Life expectancy inequalities in the elderly by socioeconomic status: evidence from Italy

A spatial indicator of environmental and climatic vulnerability in Rome

BACKGROUND

Urban areas are disproportionately affected by multiple pressures from overbuilding, traffic, air pollution, and heat waves that often interact and are interconnected in producing health effects. A new synthetic tool to summarize environmental and climatic vulnerability has been introduced for the city of Rome, Italy, to provide the basis for environmental and health policies.

METHODS

From a literature overview and based on the availability of data, several macro-dimensions were identified on 1,461 grid cells with a width of 1 km² in Rome: land use, roads and traffic-related exposure, green space data, soil sealing, air pollution (PM_2.5, PM₁₀, NO₂, C₆H₆, SO₂), urban heat island intensity. The Geographically Weighted Principal Component Analysis (GWPCA) method was performed to produce a composite spatial indicator to describe and interpret each spatial feature by integrating all environmental dimensions. The method of natural breaks was used to define the risk classes. A bivariate map of environmental and social vulnerability was described.

RESULTS

The first three components explained most of the variation in the data structure with an average of 78.2% of the total percentage of variance (PTV) explained by the GWPCA, with air pollution and soil sealing contributing most in the first component; green space in the second component; road and traffic density and SO₂ in the third component. 56% of the population lives in areas with high or very high levels of environmental and climatic vulnerability, showing a periphery-centre trend, inverse to the deprivation index.

CONCLUSIONS

A new environmental and climatic vulnerability indicator for the city of Rome was able to identify the areas and population at risk in the city, and can be integrated with other vulnerability dimensions, such as social deprivation, providing the basis for risk stratification of the population and for the design of policies to address environmental, climatic and social injustice.

Women carry the weight of deprivation on physical inactivity: Moderated mediation analyses in a European sample of adults over 50 Years of age

Deprived people are less physically active than privileged individuals. However, pathways underlying the association between deprivation and physical activity remain overlooked. We examined whether the association between deprivation and physical activity was mediated by body mass index (BMI). Consistent with an intersectional perspective (how the combination of belongingness to vulnerable social categories widens inequalities), we tested whether gender moderated this mediating pathway and hypothesized that the mediating effect of BMI would be stronger among women (vs men). Large-scale longitudinal data from 20,961 adults 50 years of age or older (57% women) from the Survey of Health, Ageing and Retirement in Europe were used. Social and material deprivation were measured by questionnaire, BMI and physical activity were reported from two to six years later. Simple mediation models showed that BMI partly mediated the association of material (total effect c = -0.14, proportion of mediated effect = 8%) and of social deprivation (c = -0.24, proportion of mediated effect = 4%) with physical activity. Moderated mediation models revealed that this mediating pathway was moderated by gender. The effect of deprivation on BMI was stronger among women (vs men), with BMI mediating 18% and 7% of the association of material and social deprivation with physical activity among women (vs 4% and 2% among men). Lower levels of physical activity observed among deprived older adults could be partly attributed to a higher BMI. Critically, this mechanism was exacerbated among women, reinforcing the need to understand how deprivation and gender interact to predict health behaviors.

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Body mass index mediates the association of material and social deprivation with physical activity.

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This mediating pattern is more pronounced among women, relative to men.

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The association between deprivation and a higher body mass index is exacerbated among women, compared to men.

Socio-economic inequalities in the use of drugs for the treatment of chronic diseases in Italy

Background

Since the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position. 

Methods

A cross-sectional study design was used to define the “prevalent” users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only “chronic” patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users.

Results

The results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend.

Conclusions

This study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits.

Associations between existing and newly diagnosed chronic health conditions and change in subjective life expectancy: Results from a panel study

Background

Subjective life expectancy (SLE) is a vital predictor of mortality, health and retirement. Nevertheless, we have sparse knowledge about what drives changes in SLE. Having a chronic health condition (CHC) is probably associated with a change SLE. However, how CHCs are associated with changes in SLE may depend on whether the CHC was newly diagnosed and the type of CHC.

