly implemented. This study examines factors influencing PC access across micro-, meso-, and macro-levels, assessing whether inequalities persist beyond clinical need. Methods: Data from SHARE (Waves 7–9) were analysed, including decedents with a completed end-of-life proxy interview and a cause of death consistent with PC needs. The outcome was self-reported PC access in the last month of life. Given the hierarchical structure (individuals nested within 27 EU countries), multilevel logistic regression models were estimated. We fitted a null model, a micro/meso-level model assessing compositional effects (including age, sex, education, income, household size, cause of death, symptom burden, and area of residence), and a full model adding a macro-level predictor (welfare regime). Results: A total of 5,320 individuals were included. The null model attributed 9.4% of the variance to country-level differences, which did not decrease after adjustment for individual determinants (ICC = 0.11), but declined to 0.06 after including welfare regimes. Compared with Nordic systems, Eastern regimes showed lower access (OR 0.39, 95% CI 0.21–0.74).Symptom burden was the strongest predictor (OR 3.52, 2.74–4.52), and diagnosis-based disparities persisted, (organ failure vs cancer: OR 0.27, 0.23–0.31). Socioeconomic factors were not significant, whereas rural residence was associated with lower access (OR 0.78, 0.61–0.99). Conclusions: Inequalities in European end-of-life care appear to be driven less by socioeconomic status than by geopolitical context, geography, and diagnostic labelling. Addressing these gaps requires shifting to needs-based eligibility and strengthening community-based services to support non-cancer trajectories and mitigate geographic barriers Key messages: • Palliative care access in Europe is shaped more by welfare systems, geography and diagnosis than by socioeconomic status, highlighting structural inequalities in end-of-life care. • Non-cancer and rural patients face lower access to palliative care, supporting a shift toward needs-based eligibility and stronger community services.
SN - 1101-1262
SN - 1464-360X
ER -