The Elderly between the Needs for Care and Active Ageing

3. Health Inequalities Among the Elderly between the North and the South

The most recent studies on inequalities in health (Padovani 2008) confirm that social unease is the principal non-biological cause of the health differences which occur in the population. And among the various dimensions of social disadvantage, those which most affect the health factor are those linked to education, those relating to material and economic resources, and those relating to life context (where one lives influences one’s health more than a little. So much so is this the case that epidemiologic investigations reveal, for example, that people live longer in urban areas than in the provinces). In other words, as Geddes da Felicaia M. and Maciocco G. (2007) confirm state of health is the product of a multiplicity of variables, interdependent on each other and acting throughout the course of life (not only individual but also environmental variables).

From processing the data of the most recent Istat Multiscope survey (2007)6 relating to a specific health indicator, i.e. incidence of disability7 it is inferred that:

1. the incidence of disability increases considerably with the advance of age8: from 65 to 69 years it equals 5.5%, from 70 to 74 years it is 9.7%, among those between 75 and 79 years it is 17.8%, and it rises to 44.5% for the over eighties (Cf. Figure 9);

2. there is a connection between gender and disability, since there are more disabled women than disabled men. 11.4% of women between the ages of 70 to 74 are disabled (compared to 7.7% of men of the same age); 20.8% of women aged 75 to 79 are disabled (compared to 13.4% of men of the same age); fully 48.9% of women over eighty, compared with 35.8% of men, are disabled (Cf. Figure 9);

3. a connection between the level of education and disability also emerges. Indeed it is observed how it is more often people with a lower level of schooling who exhibit worse health conditions. In every age group the number of people who claim to be unwell or very unwell triples or doubles among those who have attained at most an elementary school certificate compared to those with higher educational qualifications (graduates or holders of diplomas): for example among adults aged 45-64, 11.1% of those with degrees or diplomas suffer from a serious chronic pathology, while among those with at best an elementary school certificate the number almost doubles (20.9%; among the elderly aged 65-74 years it goes from 28.4% to 36.5%9 .

4. The disabled elderly are unequally distributed within the country. They form 18.6% of the population, but while 16.2% (2 percentage points less than the average) of the northern elderly are disabled, those of the south are disabled in 22.7% of the cases (4.5 percentage points above the average) (cf. Figure 10). The regions with the highest percentage of disabled are all southern ones: Sicily (26.1%), Puglia (24.2%) and Calabria (22.9%); instead the regions with the lowest percentage of disabled elderly are Trentino-Alto Adige (12.9%), Lombardy (15.2%), followed by Friuli Venezia Giulia and Emilia Romagna (15.9%) (cf. Figure 11).

Figure 9: Non self-sufficient individuals of 65 years and over by age group and sex – year 2005.
Source: Istat 2007 – our elaborations.

Figure 10: Percentage of disabled elderly by region – year 2005
Source: Istat 2007 – our elaborations.

Figure 11: Percentage of disabled elderly by geographic spread – Year 2005
Source: Istat 2007 – Our elaboration.

As shown in Figure 12 the incidence of disability among southern women is particularly high, through the “cumulative effect” of the disadvantages of gender and those linked to geographic area. The non self-sufficiency risk, in conclusion, is very unequally distributed among the population since it is influenced by variables such as age, level of education, and the life context in which one ages.

In the light of these results we questioned whether the decrease in the rate of disability too (cf. Figure 1), was harmonious throughout the country, or whether it was spread unevenly in the three macro-areas of the country. As Figure 13 shows the drop in the incidence of disability has involved the elderly of the Centre-North more consistently than those of the South. If one considers, along with Padovani (2008), that the lack of improvement in health, measured over a time span, is another indicator of the social disadvantage of a population or of a group of a given population, then one can, without doubt, conclude that the health disadvantage of the elderly in Southern Italy has its origins in the socio-economic development lacking in this area of the country.

Figure 12: Italy – Percentage of elderly disabled women out of the total of elderly women by region – Year 2005
Source: Istat 2007 – Our elaboration.

Figure 13: Variation in rate of disability among the elderly population between 1994 and 2005 by geographic spread
Source: Istat 1997, Istat 2007 – Our elaboration.