Aim

We hypothesize that newly diagnosed CHCs will be strongly negatively associated with changes in SLE than existing CHCs. As CHCs vary in their presentation and prognosis, we differentiate associations between five CHCs - arthritis, cardiovascular diseases, sleep disorders, psychological disorders and life-threatening conditions - and changes in SLE.

Method

Data from two waves of a Dutch pension panel survey, collected 3 years apart in 2015 and 2018, were used. The analytical sample included 4824 older workers between the ages of 60-65 years at wave 1. Data were analysed longitudinally using a conditional change ordered logistic regression model.

Results

In general, newly diagnosed CHCs were strongly negatively associated with changes in SLE, relative to having no CHCs. Existing CHCs were also negatively associated with changes in SLE, but to a weaker strength. Interestingly, associations between CHCs and the change in SLE differed based on the CHC in question.

Conclusion

Newly diagnosed life-threatening conditions, psychological disorders and cardiovascular diseases are strongly negatively associated with changes in SLE. These results provide insight into the differences in how older workers with CHCs experience late career work and how these experiences influence their SLE.

Mortality and life expectancy trends in Spain by pension income level for male pensioners in the general regime retiring at the statutory age, 2005-2018

Background

Research has generally found a significant inverse relationship in mortality risk across socioeconomic (SE) groups. This paper focuses on Spain, a country for which there continues to be very little evidence available concerning retirement pensioners. We draw on the Continuous Sample of Working Lives (CSWL) to investigate disparities in SE mortality among retired men aged 65 and above over the longest possible period covered by this data source: 2005–2018. We use the initial pension income (PI) level as our single indicator of the SE status of the retired population.

Methods

The mortality gradient by income is quantified in two ways: via an indicator referred to as “relative mortality”, and by estimating changes in total life expectancy (LE) by PI level at ages 65 and 75 over time. We show that, should the information provided by the relative mortality ratio not be completely clear, a second indicator needs to be introduced to give a broad picture of the true extent of inequality in mortality.

Results

The first indicator reveals that, for the period covered and for all age groups, the differences in death rates across PI levels widens over time. At older age groups, these differences across PI levels diminish. The second indicator shows that disparities in LE at ages 65 and 75 between pensioners in the lowest and highest income groups are relatively small, although slightly higher than previously reported for Spain. This gap in LE widens over time, from 1.49 to 2.54 years and from 0.71 to 1.40 years respectively for pensioners aged 65 and 75. These differences are statistically significant.

Conclusions

Along with other behavioral and structural aspects, a combination of factors such as the design of the pension system, the universality and quality of the health system, and high levels of family support could explain why LE inequalities for retired Spanish men are relatively small. To establish the reasons for this increased inequality in LE, more research needs to be carried out. An analysis of all Spanish social security records instead of just a sample would provide us with more information.

Non-linear relations between life expectancy, socio-economic, and air pollution factors: a global assessment with spatial disparities

Influential factors of socio-economic and air pollution on life expectancy (LE) show complexity. The investigations of non-linear functions of LE, socio-economic, and air pollution factors have not been largely conducted, and spatial and temporal differences of the linear or non-linear relations between LE and the influential factors have been obscured across countries in the world. In this study, the non-linear relations between LE and factors of per capita gross national income (GNI_pc), urban population rate (UPR), and fine-particulate (PM_2.5) were estimated from 2000 to 2015 by using a generalized additive model (GAM). The collected data included the 219 countries and regions with sufficient data and covers the period 2000-2015. The results demonstrate that at the global level, the GNI_pc plays a stable and significant non-linear role in LE, while the non-linear relationships between UPR, PM_2.5, and LE are not significant. The temporal variation was further investigated that the non-linear effect of PM_2.5 on LE is gradually strengthened, and the non-linear effect of UPR on LE shows a weakened trend. However, GNI_pc always plays a significantly non-linear role in the LE level. Furthermore, the spatial difference in the non-linear relations among different continents is detected. In sum, it cannot be ignored the non-linear effects of socio-economic and air pollution factors on LE at a global scale and across different continents.

