Socioeconomic inequalities in morbidity among the elderly; a European overview
Introduction
The inverse effects of socioeconomic factors on mortality have been reported by a number of studies (Illsley & Svensson, 1990; Kunst, Groenhof, Mackenbach, & the EU Working Group on Socioeconomic Inequalities in Health, 1998). Lower levels of education, occupation and income are associated with higher levels of mortality, also among elderly people (Fox, Goldblatt, & Jones, 1985; Marmot & Shipley, 1996; Ross & Wu, 1996; Amaducci et al., 1998). Until now, more studies focussed on mortality inequalities among the elderly than on morbidity inequalities. Morbidity however, is at least an equally important element of health. From the viewpoint of ‘adding life to years’, studying socioeconomic inequalities can give us clues about how much ‘life’ can still be added to the ‘years’ of elderly people that are in a socioeconomically disadvantaged position. In order to be able to reduce morbidity levels one has to identify the determinants of morbidity in old age. Socioeconomic determinants may be of key importance.
Breeze, Sloggett, and Fletcher (1999a) studied the association of socioeconomic circumstances in old age with limiting long-term illness in a British sample and conclude that health inequalities do not completely disappear in very old age. In agreement with these findings, Rahkonen and Takala (1998) reported that in a Finnish sample social class differences in self-assessed health and functional disability are still evident in later life. Similarly, Dahl and Birkelund (1997) find in their study among Norwegian elderly that the egalitarian age pension policy of Norway does not succeed in eradicating health inequalities. In the Netherlands, Broese van Groenou and Deeg (2000) also found that socioeconomic inequalities in morbidity exist in old age. Liao, McGee, Kaufman, Cao, and Coopers (1999) observed differences in morbidity in the last years of life in the United States and came to the conclusion that deceased with higher socioeconomic status experienced lower levels of morbidity in their last years than did deceased with a lower socioeconomic status. However, inequalities that are found among the elderly seem to be smaller compared to differences in morbidity among middle aged adults.
Despite an increasing number of studies, the evidence provided by the studies on morbidity among the elderly remains fragmentary. This study aims to provide a comprehensive overview of socioeconomic inequalities in self-reported morbidity among the elderly (age 60 and over) in the European Union. Several issues will be addressed in this study.
In the first place, previous studies are based on different indicators of socioeconomic status. Socioeconomic indicators that have alternately been used in the studies concerning morbidity in old age are amongst others: level of education, occupational class, or occupation before retirement, income and housing tenure. In a study on mortality among Finnish elderly Martelin (1994) suggested that no single measure proves comprehensive enough to portray the entire picture of socioeconomic position. The elderly are a specific age group for which every single indicator has its own advantages and drawbacks. Education for instance has proved to be a highly relevant factor, but level of education of elderly people will show considerably skewed distributions. Income on the other hand sometimes shows an even stronger association with morbidity, however the nature of this association is less clear. Finally, occupational status is of less relevance since most elderly people have moved out of the working population long ago. Therefore, using a set of complementary measures seems to be the best option to indicate the socioeconomic status of elderly people. In this study, level of education and income will both be used as indicators of socioeconomic status.
The second issue is that of constructing age groups. At what age does midlife end and old age start? Some researchers begin counting old age from 55 years and older (Breeze et al., 1999a; Breeze, Sloggett, & Fletcher, 1999b), while others start at 65 (Dahl & Birkelund, 1997; Rahkonen & Takala, 1998). Obviously, concluding that inequalities in morbidity persist into old age has different implications when old age is considered to start at 65, rather than 55. Furthermore, when the minimum age is decided upon, the question arises whether the elderly should be treated as one homogeneous group or whether they should be divided in groups of early old age and the oldest old. Most studies use a division of two age groups or more, because the early old and the oldest old differ from each other in some respects. The oldest old are more likely to have higher levels of morbidity and have lower education or income than those who have just reached retirement age. Thus, constructing age groups is necessary to distinguish the just retired from the elderly whose age approaches the tenth decade. In the present study, we divided the elderly population into three age groups: age 60–69, 70–79 and 80+ years.
A third point has to be made, which is not so much a methodological issue, rather a logical step following from former research on the topic. All studies described the situation among the elderly in a single country. The logical step following from this is to compare the situation in a number of countries. An important reason for comparing the situations in several different countries is the possibility that inequalities in morbidity might not prove to be a general phenomenon but instead depend on the country in which they are studied. Indeed former studies on socioeconomic health inequalities among younger age groups lead us to expect that the pattern of inequalities differs greatly between countries (Cavelaars, 1998).
In sum, this study will provide a detailed overview of socioeconomic differences in morbidity among the elderly (1) by using two complementary indicators of socioeconomic status: level of education and net household income; (2) by including three age groups of elderly people; and (3) by performing simultaneous analysis of a large number of European countries. The overview will be given for men and women separately, because the situation will in all likelihood be different between men and women.
This approach will lead to answers to the following research questions: Do socioeconomic morbidity inequalities decrease with old age, and if so, do they persist to some extent? Does this differ between income and education? and Can variations between the countries in this study be demonstrated? These three research questions constitute the core of the study.
Section snippets
Instrument
The data for the study have been derived from the first wave of the European Community Household Panel (ECHP) (Eurostat, 1999). The ECHP is a social survey, designed for the member states of the European Union, which uses a uniform design that allows for adaptation to national requirements. Through its longitudinal design it aims to represent the social dynamics in Europe, from 1994, the year of the first wave, throughout the period that is covered by the subsequent waves. In the first wave a
Results
The results of the analyses on income for all countries combined are given in Table 2. Generally the prevalence rates for men and women increase with each lower income quintile. This increase is not predominantly linear however, as the second quintile often shows higher prevalence rates than the lowest quintile. Moreover, the prevalence rates increase more sharply in the lower income strata.
Health inequalities are found for every age group. Absolute health inequalities (rate differences) as
Discussion
Absolute and relative socioeconomic morbidity inequalities persist into the oldest ages in Europe. This study indicates that absolute and relative morbidity inequalities related to income and education decline most often, but do not disappear with old age in Europe. Inequalities are found in all age groups, they are found for both indicators of socioeconomic status, in all countries and for both sexes. Variations are found between income and educational inequalities and also between countries.
Acknowledgements
Finances for this study come from the Socio-Economic determinants of Healthy Ageing project (SEdHA), which is subsidised as part of the Fifth Framework Programme on ‘Quality of Life and Management of Living Resources’ of the European Union. The authors would like to thank Jetty Dalstra and Wilma Nusselder for their comments on previous versions of this paper.
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