Indeed, epidemiologic studies confirm that health conditions are determined in the first place by socio-economic conditions. In this regard the Manifesto for Fairness published in 2005 through an AIE (Italian Epidemiology Association) initiative (cited in Padovani 2008) states “A large part of the north-south differential in the various health indicators is attributable to the territorial distribution of the socio-economic structure. In other words in southern regions the main variables which determine the socio-economic situation (level of education, average income, employment levels…) have significantly lower indexes than the national average. This means that in this part of the peninsula a series of disadvantages are added together and in many people cause a state of health that is worse than that which prevails elsewhere”.

Concerning the socio-economic condition of the elderly, Istat’s data on poverty (2006g) reveal a worrying situation in the South:

• 28.2% of families with at least one elderly member are poor (compared with 9.2% for the same family typology in the Centre and 6.3% in the North);

• 33.2% of families with two or more elderly members are poor (compared with 9.2% for the same family typology in the Centre and 7.0% in the North;

• 28.4% of families with a person of 65 years of age at its head is poor (compared with 8.2% in the Centre and 6.2% in the North) cf. Graph 6.

• The incidence of poverty rises from 36.4% (2004) to 42.9% (2005) for families with a greater number of components, in which more generations live together: for families who have an elderly member in the home, therefore, the family condition deteriorates.

• Again according to Istat (2006h) in the South, the incomes of the population in general, and of the elderly in particular, are on average lower than elsewhere.

• Families in which the main earner is aged 65 and over (2004) had an average income equal to 16,911 euro a year, a decidedly lower income, in the same part of the country, than that obtained by a family whose main earner is under 65 (for these families income varies from a minimum of 22,135 to a maximum of 28,119);

• 50% of elderly couples earned less than 16,179 euro a year, i.e. 1,348 euro a month, and 50% of families where there is at least one elderly member earned less than 12,592 a year, i.e. 1,049 euro monthly;

• The situation of lone elderly individuals is particularly disadvantaged. 50% of these elderly earned less than 10,092 euro a year, i.e. 841 euro monthly.

Figure 14: Incidence of poor families with elderly members by geographic spread – Year 2005 / Values %
Source: Istat 2006

Among the advantages linked to a territory without doubt one must also consider the quality of the services system. In the South public socio-health services are often inadequate and inefficient. One fact suffices for all: in the South there are 3.1 beds in socio-welfare centres per thousand inhabitants compared with 87.2 per thousand in the North (Istat 2007).

If one then considers the indices of take-up of care through Integrated Home Care and residential care homes, which are the services which more than any other in our country characterise socio-welfare for the elderly, one sees that the lowest are always those obtained for the southern regions (cf. Table 2 and 3)10.

Table 2: Number of users over 65 who have taken advantage of Integrated Home Care and the take-up index – year 2003.
Source: Ministry of Health 2004, Istat 2006a – Out elaboration.

Table 3: Users of the public and private residential care homes and take-up indices – year 2003
Source: Ministry of Health 2004, Istat 2006a – Our Elaboration.

6 The Istat Multiscope surveys allow us to set out the data relating to perceived health However, even though, by means of this indicator we cannot know the objective state of health and the various levels of functional dependence of the elderly, perceived health is considered by the international literature to be a methodologically reliable indicator.
7 Given the objectives of this article we consider only the incidence of disability related to the elderly population.
8 The loss of functional autonomy increases with advancing years: among persons of 6 to 44 years it equals 0.9%, from 45 to 54 years it is 1.3%, from 55 to 64 years it is 2.5% (Istat 2007)
9 The relationship between schooling and state of health has also been highlighted in the CNR’s (National Research Council’s) Targeted Programme on Ageing from ILSA (Italian Longitudinal Study on Ageing) which had actually noted a strong association between education level and physical disability, hypothesising, inter alia, that a major seriousness of prevalent pathologies was attributable to a diagnostic delay in the part of the population with a lower level of education. In this regard it is sufficient to consider that, as Istat (2007) shows the practice of preventive medical visits is less widespread among the lower social status population: In all age groups individuals with at best elementary school certificates have less check ups than those with degrees or diplomas.
10 Using the Health Ministry’s data on the elderly using Integrated Home Care and public and private residential care homes, (as part of an Irpp-cnr (Institute for Population Research – National Research Council) study for the Ministry of Welfare) the take-up indices relating to these two types of service were calculated: Istat defines the take-up indicator as the relationship between the users of a specific service and the population of reference, in this case the elderly population. This report indicates how many persons effectively made use of the service with relation to 10,000 potential users in a specific section of the country.

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