Socioeconomic Disparities in Prehospital Emergency Care in a Danish Tax-Financed Healthcare System: Nationwide Cohort Study

Background

Differences related to socioeconomic status (SES) in use of prehospital emergency medical services (EMS) have been reported. However, detailed data on potential disparities in the quality of the EMS according to SES are lacking.

Methods

A nationwide cohort study of medical emergency calls made to the Danish emergency number 1-1-2 in the period 2016–2017. To measure quality of care, performance indicators from the Danish Quality Registry for Prehospital Emergency Medical Services were used. SES was based on income, education and adherence to workforce. Poisson regression was used to measure relative risk (RR).

Results

We included 388,378 medical 1-1-2 calls, of which 261,771 were unique individuals; 42% of the calls concerned patients with low education, 5% concerned patients living in relative poverty and 23% concerned patients receiving social subsidy. There were no significant differences between the SES regarding time span for arrival of first EMS units. However, patients receiving social subsidy and retired people were more likely to be released at scene and to call again within 24 hours: Adjusted RRs were 2.79 [2.20; 3.54] and 2.08 [1.58; 2.75], respectively, compared with patients having a job. In addition, patients receiving social subsidy and retired people were more likely to call again within 24 hours after receiving telephone advice only: Adjusted RRs 2.35 [1.95; 2.82] and 1.88 [1.51; 2.35], respectively compared with patients having a job. Adjusted RRs for unplanned hospital contact after being treated and released at scene were higher for patients receiving social subsidy and retired people, respectively, relative to patients having a job.

Conclusion

Patients with low SES were significantly more likely to contact the hospital or EMS again after their first call or after treatment and release at scene compared with patients with high SES. This indicates that callers with low SES did not receive the appropriate help.

Socioeconomic, Eating- and Health-Related Limitations of Food Consumption among Polish Women 60+ Years: The 'ABC of Healthy Eating' Project

The study aimed at identifying the socioeconomic, eating- and health-related limitations and their associations with food consumption among Polish women 60+ years old. Data on the frequency of consumption of fruit, vegetables, dairy, meat, poultry, fish, legumes, eggs, water and beverages industrially unsweetened were collected with the Mini Nutritional Assessment (MNA^®) and were expressed in the number of servings consumed per day or week. Three indexes: the Socioeconomic Status Index (SESI), the Eating-related Limitations Score (E-LS) and the Health-related Limitations Score (H-LS) were developed and applied. SESI was created on the base of two variables: place of residence and the self-reported economic situation of household. E-LS included: difficulties with self-feeding, decrease in food intake due to digestive problems, chewing or swallowing difficulties, loss of appetite, decrease in the feeling the taste of food, and feeling satiety, whereas H-LS included: physical function, comorbidity, cognitive function, psychological stress and selected anthropometric measurements. A logistic regression analysis was performed to assess the socioeconomic, eating-, and health-related limitations of food consumption. Lower socioeconomic status (vs. higher) was associated with a lower chance of consuming fruit/vegetables ≥ 2 servings/day (OR = 0.25) or consuming dairy ≥ 1 serving/day (OR = 0.32). The existence of multiple E-LS limitations (vs. few) was associated with a lower chance of consuming fruit/vegetables ≥ 2 servings/day (OR = 0.72), consuming dairy ≥ 1 serving/day (OR = 0.55) or consuming water and beverages industrially unsweetened ≥6 cups/day (OR = 0.56). The existence of multiple H-LS limitations was associated with a lower chance of consuming fruit/vegetables ≥ 2 servings/day (OR = 0.79 per 1 H-LS point increase) or consuming dairy ≥ 1 serving/day (OR = 0.80 per 1 H-LS point increase). Limitations found in the studied women were related to insufficient consumption of selected groups of food, which can lead to malnutrition and dehydration. There is a need for food policy actions, including practical educational activities, to eliminate barriers in food consumption, and in turn to improve the nutritional and health status of older women.

Differences in Life Expectancy Between Self-Employed Workers and Paid Employees when Retirement Pensioners: Evidence from Spanish Social Security Records

The aim of this paper is to examine differences in life expectancy (LE) between self-employed (SE) and paid employee (PE) workers when they become retirement pensioners, looking at levels of pension income using administrative data from Spanish social security records. We draw on the Continuous Sample of Working Lives (CSWL) to quantify changes in total life expectancy at age 65 (LE₆₅) among retired men over the longest possible period covered by this data source: 2005-2018. These changes are broken down by pension regime and initial pension income level for three periods. The literature presents mixed evidence, even for the same country-for Japan and Italy, for example-with some studies pointing to higher life expectancy for SE than for PE retirement pensioners while others argue the opposite. In Spain, LE₆₅ is slightly higher for the SE than for PE workers when retirement pensioners. For 2005-2010, a gap in life expectancy of 0.23 years between SE and PE retirement pensioners is observed. This widens to 0.55 years for 2014-2018. A similar trend can be seen if pension income groups are considered. For 2005-2010, the gap in LE₆₅ between pensioners in the lowest and highest income groups is 1.20 years. This widens over time and reaches 1.51 years for 2014-2018. Although these differences are relatively small, they are statistically significant. According to our research, the implications for policy on social security are evident: differences in life expectancy by socioeconomic status and pension regime should be taken into account for a variety of issues involving social security schemes. These include establishing the age of eligibility for retirement pensions and early access to benefits, computing the annuity factors used to determine initial retirement benefits and valuing the liabilities taken on for retirement pensioners.

Disaggregation of official demographic projections in sub-groups by education level: the neglected “composition effect” in the future path of life expectancy

We developed an innovative method to break down official population forecasts by educational level. The mortality rates of the high education group and low education group were projected using an iterative procedure, whose starting point was the life tables by education level for Italy, based on the year 2012. We provide a set of different scenarios on the convergence/divergence of the mortality differential between the high and low education groups. In each scenario, the demographic size and the life expectancy of the two sub-groups were projected annually over the period 2018–2065. We compared the life expectancy paths in the whole population and in the sub-groups. We found that in all of our projections, population life expectancy converges to the life expectancy of the high education group. We call this feature of our outcomes the “composition effect”, and we show how highly persistent it is, even in scenarios where the mortality differential between social groups is assumed to decrease over time. In a midway scenario, where the mortality differential is assumed to follow an intermediate path between complete disappearance in year 2065 and stability at the 2012 level, and in all the scenarios with a milder convergence hypothesis, our “composition effect” prevails over the effect of convergence for men and women. For instance, assuming stability in the mortality differential, we estimated a life expectancy increase at age 65 of 2.9 and 2.6 years for men, and 3.2 and 3.1 for women, in the low and high education groups, respectively, over the whole projection period. Over the same period, Italian official projections estimate an increase of 3.7 years in life expectancy at age 65 for the whole population. Our results have relevant implications for retirement and ageing policies, in particular for those European countries that have linked statutory retirement age to variations in population life expectancies. In all the scenarios where the composition effect is not offset by a strong convergence of mortality differentials, we show that the statutory retirement age increases faster than the group-specific life expectancies, and this finding implies that the expected time spent in retirement will shrink for the whole population. This potential future outcome seems to be an unintended consequence of the indexation rule.

A Systematic Review of Sociodemographic, Macroeconomic, and Health Resources Factors on Life Expectancy

This review was aimed at systematically synthesizing and appraising the existing literature of sociodemographic, macroeconomic, and health resources factors on life expectancy. A systematic literature search of English databases, that is, PubMed/MEDLINE were scrutinized for exploring sociodemographic, macroeconomic, and health resources factors on life expectancy. The literature search was conducted in January 2020, covering a total of 46 articles from 2004 to 2019 met the review criteria, which were fully discussed subsequently. Among sociodemographic factors, infant mortality rate, literacy rate, education level, socioeconomic status, population growth, and gender inequality have a significant impact on life expectancy. Gross domestic product, Gini, income level, unemployment rate, and inflation rate are the main macroeconomic factors that significantly correlated with life expectancy. Among various health care resources, health care facilities, the number of the health care profession, public health expenditure, death rates, smoking rate, pollution, and vaccinations had a significant correlation with life expectancy. The systematic review showed general conformity of different studies, with a significant association between life expectancy and factors comprising several sociodemographic, macroeconomic, and various health care variables. This review found that only one study examined factors affecting life expectancy in Arabic countries. More studies on this region to fill this research gap were highly recommended.

Impact of demography and population dynamics on the genetic architecture of human longevity

The study of the genetics of longevity has been mainly addressed by GWASs that considered subjects from different populations to reach higher statistical power. The "price to pay" is that population-specific evolutionary histories and trade-offs were neglected in the investigation of gene-environment interactions. We propose a new “diachronic” approach that considers processes occurred at both evolutionary and lifespan timescales. We focused on a well-characterized population in terms of evolutionary history (i.e. Italians) and we generated genome-wide data for 333 centenarians from the peninsula and 773 geographically-matched healthy individuals. Obtained results showed that: (i) centenarian genomes are enriched for an ancestral component likely shaped by pre-Neolithic migrations; (ii) centenarians born in Northern Italy unexpectedly clustered with controls from Central/Southern Italy suggesting that Neolithic and Bronze Age gene flow did not favor longevity in this population; (iii) local past adaptive events in response to pathogens and targeting arachidonic acid metabolism became favorable for longevity; (iv) lifelong changes in the frequency of several alleles revealed pleiotropy and trade-off mechanisms crucial for longevity. Therefore, we propose that demographic history and ancient/recent population dynamics need to be properly considered to identify genes involved in longevity, which can differ in different temporal/spatial settings.

Local deprivation status and seasonal influenza vaccination coverage in adults ≥ 65 years residing in the Foggia municipality, Italy, 2009-2016

Introduction

In Italy, vaccination against seasonal influenza has been recommended for the elderly since 1980, but coverage is still far below the WHO minimum target level of 75%. Effective interventions to improve influenza vaccination should take into account socioeconomic determinants of inequalities in vaccine uptake. This study aimed to assess differences in vaccination coverage, by socioeconomic status, among people ≥ 65 years of age residing in the Foggia municipality, Italy.

Methods

A Socio-Economic-Health Deprivation Index (SEHDI) was constructed by using a multivariate analysis model. The resident population, for census block, was classified in 5 deprivation groups. Differences in demographic and socioeconomic indicators, the standardized mortality ratios (SMRs), and the average vaccination coverage among deprivation groups were evaluated with the linear F-test. The association between census variables and influenza vaccination coverage, in each deprivation group, was assessed using the Pearson bivariate correlation.

Results

The SEHDI allowed to identify factors related to ageing, housing, household size and composition, and education. Forty percent of people residing in the Foggia municipality lived in conditions of socioeconomic and health deprivation. Belonging to families with 3 or 4 members was associated with increased coverage rates. In the most deprived group, vaccination uptake was positively associated with the dependency ratio.

Conclusions

The results of this study have shown that there is still large room for improving influenza vaccination coverage among subjects belonging to the most deprived areas. Surveillance of trends in influenza vaccine uptake by socioeconomic groups is a feasible contribution to implementing effective, tailored to the frail older persons, vaccine utilization programs.